microsoft word v1i2a6.docx brief report 60 abstract the term “cross-faded,” observed in focus groups and on a variety of websites, appears to refer to overlapping drug effects of multiple substances used at the same time, particularly alcohol and marijuana. this study explores young adult understanding of the cross-faded terminology in order to inform substance use research and intervention. young adult participants (n=807, ages 18-23) in the screening survey for project transitions based in seattle, wa were asked whether they had heard of being cross-faded, what they thought it meant, and how desirable and risky they thought it was. crossfaded was a commonly understood term (87% had heard of it), most often described as using alcohol and marijuana simultaneously (43%) and second most as being both drunk and high (25%), specifically. being cross-faded was seen as moderately risky and not desirable by most, although 18.2% described it as moderately or very desirable. risk factor differences in perceptions of being cross-faded were found for sex, college status, and alcohol and marijuana use. cross-faded is a common term for the effects of using multiple substances. as such it merits further research consideration with the aim of optimizing the effectiveness of surveys and programming. key words: marijuana, alcohol, college students, daily diary, interpersonal conflict the term “cross-faded” has entered the young adult lexicon in the past decade, referring to couse of substances, typically alcohol and marijuana. “cross-fading” has come up anecdotally in focus groups and has an online presence (bergado, 2014; “cross faded”, 2005; dovey, 2014; puiu, 2017; townsend, 2017) but has not yet been explored in survey research. use of alcohol or marijuana is common in the us: 82% of young adults have used alcohol and 32% have used marijuana in the past year (schulenberg et al., 2017). of those 18 and older who report both alcohol and marijuana use, the majority report simultaneous use such that the drug effects overlap (subbaraman & kerr, 2015). high school seniors who use alcohol and marijuana at higher intensities are more likely to use them at the same time (patrick, veliz, & terry-mcelrath, 2017). simultaneous use is associated with feeling confused, having difficulty concentrating, and impaired driving (lee, cadigan, & patrick, 2017; ramaekers, berghaus, van laar, & drummer, 2004; sewell, poling, & sofuoglu, 2009; terrymcelrath, o’malley, & johnston, 2014). in human subjects, ethanol (the active ingredient in alcohol) has been shown to increase the absorption and cannabis 2018, volume 1 (2), 60-65 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.006 open access cross-faded: young adults’ language of being simultaneously drunk and high megan e. patrick1, christine m. lee2 1 institute for social research, university of michigan, ann arbor, mi, usa 2 department of psychiatry and behavioral sciences, university of washington, seattle, wa, usa corresponding author: megan e. patrick, institute for social research, university of michigan, 426 thompson st., ann arbor, mi, 48106-1248, u.s.a. email: meganpat@umich.edu cannabis, a publication of the research society on marijuana 61 drug effect of thc (the active ingredient in marijuana) (lukas & orozco, 2001). understanding young adults’ language about substance use is important for gathering accurate information about use and consequences. this study used us-regional survey research to examine: (1) how commonly recognized the term “cross-faded” is among young adults, and what it means to them; (2) to what extent being crossfaded is perceived as desirable and risky; and (3) whether perceptions of being cross-faded differ by sex, college status, or frequency of alcohol and marijuana use. method participants and procedures project transitions is a longitudinal study based in greater seattle, wa that explores young adult social role transitions and alcohol use. young adults were recruited via online and print media ads, flyers, word of mouth, and local community agencies. eligibility criteria included being 18-23 years old, residing within the seattle metropolitan area, having an email address, reporting drinking alcohol at least once in prior year, and being willing to come to the project office for consent, identity/age verification, and baseline assessment. participants were not compensated for completing the eligibly survey. all procedures were approved by the local university institutional review board and covered by a federal certificate of confidentiality. no adverse events were reported. questions about the term “cross-faded” were added to the online eligibility survey for the second half of the enrollment period (from february 2015 to january 2016). during this period, 1565 individuals provided consent and completed the survey with 58.2% (n=911) meeting initial eligibility criteria to continue to the substance use questions. of the 911 individuals, 89% answered the questions about the term “cross-faded” leaving 807 young adults with relevant data (see descriptive statistics in table 1). table 1. descriptive statistics variable % heard of cross-faded yes 87.2 no 12.8 meaning of cross-faded use of alcohol and marijuana (definition or example) 43.3 drunk and high (no marijuana mention) 25.0 use of multiple substances 17.5 other 1.5 blank response 12.8 cross-faded desirability not desirable 60.1 slightly desirable 21.7 moderately desirable 13.0 very desirable 5.2 cross-faded risk not risky 5.6 slightly risky 16.4 moderately risky 45.0 very risky 33.1 been cross-faded yes 60.4 no 39.7 sex female 58.6 male 41.4 college status not a student 24.9 2-year or votech student 24.2 4-year or grad student 50.9 m (sd) alcohol use frequency 2.6 (1.7) marijuana use frequency 1.8 (2.5) note. n = 807. measures cross-faded. participants were asked , “have you ever heard the term ‘cross-faded’ with regards to substance use?” with response options yes, no, or prefer not to answer. participants who answered “yes” were asked, “what does it mean to you?” and could type in an open-ended response. responses to the meaning of cross-faded items were coded into 4 mutually exclusive categories initially developed by the two authors: 1) use of alcohol and marijuana (i.e., both substances were specifically listed); 2) drunk and high (i.e., the high was not specified as cross-faded 62 marijuana); 3) use of multiple substances (i.e., alcohol and marijuana were not specifically listed, but the definition referred to use of more than one substance); and 4) other. each response was coded by two coders, a graduate student and a paid staff member. codes had 99.9% match between coders; the few (n=11) inconsistencies were reviewed and final decisions made by the two authors. all participants were asked, “how desirable is being ‘cross-faded’?” and “how risky is being ‘cross-faded’?” (both with responses from 1 = not to 4 = very, and a code for prefer not to answer). finally, they were asked, “have you ever been ‘cross-faded’?” with response options of yes, no, or prefer not to answer. demographics. sex at birth was coded as female, male, or prefer not to answer. current college status was coded as not currently a student, 2-year college or vocational student, 4year college student, or graduate student. due to small sample sizes, respondents in high school (n = 16) or working toward a general equivalency degree (n = 10) were coded as missing on college status. previous alcohol and marijuana use. pastmonth alcohol use was assessed with, “during the past month, how often did you usually have any kind of drink containing alcohol?” responses were 0 = never, 1 = once a month, 2 = 2 to 3 days a month, 3 = 1 day a week, 4 = 2 days a week, 5 = 3 to 4 days a week, 6 = 5 to 6 days a week, and 7 = everyday” with a code for prefer not to answer. marijuana use was assessed with “during the past month, how often did you usually use marijuana?” with the same responses as alcohol. results descriptive statistics are shown in table 1. the majority of participants (87.2%) said they had heard of the term “cross-faded.” its meaning was described as using both alcohol and marijuana by 43.3%, being both drunk and high by 25.0%, and using multiple substances by 17.5% of participants. only 1.5% of responses listed another definition for the term, and 12.8% were left blank. well over half of the participants (60.1%) said that being cross-faded was not desirable, with only 5.2% saying it was very desirable. perceived risk showed that only 5.6% rated being crossfaded as not risky, with most (78.1%) saying it was either moderately or very risky. bivariate statistics are shown in table 2. compared to females, males more often said that being cross-faded was a specific combination of alcohol and marijuana, rated being cross-faded as less risky, and had a higher endorsement of having been cross-faded themselves. non-collegestudents perceived being cross-faded as less risky, compared to 2-year and 4-year college students. more frequent users of alcohol or marijuana were more likely to have heard of being cross-faded, report being cross-faded as more desirable or less risky, and report having been cross-faded themselves. discussion “cross-faded” emerges as a commonly known term for effects of using multiple substances. it most often refers to using alcohol and marijuana simultaneously, and second-most to being drunk and high at the same time. among young adults in the seattle, washington area who had used alcohol in the past year, the majority (59%) said they had been cross-faded. however, being crossfaded was rated as not very desirable and considered moderately risky. current evidence corroborates the risks associated with simultaneous alcohol and marijuana (sam) use (lee et al., 2017; lukas & orozco, 2001; ramaekers et al., 2004; sewell et al., 2009; terrymcelrath et al., 2014), and it appears that young adults have some awareness of the consequences. males (compared to females), non-students (compared to 2-year and 4-year college students), and more frequent users of alcohol or marijuana were most likely to report having been crossfaded. the latter were also most likely to rate being cross-faded as more desirable and less risky. this finding is similar to previous research documenting that higher intensity drinkers and marijuana users are more likely to report sam use (patrick et al., 2017). additional research is needed to understand specific risk factors associated with being crossfaded, beyond heavier drinking and marijuana use. both the language of and motivations (patrick, fairlie, & lee, 2018) for sam use suggest it to be a distinct behavior in young adult experience. the current study is limited by its cannabis, a publication of the research society on marijuana 63 table 2. bivariate statistics sex college status alcohol use freq. marijuana use freq. cross-fading variable female % male % p non student % 2-year % 4-year % p mean (sd) p mean (sd) p heard of cross-faded 0.065 0.079 <0.001 <0.001 yes 85.4 89.8 89.1 82.6 88.6 2.7 (1.7) 2.1 (2.6) no 14.6 10.2 11.0 17.4 11.4 1.8 (1.7) 0.4 (1.1) meaning of cross-faded 0.036 0.210 <0.001 <0.001 alcohol and marijuana 40.0* 47.9 45.3 39.5 44.0 2.9 (1.7) 2.2 (2.6) drunk and high 26.0 23.7 23.4 22.1 27.3 2.7 (1.7) 1.8 (2.5) multiple substances 18.6 15.9 17.9 19.0 16.6 2.3 (1.7) 2.0 (2.7) other 0.9 2.4 2.5 2.1 0.7 1.7 (1.4) 1.3 (2.3) blank response 14.6 10.2 11.0 17.4 11.4 1.8 (1.7) 0.4 (1.1) cross-faded desirability 0.099 0.782 <0.001 <0.001 not desirable 62.6 56.6 58.7 63.1 59.4 2.2 (1.6) 0.9 (1.9) slightly desirable 21.6 21.9 24.9 18.0 21.9 2.9 (1.7) 2.5 (2.4) moderately desirable 12.1 14.4 11.9 13.9 13.1 3.3 (1.6) 4.2 (2.6) very desirable 3.8 7.2 4.5 5.1 5.6 3.9 (1.9) 4.1 (2.7) cross-faded risk <0.001 0.010 <0.001 <0.001 not risky 3.4* 8.7 10.5b,c 4.6a 3.7a 3.0 (2.0) 3.7 (2.9) slightly risky 14.0* 19.8 16.4 14.4 17.3 3.1 (1.6) 2.7 (2.6) moderately risky 44.2 46.1 43.3 41.5 47.5 2.7 (1.7) 2.0 (2.5) very risky 38.5*** 25.5 29.9b 39.5a 31.6 2.2 (1.7) 0.9 (2.0) been cross-faded <0.001 0.009 <0.001 <0.001 yes 54.6 68.6 69.2b,c 54.9a 58.6a 3.1 (1.7) 2.9 (2.6) no 45.5 31.4 30.9 45.1 41.4 1.9 (1.5) 0.2 (0.9) note. n = 807. reported p-values are based on chi-square tests (for two categorical variables), t-tests or anovas (for a combination of continuous and categorical variables). asterisks [*p < .05, ***p < .001] indicate significance for follow-up comparisons of specific categories. superscripts indicate significant differences for college status, whereby a=significantly different from non-student, b=significantly different from 2-year, and c=significantly different from 4-year. cross-faded 64 regional, urban, community sample in washington state where recreational marijuana is legal for those aged 21+. however, the common understanding and experience of being crossfaded suggests that it is a behavior worthy of further research consideration. documenting young adult terminology for polyand simultaneous substance use can help optimize the effectiveness of surveys and ensure that prevention and intervention efforts are relatable and accessible for young adults. references bergado, g. (2014, march 21). what happens to your body when you get drunk and stoned at the same time? popular science. retrieved from http://www.popsci.com/article/science/whathappens-your-body-when-you-get-drunk-andstoned-same-time-0 (archived at http://www.webcitation.org/70ul2y1az) cross faded (2005, september 24). in urban dictionary. retrieved from http://www.urban dictionary.com/define.php?term=cross%20fad ed (archived at http://www.webcitation.org/ 70umabke0) dovey, d. (2014, april 23). drunk and high: science explains some of the side effects that come from mixing alcohol and marijuana. medical daily. retrieved from http://www.medicaldaily.com/drunk-andhigh-science-explains-some-side-effects-comemixing-alcohol-and-marijuana-278486 (archived at http://www.webcitation.org/70ukbhic9) lee, c. m., cadigan, j. m., & patrick, m. e. (2017). differences in reporting of perceived acute effects of alcohol use, marijuana use, and simultaneous alcohol and marijuana use. drug and alcohol dependence, 180, 391-394. doi: 10.1016/j.drugalcdep.2017.08.029. lukas, s., & orozco, s. (2001). ethanol increases plasma delta(9)-tetrahydrocannabinol (thc) levels and subjective effectsafter marihuana smoking in human volunteers. drug and alcohol dependence, 64. doi: 10.1016/s03768716(01)00118-1. patrick, m. e., veliz, p. t., & terry-mcelrath, y. m. (2017). high-intensity and simultaneous alcohol and marijuana use among high school seniors in the u.s. substance abuse, 38(4), 498-503. doi: 10.1080/08897077.2017.1356421. patrick, m. e., fairlie, a. m., & lee, c. m. (2018). motives for simultaneous alcohol and marijuana use among young adults. addictive behaviors, 76, 363-369. doi: 10.1016/j.addbeh.2017.08.027. puiu, t. (2017, august 14). what happens inside your brain when you mix marijuana and alcohol. zme science. retrieved from http://www.zmescience.com/science/mixingpot-and-alcohol-brain-423432/ (arhived at http://www.webcitation.org/70ulqdkca) ramaekers, j. g., berghaus, g., van laar, m., & drummer, o. h. (2004). dose related risk of motor vehicle crashes after cannabis use. drug and alcohol dependence, 73(2), 109-119. schulenberg, j. e., johnston, l. d., o'malley, p. m., bachman, j. g., miech, r. a., & patrick, m. e. (2017). monitoring the future national survey results on drug use, 1975-2016: volume ii, college students and adults ages 19-55. ann arbor, mi: institute for social research, the university of michigan. available at http://monitoringthefuture.org/pubs/monogra phs/mtf-vol2_2016.pdf. accessed august 8, 2017. sewell, r. a., poling, j., & sofuoglu, m. (2009). the effect of cannabis compared with alcohol on driving. american journal on addictions, 18(3), 185-193. doi: 10.1080/10550490902786934. subbaraman, m. s., & kerr, w. c. (2015). simultaneous versus concurrent use of alcohol and cannabis in the national alcohol survey. alcoholism: clinical and experimental research, 39(5), 872-879. doi: 10.1111/acer.12698. terry-mcelrath, y. m., o’malley, p. m., & johnston, l. d. (2014). alcohol and marijuana use patterns associated with unsafe driving among u.s. high school seniors: high use frequency, concurrent use, and simultaneous use. journal of studies on alcohol and drugs, 75(3), 378-389. doi: 10.15288/jsad.2014.75.378. cannabis, a publication of the research society on marijuana 65 townsend, a. (2017, november 2). crossfading: what happens when you mix alcohol and weed? woahstork. retrieved from https://learn.woahstork.com/cannabisscience/crossfading/ (archived at http://www.webcitation.org/70ulyxyqc) funding: data collection and manuscript preparation were supported by grants from the national institute on alcohol abuse and alcoholism (r01aa016979 to c. lee; r01aa025037 to c. lee & m. patrick). the content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. acknowledgments: the authors would like to thank devon abdallah, stephanie stern, and kellyn spychala for assistance with data collection, management, and analysis. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 28 abstract background: the effects of marijuana on the cardiac conduction system are ill defined. the purpose of this study is to describe the association between electrocardiogram (ecg) findings and positive urine drug screening (+uds) for marijuana in the pediatric population. methods: a retrospective review was conducted through the electronic medical record from emergency department (ed) visits dated 10/1311/14 of patients ≤ 18 years of age who tested positive for marijuana exposure by +uds in the ed. inclusion criteria included: 1) +uds for marijuana performed in the ed and 2) electrocardiogram (ecg) performed on same day as +uds. each ecg was overread by a pediatric electrophysiologist, blinded to the results of the uds. results: there were 174 patients identified in the ed with a +uds, median age of 15 years (0-18 years); 42% were male. ecg was performed at time of +uds on 37 (21%) patients. an abnormal ecg finding was identified in 16/37 (43%), of which 15 had a follow-up ecg. non-specific similar ecg findings were noted on 3/15: 2 st segment changes and1 early repolarization. significant differences were noted on ecgs with +uds in 12/15 patients, including st segment changes (4), left ventricular hypertrophy (3), first-degree atrioventricular (av) block (2), and 1 each: atrial fibrillation, right ventricular hypertrophy, and mobitz type i second-degree av block. conclusions: abnormal ecg findings, including serious conduction and rhythm disturbances, can be identified in pediatric patients under the influence of marijuana. an ecg should be considered on all patients with a positive urine drug screen for marijuana. key words: cannabis, marijuana, electrocardiogram, ecg, urine drug screen, adolescents, pediatrics marijuana is the most commonly used illicit drug in the united states, and its abuse in children and adolescents has steadily increased in recent years (singh, 2000). according to recent epidemiologic data, 7.2% of 12-17 year olds are regularly exposed to marijuana (wall et al., 2011). the issue of legalized marijuana in states across the country has brought the subject of the potential hazards and health consequences of marijuana to the forefront of public debate; however, the acute and chronic effects of marijuana in the pediatric population are not completely understood. marijuana is known to be a mind-altering substance that also has significant effects on cardiovascular and autonomic nervous system function (beaconsfield, ginsburg, & rainsbury, 1972). in particular, symptoms such as palpitations and chest pain have been noted corresponding author: christopher s. snyder, division of pediatric cardiology, the congenital heart collaborative, rainbow babies and children’s hospital, 11100 euclid ave, ms rbc 6011, cleveland, oh 44106, phone: 216-844-8529, fax: 216-844-5478, email: christopher.snyder@uhhospitals.org cannabis 2018, volume 1 (1), 28-34 © author(s) 2017 researchmj.org doi: 10.26828/cannabis.2018.01.004 open access ecg findings in pediatric patients under the influence of marijuana jeffrey a. robinson1,2, sahana somasegar2, jill k. shivapour1,2 christopher s. snyder1,2 1 the congenital heart collaborative, rainbow babies and children’s hospital, cleveland, oh 2 case western reserve university school of medicine, cleveland, oh http://dx.doi.org/10.26828/cannabis.2018.01.004 cannabis, a publication of the research society on marijuana 29 during and after the use of marijuana in adults, which have been found to be tachycardia, nearsyncope, or syncope (brust, 1993; miller et al., 1977). regardless, the effects of marijuana use in children and adolescents in particular have not been extensively studied. on an anecdotal basis, otherwise healthy adolescents and young adults with no history of cardiac disease have developed acute cardiac symptoms and presented with acute onset of atrial fibrillation after ingesting marijuana (korantzopoulos, liu, papaioannides, li, & goudevenos, 2008; singh, huntwork, shetty, sequeira, & akingbola, 2014). here, it has been postulated that acute catecholamine surges in susceptible individuals—particularly those who are naïve to marijuana—could cause atrial fibrillation, as well as some of the more common cardiac symptoms, consequent to adrenergic and mechanoreceptor stimulation of the heart (brust, 1993; korantzopoulos, 2014; miller et al., 1977). the true mechanism of arrhythmia associated with marijuana use may be multifactorial. in addition to increased sympathetic tone, marijuana use has also been associated with bradycardia, as well as firstand mobitz type i second-degree atrioventricular block (wenckebach) in otherwise healthy young adults (akins & awdeh, 1981). in fact, multiple exposures to marijuana may modulate the sympathetic nervous system, such that chronic users experience decreased sympathetic activation and increased parasympathetic or vagal tone (middlekauff et al., 2014; schmid et al., 2010). previous work has demonstrated that increased parasympathetic activity can be substrate for atrial fibrillation by decreasing both the action potential duration and the atrial refractory period (coumel, 1994; pratap & korniyenko, 2012). as the use of marijuana among the pediatric population continues to rise, it is important to understand the cardiovascular effects and changes that can be noted on the electrocardiogram of a pediatric or adolescent patient. the purpose of this study is to describe the association between electrocardiogram (ecg) findings and positive urine drug screen (+uds) for marijuana in pediatric patients presenting to the acute care setting. method this single-center, retrospective chart review complies with the declaration of helsinki and was approved by the institutional review board (irb) for human investigation. the clinical chemistry database was queried for all +uds results from the emergency department (ed) in patients ≤ 18 years of age from december 1, 2013, through november 30, 2014. any ecg that these patients had received on the day of the +uds for marijuana was obtained from the hospital ecg database (muse® cardiology information system, version 7.1.1, general electric company, boston, massachusetts, usa, 2007). inclusion criteria included both +uds and ecg performed for any indication during a single ed visit during the study period. for the cohort identified, any additional ecg(s) performed for any indication on any date through november 30, 2014, were obtained from the hospital muse ecg database. printed 15-lead ecgs were deidentified of personal health information. ecgs were grouped by a study number unique to each patient. each ecg was separately overread and interpreted by a pediatric electrophysiologist using the muse® cardiology information system. the pediatric electrophysiologist was blinded to the results of the +uds. standard electrocardiographic definitions were used. repolarization abnormalities were grouped to include nonspecific t-wave abnormality, st segment changes, and early repolarization. ecg findings were then characterized in relation to the date of +uds for marijuana. comparisons were then made between ecgs for a single patient performed on the date of +uds and any performed on a different date. results there were 174 patients identified in the ed with a +uds, median age of 15 yrs (0-18 yrs); 42% were male. ecg was performed at time of +uds on 37 (21%) patients. of these, 21 (57%) patients had a normal ecg on the date of +uds. an abnormal ecg finding was identified in the remaining 16, of which 15 had an additional ecg performed on another date: either prior to or after the date of the +uds in the ed. comparisons were made between each patient’s pediatric ecg abnormalities with marijuana use 30 figure 1. 17-year-old male, with palpitations, diagnosed with atrial fibrillation. ecgs. similar ecg findings were identified in 3 of the patients, regardless of the results of the uds: 2 with st segment changes and 1 with early repolarization. the 12 other patients had significant differences in their ecgs while under the influence of marijuana, including st segment changes (4), left ventricular hypertrophy (3), firstdegree atrioventricular (av) block (2), and one each: atrial fibrillation, sinus bradycardia with mobitz type i second-degree av block, and right ventricular hypertrophy. in particular, two cases will be highlighted. first, a 17-year-old athletic, otherwise healthy caucasian male presented to the ed with new and sudden onset of palpitations. the patient was alert and answered questions appropriately. on physical exam, there was an irregularly irregular heart rhythm with ventricular rate of 112 beats per minute (bpm). ecg confirmed atrial fibrillation (see figure 1). initial blood pressure was 154/94 mmhg; however, there was no previous history of hypertension. body mass index (bmi) was within normal limits for age. the patient had a prior history of tobacco and alcohol use, as well as distant recreational use of 3,4-methylenedioxymethamphetamine (mdma). the patient had smoked marijuana occasionally, previously without cardiac symptoms. on the day of presentation, he had exposure to marijuana from a new source within a few hours of developing palpitations. no other risk factors for atrial fibrillation were identified on history and review of systems. the patient was prescribed oral doses of atenolol and aspirin in the ed. spontaneous cardioversion and return of normal sinus rhythm occurred several minutes after taking the first doses of these medications. the patient was observed overnight without recurrence of his arrhythmia. over 2.5 years of follow-up, he continued to use marijuana intermittently, twice developing palpitations with one episode of documented atrial fibrillation. the second patient was a 14-year-old, otherwise healthy african american male, who presented with new onset of acute chest pain and headache at school. he was transported by ambulance to the ed, where he was noted to be agitated, defiant, and uncooperative. on exam, baseline heart rate was 51 bpm. the patient was appropriately oriented to person, place, and time. there were otherwise no murmurs or any other positive findings on physical exam. on ecg and 24-hour holter monitor, the patient was found to have a mobitz type i second-degree av block (see figure 2). the patient smoked marijuana on cannabis, a publication of the research society on marijuana 31 figure 2. 14-year-old male, with headache/blurred vision, diagnosed with 2nd-degree atrioventricular block. a frequent basis as a therapeutic measure to relieve symptoms of anxiety. he had smoked marijuana within a few hours of this acute presentation. cessation of marijuana use was recommended and the patient was seen for follow-up in outpatient clinic several days later. there, baseline ecg was sinus rhythm. an exercise stress test was performed on a treadmill with a standard bruce ramp protocol. resting heart rate was 48 bpm and normal sinus rhythm was documented by ecg. heart rate increased to 187 bpm at peak exercise, with likewise appropriate blood pressure response to exercise. there was no additional arrhythmia or significant ectopy noted throughout exercise or during recovery. on most recent follow-up, the patient continued to use marijuana on a regular basis; repeat ecg demonstrated mobitz type i second-degree av block. discussion the prevalence of abnormal ecg findings and arrhythmias (including atrial fibrillation and second-degree av block) are largely unknown in the general pediatric population. as such, a wide differential diagnosis should be considered in the acute care setting. history and physical exam should guide subsequent evaluation, with consideration of urine drug screening for marijuana, especially when other risk factors for an arrhythmia are absent. dating back to the 1970s, several prospective studies in humans have described increases in both heart rate and blood pressure associated with acute exposure to marijuana, attributed to modulation of the autonomic nervous system (beaconsfield et al., 1972; roth et al., 1973; weiss et al., 1972). the heart rhythm abnormalities associated with these early prospective studies in humans were essentially limited to isolated, multifocal premature ventricular contractions (pvcs) and repolarization abnormalities (kochar & hosko, 1973; miller et al., 1977; pratap & korniyenko, 2012; weiss et al., 1972). subsequent manuscripts have raised concern for seconddegree av block (akins & awdeh, 1981), atrial fibrillation (aryana & williams, 2007; charbonney et al., 2005; korantzopoulos et al., 2008; korantzopoulos, 2014; kosior et al., 2000; singh et al., 2014; singh, 2000), and cardiac asystole (menahem, 2013). likewise, coronary artery vasospasm leading to acute myocardial pediatric ecg abnormalities with marijuana use 32 infarction has been associated with exposure to either marijuana or synthetic cannabinoid derivatives (arora et al., 2012; charles et al., 1979; collins et al., 1985; deharo et al., 2013; ghannem et al., 2013; gunawardena et al., 2014; mckeever et al., 2015; mir et al., 2011; mittleman et al., 2001). this study highlights the occurrence of potentially concerning arrhythmias presenting in patients with +uds for marijuana. strict causation and effect could not be demonstrated by the data collected. in particular, concurrent illicit substances were not queried in conjunction with the +uds for marijuana. comparison ecgs (those not performed on the date of the +uds for marijuana) could have been performed at any time, from birth of the patient up until the end of the study period. similarly, marijuana status (either by history or urine drug screening) was unknown for comparison. this study was performed at a single, large academic medical center. the patients in this cohort were evaluated and managed in the ed; pediatric cardiology was not consulted in all cases for clinical decision-making. likewise, there was no standard outpatient follow-up employed during this period of study for patients. as such, any follow-up examination or cardiac imaging performed by pediatric cardiology based on abnormal ecg findings was not evaluated in this study to confirm the presence of right or left ventricular hypertrophy, as detected by abnormal screening criteria on ecg. it is inherent to clinical research that a larger or multi-centered controlled trial would be necessary to further support any ecg changes resulting directly from marijuana ingestion. such information would benefit the ability of the medical community to most effectively educate patients and the general public about any potential cardiac risks associated with marijuana exposure. in the meantime, clinicians should consider marijuana in the differential diagnosis for any child or adolescent patient presenting with unexplained arrhythmia or repolarization abnormalities. conclusion marijuana use may cause ecg abnormalities, including atrial fibrillation, second-degree av block (mobitz i, wenckebach), and repolarization abnormalities. marijuana exposure should be considered in the differential diagnosis for children or adolescents who have arrhythmias identified in the acute care setting. we recommend performing a urine drug screen for all pediatric patients who present to the emergency department with unusual arrhythmia or ecg abnormality. references akins, d., & awdeh, m. r. 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(2000). paroxysmal atrial fibrillation in a young female patient following marijuana intoxication--a case report of possible association. medical science monitor, 6(2), 386-389. mckeever, r. g., vearrier, d., jacobs, d., lasala, g., okaneku, j., & greenberg, m. i. (2015). k2-not the spice of life; synthetic cannabinoids and st elevation myocardial infarction: a case report. journal of medical toxicology: official journal of the american college of medical toxicology, 11(1), 129-131. menahem, s. (2013). cardiac asystole following cannabis (marijuana) usage additional mechanism for sudden death? forensic science international, 233(1-3), e3-e5. middlekauff, h. r., park, j., & moheimani, r. s. (2014). adverse effects of cigarette and noncigarette smoke exposure on the autonomic nervous system: mechanisms and implications for cardiovascular risk. journal of the american college of cardiology, 64(16), 17401750. miller, r. h., dhingra, r. c., kanakis, c., amaty-leon, f., & rosen, k. m. (1977). the electrophysiological effects of delta-9tetrahydrocannabinol (cannabis) on cardiac conduction in man. american heart journal, 94(6), 740-747. mir, a., obafemi, a., young, a., & kane, c. (2011). myocardial infarction associated with use of the synthetic cannabinoid k2. pediatrics, 128(6), e1622-e1627. mittleman, m. a., lewis, r. a., maclure, m., sherwood, j. b., & muller, j. e. (2001). triggering myocardial infarction by marijuana. circulation, 103(23), 2805-2809. pratap, b., & korniyenko, a. (2012). toxic effects of marijuana on the cardiovascular system. cardiovascular toxicology, 12(2), 143-148. roth, w. t., tinkleinberg, j. r., kopell, b. s., & hollister, l. e. (1973). continuous electrocardiographic monitoring during marihuana intoxication. clinical pharmacology and therapeutics, 14(4), 533540. schmid, k., schonlebe, j., drexler, h., & mueckweymann, m. (2010). the effects of cannabis on heart rate variability and well-being in young men. pharmacopsychiatry, 43(4), 147-150. singh, d., huntwork, m., shetty, v., sequeira, g., & akingbola, o. (2014). prolonged atrial fibrillation precipitated by new-onset seizures and marijuana abuse. pediatrics, 133(2), e443e446. singh, g. k. (2000). atrial fibrillation associated with marijuana use. pediatric cardiology, 21(3), 284. wall, m. m., poh, e., cerdá, m., keyes, k. m., galea, s., & hasin, d. s. (2011). adolescent marijuana use from 2002 to 2008: higher in states with medical marijuana laws, cause still unclear. annals of epidemiology, 21(9), 714716. weiss, j. l., watanabe, a. m., lemberger, l., tamarkin, n. r., & cardon, p. v. (1972). cardiovascular effects of delta-9tetrahydrocannabinol in man. clinical pharmacology and therapeutics, 13(5), 671684. pediatric ecg abnormalities with marijuana use 34 copyright: © 2017 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v4i2a5_authors_final brief report 60 abstract cannabidiol, also known as cbd, has increasingly gained popularity as a cure-all product and is now found in products across a variety of industries. despite the surge in popularity, little remains known about individual motives and patterns of cbd use. the goal of this study was to gain a better understanding of the similarities and differences between motives for cbd and cannabis use as well as comparing motives for younger and older users. participants (n = 171) in u.s. states and territories with legalized cannabis for recreational use were recruited via amazon mturk and were asked to complete an anonymous survey assessing their cbd and cannabis use, effects, and motives for use. the greatest differences between self-reported cbd and cannabis use were for side effect profiles. while the recreational use motive was more commonly endorsed for cannabis, use for beauty purposes was more common for cbd. no age group differences emerged for motives to use cbd or cannabis. future research examining age-related differences in a larger, more age-diverse samples is recommended. key words: cannabidiol; cbd; cannabis; motives cannabis sativa l (cannabis spp. or cannabis) is one of the world’s oldest cultivated plants, commonly known as marijuana or hemp (russo, 2007). over 120 cannabinoids have been identified in cannabis (miller & miller, 2017). the most abundant cannabinoid, tetrahydrocannabinol (thc), is known for its psychoactive properties due to its ability to act as a partial agonist for cb1 cannabinoid receptors (national academies of sciences, 2017). cannabidiol, also known as cbd, is the second most abundant cannabinoid and does not appear to trigger the high or euphoria associated with thc (shannon et al., 2019). cbd is currently licensed for treatment of two pediatric seizure disorders (greenwich biosciences, inc., 2018). due to its low toxicity and potential antioxidant and anti-inflammatory properties, cbd is currently the subject of multiple clinical trials (larsen & shahinas, 2020). the regulatory status of cbd in the u.s. remains complicated. one of the most important factors in determining the legality of cbd is its source (corroon & kight, 2018). while cannabis plants contain high concentrations of thc and are grown for recreational use, hemp plants are industrially grown for their fibers and contain less than 0.3% thc, making them federally legal (shannon et al., 2019). the regulatory status of cbd thus depends on its source, with cannabisderived cbd considered a schedule i controlled substance by the controlled substances act (u.s. drug enforcement administration, n.d.). however, hemp-derived cbd is legal under federal law and the laws of some states as long as it contains less than 0.3% thc (corroon & kight, 2018). the situation is further complicated by the absence of strict fda enforcement, often leading to the mislabeling of cbd products, with a number of cbd products available on the market being underand over-labeled (bonn-miller et al., 2017). some cbd products also contain trace amounts of thc, sufficiently high to produce intoxication or impairment (bonn-miller et al., 2017). the popularity of cbd is on the rise. the number of cbd-related google searches has increased exponentially each year starting from 2014 (leas et al., 2019). sale reports point to the rising interest in cbd products, with projected retail sales expected to reach up to $20 billion by comparison of cbd and cannabis use motives cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.005 aksinya bilaonova1, joy a. phillips2, kristen g. anderson, ph.d.1 1adolescent health research program, department of psychology, reed college, portland, oregon 2 the donald p. shiley bioscience center, san diego state university, san diego, california corresponding author: kristen g. anderson, ph.d., professor of psychology, adolescent health research program, reed college, 3203 se woodstock blvd., portland, oregon 97202. phone: 503-517-7410. fax: 503-777-7785. email: andersok@reed.edu cannabis, a publication of the research society on marijuana 61 2024 (boulder, 2019; corroon & kight, 2018). cbd products exist in a variety of industries, including cosmetic and skincare products, food and beverages, health and wellness products and supplements, pet products, perfume, and even clothing and bedding (boulder, 2019). currently, hemp-derived cbd products can be purchased both online and over the counter throughout most of the u.s. cannabis-derived cbd products, however, can only be purchased in specialized cannabis dispensaries by qualifying patients in the states where medical cannabis is legal and by customers in states where recreational cannabis is legal (corroon & kight, 2018). cbd has been marketed online as a cure-all for a variety of health problems, including serious long-term conditions such as cancer, diabetes, and hiv/aids. understanding motives and patterns of cbd use can thus help shed light on why individuals might use cbd despite its quasiillegal status and the current scarcity of scientifically demonstrated health benefits. corroon and phillips (2018), one of the first studies on cbd motives, found that over 60% of participants were using cbd to treat a medical condition; in the order of frequency, the top medical conditions reported were pain, anxiety and depression, and insomnia. similarly, fedorova et al. (2021) concluded that cbd use among young adults was associated with motivations linked to pain and medical and psychological conditions. zenone et al. (2021) found that cbd consumers were primarily motivated by internal reasons, such as an unmet medical need that was not satisfied by other treatment options. although there is a significant overlap between recreational and medical cannabis users, medical cannabis users tend to use cannabis primarily to treat a variety of medical and psychiatric problems. vedelago et al. (2020) found that recreational cannabis use was primarily driven by positive reinforcing aspects of cannabis, such as enjoyment and celebration, while those who used cannabis for medicinal purposes predominantly reported using for negative reinforcing aspects such as social anxiety and sleep. medicinal cannabis is most frequently used to treat pain, anxiety, stress, depression, headache/migraine, nausea, insomnia, and muscle spasticity, with some patients seeking cannabis enriched with cbd (bonn-miller et al., 2014; sexton et al., 2016). individuals are seemingly using cannabis for a wide range of medical conditions, including the ones for which there is no formal research to support the use (e.g. depression and anxiety). while the main motives to use medical cannabis seem to be relatively consistent across different studies, individuals may differ both in their motives for use and the outcomes of use based on age and when regular use begins (haug et al., 2017). current research although cbd products seem to be commonly used, the data on individual motives and patterns of cbd use remains scarce. previous literature on cbd use motives focused primarily on examining health-related motives for cbd use and did not account for the relatively recent surge in popularity of cosmetic and wellness products containing cbd. no previous studies have compared cbd and cannabis (i.e., cannabis containing thc) motive endorsement for the same set of reasons to use. finally, little is known about the potential differences in cbd use motives among older and younger populations. one goal of this study was to better understand the similarities and differences between motives for cbd and cannabis use. based on the findings by corroon and phillips (2018), we expected the most frequently reported reasons for cbd use to include management of medical and psychiatric symptoms, such as pain management and joint treatment, depression, anxiety, and problems with sleep. we also extended findings from haug et al. (2017) by examining possible agerelated differences in motives to use cbd and cannabis. older participants may be more likely than younger participants to report using cbd for medical conditions, such as chronic pain and joint treatment, since those conditions tend to arise at an older age. with an estimated mean age of onset of 21.3 years for anxiety disorders (lijster et al., 2017), and 25-45 for the onset of mood disorders (kessler et al., 2007), younger participants might be more likely than older participants to use cbd for psychiatric reasons, such as management of anxiety and depression. the recent rise in popularity of cbd in cosmetic and wellness products may highlight new motives not previously assessed. finally, we also examined characteristics of cbd and cannabis use, such as cbd and cannabis motives 62 reported side effects, preferred formats of cbd and/or cannabis products, and the cost of use. methods participants using amazon’s mturk, 190 participants residing in cannabis legal states within in the us (alaska, california, colorado, district of columbia, maine, massachusetts, michigan, nevada, oregon, vermont, and washington), over 21 years of age, and had used cannabis and/or cbd in the past 30 days were recruited. participants who provided inappropriate or nonsensical answers to the open-ended questions were dropped from the dataset to reduce the influence of random responding (n = 19). nonsensical responses were defined as any responses that were inappropriate, unrelated, incomprehensible, or incoherent. the final sample (n=171), including both cbd (n = 109) and cannabis users (n = 161) was predominantly white, identified as men, between the ages of 2154, residing in california. over half of the sample endorsed using both cbd and cannabis products (table 1). socioeconomically, participants most commonly had some college education/degree and fit within the middle class income level. modal use frequency for cbd was 1-2 times per week (23.5%; n = 27) and 6-7 times per week (23.5%; n = 27) with the majority of participants using weekly or more (69.6%; n = 80). for cannabis, the most common use frequency was 1-2 days per week (21.6%; n = 30); while a sizable proportion used multiple times per day (16.6%; n = 23), 69% (n = 96) used weekly or more. measures demographic questions assessed participants’ age, gender, race and ethnicity, education level, household income, and the u.s. state of residence. use patterns and reasons to use cbd and medical cannabis were assessed using the 104item cbd and cannabis use motives checklist, adapted from a questionnaire created by corroon and phillips (2018) to include questions about both cbd and cannabis use. side effects of cbd (range: 0 – 13; ω = 0.81) and cannabis use (range: 0-11; ω = 0.79) listed 14 potential effects for each, such as dry mouth, dizziness, and balance issues (table 2). euphoria, a side effect of cbd but a desired effect for cannabis, was included in the measurement of cbd side effects but not cannabis. confirmatory factor analysis (cfa) of the side effects scales, using item-total parcels as indicators due to sample size constraints (4 parcels each), demonstrated excellent fit to the data; cbd: 𝑥!(𝑑𝑓 = 2) = 1.98, 𝑝 = .37; rmsea = .00 (ci: .00 .19), p-close = .46; cfi = 1.00; srmr = .03, n = 109; cannabis: 𝑥!(𝑑𝑓 = 2) = 0.24, 𝑝 = .89; rmsea = .00 (ci: .00 .07), p-close = .92; cfi = 1.00; srmr = .006, n = 161. a single-item assessed the cost of cbd and/or cannabis use ($/week), and a multiple choice item queried preferred format of cbd and/or cannabis products (i.e., what format of cbd and/or cannabis do you use?; e.g., smoking, edibles). checklist items (0 = absent; 1 = present) identified four general reasons for using (medical condition, general health and well-being, recreational use, beauty/skincare) for cbd and cannabis separately. individual reasons for use included health conditions for which participants use cbd and/or cannabis (20 medical; 8 psychiatric; table 3). health reasons were summed for cbd and cannabis separately (cbd: range = 0-15; ω = 0.89; cannabis: range = 0-17; ω = 0.89). cfa (3 medical parcels; 2 psychiatric) supported a single latent variable for cbd health motives, 𝑥!(𝑑𝑓 = 5) = 6.62, 𝑝 = .25; rmsea = .06 (ci: .00 .15), p-close = .39; cfi = 0.99; srmr = .04, n = 109, and for cannabis health motives, 𝑥!(𝑑𝑓 = 5) = 6.27, 𝑝 = .28; rmsea = .04 (ci: .00 .12), p-close = .49; cfi = 1.00; srmr = .03, n = 161, both models demonstrating good to excellent fit. the frequency of use and daily cannabis use among cannabis users was assessed using the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017). dfaq-cu is a 24-item, 6-factor questionnaire. we validated motives scores against the daily use (α = 0.70) and frequency scales (α = 0.83). procedure the college institutional review board approved all study procedures. mturk respondents were redirected to the survey on a secure qualtrics website. after asserting consent, participants provided demographic information cannabis, a publication of the research society on marijuana 63 and responded to the cbd and cannabis use motives checklist and dfaq-cu in randomized order. after debriefing, which included substance use resources, participants were paid $3 for 15 minutes of participation. table 1. sample demographic characteristics (n = 171) % (n) % (n) gender state of residence men 55.4(93) ca 45.6(78) women 44.0(74) co 7.0(12) non-binary 0.6(1) dc 0.6(1) age me 4.1(7) 21-24 41.2(71) ma 8.8(15) 25-54 46.2(79) mi 18.7(32) 55+ 12.3(21) or 4.1(7) race vt 1.8(3) white 81.8(139) wa 4.7(8) black/african-american 5.3(9) income american indian/native american 0.6(1) <$35,000 32.4(55) asian/pacific islander 11.2(19) $35k – 74,999 43.5(74) other 1.2(2) over $75,000 24.1(41) latinx 9.4(16) medical card 20.0(31) education use group some hs 1.3(2) cbd-only 5.9(10) hs graduate 15.2(26) can-only 36.2(62) tech/voc. ed. 2.9(5) cbd + can 57.9(99) some college 33.3(57) college graduate 47.4(81) note: hs = high school; tech/voc ed = trade/technical/vocational training; medical card = cannabis medical card holder; cbd-only = uses cannabidiol (cbd) only; can-only = use cannabis only; cbd+can = uses cbd and cannabis; state of residence = the cannabis legalstate where the participant resides (us postal abbreviations); totals may not sum to 100% due to rounding or incomplete data. cbd and cannabis motives 64 table 2. self-reported use format, side effects, and cost for cbd vs. cannabis (n = 171) cbd (n = 109) cannabis (n= 161) % (n) % (n) z/t p use format m = 5.5; sd = 2.4 m = 3.1; sd = 2.2 8.2 <0.0001 smoking 14.7(16) 70.8(114) -9.1 <0.0001 vaping 26.6(29) 37.9(61) -1.9 0.05 edibles 37.6(41) 46.0(74) -1.4 0.17 pill 17.4(19) 5.6(9) 3.1 0.002 sublingual 34.9(38) 6.2(10) 6.0 <0.0001 topical 34.9(38) 1.9(3) 7.4 <0.0001 liquid 21.1(23) 3.7(6) 4.5 <0.0001 clothes 7.3(8) 5.0(8) 0.8 0.42 cosmetics 11.9(13) 1.9(3) 2.6 0.01 side effects m = 1.7; sd = 0.2 m = 3.1; sd = 0.2 -4.6 <0.0001 red eyes 11.0(12) 51.6(83) -6.8 <0.0001 anxiety 8.3(9) 13.0(21) -1.2 0.22 calmness/relax 58.7(64) 52.8(85) 1.0 0.34 sensitivity 11.0(12) 17.4 (28) -1.4 0.15 dry mouth 10.1(11) 43.5(70) -5.9 <0.0001 stomach problems 2.8(3) 3.1(5) -0.2 0.87 sleepiness 26.6(29) 41.6(67) -2.5 0.01 poor concentration 6.4(7) 23.0(37) -3.6 0.0003 hunger/overeating 3.7(4) 40.4(65) -6.8 <0.0001 increased heart rate 1.8(2) 11.2(18) -2.9 0.004 headache 3.7(4) 3.7(6) -0.0 0.98 dizziness 7.3(8) 6.2(10) 0.4 0.71 impaired balance 2.8(3) 7.5(12) -1.7 0.10 perceptual disturbance 3.7(4) 13.0(21) -2.6 0.009 euphoria/high* 11.9(13) 64.6(104) -8.6 <0.0001 cost per week ($) m = 25.8; sd = 30.6 m = 35.8; sd = 46.2 -1.9 0.06 note: edibles = consumption in food or beverages; * euphoria was listed as a side effect of cbd use; however, it was not included in the total number of side effects for either cbd or cannabis in this analysis as it may be the desired effect of cannabis use; statistically significant differences highlighted in bold (bonferroni correct p < .0019). z derived from proportions test. cannabis, a publication of the research society on marijuana 65 table 3. reasons for using cbd and cannabis (n = 171) cbd (n = 109) cannabis (n= 161) % (n) % (n) z/t p beauty 21.1(23) 2.5(4) 5.0 <0.001 general health 63.3(69) 44.1(71) 3.10 0.002 health cond. m = 0.6; sd = 1.7 m = 0.5; sd = 1.6 -0.5 0.65 aids 1.8(2) 0.6(1) 0.9 0.35 arthritis 11.0(12) 7.5(12) 1.0 0.31 brain injury 2.8(3) 3.1(5) -0.2 0.87 cancer 1.8(2) 1.9(3) -0.0 0.99 chronic fatigue 4.6(5) 1.9(3) 1.3 0.20 chronic pain 20.2(22) 11.8(19) 1.9 0.06 diabetes 4.6(5) 3.7(6) 0.4 0.73 epilepsy 3.7(4) 1.9(3) 0.9 0.36 fibromyalgia 8.3(9) 3.1(5) 1.9 0.06 gi 2.8(3) 2.5(4) 0.1 0.90 glaucoma 2.8(3) 1.2(2) 0.9 0.37 hormonal 8.3(9) 3.7(6) 1.6 0.11 migraine 7.3(8) 8.1(13) -0.2 0.82 nausea 5.5(6) 3.7(6) 0.7 0.49 neuralgia 2.8(2) 1.9(3) 0.5 0.63 parkinson’s 1.8(2) 0.0(0) 1.7 0.08 sclerosis 0.0(0) 1.9(3) -1.4 0.15 spasms 2.8(3) 1.2(2) 0.9 0.37 wasting 1.8(2) 0.6(1) 0.9 0.35 weight loss 5.5(6) 1.2(2) 2.0 0.04 add 5.5(6) 3.7(6) 0.7 0.49 aud 2.8(3) 4.4(7) -0.7 0.50 alz 1.8(2) 0.6(1) 0.9 0.35 anxiety 39.5(43) 26.7(43) 2.2 0.03 autism 1.8(2) 1.2(2) 0.4 0.70 depression 20.2(22) 16.2(26) 0.9 0.39 insomnia 15.6(17) 11.8(19) 0.9 0.37 ptsd 6.4(7) 3.1(5) 1.3 0.20 recreation 34.9(38) 76.4(123) -6.8 <0.001 note: gi = gastrointestinal problems; add = attention deficit disorder; aud = alcohol use disorder; alz = alzheimer’s disease; ptsd = post-traumatic stress disorder; z derived from proportions test; statistically significant differences highlighted in bold (bonferroni correct p < .0015). cbd and cannabis motives 66 results all analyses were conducted in stata 16.1 (statacorp, 2021). for items that were frequency counts (i.e., number of conditions endorsed, number of side effects), t-tests compared mean differences across cbd and cannabis. when considering single item frequencies (e.g., individual diagnoses, side effects), z proportions were used to compare the percentage of the sample who used cbd or cannabis for that purpose. on average, cbd formats were more varied than for cannabis. sublingual, topical, and liquid cbd formulations were more commonly endorsed than for cannabis (table 2), whereas smoking was greater for cannabis than for cbd. overall, more side effects were reported for cannabis than cbd. cannabis use was associated with more reports of red eye, dry mouth, hunger/overeating, and increased pulse/heart rate than for cbd. euphoria, generally a desired effect for cannabis, was substantially higher than for cbd. the average amount spent per week on cbd and cannabis varied greatly but did not differ between the two (table 2). no statistically significant age group differences emerged for use patterns or side effects (bonferroni p < 0.001). while the recreational use motive was more commonly endorsed for cannabis, use for beauty purposes was more common for cbd (table 3). general health and well-being motives and endorsement of the specific use motives for medical/psychiatric conditions were commensurate for cbd and cannabis. despite predictions, no age group differences emerged for motives to use cbd or cannabis (bonferroni p < 0.0008). pairwise correlations examined associations between use motives, daily cannabis use, and frequency of cannabis use. daily use of cannabis correlated with use of cannabis for general medical reasons, r = 0.60, p = 0.002. cannabis frequency was correlated with cannabis use for reasons of general health, r = 0.45, p < 0.001 and recreation, r = 0.38, p < 0.001. cbd use motives were not statistically related to either dfaq-cu use metric. discussion this investigation examined differences between use patterns, use characteristics, and specific motives for cbd and cannabis use in a sample of adults over 21 living in recreational legal states in the u.s. as might be expected, the greatest differences between self-reported cbd and cannabis use were for effect profiles, given pharmacological differences between cbd and cannabis (grotenhermen, 2003). differences emerged for use formats with smoking for cannabis and sublingual, topical, and liquid formulations for cbd. similar to the findings by corroon and phillips (2018), who found that the top conditions for which people used cbd were pain, anxiety and depression, and insomnia, the most frequently reported conditions for which participants used cbd were anxiety, depression, chronic pain management, and insomnia. significantly, there was an overlap between the conditions for which cannabis and cbd were used, possibly due to the presence of cbd in cannabis. however, this requires further study, including items specific to dosing and cbd/thc content. overall, this study suggests that both cannabis and cbd are used to treat and manage medical and psychiatric symptoms as well as to promote general health and wellness. we also examined possible age-related differences in motives to use cbd. contrary to haug et al. (2017), age group differences did not emerge here; sampling difference (ages 21-55+ vs. 18-74) may have led to differential findings. future research is needed to further explore agerelated differences in a larger, more age-diverse samples. all cannabis use motives, except beauty/skincare, correlated with daily or frequency of cannabis use. demonstrating discriminant validity, cbd use motives were not statistically related to either use metric. the present study contributes to the emergent literature on cbd users in the u.s. the findings of the study provide insights into cbd use patterns and motives among a younger sample than previously described. furthermore, this is the first study that examined health condition motives, including psychiatric disorders, for cbd and cannabis use separately and assessed nonmedical motives to use cbd. some of the limitations of this study include the relative homogeneity of the sample, small sample size, and the use of self-report. future studies with large, diverse samples of cbd and cannabis users should more fully evaluate the factor structure and construct validity of the checklist employed. cannabis, a publication of the research society on marijuana 67 the veracity of self-report for cannabis in mturk samples has been questioned (kim & hodgins, 2017); as such, caution should be used when interpreting these results. to extend the findings from the current study, participants under the age of 25 and participants over the age of 55 should be actively recruited to compare their motives for use. in order to get a more representative sample of cannabis and cbd users, participants from the states that have not yet legalized medical and recreational cannabis should be recruited. on balance, these results provide preliminary support for further examination of similarities and differences among users of cbd and cannabis for a variety of reasons, beyond simply those for self-medication. references bonn-miller, m. o., boden, m. t., bucossi, m. m., & babson, k. a. 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(2021). what are the informational pathways that shape people's use of cannabidiol for medical purposes? journal of cannabis research, 3(1), 13. funding and acknowledgements: reed college initiative grant (a. bilaonova). copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 112 abstract public perception of marijuana is changing dramatically and anecdotal claims regarding the potential risks and benefits of marijuana use proliferate. these perceptions have implications for choosing to engage in marijuana use. the goal of this study was to describe perceptions of risks, benefits, and worry related to personal marijuana use and to identify the extent to which these beliefs were associated with marijuana use and problem severity. further, we explored the extent to which individual perceived risk and worry items best predicted problem severity. regular adult marijuana users (n = 96) completed assessments of their marijuana use, marijuana beliefs, and monitored their behavior over two weeks. perceptions of risk and worry were low while perceptions of benefits were moderately high. perceived risk and worry were positively associated with marijuana problem severity, but not marijuana use crosssectionally or prospectively. exploratory relative weight analyses indicated perceived risk and worry about negative mental health outcomes were most strongly associated with problem severity. although users may experience problems, these do not seem to vary perceptions of benefits. as scientific support for marijuana’s risks and benefits increases, this information should be relayed to the public in order to correct misperceptions and prevent problems. key words: marijuana use, perceived risk, perceived benefits, worry, marijuana problems public perception of marijuana use is shifting dramatically (okaneku, vearrier, mckeever, lasala, & greenberg, 2015; pacek, mauro, & martins, 2015). claims about the potential benefits of marijuana abound, which have implications for misinformation about the health risks and benefits of marijuana use (e.g., the perception that legal status is equivalent to safe). empirically establishing the positive and negative health consequences of marijuana use will require considerable time and scientific inquiry. however, a clearer understanding of current perceptions of risks and/or benefits of marijuana among users may provide targets for intervention development (e.g. motivations for use) to increase risk accuracy, inform marijuana use decision-making, and prevent problems. a supposition of many health behavior theories (e.g., health belief model; janz & becker, 1984) is that perceived risk (i.e. a belief that one is susceptible to harm) of a health threat motivates health-protective action. there is general support for this relationship across a variety of health behaviors (e.g., brewer et al., 2007; sheeran, harris, & epton, 2014), including marijuana use (e.g., salloum, krauss, agrawal, bierut, & grucza, 2018). however, investigations of perceived risk of marijuana use tend to focus on cannabis 2019, volume 2 (2), 112-119 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.02.001 open access “it’s all good”: perceived benefits but not perceived risks or worries among adult marijuana users corresponding author: renee e. magnan, department of psychology, washington state university vancouver, 14204 ne salmon creek ave., vancouver, wa, 98626, email: renee.magnan@wsu.edu, phone: 360-546-9403 renee e. magnan1,2, benjamin o. ladd1,2 1 department of psychology, washington state university vancouver, vancouver, wa, usa 2 translational addiction research center, washington state university, pullman, wa, usa mailto:renee.magnan@wsu.edu marijuana user perceptions 113 global perceptions of risk (e.g., how much do marijuana users risk harming themselves; e.g., grevenstein, nagy, & kroeninger-jungaberle, 2015; morgan, noronha, muetzelfeldt, fielding, & curran, 2013; pacek et al., 2015; piontek, kraus, bjarnason, demetrovics, & ramstedt, 2013; salloum et al., 2018) rather than perceptions of personal risk (e.g., how much do you risk harming yourself due to your marijuana use). one exception is kilmer, hunt, lee, and neighbors (2007) who asked about non-health related outcomes regarding the extent to which marijuana use would interfere with getting good grades and making new friends. this distinction of risk to self and risk to others is important as individuals often believe they are at less risk compared to similar others (weinstein, 1999) and lower perceptions of personal risk may correspond with weaker intentions to take health-protective action (shepperd, waters, weinstein, & klein, 2015). how one feels about their risk is also a determinant of health decisions and behavior (loewenstein, weber, hsee, & welch, 2001; slovic, finucane, peters, & macgregor, 2004). one specific feeling of risk is worry, a combination of negative affect and negative thoughts experienced while thinking about future events (mccaul, magnan, & mead, in press). worry is associated with protective health behavior intentions and actions (e.g., hay, mccaul, & magnan, 2006), and in some cases, predicts effects beyond those of perceived risk (e.g., magnan, koblitz, zeilke, & mccaul, 2009). health behaviors targeted in these investigations often have clear negative health outcomes (e.g., the well-known connection between cigarette smoking and lung cancer). however, for many, marijuana use is a behavior that has ambiguous health consequences. while there are negative consequences of use (volkow, baler, compton, & weiss, 2014), there could be benefits (e.g. chronic pain management; whiting et al., 2015) and some people anecdotally experience additional benefits. limiting focus only on negative consequences of behavior does not capture the full extent of the decision-making process as individuals likely consider thoughts and feelings related to disadvantages as well as advantages of their behavior, and evidence supports associations between perceived benefits and health behaviors (halpern-felsher, biehl, kropp, & rubinstein, 2004; song et al., 2009). marijuana use might be a particularly important target for investigating the competing roles of perceptions of risk and benefits (freeman, wilson, & mackie, 2018) although it has received little attention to date. for example, morgan and colleagues (2013) had drug users rate perceived risks and benefits of 18 psychoactive substances. marijuana was consistently rated as low harm and high benefit, and as being lower risk than alcohol and tobacco. however, these outcomes were not associated with frequency of use. the first aim of the current investigation is to identify marijuana users’ perceptions of personal likelihood of negative health consequences, worry about negative health consequences, and perceptions of likelihood of positive health consequences associated with marijuana use. the second aim is to test associations among these constructs, along with marijuana use and problem severity. we hypothesized a positive relationship between perceived risk and worry and a negative relationship between perceived benefits with perceived risk and worry. we further hypothesized that marijuana use would be negatively associated with perceived risk and worry, but positively associated with perceived benefits. we expected positive relationships between marijuana problem severity and perceived risk and worry, but a negative relationship with perceived benefits. an exploratory aim was to test the relative importance of the individual risk, benefit, and worry items to determine if there is a facet of these constructs that is particularly important for predicting marijuana use problem severity and behavior. method participants participants (n = 102) were recruited from the community to participate in a study on marijuana and health. inclusion criteria were 1) age 21 or older, 2) having a personal smartphone, and 3) reporting marijuana use at least two times per week for the past year. for the current analysis, six pilot individuals were excluded because perceived risk, worry, and perceived benefit questions were added after they participated. the final baseline sample (n = 96) was 56.3% female, cannabis, a publication of the research society on marijuana 114 predominantly white/caucasian (80.0%), and on average 35.84 years (sd = 11.02, range: 21-77) of age. see table 1 for sample characteristics. the study was approved by the washington state university irb prior to implementation. procedure after providing written informed consent, participants completed an in-person baseline assessment of their marijuana use perceptions and behavior and received instructions for completing a 2-week ecological momentary assessment (ema) protocol during which they answered up to five brief daily assessments related to their marijuana use. ema questionnaires were customized using metricwire (www.metricwire.com) which is downloaded as an application on personal smartphones. for current purposes, we only use assessments completed at the end of each day. participants received up to $100 in online gift cards for completing the 2-week study. measures marijuana use. baseline marijuana consumption was measured as total grams of marijuana (flower, edible, oil, topical) used over the past 30 days with the timeline follow-back (tlfb: sobell & sobell, 1996). on average, participants consumed 26.11 grams (sd = 38.37) over the past 30 days. we used the end-of-day ema questionnaire to compute prospective marijuana use. we dropped the first and last day because these were not full monitoring days, thus total possible days of responding was 12. first, we computed compliance rates for this survey (completing the survey between 8pm and 4am). seven people were less than 25% compliant with the end of day questionnaire and removed from the prospective analysis (assessing correlates with next 12-day use) resulting in a sample of n = 89 for these analyses. the final compliance rate for those included in the prospective analyses was 56.3%. we calculated proportion of days used by dividing the number of days participants indicated they used marijuana by the total number of surveys each individual completed. on average, participants reported using 89.9% of the days they responded. quantity was measured as the average daily amount of marijuana reported each day on a 5-point scale (0 = less than 0.1 gram, 4 = more than 0.25 grams). a total 12-day consumption score was computed by multiplying proportion of days used by average daily amount. marijuana problem severity. we used a modified version of the 11-item marijuana dependence scale (mds; stephens, roffman, & curtin, 2000) as an indicator of problem severity. each item reflects one of the symptoms of table 1. sample characteristics variable female (n = 54) male (n = 41) total (n = 96) response range age 36.44 (12.02) 35.05 (9.64) 35.84 (11.02) 21-77 % white 85.2% 70.7% 80.0% perceived risk 1.65 (0.79) 1.75 (0.95) 1.71 (0.87) 1.00-4.5 worry 1.44 (0.62) 1.60 (0.98) 1.52 (0.79) 1.00-5.0 perceived benefit 4.45 (1.62) 4.54 (1.63) 4.48 (1.61) 1.00-7.0 mds 2.33 (2.37) 2.51 (2.31) 2.41 (2.32) 0.00-9.0 past 30-day consumption (grams)* 15.69 (21.24) 40.33 (50.34) 26.11 (38.37) 0.05-240 next 12-day consumption† 0.84 (0.30) 0.90 (0.26) 0.86 (0.29) 0.01-1.0 note. values are raw scores, and means and standard deviations (sd) unless otherwise indicated. one person did not indicate their gender. *denotes a significant gender difference at p < .001. †next 12-day consumption (n = 89) includes n = 54 females and n = 35 males. marijuana user perceptions 115 cannabis use disorder in the dsm-5 (apa, 2013). for each item, participants indicated (yes/no) if they experienced a symptom in the past year. scores were summed such that higher scores indicate greater problems (α = .75). the average mds score was 2.41 (sd = 2.32), suggesting criteria of a mild cannabis use disorder. perceptions of risk, benefit, and worry about marijuana use. assessments used 7-point response scales (1 = very low/very small/not at all, 7 = very high/very big/extremely). participants indicated the chances of experiencing perceived benefits of their marijuana use (α = .89), perceived risk of their marijuana use (α = .76), and the extent to which they worried about negative consequences of their marijuana use (α = .70) across four domains: personal benefit/harm, positive/negative health outcome, positive/negative mental health outcome, and benefitting/harming someone else due to their marijuana use at some point in their lives. analysis worry and past 30-day consumption were natural log transformed because they did not meet assumptions of normality. we calculated means and proportions for descriptive purposes. associations across variables of interest used bivariate correlations. the exploratory test of relative importance of specific risk and benefit items used a relative weight analysis (rwa; johnson, 2000) using rwa-web (tonidandel & lebreton, 2015). rwa breaks down the predicted variance in the criterion by transforming the set of predictors in the model to be orthogonal and uncorrelated. the analysis provides an estimate of the proportionate contribution of each variable relative to the complete set of variables in the model. confidence intervals (95%) based on 10,000 replication bootstrapping around the estimates determine if each predictor accounts for significant variance in the criterion. results relationships among perceived benefits, risks, worry and use table 2 provides the means and correlations across beliefs of marijuana use, problem severity, and marijuana use. on average, perceived risk and worry were quite low, while perceived benefits were relatively high. perceived risk was positively associated with worry and negatively associated with perceived benefits. worry and perceived benefits were not significantly associated, but the association was in the anticipated negative direction. mds was positively associated with both perceived risk and worry, but not perceived benefits. perceived risk, perceived benefits, and worry were not associated with past 30-day or next 12-day consumption. controlling for age, gender, and race did not change the interpretation of these results. table 2. correlations among study variables. 1 2 3 4 5 1. perceived risk 2. worry .64* 3. perceived benefit -.37*** -.19± 4. mds .44*** .48*** -.08 5. past 30-day consumption (grams) -.13 -.11 .13 .16 6. next 12-day consumption -.08 -.16 -.03 .09 .58*** note. worry and baseline past 30-day consumption were log transformed prior to analysis. ±p<.10, ***p<.001. controlling for age, gender, and race (% white) did not alter interpretation. cannabis, a publication of the research society on marijuana 116 table 3. relative importance of individual perceived risk and worry variables on marijuana problem severity. variable rw rs-rw llci ulci perceived risk personal harm .009 3.50 -.118 .020 negative health outcome .068 25.50 -.056 .147 negative mental health outcome .165 61.91 .011 .322 harm someone else .024 9.09 -.102 .068 r2 = .27 worry personal harm .012 4.63 -.023 .075 negative health outcome .085 33.75 .008 .247 negative mental health outcome .129 50.99 .026 .269 harm someone else .027 10.63 -.006 .117 r2 = .25 note. rescaled relative weight (rs-rw) represents each variable’s percentage of the predicted criterion accounted for by the set of variables in the model (r2). bolded values are significant at p < .05. llci=lower limit 95% confidence interval, ulci=upper limit 95% confidence interval, rw = relative weight. including age, gender, and race (% white) did not alter interpretation . exploratory relative weight analysis because the only significant relationships were between perceived risk and worry with mds, we limited the exploratory analysis to these variables (table 3). the relative weights (rw) indicated that perceived risk of negative mental health outcome (rw = .16) accounted for a significant amount of variance in mds in the perceived risk model. worry about health (rw = .09) and mental health (rw = .13) accounted for a significant amount of variance in mds in the worry model. perceived risk and worry of a negative mental health outcome were the most important predictors in the perceived risk and worry models, accounting for 61.91% and 50.99% of the predicted variance in mds, respectively. including age, gender, and race as predictors did not change the interpretation of these findings, nor did these demographic variables explain predicted variance in mds in either the perceived risk or worry models. discussion outcomes of the current study suggest regular users believe marijuana has a moderately high upside (i.e. potential for benefit) while having a low downside (i.e. potential for harm). demographic factors may not influence this pattern of beliefs, as controlling for gender, age, or race did not substantively change observed relationships. this has implications for future research and clinical efforts to minimize the adverse consequences of marijuana, which can be both physical and psychological (volkow et al., 2014). interestingly, perceived benefits were not associated with problem severity. perceived risk and worry were associated with problem severity suggesting that those experiencing some problems were more accurate regarding their risk. further, exploratory analyses indicate that concern about the negative mental health effects of marijuana appears to be a driving factor of these relationships. thus, from a clinical perspective, emphasis on the influence of marijuana on mental health may be a useful avenue in prevention and treatment settings. at the same time, while users perceived high benefit of marijuana use, the marijuana user perceptions 117 mental and physical value of marijuana remains unclear scientifically speaking. as empiricallysupported findings on the health risks and benefits of marijuana use grow, it will be important for researchers to use this information to correct public misperceptions. although perceived risk and worry were both positively associated with mds, neither were retrospectively or prospectively associated with use. work supporting links of perceived risk with marijuana use commonly dichotomize use (users versus nonusers; e.g. piontek et al. 2013) or includes nonusers (e.g. grevenstein et al., 2015). for example, kilmer et al. (2007) found that perceived risk of academic and social consequences of marijuana use differed among users and nonusers, but was not associated with frequency of use among users. thus, perceptions of use may not vary within users, and/or current measures of marijuana consumption may not be sensitive enough to find differences within users (e.g., asbridge, duff, marsh, & erickson, 2014). additionally, it is possible that as people engage in behavior and do not experience immediate negative consequences, they reappraise their risk to be lower (salloum et al., 2018). thoughts and feelings about risk (and benefits) also may be more strongly associated with behaviors that have well-recognized health threats compared to those with a range of perceived positive and negative health consequences like marijuana use. for example, perceived ambiguity of health recommendations (e.g. advantages and disadvantages of genetic cancer screening; cameron & diefenbach, 2001) is associated with weaker interest in taking protective action. there are several limitations worth noting. measurement of risk, benefits, and worry did not ask about specific health-related outcomes (e.g. cognitive impairment, pain reduction) in order to reduce burden and the likelihood of hinting at potential outcomes. asking about a specific outcome may remind respondents of that outcome when they had not been considering it (weinstein, 1999). it would be informative to identify more nuanced associations of risks and benefits across the use spectrum. participants could generate a list of their own perceptions or select from a list of options that may or may not be associated with use. strengths of these measures is that they were self-focused and included several broad outcomes instead of global assessments. additionally, due to the various ways in which one may use marijuana (e.g., flower, edibles) we chose to use measures that incorporated multiple forms of use. thus, the assessment may not differentiate among users (e.g., administration method, potency) and has limited variability across the sample. despite inclusive recruitment criteria of only weekly users, the sample consisted of regular, frequent users (approximately 50% daily users at baseline). thus, we were unable to test these associations among less frequent users and the findings may only generalize to heavier users. finally, although relationships with behavior were tested both cross-sectionally and prospectively, all tests were nonetheless nonexperimental and correlational in nature preventing conclusions of directionality. indeed, the relationship of perceived risk and marijuana use may be reciprocal (grevenstein et al., 2015; salloum et al., 2018). the current study suggests marijuana users believe marijuana has the potential to improve their health with limited adverse side effects. however, the current body of empirical knowledge suggests a different picture – there are established risks of use (e.g., volkow et al., 2014) but the benefits are less clear (e.g., national academies of sciences, engineering, & medicine, 2017). consideration of specific perceived benefits of marijuana use, such as those suggested by anecdotal evidence, may identify motivations that may not be captured by current assessment strategies. additionally, a greater understanding of concerns about marijuana’s effects on health (such as negative mental health outcomes) may inform harm reduction efforts and provide fruitful intervention targets. references american psychiatric association. 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(1999). what does it mean to understand a risk? evaluating risk comprehension. journal of the national cancer institute monographs, 25, 15-20. whiting, p. f., wolff, r. f., deshpande, s., di nisio, m., duffy, s.,… kleijnen, j. (2015). cannabinoids for medical use: a systematic review and meta-analysis. jama, 313, 24562473. funding: this research was supported in part by funds provided by the state of washington initiative measure no. 502. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i3a1_authors_final brief report 1 ved abstract background. the effects of medical cannabis laws (mcls) on adolescent alcohol use remains unclear. previous literature investigates alcohol consumption rather than alcohol initiation among adolescents, and does not examine the effect by sociodemographic characteristics and state-level dispensary status. we used population representative, state-level data to examine the relationship between mcls and adolescent alcohol initiation. methods. data for this study were derived from the youth risk behavior survey (yrbs), a nationally representative, cross-sectional school-based survey administered by the centers for disease control (cdc) in odd-numbered years from 1991 to 2015. we used a difference-in-difference model to assess pre and post effects of state mcl enactment on adolescent alcohol use initiation. logistic regression analyses assessed associations between mcls and varying ages of initiation. we further stratified our results by race/ethnicity, gender, and dispensary status. results. results from adjusted logistic regression models showed higher odds of initiating alcohol among adolescents in states without mcls when compared to adolescents in states with mcls (or 1.37, [95% ci = 1.29, 1.44]). this effect was consistent across age, race/ethnicity, and gender groups. reductions in self-report of alcohol initiation were also consistently found in multiple age strata (9-10, 11-12, and 13-14), though this finding did not reach conventional levels of statistical detection in all race/ethnicities. conclusions. our findings support a substitutive effect, suggesting that adolescents in states with mcls, as opposed to states without mcls, may substitute cannabis for alcohol. considering the evolving landscape of medical cannabis laws and the proliferation of state-level legalization laws, further research into the effects of such policies, such as adult-use cannabis laws, is warranted to further elucidate their effects on adolescent substance use. key words: = medical cannabis laws; alcohol initiation; adolescents; drug policy; cannabis as of august 2021, 36 states have approved medical cannabis laws (mcls), permitting cannabis use with a medical evaluation for a wide range of clinical needs. the public perception of cannabis’ safety is changing, particularly among youth, likely due in part to changing cannabis laws across the united states (hammond et al., 2020; carliner et al., 2017). for instance, perceptions of the drug’s risks have been shown to be lower in mcl states than in non-mcl states (keyes et al., 2016; miech et al., 2016). the recent increase in state laws legalizing adult-use cannabis may further contribute to this trend (cerdá et al., 2017). however, changing gregory a. hard1,2, abenaa a. jones3, abhery das4, & julie k. johnson5 1mgh institute of health professions, 36 first avenue, boston ma 02129 2division of child and adolescent psychiatry, mclean hospital, belmont, ma 02478 3department of human development and family studies, the pennsylvania state university, 105 health and human development building, university park, pa 16802, usa 4university of california, irvine, 653 east peltason drive, irvine, ca 92617 5cannabis policy research center of excellence, research department, cannabis control commission, commonwealth of massachusetts, 2 washington square, 2nd floor, worcester, ma 01604 cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.001 medical cannabis laws and adolescent alcohol use initiation corresponding author: gregory a. hard, rn, mhs, mgh institute of health professions. boston, ma 02129. phone: (781) 901-1133. email: ghard@mghihp.edu. medical cannabis laws and adolescent alcohol initiation 2 perceptions do not appear to translate into increased rates of cannabis use (sarvet et al., 2018), with multiple analyses showing no relationship between the enactment of mcls and increased rates of cannabis use (johnson et al., 2017; johnson et al., 2021; melchior et al., 2019). the effects of mcls on the use of other substances by adolescents, including alcohol, remains unclear and a subject of debate. one analysis evaluated the effects of mcls on the prevalence of past 30-day and 12-month alcohol use and report decreases in the rates of alcohol consumption among 8th graders after mcl enactment, with no effect noted in 10th or 12th graders (cerdá et al., 2018). a study examining substance use behaviors in ten mcl states before and after implementation report no effect on alcohol consumption in 12-20 year olds (wen et al., 2015). an analysis by johnson and colleagues report modest reductions in the odds of past 30day alcohol consumption and binge drinking behavior among adolescents in mcl states versus non-mcl states, including in states with less restrictive mcl provisions (johnson, et al., 2017). the data are mixed as to whether the relationship between alcohol and cannabis is complementary or substitutive, with some studies supporting substitution and others supporting complementarity. a literature review of 39 studies examining this relationship found that the liberalization of cannabis laws may decrease alcohol consumption, acting as a substitute, whereas environments with more restrictive alcohol policies may decrease cannabis use, thus acting as a complement (subbaraman, 2016). an overlap in the usage patterns and trajectories between alcohol and cannabis has been noted in the literature (nelson et al., 2015), with the use of both substances co-occurring. in one study of college students (o’hara et al., 2016), authors report a direct relationship between alcohol consumption and the odds of cannabis use, suggesting complementarity. however, an inverse relationship was found in students who reported self-medicating with these substances, with reductions in alcohol consumption being associated with increases in cannabis use in this population, supporting a substitutive effect. a study in youth who were paid to abstain from cannabis for four weeks demonstrated an increase in the frequency of use and the amount of alcohol consumed during the abstinence period, further supporting a substitutive effect (schuster et al., 2021). although the existing literature is illustrative, there are several limitations. first, much of the existing research examines alcohol consumption and alcohol use among adolescents, but does not evaluate the age of alcohol initiation. earlier onset of alcohol initiation is considered to be a risk factor for the future development of alcohol and other substance use disorders (bolland et al., 2013; hawkins et al., 2015). additionally, early initiation of alcohol is associated with adverse psychosocial outcomes, including an increased risk and earlier onset of major depression (pedrelli et al., 2016; rohde et al., 2001) and an increased risk of suicidal ideation and suicide attempts (baiden et al., 2019; bossarte & swahn, 2011). previous literature has not evaluated alcohol initiation across different races, ethnicities or genders. research suggests that african american adolescents initiate alcohol later than white adolescents, and that female adolescents are more likely to continue using alcohol than their male counterparts (malone et al., 2012). investigating the association between mcls and age of alcohol initiation allows for more a more effective deployment of substance use prevention resources. further, the differential effects of alcohol initiation by age as well as race/ethnicity and gender may facilitate more targeted prevention strategies. given the possibility of a substitutive effect, we evaluated the relationship between mcls and age of alcohol use initiation in adolescents. we examined 939,725 individuals in 46 states from 1991-2015, a period coinciding with the proliferation of mcls. given the spread of mcls and the recent emergence of legalized adult-use cannabis in different states, it is essential to further elucidate the effects that such laws have on adolescent alcohol consumption and other substance use behaviors. results from our study may hold particular relevance to understanding the ecology of mcls as it relates to alcohol use initiation in adolescents. methods population data for this study were derived from the state-level youth risk behavior survey (yrbs), cannabis, a publication of the research society on marijuana 3 which was established by the centers for disease control and prevention (cdc) to monitor the prevalence of health risk behaviors among adolescents (brener et al., 2013). the yrbs is a representative, cross-sectional school-based survey administered to students in 9th through 12th grade in odd-numbered years from 1991 to 2015 across 46 states (n=939,725). data from the remaining states (oregon, washington, minnesota, and hawaii) were unable to be obtained for varying reasons, including: application processes, lack of yrbs participation, or insufficient response rate. table 1. sample characteristics (race/ethnicity, gender, and age) for participants in the yrbs from 46 u.s. states, 1991-2015 (n = 939,725) demographics n (%) race white a 574,454 (61.1%) black a 136,543 (14.5%) hispanic 132,783 (14.1%) other race a 95,945 (10.2%) age 12 years or younger 3,440 (0.37%) 13 years old 3,426 (0.36%) 14 years old 114,522 (12.19%) 15 years old 245,825 (26.16%) 16 years old 249,933 (26.60%) 17 years old 213,367 (22.71%) 18 years old or older 109,212 (11.62%) gender male 461,593 (49.1%) female 478,132 (50.9%) anon-hispanic the yrbs uses a two-stage cluster sampling design. schools are randomly selected to participate, with the likelihood of selection being proportional to its enrollment. a random sample of classrooms are selected within each school, and all students within each class are asked to participate in the survey. students complete the survey voluntarily during class, and parental permission is obtained in accordance with local school district policies. data are weighted to adjust for nonresponse and the distribution of students by age, sex, and race/ethnicity in each school district. more information regarding the methodology of the yrbs is documented elsewhere (brener et al., 2013). measures the primary exposure of interest in this analysis is the enactment of mcls. survey results in states with mcls enacted at the time of data collection were compared to results from nonmcl states. the outcome of interest, the age of alcohol initiation as reported by survey respondents was assessed by the item: “how old were you when you had your first drink of alcohol other than a few sips?” the answer options included: “never initiated alcohol,” “8 years old or younger,” “9-10 years old,” “11-12 years old,” “1314 years old,” “15-16 years old,” and “17 years old or older.” adjustment variables included: state, year, and demographic variables (race/ethnicity, gender, and age). control groups included all states without mcls in any of the years of data collection and states without mcls in any of the years of data collection combined with mcl states that did not enact mcls by the year of data collection. analyses additionally assessed whether states permit the operation of cannabis dispensaries in the enabling legislation and includes both active and inactive dispensary implementation (‘yes’, ‘no’), and whether states medical cannabis laws and adolescent alcohol initiation 4 had dispensaries actively operating in the year of data collection (‘yes’, ‘no’). data analysis logistic regression models assessed associations between mcls and varying ages of alcohol use initiation, race/ethnicity, and gender cohorts. difference-in-difference (did) methodology assessed changes in alcohol use initiation among youth in states with and without medical cannabis laws pre-and-post mcl enactment. this econometric approach controls for external secular trends by using non-mcl state as a counterfactual. the did methodology is frequently used to assess the effects of cannabis legalization laws (cerdá et al., 2017; hasin et al., 2015) as well as in public health policy research more broadly (dimick & ryan, 2014). this approach assumes parallel trends in the outcome among the treatment and control groups prior to implementation of the policy. by visualizing outcomes over time, we confirmed that mcl and non-mcl states had parallel trends in the outcome prior to policy implementation. stata 15 was used for all analyses. to account for the complex sampling design, stata’s svyset command was used to assign yrbs design variables as provided by all state yrbs datasets (brener et al., 2013). we used robust standard errors to adjust for heteroscedasticity in the residuals and any correlation of errors within the specified clusters (i.e., states). johns hopkins bloomberg school of public health institutional review board deemed this study exempt because it used publicly available, deidentified data. table 2. states that enacted mcls between 1991-2015 (study years) state year mcl enacted years of data pre-mcl enactment years of data post-mcl enactment california (ca) 1996 0 1 alaska (ak) 1998 1 5 maine (me) 1999 2 8 colorado (co) 2000 0 3 nevada (nv) 2000 4 7 montana (mt) 2004 6 6 vermont (vt) 2004 0 3 rhode island (ri) 2006 4 5 new mexico (nm) 2007 2 5 michigan (mi) 2008 6 4 arizona (az) 2010 4 3 new jersey (nj) 2010 3 2 delaware (de) 2011 5 2 connecticut (ct) 2012 5 2 massachusetts (ma) 2012 7 2 illinois (il) 2013 5 2 new hampshire (nh) 2013 7 2 new york (ny) 2014 8 1 maryland (md) 2014 5 1 cannabis, a publication of the research society on marijuana 5 results table 1 contains the demographic composition of the study sample comprising white, black, hispanic, and other race/ethnicities, with the majority of adolescents ranging from 12-18 years old. table 2 lists all the states included in our analysis, the year the mcl was enacted in that state and the number of years that were available for analysis both pre-enactment and postenactment. table 3 contains the number of participants in mcl versus non-mcl states from 2001-2015, biannually. table 4 displays logistic regression results of adjusted odds ratios and their corresponding confidence intervals, stratified by gender, age, race/ethnicity, and state dispensary status. figure 1 displayes the trends of alcohol initiation over time, stratified by age. table 3. non-mcl and mcl state samples, 2001-2015 year non-mcl states n (%) mcl states n (%) 2001 37,235 (93.0%) 2,815 (7.0%) 2003 62,414 (92.4%) 5,143 (7.6%) 2005 84,276 (88.9%) 10,502 (11.1%) 2007 81,124 (85.9%) 13,303 (14.1%) 2009 82,367 (71.8%) 32,324 (28.2%) 2011 83,267 (64.2%) 46,455 (35.8%) 2013 120,267 (72.5%) 45,557 (27.5%) 2015 48,357 (24.1%) 151,925 (75.9%) figure 1. alcohol initiation by age group, 1991–2015 medical cannabis laws and adolescent alcohol initiation 6 after adjusting for state effects, year effects, and demographic variables, there is a significant increase in the odds of initiating alcohol among adolescents in states without mcls relative to states with mcls (or 1.37, [95% ci = 1.29, 1.44]). this general effect is consistent across all races and genders. reductions in self-reported alcohol initiation are also consistently found in multiple age strata (9-10, 11-12, and 13-14), though this finding did not reach statistical significance in all race/ethnicities. among specific age strata, the most significant reductions in self-reported age of alcohol initiation are noted among the 9-10 year old (or 0.88, [95% ci = 0.83, 0.95]) and 11-12 year old cohorts (or = 0.91, [95% ci = 0.86, 0.96]). a modest but statistically significant increase in alcohol initiation among the 15-16 year-old cohort was noted (or = 1.06, [95% ci = 1.01, 1.12]). when stratified by race and gender, this effect only reaches significance for the 15-16 year-old female (or = 1.12, [95% ci = 1.04 1.20]) and in hispanic cohorts (or = 1.13, [1.03 1.24]). this effect is not found among all males in the same age strata or among any of the other age or racial/ethnic strata. no differences were found in states with active dispensaries versus those without, across all strata. table 4. adjusted odds ratios (ors) for adolescent alcohol initiation and state-mcl enactment status, 1991-2015 (n=939,725) age of alcohol initiation adjusted or (95%ci)a never initiated alcohol 1.37 (1.291.44)*** 8 years old or younger 1.00 (0.931.07) 9-10 years old 0.88 (0.830.95)*** 11-12 years old 0.91 (0.860.96)*** 13-14 years old 0.94 (0.90-0.99)* 15-16 years old 1.06 (1.011.12)* 17 years old or older 1.04 (0.95-1.14) female never initiated alcohol 1.36 (1.28-1.45)*** 8 years old or younger 0.99 (0.91-1.08) 9-10 years old 0.85 (0.77-0.95)** 11-12 years old 0.89 (0.820.97)** 13-14 years old 0.96 (0.921.01) 15-16 years old 1.12 (1.041.20)** 17 years old or older 1.00 (0.89-1.13) male never initiated alcohol 1.37 (1.291.46)*** 8 years old or younger 1.00 (0.921.09) 9-10 years old 0.90 (0.830.99)* 11-12 years old 0.92 (0.86-0.98)* 13-14 years old 0.93 (0.86-0.998)* 15-16 years old 1.00 (0.941.07) 17 years old or older 1.08 (0.941.24) white never initiated alcohol 1.35 (1.261.44)*** 8 years old or younger 0.96 (0.871.06) 9-10 years old 0.93 (0.841.02) 11-12 years old 0.90 (0.840.96)** 13-14 years old 0.96 (0.911.02) 15-16 years old 1.04 (0.981.12) 17 years old or older 1.09 (0.971.22) black never initiated alcohol 1.37 (1.271.48)*** (table continues) cannabis, a publication of the research society on marijuana 7 8 years old or younger 0.98 (0.86-1.13) 9-10 years old 0.80 (0.69094)** 11-12 years old 0.84 (0.720.98) 13-14 years old 0.89 (0.810.99)* 15-16 years old 1.09 (0.951.25) 17 years old or older 0.96 (0.741.24) hispanic never initiated alcohol 1.34 (1.221.46)*** 8 years old or younger 1.08 (0.921.27) 9-10 years old 0.89 (0.771.02) 11-12 years old 1.06 (0.931.20) 13-14 years old 0.96 (0.88-1.04) 15-16 years old 1.13 (1.031.24)* 17 years old or older 0.99 (0.781.25) other race never initiated alcohol 1.46 (1.271.68)*** 8 years old or younger 1.07 (0.901.28) 9-10 years old 0.88 (0.731.06) 11-12 years old 0.93 (0.791.10) 13-14 years old 0.88 (0.77-0.996)* 15-16 years old 1.06 (0.941.20) 17 years old or older 1.03 (0.781.37) dispensaries allowed never initiated alcohol 1.27 (1.191.35)*** 8 years old or younger 1.08 (0.991.18) 9-10 years old 0.88 (0.800.95)** 11-12 years old 0.91 (0.850.97)** 13-14 years old 0.95 (0.900.997)* 15-16 years old 1.09 (1.021.16)** 17 years old or older 1.05 (0.941.17) dispensaries active 2015 never initiated alcohol 1.27 (1.201.35)*** 8 years old or younger 0.96 (0.891.05) 9-10 years old 0.89 (0.820.97)** 11-12 years old 0.90 (0.840.97)** 13-14 years old 0.95 (0.910.997)* 15-16 years old 1.07 (1.011.13)* 17 years old or older 1.12 (1.001.24)* note. estimates are weighted using yrbs weights [*p <.05, **p<.01, ***p<.001]. aadjusted for: year, state, and individual demographics: age, gender, and race (white, black, hispanic, and other). discussion interpretation this analysis, which used repeated crosssectional data from 46 states in the youth risk behavior survey data, found a significant increase in the overall likelihood of alcohol initiation among adolescents residing in non-mcl states compared to those in mcl states. these results support a substitutive effect of alcohol initiation among youth in states that have enacted mcls. this effect was fairly consistent across gender and race/ethnicity, though many age-stratified odds ratios did not reach statistical significance. there were no substantial differences noted among states with active dispensaries compared to those without. further research is warranted to elucidate the relationship between cannabis access laws and medical cannabis laws and adolescent alcohol initiation 8 the use of alcohol and other substances by youth. continued monitoring is pertinent as cannabis laws continue to develop, evolve, and saturate across states. implications and future directions with the evolving nature of cannabis policy in the united states, ongoing research into the effects of such policies warrants further investigation regarding their effects on adolescent substance use and on public health more broadly. the continued federal criminalization and classification of cannabis as a schedule 1 drug under the controlled substances act, combined with a patchwork of evolving state-level policies with varying restrictions and provisions, introduces a unique research challenges, leaving many gray areas for policy makers to navigate when drafting cannabis policies. these facts are also illustrative of the need for continuing, ongoing research that takes into account the dynamic and heterogeneous nature of these provisions. future research efforts should examine the effects of adult-use cannabis laws, which could theoretically increase adolescent access to cannabis and subsequently affect other substance use behaviors, including alcohol. given the relative novelty of adult-use cannabis laws and the evolving nature of these policies, regulations, and enforcement, and the overall changing political landscape, limited data exists on this topic and should be a target for future research. limitations and strengths these results should be considered in the context of its limitations. we did not account for the enactment of additional policies that could also affect alcohol initiation, such as cooccurring state-level prevention efforts or the proliferation of adult-use cannabis laws across the u.s. starting in 2012, that this study was unable to obtain data for. we attempted to account for these differences in our analysis by using state and year fixed effects along with a difference-in-difference methodology to account for co-occurring trends across states and years (angrist & pischke, 2008). the yrbs data, which was the basis for this study, surveyed adolescents in public school settings. although weighting was used to achieve samples that were representative of the state populations, these results may not be entirely generalizable to all adolescents, such as those who have dropped out, are home schooled, attend private or religious schools, or students who were placed in other alternative school settings. the yrbs relies on self-report, introducing the possibility of recall bias and social acceptance bias. conclusion the likelihood of alcohol initiation among adolescents is higher in states without mcls compared to those with mcls. these data support a substitutive effect, with adolescents potentially substituting alcohol for cannabis. with the proliferation of adult-use cannabis laws, future research should examine whether those laws are associated with decreases in alcohol initiation or increases in cannabis use among adolesceents. due to the possibility of a substitutive effect, particularly in adolescents who self-medicate with cannabis, further research should examine the psychosocial and mental health impacts of increased cannabis consumption in this population. further, analyses should adjust for cannabis policy heterogeneity, as differences in policy and regulation may have differential outcomes in youth cohorts. references angrist, j. d., & pischke, j. s. 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(2018). recent rapid decrease in adolescents’ perception that marijuana is harmful, but no concurrent increase in use. drug and alcohol dependence, 186, 68–74. schuster, r. m., potter, k., lamberth, e., rychik, n., hareli, m., allen, s., broos, h. c., mustoe, a., gilman, j. m., pachas, g., & evins, a. e. (2021). alcohol substitution during one month of cannabis abstinence among non-treatment seeking youth. progress in neuropsychopharmacology & biological psychiatry, 107, 110205. subbaraman, m. s. (2016). substitution and complementarity of alcohol and cannabis: a review of the literature. substance use & misuse, 51(11), 1399–1414. wen, h., hockenberry, j. m., & cummings, j. r. (2015). the effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances. journal of health economics, 42, 64–80. funding and acknowledgements: this research was supported by the national institute on drug abuse (nida) grants: 5f31da036923-02 (pi: julie k. johnson), 4t32da007292-24 (julie k.johnson, abenaa a. jones, pi: renee m. johnson), r01da040488-04s1 (abenaa a. jones), k01da051715 (pi: abenaa a. jones), and commonwealth of massachusetts, massachusetts cannabis control commission. this content of this article is solely the responsibility of the authors and may not reflect the official views of nih, nida, or massachusetts cannabis control commission (julie k. johnson). authors would like to acknowledge renee m. johnson and jeremy kane for their mentorship during this study. no authors report any financial conflict of interest. however, dr. aa jones’ spouse works as an independent contractor for a 501c3 non-profit educational organization that educates citizens on the science of marijuana with an aim to decrease its use and related consequences. dr. jones’ spouse did not play a role in this study. no other disclosures are reported. all authors have participated in study conception and design, analysis and interpretation of data, and drafting or revising of the manuscript. gah wrote the manuscript in consultation with aaj, jkj and ad. jkj conducted the statistical analysis. the authors are all in agreement with manuscript content, take responsibility for the reported research, and approve the manuscript as submitted. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 144 abstract we tested the feasibility of a new approach to examining drugged driving – the in vivo driving impairment research method (ivdirm). heavy cannabis users with a history of driving after using were recruited. the volunteers agreed to have their cars instrumented with data loggers and drive normally for six to 10 days. participants also agree to provide oral fluid samples, which later were assayed for cannabinoid concentrations, whenever they drove. we anticipated that participants, of their own volition, would produce multiple occurrences of drugged driving at different measured drug levels. cannabinoid concentrations then would be used to predict driving behavior measured by the instrumentation, using a within-subjects design to accommodate individual differences in personality, driving style, risk-taking, etc. we tested the hypothesis that measuring and modeling cannabidiol (cbd) would improve prediction of driving impairment beyond simply looking at delta-9-tetrahydrocannabinol (thc). a sample of 30 participants provided 358 oral fluid samples that were linked to driving data, indicating indeed that the ivdirm method was viable. mixed-model analysis found that subjects’ cbd levels were important for predicting risky driving; participants with high thc concentrations who also tested positive for cbd demonstrated a higher rate of elevated g-force events while driving than those who tested negative for cbd. when cbd was zero, the predicted proportion of elevated x-axis g-force events (from acceleration and braking) ranged from approximately 0.05 to 0.08 across the distribution of thc scores. when cbd was positive, the predicted proportion ranged from approximately zero to above 0.14. for elevated y-axis g-force events (from turning and swerving), when cbd was zero the proportion was close to 0 and flat across thc scores. when cbd was positive, predicted elevated y-axis events ranged from 0 to approximately 0.025. key words: cannabis use, menstrual cycle, stress, sex, females this brief report has two objectives. the first is to introduce a new methodology for examining drugged driving, with a current focus on cannabis. despite increased research on the topic, it remains unclear whether and to what extent cannabis contributes to crash involvement. experimental cannabis dosing studies routinely find evidence of dose-specific impairment on cognitive and psychomotor driving-related skills, as well as on simulated driving (capler et al., 2017; hartman & huestis, 2013). however, these studies tend to lack external and ecological cannabis 2019, volume 2 (2), 144-150 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2019.02.004 open access a feasibility test of the in vivo driving impairment research method: examining cannabinoid concentrations as predictors of risky drinking corresponding author: mark b. johnson, pacific institute for research evaluation, 11720 beltsville drive, suite 900, calverton, md, 20705, email: mjohnson@pire.org mark b. johnson1 1 pacific institute for research and evaluation, calverton, md, usa in vivo driving impairment research method 145 validity. on the other hand, epidemiological drugged driving crash studies tend to lack internal validity (i.e., no experimental control) and have produced inconsistent findings. the two most recent major field crash studies produced contrasting results (hels et al., 2011; lacey et al., 2016), and in a recent meta-analysis (gjerde et al., 2015) one in three studies examined found no association between cannabis use and crashes. another meta-analysis (rogeberg & elvik, 2016) found that associations between cannabis use and crashes were weaker in higher quality studies. the new methodology described herein – the in vivo driving impairment research method (ivdirm) – is a naturalistic, hybrid method designed to bridge the gap between existing approaches. we present an initial feasibility study to test this methodology. the second objective is to test the novel hypothesis that driving impairment is predicted not only by delta-9-tetrahydrocannabinol (thc) but also by cannabidiol (cbd), a compound that appears in only some strains of cannabis. whereas thc is responsible for the euphoric high of cannabis (along with associated side effects of anxiety and paranoia) (moore et al., 2007) some toxicological studies link cannabis high in cbd to mental and physical sedation (crippa et al., 2004; pearce et al., 2014; zhornitsky & potvin, 2012). cannabis high in cbd mixed with thc is described as producing a sleepy, dreamlike experience and cannabis high in cbd alone as producing a lethargic “body-stoned” experience (frank & rosenthal, 1988; martin, 2012). because attention and vigilance are key factors to safe driving (evans, 2004; klauer et al., 2006), compounds that promote sedation might interfere with safe driving even if not intoxicating. in this research we examined both thc and cbd as predictors of driving impairment and hypothesized that high cbd would be associated with riskier driving. few studies have examined cbd as a potentially impairing agent. evaluations of a thc-cbd medical nasal spray found no effects on self-perceptions of impairment or psychomotor task performance (celius & vila, 2018; rekand, 2014), nor did a laboratory study of pharmaceutical cannabinoids (bird et al., 1980). however, a small pilot study on medicinal cannabinoids found trends suggesting impairment from cbd on vigilance tasks (guy, robson, earnshaw & flint, 2000). the ivdirm feasibility study is the first to examine the relationship between thc and cbd on real-world driving and uses commercially available cannabis products to do so. method the ivdirm is an example of “controlled epidemiology”. the method involves (1) recruiting heavy cannabis users with a history of driving after using; (2) equipping participants’ vehicles with instrumentation and asking them to drive normally for six to 10 days; and (3) having them provide oral fluid samples during each driving trip. oral fluid samples were assayed for thc and cbd concentrations (ng/ml) which were linked to driving behavior captured by the vehicle instrumentation. we anticipated that these heavy users, of their own volition, would produce multiple occasions of drugged driving and at varying drug levels. these cannabinoid concentrations would be used to predict risky driving. like other epidemiological drugged driving studies, analyses were based on drug levels measured in-the-system rather than on a comparison of strain potencies. because we examined the same participants over time, we could control for individual differences in personality, driving style, risk-taking, etc., in relating drug results to driving. success of the ivdirm feasibility trial was predicated on participants providing oral fluid samples that could be linked to driving data, and the method producing analyzable data. participants participants were recruited via advertisements in cannabis dispensaries and through listservs of private cannabis clubs around denver, colorado. eligible participants (a) used cannabis at least twice monthly; (b) drove several times per week; (c) were aged 21 and older; (d) were not pregnant; (e) had no more than two moving violations or one at-fault accident in the past 3 years; (f) had no driving while intoxicated (dwi) or driving under the influence (dui) arrests on their driving record; (g) scored <12 on the drug abuse screening tool [21]; (h) had no use of illicit drugs other than cannabis; and (i) had cannabis, a publication of the research society on marijuana 146 no indication of psychosis (degenhardt, hall, korten & jablensky, 2005). protocol instrumentation. participants’ vehicles were equipped with aaronia gps data loggers (http://www.aaronia.com/products/spectrumanalyzers/gps-logger) which recorded vehicle gps information (e.g., coordinates, speed, heading, etc.) at one reading per second and acceleration data (g-forces on the x, y and z) at four readings per second. biological samples. participants were instructed to provide an oral fluid sample using a quantisaltm collection tube each time they went driving. for longer trips, subjects were asked to provide a second sample. subjects stored tubes in a cooler provided by the study and samples were picked up every other day. oral fluid samples were assayed for thc and cbd by immunalysis corporation (pomona, california). confirmation tests (to obtain quantitative concentrations) were performed using gas chromatography-mass spectrometry (gc/ms) or liquid chromatographymass spectrometry (lc/ms/ms) technology. in addition to oral fluid collection, participants were given a calibrated breathalyzer that stored results internally and were instructed to provide a breath sample each time they provided a saliva sample. data elements cannabinoid and alcohol concentrations. assays of oral fluid samples produced quantitative concentrations (ng/ml) of thc and cbd. we determined a priori that drug concentrations would be valid for a 10-minute period and used to predict driving behavior within that period. if an oral fluid sample was collected at 1:05 p.m. those resultant drug concentrations would be used to predict only the driving data that occurred from 1:00 to 1:10 p.m. there were only two occurrences of mixing alcohol with cannabis, and both bacs were below .02 g/dl. alcohol readings were not included in analyses. gps data. time-stamped gps readings provided a temporal framework for the dataset. a new driving trip was indicated by a 10-minute break in driving. gps coordinate data were geocoded using arcgis software to reflect individual roads and formal road classifications (i.e., parking lot, interstate, expressway, arterial roadway, residential street, and ramps/exist). accelerometer data. accelerometer data were collected at 4 readings per second and were automatically linked with gps data. given the goal of the research, we only examined accelerometer data that fell within the 10-minute windows for which we had thc and cbd concentrations (see above). in other words, subjects provided one or two saliva samples per trip, and we only examined driving data collected in close proximity to the drug results. our analytic strategy involved leveraging the vast amount of accelerometer data collected to improve statistical power. however, raw accelerometer data is cumbersome and noisy and perhaps too refined for driving behavior. to simplify, we aggregated the raw data into 5second blocks, which served as the unit of analysis for the study. every five-second block, therefore, included 20 accelerometer readings (5 seconds x 4 readings per second) from which we computed the dependent measures. every 10-minute window of valid thc/cbd concentrations contained 120 5second blocks (120 x 5 seconds = 600 seconds). dependent measures. for this brief report we examined elevated g-force events as a measure of risky driving. prior research found that “jerky driving”—for example, driving events (such as braking) exceeding 4.0 m/s2 (.408 gs)—predicted crashes and near crashes (bagdadi & varhelyi, 2011; simons-morton et al., 2012). therefore, in this study, for each 5-second block of driving data we used maximum absolute g-force readings from the accelerometer to compute whether or not there was an elevated g-force event. separate xand yaxis elevated g-force variables were created, and these served as the dependent measures. results sample out of 91 individuals who expressed interest, 30 were deemed eligible, recruited and consented. the majority (56.7%) was male and ages ranged from 22 to 57 (median = 37). most of the sample was white, non-hispanic (63.3%), with five black, four hispanic, one asian, and one native american driver. most participants (60%) used cannabis several times per day, while the remainder used daily or almost daily. all http://www.aaronia.com/products/spectrum-analyzers/gps-logger/ http://www.aaronia.com/products/spectrum-analyzers/gps-logger/ in vivo driving impairment research method 147 participants had a history of driving while under the influence of cannabis at least monthly. most participants had not driven within 2 hours of drinking (86.7%) in the past six-months. data summary participants produced 358 oral fluid samples from 258 distinct driving trips that were matched with driving data. we collected some driving data without oral fluid samples as well as samples without matched driving data (likely due to technical error or forgetful subjects). this is a discussed as a limitation. only a small proportion of oral fluid samples (10.9%) tested negative for thc. the median thc concentration was 157 ng/ml, while the mean was 454 ng/ml (sd = 721.3). most cbd concentrations (67.3%) were 0 ng/ml. the mean cbd value was 3.0 ng/ml (sd = 20.1) but the maximum was 290 ng/ml. thc and cbd concentrations were moderately correlated, r (358) = .27, p < .01. given that the distribution of thc scores was positively skewed, we subjected those values to a natural logarithm transformation (first adding .0001 to all cases to make it possible to solve when thc was 0). because two-thirds of the oral fluid tests were negative for cbd and the positive scores were highly skewed, it was unclear whether any quantitative transformation was appropriate. therefore, we dichotomized cbd (cbd = 0 ng/ml or cbd > 0 ng/ml) for the analyses. main analyses multilevel logistic regression was conducted using generalized linear mixed modeling in sas. we accommodated the multiply-nested data structure by modeling subject and trip-withinsubject as random effects. the primary predictors were the natural log (ln) thc concentrations, cbd category (0 versus >0), and the ln thc x cbd category interaction. driver sex, race (white versus non-white), age, frequency of cannabis use, and road type were included as covariates. elevated x-axis events involved observed occurrences of driving where acceleration or braking exceed .408 g-forces (4.0 m/s2). a dichotomous outcome (no or yes) was created for each 5-second block and regressed onto the predictors (described above). results are displayed in table 1. table 1. analysis of the likelihood of elevated xaxis events effect test statistics age f(1, 18418) = 1.5, p = .22 sex f(1, 18418) = 2.3, p = .13 race f(1, 18418) = .2, p = .63 cannabis use f(1, 18418) = 0.1, p = .81 road type f(3, 18418) = 17.9, p < .01 ln thc f(1, 18418) = 21.5, p < .01 cbd category f(1, 18418) = 5.5, p < .05 ln thc x cbd f(1, 18418) = 8.3, p < .01 figure 1. proportion of elevated x-axis g-force events as a function of ln thc and cbd category cannabis, a publication of the research society on marijuana 148 figure 2. proportion of elevated y-axis g-force events as a function of ln thc and cbd category model-estimated likelihoods were computed across the range of thc scores, separately for samples with 0 cbd and those with cbd > 0 (aiken & west, 1991). the results pattern is reflected in figure 1. elevated x-axis events were associated with increasing thc, but with a significantly steeper slope when cbd was positive. being cbd positive predicted greater risk at higher thc levels but appeared protective at lower thc levels. table 2. analysis of the likelihood of elevated y-axis events effect test statistics age f(1, 18408) = 0.6, p = .44 sex f(1, 18408) = 3.0, p = .08 race f(1, 18408) = 3.2, p = .07 cannabis use f(1, 18408) = 0.1, p = .75 road type f(3, 18408) = 20.2, p < .01 ln thc f(1, 18408) = 0.5, p = .46 cbd category f(1, 18408) = 67.0, p < .01 discussion the feasibility of the ivdirm was predicated (a) on heavy cannabis-using participants successfully collecting oral fluid samples without direct supervision, and (b) our ability to process the data to allow statistical examination. both were accomplished in this trial. thirty participants provided 358 oral fluid samples collected at the same time driving data were recorded via vehicle instrumentation. while this suggests strongly that the method is viable, the process was not perfect. for example, for some trips we had driving data but no oral fluid samples, and vice versa. although we believe this to be random, rigor should and can be improved through more user-friendly instrumentation and enhanced case management of subjects. the data were analyzed to test a novel hypothesis about cbd as a predictor of driving impairment. thc concentrations were associated with increased elevated x-axis events (i.e., “jerky” acceleration and braking), but the association was stronger when participants also tested positive for cbd. a similar pattern emerged for elevated yaxis events (“jerky” turning and swerving), but stronger statistical evidence suggested that being cbd-positive was linked to greater risk regardless of thc concentrations. the results of this naturalistic ivdirm study are taken as proof-of-principle evidence that measuring and modeling cbd, and not just thc, may inform our understanding and prediction of drug impaired driving. the unique feature of the ivdirm is that it objectively measures real-world driving and examines the same driver over time at different in vivo driving impairment research method 149 drug levels; this allows us to control for individual differences in personality, driving style, risktaking, etc. it is important to remember, however, that the ivdirm is not experimental. we did not randomize subjects to drug conditions, but rather relied on naturalistic data collection, and it is not appropriate to make causal inferences from ivdirm data. it also should be noted that throughout paper we discuss the sedating effects of high-cbd cannabis, but some argue (russo, 2011; piomelli & russo, 2016) that the sedation is not even due to cbd but rather to the terpene myrcene which often co-occurs with cbd in natural cannabis. in this case, cbd serves as a predictive proxy, further underscoring that ivdirm should not be used for causal statements. we further do not know if subjects actually felt sedated while driving with cbd in their systems. higher elevated g-force events could reflect corrections to lapses in control if sedated drivers “zoned out”, but they also could reflect aggressiveness. we did not measure participants’ subjective experiences and thus cannot address whether the sedation hypothesis is correct. all we have are data relating cannabinoid concentrations to vehicle behavior. however, analyses of additional driving measures and two additional supporting studies are available in preprint form at http://biorxiv.org/cgi/content/short/387936v1. additional research on how cannabinoids other than thc relate to driving is needed. we intend to apply future applications of the ivdirm to confirming the results of the feasibility study but with a larger sample and closer attention to drug tolerance. the ivdirm is not a perfect methodology, but it fills an important gap between extant 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(2012). cannabidiol in humans—the quest for therapeutic targets. pharmaceuticals, 5(5), 529-552. funding: the research was funded by a grant from the national institutes of health (r01 da034616) to the author. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. http://www.druid-project.eu/druid/en/deliverales-list/downloads/deliverable_2_3_5.pdf?__blob=publicationfile http://www.druid-project.eu/druid/en/deliverales-list/downloads/deliverable_2_3_5.pdf?__blob=publicationfile http://www.druid-project.eu/druid/en/deliverales-list/downloads/deliverable_2_3_5.pdf?__blob=publicationfile http://www.druid-project.eu/druid/en/deliverales-list/downloads/deliverable_2_3_5.pdf?__blob=publicationfile http://www.nhtsa.gov/dot/nhtsa/nrd/multimedia/pdfs/crash%20avoidance/driver%20distraction/810594.pdf http://www.nhtsa.gov/dot/nhtsa/nrd/multimedia/pdfs/crash%20avoidance/driver%20distraction/810594.pdf http://www.nhtsa.gov/dot/nhtsa/nrd/multimedia/pdfs/crash%20avoidance/driver%20distraction/810594.pdf http://www.weedist.com/2012/06/major-compounds-in-cannabis-and-the-impact-to-your-high http://www.weedist.com/2012/06/major-compounds-in-cannabis-and-the-impact-to-your-high http://www.weedist.com/2012/06/major-compounds-in-cannabis-and-the-impact-to-your-high https://creativecommons.org/licenses/by/4.0/ v5i1a1_authors_final research article 1 ved abstract until recently, marijuana research has often relied on self-reported frequency of use (e.g., days used per month). these estimations may oversimplify use at times, as they can only infer the quantity that one uses, rather than directly measure it. while some studies have estimated quantity (e.g., number of joints, grams), research has supported that user estimates of marijuana weight are often inaccurate and overestimate the true quantity. since weight misestimation varies by participant, it may be important to identify individual difference factors (e.g., personality) that influence weight estimation. one such factor may be impulsivity, as it is known to relate to other marijuana-use measures (e.g., frequency, consequences). however, research has yet to examine the specific relation between impulsivity and misestimation of marijuana weights. the present study investigated impulsivity as a predictor of marijuana quantity estimation, using objectively weighed quantity data. we hypothesized that impulsivity facets would relate to marijuana quantity misestimation. we asked attendees at a marijuanarelated event to roll a joint or pack a bowl, and then take, among a battery of measures, the supps-p impulsive behavior scale. we found that negative urgency, positive urgency, and lack of perseverance were not significantly associated with misestimation, while lack of premeditation was significantly negatively related to misestimation. findings indicated that individuals who lacked in premeditation made more accurate quantity estimates than those higher in premeditation. future directions should investigate the relation between impulsivity, marijuana intoxication, and marijuana quantity estimation. key words: = personality; cannabis; quantity recent publications examining self-reported marijuana use commonly measure frequency of use, such as days used per month or times used per day (e.g., cerdá et al., 2017; glowacz & schmits, 2017; prince et al., 2018; vadhan et al., 2017). however, unlike alcohol and the definition of a standard drink, there is no commonly accepted standard dose of marijuana (parnes et al., 2018). having a standard dose allows for various forms of consumption (e.g., different alcoholic beverages like wine and beer; national institute on alcohol abuse and alcoholism, 2011) to be compared across frequency and quantity measures. in fact, the national institute on drug addiction has indicated strong support for a standardized marijuana dose to facilitate research (volkow & weiss, 2020). a lack of a standardized marijuana dose prohibits estimating quantity used based on reported use frequency. estimating quantity becomes additionally confounded by differing marijuana products and potencies available in dispensaries and illegal markets (parnes et al., 2018, prince et al., 2018;). some studies have attempted to measure quantity used (e.g., walden & earleywine, 2008), however self-reported quantity used is often inaccurate and misestimated (prince et al., 2018). most researchers would and do argue that when we measure marijuana use, we are attempting to measure the quantity of cannabinoids ingested, not how often marijuana is used (freeman & lorenzetti, 2020). researchers interested in studying the psychoactive effects of marijuana are then interested in the amount of ∆9-tetrahydrocannabinol (thc) those using cannabis are ingesting. it is unclear how asking cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.001 the relation between impulsivity and estimation of marijuana weight corresponding author: jamie e. parnes, phd, department of psychology, colorado state university. 1876 campus delivery, fort collins, co 80523. phone: 585-708-9384. email: jamie_parnes@brown.edu jamie e. parnes1, shane d. kentopp1, joshua sommerfeld1, bradley t. conner1 1department of psychology, colorado state university impulsivity and marijuana estimation 2 research participants to self-report the frequency of their marijuana use gives researchers any information about the amount of thc ingested. thus, it is vitally important that marijuana researchers assess both quantity and frequency of use and, when available, potency of the marijuana being used. despite the importance of measuring both frequency and quantity consumed to depict marijuana use most accurately, as noted, most studies solely rely on reported frequency. as prince and colleagues (2018) noted, frequency often is an oversimplified measurement of marijuana consumption. for example, two people may both report using 30 days per month; however, one individual could consume a small amount of cannabis in the evenings, while another could use throughout the day. these consumption habits are drastically different, but due to a limited measurement (i.e., 30-day frequency), the two disparate use patterns would likely both be identified as “daily users”. this example is supported by latent profile analyses, which identified multiple groups of users with similar past 30-day use frequency but a differing number of sessions per use day (pearson et al., 2017). this research, among others, supports the importance of measuring both quantity consumed and frequency of use. studying quantity is important, as the more marijuana consumed in one sitting directly correlates to a higher number of consumption sessions as well as a higher number of marijuanarelated problems (zeisser et al., 2012). however, the few studies that examined marijuana use quantity have employed inconsistent measures of quantity: estimated grams consumed per day or per week, number of joints consumed, or number of quarter ounces consumed per month (e.g., buchan et al., 2002; johnson, 2014; walden & earleywine, 2008; williams & nowatzki, 2005). this limited research relies on self-reported quantity, which may be inaccurate and varies across participants (prince et al., 2018). one study examining marijuana quantity estimation found that when people are asked to weigh a specific amount of flower or concentrate, most people overestimated the quantity they used (prince et al., 2018). therefore, studies collecting selfreported quantity of use are likely relying on inaccurate data. another issue that complicates the assessment of thc ingested is the different methods of consuming marijuana (freeman & lorenzetti, 2020, prince et al., 2018). while traditional methods for using marijuana rely on combustion of the flower and bud plant materials, either in joints, pipes, and bongs, to name a few, or digestion of baked good, with changes over time and changes in legislation, there have been significant advances in methods or routes of administration. newer forms of consumption include, but are not limited to, use of concentrated marijuana in oils, waxes, and other substances, oral tinctures, capsules, tablets, topical ointments, and in liquid forms, while edible forms have increased to include gummies, lollipops, gum, popsicles, ice creams, and butters, and other types of foods. all of these advances have complicated issues related to estimating the amount of thc consumed during a marijuana use episode. for instance, it takes far less of a concentrated form of marijuana, which typically is upwards of 50% thc, and more commonly above 80%, to get to 5 mg of thc ingested (the suggested standardized dose endorsed by the national institute on drug abuse [nida]; volkow & weiss, 2020) than it does when using flower, which typically maxes out at around 30% thc. conversely, edibles are usually packaged in 5 mg quantities, making estimating thc content much easier. however, use of edibles leads to slower absorption of thc. in fact, the number of variables involved in estimating the amount of thc is much more than just quantity and frequency, with method of administration and % thc being among two of the most important. however, the last, and among the most important, is the source of information on thc. most research still relies heavily on self-reported marijuana use estimates as the primary measurement. thus, it is critical that researchers understand the advantages and short comings of self-reported marijuana use, especially individual difference variables, such as personality traits like impulsivity, that could introduce systematic error into these types of estimates. several past studies have linked impulsivity to marijuana use frequency (moreno et al., 2012; pearson et al., 2018; vanderveen et al., 2016). these studies noted that increased impulsivity, including reduced inhibitory control and trait impulsivity, was associated with increased use frequency. a well-established multidimensional model of impulsivity describes four distinct facets: cannabis, a publication of the research society on marijuana 3 positive urgency, negative urgency, lack of premeditation, and lack of perseverance (whiteside et al., 2005). although sensation seeking is sometimes included as part of impulsivity, research suggests that sensation seeking and impulsivity are separate constructs (hare & schalling, 1978; magid et al., 2007; quinn & harden, 2013). each of the other facets holds unique associations with marijuana use behavior. positive urgency is defined as the tendency to have greater difficulty resisting urges when in a positively elevated mood (whiteside et al., 2005). robinson, ladd, and anderson (2014) discovered a direct relation between positive urgency and frequency of marijuana use, demonstrating its importance as a predictor of use. negative urgency is defined as engaging in rash behavior in the presence of strong negative affect (whiteside et al., 2005). negative urgency is robustly associated with increased marijuana use and use-related consequences (pearson et al., 2018; robinson et al., 2014). lack of premeditation is an inability to fully consider the consequences of one’s actions (whiteside et al., 2005). limited research has found associations between lack of premeditation and marijuana use, as these individuals may have difficulty considering the outcomes of use when deciding whether or not to use (bravo, anthenien, et al., 2017; bravo, prince, et al., 2017). individuals lacking in perseverance have difficulty continuing tasks (gullo et al., 2014). this facet has been found to have no significant effect on one’s marijuana use (vanderveen et al., 2016). although it has been established that impulsivity is related to increased marijuana use and use-related harms (vanderveen et al., 2016), there is no research examining the possible link between impulsivity and whether individuals can accurately estimate and report the quantity of marijuana they are using. some research exists linking impulsivity to other types of estimation, particularly time estimation. the research on the topic has been mixed, as some studies have found no association between impulsivity and time estimation (lennings & burns, 1998), while others have found impulsive individuals tended to overestimate how much time passed (baumann & odum, 2012; jokic et al., 2018). therefore, impulsivity may play a role in various types of estimation. however, research on the relation between impulsivity and quantity estimation remains as a gap in the literature. as most, but not all, individuals tend to overestimate quantity (prince et al., 2018), it may be important to understand if impulsivity relates to overestimation, underestimation, or bears no influence. given the importance of measuring quantity used, it is equally important to understand what individual difference factors may influence quantity misestimation. the present study addressed this gap in the literature by examining if impulsivity was related to marijuana quantity estimation. as no previous research has examined the role of impulsivity in quantity estimation, but that some research indicates that facets of impulsivity affect time estimation, we started with the broad hypotheses that greater amounts of each facet of impulsivity would predict increased marijuana quantity misestimation. methods participants and procedure this secondary data analysis examines 79 participants who completed an extended testing battery at a research event at a marijuana club. twenty one participants reported they did not use flower marijuana and were not administered the flower marijuana estimation task. therefore, these participants were excluded from the analytic sample. of the remaining 58 participants, n = 46 completed all relevant survey measures and were included in the final analytic sample. among the analytic sample, 52.2% of participants were female and had an average age of 29.46 (sd = 6.03, range [22.16, 51.88]). 73.91% of participants were white (<1% american indian/alaskan native, 6.5% black, 8.7% other/multiracial) and 80.0% were non-hispanic. participants were asked, “on how many days during the last 30 days did you consume marijuana (in any form)?” the majority of participants (58.7%) reported consuming marijuana on 30 of the past 30 days (m = 25.74, sd = 7.38, range [3, 30]). data were collected from a marijuana use event at a private marijuana club that was open to adult (21 years old or older) marijuana users. in this observational study, participants were instructed to use marijuana flower (i.e., marijuana buds) that they brought with them to impulsivity and marijuana estimation 4 the club to either fill the bowl of a pipe or roll a joint according to their preferred method of use. participants were then asked to estimate, in grams, the amount of marijuana flower they used. next, participants placed the bowl or joint on a digital scale and researchers weighed and recorded the actual amount of marijuana. participants then retrieved the packed or rolled marijuana from the scale and were free to do with it what they wanted, including consume it. participants also completed a computerized survey as part of the larger study. participants were given a $20 gift card for compensation. the study protocol was approved by the university’s institutional review board. for more information on study participants and procedures, please see prince and colleagues (2018). measures measures included the following demographic variables: age, sex, race, ethnicity, frequency of marijuana use, and whether the participant worked in the marijuana industry. to measure the various dimensions of impulsivity, participants were administered the supps-p impulsive behavior scale (cyders et al., 2014). the supps-p is a 20-item scale that measures positive urgency, negative urgency, lack of premeditation, sensation seeking, and lack of perseverance. items related to sensation seeking were removed as sensation seeking is not conceptualized as a facet of impulsivity (quinn & harden, 2013). items were measured on a 4-point likert scale (1: “strongly disagree”, 2: “disagree”, 3: “agree”, 4: “strongly agree”) to assess positive urgency (4 items, m = 1.80, sd = 0.80), negative urgency (4 items, m = 2.20, sd = 0.77), lack of premeditation (4 items, m = 1.65, sd = 0.48), and lack of perseverance (4 items, m = 2.08, sd = 0.38). the supps-p subscales demonstrated good internal consistency in this sample, chronbach’s a ranged from 0.75 to 0.90. because larger quantities allow for larger estimation errors (and vice versa), we accounted the covariance between misestimation and quantity by operationalizing misestimation as the proportion of error relative to the actual quantity. we subtracted the actual marijuana weight from the estimated marijuana weight and divided the difference by the actual weight. for instance, if a participant used 1.0g of marijuana flower, but estimated 1.2g, then the misestimation value would be 0.2. if a participant used 1.0g of marijuana flower, but estimated 0.9g, then the misestimation value would be -0.1. the resulting misestimation variable was normally distributed, with skewness of 1.64 (se = 0.350). average misestimation was 0.67 (sd = 1.15) and ranged from -0.76 to 4.56. because filling the bowl of a pipe and rolling a joint both use flower, both methods of flower misestimation were collapsed into one variable. participant flower estimates varied from .02g to 1.23g, while actual weights varied from .05g to 1.00g. analysis the study hypothesis was tested using linear regression with misestimation as the dependent variable and the facets of impulsivity as the independent variables. all cases with missing values for the dependent variable were deleted list wise. because the dependent variable contained extreme values (e.g., 460% over-estimation), it was winsorized at its 90th percentile. the independent variables were centered at their mean. an ordinary least squares regression model was estimated using r version 4.0.3. because it is possible to underestimate as well as overestimate quantities, it should be noted that error estimation is not a monotonic construct. estimation errors closer to zero reflect better accuracy, whereas estimation errors with large values (either positive or negative) reflect worse accuracy. therefore, it is necessary to plot model results to fully understand the relation between impulsivity and estimation error. the fitted relation between significant predictors and estimation error, holding all other facets of impulsivity constant at their mean, was plotted alongside observed values. cannabis, a publication of the research society on marijuana 5 table 1. means, standard deviations, and correlations with confidence intervals variable m sd 1 2 3 4 1. negative urgency 2.20 0.77 2. lack of perseverance 2.08 0.38 .07 [-.22, .36] 3. lack of premeditation 1.65 0.48 .35* .39** [.06, .58] [.11, .61] 4. positive urgency 1.80 0.80 .57** -.11 .21 [.34, .74] [-.39, .19] [-.08, .47] 5. misestimation 0.67 1.15 .02 -.24 -.32* .03 [-.27, .31] [-.49, .06] [-.56, -.03] [-.26, .32] note. m and sd are used to represent mean and standard deviation, respectively. values in square brackets indicate the 95% confidence interval for each correlation. the confidence interval is a plausible range of population correlations that could have caused the sample correlation (cumming, 2014). * indicates p < .05. ** indicates p < .01. figure 1. predicted marijuana weight estimation error as a function of lack of premeditation, with observed values impulsivity and marijuana estimation 6 results a matrix of correlations among the study variables in presented in table 1. significant correlations were present between negative urgency and lack of premeditation (r = .35, p < .05), negative urgency and positive urgency (r = .57, p < .01), lack of perseverance and lack of premeditation (r = .39, p < .01), and lack of premeditation and estimation error (r = -.32, p < .05). impulsive traits explained approximately 15% of the total variability in estimation error (r2 = 0.15), a medium effect (cohen, 1988). among the facets of impulsivity, lack of premeditation was a significant predictor of estimation error (b = -0.58, se = 0.29, p < .05). the results indicated that for a one unit increase in an individual’s lack of premeditation score, their predicted estimation error decreased by 58%. positive urgency (b = 0.01, se = 0.19, p = .96), negative urgency (b = 0.17, se = 0.20, p = .38), and lack of perseverance (b = -0.29, se = 0.35, p = .41) were not significant predictors of estimation error. predicted values of estimation error are plotted as a function of lack of premeditation in figure 1. intercorrelations among the facets of impulsivity and misestimation were examined, to assess for potential suppression effects (see table 1). the positive correlations between negative and positive urgency, as well as between lack of premeditation and lack of perseverance, were consistent with previous research that suggests the upps-p subscales tend to load onto two higher-order factors representing general urgency and general lack of conscientiousness (cyders & smith, 2007). the significant positive zero-order correlation between lack of premeditation and misestimation suggests that the significant regression coefficient associated with lack of premeditation was not due to a suppression effect. discussion the purpose of the present study was to determine whether specific facets of impulsivity predicted weight misestimation of marijuana among marijuana-using adults. lack of premeditation was found to significantly negatively predict misestimation, such that individuals higher in lack of premeditation (i.e., lower premeditation) had lower misestimation. positive urgency, negative urgency, and lack of perseverance did not predict misestimation. study findings were largely inconsistent with study hypotheses, which predicted that all impulsivity facets would be related to misestimation. however, the results indicate that individual differences can affect weight estimation. as researchers work to establish consistent measurement of %thc consumed, suggested as necessary by freeman and lorenzetti (2020) and supported by nida (volkow & weiss, 2020), we must also identify individual difference variables that could systematically bias weight estimations. the results reported herein indicate that individuals lacking in premeditation were more accurate at estimating, rather than having greater misestimation. previous research has found associations between impulsivity, including lack of premeditation, and marijuana use (bravo, anthenien, et al., 2017; bravo, prince, et al., 2017). in turn, individuals higher in premeditation may have greater previous use episodes, and thus possibly more experience estimating quantities of marijuana. conversely, those higher in premeditation may have had relatively fewer use episodes and less familiarity with marijuana quantity. another explanation, related specifically to premeditation, could be explained by the theory of overthinking. past research investigating overthinking and motor performance demonstrated that greater amounts of time spent thinking about an action correlates to worse task performance (flegal & anderson, 2008). moreover, overthinking when interacting with others can induce anxiety and cognitive distraction, which may further impair task performance (talbert, 2017). individuals higher in premeditation may have engaged in overthinking, thus impairing their estimation ability. conversely, individuals who lack premeditation may be less likely to overthink and instead provide and unimpaired weight estimate. however, research has yet to examine if there are significant relations overthinking, impulsivity, and weight estimation; therefore, this is a tentative explanation for the observed findings. neither positive, nor negative, urgency significantly predicted participants’ estimation error. while these results were contrary to what was hypothesized, it is important to remember that this was the first study to assess the role of cannabis, a publication of the research society on marijuana 7 impulsivity in the estimation of quantity of marijuana in joints, pipes, and bowls. it may be the case the negative and positive urgency play no role in estimation error as they specifically assess impulsive acts when an individual is experiencing positive or negative affect. nothing about the task used in this study was designed to induce positive or negative emotional states. it may be the case that other individual difference factors, including other operationalizations of impulsivity, sensation seeking, cognitive ability, executive functioning, that may be more likely to impact quantity estimation. these findings are important because the few studies that measure marijuana quantity rely on self-reported quantity rather than objective measurements. our findings support that participants may be likely to misestimate marijuana quantities, and that certain facets of impulsivity accounts for some of the variance in misestimation. one implication of this finding is that self-reported quantity may be subject to distal individual difference influences (e.g., personality), which may limit predictive ability to quantity estimations. therefore, it may be important to assess participant individual differences alongside marijuana quantity estimates to help account for these differences, particularly when using weight estimations. additionally, since participants misestimated by different amounts, utilizing more accurate measurements of quantity (e.g., objective digital scales) may improve the reliability and predictive ability of quantity measurements. misestimation may also lead to inaccurate beliefs about dosedependent effects. frequent overestimation, as seen in this study, may lead participants to associate larger quantities with subjective effects that are actually related to smaller amounts of marijuana. in turn, when given more objective weights (e.g., buying a one gram joint from a dispensary), participants may possibly overconsume marijuana based on their skewed perception of dose-dependent effects. results can be used to identify individuals that may be more likely to misestimate marijuana quantity and inform personality-based interventions (e.g., conrod et al., 2007). there are several strengths to this study. one of the strongest aspects of this study is that the sample was adult marijuana users from the general population. most studies assessing marijuana use college student samples, thus generalizing to college students rather than adult marijuana users. our study took place at a community-based marijuana event, so the sample population is more likely to represent frequently using community adults. another strength of this study is the use of objective measurements for marijuana. most research that has been conducted relies on self-reports, which may be inaccurate (prince et al., 2018). an objective quantity measurement removes potential biases and misestimation resulting from self-report data. in turn, conclusions drawn from objective data better estimate use quantity and related factors. one primary limitation is the small study sample, which may have limited the conclusions drawn from this study. additionally, there may have been a selection bias within the study participants. it is still relatively novel for community individuals to be able to take part in studies using real marijuana products, so marijuana enthusiasts may be more likely to selfselect into participating in this study. this population may differ from users who prefer to keep their use private or may not be as interested in participating in research. similarly, participants in this sample reported frequent marijuana use, and therefore results may not generalize to infrequent marijuana-using adults. lastly, this study solely examined marijuana flower estimations, and therefore, findings do not generalize to other forms of marijuana (e.g., concentrates, edibles). there are several future directions recommended from this study. foremost, studies should replicate these findings among other community samples to best understand the influence of impulsivity on marijuana quantity estimation. additionally, researchers should identify other individual difference variables that may be associated with marijuana estimation (e.g., sensation seeking, emotion dysregulation, or 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(2012). a ‘standard joint’? the role of quantity in predicting cannabis-related problems. addiction research & theory, 20(1), 82–92. funding and acknowledgements: research reported herein is supported by a grant (20173415) from the colorado department of public health and environment, denver, colorado. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. microsoft word v3i1a5_final.docx research article 41 abstract recreational use of cannabis in canada has recently been legalized. previous studies indicate long-term neurocognitive and cognitive sensitivity of the adolescent brain to cannabis. the present study investigates cannabis consumption among college students, including their reasons for consumption and their perceptions of its effects on their health and social functions, including learning. an online, anonymous, voluntary survey was given to students at a community college in vancouver. of the 320 students surveyed, 71% had consumed cannabis, 44% within the last week. a significant portion perceived harmful short-term effects (ranging from paranoia to inability to focus) and long-term impacts (ranging from decline in lung function to loss of memory). students reported therapeutic effects such as alleviation of stress and anxiety and improved sociability. more than half reported a mix of beneficial and harmful impacts or no impacts. the reasons for consuming cannabis were recreational (52%), recreational and therapeutic (37%), and purely therapeutic (6%). forty-three per cent (43%) consumed cannabis for therapeutic reasons including insomnia, anxiety, pain and nausea as top reasons. a significant portion of student consumers of cannabis reported harmful effects that are consistent with previous studies using objective measures. students consume cannabis for both recreational and therapeutic reasons, even while experiencing harmful short and long-term effects. national cannabis policy, currently being revised in canada to legalize recreational consumption, should include public education aimed at young adults. key words: cannabis, students, drug use, marijuana globally, cannabis sativa is the most commonly used illicit drug (united nations, 2008). in british columbia, canada, rates of cannabis consumption are higher than in other parts of canada (stockwell, sturge, jones, fischer & carter, 2006; health canada, 2011). metropolitan vancouver, british columbia’s largest urban area, has a history of permissive social attitudes concerning recreational consumption of cannabis dating back to at least the 1960s. the nearby american states of washington, oregon, california, and colorado have recently legalized cannabis consumption by adults. as of 2013, health canada has enabled cannabis production, distribution and medical use under a physician’s prescription (health canada, n.d.) and recreational cannabis use was legalized in october of 2017. attitudes within the medical and legal spheres are changing as cannabis becomes more easily available in british columbia and other canadian jurisdictions. the average age of initiation to cannabis consumption in canada is 15.6 years (health canada, 2011), indicating that secondary school cannabis 2020, volume 3 (1), 41-51 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.005 open access cannabis and college students in british columbia: attitudes, patterns of consumption and perception of harm *all authors contributed equally to this work. corresponding author: janet douglas, social service worker department, langara college, 100 west 49th avenue, vancouver, bc, v5y 2z6, canada, email: jdouglas@langara.ca d. margo nelson1*, janet douglas1, paul s. sunga2, daryl j. smith3 1 department of social services, langara college, vancouver, bc, canada 2 department of health sciences, langara college, vancouver, bc, canada 3 department of biology, langara college, vancouver, bc, canada cannabis use and baby boomers 42 and post-secondary students are among consumers. in a longitudinal study in the canadian province of ontario, 21.3% of highschool students self-reported cannabis consumption and 37% of grade 12 students reported using cannabis within the past year (boak, hamilton, adlaf & mann, 2013). other data from this study showed about 2% reporting daily consumption (crepault, rehm, & fischer, 2016). while societal acceptance of cannabis use may be changing, studies on the effects of cannabis on adolescents and young adults are raising concerns. these studies have suggested an increased risk of neurological alterations (shollenbarger, price, wieser & lisdahl, 2015) which may manifest as acute or non-acute neurocognitive and memory deficits (ragnanathan & d’souza, 2006) and may include effects key to learning processes (crane, schuster, fusar-poli & gonzalez, 2013). recent studies in this area have been strengthened by the use of placebo-controlled lab experiments as well as investigations into thc dose-effect relationships (d’souza et al., 2012). more recent results are consistent with earlier observations that thc can acutely impair episodic memory, including immediate and delayed recall, procedural memory, and associative learning and memory. these effects have been found both among occasional and regular cannabis users in comparison to non-users (volkow et al., 2016). the present study explores the attitudes about cannabis, patterns of consumption, as well as perceived effects of cannabis, among college students in central vancouver, canada. the objective of the study is to contribute insights about consumption among young adults to the current policy development process, as well as to inform public health institutions and educators. method participants of 320 respondents, 177 (55.31%) were female, 132 (41.25%) were male, and 11 (3.44%) identified as transgender or “other”. the average age of the respondents was 22.95 years old, 73% of whom were born in canada, 96 % were students and 46% lived with their parents. procedures this study involved the collection of data through the use of lime survey, an open source on-line survey application. the survey was voluntary and anonymous and made available on the campus for students to complete. respondents could complete the survey through any computer or device with internet access. data was collected over a 15-month period between september 30th, 2014 and december 1st, 2015. three hundred and twenty-one students participated. as this research involved human subjects, approval was sought and received by the research ethics board of the college. study variables the survey was created specifically for this study and is non-standardized. however, study variables were based on a review of existing literature on cannabis, youth, learning, and mental health. variables were organized to gather responses in the following areas: demographic background. participants were asked about age, gender identity, ethnicity, sexual orientation, living situation, financial situation, and relationship status. cannabis use habits. questions included whether respondents used cannabis, frequency of use, source of cannabis, form of cannabis used, method of use, and reasons for use. attitudes towards cannabis use in society. participants were asked about their opinions regarding legalization of cannabis, perceived dangerousness of cannabis, and attitudes about youth using cannabis, perceived effects of cannabis on personal physical, mental, and social functioning. respondents were asked how they felt after using cannabis, and how they felt the day after using, as well as how they felt about the amount of cannabis they used. they were asked about the positive and negative impacts of cannabis use on physical well being, on ability to manage work and schoolrelated tasks, impacts on social life and friendships, impacts on home life, impacts on mental health, and impacts on intimate relationships. drawing on the kessler psychological distress scale (kessler & andrews, 2002), respondents were asked about mental health symptoms related to depression, and cannabis, a publication of the research society on marijuana 43 anxiety. drawing on the rand 36-item short form survey, students were asked about their physical health status (ware & sherbourne, 1992). for each of these, participants were asked if they felt that cannabis had positive or negative impact in these areas, and then were provided the opportunity to describe these impacts. perceived effects on learning ability and performance. participants were asked whether, and in what ways cannabis use impacted school and work, whether they experienced learning problems associated with cannabis use, and ability to focus on school the day after using cannabis. in order to achieve the most comprehensive findings possible, both fixed and open-ended questions were used in the survey. respondents were given opportunities to provide qualitative information in addition to answering the fixed response survey questions. sampling sampling was purposeful; only college students were recruited for the study (total student population of approximately 10,000). researchers were involved in the recruitment of students and were assisted by faculty members and students. leaflets with information about the study and a link to the questionnaire were distributed in the common areas of the college by faculty and students. these areas included the cafeteria, student seating areas, and the student union building. posters were displayed throughout the college and on the researcher’s office doors and included a qr code for easy access to the survey. classrooms were also visited by faculty and student assistants to recruit students in person. data analysis frequencies were calculated on all variables to provide a descriptive representation of the students included in the study. cross tabulations were utilized to examine the relationship between key variables as identified by the literature. the qualitative analysis plan for this study employed a general approach to qualitative data analysis as articulated by maxwell (2005). responses were grouped into categories (i.e. different types of positive effects on mental health) and representative quotes were selected for inclusion in this report. all data management and analysis were conducted using lime survey, excel and spss. limitations of dataset the data set consists of only the students who voluntarily participated in the study. there is no data available on the attitudes and use of cannabis for students who did not participate, therefore the present findings cannot be generalized to the entire student population of the college. results with respect to having ever consumed cannabis, 73% reported having ever used cannabis, with 36% of those who had used cannabis reporting that they had used it within the last month (see table 1of those who reported that they were currently cannabis consumers, 23% were daily users. another 28% of current users (28/154) reported using it once a week or more. reasons for cannabis use a subset of 112 cannabis users reported on the reasons for using it. of these, 52% (58/112) reported doing so solely for recreational purposes, while 37% (41/112) did so for both recreational and therapeutic purposes. another 6% (7/112) consumed cannabis purely to address physical (2%) or mental health issues (4%). participants reported that sleeplessness was the most common health condition for which they used cannabis followed by anxiety, pain, and nausea (see table 1; respondents could report more than one condition). although depression and attention deficit hyperactivity syndrome (adhd) were not options in the survey, several respondents added these as other conditions for which they take cannabis. perceived short-term effects of cannabis students reported a range of short-term effects of cannabis consumption: 55% felt happy, relaxed, lively and talkative, 17% reported relief cannabis use and baby boomers 44 table 1. summary of cannabis use and reasons for use how long has it been since you last used cannabis? (n= 194) percentage (and frequency) of responses less than 1 hour 9.79% (19) less than 1 day 17.53% (34) less than 1 week 16.49% (32) less than 1 month 17.01% (33) less than 1 year 21.13% (41) more than 1 year 18.04% (35) how often do you use cannabis? (n= 154) percentage (and frequency) of responses daily 23.87% (37) weekly 18.06% (28) monthly 23.87% (37) other 33.55% (52) what are your reasons for using cannabis? (n= 148) percentage (and frequency) of responses medicinal purposes physical health concern 2.02% (3) medicinal purposes mental health concern 4.05% (6) recreational use 48% (71) both medicinal and recreational use 36% (54) social pressure 4.05% (6) other 5.40% (8) what health conditions are you using cannabis to treat? (n= 112) *respondents could report more than one health condition percentage (and frequency) of responses sleeplessness 29.38% (94) anxiety 24.68% (78) pain 18.75% (60) nausea 13.13% (42) from aches and pains, and 12.5% were quiet and unsociable. with respect to negative effects, 8.5% reported paranoia and 2% experienced hallucinations. when asked specifically about their perception of the effects on mental acuity on the day after cannabis consumption, 51% reported no effects, 34% reported a degree of “foggy mindedness”, and 13% reported feeling sharpminded. further data was collected with respect to the short-term effects of cannabis consumption on school and learning: 54% reported no effect on their focus at school, 26% reported difficulty focusing at school, and 20% reported being focused at school. with respect to the ability to manage work or school, 62% reported no effect, 14% reported that it has both harmed and improved it, 13% reported an improvement, and 11% reported that it had a negative effect. perceived longer-term impacts of cannabis use participants answered questions about their perceptions of cannabis use on their physical and mental health, social well-being, and school and work. perceived effects on physical well-being and health of those responding to the question about physical well-being, 56% reported that there were no effects, 32% reported both harm and improvement, 18% thought that their physical well-being was improved by using cannabis, and 7% reported it had harmed them (see table 2). although only 7% of participants reported that cannabis had been harmful to their physical cannabis, a publication of the research society on marijuana 45 table 2. summary of self-perceived effects of cannabis use effects of cannabis consumption on physical health (n = 170) percentage (and frequency) of responses it has improved it 2.01% (31) it has harmed it 4.03% (12) it has both improved and harmed it 48% (32) it has had no impact 56% (95) effects of cannabis consumption on mental health (n = 162) percentage (and frequency) of responses it has improved it 18% (49) it has harmed it 7% (13) it has both improved and harmed it 19% (27) it has had no impact 56% (73) mental state the day after cannabis consumption (n = 174) percentage (and frequency) of responses highly focused on school 5.74% (10) somewhat focused on school 13.79% (24) no effect 55.18% (96) somewhat difficult to focus on school 16.67% (29) difficult to focus on school 8.62% (15) has cannabis use impacted your ability to manage work or school? (n = 167) percentage (and frequency) of responses it has improved it 12.57% (21) it has harmed it 10.77% (18) it has both improved and harmed it 4814.38% (24) it has had no impact 62.28% (104) health, an additional 18% reported a mix of both harmful and helpful effects. some participants reported reduction of lung function; a few mentioned that using cannabis prompted them to smoke tobacco. comments with respect to lung function included: “i get coughs and chest and throat irritation due to smoking cannabis. i'm experimenting with using oils and vaporizers but have yet to see if alternate methods make a big difference.” “i feel that my lung capacity has decreased, and i have a chronic cough.” other negative physical effects included weight gain: “sometimes after i use cannabis, i end up eating too much or eating really unhealthy foods that i wouldn't normally consume.” “the only way it has been detrimental to my physical well-being is by making me eat a lot and i have gained weight because of my weed consumption.” when asked to specify how cannabis had improved their physical well-being, participants listed a range of positive effects. these include pain management: “…helps with migraines that do not respond to traditional treatments.” “physically, it has relieved aches and pains associated with injury.” “i have chronic pain from a motor vehicle accident and cannabis helps that pain be less. it also helps to take tension out of my neck and back when i'm stressed.” some participants listed the relief of menstrual pain: “i get very painful cramps from my period and cannabis is the best alternative; i've tried advil/pain medication which was making me sick from taking too much.” cannabis use and baby boomers 46 others mentioned the use of cannabis to improve appetite, decrease nausea, and treat anorexia: “i cannot eat properly without using cannabis and become even more underweight.” “i sometimes have periods where i have no appetite and everything i eat makes me feel sick, so smoking weed helps me be able to eat without feeling nauseated.” “it has helped me get back to a normal weight in recovery from anorexia.” several mentioned that cannabis use helps them exercise more effectively: “before heading to the gym, i'd eat a brownie to stay more focused on the specific workouts. i'd do each set with less mistakes because i'm concentrating on my body.” “i like to go for walks sometimes after i use cannabis, which counts as exercise.” “i go to the gym while 'high' and it can improve my workouts (more focus/workout longer)” perceived effects on mental health when asked, “how has cannabis affected your mental health?”, 45% reported no impact. 30% reported improvements to mental health 17% reported both harm and benefit, and 8% of participants reported harm to their mental health. commentary referred to feelings of paranoia and anxiety: “i get very paranoid, in my head too much, unable to take control of my thoughts.” “it has made me a little paranoid, a little scatterbrained at times, and for a year or so after i quit smoking large quantities of weed i felt an impact on my long-term and short-term memory.” “depression and anxiety worsened.” others wrote about the benefits of cannabis use to their mental health: “i have struggled most of my life with chronic depression and anxiety and coupled with counselling it has helped greatly with stress management and reducing self-harm.” “it has helped me to relax and get to sleep many times which is part of self-care which helps improve mental health.” “i have a lot of anxiety and ocd. cannabis has helps me forget what i was worrying about and helps me relax when i'm stressed out.” “i feel less depressed and anxious when i smoke weed.” perceived effects on learning, school and work there were a number of comments on a general lack of motivation or laziness associated with cannabis use: “i am unproductive immediately following and the day after use” “i had a hard time concentrating and memorizing things at school. i felt very unmotivated at school and at work”. the majority of respondents (62%) reported no impact of cannabis on work or school, 14% thought cannabis had both positive and negative effects, while 13% reported that cannabis led to benefits, and 11% reported that it had caused harm. positive effects reported by participants included improved focus: “cannabis is stimulating for me so it gives me a boost and i'm able to concentrate and focus.” “i'm more focused now than i was before; i don't get as distracted anymore.” “without cannabis i am unable to remain seated, let alone focused, while doing my school work.” stress reduction was also mentioned as a benefit: “it relaxes me when i am anxious and i believe that once i started smoking, the relaxing effects have helped me calm down and be less stressed out which in turn has improved my marks.” “it relaxes me so i don’t break down from parental pressure.” “emotionally i feel more able to pursue an education. socially, i am not anxious about going and having to interact with others.” social aspects and perceived social impacts with respect to the social pattern of consumption, 76.5% of cannabis consumers reported doing so with friends, partners or family members, while 23.5% reported consuming it alone. those who selfidentified as consumers of cannabis were asked of their perception of the amount they consumed. in response, 78% of participants stated that the amount of cannabis they use is “just the right amount”, 12% reported cannabis, a publication of the research society on marijuana 47 not using enough, while 10% reported using too much. it was also of interest to note that 16% reported that they felt the cannabis they used was too strong. the majority of participants (67%) reported a mix of harmful and helpful benefits, or no impact on social life. 30% of participants reported that cannabis had improved their social life, while 3% report that it has harmed their social life. comments about negative effects include concerns about being antisocial: “smoking a lot of cannabis in the times of life where i smoked daily and close to a gram a day, i would withdraw completely from friends. too paranoid to meet up, cancel plans and not care too much about maintaining friendships, which for women is sacrilege, but yeah, it happened.” “too stoned to call, text, or care about seeing people.” others spoke about how cannabis use distanced them from friends who do not use cannabis: “some friends do not agree with the use of cannabis for recreational and/or medicinal purposes.” “some friends disapproved and distanced themselves from me.” “pretty much separated me from all my friends that don't blaze.” for some respondents, cannabis use was associated with substance dependence: “it led to some friends getting other addictions.” “previous partner was dependent on cannabis use, created a problem between us.” “along with smoking, i started to drink, and the friends i was spending my time with were encouraging me to drink, which led to me skipping class so i could spend time with them.” comments about positive effects included increased bonding with friends: “i feel more deeply engaged and connected.” “it is a social drug. much like alcohol, it creates bonds within a social group. many of my friends and co-workers smoke on the weekends. these social hangouts are an excellent way of learning more about their interests and personalities.” “my best friend and i smoke together. it allows us to discuss very interesting topics and we bond over it.” others spoke about reducing social anxiety: “it has allowed me to relax in new social situations. i have anxiety in large crowds and it has allowed me to participate in events i would otherwise avoid.” “i become more talkative during the use of cannabis. i become more comfortable talking to strange people during the use of cannabis.” “i was less anxious, so it was easier to make friends.” some spoke about expanded perspectives that they associate with their cannabis use: “my cannabis use has makes me more openminded and empathetic, and able to see things from different perspectives if i am having a conflict with somebody especially when i am "high" and am thinking about situations.” “before i started using cannabis, i found myself becoming short tempered with matters that were stupid and mindless. i have always had friends and have been in the "cool" group, but after the use of cannabis i found myself being more sociable and not concerning myself with mindless and unimportant matters.” discussion this study explored attitudes about cannabis consumption among college students, including consumption patterns, their reasons for consumption, and their perceptions of short and longer-term effects on health and social and academic function. an understanding of the reasons young people consume cannabis and their perceptions of its harms and benefits is of potential importance to improving the implementation of cannabis legislation, policy, and public education in canada which are undergoing review and development as of this writing. general pattern of consumption in our study among students in vancouver, 42% of respondents reporting using cannabis within the last month while 8% reported daily use. these patterns of use are significantly higher than the canadian average for college students, 40% of whom report having ever used cannabis, cannabis use and baby boomers 48 and 16% of whom report using within the last month (american college health association, 2013). this pattern may be broadly consistent however, since the present sample is not assumed to be representative of the overall student population. the present survey was voluntary and is assumed therefore to be subject to self selection bias – cannabis users may have been more motivated (or less motivated) to participate in the study compared to non-users. at the national level, statistics canada found that 51% had ever consumed cannabis and roughly a third of 18to 24-year-old canadians had consumed cannabis within the previous year. the 18 to 24year-old age group was found to have the highest prevalence of cannabis use in the canadian population (rotermann & langlois, 2015). it is clear that cannabis is widely consumed among college attendees, at least sporadically, with a significant portion of them consuming it daily. it should be noted that young adults have been found to downplay risks (gough, fry, grogan & conner, 2009) and under-report consumption of other harmful substances (tobacco and alcohol), which hints that usage frequency and the perception of harm could be under-reported by students in the present study. reasons for use understanding the reasons college students consume cannabis provides insight into their perception of the social and therapeutic role of the drug in canadian society, and also provides hints as to how students perceive and experience benefits and harms. surprisingly, 43% of those who consumed cannabis indicated that it was for therapeutic reasons (most reported both therapeutic and recreational purposes combined). in comparison, the 2011 canadian alcohol and drug use monitoring survey, a large telephone survey conducted in all provinces and territories in canada reported that 17.1% of cannabis consumers did so for medicinal purposes (health canada, 2011). both of these results point out that a large portion of young adults identify cannabis as having therapeutic value to them. perception of harm while a perception of therapeutic value is widespread, a significant portion of cannabis users perceived harm to their mental and physical health, social and school/work function. aside from short-term psychoactive effects, and dayafter fogginess, 39% of consuming students reported that it had harmed their physical health, and 21% reported perceived harm to their mental health. these longer-term impacts may also be reflected in the 25% of students who felt that cannabis had harmed their ability to manage school or work and had impaired their ability to concentrate at school. with respect to perceptions of mental health and school effects, these findings confirm the results of other studies using objective tests that show adverse effects on working memory, motivation and ability to focus on mental tasks (hanson, winward, schweinsburg, medina, brown & tapert, 2010). on the other hand, a significant number of students reported using cannabis for to address anxiety and for management of stress. data from a 2013 study on the health of college students revealed that 28% of post-secondary students in canada thought that anxiety had an adverse effect on their academic performance, with 38% identifying stress as a factor that interfered with their academic success, and 56% reporting feeling overwhelming anxiety at least once during the previous year (american college health association, 2013). a clinical study on the management of stress in the form of posttraumatic stress syndrome has been approved by health canada (government of canada) as a medical rationale for cannabis consumption (university of british columbia news, 2016). yet it already is an important reason for unofficial cannabis use among a significant portion of young adults experiencing school, work and family pressures, as indicated in significant commentary from these respondents. evidently the perceived benefit of cannabis as a reducer of stress and anxiety overcomes concerns about perceived negative impacts on learning and cognition. a further motivating reason for students to use cannabis is likely to be social, given than 30% of participants thought that cannabis had improved their social life and another 66% reported a mix of harmful and helpful benefits, or no impact. for those with difficulties in social areas, cannabis may offer one avenue for social engagement. in one british columbia study, the odds of initiating cannabis use were found to be cannabis, a publication of the research society on marijuana 49 significantly increased in youth with a weak selfperception of community belonging (health canada, 2016). implications for education a concern is that cannabis use is harming academic performance, with repercussions for individuals and for society as a whole. 25% of student cannabis users thought that cannabis use harmed their work or school function. specifically, 25% of respondents reported difficulty focusing at school. epidemiological, clinical and animal studies indicate that cannabis consumption has dose-dependent effects on a variety of neurological indicators and cognitive functions. at least some studies have shown an overall, long-term and permanent deficit in cognitive function in chronic, heavy consumers of cannabis. the present study surveys the perceptions of students with respect not only to their pattern of cannabis use, but their perception of its effects on them. educational institutions may be experiencing the effects reflected in learning patterns, learning challenges and academic results. the apparent identification of cannabis consumption as a means of seeking relief from academic, social and family pressure may warrant further study to determine the extent to which students may require support in these areas. as well, a risk-benefit analysis could consider the benefits of any reduction in anxiety on learning resulting from cannabis use, along with the documented risks to cognitive function associated with cannabis use, especially for daily users. implications for social policy this confirmation of the longer-term effects of cannabis supports the need for cannabis policy and legislation to address the potential educational, professional and economic impacts of chronic cannabis use on college students. the age at which recreational use of cannabis is being set by each province, mostly in line with the canadian government task force recommendation of the legal age of purchase to be the same as that for alcohol consumption (18 or 19 years of age depending on the province) (health canada, 2016), in contrast to the recommendation of the colleges of physicians and surgeons of ontario and b.c. of a legal age for medical consumption of 25 years (2015). policy changes should include mechanisms that support public education concerning evidence of harm to cognitive and behavioural function at various stages of life. while adolescent cognitive development is sensitive to cannabis (abdullaev, posner, nunnally & dishion, 2010; shollenbarger, price, wieser & lisdahl, 2015), the next older cohort those at college age – at least clearly perceive health cognitive impacts. public education aimed at adolescents and college students may be particularly worth the effort as there is evidence that public awareness campaigns can result in reduced prevalence of consumption (bachman, johnston & o’malley, 1990). references abdullaev, y., posner, m. i., nunnally, r., & 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(2005). qualitative research design: an interactive approach, 2nd edition. thousand oaks, ca: sage. ranganathan, m., & d'souza, d. c. (2006). the acute effects of cannabinoids on memory in humans: a review. psychopharmacology, 188(4), 425-444. https://doi.org/10.1007/s00213-006-0508-y rotermann, m. & langlois, k. (2015). prevalence and correlates of marijuana use in canada, 2012. health reports, (26)4, 10-15. statistics canada, catalogue no. 82-003-x http://www.statcan.gc.ca/pub/82-003x/2015004/article/14158-eng.pdf shollenbarger, s. g., price, j., wieser, j. & lisdahl, k. (2015). impact of cannabis use on prefrontal and parietal cortex gyrification and surface area in adolescents and emerging adults. developmental cognitive neuroscience, 16, 46-53. https://doi.org/10.1016/j.dcn.2015.07.004 stockwell, t., sturge, j., jones, w., fischer, b., & carter, c. (2006). cannabis use in british columbia: patterns of use, perceptions, and public opinion as assessed in the 2004 canadian addiction survey. centre for addictions research of bc. https://dspace.library.uvic.ca/handle/1828/476 5 united nations office on drugs and crime. (2008). world drug report. http://www.unodc.org/documents/wdr/wdr_2 008/wdr_2008_eng_web.pdf cannabis, a publication of the research society on marijuana 51 university of british columbia news. (2016). health canada approves cannabis ptsd study. ubc news. http://news.ubc.ca/2016/09/12/health-canadaapproves-cannabis-study/ volkow, n. d., swanson, j. m., evins, a. e., delisi, l. e., meier, m. h., gonzalez, r., ... & baler, r. (2016). effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review. jama psychiatry, 73(3), 292-297. https://doi.org/10.1001/jamapsychiatry.2015.3 278 ware, j.e., jr., & sherbourne, c. d. (1992). the mos 36-item short-form health survey (sf36): i. conceptual framework and item selection, medical care, 30:473-483. funding: there are no known conflicts of interest for any of the authors of this paper. a $3000 grant from langara research funds supported this research. no external funding sources were used to support this research. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. microsoft word v3i1a4_final.docx research article 31 \ abstract young adults who use cannabis frequently often attempt to quit on their own and may try several times before achieving cessation. preparing to quit may increase the likelihood that abstinence will be achieved. however, little is known about the process of preparing to quit in this population and how that process relates to patterns of use during the quit attempt. in a community sample of 18-25 year olds reporting daily/near-daily cannabis use and planning to quit (n=34), we assessed changes in momentary and daily cannabis use-related factors during two weeks prior to a self-quit attempt, and evaluated whether these changes predicted abstinence, time to lapse, and cannabis use days during the 2-week quit attempt. several factors changed from the first week to the second week prior to the quit attempt, including decrease in momentary positive affect, cannabis craving, availability, situational permissibility, use since last report, bad feeling following use, daily withdrawal symptoms and use in the past 24 hours, and increase in momentary and daily confidence to not use cannabis. greater difference in cannabis use days between two weeks and one week (decrease in use) before the self-quit attempt predicted all three measures of quit success, including abstinence, longer time to lapse, and fewer use days. in summary, young adults preparing to quit cannabis demonstrated changes in advance of quitting that may reflect preparatory actions; only reducing cannabis use before a quit date predicted success with attempting abstinence. further research on pre-quit changes will be important for developing effective tools and strategies to aid frequently-using young adults to successfully quit on their own. key words: cannabis, young adults, quit attempts, ecological momentary assessment young adults have the highest rates of frequent cannabis use of any age group; in 2017, from 6% (18 year olds) to 9.2% (23–24 year olds) used cannabis daily or near-daily (miech et al., 2018; schulenberg et al., 2018). not surprisingly, young adults also have the highest rates of cannabis use disorder (cud); in 2016, approximately 1.7 million young adults aged 18 to 25 (5%) had a cud in the past year (substance abuse and mental health services administration, 2017). rates of cud are increasing among young adults (hasin, shmulewitz, & sarvet, 2019). despite the high risk of harm from early onset and heavy cannabis use (volkow, baler, compton, & weiss, 2014), only a small fraction of young adults with cud receive substance use treatment (substance abuse and mental health services administration, 2017). cannabis 2020, volume 3 (1), 31-40 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.004 open access corresponding author: lydia a. shrier, division of adolescent/young adult medicine, boston children’s hospital, 300 longwood avenue, boston, ma 02115, email: lydia.shrier@childrens.harvard.edu, phone: 617-355-8306, fax: 617-730-0004. changes in cannabis userelated factors prior to a selfquit attempt in young adults lydia a. shrier1,2, ziming xuan3, sion kim harris1,2 1 division of adolescent/young adult medicine, boston children’s hospital, boston, ma, usa 2 department of pediatrics, harvard medical school, boston, ma, usa 3 boston university school of public health, boston, ma, usa young adults preparing to quit cannabis 32 young adulthood is a unique developmental period marked by rising educational and occupational demands and shifting roles and relationships (arnett, 2000). in this life course context (hser, longshore, & anglin, 2007; liebregts et al., 2013), many young adults using cannabis frequently recognize problems with their use and will attempt abstinence on their own, often briefly, repeatedly, and unsuccessfully (copersino et al., 2006; cunningham, 2000; hughes, naud, budney, fingar, & callas, 2016; shrier, rhoads, burke, walls, & blood, 2014). however, limited research has examined the process of self-quitting cannabis among frequently-using young adults. studies in adults suggest many factors that may facilitate or impede quitting, including cannabis effect expectancies (boden, mckay, long, & bonn-miller, 2013), negative affect (buckner, zvolensky, & ecker, 2013), social context (e.g., being in situations where peers are using (buckner et al., 2013), social support (pettersen et al., 2019), self-efficacy and motivation to quit (zvolensky et al., 2018), and withdrawal symptoms (buckner et al., 2013; levin et al., 2010). in a study of young adults age 18-25 years intending to quit daily/near-daily cannabis use, we conducted baseline assessments and then used ecological momentary assessment (ema) to evaluate momentary and daily cannabis use-related factors over two weeks prior to a selfquit attempt (shrier, sarda, jonestrask, & harris, 2018). we found that being in situations that permitted use, along with having lower baseline negative marijuana effect expectancies, perceived family support, and abstinence self-efficacy, predicted lapse during the quit attempt. although we instructed participants to use marijuana as they usually did for the two weeks, we observed that their use frequency declined from two weeks to one week before the quit attempt. we hypothesized that participants may have been preparing to quit to increase the likelihood that they would achieve abstinence (hughes et al., 2016). through analysis of the ema intensive longitudinal momentary and daily data, we thus sought to answer the following research questions: 1) how do cannabis use-related factors change during the two weeks before a quit attempt? 2) do changes in cannabis use-related factors pre-quit predict success during a quit attempt? method participants we recruited a community sample of individuals age 18-35 years using cannabis (“marijuana”) daily or near-daily (at least 5 days per week in the past 3 months) who wanted to quit and planned to try on their own; details of the study have been described (shrier et al., 2018). in brief, we posted craigslist recruitment advertisements twice a day from november, 2015 through october, 2016 (prior to legalization of recreational marijuana in the state where the study was conducted); 105 age-eligible individuals expressed interest and 66 (62.9%) were screened by phone. eligible individuals were not currently in treatment, were willing to abstain from cannabis for two weeks during the study, had their own smartphone, would not be out of their usual routines during the study period, and did not report hazardous alcohol consumption on the alcohol use disorders identification testconsumption (audit-c) (babor, higgins-biddle, saunders, & monteiro, 2001). forty enrolled, of which 34 were included in the analyses (5 had a negative urinary tetrahydrocannabinol screen and 1 did not report use during the 2-week prequit use assessment period). participants were a mean (+sd) age of 22.0 (+2.5) years and 16 (47.1%) were female; nearly all (91%) were in school or working. they began using cannabis at a young age [m(+sd) = 15.0+2.0 years] and all but 2 participants (94%) met criteria for cannabis use disorder. the investigators’ affiliated institutional review board approved the study. at the end of study participation, individuals received up to $250 remuneration and information about marijuana and marijuana treatment. procedures at baseline, participants completed a computerized survey that included sociodemographic characteristics and substance use history, and a timeline follow-back (tlfb) calendar of the past 28 days of substance use. participants then put the study application cannabis, a publication of the research society on marijuana 33 (“app”; metricwire, inc.) on their personal smartphone and received training on completion of the ema reports. each day for 4 weeks, the app emitted signals at 6 quasi-random times (momentary reports) and one scheduled time (10 pm; daily reports). momentary reports queried marijuana use since last signal, craving, marijuana availability, situational permissibility of marijuana use, and confidence not to use marijuana. report of marijuana use prompted questions about the context of use, including companionship, time of day, reason for use, and feelings about use. daily reports queried cannabis withdrawal symptoms, motivation to quit marijuana (readiness, importance, and confidence), social support (in general, for using marijuana, and for quitting marijuana), and past24-hour marijuana use. after 2 days of practice, participants completed ema reports for two weeks using marijuana as usual (“pre-quit”), then were instructed by text message and/or phone call to abstain for marijuana for two weeks (“quit attempt”) while continuing to complete ema reports. ema response rates in this study (shrier et al., 2018) were comparable to those in other substance use studies (meta-analysis pooled response rate, 75.06% (jones et al., 2019). participants completed a 28-day tlfb calendar of use at the end of the 4 weeks of ema reporting. all participants (100%) completed baseline and follow-up surveys and tlfb calendars. measures marijuana use. we assessed marijuana use on each of the three data sources. on the momentary reports, we asked, “since the last signal you answered, have you used marijuana?” and, if yes, when (early morning 12:00 am 5:55 am, morning 6:00 am 11:55 am, afternoon 12:00 pm 5:55 pm, evening 6:00 pm 11:55 pm). we identified the date of the use event based on the time block and the dates of the current and previous reports. on the daily reports, we asked whether the participant had used marijuana in the past 24 hours (yes/no). on the tlfb calendar, we recorded each marijuana event for the 28 days before starting ema data collection and for the 28 days of ema data collection (2 weeks pre-quit and 2 weeks during quit attempt; the 2-day practice period was not included). momentary variables. we assessed momentary affect with four positive and four negative items adapted from the positive affectnegative affect schedule (watson, clark, & tellegen, 1988; shrier et al., 2014b); responses (1not at all to 5-extremely) were summed and averaged to create positive and negative affect scores (each 1-5). we measured momentary craving for marijuana as “such a strong desire to use marijuana that you felt you would not be able to keep from using” (yes/no) (johnston, o'malley, bachman, & schulenberg, 2013; litt, cooney, & morse, 1998; shrier et al., 2014a). participants reported ease of acquiring marijuana in the moment on a 5-point scale (shrier et al., 2012), which we dichotomized into very/fairly easy vs fairly difficult/very difficult/impossible owing to the skewed distribution. participants also reported situational permissibility by responding to the question, “if you had marijuana, would you be able to use it in your current situation?” (yes/no) (litt, kadden, & kabela-cormier, 2009). we measured momentary confidence to abstain on a scale from 0-not very confident to 9-very confident (shrier et al., 2014a). use event variables. when participants reported using marijuana since the last signal, they were prompted to report whether they used alone (yes/no) and, if not, with whom (family, friends, acquaintances, other). they also reported why they used marijuana (for social reasons, to cope with negative feelings, for pleasure, to conform to what others were doing, to expand my mind) (simons et al., 1998); based on prior research (ross et al., 2018), we examined using to cope vs. using for other reasons. we asked participants how they felt in general about the use (1-very bad to 5-very good) (shiffman et al., 1997), dichotomized into bad (very bad/a little bad) vs. other, and how guilty they felt (0-not at all to 3-very) (shiffman et al., 1997), dichotomized into any guilt vs. none. daily variables. we measured withdrawal symptom intensity (19 items, each 0-10) and negative impact on normal daily activities (19 items, each 0-10) using the cannabis withdrawal scale (allsop, norberg, copeland, fu, & budney, 2011). participants reported their daily motivation to quit marijuana on confidence, readiness, and importance scales (each 0-9). they indicated the degree of social support from the four people most important to them on three young adults preparing to quit cannabis 34 items: general support, support of your marijuana use, and support of you stopping your marijuana use (each 0-9) (zimet, powell, farley, werkman, & berkoff, 1990). analyses we examined descriptive statistics for the momentary and daily variables by week (2 weeks and 1 week before the quit attempt), then compared the variables between the two pre-quit weeks. bivariate analyses for dichotomous variables utilized the chi-square test in sudaan 11.0.1 software to account for clustering of observations within individuals. for continuous variables, we ran linear regression models with generalized estimating equations, nesting observations within individuals. next, we created difference variables (2 weeks minus 1 week before the quit attempt) for those momentary and daily cannabis-use related factors significantly different between the two pre-quit weeks and examined the pearson r correlations between these change variables. we conducted linear regression modeling to assess the association between changes in cannabis use-related factors before the quit attempt and each of the three outcomes for success during the quit attempt: 1) abstinence (no vs. any use during the 2-week quit attempt); 2) days to first cannabis use (lapse) as a time-to-event variable; and 3) number of cannabis use days as a continuous outcome. specifically, we employed a logit link function for the outcome of any use, an identity link function for the outcome of use days, and used cox regression to analyze time to first use (lapse) during the abstinence period. we applied a backward elimination procedure to identify the most parsimonious model in predicting each outcome. we conducted these regression analyses using sas version 9.4 (sas institute, inc.). results with p<0.05 were deemed statistically significant. results several factors related to cannabis use significantly changed from two weeks to one week prior to the self-quit attempt (table 1). among the momentary factors, positive affect, craving, availability, and being in a situation that permitted cannabis use declined, and confidence to not use increased across the weeks. among the use event factors, use since last momentary report and bad feeling after use also declined. among the daily factors, cannabis withdrawal symptoms and use in the past 24 hours decreased and confidence to not use increased. of the variables that changed significantly over the two weeks prior to the abstinence attempt, change in daily confidence to not use was positively correlated with change in momentary confidence to not use (r = .63) and negatively correlated with change in momentary craving (r = -.57). there were no other significant correlations among the significant change variables. approximately one-fifth of participants (21%) abstained from cannabis for the 2-week attempted abstinence period (table 2). time to first use was a mean of 1.52 days. participants used a median of 7 out of 14 days. only change in number of cannabis use days during the pre-quit period was significantly associated with each of the three quit success outcomes, such that greater difference in cannabis use days between 2 weeks and 1 week (decrease in use) before quit attempt predicted quit success. for each 1-day increase in the difference in cannabis use days from 2 weeks to 1 week (decrease in cannabis use days) before the quit attempt, the likelihood of abstinence increased by 2.73 times. for each 1-day increase in difference (decrease) in cannabis use days from 2 weeks to 1 week pre-quit, the hazard rate for lapse was reduced by 35%, although not significant at p<0.05. a greater difference in cannabis use days from 2 weeks to 1 week pre-quit predicted fewer days of use during the quit attempt, such that for each 1-day decrease in cannabis use days pre-quit, the number of days of use during the quit attempt was decreased by 1.6 days. discussion young adults using cannabis daily/near-daily reported changes in several use-related factors in the two weeks prior to a self-quit attempt, including decreases in positive affect, cannabis craving, cannabis availability, situational permissibility, bad feeling following use, and withdrawal symptom intensity, and increase in confidence to not use cannabis. the findings suggest that participants were preparing to quit by spending less time in contexts in which they could easily obtain or use cannabis (e.g., by cannabis, a publication of the research society on marijuana 35 changing where they spent time to avoid cannabis or by not having cannabis around in the contexts table 1. change in cannabis use-related factors 2 weeks to 1 week before a self-quit attempt factor t-2 weeks, m t-1 week, m test statistic p momentary n = 1012 n = 921 positive affect (1-5) 3.14 2.97 b = 7.25 0.007 negative affect (1-5) 1.85 1.85 b = 0.00 0.99 craving (any) 24.2% 18.0% c² = 11.10 <0.01 craving intensity (1-10) 6.9 6.5 b =.706 0.40 availability 65.9% 58.7% c² = 10.5 0.001 situational permissibility 61.1% 51.5% c² = 18.4 <0.0005 confidence to not use (0-9) 6.7 6.9 b = 5.15 0.02 use event n = 308 n = 216 use since last report 30.4% 23.5% c² = 12.0 0.001 context of use at home 55.5% 53.2% c² = 0.27 0.61 in morning 30.0% 31.0% c² = 0.06 0.81 with friends 53.4% 45.8% c² = 2.86 0.09 alone 32.7% 37.1% c² = 1.1 0.30 use to cope 13.7% 12.2% c² = 0.23 0.63 bad feeling about use 12.3% 6.9% c² = 4.4 0.04 guilt after use 38.0% 35.7% c² = 0.30 0.58 daily n = 198 n = 179 cannabis withdrawal symptom intensity (0-190) 26.78 19.27 b = 3.09 <0.01 cannabis withdrawal symptom negative impact (0-190) 17.22 13.81 b = 1.46 0.15 motivation to not use (each 0-9) confidence 6.27 6.87 b = -2.28 0.02 readiness 5.49 6.03 b = -1.91 0.057 importance 4.44 4.77 b = -1.04 0.30 social support (each 0-9) general 5.76 5.75 b = 0.02 0.98 you using cannabis 4.59 4.43 b = 0.50 0.62 you not using cannabis 5.73 5.87 b = -0.45 0.65 use in past 24 hours 76.9% 56.0% c² = 18.5 <0.01 table 2. difference in use days from 2 weeks to 1 week before a self-quit attempt predicting quit success outcomes outcome descriptive statistics model estimate test statistic p abstinence 21% (7/34) logistic regression 1.00 c² = 6.03 0.01 time to lapse m(+sd) = 1.52(+0.94) days cox proportional hazard -0.43 c² = 3.82 0.05 days of use mdn(iqr) = 7(2-12) days linear regression -1.62 t = 2.05 0.049 where they spent time). consistent with this finding, adults not in treatment have reported the perception that changing their environment was the most helpful strategy for quitting (boyd et al., young adults preparing to quit cannabis 36 2005). it would be useful in future research to assess whether participants changed their cannabis acquisition to reduce their access or whether they told people close to them about their impending quit attempt, which has been associated with longer duration of abstinence (hughes et al., 2016). participants may have been feeling less positive over time as they anticipated their attempt at cannabis cessation, while also feeling less badly about their use and more confident in their ability to quit. anticipation of an event that has positive and negative aspects to it (such as a quit attempt) is, not surprisingly, also an ambivalent experience (kruschwitz et al., 2018). ambivalence is a hallmark of the contemplation stage of change (prochaska & velicer, 1997), consistent with our recruitment of individuals who wished to quit cannabis. young adults in this study also reported using cannabis less frequently over the two weeks prior to their self-quit attempt. reducing cannabis use in preparation for quitting may be considered a form of practicing abstinence. in so far as frequent cannabis use is a learned behavior, decreasing use frequency prior to quitting may foster learning during behavior extinction that contributes to subsequent successful behavior change (mccarthy, bold, minami, & yeh, 2016). consistent with this perspective, only reduction in cannabis use days prior to the quit attempt was associated with successful abstinence, as well as longer time to lapse and fewer use days during the quit attempt. among smokers, reducing cigarettes per day increases the probability of cessation (klemperer & hughes, 2016). additionally, in a study of adults smoking cigarettes daily, prescribed practice quitting prior to a target quit day delayed time to first lapse and prevented relapse among those who lapsed (mccarthy et al., 2016). among adults intending to quit cannabis in the next three months, those who tried and failed to quit in the first month were more likely than those who did not have an unsuccessful quit attempt to try again in the second or third month, suggesting that repeated efforts to quit are part of the process of change in cannabis use behavior and may represent motivation to change (hughes et al., 2016). as suggested by the limited prior research on adults attempting to stop or reduce cannabis use (hughes et al., 2016; hughes, peters, callas, budney, & livingston, 2008), our findings support the view that quitting cannabis exists on a behavior change continuum that begins with pre-quit changes. as noted above, we observed that cannabis withdrawal symptom intensity declined (and negative impact of withdrawal symptoms also declined, although non-significantly) over the two weeks before the quit attempt. these changes were not correlated with decline in cannabis use frequency. the symptoms assessed with the cannabis withdrawal scale are not specific to cannabis withdrawal and include lack of appetite, nausea, problems falling or staying asleep, restlessness, and other physical symptoms, as well as thoughts about cannabis or being stoned and negative mood. some of these symptoms may motivate cannabis use and/or be a consequence of use. for example, difficulty with sleep is an intense cannabis withdrawal symptom that causes significant distress (allsop, et al., 2011), a symptom that may prompt using cannabis (lee, neighbors, hendersot, & grossbard, 2009; lintzeris, driels, elias, arnold, mcgregor, & allsop, 2018), and a symptom that can result from cannabis use (babson, sottile, & morabito, 2017). we did not assess reasons for changes in withdrawal symptoms, which may have been unrelated to cannabis use per se, but may have been related to anticipating cannabis cessation. participants may have prepared for quitting by developing new health behaviors (e.g., eating or sleeping routines) or employing cognitive strategies (e.g., to distract from thinking about cannabis), resulting in a reduction in symptoms on the cannabis withdrawal scale. our findings have implications for further research and for treatment. although the majority of cannabis quit attempts appear to be preceded by a variety of preparatory activities (hughes et al., 2016), we found that only reducing use was associated with quit success. support for individuals wishing to quit frequent cannabis use may be strengthened by emphasizing use reduction prior to a quit attempt. research is needed to determine whether formal abstinence practice improves quit success, as seen in a modest way for cigarette smoking (mccarthy et al., 2016). further, although a self-report method, ema assesses near-real time feelings, thoughts, contexts, and behaviors without necessarily requiring individuals to opine about the linkages among these constructs or to share their intent. in other words, the momentary and daily cannabis, a publication of the research society on marijuana 37 assessments can be “just the facts,” leaving determination of associations and patterns to the researchers. future research should marry this approach with quantitative and qualitative information about the how and why of the changes we observed. for example, did participants intentionally change their environments? avoid cannabis use opportunities? avoid using even in the face of opportunity? how did they feel about the changes they made prior to trying to quit? development of rapid assessment and feedback tools to study and intervene on this highly dynamic and individualized change process will inform research on and, ultimately, recommendations for strategies for optimizing self-quit success. this study has several limitations. first, the sample was small and drawn from a single urban area in the northeastern united states, potentially limiting generalizability to other populations of young adults using cannabis frequently and planning to quit. second, nationally, the legal and social landscape of cannabis use is rapidly changing toward more favorable attitudes and easier access to cannabis. these developments may influence quit motivations, pre-quit strategies, cannabis-related environments, and measures of quit success; replication and expansion on this study is required to elucidate the self-quit process in the current context. third, participants may have changed their responses or behaviors as a result of the frequent assessments. previous studies have been mixed on the effect of ema selfmonitoring alone on frequency of substance use (litt, cooney, & morse, 1998; peters & hughes, 2009). reactivity to ema may be more likely to occur with extended periods of assessment, e.g., 812 weeks (wray, merrill, & monti, 2014), review). we did not formally assess ema reactivity in this study. however, we believe the phenomenon is unlikely to have occurred for at least two reasons. although we saw changes in the pre-quit period in directions suggesting preparation for quitting, in general the significant changes from 2 weeks to 1 week pre-quit were not correlated with each other (the exception being daily confidence to not use and craving); we would have expected change secondary to response reactivity to result in highly correlated change among the variables. additionally, even if reactivity occurred in our study, to influence the results of our analyses reactive changes would have to differ between those who reduced, delayed, or ceased cannabis use during the quit attempt, and those who did not. fourth, we did not assess cannabis quantity or potency; it is possible that participants changed cannabis dose in the pre-quit period (e.g., decreased dose as part of preparing to quit, or increased dose to counter effects of reduced use frequency). fifth, pre-quit strategies and quit success may have been influenced by the studyprescribed quit date. finally, we observed an attempted abstinence period of only two weeks’ duration. individuals using cannabis frequently may make multiple, brief attempts to quit and may achieve use reduction rather than abstinence (hughes et al., 2016); further research over longer periods are required to determine the effects of pre-quit changes on cannabis use and abstinence over time. in summary, young adults preparing to quit cannabis in the context of a research study demonstrated changes in advance of quitting that may reflect preparatory actions. only the oftenrecommended strategy of reducing use of a substance prior to attempting cessation was associated with improved success with trying not to use cannabis following the quit date. further ema research on momentary and daily changes in anticipation of cannabis cessation will be important for developing effective pre-quit tools and strategies to aid young adults using cannabis frequently to successfully quit on their own. references allsop, d. j., norberg, m. m., copeland, j., fu, s., & budney, a. j. 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(2014). using ecological momentary assessment (ema) to assess situation-level predictors of alcohol use and alcohol-related consequences. alcohol research: current reviews, 36(1), 1927. young adults preparing to quit cannabis 40 zvolensky, m. j., paulus, d. j., garey, l., manning, k., hogan, j. b. d., buckner, j. d., . . . kathryn mchugh, r. (2018). perceived barriers for cannabis cessation: relations to cannabis use problems, withdrawal symptoms, and self-efficacy for quitting. addictive behaviors, 76, 45-51. doi:10.1016/j.addbeh.2017.07.011 funding: this research was funded by the boston children’s hospital research faculty council and presented in part at the 3rd annual meeting of the research society on marijuana in vancouver, wa in july 2019. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. microsoft word v3i1a2_final.docx review article 11 abstract to assess the effect of prenatal marijuana exposure (pme) on the newborn, infant and early childhood development through review of current literature. a systematic literature review was conducted in the electronic database from 1996 to 2017 for the effects of pme and their fetal and early childhood outcomes. 7% of pregnant women self-reported using marijuana in the last year, while 16% of them reported neardaily use. marijuana use has been reported to: a) interfere with normal placentation leading to miscarriage, preeclampsia and preterm labor through imbalance in cannabinoid receptor type 1 (cbr1) stimulation; b) could lead to reduction of fetal growth and head circumference due to increased plasticity and resistance of uterine artery; c) be associated with impaired memory function, decreased verbal scores, increased aggression and hyperactivity, impaired abstract and visual reasoning; and d) could alter sleep patterns. finally, there is no consensus regarding the effects of marijuana through breastfeeding exposure and no postpartum withdrawal effects in the newborn were reported. research on the effects of pme on offspring has been limited by several confounding factors including self-reporting bias, concomitant use of other illicit drugs and psychosocial factors. overall, pme may lead to negative consequences on the developing offspring. public health messages to health care providers and pregnant women regarding the harmfulness of pme should become a high priority. further research is needed to reinforce the existing data and examine additional potential negative effects on the developing child. key words: cannabis exposure; pregnancy; early childhood dramatic reductions in perceived harmfulness of cannabis as well as its increased availability have made it a widely used psychoactive substance (patrick et al., 2016; warner et al., 2014). the cannabis legalization debate continues worldwide, while various legislative enactments of new regulations proceed. new types of cannabis with increased potency of its psychoactive component tetra hydro cannabinol (thc) as well as advanced cannabis delivery devices (e.g., ecigarettes vaping, juul) emerge rapidly (warner et al., 2014). at this juncture the need to attend to the risks and negative health consequences related to cannabis use is arguably more important than ever. an important subpopulation of marijuana users are pregnant women where use has been growing during the last decade (jarlenski et al., 2017). although marijuana has been the most commonly used illicit drug during pregnancy, the effect of prenatal marijuana exposure (pme) on the offspring has been understudied. a cross sectional study report based on self-report states that seven percent of pregnant women used cannabis 2020, volume 3 (1), 11-18 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.002 open access the effects of prenatal exposure to marijuana on early childhood development: a systematic literature review corresponding author: yifrah kaminer, department of psychiatry and alcohol research center, university of connecticut school of medicine, 195 farmington avenue, farmington, ct, 06030-6326, email: kaminer@uchc.edu dhurga krishnamoorthy1, yifrah kaminer1 1 department of psychiatry and alcohol research center, university of connecticut school of medicine, farmington, ct, usa prenatal exposure to marijuana 12 marijuana during the last year (ko et al., 2015). sixteen percent of them reported near daily use. a recent study reported that the prevalence rate of marijuana during pregnancy when studied by age was, 16.2% for those aged 15 to 17, 7.4% for those aged 18-25 and 1.9% for those ages 26 to 44 (calvigioni et al., 2014). notably, 48–60% of the women continued to use during pregnancy, believing that it is relatively safe to use (committee opinion no. 637, 2015). the proportion of treatment admissions for women who were pregnant remained stable at 4%, however the admissions of pregnant women reporting marijuana use increased substantially from 29% to 43% (martin et al., 2015). this alarming increase in use could be attributed to the continued trend of reduction in the perception of harm caused by cannabis use as well as increased access to marijuana (ko et al., 2015). furthermore, these changes in perception of harmfulness and increased availability of marijuana are related to the increase in number of states that have legalized marijuana for medicinal or recreational purposes. for example, the most recent data provided by the state of colorado where cannabis use is legal shows a high use of 12.8% among pregnant women between the ages of 15-24 years (gosh et al., 2017). a growing concern for marijuana use in pregnancy has been its consumption for anti-emetic effects. a clinical retroactive self-assessment survey of marijuana use in “hyperemesis gravidarum” was conducted in canada. 75% of the respondents reported that marijuana was ‘extremely effective’ as a therapy for nausea during pregnancy. the objective of this review is to critically appraise and summarize the literature on the impact of prenatal marijuana exposure on fetal, infant and early childhood development. we recognize that there are some methodological confounds that challenge finding reported on the psychological and neurobiological consequences in exposed offspring. it includes recall and selfreporting bias by pregnant women; coconsumption of other drugs like opioids (12%), stimulants (10%), alcohol (4%) or cigarettes (burns et al., 2006; godding et al., 2006) which may have independent effect on the growing fetus. also adverse socioeconomic like poverty, malnutrition, lower levels of education, lower household income, less likely use of folic acid supplementation may have additional risk on adverse pregnancy outcome conditions (van gelder et al., 2010). nevertheless, it is imperative from a public health perspective to assess, understand, and disseminate the present findings regarding the harmfulness of perinatal exposure to cannabis to the public in general and to healthcare providers and pregnant women in particular. method a systematic review of the literature was performed using pubmed and scopus database for relevant articles between 1996 to 2017 for the effects of prenatal marijuana exposure and their fetal and childhood outcomes through 3 years of age. broad range of keywords that focused on cannabis or marijuana and prenatal or perinatal or fetal or neonatal or early childhood and outcomes were used to search each data base. studies that included review articles, randomized controlled trials (rct), case control studies and cross-sectional studies were searched. after carefully reviewing 133 article titles and abstracts, 42 articles were excluded due to duplication or their irrelevance to the selection criteria. 91 articles were included in this review (see figure 1). results and discussion marijuana use and its generally known negative consequences the potency of marijuana has substantially increased in the past 40 years in the united states (mclaren et al., 2008). the psychoactive potency of marijuana is measured by the percentage of the thc content. thc is a small and highly lipophilic molecule, it is rapidly distributed to the brain and fatty tissues and it freely crosses placenta (hutchings et al., 1989). the mean concentration of thc has increased from 4% to 12% in the last 20 years (el sohly et al., 2016). it was reported that in colorado’s legal bud, the average concentration of thc is 18.7% and some retail pot contains 30% thc or more (briggs, 2015). this trend of increased thc concentration is likely to continue. there is also an increase in the amount of marijuana consumed due to the growing popularity of blunts (marijuana filled cigars) compared to joints and pipes (warner et al., 2014). cannabis, a publication of the research society on marijuana 13 figure 1. explains the selection process of relevant articles on prenatal marijuana exposure and the effect on offspring the blunt has greater amount of marijuana – up to 1.5 times more than joints and 2.5 times more than pipes (mariani, 2011). not only there are different ways to consume marijuana including smoking, vaporization, dabbing (i.e., vaporizing concentrated marijuana), edibles, topical applications etc., there are different delivery systems including e-cigarettes, dab, bongs (i.e., specialized waterline with large chamber where smoke is suspended prior to its release) or needle which attracts anyone including pregnant women to consume marijuana (gosh, 2017). although difficult to demonstrate causality, research across multiple domains highlights the shortand long-term deleterious effects associated with cannabis use. early age of use initiation has been associated with increased risk for early onset psychosis in adolescents (bagot et al., 2015). regular cannabis use is associated with poorer academic performance and greater likelihood of dropping out of high school, increased family conflict, increased probability of high-risk behaviors including intoxicated driving, legal problems, unprotected sex, and higher health-care costs (ammerman et al., 2015). endocannabinoid system during prenatal and postnatal development the endocannabinoid system (ecs) is a group of endogenous cannabinoid receptors located in studies identified through database searching prenatal marijuana exposure441 review articles, rct, case control studies, cross sectional studies, abstracts, clinical trials 349 limited to prenatal marijuana exposure in newborn and early childhood (1996 to 2017) 133 total number of articles included for this review after excluding the duplicates, irrelevant articles: 91 prenatal exposure to marijuana 14 mammalian brain and throughout the central and peripheral nervous system. among the cannabinoid receptors, the cbr1 plays a major role in normal brain development and neuro transmitter system including neuronal proliferation, migration, differentiation, and survival (campolongo et al., 2011). cbr1 regulates the neural progenitor differentiation into neurons and glia and guides axonal migration and synaptogenesis (fride, 2008). this receptor is exhibited in the human fetus and the placenta as early as 14 weeks of gestation with increasing receptor density with advancing gestational age (wilford, 2010). manipulating the ecs by pre and post-natal administration of cannabinoids through maternal external marijuana exposure has significant effects on the offspring (fride, 1999). prenatal marijuana exposure as the thc freely crosses placenta, the fetal plasma thc levels are 10% of maternal level and it significantly increases after repeated exposure (hutchings et al., 1989). this explains why the prenatal marijuana exposure affects the growing fetus. a national survey conducted in 2012 by the substance abuse and mental health services administration reported marijuana abuse in each trimester and concluded that its prevalence is higher during the first trimester (10.7%) as compared to 2.8% and 2.3% in second and third trimester respectively (substance abuse and mental health services administration, 2013). this is because many women report cessation of marijuana use on discovery of pregnancy by the end of the first or early second trimester. effect on pregnancy and implantation both animal and human studies (sun et al., 2010; fonseca et al., 2013) found that the stimulation of cbr1 receptor by exogenous cannabinoids like thc causes disruption in trophoblast proliferation and differentiation thereby inhibiting successful placentation. this leads to several pregnancy related complications like miscarriage, pre-eclampsia, growth restriction and preterm labor (fonseca et al., 2013). marijuana use in pregnancy is associated with increased fetal pulsatility index and increased uterine artery resistance index suggestive of increased placental resistance (el morroun et al., 2010; behnke et al., 2013). this provides a partial explanation for intra uterine growth retardation. effect on growing fetus marijuana use in pregnancy affects the fetal growth (hurd, 2005). this study examined fetal weight and height on elective mid gestational aborted fetus (17-22 weeks) who were exposed to marijuana, tobacco and alcohol and showed decrease in both weight (by 14.53gm) and foot length (by 0.08cm). moreover, fetal foot length development was negatively correlated with the amount and frequency of marijuana use reported by the mothers. effect on head circumference in neonates a longitudinal study on the growth parameters found that cannabis-exposed children have statistically significant smaller head circumferences at birth (fried et al., 2011). it should be noted that the head growth especially in first month of life is significantly associated with future intelligence quotient (smithers et al., 2013). effect on neonatal withdrawal and sleep neonatal withdrawal including irritability, anxiety, and restlessness from prenatal marijuana exposure alone has not been reported in any of the prospective, longitudinal studies in our search domain. there are studies addressing sleep changes in newborns attributed to prenatal marijuana exposure with concomitant alcohol use. this included altered sleep patterns of the newborn including decreased quiet sleep, increased body movements during sleep and increased nighttime arousals (warner et al., 2014). neuro-developmental findings in the offspring there are studies including animal studies and longitudinal prospective studies confirming that pme influences the neuro-cognition of the offspring. persistent use of cannabis may impact brain development and neuropsychological functioning including executive functions, cannabis, a publication of the research society on marijuana 15 memory, processing speed, perceptual reasoning, and verbal comprehension (jarlenski et al., 2017). this process is due to altering the dopamine pathway in the nigrostriatum (dinieri et al., 2011). it also causes changes in prefrontal area and impaired functioning of the hypothalamic pituitary axis. this also explains the association with attention deficit and hyperactivity (nigrostriatum pathway) and mood disturbances (prefrontal cortex). a cohort study reported that intrauterine exposure to cannabis was associated with an increased risk for aggressive behavior and attention problems as early as 18 months of age in girls, but not boys (el marroun et al., 2011). this finding was reported in other studies as well (fried et al., 2008; goldschmidt et al., 2000). a prospective study reported that the level of cognitive and intellectual deficits in children exposed to prenatal marijuana is also related to timing and degree of the in utero exposure (goldschmidt et al., 2000). the study concluded that heavy use (defined as >1 joint/ day) during the first trimester was associated with low verbal reasoning scores whereas the second trimester use was associated with deficits of composite, short-term memory and quantitative scores. there was also a report on defects in visual problem solving, visual motor coordination and visual analysis (wilford et al., 2010). with regards to learning difficulties in early school years, its less clear if caused by prenatal marijuana exposure alone due to co-consumption of other substances during pregnancy. however, a prospective study reported that prenatal marijuana exposure significantly interferes with school achievement scores as early as 6 years of age (goldschmidt, 2008). a recent report found a dose–response relation between pme and expression of a dopamine gene in the amygdala, demonstrating an effect of prenatal exposure on the systems that regulate emotional behavior (wang et al., 2004). neuro psychiatric illness in future in utero cannabis exposure alters neurotransmitter homeostasis, including ventral striatal dopamine d2 gene regulation and expression which is involved in major reward pathway causing increased vulnerability to addiction (dinieri et al., 2011; wang et al., 2004). this not only leads to impulse control disorders and addiction behaviors, but also increases sensitivity to drug abuse in the future (hansen et al., 2008; szutorisz et al., 2014). hence it is necessary to further study the dosage and timing of prenatal marijuana exposure to further understand the drug seeking behavior and impaired executive functions. a prospective study reported that children born following pme showed depressive symptomatology that did not meet the criteria for mdd and that this early onset depression might predict the subsequent development of psychiatric disorders and problem behaviors such as substance abuse (gray et al., 2005). maternal marijuana use and lactation the passage of thc in breast milk has not been extensively studied so far. the american college of obstetrics and gynecology committee urges all breastfeeding women to discontinue marijuana use as the potential risks of exposure to its metabolites are unknown (committee opinion no 637, results from national survey 2012). prevention a most recent phone survey of 400 dispensaries in colorado reported that in 70% of contacts the workers recommended cannabis products to treat nausea in the first trimester (dickson et al., 2018). few dispensaries encouraged discussion with a health care provider without prompting. it is important to understand the status of public health (ph) messages regarding perinatal marijuana use in an evolving policy context (jarlenski et al., 2017 ). the american academy of pediatrics has concluded that perinatal marijuana exposure has negative effects on short-term and longer-term neurobehavioral development and cognition in childhood (behnke and smith, 2013). following a most recent systematic search of 51 states and 5 federal public health agencies’ web sites jarlenski et al., 2017 concluded that the volume of ph messages about perinatal marijuana use is low, content of messages differs across state agencies, and perinatal marijuana is seldom addressed in content published by federal agencies. prenatal exposure 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(2014). it’s noty mother’s marijuana: effects on maternal-fetal health and the developing child. clinics in perinatology, 41, 877–894. willford, j. a., chandler, l. s., goldschmidt, l., & day, n. l. (2010). effects of prenatal tobacco, alcohol and marijuana exposure on processing speed, visual-motor coordination, and interhemispheric transfer. neurotoxicology and teratology, 32(6), 580– 588. funding: no external funding was received. copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 66 abstract cannabis use has more than doubled in the past decade and nearly three of 10 users develop a cannabis use disorder. the increase in users, combined with the ongoing changes in the medical, legal and social status of cannabis, has contributed to interest in the antecedents of cannabis use. in the current preliminary study, we gathered information from a community sample (n = 54) of regular cannabis using young adults. assessments included perceived self-efficacy for reducing intake or abstaining (se-r/a), use of cannabis protective strategies (cps), and average quantity of cannabis use per day. we systematically explored which specific cps were most strongly associated with self-efficacy and cannabis use. three clinically relevant subgroups of cps emerged from this analysis: strategies strongly associated with only self-efficacy, only cannabis use, and both variables. we hypothesized that self-efficacy would be associated with less cannabis use via use of cps. among specific cps examined, “use a little and then wait to see how you feel before using more” had the strongest association with self-efficacy while “avoid methods of using cannabis that can make you more intoxicated than you would like” had the strongest negative association with cannabis use. we observed a significant indirect relationship from self-efficacy to cannabis use through use of cps. our findings suggest that use of cps is a potential mechanism by which cannabis users reduce use, and a more proximal antecedent of cannabis use than personal confidence in one’s ability to stop using. these preliminary findings highlight the value of studying individual strategies. they also may have implications for promoting use of cannabis protective strategies when treating those with cannabis use problems. key words: self-efficacy, cannabis use, marijuana, cannabis protective strategies in the us, the legal status of cannabis continues to evolve. as of 2017, 29 states have legalized the use of medical cannabis, and nine permit recreational use. nationwide, cannabis is the most widely used illicit drug and overall usage rates are increasing (johnston, o’malley, bachman, schulenberg, & miech, 2015). as the population of users has increased, the number of individuals diagnosed with cannabis use disorder (cud) has followed suit (hasin, 2018). young adults are at particularly high levels of risk for abusing cannabis and developing associated negative consequences (pedersen, hummer, rinker, traylor, & neighbors, 2016). in fact, research has shown that (a) daily use among college students is at its highest level in over three cannabis 2018, volume 1 (2), 66-76 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.007 open access the indirect effects of selfefficacy on cannabis use via cannabis protective strategies: a preliminary study corresponding author: eleftherios m. hetelekides, research institute on addictions, university at buffalo, 1021 main street, buffalo, ny 14203. phone: 585-739-8252, email: elefther@buffalo.edu eleftherios m. hetelekides1, alexander j. tyskiewicz2, mark a. prince2, r. lorraine collins1,3 1 research institute on addictions, university at buffalo, buffalo, ny, usa 2 department of psychology, colorado state university, fort collins, co, usa 3 department of community health and health behavior, university at buffalo, buffalo, ny, usa cannabis, a publication of the research society on marijuana 67 decades, (b) 1 in 10 non-college attending young adults report daily use, and (c) about 1 in 17 high school seniors report using cannabis daily (johnston et al., 2015). a variety of negative consequences may follow from excessive use. these include cud; motor vehicle accidents; decreased academic performance; impaired respiratory and cardiovascular health; unintentional childhood exposure; as well as higher risk for experiencing psychiatric symptoms (hasin, 2018; national academies of sciences, engineering, and medicine, 2017). psychosocial interventions are generally used to help individuals to lessen their cannabis use. cognitive behavioral therapy (cbt) and motivational enhancement therapy (met) are two intervention approaches that have been significantly more effective in reducing cannabis use and consequences compared to control conditions (copeland, swift, roffman, & stephens, 2001; walker et al., 2011). even so, the efficacy of these treatments could be improved and new psychosocial interventions could be developed. to achieve this, it is essential to understand the mechanisms of change involved in reducing cannabis use. therapeutic methods such as cbt include the use of behavioral strategies that promote abstinence or decreased drug use and related consequences (copeland et al., 2001). although such interventions are theoretically supported (labrie, napper, grimaldi, kenney, & lac, 2015), clinical success has been limited and research examining treatments that directly target individually-tailored protective behavioral strategies (pbs) for substance use are rare, despite having shown promise (bingham et al., 2011). similarly, examination of the role of selfefficacy is lacking, even in research that prioritizes its enhancement as a means of reducing substance use and consequences (litt, kadden, & petry, 2013). this is in part due to a lack of concrete procedures for increasing selfefficacy levels (kadden & litt, 2011). self-efficacy is an important construct in the behavior change literature, especially with regard to substance abuse disorders. bandura (1977) first described the concept as one’s belief in one’s personal ability to effectively execute the behaviors required to produce a specific outcome. self-efficacy has strong explanatory power in predicting and mediating treatment effects across a variety of addictive behaviors (diclemente, prochaska, & gibertini, 1985; litt, kadden, & dabela, 2008). it has been shown to play a positive role in treatment for alcohol use disorders (adamson, sellman, & frampton, 2009; maisto et al., 2015), smoking cessation (condiotte & lichenstein, 1981; diclemente, fairhurst, & piotrowski,1995; gwaltney, metrik, kahler, & shiffman, 2009) and outcomes of cannabis treatment (litt & kadden, 2015; litt et al., 2008; litt et al., 2013; stephens, wertz, & roffman, 1995). protective behavioral strategies have been identified as a mechanism for reducing harm related to managing risky behaviors, including substance use (pedersen et al., 2016). the alcohol research literature has provided evidence of negative associations between frequency of pbs use and alcohol use, and/or alcohol-related negative consequences, across a variety of groups (borden et al., 2011; braitman, lindencarmichael, & henson, 2017; kenney, napper, labrie, & martens, 2014; labrie, kenney, & lac, 2010). additional findings indicate that pbs use plays a moderating role in the relationship between binge drinking and alcohol problems, and that interventions focusing on increasing the number of strategies used by individuals within risky situations may be beneficial for reducing problematic alcohol-related behaviors and consequences (borden et al., 2011; braitman et al., 2017). the fledgling literature on the effects of pbs on cannabis use yields similar evidence. the results of research that has examined the associations among use of protective strategies, cannabis use, and negative consequences indicate that pbs use for cannabis is inversely associated with both other variables (e.g., bravo, prince, pearson, & marijuana outcomes study team, 2017; pedersen et al., 2016). further, use of protective strategies may atemporally (without implying causation; see winer et al., 2016) mediate the relationship between self-efficacy and cannabis use/consequences, with pbs use serving as a mechanism by which self-efficacy is manifested as behavioral control. in the current study, we examined whether the use of cannabis protective strategies (cps) may atemporally mediate the relationship between self-efficacy to reduce or abstain (ser/a) from using cannabis, and cannabis use (winer et al., 2016). cps are behaviors that occur more proximally to cannabis use relative to self indirect effects of self-efficacy on cannabis 68 efficacy, which is expected to motivate use of such strategies. we examined the relations among average cannabis quantity per day (i.e., the sum of all joints reported per day of the week divided by 7), use of cps, and participant’s se-r/a from cannabis use, and hypothesized that greater levels of se-r/a would be negatively associated with quantity of cannabis use and positively associated with the use of cps. moreover, we hypothesized that particularly effective cps could be identified across participants. this item-level analysis provided a deeper, qualitative look at the relations among se-r/a, use of cps, and cannabis use. it also could provide clinically relevant insights into the types of strategies that may be more or less beneficial to individuals across the range of se-r/a. method participants participants were community residents (n = 54; 34 (63%) men and 20 (37%) women) from the buffalo, ny metropolitan area, who self-reported regular cannabis use. although use of medical cannabis (mainly oil-based cbd products) now is legal in new york state, our participants were recreational users of cannabis and did not use cannabis for medicinal purposes. selection criteria included: being 18-30 years of age (m = 24.33; sd = 3.07); possession of a high school diploma or ged equivalent, and using cannabis at least 3 times per week. along with cannabis use, most participants (78%) reported social drinking (no more than 3 drinks per week; m = 1.11 drinks per day; sd = 1.02) and low rates of lifetime use of a variety of substances, including for tobacco products and cocaine. the majority of the sample was single (85.1%) and not attending school (83.3%). some (22.2%) participants were unemployed and 58.5% reported a total household income of less than $20,000. the sample indicated they were european american (44.4%), african american (27.8%), from more than one background (16.7%), unknown (3.7%), and other (5.6%). the majority (74.1%) of participants identified as non-hispanic. we used facebook advertising to recruit participants. individuals who clicked the advertisement were taken to our study page and asked to call or leave a facebook message with their phone number to indicate interest. eligibility was identified through a 20-minute phone screen. participants were found ineligible if they reported a history of serious or ongoing legal or medical issues, legal issues due to cannabis use, signs of severe mental illness, or drug abuse problems other than those associated with cannabis (e.g., abusing other illicit or licit drugs). this study was approved by the institutional review board of the university at buffalo. all participants provided their written informed consent, in which they agreed to be audio recorded. each received $50 for participating in all aspects of the study. procedure each participant was assigned to one of the eight semi-structured focus groups conducted for the study. each group was facilitated by two trained clinicians. during each group, participants were prompted to identify reasons they could imagine someone might want to quit or “cut down” on cannabis and to describe strategies that they felt could be used to achieve this goal. at the end of the group discussion, they individually completed a computerized survey that assessed the constructs of interest, using the measures described below. measures marijuana use questionnaire (muq; collins, vincent, yu, liu, & epstein, 2014). we used the muq to assess the typical quantity of cannabis used. participants were shown an image of an “average-sized joint” (1/2 a gram) and instructed to report the typical number of average-sized joints or equivalent amount used based on mode of use (e.g., smoke, vaporize), for each day of the week over the past 30 days. on average, participants reported smoking 3.10 joints on any given day of the week (sd = 2.12, range = 0.71 – 10.43). two participants’ scores were extreme outliers, so they were winsorized to the 95th percentile. protective behavioral strategies for marijuana (pbsm; pedersen et al., 2016). this measure was used to assess use of cannabis protective strategies. participants indicate the degree to which they used a pre-defined list of behaviors to lessen cannabis use and related cannabis, a publication of the research society on marijuana 69 negative consequences, on a scale, from 1 = never to 6 = always. sample items included “use a vaporizer or other smokeless method to avoid carcinogens”, “avoid buying marijuana”, and “avoid using marijuana early in the day”. in the current study, we used the 50 items in the original pbsm, rather than the 39-items in the measure finalized by pedersen et al. because the examination of strategy use is in its infancy and the pbsm is a relatively new measure, we felt that the additional 11 items might provide useful insights given our research goals. the 11 items that were not included in the original 39-item single factor pbsm have been italicized in table 1. for this sample, individuals on average and across all items reported using strategies “occasionally” (m = 2.94, sd = 1.00). self-efficacy to reduce consumption or abstain from using cannabis (se-r/a; stephens et al., 1995). this measure asked participants to rate how confident they would be in resisting the temptation to smoke cannabis in the context of 20 different situations. responses were recorded on a 7-point scale from 1 (not at all confident) to 7 (extremely confident). examples include asking participants how confident they would be in reducing or abstaining if “offered marijuana by someone”, “bored with nothing to do”, and “stressed out and needing to calm down.” stephens et al. examined the internal consistency of the se-r/a at pretreatment and posttreatment, and reported alphas of 0.89 and 0.94, respectively. for the current sample, participants rated their se-r/a levels at 3.54 on average (sd = 1.82), and alpha reliability was excellent (α = 0.96). analysis plan we tested our atemporal mediation hypothesis that cannabis use is predicted by se-r/a indirectly, via use of cps, using a path analysis (see model in figure 1). cannabis use is typically a highly skewed count variable; however, in the present study of regular to heavy cannabis users, the cannabis use variable was best modeled as approximately normal. analyses were conducted using mplus 7.4 (muthén & muthén, 1998–2012). the a priori path model is fully saturated, which precludes tests of overall model fit. the primary challenge in making appropriate determinations regarding the strength of an indirect effect is that the product of two regression slopes is not normally distributed. the violation of the normality assumption results in a loss of statistical power for many traditional approaches to testing mediation (e.g., the sobel test). in order to circumvent this issue, the best practices approach is to assess asymmetrical confidence intervals (acis) that best represent the true distribution of the product of coefficients. acis that do not contain zero are considered to be statistically significant. we examined the indirect effect of self-efficacy on outcomes using biascorrected bootstrapped estimates (efron & tibshirani, 1993) based on 10,000 bootstrapped samples, which provides a powerful test of mediation (fritz & mackinnon, 2007) and are asymmetrical. statistical significance was determined by 95% bias-corrected bootstrapped confidence intervals that do not contain zero. we used pearson’s correlations to explore item-level analyses of cps associations with selfefficacy and cannabis use. the goal of these analyses was to assess the degree of variability in the magnitude of the associations between each individual protective strategy (based on pbsm items) with self-efficacy and cannabis use to determine which specific strategies were most strongly linked to each variable. results typical cannabis use the current sample used cannabis near daily, reporting on average 27.02 (sd = 6.50) using days in the past month and 6.71 (sd = 1.06) in the week on average. mean age of first use was 14.65 (sd = 2.91), and participants reported starting to use cannabis regularly on average at age 16.89 (sd = 3.18). regarding quantity consumed, participants reported an average of 75.46 (sd = 47.96) standard joints (1/2 a gram) in the past month, which is equivalent to 1.50 (sd = 0.94) grams per using day. the sample also reported experiencing an average of 8.58 (sd = 5.62) out of 27 cannabisrelated problems in the past month. subjective intoxication was rated on average at 6.70 (sd = 1.77) out of 10. prediction of cannabis use by self-efficacy we used path analysis to examine whether cannabis use was predicted by self-efficacy (as indirect effects of self-efficacy on cannabis 70 measured by the se-r/a) indirectly, via cps use (see figure 1). we found that our measure of selfefficacy explained 23% of the variance in cps, as measured by the pbsm. self-efficacy and cps use explained 25.5% of the variance in cannabis use. self-efficacy significantly and positively predicted cps use (b = .27, se = .09, p = .004, 95% bias-corrected bootstrapped ci [.14, .72], β = .48), but did not significantly predict cannabis use (b = -.13, se = .12, p = .27, 95% bias-corrected bootstrapped ci [-.35, .09], β = -.16). however, in bivariate models, self-efficacy significantly negatively predicted cannabis use. use of cps significantly negatively predicted cannabis use (b = -.56, se = .22, p = .01, 95% bias-corrected bootstrapped ci [-.96, -.10], β = -.41). the indirect effect of self-efficacy predicting cannabis use via cps use was statistically significant (b = -.15, se = .08, p = .03, 95% bias-corrected bootstrapped ci [-.34, -.05], β = -.19). associations among use of cannabis protective strategies, self-efficacy, and typical cannabis use we sought to identify specific cannabis protective strategies that were particularly strongly associated with greater levels of selfefficacy (i.e., the se-r/a) and less cannabis use, across participants. we identified three broad patterns of findings based on medium to large effect sizes (see table 1). specifically, we found: 1) a set of six strategies with medium to large effect sizes associated with self-efficacy, but not with typical quantity of cannabis; 2) a set of four strategies with medium to large effect sizes associated with typical quantity of cannabis use, but not with self-efficacy; and, 3) a set of 19 strategies with medium to large effect sizes associated with both self-efficacy and typical quantity of cannabis used. overall, 29 items had medium to large effects related to at least one variable, including four items that did not load onto the original 39-item pbsm, identified by pedersen et al. (2016). some studies in the alcohol literature have demonstrated that pbs can be differentiated, and that different types of pbs are more effective for certain individuals (e.g., linden, kite, braitman, & henson, 2014). table 1 includes all 50 strategies from the original pbsm measure (pedersen et al., 2016), presented in descending order based on effect sizes and grouped into four clusters. the first cluster consists of strategies with medium to large effect sizes in relation to self-efficacy (i.e., se-r/a), then medium to large effect sizes with cannabis use, then medium to large effect sizes with both self-efficacy and cannabis use. the final set of strategies had less than medium sized effects. discussion in the present study, we examined the role of cannabis protective strategies (cps) in atemporally mediating the effects of reported selfefficacy to reduce or abstain (measured by the ser/a) on typical quantity of cannabis used. specifically, higher levels of self-efficacy were significantly associated with more frequent strategy use. more frequent use of cps was in turn significantly associated with lower levels of cannabis use. some subsets of strategies had stronger effect sizes in relation to greater selfefficacy and/or less cannabis use. our findings are framed using the distinction made between temporal and atemporal mediation (winer et al., 2016). atemporal analyses do not speak to the causality of why mediation is occurring as a function of time. in this way, the path model is not implying a one directional relationship between the variables. therefore it is possible and theoretically likely that in reality this relationship is reciprocal, for example, less cannabis use leading to more use of cps, and greater levels of self-efficacy. we grouped the strategies, assessed using items from the pbsm, based on the size of the effect related to self-efficacy and cannabis use. the first group of strategies can be broadly classified as strategies used to modify cannabis use in specific ways, and are highly associated with se-r/a, but not cannabis use. two pbsm items that did not load onto the original factor described by pedersen et al. (2016) were a part of this group (“use higher potency marijuana so you can take less hits and avoid lung damage” and “use your own marijuana (if alone or sharing with friends) so you know what you are using”). efforts to modify cannabis use are thus linked to se-r/a. however, effective use of cps (i.e., use of strategies that leads to less cannabis use) does not necessarily follow attempts to use these strategies. for example, “do not keep marijuana cannabis, a publication of the research society on marijuana 71 table 1. pearson’s r effect sizes among pbsm items, self-efficacy to reduce/abstain (se-r/a) and cannabis use (cu). strategies with medium to large effects with se-r/a only (bolded) pbsm item se-r/a cu use higher potency marijuana so you can take less hits and avoid lung damage. .483 -.221 avoid using marijuana for several days in advance of a big test, interview, performance, or other engagement for which you need to be crisp and are being evaluated. .436 -.165 do not keep marijuana in the car, whether as a driver or passenger. .408 -.129 use your own marijuana (if alone or sharing with friends) so you know what you are using. .387 -.237 keep track of your costs to get an accurate picture of how much you spend on marijuana. .344 -.171 to decrease tolerance, take a break for a week or two, or take longer breaks than usual between use. .313 -.271 strategies with medium to large effects with cannabis use only (bolded) pbsm item se-r/a cu avoid using marijuana before work or school. .289 -.412 stop using marijuana if you become anxious or paranoid. .112 -.360 avoid mixing marijuana with other drugs. .159 -.358 take a break from using if feeling a loss of motivation. .246 -.320 strategies with medium to large effects with se-r/a and cannabis use (bolded) pbsm item se-r/a cu avoid using marijuana habitually (that is, every day or multiple times a week). .483 -.451 use a little and then wait to see how you feel before using more. .461 -.453 avoid methods of using marijuana that can make you more intoxicated than you would like (e.g., using large bongs, volcano, ‘edibles,’ etc.). .400 -.497 if attending a party or going out to a social event (e.g., bar), decide in advance whether you want to use marijuana or not. .430 -.458 only use before special events (e.g., movies, concerts) or on special occasions. .397 -.460 avoid using marijuana before engaging in physical activity (i.e., exercise, hiking). .390 -.467 limit the amount of marijuana you smoke in one sitting. .455 -.397 use enough only to achieve a slight buzz or to avoid getting "too high". .400 -.422 only use marijuana on private property. .456 -.352 take periodic breaks if it feels like you are using marijuana too frequently. .380 -.426 avoid buying marijuana. .440 -.365 avoid using marijuana early in the day. .395 -.399 avoid using marijuana out of boredom. .446 -.348 only use one time during a day/night. .396 -.388 pass on shared joints, bongs, etc. if already feeling high. .303 -.429 avoid using when feeling anxious (e.g., using to calm you down or stop worrying). .327 -.404 avoid driving a car after using. .325 -.373 avoid using marijuana in concentrated forms (e.g., hashish, hashish/honey oil, kief, marijuana butter/oil, etc.) to avoid getting too high. .333 -.342 only use when you know you have nothing important to do for the rest of the day/night. .312 -.308 indirect effects of self-efficacy on cannabis 72 table 1 continued. pearson’s r effect sizes among pbsm items, self-efficacy to reduce/abstain (se-r/a) and cannabis use (cu). strategies with less than medium effects (bolded) pbsm item se-r/a cu use eye drops so others do not know you have used. .263 -.254 use a vaporizer or other smokeless method to avoid carcinogens. .258 -.229 avoid using marijuana to cope with emotions such as sadness or depression. .229 -.242 avoid using marijuana in large gatherings or crowds. .285 -.185 use only at home. .157 -.269 avoid using marijuana in public places. .120 -.289 only use at night (that is, not during the day). .236 -.166 avoid using marijuana if currently taking any kind of prescription drug that might intensify the effects (e.g., make you feel more tired). .144 -.219 avoid possibilities of legal repercussions (e.g., smoke in a safe place like home, avoid having marijuana with you where you might get searched, etc.). .152 -.206 only purchase marijuana from a trusted source. .174 -.139 use a designated driver (i.e., someone who has not used) after using marijuana. .109 .201 limit use to weekends. .204 -.093 excuse yourself from the room if people are smoking marijuana and you feel uncomfortable or do not wish to be offered marijuana. .126 -.147 only use marijuana after completing all of the day's responsibilities. .169 .093 avoid mixing marijuana with alcohol. .050 -.189 avoid use while spending time with family. .045 -.192 buy less marijuana at a time so you smoke less. .106 -.066 avoid situations that you anticipate being pressured to use marijuana. .131 -.035 having a set amount of “times” you take a hit (e.g., passing on a shared joint if you have already hit that limit). .155 -.010 use marijuana only among trusted peers. .048 -.089 avoid bringing marijuana into events or venues where you are likely to be searched. .064 -.031 note. italicized items were not included in the single factor pbsm scale developed by pedersen et al., 2016. in the car, whether as a driver or passenger” is a strategy that even if successfully employed to reduce the risk of consequences, does not have direct implications for overall cannabis use. these modification-based strategies may still play a significant role in reducing the number of negative, cannabis related consequences experienced by individuals. the four cps in the next group were strongly associated with reductions in cannabis use but not se-r/a beliefs. examples include “avoid mixing marijuana with other drugs”, “stop using marijuana if you become anxious or paranoid”, and “avoid driving a car after using.” these strategies may be a particularly useful subset for individuals seeking to decrease their cannabis use, because they can be used even by individuals who have low selfefficacy (as measured by the se-r/a). this may be because each of these strategies operate within a context where there are a priori reasons that provide situational motivation to limit use, such as feeling anxious or needing to operate a motor vehicle. the strategies from the next cluster are highly associated with both greater self-efficacy and less typical cannabis use. two of these strategies also did not load onto the original pbsm factor structure (specifically, “if attending a party or going out to a social event (e.g., bar), decide in advance whether you want to use marijuana or not” and “only use before special events (e.g., movies, concerts) or on special occasions”). additional examples from this cluster of strategies (and from the original 39-item pbsm) include “avoid using marijuana habitually cannabis, a publication of the research society on marijuana 73 (that is, everyday or multiple times a week)”, “avoid using marijuana early in the day”, and “take periodic breaks if it feels like you are using marijuana too frequently.” these strategies modified cannabis use behaviors and provided concrete reductions in overall use. these strategies may be useful for individuals who would most benefit from bolstered levels of selfefficacy, because using them likely will result in reaching one’s goals, thereby creating a positive cycle that boosts self-efficacy. together, the itemlevel analysis of strategies listed in the pbsm provides qualitative support for the conceptual framework of the path model, by identifying the strategies that are most strongly associated with self-efficacy, with typical cannabis use, and with both. the item-level analysis in tandem with the indirect effects provide evidence that use of cps may be a mechanism by which self-efficacy contributes to reductions in cannabis use. cannabis-specific treatment programs typically are designed to provide cannabis users with useful, viable tools for regulating their use and reducing harm. in this study, the use of cps had a strong cross-sectional association with lower levels of cannabis use. moreover, we found that cps use had a more proximal association to cannabis use than self-efficacy, as measured by the se-r/a. thus, we recommend that use of cps serve as high priority targets for promoting abstinence and/or reductions in cannabis use. further, we recommend that interventionists work to bolster self-efficacy, as it may increase the number of strategies that cannabis users employ as well as being directly related to lessening cannabis use. additionally, because strong selfefficacy beliefs are associated with generally positive outcomes after treatment, encouraging strategy use that naturally promotes increased levels of self-efficacy may help to maximize positive treatment outcomes. in sum, the relationship between these variables may be most effectively utilized in clinical settings by boosting the existing positive feedback loop to minimize recurrent cannabis use and problems. finally, this research presents preliminary evidence that highlights the clinical value of studying different types of strategies, and encourages additional research to examine how different types of cps may be more or less useful to different individuals. there are several strengths and limitations to this study. first, we collected these data from a community sample of young-adults who reported regular use of cannabis a population at high risk for experiencing negative cannabis-related consequences. it is also the first study to examine the relationship among self-efficacy, use of cps, and cannabis use, and which provides both aggregate and item-level analyses of these relationships. limitations include the small sample size, lack of information gathered regarding participant’s use of thc concentrates, as well as the correlational design of the study. the use of cps has been identified as a broad negative predictor for cannabis use quantity, frequency, and consequences. our findings are consistent with previous research in suggesting that intervention programs should promote strategy use as a way of helping individuals attenuate their use and level of risk (bravo, anthenien, prince, pearson, & marijuana outcomes study team, 2017; pedersen et al., 2016). cps also have been shown to buffer and enhance a variety of risk and protective factors (bravo, anthenien et al., 2017). though more research is needed to identify specifically what other variables may be involved in the relationships examined in this manuscript, this study suggests that use of protective strategies are one mechanism by which self-efficacy is associated with reductions in cannabis use. references adamson, s. j., sellman, j. d., & frampton, c. m. 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(2002). therapeutic alliance, group cohesion, and homework compliance during cognitive-behavioral group treatment of social phobia. behavior therapy, 33(1), 5-27. doi: 10.1016/s00057894(02)80003-x funding: the development of this report was supported by the howard t. blane director’s award for the development of innovative research in the addictions to mark a. prince. this research was also supported by the national institute on alcohol abuse and alcoholism/nih grant t32-aa007583, which supported mark a. prince. https://doi.org/10.2190/de.40.4.c https://doi.org/10.2190/de.40.4.c http://doi.org/10.1007/s11121-015-0549-8 https://doi.org/10.1016/j.addbeh.2013.10.008 http://dx.doi.org/10.1037/adb0000085 http://dx.doi.org/10.1037/adb0000085 https://doi.org/10.1002/data.20073 https://doi.org/10.1002/data.20073 https://doi.org/10.1016/j.addbeh.2012.08.011 http://doi.org/10.1111/acer.12649 http://doi.org/10.15288/jsad.2016.77.441 http://dx.doi.org/10.1037/0022-006x.63.6.1022 http://dx.doi.org/10.1037/a0024076 http://dx.doi.org/10.1037/a0024076 https://doi.org/10.1016/s0005-7894(02)80003-x https://doi.org/10.1016/s0005-7894(02)80003-x indirect effects of self-efficacy on cannabis 76 copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ v4i2a1_authors_v2 research article 1 ved abstract background: the current study examined how cannabis use status impacts cognitive and emotional reactions to public health campaigns about cannabis, and the degree to which these reactions influence message likeability and attitudes about cannabis-related harms. methods: in a between-subjects design, 252 subjects recruited via amazon mechanical turk viewed six real-world cannabis education messages: three message themes (cognitive ability, driving, and health harms) from each of two real-world public campaigns. subjects answered questions measuring their cognitive and emotional reactions to each message as well as message likeability and harm perceptions of cannabis. analyses examined the mediating effects of message responsiveness on the association between baseline cannabis use (user vs non-user) with indices of liking and harm. results: for all three message themes, informativeness ratings mediated the effect of cannabis user status on the outcomes of perceived harmfulness and message likeability. specifically, cannabis users perceived cannabis as less harmful and reported all messages as less likeable compared to non-users, partly because they perceived the messages to be less informative than non-users. surprisingly, users found some of the messages to be more pleasant, which was associated with increased perceptions of harm and message liking compared to non-users. conclusions: cannabis education campaigns that take into account differences in emotional and cognitive reactions by use experience, rather than use a “one size fits all” approach, could possibly maximally impact likeability and harm perceptions of these messages. key words: = cannabis, use status, public health campaign, health communication, health messaging, perceptions of harm, message liking given the rapid proliferation of new laws and policies surrounding cannabis use across the united states (hartig & geiger, 2018), the importance of conveying the risks of cannabis use to the public also increases (monte et al., 2015). as of april 2021, 17 states have legalized recreational cannabis use, 36 states have legalized medical use, and 32 states have decriminalized use. in 2018 among americans over the age of 12 years, 27.7 million reported cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.001 how cannabis use status affects responses to anticannabis messages corresponding author: elise m. stevens, phd, department of population and quantitative health sciences, division of preventative and behavioral medicine, university of massachusetts medical school. 368 plantation street, worcester, ma 01605. email: elise.stevens@umassmed.edu elise m. stevens1, glenn leshner2, amy m. cohn3,4, seunghyun kim5, theodore l. wagener6 1department of population and quantitative health sciences, division of preventative and behavioral medicine, university of massachusetts medical school, worcester, ma 2gaylord college of journalism and mass communication, the university of oklahoma, norman, ok 3health promotion research center, stephenson cancer center, university of oklahoma health sciences center, oklahoma city, ok 4department of pediatrics, college of medicine, university of oklahoma health sciences center, oklahoma city, ok 5department of marketing and advertising, college of business, university of arkansas at little rock, little rock, ar 6medical oncology, the ohio state university, columbus, oh responses to anti-cannabis messages 2 using cannabis in the past 30 days (national survey on drug use and health, 2018). because changes in cannabis policies could lead to increased acceptability of cannabis use and potentially, rises in the prevalence of initiation and use, it is important for public education efforts to be implemented in step with legalization in order to minimize potential public health harms from problematic cannabis use and related negative health outcomes (monte et al., 2015). health risks associated with cannabis use include cancers (cooper & haney, 2009; y.-h. j. huang et al., 2015; mehra et al., 2006), drug and alcohol use (kam et al., 2009; white et al., 2005, 2006), lowered cognitive ability (arria et al., 2013; d. y. c. huang et al., 2011) and mood disorders (crane et al., 2015; gage et al., 2015), as well as injury or death from car accidents (blows et al., 2005). one effective way to raise awareness of these negative outcomes is through public health messaging campaigns, which reach many people at a relatively low cost (farrelly et al., 2007; goldman & glantz, 1998). however, the empirically-tested public health campaigns that highlight the risks of cannabis use are nearly 20 years old (palmgreen et al., 2001), which leaves an important gap in our understanding as to how best to convey these risks. when designing messages within public health campaigns, there are various elements to consider. specifically, it is important to understand the target audience’s cognitive and emotional responses to the message or messages within a campaign (batra & ray, 1986; burke & edell, 1986) including their liking and receptivity of the message (mackenzie et al., 1986). these responses indicate how the audience evaluates the messages and how such messages could impact their future health behavior (alvaro et al., 2013). mcguire’s communication persuasion matrix (2001) shows that the steps in persuasion are as follows: step 1) exposure to the message, step 2) attention to the message, step 3) cognitive and emotional responses to the message, step 4) attitude towards the message and perceptions of the product, and step 5) product use or non-use; where step 4 is captured by likeability of the message (e.g., attitudes towards the message) and harm perceptions of cannabis (e.g., perceptions of the product). this study employs steps one through four to understand how cannabis education messages impact individuals’ responses to these messages. this study will inform which messages are best suited for interventions and thus be used in subsequent studies about product use (step 5). specifically, this study examined how cognitive and emotional responses to a message (e.g., measured by pleasantness, unpleasantness, arousal, informativeness; step 3) mediate the association between cannabis use status and attitude toward the message and perceptions of the product (e.g., message liking, perceived harmfulness of cannabis; step 4). previous research has illustrated how cognitive and emotional responses outlined by step 3 in the persuasion matrix can impact perceptions and liking (step 4 in the persuasion matrix), which in turn impact use or non-use of the product (step 5). for example, one metaanalysis examining health messages found that messages that elicited an unpleasant emotional response (step 3 in the persuasion matrix), triggered perceptions of the product (step 4), and eventually had the ability to impact behavior change, step 5 (witte & allen, 2000). in addition, a study that examined perceptions of harm about lyme disease after viewing a health message about the lyme disease vaccine showed that increased harm perceptions of the disease (step 4) impacted engagement in getting the vaccine (e.g., step 5 participating in the health behavior; brewer et al., 2004). with regard to message liking, advertising studies for everyday products such as toothpaste have shown that liking of the message/advertisement was an important indicator of future positive behavior change/buying the product (step 4 and 5; mackenzie et al., 1986). in summary, understanding how audiences might respond to health messages about cannabis is imperative to spreading awareness about the risk of use. based on health communication literature, two key factors may help to determine optimal message content in cannabis public health messages: 1) theme of the message (e.g., addiction, cessation, health or social consequences; beaudoin, 2002) and 2) whether or not the intended audience has used or has had experience with the health behavior in question – in this case, having ever used or currently using cannabis (cho et al., 2016; dillard & shen, 2005; national cancer institute, 2008; wakefield et al., 2013). first, understanding how audiences react to different message themes can help campaign cannabis, a publication of the research society on marijuana 3 designers select optimal message content. emotions, both positive and negative, can effectively change attitudes and behavior, and different types of message themes can elicit those emotions (dillard & nabi, 2006). thus, it is important that messages elicit strong emotions, which can trigger beliefs (e.g., greater liking, increased perceptions of harm; brewer et al., 2004; mackenzie et al., 1986), and not the emotions that will likely deter people from the processing and remembering the message (e.g., disliking the message; brewer et al., 2004; mackenzie et al., 1986). while no study has examined the themes of public health messages focused on cannabis, one review of anti-tobacco messaging studies found that different themes (e.g., addiction, industry manipulation, cessation, health consequences of tobacco) were effectively employed to cater to the target audience (beaudoin, 2002). results of this review showed that messages targeted at adults were mostly fear appeals and focused on long-term health consequences (beaudoin, 2002). the second factor that may play a role in audience reactions is prior or current experience with the behavior highlighted in the message, in this case, cannabis use status. for example, tobacco studies have shown that cigarette smokers are less inclined to react positively to anti-smoking messages and can feel annoyed or defensive (wolburg, 2006), while non-smokers have been shown to react positively (national cancer institute, 2008). it is possible that individuals who have experience using cannabis, either in the past or who currently use, may react differently to messages about cannabis-related health risks than individuals who have never used cannabis. thus, the first step in implementing cannabis public health messages is to understand responses to messages with regard to theme and use status. if use status is an important factor in message responsiveness in terms of perceived harmfulness of cannabis and message liking, this would mean that anti-cannabis messages should not be developed as a “one size fits all” approach, but rather, messages should be created to separately target users and non-users, perhaps with themes and message types that are unique to their experiences with the product. this study proposes to examine cognitive and emotional reactions to public health education messages about cannabis so that existing and future campaigns can have a greater impact. specifically, the current study examined whether cognitive and emotional reactions mediate differences in cannabis users’ and non-users’ responses to real-world cannabis public health campaigns, spanning three message themes: 1) cognitive ability, (2) driving fatalities, and 3) health harms. after viewing each message, participants were asked to evaluate their emotional state, arousal, perception of the message (how informative the message was), liking of the message, and harm perceptions of cannabis use. understanding audience reactions to currently existing messages may help identify areas of strength and weakness for effective message development that target these risk perceptions. based on previous research, we hypothesized that non-users would show evidence of more positive responses to messages (e.g., increased message liking and increased perceptions of harm) and that increased perceptions of informativeness and unpleasantness would in turn be associated with increased message liking and increased perceptions of harm. methods participants (n = 258) were cannabis users and non-users recruited from amazon mechanical turk (mturk) during the summer of 2017. mturk samples have been found to be similar to nationally representative survey samples (coppock, 2019; kees et al., 2017; walters et al., 2018). inclusion criteria were: aged 18 or older and located within the united states (as verified by ip address). the survey link was posted on mturk and users could opt-in to answer a survey advertised as, “we are researchers studying the perceptions of health messages. we are inviting you to participate in our online survey. participation in this research includes viewing health messages and then answering questions about your perceptions of those messages and attitudes after viewing the messages. it will take you approximately 25 minutes.” after consent was obtained, participants answered questions about demographics (age, sex, and race) and current cannabis use (“somedays,” “every day,” “not at all”). then, participants viewed six anti-cannabis print messages obtained from real world campaigns in the united states. after viewing responses to anti-cannabis messages 4 each message, participants answered questions in the following domains: pleasant and unpleasant affect, arousal, perceived message, perceived message informativeness, message liking, and perceived harmfulness of cannabis. all participants saw all messages, and messages were presented to participants in a random order. participants spent on average, 8.04 minutes (sd = 4.98 minutes) completing the survey. they could view the messages for as long as they wanted. procedures were approved by the university of oklahoma’s institutional review board. participants were paid $0.50 for completing the task, which is slightly higher than a typical survey of this length on mturk (buhrmester et al., 2015). anti-cannabis messages messages were obtained from two real world public health campaigns: the “do the math” print campaign developed by the liberty alliance for youth, a coalition in liberty, mo (http://libertyalliance4youth.com/), and the “spread the facts” print campaign developed for adolescents by the national institute on drug abuse for teens (https://teens.drugabuse.gov/). participants viewed three messages from each of the two campaigns, and both campaigns provided a message from each of the following themes: cognitive ability, driving ability, and health harms associated with cannabis use. cognitive ability messages focused on drops in iq from cannabis use. driving messages focused on car accidents due to being under the influence of cannabis. health harms messages focused on medically necessary admissions for drug treatments and increases in anxiety and depression due to cannabis use. messages from the “do the math” campaign contained stick figure drawings and messages from the “spread the facts” campaign contained real life imagery. see table 1 for a description of the stimuli. this study aimed to combat single-message design effects by having participants in the study view two different messages per message theme (one message per theme from each campaign), an approach that aligns with other published studies (e.g., goodall et al., 2013; jensen, 2008; kim et al., 2012; lee et al., 2011). this allowed us to attribute differences due to the theme category and not attributes in a single message. it also allowed us to strengthen our ability to generalize the results to the real world (leshner, 2013; o’keefe, 2003; reeves & geiger, 1994; tao & bucy, 2007; thorson et al., 2012). table 1. cannabis messages cognitive ability cognitive ability text: marijuana. it lowers your intelligence. new research shows a permanent drop in iq when marijuana is used regularly before the age of 18. image: photograph of woman holding her hand to her face. text: do the math. fact: marijuana has been shown to permanently drop iq by an average of 8 points. image: a math equation showing a drawing of a cannabis leaf and a plus sign with a drawing of a human head and brain on the other side. after the equals sign, there is an image of the letters “iq” that points downard. driving driving text: marijuana. it impairs driving. in the united states, marijuana is the most commonly identified illegal drug in fatal crashes (14% of drivers). image: photograph of car crash scene with an ambulance and emergency helicopter. text: do the math. fact: marijuana is the most common illegal drug found in drivers who are in car accidents. image: a math equation showing a drawing of a cannabis leaf and a plus sign with a drawing of a human head and brain on the other side. after the equals sign, there is an drawing of a car driving into a lamppost. (table continues) cannabis, a publication of the research society on marijuana 5 health harms health harms text: marijuana. it’s hamrful to youth. about 68% of all medically necessary drug treatment admissions for youth ages 12-17 are for marijuana. image: photograph of a young man sitting in an empty hallway with his elbows resting on his knees and his head hanging. text: do the math. fact: marijuana has been shown to double the risk of anxiety and depression. image: a math equation showing a drawing of a cannabis leaf and a plus sign with a drawing of a human head and brain on the other side. after the equals sign, there is stick figure human with a thought bubble that reads, “anxiety & depression.” measures independent variable cannabis use status. participants answered the question “how frequently do you use marijuana?” response options were “somedays,” “every day,” and “not at all.” participants who answered “somedays” or “every day” were categorized as cannabis users and those who answered “not at all” were categorized as nonusers. for mediation models (described below) users were coded as 1 and non-users were coded as 0. covariates demographics. age, sex, and race were used as covariates. race was assessed with the following categories: asian, black/african american, native american/alaskan, pacific islander, white/caucasian, more than one/other. race was recoded into the three largest categories. asian, white, and other. mediators pleasant affect. pleasant affect was measured post-message viewing, using the question, “how pleasant did this message make you feel?” on a scale from 1 (not at all) to 7 (extremely). this measure was adapted from an existing measure to assess positive affect (bradley & lang, 1994; clayton et al., 2018; watson et al., 1988) and was averaged for each message theme. unpleasant affect. unpleasant affect was measured using the question, “how unpleasant did this message make you feel?” on a scale from 1 (not at all) to 7 (extremely). this measure was adapted to assess negative affect (bradley & lang, 1994; clayton et al., 2018; watson et al., 1988) was averaged for each message theme. arousal. arousal was measured using the question, “how did this message make you feel?” on a scale from 1 (calm) to 7 (excited). this was an adapted measure (bradley & lang, 1994; clayton et al., 2018; watson et al., 1988) with higher scores reflecting greater arousal. it is important to note that arousal is typically measured separately from pleasant and unpleasant affect as a separate construct (watson & tellegen, 1985). items were averaged for each message theme. message informativeness. message informativeness was measured with the question, “please rate the message on the following: this message was informational” on a scale from 1 (not at all) to 7 (extremely). items were averaged for each message theme. dependent variables message liking. participants were asked how much they liked the message they just saw, “please rate this message on a scale from 1 (disliked it very much) to 7 (liked it very much),” which was adapted from previous work (unger et al., 1995). items were averaged for each message theme. perceived harmfulness of cannabis. perceived harmfulness of cannabis was assessed using the question, “how harmful do you think marijuana is to your health?” on a scale from 1 (not harmful at all) to 5 (extremely harmful) (national institutes of health [nih] and the u.s. food and drug administration [fda], 2013). items were averaged for each message theme. data analysis figure 1 shows the conceptual mediation model of the association between cannabis use status and perceived harmfulness of cannabis and message liking as the primary dependent responses to anti-cannabis messages 6 variables of interest, with pleasant, unpleasant, arousal, and message informativeness, as mediators. all models controlled for age, sex, and race. analyses were conducted in ibm’s spss 24 using andrew hayes’ process v3.3 model number 4. direct effects of use status on the two dependent variables (perceived harmfulness and message liking) for each of the three message themes (cognitive ability, driving, and health harms) are discussed first. it is important to note that direct effects of use status on each of the outcome variables control for the effects of the four mediators. then, the indirect effects of the four mediating variables (pleasant, unpleasant, arousal, informativeness) on each dependent variable are discussed. separate mediation models were conducted for each message theme. in process, the a*b paths were used to estimate the indirect effects of cannabis use status on either perceived harmfulness or message liking across the four potential mediating variables (pleasant, unpleasant, arousal, informativeness). p-values of less than 0.05 were considered statistically significant and 95% confidence intervals are reported for each model for the indirect effects. figure 1. conceptual multiple mediation model note: c’ represents the direct effect of use status on a dependent variable. results participants participants (n = 252) ranged in age from 18 to 76 (m = 37.24, sd = 11.57) and were 48.8% female (n = 126; nine individuals did not report their sex). the majority of participants were white (67.8%), followed by asian (16.7%). fiftyeight percent (58.5%) (n = 151) were cannabis nonusers, while 39.1% were “somedays” or “everyday” users (n = 101; six individuals did not report their use status). users and non-users differed on demographics, where users were younger [f(1, 249) = 46.56, p < .001], more likely to be male (χ2 = 8.22, p < .01), and more likely to be white (χ2 = 7.11, p < .05). see table 2 for a summary of means and standard deviations by use status for each message theme. use status (non-user) pleasant unpleasant perceived harmfulness or message liking arousal informational a1 a3 a2 a4 b1 b2 b4 b3 c’ cannabis, a publication of the research society on marijuana 7 table 2. means for measures by message theme and cannabis use status message themes cognitive driving health harms measures non-user user ηp2 non-user user ηp2 non-user user ηp2 pleasant 2.24 (1.32) 3.10 (1.87) .07*** 2.10 (1.37) 3.04 (1.79) .08*** 2.28 (1.39) 2.99 (1.90) .04** unpleasant 4.54 (1.67) 4.05 (1.84) .02* 4.90 (1.60) 4.15 (1.67) .05** 4.58(1.70) 4.16 (1.81) .01 arousal 3.60 (1.52) 3.72 (1.71) .00 4.08 (1.58) 3.92 (1.77) .00 3.59 (1.51) 3.80 (1.55) .00 informational 4.94 (1.56) 3.90 (1.86) .08*** 5.09 (1.42) 3.93 (1.82) .11*** 4.93 (1.44) 3.99 (1.88) .07*** liking 4.40(1.51) 3.65 (1.79) .05** 4.39 (1.50) 3.77 (1.81) .03** 4.31 (1.60) 3.58 (1.79) .04** harmful 3.07 (1.18) 2.42 (1.13) .07*** 3.03 (1.17) 2.38 (1.11) .07*** 3.09 (1.19) 2.40 (1.14) .09*** note: cell entries are means; standard deviations are in parentheses. pleasant, unpleasant, and informational ranged on a scale from 1 “not at all” to 7 “extremely.” arousal ranged from 1 “calm” to 7 “excited.” message liking ranged from 1 “disliked it very much” to 7 “liked it very much.” perceived harmfulness ranged from 1 “no harm at all” to 5 “extremely harmful.” *p < .05, **p < .01, ***p < .001. responses to anti-cannabis messages 8 table 3. mediators and indirect effects predicting perceived harmfulness and message liking outcome perceived harmfulness message liking message theme cognitive ability driving health harms cognitive ability driving health harms path b b se b se b se b se b se b se b1 (pleasant) .10* .05 .12** .05 .03 .04 .33*** .05 .37*** .05 .03 .04 b2 (unpleasant) .07 .05 .06 .05 .04 .04 -.03 .05 .05 .06 .04 .04 b3 (arousal) .08 .06 .07 .05 .17** .05 .19** .06 -.001 .06 .17** .05 b4 (informational) .25*** .04 .28*** .05 .31*** .04 .48*** .05 .53*** .06 .31*** .04 a*b b se b se b se b se b se b se pleasant .07 .05 .08* .04 .02 .03 .24* .09 .26* .10 .02 .03 unpleasant -.02 .03 -.04 .04 -.02 .02 .01 .03 -.04 .05 -.01 .02 arousal .01 .03 -.005 .02 .04 .04 .04 .5 .000 .02 .04 .04 informational -.27* .08 -.35* .09 -.30* .08 -.52* .13 -.66* .15 -.30* .09 direct effects b se b se b se b se b se b se cannabis use status -.47** .15 -.36* .15 -.53*** .14 -.49** .16 -.19 .18 -.53*** .14 note. all models controlled for age, sex, and race. cannabis use status was coded “0” for non-users and “1” for users. * p < .05 ** p < .01 *** p < .001 cannabis, a publication of the research society on marijuana 9 direct effects of cannabis use status on perceived harmfulness and message liking table 3 shows the results of the mediation models. for each of the three message themes, users reported significantly lower perceived harm of cannabis, post-message viewing, than did nonusers (all p’s < .05; table 3). in addition, there were significant negative direct effects for cognitive ability and health harms themes on message liking. specifically, for perceived harmfulness, cannabis users rated cannabis as significantly less harmful than non-users in every message theme category: cognitive ability messages (b = 0.47, p < .01), the driving messages (b = -0.36, p < .05), and the health harms messages (b = -0.53, p < .001). sex was significantly associated with perceived harmfulness (b = -29, p < .05), such that men rated cannabis more harmful than women in cognitive ability message category. similar associations were found for the direct effect of cannabis use status on message liking for two of the three message themes. specifically, cannabis users reported significantly lower message liking for cognitive ability messages (b = -0.49, p < .05) and for health harms messages (b = -0.53, p < .001). sex (b = -.27, p < .05) was significantly associated with message liking such that men liked the cognitive ability messages more. age was also significantly associated with liking of the message, such that older participants liked the messages more in two categories (cognitive ability: b = .01, p < .01; driving: (b = .01, p < .001). mediation models six multiple mediation models were tested. the a paths (i.e., the path from use status to each mediating variable) for each message theme are shown in table 4. the b paths (i.e., the paths from each mediator variable to each of the two dependent variables) for each message theme are shown in table 3. also shown in table 3 are the indirect effects of cannabis use status on each dependent variable through the mediators (a*b paths). table 4. use status predicting mediators message theme cognitive ability driving health harms b se b se b se path a a1 (pleasant) .72** .23 .70** .22 .61** .23 a2 (unpleasant) -.37 .25 -.72** .24 -.35 .25 a3 (arousal) .23 .23 -.01 .24 .25 .22 a4 (informational) -1.09*** .24 -1.25*** .23 -.98*** .23 note. all models controlled for age, sex, and race. * p < .05 ** p < .01 *** p < .001 indirect effects of cannabis use status on perceived harmfulness of cannabis cognitive ability messages. there was an indirect effect of ratings of message informativeness on the association between cannabis use status and perceived harmfulness (b = -0.27, 95%ci = [-0.44, -0.13]). users rated the cognitive ability messages as less informative than non-users (b = -1.09, p < .001), and ratings of informativeness were positively associated with perceived harmfulness (b= 0.25, p < .001). therefore, compared to non-users, users reported significantly lower perceived harm after viewing the cognitive ability messages, partly because they rated the messages as less informative. driving ability messages. similar to the cognitive ability messages, there was an indirect effect of ratings of informativeness on the association between cannabis use status and perceived harmfulness (b = -0.35, 95%ci = [-0.54, -0.19]). users rated the driving messages as less responses to anti-cannabis messages 10 informative than non-users (b = -1.25, p < .001), and ratings of message informativeness were positively associated with perceived harmfulness (b = 0.28, p < .001). therefore, users (compared to non-users) perceived cannabis to be less harmful after viewing the driving messages, partly because they rated the messages as less informative. there was also an indirect effect of pleasantness ratings on the association between cannabis use status and perceived harmfulness (b = 0.12, 95%ci = [0.01, 0.18]). users (compared to non-users) reported more pleasantness in response to the driving messages (b = 0.70, p < .01) and pleasantness was positively associated with perceived harmfulness (b = 0.12, p < .01). therefore, users perceived cannabis as more harmful than non-users, partly because they felt more pleasant after viewing the messages. health harms messages. similar to both the cognitive ability and the driving messages, there was an indirect effect of ratings of message informativeness on the association between use status and perceived harmfulness for the health harms messages (b = -0.30, 95%ci = [-0.48, -0.15]). users rated the health harms messages as less informative than non-users (b = -0.98, p < .001), but ratings of informativeness were positively associated with perceived harmfulness (b = 0.31, p < .001). therefore, users (compared to nonusers) perceived cannabis as less harmful, partly because they rated the message as less informative. message liking as the outcome cognitive ability messages. ratings of informativeness (b = -0.52, 95%ci = [-0.78, -0.28]) and pleasantness (b = 0.24, 95%ci = [0.07, 0.44]) both emerged as significant mediators of the association between cannabis use status and message liking. specifically, users rated the cognitive ability messages as less informative than non-users (b = -1.09, p < .001), and message informativeness was positively associated with message liking (b = 0.48, p < .001). therefore, users liked the cognitive ability messages less than non-users, partly because they rated the messages as less informative. the indirect effect of pleasantness showed a different pattern. users (compared to non-users) had greater feelings of pleasantness when viewing the cognitive ability messages (b = 0.72, p < .01), and pleasantness was positively associated with message liking (b = 0.33, p < .001). therefore, users liked the cognitive ability messages more than non-users, partly because they felt more pleasant. driving ability messages. for the driving messages, ratings of informativeness (b = -0.66, 95%ci = [-0.99, -0.39]) and pleasantness (b = 0.26, 95%ci = [0.07, 0.46]) both emerged as significant mediators of the association between cannabis use status and message liking. specifically, users rated the driving messages as less informative than non-users (b = -1.25, p < .001), and perceived informativeness was positively associated with message liking (b = 0.53, p < .001). therefore, users liked the driving messages less than nonusers, partly because they rated the messages as less informative. the indirect effect of pleasantness showed a different pattern. users (compared to non-users) reported more pleasantness in the driving message category (b = 0.70, p < .01) and pleasantness was positively associated with message liking (b = 0.37, p < .001). therefore, users liked the driving messages more than nonusers partly because they reported feeling more pleasant. health harms messages. similar to both the cognitive ability and the driving messages, informative ratings emerged as a mediator of the association between use status and message liking (b = -0.30, 95%ci = [-0.75, -0.24]). users rated the health harms messages as less informative than non-users (b = -0.98, p < .001), but informative ratings were positively associated with message liking (b = 0.31, p < .001). therefore, users perceived the health harms messages as more likeable than non-users, partly because they rated the message as less informative. see table 3. cannabis, a publication of the research society on marijuana 11 figure 2. indirect effects of use status on perceived harmfulness and message liking note: only statistically significant indirect paths are shown (p < .05). discussion the current study is one of the first to examine how cannabis use status impacts important cognitive and emotional reactions to public health campaigns about cannabis, and the degree to which these reactions influence message likeability and attitudes about cannabis-related harms. consistent with previous work (kilmer et al., 2007), across all three message themes (cognitive ability, driving, and health harms), cannabis users reported lower ratings of perceived harm than non-users. because we did not measure and control for individual differences in cannabis harm perceptions prior to message viewing, we cannot determine if this effect was a result of message viewing or pre-existing differences in harm perceptions. similar direct effects of cannabis use status were found for message liking, wherein users, overall, reported lower message likeability than non-users for the cognitive ability and health harms messages. these direct effects remained despite significant indirect effects, suggesting that there may be other mediators, not measured in this study, that could better explain these associations. these use status (user) pleasant perceived harmfulness informational message theme cognitive ability driving health harms use status (user) pleasant informational message liking responses to anti-cannabis messages 12 may include other factors such as comorbid alcohol or tobacco use, depression, and anxiety as well as degree of knowledge about cannabis. however, these results do support the notion that use status is an important factor to consider when designing health messages about cannabis. a primary goal of this study was to examine cognitive and affective mechanisms that underlie responsivity and effectiveness of health messages about cannabis. we approached this by considering several possible mediating variables that may influence the relationship between cannabis use status and two important message outcomes—perceived cannabis harmfulness and message liking. several noteworthy indirect effects were found. across all three message themes, users reported all messages as being less informative than non-users, and lower perceived informativeness was associated with lesser perceived harm of cannabis use and message liking. one possible explanation for these mediating results could be that users think they already know the negative impacts cannabis use has on cognitive ability, driving, and on one’s health, and information in these messages was merely re-iterating existing knowledge, or did not provide new or novel facts. another possible explanation could be that cannabis users may not believe the risks noted in the messages because these risks may be at odds with their personal experiences with cannabis use (e.g., i have driven after smoking cannabis and have never been in a car accident). although both explanations are speculative, it is noteworthy that users’ lack of perceived informativeness of message content was consistently associated with both reduced perceived cannabis harmfulness and reduced message liking. to enhance the effectiveness of such messages, it would be important that message content is novel. interestingly, we found that for the driving messages, reported pleasantness showed a positive indirect effect, such that users thought the messages were more pleasant than non-users, which then was associated with increased perceived harmfulness and increased message liking. this same result was also found in the cognitive ability messages associated with message liking. one explanation for this may be that feeling pleasant has the capability to “broaden and build” one’s mind (fredrickson, 2001), thus resulting in more positive perceptions of the message and the information conveyed in the message. taken together, presenting pleasantly emotionally charged education messages with novel information may be an effective approach to enhancing cannabis harm perceptions when targeted specifically toward cannabis users. messages that do not invoke a high level of emotionality (biener et al., 2000, 2006; dillard & peck, 2000; pechmann & reibling, 2006) and those that contain less “newsworthy” and perhaps outdated facts on cannabis use may not be interesting or mentally stimulating enough to capture the attention or retain in memory as long (peters et al., 2019), and thus have little impact on attitudes about the risks of using. although this study is the first to examine cannabis public health campaigns, it does align with past work focused on health campaigns for other health behaviors, such as flossing, alcohol use, and tobacco use (witte & allen, 2000; wolburg, 2006). in the current study, we found that non-users liked the messages more than users, which is in line with some tobacco research comparing smokers and non-smokers (national cancer institute, 2008; wolburg, 2006). more work needs to be done to determine which message themes increase message receptiveness for users and change actual behavior. not only did this study highlight the importance of theme and use, it also identified possible mediating variables, particularly how informative and how emotional viewers perceive the message to be. however, this study is not without its limitations. first, this study utilized mturk making it a convenience sample that may not be generalizable to the american population (kraemer et al., 2017). for instance, the percentage of cannabis users in this study was higher than the national average (national survey on drug use and health, 2018). although this study was focused on examining various responses to cannabis public health messages, actual behavior or behavioral intentions following message viewing were not assessed. in addition, ethnicity was not assessed either. future studies should examine how cognitive and affective responses to cannabis health messages may impact behavioral measures as well as more demographics of the audience. although considered a strength, this study examined realworld campaigns that had already been developed. as a result, we were unable to cannabis, a publication of the research society on marijuana 13 experimentally manipulate message content to determine which specific aspects of content could optimally impact harm perceptions and message likeability. future studies should isolate specific features of each message to better understand which features impact responses to the messages. lastly, while we tested mediation, our models align with statistical mediation, not causal mediation, because the mediators and the outcomes were assessed at the same time. overall, this study highlighted the importance of theme and cannabis use status when designing and testing the potential impact of cannabis public health messages on harm perceptions and message liking. findings highlight that different message themes resonate to a different degree with adults. further, different messages appear to have unique effects on cognitive and emotional processing. taken together, our findings suggest that cannabis education campaigns that incorporate several different message themes, rather than use a “one size fits all” approach, could maximally impact likeability of these messages and harm perceptions associated with cannabis. this study is the first study to our knowledge to examine responses to cannabis public health messages to understand the impact of theme and cannabis use status and explore several mediating mechanisms. the relationships analyzed in this paper are important mechanisms along the pathway from message exposure to behavior change. future studies should continue to examine this area as legalization of cannabis spreads across the u.s. references alvaro, e. m., crano, w. d., siegel, j. t., hohman, z., johnson, i., & nakawaki, b. 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(2006). college students’ response to antismoking messages: denial, defiance, and other boomerang effects. journal of consumer affairs, 40, 294–323. funding and acknowledgements: ems tlw were partially supported by the oklahoma tobacco settlement endowment trust. ems was supported by k99da046563. amc was supported by fy21 oklahoma tobacco settlement endowment trust (tset) contract number 092-016-0002 and nci grant p30ca225520 awarded to the stephenson cancer center. we would like to thank dr. andrea villanti (university of vermont) for her assistance in study design and helpful review. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 151 abstract past research has shown that cannabis use is common among adults in the u.s. similarly, physical activity (pa), such as exercise, is often a component of many american’s daily routines. anecdotal information suggests that a subset of individuals use cannabis in conjunction with pa, but evidence is lacking. the purpose of this study was to assess the frequency, methods of ingestion, strain types, and timing (before, during or after) of cannabis use in combination with pa. we also sought to better understand the types of pa that cannabis is being used with and reasons why individuals may use cannabis with pa. a brief survey was developed and administered online to participants (n = 105) who reported use of cannabis with pa. analysis of survey responses revealed that participants were using cannabis in combination with a wide range of physical activities. while use of cannabis was reported within 1-hour before, during, and within 1-hour after pa, the majority of participants (92%) reported using cannabis prior to pa. over three-fourths of all participants reported feeling that the use of cannabis with their pa had a positive effect on their performance. the majority of participants (60%) reported using multiple strains (i.e. indica, sativa, or hybrid) before, during, or after their pa. although participants reported a range of reasons for using cannabis before, during, or after pa, pain management was the only reason reported across all time periods. findings from this study suggest that there is a population of physically active individuals using cannabis with pa, many who believe that cannabis use has a positive effect on their performance. future research should explore these perceptions of cannabis use and performance to provide scientific data to support or refute these anecdotal claims. key words: marijuana, exercise, fitness, supplement, timing cannabis products, also commonly referred to as marijuana, are derived from the flower, stems and leaves of the hemp plant. the legal status of recreational products derived from cannabis in the u.s. varies by state. legalization of cannabis for recreational purposes began in 2012, and today, eleven states allow recreational consumption. in direct contrast, cannabis is still federally classified as a schedule i drug. with nearly 9% of the population reporting use of cannabis products in 2016, cannabis remains the most commonly used federally illegal drug in the u.s. (substance abuse and mental health services administration, 2017). cannabis 2019, volume 2 (2), 151-164 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2019.02.005 open access patterns and perceptions of cannabis use with physical activity jonathon k. lisano1, kristina t. phillips2, jeremy d. smith1, matthew j. barnes3, laura k. stewart1 1 school of sport and exercise science, university of northern colorado, greeley, co, usa 2 school of psychological sciences, university of northern colorado, greeley, co, usa 3 independent researcher, co, usa corresponding author: laura k. stewart, school of sport and exercise science, university of northern colorado, gunter hall, campus box 39, greeley, co, usa 80639, email: laura.stewart@unco.edu cannabis use and physical activity 152 phytocannabinoids, the active components in cannabis, mimic the effects of the endogenous cannabinoids in the body (mccoy, 2016). delta-9tetrahydrocannabinol (thc) and cannabidiol (cbd) are the two most abundant phytocannabinoids present in cannabis products and have received the most attention from the scientific community. however, thc and cbd are just two of more than 100 known phytocannabinoids (radwan et al., 2009) and the effects of these compounds have yet to be fully elucidated. products of the cannabis plant can further be described by their cultivar, or strain, and are often separated into two general categories: cannabis indica (indica) and cannabis sativa (sativa) (leghissa, hildenbrand, & schug, 2017), with varying hybrids of the two strains. among medical cannabis users, common reasons for the use of indica include pain management and as an aid in sedation and sleep, while sativa users often prefer this strain for its perceived induction of euphoria and energy enhancement (pearce, mitsouras, & irizarry, 2014). while the psychoactive and medicinal properties of cannabis have been explored for centuries, there is now both pressing interest and need for research related to cannabis use with physical activity (pa). the proportion of u.s. adults over the age of 18 that met the federal guidelines for aerobic activity and muscular strengthening has increased from 14.3% in 1998 to 21.6% in 2015 (national center for health statistics, 2017). over half (51.7%) of u.s. adults over the age of 18 years self-reported meeting the federal pa guidelines of at least 150-minutes of moderate or 75-minutes of vigorous activity per week (national center for health statistics, 2017). with the current gap in knowledge in cannabis use with pa, researchers must rely on studies performed decades ago to receive any insight as to how cannabis use might affect pa. it was previously observed that moderate (greater than 5 uses per month but less than daily use over the past year) and heavy users (daily use for at least the past year) of cannabis were less active the day after heavy cannabis use (babor, mendelson, & kuehnle, 1976). researchers speculated these findings may have been associated with social reasons rather than the pharmacological effects of cannabis (babor et al., 1976). the limited availability of research pertaining to cannabis use and pa within the general population has also forced researchers to rely instead on data collected from elite athletes. among male and female division 1 national collegiate athletic association (ncaa) athletes surveyed about their personal use of cannabis, 36.8% reported use within the past year (labrie, grossbard, & hummer, 2009). thirty-eight percent of the athletes reporting cannabis use within the past year reported using on average once per month, with male athletes more likely to report use compared to their female counterparts (labrie et al., 2009). a more recent study found that athletes are more likely to use cannabis if they are male, caucasian, or using performance enhancing drugs (brisola-santos et al., 2016). while these studies do provide novel insight into describing cannabis use among athletic populations, more research is needed to truly assess whether similar trends exist among the average physically active individual and provide insight as to why and how these individuals are using cannabis with pa. new evidence suggests that the euphoric effects experienced during exercise, also termed as “runner’s high,” may be the result of the actions of endogenous cannabinoid release during exercise rather than endorphins (gillman, hutchison, & bryan, 2015). the g-protein coupled cannabinoid 1 receptors (cb1) in the brain have been observed to be closely linked to opioid receptors, and the dopaminergic reward pathways suggesting endogenous cannabinoid release with pa could be a major reason why regular exercise is perceived as highly rewarding (ashton & moore, 2011; garland et al., 2011). it is possible that using cannabis products high in cb1 agonists, such as thc (matsuda, lolait, brownstein, young, & bonner, 1990), could increase associated pleasure/reward already observed with regular exercise and increase motivation to partake in pa. conversely, delayedonset muscle soreness (doms) is often associated with muscle damage resulting from acute inflammation from strenuous exercise (lewis, ruby, & bush-joseph, 2012). pain associated with doms may even result in exercise avoidance (george, dover, & fillingim, 2007). recent evidence suggests that cannabinoids like thc and cbd are associated with pain reduction (wilsey et al., 2013) and may have anticannabis, a publication of the research society on marijuana 153 inflammatory effects through their repressive effects on immune tissue (kozela et al., 2010). as a result, the use of cannabis may be a tempting option to reduce exercise-induced pain and inflammation. yet, there is little evidence in human populations on how cannabis use combined with pa affects motivation to partake in exercise as well as how cannabis use affects recovery from exercise. with the growing availability of recreational cannabis products and the need for foundational research in the area of cannabis use with pa, the primary goal of this exploratory study is to describe cannabis use as it relates to pa among the general population. more specifically, this study examines the frequency, method and timing (before, during or after) of cannabis use in combination with pa. secondary goals include characterizing cannabis use as it relates to modes of pa and strain use and the examination of characteristics (e.g., age, gender) associated with participants’ cannabis use in conjunction with pa. finally, we aim to better understand reasons that participants use cannabis with pa. method participants and procedures during the fall of 2017, 140 adults between the ages of 18 to 66 years across the u.s. were surveyed about their cannabis use habits in combination with their pa. recruitment of participants was conducted online through social media (e.g., facebook and snapchat). facebook page administrators of cannabis focused/educational pages were contacted and asked to post a brief standardized description of the survey along with a link to the survey on their feed. participants were also asked to share the link on their feed as well after completion of the survey. snapchat was used by having administrators of local universities post a link to the survey on their story. all advertising routes contained a link which took participants to a qualtrics survey titled cannabis use and pa questionnaire (cupaq), which they completed online. recruitment materials specifically sought participants who use cannabis and cannabis products in relation to their exercise and pa habits. participation was anonymous and took approximately 10 minutes. no external incentive was given for survey completion. this study was approved by the institutional review board at the university of northern colorado. survey design and administration initial contact in qualtrics provided participants with a brief overview of the purpose of the study, emphasized that participation would remain anonymous, and noted the time required for participation (10 minutes). participants were asked to complete informed consent, confirm their age (18 or older) and confirm u.s. residency prior to beginning the survey. the survey consisted of 39 questions which were divided into three main sections. section 1 consisted of 9 questions designed to gather general participant cannabis use habits (i.e., frequency and duration of use), age, gender, minutes of pa completed each week, and u.s. state of current residence. quantification of pa was conducted through participant self-report in response to being prompted: “how many minutes per week are you involved in structured physical activities (going to the gym, swimming running, biking, hiking etc.)?” to limit the length of the survey and focus the majority of the questions around participant use of cannabis with pa, no further questions were asked describing the method, duration, or frequency of participant pa throughout an average week. section 2 of the survey included 18 questions focused on participants’ cannabis use habits as it pertained to their use before, during and after pa. use of cannabis before pa was defined as: within 1-hour of starting pa, and use after pa was defined as within 1-hour of cessation of pa. the frequency of cannabis use associated with pa over the last year and most recent episode of use were also assessed. skip logic was programmed into qualtrics so that participants who did not report cannabis use at one or more of the pa time points (before, during, or after) did not receive those questions. when cannabis was used before, during, and/or after pa, participants were asked to select the most common method of ingestion (e.g., smoking using a joint, inhaling via a vaporizer) and the strain (i.e., indica, sativa, or indica/sativa hybrid) if known. participants then indicated the specific activities (e.g., weight lifting, kayaking) where cannabis was used before, during, and after pa. lastly, three separate open-ended questions assessed reasons cannabis use and physical activity 154 for using cannabis before, during, or after pa. skip logic built into the survey only allowed participants to provide a response to these questions if they had reported using cannabis before, during or after pa previously in the survey. section 3 of the survey consisted of 12 questions aimed at describing the amount and percentage of thc and cbd consumed. using skip logic, questions were further divided into three categories based on participant selfreported primary form of cannabis use, including flower or bud, concentrates (i.e., oils, wax, shatter, dabs), and edibles. in assessing the quantity of the flower or bud, a visual aid and terminology were adapted from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu) (cuttler & spradlin, 2017). statistical analysis a total of 140 survey responses were obtained at the conclusion of the study. three participants failed to agree to the informed consent, and 32 participants reported never using cannabis products with their pa. these 35 participants were removed from the dataset. the remaining n=105 participants responses were used for data analyses. all analyses were conducted using spss version 24 (ibm corp.; armonk, ny) and data are reported as frequency, percent or mean ± standard deviation. we present descriptive statistics to summarize the background characteristics of the sample and to examine participant use of cannabis before, during or after pa. to assess whether a range of demographic characteristics (e.g., age, gender) were associated with participant cannabis use during pa, we used a series of chi square, anova, and t-test analyses with alpha set at p < 0.05. lastly, open-ended questions related to the reasons for using cannabis before, during, or after pa were examined through a content-analysis (marks & yardley, 2004) which allowed for the categorization of responses from each question into six or seven different themes. responses for each of the three questions were coded independently by two coders into each of the theme categories. agreement on these classifications was reached prior to listing a response under a specific theme category (prior to agreement, interrater reliability [k] = .80 – 1.00). the frequency of responses was calculated and reported for each theme. each response could be coded for multiple themes if necessary. results background characteristics and cannabis use participants (53% male) ranged from 18-66 years of age (m = 31.4 ± 11.2 years) and were from 21 states across the u.s. in total n = 70 participants were from states where recreational use of cannabis is legalized. participants reported an average of 74.5 ± 111.5 months (6.2 ± 9.3 years) in duration of regular cannabis use. ongoing cannabis use frequency revealed that 1.9% used less than once per month, 6.7% reported using between 1-3 times per month, 22.9% reported using between 1-6 times per week, and 68.6% reported using cannabis products daily. physical activity and cannabis use survey participants reported engaging in an average of 399.87 ± 543.82 minutes of pa throughout a typical week (57.12 ± 77.69 minutes of pa per day) with a range of 25-3600 weekly minutes. the average age of participants when they first reported using cannabis with pa was 23 ± 8 years. 63.8% of the participants reported that their last use of cannabis with pa was within the past week. breakdown of average participant frequency of cannabis use in combination with pa was self-reported as: 9.5% of participants using cannabis in combination with pa less than once a month, 12.4% between 1-3 times per month, 41.0% 1-6 times per week, and 37.2% reported using cannabis at least once per day in combination with their pa. overall, 78.2% of all participants were using cannabis at least once per week on average with pa. participants also reported the method and quantity of cannabis used most frequently with pa. methods/forms of cannabis consumption were grouped into four general categories: inhalation of flower/bud, edible, concentrate (dabbing), and other. the majority (n = 84; 80.0%) of participants reported that their primary method of cannabis use with pa was by inhalation of flower/bud. primary methods of inhalation of those participants that reported the use of flower/bud as their main method of cannabis use are as follows: cannabis, a publication of the research society on marijuana 155 hand pipe (n = 23; 27.4%), vaporizer (n = 22; 26.2%), bong (n = 18; 21.4%), joint (n = 11; 13.1%) and blunt (n = 6; 7.1%). only n = 12 (11.4%) of participants reported primarily using concentrates with pa, n = 6 (5.7%) used edibles, and n = 3 (2.9%) used “other,” which included topical/salves, capsules, and fresh, nondecarboxylated). timing of cannabis use with pa when asked when they had used cannabis in conjunction with pa, 92% (n = 97) of all participants reported having used cannabis before beginning pa, 21% (n = 22) reported having used cannabis during their pa, and 73% (n = 77) reported having used cannabis after pa. when all participants were polled on when they used cannabis with pa most often, 53.3% (n = 56) reported using most often before pa, 4.8% (n = 5) reported using most often during pa, and 41.9% (n = 44) reported using most frequently after their pa. when asked when participants had used cannabis with pa, a total of 23.8% of participants reported using cannabis only before pa, while 48.6% reported using before and after pa, followed by 18.1% reporting using before, during, and after. 6.7% of participants reported using cannabis only after pa, 1.9% using before and during and 1.0% reported using only during. participants were asked to indicate their primary method of use when they use cannabis before, during or after their pa (table 1a). over threefourths of participants who used cannabis either before, during, or after pa reported their primary method of use was through inhalation. chi-square analysis showed there was no association between the method of use (inhalation, edible, concentrate, other) and timing of use before, during or after pa, χ2(6, n = 248) = 7.82, p = 0.25. table 1. primary method of cannabis consumption & strain of cannabis used before, during or after physical activity table 1a. category method frequency before n (% of total) frequency during n (% of total) frequency after n (% of total) inhalation (flower/bud) joint 12 (11.7%) 15 (29.4%) 13 (13.8%) blunt 7 (6.8%) 4 (7.8%) 7 (7.4%) hand pipe 25 (24.3%) 11 (21.6%) 20 (21.3%) bong 21 (20.4%) 1 (2.0%) 17 (18.1%) vaporizer 20 (19.4%) 12 (23.5%) 14 (14.9%) edible edible 5 (4.9%) 3 (5.9%) 2 (2.1%) concentrate dabbing 11 (10.7%) 4 (7.8%) 14 (14.9%) other other* 2 (1.9%) 1 (2.0%) 7 (7.4%) total 103 51 94 table 1b. strain frequency before n (% of total) frequency during n (% of total) frequency after n (% of total) indica only 8 (7.8%) 3 (4.9%) 26 (27.1%) sativa only 34 (33.3%) 15 (24.6%) 7 (7.3%) hybrid only 16 (16.7%) 20 (32.8%) 19 (19.8%) didn’t know 6 (5.9%) 6 (9.8%) 6 (6.3%) multiple strains 38 (37.3%) 17 (27.9%) 38 (39.6%) total 102 61 96 note. frequencies are reported in combination with the percentage of the total number of valid responses (total (n)). table 1a: participants were only allowed to indicate a single method of use that they personally used most often when using cannabis before, during or after pa. *other forms of use included but were not limited to: topical/salves, capsules, and fresh non-decarboxylated. table 1b: participants reported the strain(s) that they had used before, during and after pa. participants could select as many strain options as applied to them at each time point. cannabis use and physical activity 156 figure 1. frequency of cannabis use before (1a), during (1b), and after (1c) a variety of physical activities participants that reported using flower/bud as their primary method of use (n = 84) reported the average amount of flower/bud they personally used in grams using the visual aid from the dfaq-cu. the average amount of flower/bud used before, during, or after pa were: 0.44 ± 0.45 grams, 0.54 ± 0.49 grams, 0.78 ± 0.86 grams, respectively. there was a statistically significant difference between the amount of flower/bud consumed before, during, and after pa determined by one-way anova, f (2, 221) = 6.274, p = .002. tukey post hoc testing revealed that there was no significant difference in selfreported flower/bud used before and during or during and after pa (p > 0.05). however, a significant difference was observed between the amount of flower/bud consumed before and after pa (p < 0.05). the frequency of reported strain of use (i.e. only indica, only sativa, only hybrid, didn’t know or multiple strains) before, during, or after pa are presented in table 1b. of the 105 participants, 63 (60%) reported using multiple strains at multiple time points in relation to their pa. perception of cannabis use on performance when participants were asked to report whether cannabis use with pa had a positive, negative, or no effect on their performance, 81 (77%) respondents reported they felt using cannabis in combination with their pa had a positive effect on their performance. fewer participants (n = 21; 20%) reported feeling that the use of cannabis had no effect on their performance, and only 3 participants (3%) reported feeling as though use of cannabis with the pa had a negative impact on their performance. 0 2 0 4 0 6 0 8 0 1 a . u s e d c a n n a b is b e fo re f r e q u e n c y r u n n in g c y c lin g r e s is ta n c e t ra in in g s k iin g /s n o w b o a rd in g h o c k e y /s k a tin g r o c k c lim b in g k a y a k in g h ik in g y o g a g o lf w a lk in g s w im in g o th e r 0 1 0 2 0 3 0 4 0 1 b . u s e d c a n n a b is d u r in g f r e q u e n c y r u n n in g c y c lin g r e s is ta n c e t ra in in g s k iin g /s n o w b o a rd in g h o c k e y /s k a tin g r o c k c lim b in g k a y a k in g h ik in g y o g a g o lf w a lk in g s w im in g o th e r 0 2 0 4 0 6 0 1 c . u s e d c a n n a b is a fte r f r e q u e n c y r u n n in g c y c lin g r e s is ta n c e t ra in in g s k iin g /s n o w b o a rd in g h o c k e y /s k a tin g r o c k c lim b in g k a y a k in g h ik in g y o g a g o lf w a lk in g s w im in g o th e r 0 2 0 4 0 6 0 1 c . u s e d c a n n a b is a fte r f r e q u e n c y r u n n in g c y c lin g r e s is ta n c e t ra in in g s k iin g /s n o w b o a rd in g h o c k e y /s k a tin g r o c k c lim b in g k a y a k in g h ik in g y o g a g o lf w a lk in g s w im in g o th e r cannabis, a publication of the research society on marijuana 157 table 2. categorized reasons of cannabis use before, during or after pa reasons for using cannabis before pa frequency n (%) pain management/relief 25 (17.1%) improve focus, get in the flow, or “get in the zone” 25 (17.1%) calm mind and body; relaxation 25 (17.1%) improve enjoyment of activity 19 (13.0%) improve motivation and state of mind 18 (12.3%) other 18 (12.3%) enhance performance, decrease fatigue, or to push harder 16 (10.9%) reasons for using cannabis during pa frequency n (%) increase/restore energy, push harder, or to use during a break 12 (21.4%) improve enjoyment of activity 11 (19.6%) pain management/relief 11 (19.6%) other 11 (19.6%) improve focus, get back in or stay in the zone 7 (12.5%) maintain the high 4 (7.1%) reasons for using cannabis after pa frequency n (%) relaxation 52 (44.4%) pain management/relief 25 (21.4%) other 18 (15.4%) aid in recovery 9 (7.7%) stimulate/increase appetite 7 (6.0%) aid in sleep 6 (5.1%) reported physical activities with cannabis use participants described using cannabis in association with both indoor and outdoor activities, as well as team and individual pa. participants reported using cannabis before (figure 1a), during (figure 1b) and after (figure 1c) a variety of pa. when participants used cannabis before pa, hiking (n = 69), running (n = 54), yoga (n = 47), cycling (n = 46), and resistance training (n = 44) were the most commonly reported. the most frequent activities reported where cannabis was used during pa were: hiking (n = 38), golf (n = 19), yoga (n = 16) and skiing/snowboarding (n = 16). the most popular activities that participants reported using cannabis after completion of the activity were: hiking (n = 51), running (n = 49), resistance training (n = 47) and cycling (n = 39). participant reasons for using cannabis with pa three separate open-ended questions were presented to participants asking them to describe their reasons for having used cannabis before, during, or after pa. coded responses can be found in table 2. only participants who reported cannabis use during one or more of these times were provided with the respective open-ended questions. the three most common reasons for using cannabis before pa were: pain relief, to improve focus or get in the zone and to calm the mind and/or body or to relax. the most popular reasons for using cannabis during pa was to increase/restore energy, push harder, or use as a break. participants also described using cannabis during pa to improve their enjoyment of an activity and for pain management/relief. the most frequent theme across participant responses for using cannabis following pa was for relaxation and to decrease pain or soreness, with minor reasons including appetite stimulation, and aid in sleep and recovery (table 2). the only category that was present as a reason for cannabis use in all three times (before, during and after pa) was pain relief/management. demographic characteristics associated with cannabis use and performance to assess whether participant age influenced method of use, perception of use with pa, and cannabis use and physical activity 158 other factors, participants were separated in to two groups: young and older. participants that were classified as young (≤ 27 years of age; n = 53) would have been under the age of 21 when cannabis was first recreationally legalized at the state level, while participants classified as older (≥ 28 years of age; n = 52) would have been over the age of 21 at that time. chi-square analysis revealed a significant difference between younger and older cannabis users with respect to their primary method of cannabis use with pa χ2(2, n = 102) = 7.86, p = 0.02. older users favored more traditional methods of consumption via inhalation (i.e. joint, bong, pipe, vaporizer, and blunt), while younger users were more likely to use concentrates (dabbing). younger users started using cannabis with pa at an earlier age (19.3 ± 2.9 years) when compared to older users (26.5 ± 10.5 years; p = 0.02). with respect to perceptions of cannabis use on performance, older users were more likely to report feeling that cannabis use had a positive effect on their pa performance. in contrast, younger users were more likely to report feeling that cannabis use had no effect on performance χ2(2, n = 105) = 7.09, p = 0.03. there were no significant differences between younger and older users with respect to the timing of cannabis use with pa (before, during, after; p = 0.44) or the frequency of cannabis use with pa (p = 0.74). participant state of residence was used to classify participants into two separate groups: one group included states in which cannabis was legal for recreational consumption (lg; n = 70), and another group included participants from states that recreational use of cannabis was not legal (nl; n = 35). chi-square analysis did not reveal any significant disparities between lg and nl groups pertaining to frequency of cannabis use, frequency of cannabis use with pa, or the primary method of use before, during or after pa. there was no significant difference (p = 0.06) in the average age of lg (31.59 ± 12.21 years) or nl (31.17 ± 9.09 years) groups. no significant differences in average age at first use of cannabis (p = 0.07; lg = 21.59 ± 7.89 years, nl = 25.09 ± 9.01 years) or average age of first use of cannabis with pa (p = 0.13; lg = 23.23 ± 8.08 years, nl = 25.88 ± 8.68 years) were found between the two groups. the lg group had significantly higher (p = 0.002) self-reported minutes of pa (466.7 ± 646.7 minutes or 7.8 ± 10.8 hours) per week compared to the nl group (266.2 ± 168.0 minutes or 4.4 ± 2.8 hours) per week. there was also a significant difference (p = 0.013) in the duration of regular cannabis use between groups (lg = 83.9 ± 131.3 months or 7.0 ± 10.9 years; nl = 56.1 ± 53.0 months or 4.7 ± 4.4 years). in lg and nl participants that reported flower or bud as their primary method of use (table 3), 2-way anova with tukey’s multiple comparisons determined that both lg and nl groups consumed significantly more flower/bud after pa compared to before pa, f(2, 217) = 4.628, p = 0.01. there was no difference in the amount consumed before, during or after pa between lg and nl groups f(1, 217) = 1.641, p = 0.20. table 3. reported typical amount of cannabis flower/bud use before, during or after pa by participants in recreationally legal and non-legal states group amount used before grams ± sd (n) amount used during grams ± sd (n) amount used after grams ± sd (n) legal .496 ± .509 (60) * .578 ± .518 (34) .797 ± .908 (58) * non-legal .319 ± .264 (29) + .442 ± .401 (13) .732 ± .751 (29) + note. participants were asked to report the typical amount of flower/bud they personally used before, during or after pa using the dfaq-cu visual aid. *significant difference between the amount of flower/bud consumed by participants from legal states before and after pa. +significant difference in the amount of flower/bud used before and after pa of participants from non-legal states. cannabis, a publication of the research society on marijuana 159 discussion this study provides novel insight into how and why individuals are using cannabis before, during and after pa. while participants responded to using cannabis before, during, and after pa, cannabis use was most often reported before or after pa. most participants reported that when being physically active they were using cannabis with their pa at least once per week, and largely under the impression that the use of cannabis with their pa had a positive effect on their performance. this could be attributed to the fact that at all three-time points (before, during and after) some participants were reporting the use of cannabis to mediate pain. it is possible that suppression of pain could lead to increased enjoyment of the activity, which was also commonly reported by participants as a reason for using cannabis prior to pa. studies assessing cannabis use among elite athletes have found that individuals who were caucasian, male, or played hockey were the most likely to use cannabis products (brisola-santos et al., 2016; labrie et al., 2009). in an effort to address the gap in knowledge on recreational use of cannabis with pa in the general population, the present study provides new insight into this topic area. cannabis use with pa was reported equally among males and females and across a wide range of activities in recreationally physically active individuals. surprisingly, hiking was the most frequently reported activity where cannabis was used before, during, and after pa. this finding may be attributed to 59 of the participants residing in the state of colorado at the time of the survey, thus having easier access to both recreational legal cannabis and hiking trails. in addition, the predominance of reported cannabis use with hiking and other outdoor activities (i.e. running, cycling, golf, etc.) could be attributed to the fact that the predominant method of cannabis use with pa was through inhalation of flower/bud. as inhalation is stereotypically done outdoors, the researchers speculate that this could be a reason as to why cannabis was used with so many outdoor activities. these findings should be explored further by future research to fully elucidate as to whether there is a relationship between method of use and type of pa. further observation suggests that the timing of cannabis use could also be dependent on the specific type of pa. for example: running, cycling, and resistance training were the 3rd, 4th, and 5th most frequently reported with cannabis use prior to activity, and were the 2nd, 3rd, and 4th most frequently reported activities to use cannabis with after. however, reported prevalence of cannabis use while running, cycling, and resistance training dropped to 6th, 7th and 8th most frequently reported respectively. this could in part be attributed to the inconvenience of having to stop mid run, ride or excuse yourself from the gym to use cannabis. the most popular reported activities to use cannabis during pa were: hiking, golf, skiing/snowboarding, and yoga. these activities are more intermittent rather than continuous and may provide logical breaks in activity to partake in using cannabis. data from the present study suggests that the majority of participants felt that the use of cannabis products with their pa had a positive effect on their performance. however, this insight may not be truly representative of physically active individuals’ perspective of cannabis use on performance as many participants were recruited through social media pages that presented a positive perspective on cannabis. these numbers may be different if the survey was also distributed on non-pro-cannabis web pages. the perception of improved performance with cannabis use may be purely subjective. the most recent studies which examined this question were conducted 40 years ago and demonstrated that acute use of cannabis containing thc increased resting heart rate (avakian, horvath, michael, & jacobs, 1979; steadward & singh, 1975), systolic and diastolic blood pressure (steadward & singh, 1975) as well as reduced time to exhaustion during a cycling bout (renaud & cormier, 1986). yet, no acute effects of thc administration were reported with respect to oxygen uptake or ventilation during submaximal exercise (avakian et al., 1979). unfortunately, the concentration of thc in the cannabis used in these studies is no longer reflective of current cannabis products available on the market today, as thc content in cannabis has been steadily increasing over the past several decades (mehmedic et al., 2010). while evidence is lacking related to assessing the effects of acute consumption of cannabis on exercise performance, a recent study explored the effects of chronic cannabis use on exercise performance. in this study, participants were cannabis use and physical activity 160 assessed for pulmonary, cardiovascular, anaerobic and strength while at least 12-hours removed from last use of cannabis. when compared to a non-cannabis using control group this cross-sectional study determined that there were no differences with respect to pulmonary, cardiovascular, anaerobic, or strength performance (lisano et al., 2017). findings from the present study revealed that a large portion of participants believed that cannabis use had a positive effect on their performance. further research is needed within this area to truly discern whether the acute use of cannabis has the ability to affect pa performance. previous research has shown that adults aged 18-25 have the highest reported percentage of cannabis use, with 20.8% reporting use at least once within the past month substance abuse and mental health services administration, 2017). while the current study did not assess cannabis use rates among age groups of physically active adults, an age-based analysis was done to assess if individuals 18-27 years of age had different perceptions and methods of use compared to adults over 28 years of age. chi-square analysis revealed that adults ages 18-27 were significantly more likely to report using concentrates as their primary form of cannabis and began using cannabis with pa at a significantly younger age (i.e., 7 years earlier). however, adults over the age of 28 were significantly more likely to report feeling that cannabis use had a positive effect on their performance compared to adults aged 18-27. emerging research shows that use of concentrates via dabbing may be associated with greater negative consequences, tolerance, and withdrawal compared to flower use (loflin & earleywine, 2014). we did not assess negative consequences related to participants’ cannabis use, but future research should explore whether those using cannabis with their pa are more likely to have problems related to their use and if they are more likely to use cannabis with pa for specific reasons (e.g., pain management). results from this study revealed that 92% of survey participants reported cannabis use before pa, suggesting that more research to ascertain the effects of acute cannabis use on pa performance may be necessary. conversely, the perceived performance enhancing effect of cannabis on pa performance could be related to the reduced perception of pain. when asked an open-ended question as to why participants used cannabis before, during, and after pa, pain management/relief was the only reason to be reported across all time points. pain management was the most common reason for cannabis use before pa, and the second most common reason for use during and after pa. this pain control theme is supported by a recent study which found that pain was the most commonly reported reason for seeking use among medicinal cannabis users (bonn-miller, boden, bucossi, & babson, 2014; walsh et al., 2013) with those seeking pain relief preferring indica (cohen, heinz, ilgen, & bonnmiller, 2016; pearce et al., 2014). products derived from indica are typically lower in thc and contain higher quantities of cbd, reducing the perceived psychoactive effects while still maintaining high pain suppressive effects. mechanistically cannabinoids modify synaptic transduction in the central nervous system and the periphery. thc and cbd are agonists of the two primary cannabinoid receptors, cb1 and cb2 (mccoy, 2016), with cb1 being highly expressed in the central nervous system (wachtel, elsohly, ross, ambre, & de wit, 2002) and cb2 more abundant in the periphery (galiègue et al., 1995). these cannabinoids act on cb1 and cb2 receptors expressed on the pre-and post-synaptic membrane blocking calcium influx, and blocking synaptic vesicle release (zou & kumar, 2018). activation of these receptors blocks synaptic signal transduction and has even been implicated in long-term depotentiation (xiong et al., 2012). conversely, another explanation for the use of cannabis to reduce pain associated with pa is due to the immunosuppressive effects of cannabinoids like cbd (elliott, singh, nagarkatti, & nagarkatti, 2018; malfait et al., 2000). while thc has a slight propensity to bind the cb2 receptor, cbd is the primary cb2 agonist within cannabis (burstein, 2015). the cb2 receptor is highly expressed throughout immune related tissues, including those that are responsible for inflammation (galiègue et al., 1995). tissue damage resulting from novel or intense pa has been shown to increase local inflammation at the area of injury and produce cognitive pain often referred to as doms (kanda et al., 2013; matsuda et al., 2015). it is highly plausible that, especially in participants that reported using cannabis after pa for pain management (n = 25) and recovery (n = 9), they are either consciously or incidentally cannabis, a publication of the research society on marijuana 161 utilizing the anti-inflammatory effects of cannabis to help combat pain associated with pa. interestingly, individuals that utilize cannabis for pain mediation have been found to be at lower risk of development of cannabis use disorders (cohen et al., 2016). in conjunction with pain management, the most common reasons reported for cannabis use prior to pa were related to improved focus and to calm or relax the mind and body. this was unexpected, as sativa strains appear to be used more often prior to pa than following pa. this could be that use of sativa strains are commonly associated with feelings of euphoria and energy enhancement (pearce et al., 2014). after pa, using cannabis for relaxation was reported more frequently than any other response. given the reported perceived effects of indica related to sedation and pain management (pearce et al., 2014), it was expected that this strain may be used predominately post-exercise. findings from the present study indicate that this phenomenon may exist with 27.1% of participants reporting the use of only indica after pa compared to 7.8% and 4.9% reporting use of only indica before and during pa, respectively. while the potential disparity of initial findings suggests participants are using sativa before pa and indica after pa were consistent with our initial hypothesis, the unexpected observation that the majority of participants were using multiple strains regardless of timing of activity may suggest that cannabis strain of use may not only be dependent on timing of activity, but the type of activity. however, there should be caution when interpreting these findings because the survey question in the present study was not designed to ascertain this specific effect. although this study provides new information on why and how physically active individuals are using cannabis products with their pa, there are limitations to this study. the design of the study was cross-sectional and conducted as an online survey. as a result, the conclusions of this study are only applicable to individuals who reported using cannabis with their pa. additionally, as previously mentioned, participants recruited through social media were done so through web pages that had an overall positive view on cannabis use. this limits the results of this study to individuals that have a positive view or experience of cannabis use with pa, as individuals that had a negative experience with cannabis use and pa may have been deterred from participating in the survey. there are limitations associated with self-report data, even though online and in-person administration of surveys has been shown to yield similar results (weigold, weigold, & russell, 2013). recent findings show that users of cannabis overestimate their use of flower/bud when preparing bowls and joints and that self-report estimates can be inaccurate (prince, conner, & pearson, 2018). while the current study presented participants with a visual aid to help report flower/bud use, it is possible that participants were still overestimating the amount of flower/bud used before, during, or after pa. reported weekly minutes of pa varied dramatically, with a range of 25 to 3600 minutes of pa per week. the wide range in self-reported pa could be the result of inaccuracy associated with self-report pa (brenner & delamater, 2016) or misinterpretation of the question. it is also possible that the individuals that reported extremely high rates of pa could have highly physically demanding jobs in construction, nursing, fitness, etc. in an effort to allow participants to report any type of pa, participants were not asked if they were physically active for recreational reasons, or if their pa was a part of a structured exercise regimen. although this approach allows for more broad interpretation of pa, it should be considered a limitation and future work should further examine this question. in addition, the present study did not explore if participants experienced any negative side effects due to their cannabis use, such as those associated with cannabis use disorder. finally, not all states within the u.s. were represented or dispersed equally within this data set, this could cause regional bias to skew these results. future studies exploring the use of cannabis with pa may want to discern whether individuals are consuming cannabis ad libitum as they are coincidentally engaging in pa or are intentionally using cannabis in conjunction with structured exercise. with results from the present study revealing that most participants were using cannabis before pa, future research should seek to explore if the use of cannabis before engaging in pa has an effect on that task. this can further be further explored by assessing the specific use of products high in either thc or cbd and how these products, when isolated from each other, cannabis use and physical activity 162 affect performance, enjoyment, pain mediation and recovery. even though chi-square analysis did not reveal any notable differences between general method of use (inhalation, edible, concentrate, other) and timing of activity (before, during, or after pa), future research should further examine the relationship between method of use and timing of pa. further exploration of the specific effects of cannabis use based on specific activity performance, i.e. the effects of cannabis use with pa in golfers or runners, may provide valuable insight in the future. in summary, this study provides novel insight into cannabis use among individuals that reported using cannabis in combination with their pa. findings from this study revealed that the most common time to use cannabis in combination with pa was before pa, with the majority of individuals reporting use through traditional inhalation methods of flower/bud. most participants reported feeling that the use of cannabis with pa had a positive effect on their pa performance. reasons for cannabis use with pa varied depending on when cannabis was used in combination with pa, with pain management as the only reason reported frequently before, during, and after time points. references ashton, c. h., & moore, p. b. 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(2018). cannabinoid receptors and the endocannabinoid system: signaling and function in the central nervous system. international journal of molecular sciences, 19(3), 833. doi:10.3390/ijms19030833 funding: the authors would like to thank the university of northern colorado for the support of this project. we would also like to thank our participants for volunteering their time to participate in this study. finally, we would like to thank the reviewers for their helpful comments in the revision of this work. the authors disclose that no competing financial interests exist related to the data presented in this manuscript. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i1a2_authors_final brief report 10 ved abstract marijuana use in middle and late adolescence is a significant public health concern given that an earlier age of onset is prospectively associated with numerous marijuana misuse outcomes. the outbreak of covid-19 resulted in stay-at-home orders and social distancing guidelines across the united states yet the impact of these orders on adolescent marijuana use is unknown in the u.s. the aims of this study were to examine adolescents’ recall of changes in marijuana use patterns following the covid-19 outbreak as a function of one’s typical levels of use, and to qualitatively assess reasons for perceived change. a screening survey for a larger study was completed by 156 adolescents (ages 15-18, 78% male) after the stay-at-home order was put in place in washington state in march 2020. the cross-sectional survey included self-reported demographic information, marijuana use, and retrospective recall of changes to marijuana use following the state’s stay-at-home order. initial findings did not reveal any pattern of change that described the entire sample, however adolescents’ recall of changes in use significantly varied as a function of typical use such that moderate/heavy users had higher odds of reporting maintained (5.04 times higher) or increased use (3.07 times higher) compared to irregular/light marijuana users. primary reasons for decreasing use included decreased availability and socialization. primary reasons for increasing use included more free time and coping with stress and anxiety. the findings suggest that pandemic-related changes in marijuana use are not consistent across adolescents and that moderate and heavy users may be at increased risk of marijuana misuse under pandemic conditions. key words: marijuana; cannabis; adolescents; covid-19; pandemic adolescence is an important developmental period with regard to marijuana use. many individuals initiate and escalate use during adolescence, in particular, middle and late adolescence which encompasses youth in high school and early college, and early age of onset is associated with negative outcomes (ellickson et al., 2004; griffin et al., 2010; gruber et al., 2014; schuster et al., 2016). further, adolescent marijuana use is a timely public health concern in the u.s. more states continue to legalize recreational and medical marijuana use, while adolescents’ perceptions of marijuana’s harms are at their lowest in the history of the monitoring the future study (johnston et al., 2020). marijuana use may have recently been impacted by the stayat-home orders and social distancing guidelines during the outbreak of covid-19. when the pandemic began, many late adolescents were ordered to stop in-person attendance in high schools and colleges, and adapted to remote learning. in washington state, an official stay-atjason j. ramirez1, li-hui chu1, elliot c. wallace1, anna e. jaffe2 1department of psychiatry & behavioral sciences, university of washington 2department of psychology, university of nebraska-lincoln cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.002 retrospective recall of marijuana use patterns following the covid-19 outbreak vary as a function of user type among adolescents in washington state corresponding author: jason ramirez, ph.d., university of washington, school of medicine, department of psychiatry & behavioral sciences. 1100 ne 45th street, suite 300, seattle, wa 98105. email: jjramirz@uw.edu. cannabis, a publication of the research society on marijuana 11 home order was issued on march 23rd, 2020, mandating all residents to stay at home unless pursuing essential, socially-distant activities. these restrictions resulted in societal changes that could alter adolescents’ marijuana use, including changes to marijuana availability, parental/guardian supervision, amount of free time, and stress. despite these possible changes, little is known about the impacts of the covid-19 pandemic on late adolescent marijuana use in the u.s. in one known study on this topic, dumas et al. (2020) surveyed canadian high school students in april 2020 about their recent and pre-pandemic substance use. they found prevalence of marijuana use decreased from 17.0% pre-covid19 to 13.8% during covid-19, but frequency of marijuana use increased from 0.94 days precovid-19 to 1.10 days during covid-19. recent research in adults also indicates broad pandemicrelated changes in marijuana use. in a national survey among canadian adults following the covid-19 outbreak, marijuana consumption increased in 6% of adults and decreased in 4% of adults (canadian centre on substance use and addiction [ccsa], 2020). common reasons for increased use included lack of a regular schedule, stress, and boredom, whereas the most common reason for decreased use was not being a typical marijuana user (ccsa, 2020). for those who were previously marijuana users, in a study of israeli and russian social work students, about half increased their marijuana consumption during covid-19 (yehudai et al., 2020). similarly, among adults in poland who use recreational drugs, 21% reported increased use in april 2020, whereas 18% decreased use (chodkiewicz et al., 2020). such research among adults has most often highlighted mental health challenges during the pandemic and framed changes in substance use as an attempt to cope with distress. the variability observed in substance use changes suggests different reasons for change may be relevant for different individuals. for example, fewer financial resources and reduced accessibility of substances may lead to decreased use for some individuals (rehm et al., 2020), whereas others may increase their use of substances to cope with stressors related to covid-19, as has been observed in some adults (ccsa, 2020; rodriguez et al., 2020; mcphee et al., 2020). increased use of substances to cope may be particularly likely for at-risk individuals with a history of chronic or regular use whose neurobiological pathways may have adapted to respond to stressors with cravings (clay & parker, 2020). although there is much concern about managing potential increases in use among clinical populations of patients with substance use disorders (e.g., columb et al., 2020; kim et al., 2020), this emerging literature focuses primarily on alcohol use in adults, and it remains unclear how changes in substance use patterns might differ as a function of typical use. the overarching aim of the current study was to examine late adolescents’ retrospective recall of changes to their marijuana use patterns in the months immediately following the covid-19 stay-at-home orders in washington state. we further sought to examine whether perceived changes in marijuana use were different for adolescents who considered themselves to be irregular, light, moderate, or heavy users. finally, to understand reasons why use changed and move beyond standard response options (ccsa, 2020), we examined open-ended responses of adolescents’ primary reasons for increasing or decreasing marijuana use during this time. methods participants participants were middle to late adolescents ages 15-18 recruited from the greater seattle area who completed a screening survey for a larger study examining the associations between marijuana use and identity among adolescents. the larger study focused on this developmental period because marijuana use is already prevalent at this age (johnston et al., 2020), thereby producing sufficient variability in identification as a marijuana user. the survey included items assessing demographics and marijuana use. items assessing participants’ recall of how the pandemic impacted their marijuana use were added on april 2nd, 2020. the university’s institutional review board approved the study and a federal certificate of confidentiality was obtained. all participants provided consent/assent to complete the screening survey. a waiver of parental consent was obtained due to the study being deemed as carrying minimal risk. covid-19 adolescent marijuana use 12 procedures recruitment for the larger study was primarily conducted via advertisements requesting paid online research participation that were promoted on instagram to reach local adolescents (ages 15-18). the larger study aimed to recruit a representative sample of adolescents in the greater seattle area with a nearly equal number of males and females. however, at the time when covid-19 items were added to the survey, more females had previously enrolled, and several recruitment ads were promoted for males only. no other promotion criteria aside from age, gender, and proximity to seattle were selected that would bias the sample characteristics. interested individuals completed a brief online survey to determine study eligibility, which included assessments of marijuana use in the previous three months and items to assess how the covid-19 outbreak affected their use. in the larger study, 545 individuals completed screening. however, screening data described here were completed between april 2nd and may 18th, 2020 (n=156). the mean age of this subset of participants was 17.0 years (sd=1.1) and the majority (78%) were male. among participants, 76.3% identified their race as white/caucasian, 22.4% asian/asian-american, 4.5% african american, 3.8% native hawaiian/pacific islander, and 5.1% “other,” with 11.5% identifying their ethnicity as hispanic/latinx. measures typical marijuana use. participants were asked to describe their typical marijuana use prior to the pandemic by indicating if they had never used marijuana or were a light, moderate, heavy or irregular user (have previously used marijuana but haven’t used recently). for descriptive purposes and to examine accuracy of participants’ user type self-categorization, the marijuana daily questionnaire (lee et al., 2013) was used to assess the number of marijuana use days in a typical week in the past three months. covid-19 impact on use. participants were asked to respond to how covid-19 has impacted their marijuana use (i.e., “how has the novel coronavirus (covid-19) impacted how much marijuana you’ve recently used?”). response options were: “i have never used marijuana”, “i used similar amounts of marijuana as i typically do (no change)”, “i used more marijuana”, “i used less marijuana”, or “i stopped using marijuana.” reasons for change. participants were then asked to explain any perceived changes to their marijuana use patterns as a result of covid-19 via an open-ended question (i.e., “please explain why your marijuana use has changed.”). results descriptive statistics in the sample, 58 participants described themselves as never having used marijuana in their lifetime. among those who had used in their lifetime, 36 described themselves as irregular users, 19 as light users, 27 as moderate users, and 19 as heavy users. due to the relatively small sample size, irregular and light users were combined into one group (n=55), and moderate and heavy users were combined into another group (n=46) for analyses. independent t-tests revealed that participants’ self-categorization of user status aligned with reported use; moderate/heavy users reported using significantly more use days (m=6.11, sd=1.69) in a typical week in the past three months compared to irregular/light users (m=1.09, sd=1.31; t[99]=16.81, p<.001) covid-19 patterns of marijuana use none of the 58 participants that described themselves as never having used marijuana in their lifetime reported marijuana use after the covid-19 outbreak. of the 98 participants who reported any lifetime use of marijuana, 41 reported stopping or decreasing their use, 30 reported using similar amounts as before, and 27 reported increased use following the covid-19 outbreak. figure 1 shows perceived changes in use as a percentage of user type. among those who used marijuana, a chi-square test of independence revealed that perceived changes in use significantly varied as a function of typical use, χ2(2, n=98)=29.79, p<.001. the odds of irregular/light marijuana users stopping or decreasing their use was 13.73 times higher than cannabis, a publication of the research society on marijuana 13 figure 1. percentage of participants that perceived changes in their marijuana use following the covid-19 outbreak as a function of user type. user type was separated by light/infrequent users and moderate/heavy users. moderate/heavy users. moderate/heavy users had 5.04 times higher odds of maintaining their current use and 3.07 times higher odds of increasing their use compared to irregular/light users following the covid-19 outbreak. reasons for perceived changes in marijuana use open-ended responses regarding reasons for perceived change in use were independently coded by two coders with discrepancies resolved through discussion. because responses were open-ended, some responses were coded as having multiple reasons for a change. table 1 lists the coded reasons for changing use endorsed by at least two participants and frequencies of endorsement separated by user type. among those who recalled increases in use, the primary reason for this change was increased free time and/or decreased responsibilities (70.4% of those who increased used). other reasons for increasing use reported by two or more participants included confinement/boredom (18.5%), coping with negative affect (14.8%), and increased ease of marijuana access (14.8%). among those who recalled decreases in or stopping use, the primary reason for this change was reduced or no marijuana access (61.4% of those who decreased use). the second-most endorsed reason for decreasing use was reduced social interactions (25.0%). other reasons for decreasing use recalled by two or more participants included a lack of urge/interest (9.1%), increased parental/family supervision (6.8%), personal choice (4.5%), and inability to afford marijuana (4.5%). decreased, 67% decreased, 13% no change, 15% no change, 48% increased, 17% increased, 39% 0% 20% 40% 60% 80% 100% light / infrequent users (n = 52) moderate / heavy users (n = 46) pe rc en ta ge p er u se r t yp e covid-related changes in marijuana use covid-19 adolescent marijuana use 14 table 1. reasons provided for perceived changes in marijuana use during pandemic reasons for decreasing use example quote endorsement by user type reduced or no access “no access with covid-19 quarantine in washington state.” light/irregular, n = 25 heavy/moderate, n = 2 reduced socialization “i’m home all the time and since i’m a social smoker there’s not many situations to smoke.” light/irregular, n = 10 heavy/moderate, n = 1 lack of urge or interest “i don’t have the urge to use it.” light/irregular, n = 4 heavy/moderate, n = 0 increased parental or family supervision “as a family, it’s harder to hide your drug use when everybody is crammed into one household all the time.” light/irregular, n = 3 heavy/moderate, n = 0 making personal choice (for health or safety) “i felt like it was becoming an unhealthy habit and wanted to better myself by stopping early.” light/irregular, n = 1 heavy/moderate, n = 1 inability to afford marijuana “no money.” light/irregular, n = 0 heavy/moderate, n = 2 reasons for increasing use example quote endorsement by user type increased free time/fewer responsibilities “with less going on, i have become more apt to use marijuana with increased amount of free time i have been given.” light/irregular, n = 7 heavy/moderate, n = 12 confinement/boredom “boredom gets brutal.” light/irregular, n = 2 heavy/moderate, n = 3 coping with negative affect “i don’t have anything else to do to cope with anxiety.” light/irregular, n = 1 heavy/moderate, n = 3 increased ease of access “gained very easy access because my friend’s brother had to come home from college.” light/irregular, n = 0 heavy/moderate, n = 4 note. reasons given by two or more participants are included here. cannabis, a publication of the research society on marijuana 15 discussion the current study found no single pattern of perceived changes in marijuana use following the covid-19 outbreak that represented our full sample of adolescents. among adolescents who had ever used marijuana, at the time assessment post-outbreak of the pandemic, most retrospectively recalled having decreased or stopped their use, aligning with another recent finding reporting a decrease in the percentage of canadian adolescents who used marijuana following the pandemic (dumas et al., 2020). however, when examining retrospective recall of changes in marijuana use by user type, clear differences emerged with irregular/light users reporting higher odds of decreasing their use relative to moderate/heavy users. conversely, moderate/heavy users reported stronger relative odds of maintaining or increasing their levels of use following the covid-19 outbreak. primary reasons for marijuana use patterns emerged in open-ended responses, with most participants citing more free time/fewer responsibilities and decreased availability as reasons for increasing and decreasing use, respectively. these openended responses mirror recent findings describing reasons for changes in canadian adults’ marijuana use during the pandemic (ccsa, 2020). other reasons for increasing use included increased boredom, availability, and negative affect. additional reasons for decreasing use included decreased socialization, increased parental supervision, and a lack of interest or urge to use. the findings demonstrate the importance of user type when examining marijuana use patterns during the covid-19 outbreak. specifically, adolescents who consider themselves to be moderate/heavy users may be at increased risk for elevated marijuana use and may experience accompanying marijuana-related consequences. although irregular/light users were likely to report decreased use and access to marijuana, moderate/heavy users may have more reliable access to marijuana that was less affected by stay-at-home orders. assuming fewer barriers to access, the increased free time resulting from stay-at-home orders contributed to increased marijuana use according to many moderate/heavy users. another prominent reason for decreased use was a lack of socialization, and irregular/light users have been previously shown to be more likely to use in social settings compared to daily users (phillips et al., 2018). indeed, most canadian adolescent users recently reported solitary marijuana use post-pandemic (dumas et al., 2020). therefore, those most likely to decrease use may be those who typically (or solely) use in social contexts. although we did not assess marijuana use motives, future research might examine marijuana use changes as a function of motives. current findings have important implications for intervention and prevention strategies targeting adolescent marijuana misuse. first, the conditions created during stay-at-home orders may represent a high-risk time for marijuana misuse among those already at most risk (i.e., moderate/heavy users). given that the most frequently endorsed reason for increased use was a decrease in responsibilities, preventative strategies may include providing adolescents with substance-free, socially-distant activities. regarding decreased use, the most frequently endorsed reason was reduced access to marijuana. this highlights the importance of marijuana availability and access among adolescents, who are below the legal age to purchase marijuana and rely on illegal means of access. understanding how adolescents access marijuana may inform preventative strategies to reduce access among this age range. finally, although less frequently endorsed, some participants also reported increases in marijuana use due to increased negative affect. providing adolescents with healthy ways to cope with negative affect and ensuring safe access to mental healthcare (e.g., telehealth) may also be important. there are several important study limitations to highlight. first, our screening survey did not distinguish between medical and recreational use, which has implications for access. however, only a small minority (4.2%) of those enrolled in the larger study reported medical access, suggesting legal access to medical marijuana was rare in the current sample. second, the current study involved a cross-sectional design, precluding direct observation of changes in use. third, despite instructions to consider pre-pandemic use, it is still possible that pandemic-related changes in marijuana use may have contributed to one’s identification as an irregular/light user or moderate/heavy user. further, the categorization covid-19 adolescent marijuana use 16 of user type was self-reported and open to participant interpretation. however selfcategorized groups significantly differed by selfreported typical marijuana use lending some credence to participants’ ability to self-categorize themselves into meaningfully different groups. fourth, although all participants in the study were under 21, the impact of state-wide legal access to recreational marijuana for adults (aged 21+) on norms in adolescents is unclear and whether results generalize to other states is unknown. further limiting generalizability, the current sample was predominantly male and white with only asians and asian-americans being well-represented among racial minority groups. finally, data were collected between april 2nd and may 18th, 2020 and therefore represent what might be immediate impacts of the stay-athome orders. follow-up research may clarify whether any perceived changes in use persist for longer durations. overall, using participants’ recall of what their use was like prior to the pandemic, findings show a stark difference in changes in marijuana use between irregular/light users and moderate/heavy users following the covid-19 outbreak. moderate/heavy users were more likely to recall increases rather than decreases in marijuana use during this time, 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(2016). early onset marijuana use is associated with learning inefficiencies. neuropsychology, 30(4), 405-415. yehudai, m., bender, s., gritsenko, v., konstantinov, v., reznik, a., & isralowitz, r. (2020). covid-19 fear, mental health, and substance misuse conditions among university social work students in israel and russia. international journal of mental health and addiction, 1-8. funding and acknowledgements: this research was supported by the alcohol and drug abuse institute at the university of washington and by nida r21da045092 (pi: ramirez). the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors declare no competing interests. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources are not modified, and the source is not used for commercial purposes. v5i3a5_authors_final research article 47 ved abstract introduction: as cannabis legalization continues to spread, best regulatory practice remains ill-defined and elusive, exposing the population to potential harms. methods: we conducted an annual, statewide, crosssectional survey to assess cannabis-related laws in effect by january 1, 2020, in local california jurisdictions and at the state level and measured adoption of potential best practices. results: the current laws of all 539 jurisdictions were located; 276 jurisdictions allowed any retail sales (storefront or delivery) covering 58% of the population, an increase of 20 jurisdictions (8%) from year 1 of legalization (2018). half allowed sales of medical cannabis, whereas slightly fewer jurisdictions (n = 225) allowed adult-use sales. only 9 jurisdictions imposed any restrictions on products stricter than state regulations. cannabis temporary special events were allowed in 22 jurisdictions, up from 14 in the year prior. thirty-three jurisdictions required additional health warnings for consumers. just over half of legalizing jurisdictions taxed cannabis locally and little revenue was captured for prevention. no new jurisdictions established a potency-linked tax. of jurisdictions allowing storefront retailers (n = 162), 114 capped outlet licenses, and 49 increased the state-specified buffers between storefronts and schools. thirty-six allowed on-site consumption, up from 29. as of january 2020, the state had not updated its regulations of key provisions addressed in this paper. conclusions: in year 2 of legalized adult-use cannabis sales in california, the state remained split between retail bans and legal sale. local policy continued to vary widely on protective measures, and state policy remained misaligned with protection of youth and public health. key words: cannabis; cannabis policy; tobacco control; cannabis regulation; cannabis law; marijuana policy since the first report was published on the california cannabis local laws passed in 2018 (silver et al., 2020), the first year of legalized adultuse sales in the state, legalization of cannabis has continued to sweep the nation. as of june of 2021, only 3 states in the u.s. had not legalized cannabis in some form, and 18 states had legalized adult-use cannabis retail sales (hartman, 2021), though not all have yet reached the licensing stage. though the promise of legalization includes access to medicinal cannabis for some valid medical applications and decriminalization to reduce inequitable and excessive punishments in drug policy, it also raises serious concerns about the potential risk of harms, especially to vulnerable populations such as youth and those exposed in utero. many calls have been issued for applying lessons of tobacco control to the cannabis market (barry & glantz, 2016; california tobacco education and research oversight committee (teroc), 2018; richter & levy, 2014; silver et al., 2020), such as: avoiding the product diversification and marketing trends that have characterized the tobacco industry (ayers et al., 2019), controlling conflicts of interest (bowling & glantz, 2019), and others have recommended limiting the rapid alisa a. padon1, kelly c. young-wolff2, lyndsay a. avalos2, lynn d. silver1 1prevention policy group, public health institute 2division of research, kaiser permanente northern california cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.005 local laws regulating cannabis in california two years post legalization: assessing incorporation of lessons from tobacco control corresponding author: alisa a. padon, phd, director of research, prevention policy group, public health institute. e-mail: apadon@phi.org local laws regulating cannabis in california 48 increases in product potency that have characterized the cannabis market and may increase risk of psychosis and other harms (murray & di forti, 2016; volkow et al., 2016). cannabis is the most commonly used illicit drug among adolescents in the u.s. (johnston et al., 2021). in california, past 30 day use among 1217 year olds rose significantly from 13.3% in 2016/17, just as adult-use legalization was coming to fruition, to 15.8% in 2018/19 (substance abuse and mental health services administration (samhsa), 2020). adjusted rates of use among pregnant women in northern california increased from 4.1% in 2009 to 8.7% in 2018 and adjusted rates of co-use of cannabis and alcohol during pregnancy also rose from 1.1% in 2009 to 1.9% in 2018, despite overall declines in prenatal alcohol use during the same time period (young-wolff et al., 2022). in a 2017 meta-analysis, the national academies of science, engineering and medicine (nasem) found substantial evidence supporting an association between cannabis use and serious harms such as psychosis, schizophrenia, and cannabis use disorder, among others, especially when use is initiated during adolescence and used frequently (national academies of sciences, engineering, and medicine, 2017). since that review, evidence continues to mount indicating an association between use during adolescence and poorer later life outcomes (chan et al., 2021); significant associations with psychosis incidence (forti et al., 2019), especially with higher potency products; associations with myocardial infarction (ladha et al., 2021); increased depression and suicidality (gobbi et al., 2019); and use of other substances (thrul et al., 2020; wardell et al., 2020). there is emerging evidence of an association with significant long-term neurological effects after in utero exposure (paul et al., 2020). there have been mixed findings on the effects of legalization on cannabis use among certain populations more vulnerable to harms such as youth, pregnant women and individuals at risk for cannabis use disorder (ammerman et al., 2015; anderson et al., 2019; berg et al., 2018; cerdá et al., 2017, 2019; chu, 2014; coley et al., 2019; dilley et al., 2018; schlienz & lee, 2018; shi, 2016; stolzenberg et al., 2016), perhaps due in part to varied research methods and cannabis policy environments across the u.s. (berg et al., 2018). the diversification of products in the legal cannabis market, including the trend towards high potency concentrates and edibles, raises new questions about long-term safety and effects (alzghari et al., 2017; meier et al., 2019; monte et al., 2019; reboussin et al., 2019; rup et al., 2021), and adoption of regulatory solutions to these concerns are, to date, scarce (silver et al., 2020; soroosh et al., 2020). today, protecting youth and public health in cannabis legalization may be less about being for or against, but rather about “how.” proposition 64, a california ballot initiative (california proposition 64, marijuana legalization, 2016), legalized use of “adult-use” cannabis in november of 2016, and production and sale of cannabis in january of 2018, while incorporating relatively few best practices from tobacco control. cities and counties retained broad discretion to allow legal cannabis commerce, or not, and to regulate its practice, despite ongoing unsuccessful regulatory and legislative attempts to curtail local control, including a regulation allowing delivery everywhere that was challenged and subsequently limited (mcgreevy, 2020). if a local jurisdiction does not implement cannabis policy, state law allowing commerce will apply. generally local government can only be stricter than the state, but in certain areas, such as buffers, they may also be more lenient. beginning in january of 2018 when the first legal adult-use storefronts in california opened, the california local cannabis law database was initiated as a tool for research and community engagement, collecting data on cannabis-related state and local laws in all 539 of california’s cities and counties (silver, naprawa, & padon, 2020). the database supports assessment of health outcomes in relation to the natural experiment of policy variation, tracking evolution of local policy as an outcome in its own right and identification and sharing of local policy innovation. in 2020, the first report using this database examined the extent to which recommendations from the public health community and potential lessons from tobacco control and other legal but harmful products had been adopted in the first year of legal adult-use sales (silver et al., 2020). almost half of jurisdictions had allowed some retail sale of cannabis, providing legal access to 57% of the state’s population. just under two-thirds of jurisdictions that allowed storefront outlets to operate imposed a cap on the number of storefronts cannabis, a publication of the research society on marijuana 49 licenses, a policy found to be effective at reducing youth initiation of tobacco use (henriksen et al., 2008). potentially undermining smoke-free air progress, some authorized consumption of cannabis at storefronts, and one in ten allowed permits for cannabis-related temporary events such as at county fairs or concerts. only 28% imposed greater buffers between storefronts and schools than the state-mandated 600 feet, only 2 city blocks, and over half did not tax retail sales locally. despite public support for equity in licensing (e.g., prioritizing those who had been convicted of cannabis-related crimes), only 5 cities had adopted such provisions. finally, conspicuously absent across state and local law were regulatory constraints on three cannabis industry behaviors directly adopted from tobacco industry practices: manufacturing or sale of products that attract youth, increases in the amount of the addictive component (percentage of tetrahydrocannabinol [thc]), and aggressive marketing (silver et al., 2020). the purpose of this project was to assess whether cannabis regulators shifted their focus from the initial challenge of creating a legal system to strengthening public health protections. in conducting this year 2 assessment, we addressed a criticism that the literature contains a lack of reproducible surveillance of the cannabis policy environment (berg et al., 2018). methods repeating the cross-sectional design used to study laws and regulations in california in year 1 of legalization (silver et al., 2020), we studied local and state california law to examine the extent to which recommendations for potential best practices had been incorporated into active cannabis legislation passed by january 1, 2020. silver et al. (2020) identified these potential best practices through a comprehensive literature review and 62 key informant interviews conducted over 2 years. selected practices included buffer zones between storefronts and sensitive use sites like schools, parks, or residential areas; restrictions on density of storefronts and their operation, certain product types, delivery, and marketing; preservation of smoke-free air; provision of health warnings; pricing and taxation measures; controls on conflicts of interest; and equity policies in licensing, hiring and revenue capture (antman elliott et al., n.d.; bowling & glantz, 2019; california tobacco education and research oversight committee (teroc), 2018; centers for disease control and prevention, 2014; drug policy alliance, 2017; health canada & task force on cannabis legalization and regulation, 2016; u.s. department of health and human services, 2000; world health organization, 2005). verification of laws: active local laws of 539 california cities and counties were verified using the fyllo (formerly cannaregs) commercial database, a compilation of proactively collected cannabis-related bills, ordinances, regulations, and rules from local jurisdictions in california and across the us (fyllotm | regulatory database for cannabis, 2022). their database was complemented by verification on jurisdictions’ websites and their municipal codes. when status remained unclear, city or county clerks were contacted directly. because san francisco is both city and county, it was counted only as a county, leaving a universe of 539 jurisdictions: 58 counties and 481 cities. state law and regulation was verified through examination of law and regulations posted on the state cannabis portal in effect january 1, 2020 (california, 2022) in california health and safety and business and professions code. random samples of cities (5%) and counties (10%) were iteratively coded by two independent coders and tested for inter-rater reliability, with 94% agreement. remaining jurisdictions were coded by a single public health lawyer. laws were coded as affirmatively allowed, affirmatively prohibited, or silent, which meant state law would apply, except in the cases of onsite consumption and temporary events which require affirmative local permission. this research was determined not to be human subjects research by the institutional review board of the project’s institution. results cannabis retail businesses. (see table 1) the cannabis laws passed through 1/1/2020 of all 539 of california’s cities and counties were successfully identified. of these, 276 jurisdictions allowed any retail sale of cannabis, covering 58% of the state’s population, an increase of 20 jurisdictions (8%) from year 1. two hundred and twenty-five jurisdictions allowed sales of adultlocal laws regulating cannabis in california 50 use cannabis, up from 194, and 270 allowed medical sales, compared to 251 in year 1. by cannabis and retailer type, 162 allowed storefront sales, with 147 allowing both medicinal and adultuse cannabis sales, 9 allowed only medicinal sales, and 6 allowed only adult-use sales. twelve jurisdictions prohibited all delivery, but only allowing cannabis retailing by delivery (prohibiting storefronts) was a common practice used by 114 jurisdictions. of these, 76 allowed deliveries of both medicinal and adult-use cannabis, and 42 allowed medicinal only. cannabis non-retail businesses. the number of jurisdictions allowing non-retail cannabis businesses also increased between years 1 and 2. cultivation increased from 167 to 175 jurisdictions, manufacturing from 174 to 193, distribution from 181 to 195, and testing from 201 to 219. as of january 1, 2020, 224 jurisdictions continued to prohibit cannabis businesses or sales of any kind. density and location of storefront retailers. (see table 2) of jurisdictions allowing any storefront businesses (n = 162), 114 limited the maximum number of licenses to be issued, an increase from 97 in year 1, averaging a maximum of 1 store for every 19,845 residents in the jurisdictions with such a regulatory cap. the state imposed no limits on the number of storefront or delivery businesses that could be licensed. six additional jurisdictions (beyond the 43 from year 1) imposed a buffer between storefronts and schools greater than the state regulated 600 feet, yet 8 (up from 6) made use of a state exception for a local jurisdiction to specify a different radius and allowed storefronts to locate closer to schools, averaging 293 feet. one hundred and ten (up from 100) jurisdictions added establishments to the state’s list of sites from which storefronts must be distanced (i.e., k-12 schools, day care or youth centers). locally adopted examples included colleges, public beaches, libraries, residential zones, and tutoring centers. buffers between storefronts were imposed by 63 jurisdictions, with a median of 700 ft, down 100 ft from year 1. on-site consumption. despite california laws prohibiting smoking cannabis in most workplaces or in any place where smoking tobacco is prohibited by law, 35 jurisdictions, up from 29, allowed on-site cannabis consumption in some form at cannabis business locations. of these, 1 allowed edibles consumption only, arguably the only method that would protect other customers and employees from exposure to smoke or vapor, 1 allowed vaping and edibles only, 30 allowed any product type to be consumed, and 4 allowed staffuse only. the state allows on-site consumption where locally authorized. delivery restrictions. of the 266 jurisdictions that allowed delivery sales, most (n = 202) required some form of permitting. of the 114 jurisdictions that allowed delivery-only, prohibiting storefront retailers, 31 allowed deliveries originating from businesses based inside and outside the jurisdiction, 7 allowed only deliveries originating inside their jurisdiction, and 76 allowed only those originating outside. among those 76 that only allowed outsideoriginating delivery, 41 imposed no permitting or other registration requirements on delivery sales to their residents. the state allows delivery licensees to sell anywhere, but respecting local restrictions. health claims and warnings. the state continues to require only a limited health warning in hard-to-read 6-point font on packages, however 7 more local jurisdictions, totaling 29, required additional health warnings be posted or handed out in stores or by delivery, and 2 new, totaling 6, required additional health warnings on packages. no jurisdiction required warnings on advertising in either year of legalization. only mono county has prohibited all health-related claims on cannabis labels, advertising, and marketing and in retailer names since year 1. while the state’s cannabis advisory committee had recommended in march of 2018 that adult-use cannabis businesses not be allowed to make health claims in advertising, this recommendation was not adopted by the state regulatory agency. restrictions on products allowed for sale. in both year 1 and 2 of legalization, jurisdictions imposing limits on products with characteristics attractive to children or youth, the “cannabis kids menu” (e.g., flavored products, infused beverages, and other products with youth appeal such as those typically consumed by or marketed to kids such as rice krispie treats, sugary cereal, candy) were sparse: 1 prohibited flavored products for combustion or inhalation (contra costa county), 4 prohibited cannabis-infused beverages, or “cannapops,” (pasadena, san diego county, mono county and chula vista) and mono county also restricted products appealing to youth as cannabis, a publication of the research society on marijuana 51 table 1. commercial cannabis activities allowed in california cities and counties (n = 539) in year 1 (2018) and year 2 (2019) of legalization note. data includes 58 counties and 481 cities. if a jurisdiction was silent then state law applied. the city and county of san francisco were treated as a county. aof the 114 jurisdictions that only allowed delivery retail sales, 76 only allowed delivery from businesses based outside the jurisdiction. determined by the county. four jurisdictions imposed restrictions on edibles beyond state regulations: palm springs limited edibles' descriptions to generic food names; pasadena defined products attractive to youth as a type typically consumed by, or marketed to, children or youth, such as a specific candy or baked treat; salinas prohibited products requiring refrigeration or hot-holding (i.e., heating to a temperature at which food is safe for consumption); and san diego county prohibited the sale of edibles as of 1/1/2020. by year 2, 2 prohibited the sale of vaporizers (contra costa county and pomona), though pomona did not ban the sale of vapor cartridges. no jurisdictions limited potency of products sold, but per resolution 11067, the city of san luis obispo awards more points in the application selection process to businesses who committed to offering lower dose thc products. state regulations continue without restriction on potency or flavors, other than a standard edible dose, and there is no pre-market product review system. while the state’s cannabis advisory committee recommended in 2020 the creation of a scientific task force without conflicts of interest to review the evidence on increasing potency of cannabis and cannabis products and make recommendations for regulation, the regulatory agency has declined to act to date. equity in licensing and criminal justice. whereas provisions to promote economic equity and diversity in cannabis licensing were limited to five of the largest cities in the first year of legalization, by 1/1/2020, that small number had more than tripled and twelve additional jurisdictions (17 total) had established some equity provisions. a definition of “equity” applicants was developed by 15 jurisdictions, for example, prioritizing those who had been convicted of cannabis related crimes or had someone in their immediate family convicted, or resided in impacted neighborhoods. nine gave priority in licensing to equity applicants, 10 established some hiring requirements related to worker income, transitional status, or local hires, and 7 new (11 total) implemented reduced or deferred licensing fees or other costs for equity applicants. the state regulatory agency did not establish any equity licensing system, but in 2019, activity type allowed medical & adult-use allowed adult-use banned, medical only allowed medical banned, adult-use only allowed any legal allowed retail sale n (%) n (%) n (%) n (%) storefront-only sales (delivery not allowed) 2018 8 (2) 6 (1) 3 (1) 17 (3) 2019 6 (1) 1 (0) 3 (1) 10 (2) delivery-only sales (storefronts not allowed)a 2018 66 (12) 42 (8) 0 (0) 108 (20) 2019 72 (13) 42 (8) 0 (0) 114 (21) any retail sales (storefront-only, delivery-only, or both) 2018 189 (35) 62 (12) 5 (1) 256 (48) 2019 219 (41) 51 (10) 6 (1) 276 (51) cultivation businesses 2018 145 (27) 17 (3) 5 (1) 167 (31) 2019 161 (30) 13 (2) 1 (0) 175 (33) manufacturing businesses 2018 156 (29) 16 (3) 2 (0) 174 (32) 2019 180 (33) 12 (2) 1 (0) 193 (36) local laws regulating cannabis in california 52 table 2. adoption of potential best regulatory practices beyond state law in cannabis regulation in california jurisdictions as of january 1, 2020 regulatory practicea 2018 n (%) 2019 n (%) among jurisdictions that allow storefront retail n = 148 n = 162 cap on storefronts 97 (66) 114 (70) ratio of storefront cap to population (mean (min-max)) 1:20,788 (1:154-1:355,143) 1:19,845 (1:154-1:355,143) buffers from schools >600 ft state rule 43 (29) 49 (31) <600 ft state rule 6 (4) 8 (5) additional sensitive-use sites identifiedb 100 (68) 110 (68) buffers between stores (median (min-max)) 800 (50-5280) 700 (50-1500) on-site consumption prohibitions allowed 29 (20) 35 (22) banned 79 (53) 92 (57) silent 40 (27) 35 (22) among jurisdictions that allow delivery retailc -n = 264 delivery permit required -202 (76) delivery origination outside-only -81 (31) inside-only -32 (12) inside and outside -67 (25) among jurisdictions that allow any retail n = 256 n = 276 health claims’ restrictions 1 (0) 2 (1) additional health warnings required 26 (10) 33 (12) restrictions on products any below 8 (3) 9 (3) attractive to youth 1 (0) 1 (0) flavors 1 (0) 1 (0) beverages 4 (2) 4 (1) potency 0 (0) 1 (0) edibles 4 (2) 4 (1) vapor products 0 (0) 2 (1) equity considerations 5 (2) 17 (6) conflicts of interest considerations 58 (23) 69 (25) price discounts prohibited 4 (2) 3 (1) minimum price required 0 (0) 0 (0) any tax on retail 121 (47) 140 (51) among jurisdictions that allowed any retail and passed a local gross receipts tax on retail n = 120 n = 138 retail tax (median % (min-max))d 5% (0-18) 5% (0-18) among all jurisdictions n = 539 n = 539 temporary special events prohibited 21 (4) 28 (5) advertising restrictions 81 (15) 104 (19) a these provisions refer to measures that are stricter than state law. b jurisdictions that identified additional sensitive-use sites to the state’s list of sites from which storefronts must be distanced, which consisted of k-12 schools, day care or youth centers. examples included colleges, public beaches, libraries, residential zones, and tutoring centers. c origination of delivery and delivery permitting restrictions were not captured in year 1 of legalization. d retail tax represents the median gross receipts tax rate in % across jurisdictions that allowed retail sales and implemented a local tax on cannabis sales at retailers. this figure excluded the 2 jurisdictions that taxed retail activities solely by square footage of the storefront business cannabis, a publication of the research society on marijuana 53 the legislature established the cannabis equity grants program for local jurisdictions to aid local equity program efforts (california governor’s office of business and economic development, 2021). proposition 64 established the right to expunge certain past cannabis convictions, and in response to limited use of the opportunity, state legislation subsequently approved a process for automatic expungement via assembly bill 1793, however in many cases the courts have failed to meet the july 1, 2020 deadline to clear convictions (bill text ab-1793 cannabis convictions: resentencing., 2018; health and safety code §11361.9. division 10. uniformed controlled substances act. chapter 6. offenses and penalties. article 2. cannabis, 2019; sacramento bee editorial board, 2021). we did not identify any separate expungement provisions in local law. conflicts of interest. sixty-nine, up from 58, jurisdictions added some form of conflict of interest rule, such as prohibiting physicians from being available in storefronts to issue medical cannabis identification cards, or owners/employees from participating on oversight committees. the state prohibited those involved in cannabis regulation, enforcement or appeals from holding cannabis licenses or having a financial interest in a cannabis business, but the state has not prohibited those with cannabis financial interests from participation in advisory bodies, and such participation is occurring. persons licensed for testing laboratories may not hold other cannabis licenses, per state regulation. price and taxation measures. of 315 jurisdictions legalizing any commercial cannabis activity (including retail, cultivation, manufacturing, distribution, or testing), 53% did not tax cannabis activity locally, down from 55% after year 1 of legalization. of those that did pass a local tax, 91% passed a “general” tax, which in california is a tax without a legally binding use and 2% passed a special tax, dedicated to uses such as police/law enforcement, fire services, parks and recreation, repairing city streets or enhancing community centers. the median tax rate collected locally on gross receipts from retail sales remained steady at 5%. as of 1/1/2020, cathedral city was still the only jurisdiction to impose a higher tax on higher thc potency cannabis products. only 3 jurisdictions prohibited discounting (imperial beach, pomona and pasadena), such as redemption of coupons, discount days or other promotions, and none implemented a minimum price law which has been used effectively in tobacco control globally (farrelly et al., 2008; licht et al., 2011). the state continues to prohibit distribution of free products but has implemented no other price control policies and has not adjusted its original 15% excise tax on retail sales. in fiscal year 2020-2021, cannabis tax revenues increased by 55% in one year to an estimated $817 million (kerstein, 2021). in that year, $178m was allocated to a youth education, prevention and treatment of youth substance abuse disorder and school retention fund, of which $125 million went to subsidized childcare, approximately $33m to youth substance use disorder prevention and outreach grants, $12m was allocated to cannabis surveillance and education, and $8m to natural resource youth programs. an additional $40m went to the state department of community corrections, some of which was used for youth programs and additional funds supported traffic safety and parks and recreation programs (office of the governor, 2020). although the amounts for youth have increased, together with other funds channeled to youth through the corrections system, they remain only a modest part of cannabis tax revenues. temporary special events. twenty-two jurisdictions in california (up from 14) established a permit system for cannabis-related temporary special events (e.g., cannabis booths displaying and selling products and allowing onsite consumption at fairs or outdoor concerts), while 28 banned them (an increase of 7) and most were silent. restrictions on advertising. an increase of 23 jurisdictions, totaling 104, limited advertising in some way; 95 of them through limiting business signage. twelve restricted billboards or other outdoor advertising, and 20 banned cannabis advertising on billboards, primarily through an existing general billboard ban. no new jurisdictions limited advertising on tv, radio, online or in print in year 2 (n = 4), though 7, an increase of 2, prohibited advertisements attractive to youth more explicitly than the state. the state did not require warnings on ads and in january of 2019 used regulation to weaken proposition 64’s prohibition on billboards on highways which cross state borders, limiting local laws regulating cannabis in california 54 application to roads within 15 miles of the state border (california code of regulations, title 16 division 42. § 5040(b)(3). advertising placement, 2019). in november of 2020, however, a judge found the regulation inconsistent with state law, leading to subsequent withdrawal (“california judge rules against cannabis billboard ads on interstate highways,” 2020). in september of 2021 the state legislature voted to allow cannabis billboards again, a measure whose legality was then questioned as inconsistent with the voterapproved ballot initiative (michael colantuono, 2021), and which was ultimately vetoed by the governor for this reason (gavin newsom & office of the governor, 2021). discussion this review reveals an evolving landscape of cannabis legalization across california cities and counties. while possession and cultivation of up to 6 plants is legal everywhere, the state continued to be almost equally divided between communities that legalized cannabis retail commerce and those that prohibited it. allowance of legal cannabis businesses increased slightly across the state, bringing job opportunities, and capturing tax revenue, although also potentially increasing cannabis associated harms. there have been modest shifts both towards and away from protection of vulnerable populations, reflecting the ongoing tension between legalization that prioritizes economic opportunity versus prioritizing public health and youth. regulation of the legal market is often cited as contributing to the persistence of the illicit market however there is little evidence to support the idea that less taxation or regulation, particularly of public health-focused rules, will lead to more rapid elimination of the illegal market. further, as yet there is insufficient information on the countervailing costs of legalization, such as negative health or social impacts, against its economic benefits. as in the first year of legalization, fundamental lessons from tobacco control to limit harm and prevent youth use have been left out of cannabis policy across state agencies, the legislature, and many local governments in california. there is little evidence of a shift from the initial focus on structuring the legal market to better protecting health or promoting equity and social justice. policies that had been widely and long since abandoned for tobacco such as allowing indoor smoking in lounges or storefronts near schools are being adopted for cannabis. jurisdictions allowing cannabis consumption inside of storefronts increased 21% from the first year of legalization. on-site consumption provisions may attempt to address legitimate concerns that without designated cannabis smoking/vaping areas somewhere, there could be increases in public use, or use in multi-unit housing posing risks to vulnerable groups like children and the elderly, or/and more policing and displacement of low-income and minority residents for cannabis use in their rental units or in public, exacerbating housing or criminal justice disparities. yet, there is strong evidence that cannabis smoke contains similar toxins to tobacco smoke and that cannabis smoke and cannabis vapor produce emission rates of secondhand smoke/vapor greater than that of cigarettes (ott et al., 2021), and it is not feasible to assure safe indoor air quality with current ventilation or engineering techniques (ashrae environmental tobacco smoke position document committee, 2020). there was a 33% increase in jurisdictions permitting cannabis temporary events, often held in formerly smoke-free public parks, at fairs and concerts, which present greater opportunities for youth exposure to public use, marketing, and youth access compared to storefronts with robust security and transactions taking place out of the public eye. increases in the price of tobacco products is one of the most effective tobacco control policies in reducing tobacco use, particularly among young people (gilbert & cornuz, 2003; levy et al., 2018). yet in california, no jurisdiction implemented a price floor and few restricted discounts. further, no local tax revenue was dedicated to prevention or education through a special tax. only through less permanent solutions have some communities acquired revenue for youth services, prevention and/or education, such as development agreements or cannabis sub-funds created with general fund resources. capping the number of storefront licenses continued to be the most adopted protective policy, with most jurisdictions adopting a relatively prudent ratio of 1:19,845 residents on average. more outlets mean more competition, typically increasing marketing and lowering cannabis, a publication of the research society on marijuana 55 prices to maximize sales. capping licenses has led to lower rates of initiation of alcohol and tobacco use by youth, as well as decreased youth exposure to marketing (chen et al., 2009; countertobacco.org, n.d.; truong & sturm, 2009). more restrictive marketing policies, such as the limits on business signage instituted in 99 california jurisdictions in year 2, and reversal of highway billboard friendly policies by governor newsom’s veto may dampen the aggressive outdoor marketing seen in year 1 (trangenstein et al., 2021; whitehill et al., 2020); however online, print and off-highway marketing persist. these practices may continue to increase youth substance use uptake and lower perceptions of cannabis risks (trangenstein et al., 2021), as seen in a robust literature from alcohol and tobacco advertising studies (jernigan et al., 2017; paynter & edwards, 2009; slater et al., 2007). at the state level, products being marketed continue to lack almost any flavor or potency restrictions, a concerning omission given the association between flavoring and youth initiation of other substances (albers et al., 2015; ambrose et al., 2015; california department of public health, 2019), and growing evidence of a link between cannabis potency and psychosis, dependency, and other negative health impacts (arterberry et al., 2018; hines et al., 2020; national academies of sciences, engineering, and medicine, 2017). other states such as connecticut have recently acted to limit potency and to require retailers to stock lower potency products (sb 1201 an act concerning responsible and equitable regulation of adult-use cannabis, n.d.). compounding the potential for harms, residents still lack clear and salient health warnings such as those used on cannabis products in canada or on tobacco products in the usa (freeman & winstock, 2015; galli et al., 2011; volkow et al., 2014). strengths of this study include the complete coverage of california jurisdictions, and the wideranging scope of regulatory variables collected. regulation continues to evolve, and we will assess change annually. nevertheless, limitations should be noted. we primarily focused on examining local cannabis laws and may have missed other local laws such as zoning or smokefree air that indirectly affect cannabis businesses. we also analyzed only policy environment and not the number of legally operating businesses. these findings cannot be generalized to other states or locations in which the process of legalization and extent of local authority differ from california. however, the potential best practices identified are broadly relevant for governments considering cannabis regulation. the use of required nonprofit or public monopoly models was not discussed because they do not exist in the state, but this continues to be an additional potential best practice, currently in use in the province of quebec (francois gagnon, 2021). policy surveillance provides a valuable tool for future research on california’s evolving natural experiment of local control and may help answer fundamental questions of what types of cannabis policies lead to net public health benefit or harm. conclusion in the nation’s most populous state, the legal landscape in the second year of adult-use commerce continues to largely favor economic opportunity over heeding lessons from tobacco control and other legal but harmful products to protect youth and public health. examples of local innovation are growing, however, offering precedents for others to adopt a more cautionary approach. the health impacts of these alternate approaches must be assessed. as legalization spreads and is debated in congress, consideration of more precautionary policy approaches is increasingly pressing to fulfill our collective responsibility to both end the war on drugs (american civil liberties union, 2020) and protect youth and health in the coming years (barry & glantz, 2016). references albers, a. b., siegel, m., ramirez, r. l., ross, c., dejong, w., & jernigan, d. h. 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(2022). trends in cannabis polysubstance use during early pregnancy among patients in a large health care system in northern california. jama network open, 5(6), e2215418. funding and acknowledgements: the authors wish to acknowledge the support of the california tobacco related disease research program, the conrad n. hilton foundation, and the national institute on drug abuse at the national institutes of health. the authors have no potential conflicts of interest, real or perceived. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i2a3_authors_v2 research article 31 abstract medical and recreational cannabis are becoming more accessible and socially accepted across the united states. emerging adults (eas; 18 to 29) are the largest group of cannabis users. studies have found that veterans are more likely to report cannabis use compared to nonveterans. while research exists on the use levels of cannabis, limited knowledge is available on the perceived risks and benefits of using cannabis among ea military and veteran populations. helping professionals encounter veterans who use cannabis and must consider military cultural factors and attitudes towards cannabis that may influence or exacerbate cannabis use. we conducted a qualitative study with 23 ea veteran and military members with high-risk substance use and asked about their thoughts on the acceptability, risks, and perceived benefits associated with cannabis. two qualitative coders used nvivo to find themes following the six steps of thematic analysis. results provide in-depth understanding of ea military members and veterans’ perceptions of cannabis. overall, we found participants were receptive to using cannabis for pain ailments, mental health issues, and as an alternative to benzodiazepines, opioids, and alcohol. however, they acknowledged restrictions are needed to moderate cannabis use and mitigate negative outcomes. lastly, participants recognized the incongruence of cannabis use with military job responsibilities and expectations. these findings shed light on potential risk and protective factors related to using cannabis for recreational or medical reasons and should be considered when consulting ea military members and veterans. key words: = cannabis; veteran; qualitative methods; substance use; military; emerging adults across the world, cannabis is the most used drug after alcohol and tobacco (budney et al., 2019). today cannabis use is at the highest it has been in three decades, as one study shared the rate was approaching 36.5% prevalence for past year use (schulenberg et al., 2017). dsm iv cannabis use disorder (cud) diagnoses significantly increased in the general population (4.1% to 9.5%) from 2003 to 2013 (hasin et al., 2017). further, we see continued increases within demographic subgroups (i.e., gender, age, race/ethnicity, income, education, marital status, urbanicity, region, pregnancy status, disability status; hasin et al., 2019). approximately 1 in 5 cannabis users may be at risk for a cud diagnosis, with the majority occurring within the first 4 years of first use (leung et al., 2020; feingold et al., 2020). the peak prevalence of substance use, mostly cannabis and alcohol use, occurs in emerging adulthood (ages 18-29; schulenberg et al., 2017). approximately 1.7 million eas have a past year cud (about 5% of 18 to 29-year old’s; samhsa, 2016). a decade-long trend is that eas now perceive fewer risks of physical harm associated with using cannabis. according to the national survey on drug use and health (nsduh), the percentage of adults indicating that there was “no risk” associated with cannabis use increased from 6% to 15% during 2002 to 2014 and perceiving “great risk of harm” the green sheep: exploring the perceived risks and benefits of cannabis among young military members and veterans cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.003 kelly lynn clary1, megan habbal2, douglas c. smith3, iulia fratila4 1school of social work, texas state university 2department of psychology, university of illinois at urbana-champaign 3school of social work, university of illinois at urbana-champaign 4community health, university of illinois at urbana-champaign corresponding author: kelly lynn clary, ph.d., msw, school of social work, texas state university, 601 university drive, san marcos, tx, 78666. email: klc385@txstate.edu. phone: 815-666-8091. note on article title: ‘green sheep’ is often used as a slang term for being open minded about discussing and using cannabis. since stigmas and negative connotations still exist about cannabis, being vocal about cannabis can be challenging. further, since cannabis is illegal to use within the military, discussing cannabis with active-duty members and veterans may be perceived as a taboo topic. perceptions of cannabis benefits among mm & veterans 32 related to smoking one to two times per week dropped from 50.4% to 33.3% (compton et al., 2016). these trends illuminate a likely inverse relationship between risk associated with cannabis use and cud. meaning, as perceived risks and harm associated with cannabis use decrease, cannabis use may continue to increase. this is important and highlights the possibility of significant public health risks associated with legalization of both medical and recreational use of cannabis. to date, 36 states and four territories have passed cannabis legalization policies for medical and/or recreational use since 1996 (hasin, 2018; national conference of state legislatures, 2021). further, the literature addresses the increased risk of negative effects related to physical and mental health, social and occupational functioning, and increase in substance use disorders, psychosis, mental health issues, and schizophrenia as a result of cannabis use (svrakic et al., 2012; national academics of sciences, engineering, and medicine, 2017). background among all eas, active-duty military members and veterans often have higher rates of substance use and related consequences than their civilian counterparts (larson et al., 2012; mitchel et al., 2017). veterans with a diagnosable mental health or a substance use disorder increased from 27% to 41% from 2011 to 2014 (u.s. department of veterans affairs, 2016). more specifically, 18-25year-old male veterans have higher substance use rates than their civilian counterparts (teeters et al., 2017), substance use disorder diagnoses have increased by 81% among women veterans (cucciare & ghaus, 2012), and veterans have higher rates of alcohol-related consequences than civilians (mitchell et al., 2017). one study shared veterans are more likely to report using cannabis than comparable nonveterans (wagner et al., 2007), and the increasing rates of cannabis use and cud are evident in the literature (metrik et al., 2018). a recent nationwide sample of veterans showed that in 2018, approximately 9% of veterans reported past year cannabis use (davis et al., 2018). during 2014, in states where medical cannabis was legal, 41% of veterans who used cannabis in the past year reported doing so for medical purposes (davis et al., 2018). moreover, the percentage of veterans with comorbid posttraumatic stress disorder (ptsd) and cud diagnoses at the veterans affairs health care system increased from 13% in 2002 to 22.7% in 2014 (bonn-miller & rousseau, 2015). this is two times higher than the general population, but also undercounts the actual number of veterans using and misusing cannabis because not all veterans utilize the veterans affairs health care system. in addition, ptsd has been documented as the most likely co-occurring diagnosis with cud among veterans (metrik et al., 2020). this is important as research has cited that one of the most prevalent coping strategies to alleviate symptoms related to ptsd is the use of cannabis (kondev et al., 2021). more so, veterans have been documented to view cannabis as a mechanism for reducing ptsd symptoms (earleywine & bolles, 2014), in addition to a sleeping aid (bonn-miller et al., 2014), pain management (baron et al., 2018), and assisting with emotional triggers (tull et al., 2007). recent alterations in policy and research have brought about a rapid perspective shift on the use of medical cannabis for the treatment of physical ailments, sleep disturbances, and psychological disorders among young veterans (aggrawal, 2009). modern research findings continue to point to medical cannabis as a potentially effective alternative to prescription medications for treating a broad range of medical conditions. for example, participants in one study described cannabis as a safer alternative to alcohol, illicit drugs, and pharmaceuticals (lau et al., 2015). multiple research studies have illustrated the benefits derived from using cannabis for various medical reasons (institute of medicine, 2011; national academics of sciences, engineering, and medicine, 2017), such as for chronic pain, nausea/vomiting, muscle spasms, and seizures/epilepsy (ebbert et al., 2018). however a recent scoping review reports there are mixed findings about benefits and harms from cannabis, and moderate harms were commonly reported throughout the documented studies (pratt et al., 2019). further, research has also shown biopsychosocial impairments can be linked to cud characteristics (budney, 2006; hasin et al., 2013; sofis et al., 2020, volkow et al., 2014). this is concerning due to the increasing rates of cannabis use across the country, decrease of risks associated with use among young veterans, limited knowledge about cannabis being an cannabis, a publication of the research society on marijuana 33 effective treatment for ptsd (bonn-miller & rousseau, 2015; krcevski-skvarc et al., 2018;), and growing body of literature unveiling the spectrum of behavioral, mental health, and neurobiological risks associated with cannabis use (i.e. psychosis, anxiety, depression, social impairments, cognitive deficits, social impairments and drug addiction; bassir nia et al., 2016; charilaou et al., 2017; leweke & koethe, 2008; malone et al., 2010; kedzior & laeber, 2014; feingold et al., 2017; crean et al., 2011). summary a great deal of literature focuses on the relationship of ptsd, major depressive disorder, sleep, and anxiety with cannabis (grant et al., 2016; metrik et al., 2016). however, it is evident that identifying specific motives and perspectives for cannabis use is important for empiricallybased support-treatments (metrik et al., 2016). we acknowledge ea military members and veterans are using cannabis for medical issues and recreational purposes, which continues to be a growing concern (bonn-miller & rousseau, 2015). further, the literature cites there are risks for veterans using cannabis, but we should expand our understanding with active-duty service members as well. active-duty service members who use cannabis may be at risk for substantial consequences due to their military status. in summary, minimal qualitative research exists on the perceived risks and benefits associated with cannabis use among ea military populations. research should focus on uncovering protective and risk factors among ea active-duty military members and veterans to tailor education and treatment programs. the current study this exploratory qualitative study sought to understand the perceptions and attitudes of ea military members and veterans using cannabis. we specifically uncovered perceived benefits and risks of cannabis among ea military members and veterans using cannabis for medical and recreational purposes. this study is unique in asking ea military members and veterans their perceptions of cannabis. for this study we defined eas as individuals ages 18-29, as recent literature has established adulthood as beginning at age 30 (mehta et al., 2020). this also aligns with the guidelines put forth from the society of the study of emerging adulthood (ssea), a large scholarly organization (ssea, 2014). this developmental time is challenging and eas are at heightened risk for substance use problems (arnett, 2005). because of this, we interviewed ea veterans and military members. this qualitative study adds to the literature by focusing on ea military members and veterans with risky substance use. moving forward, this information can inform substance use programming and harm reduction approaches for ea veterans and military members. methods data collection in a midwestern state, we received institutional review board (irb) approval from a large university and obtained a national institutes of health certificate of confidentiality. this current study is part of a dissertation study that focused on the relationship between substance use behaviors including alcohol and cannabis and the five emerging adulthood theory developmental dimensions among ea military members and veterans (arnett, 2000; clary, 2020). we used social media and snowball recruitment across the united states by advertising the study through social media (i.e., linkedin, facebook) and on university listservs (i.e., campus veteran center), as well as through word of mouth from participants (i.e., participants shared the study with their peers). participants were eligible if they were currently serving in the military or a veteran, between the ages of 18-29 years old, spoke english, currently living in the united states, and met threshold for high risk substance use behaviors through the alcohol use disorders identification tool (audit-c) or drug abuse screening tool (dast-10). forty-three participants emailed inquiring about the research study, 36 (100%) people were screened for eligibility via telephone, 30 (83%) people were eligible to participate, 26 (72%) individuals completed the study, and 23 (64%) participants discussed the questions related to perceived risks and benefits of cannabis use. eligible participants completed an online qualtrics survey taking approximately 20 minutes. data for this study was collected from february 2019 to august 2019. perceptions of cannabis benefits among mm & veterans 34 participants received a $30 amazon gift card for completing a semi-structured interview on a wide range of topics. measures two reliable and valid measures assessed for high-risk substance use behaviors. eligible participants had to meet high risk from either instrument. alcohol use disorders identification tool-c (audit-c) the alcohol use disorders identification test (audit-c) questionnaire is a modified version of the 10 questionnaire audit instrument, which demonstrates good specificity and sensitivity for identifying high risk alcohol behaviors (rumpf et al., 2002). the audit-c includes the first three items of the audit, which screens for hazardous alcohol consumption or those who might have an alcohol use disorder (bush et al., 1998). a score of four or higher is considered positive for hazardous drinking for men and a three or higher for women (range = 0-12). drug abuse screening tool-10 (dast-10) the drug abuse screening test (dast-10) is a brief administrative tool used to understand the extent of problems due to substance use, other than alcohol and tobacco use. the cut off for this test is 3 or higher (range = 0-10). a comprehensive review validates adequate reliability and validity of this tool for use in clinical and research settings (yudko et al., 2007; skinner, 2001). interview protocol & questions participants living near the university had the choice to complete the interview in-person, and those not living in close proximity to the university completed the interview virtually. twenty-three semi-structured audio-recorded interviews were completed via zoom (n=19) or inperson (n=4). on average, interviews lasted approximately 71 minutes and one interviewer asked questions regarding their transition into adulthood, substance use behaviors, mental health stigma, and perceptions and attitudes related to risks and benefits of cannabis. the structured questions that were analyzed for this study are (1) “can you talk about cannabis within the military?,” (2) what do you believe are the perceptions of military members and veterans using cannabis?,” and (3) “what are the risks and benefits of veterans using cannabis?” additional interview questions were analyzed in other articles (clary & byrne, 2021; clary et al., 2021). qualitative data analysis qualitative methods are beneficial when establishing an understanding about a phenomenon with limited knowledge (taylor & bogdan, 1998). interviews were transcribed verbatim by a confidential transcription service for objectivity, and transcripts were uploaded to nvivo software for analysis (hilal & alabri, 2013). the first two authors completed reflexive thematic analysis coding (braun & clarke, 2006). both coders are well-versed in qualitative methodology (i.e., completed qualitative methodology courses), have used nvivo software for previous qualitative coding projects, and have previously published qualitative studies. thematic analysis the two coders utilized the six-phase process of thematic analysis (braun & clarke, 2006), a widely-used qualitative method (boyatzis, 1998; roulston, 2001; javadi & zarea, 2016). this recursive process includes (1) familiarization with data by reading through the transcripts and listening to audio recordings, (2) generating initial codes and creating a codebook, (3) searching for themes, (4) reviewing potential themes, (5) refining, defining, and naming themes, and (6) producing the findings report with illustrative quotes. we used a phenomenological research approach appropriate for inductively identifying common themes (bliss, 2016). the first two authors read each transcript while listening to the audio recordings and made notes of patterns among the cannabis question (taylor & bogdan, 1998; braun & clarke, 2012; gilgun, 2015). next, transcripts were open coded (strauss & corbin, 1990; charmaz, 2006) line by line to find meaningful patterns. transcripts were coded independently in nvivo and weekly reflexive meetings ensued to address discrepancies among cannabis, a publication of the research society on marijuana 35 codes. we then moved into a more concise way of understanding the initial generated codes by creating a manageable codebook using excel. during this phase, the two coders condensed the open codes to create axial codes (ryan & bernard, 2000; strauss & corbin, 1990), and independently line by line coded the interviews. next, peer debriefing with all authors regarding the results and illustrative quotes occurred. lastly, the first two authors wove together the narrative with the overarching themes and selected quotes. the coders followed a rigorous qualitative coding method that included an audit trail, reflexivity, and peer debriefing to ensure the final report accurately illustrated the overarching themes and lived experiences of the participants. demographic characteristics average age of participants was 24.8 (range = 20-29). the majority were male (n = 18, 78%). of the 23 participants, 18 (78%) were white, 1 (5%) was asian, and 4 (17%) identified as white and hispanic. the majority were in the marines (n = 11, 48%), with balance from the navy (n = 6, 26%), army (n = 3, 13%), air force (n = 1, 4%), air national guard (n = 1, 4%), and national guard and army (n =1, 4%). of the sample, 13 (56%) were currently serving, and 10 (44%) identified as veterans. many participants had been deployed (n = 13, 56%). participants were living across the united states in 9 states (i.e., illinois, north carolina, arizona, california, virginia, michigan, maryland, oklahoma, and colorado), with the majority (n = 10, 38%) living in illinois. average age of substance use onset was 16.3 (range = 1322, sd = 2.46). average audit-c scores were 5.3 (range = 3-10, sd = 2.14), and the average dast10 score was 0.7 (range = 0-6, sd = 1.72). results qualitative themes revolved around risks and benefits of cannabis use and included: (1) receptive to using cannabis due to perceived benefits for pain ailments, mental health issues, and as a substitute or alternative to benzodiazepines, opioids and alcohol, (2) regulations are needed, and (3) incongruence with military job responsibilities. overarching themes and illustrative quotes follow each theme. please refer to table 1 for the final themes, sub-themes, and definitions. receptive to using for self and others overall, participants were receptive to use cannabis for pain, mental health issues, and as an alternative or substitute to using prescription medications. they were open-minded about using cannabis for various medical issues including pain and mental health concerns, and also saw the potential benefit of using cannabis as a substitute to opioids and benzodiazepines, and a safer alternative to alcohol for recreational purposes. most participants acknowledged that there is an increase of cannabis use when one discharges from the military, which aligns with previous research on substance use during the transition out of the military. a study showed 31% of veterans reported increase of substance use during their first year into the civilian sector (sayer et al., 2010). one participant explained cannabis use within the national guard: “no one would like straight up be like, yeah, i smoke weed every day or whatever. but there would be occasions where people would like mention that they smoked or something in the guard… i actually smoked and i was in the military”. –female, 26, air national guard, veteran. further, participants exemplified the increase in cannabis use after transitioning out of the military: “yeah, especially right after they get out. there’s a honeymoon period, if you couldn’t do it [smoke cannabis] for 4 or 5 years or if you were in longer, you cannot do it, so once you get out and you’re able to do it, yeah, like everyone takes advantage of that and eventually it just tapers off” –male, 25, marine corps, veteran. “so, there’s those that definitely plan on using it [cannabis] when they get out [of the military]” –female, 25, navy, active duty. “a lot of people that i know that have gotten out, they're like, oh, you know, the second i get out, i'm going to go, you know, buy, you perceptions of cannabis benefits among mm & veterans 36 know, a bunch of weed to just smoke it, you know, um, whether this be just because they couldn't do before and now they can, you know” –male, 26, army, active duty. it is unclear whether cannabis use increases due to the legality of it outside of the military for recreational purposes, or if it is being used for self-medicating (shadur et al., 2015) mental health and medical problems. however, the decrease in associated risks with cannabis use may be a factor at play. one participant mentioned: “i think marijuana use in general, i mean based off people i know and the ones i’ve met at school it’s...marijuana itself is very common. i think a lot of people, i mean we have a couple of veterans that advocate for it, essentially. i know a couple of student veterans here who are really into it, really a believer of it. i think it is a little bit more common, it could be also be that the younger generation itself accepts it a lot more, so that could just be my experiences with the veteran students here who tend to be younger. –male, 26, navy, veteran. this participant’s statement aligns with the decade-long trend that young adults perceive fewer risks associated with cannabis (samhsa, 2018). a few more participants acknowledged the perceived benefits of cannabis: “i mean it [cannabis] has a lot of medical benefits to it.” – female, 26, air national guard, veteran. “if something works, i’m a true believer in if it works you should be able to do it. whether it’s for veterans, people who have arthritis or different things, you know, things like that. if it works, i think, absolutely. i mean it's been one of those things that's been, you know, kind of like the black sheep that no one really wanted to talk about or you know, try and pass. and i think it’s awesome what's going on, you know, these days with everyone trying to pass different law, states legalizing it, everything else. –male, 24, marine corps, veteran. these two participants illustrate the majority’s perceptions of benefits derived from cannabis for medical issues, once discharged from the military. we explain them further by including examples discussed by the participants which include pain ailments and mental health issues. pain ailments some participants expressed the use of cannabis for treating pain ailments. this is crucial as pain is one of the most frequently endorsed symptoms of veterans returning from military action and it is likely many veterans will endure clinically significant pain due to their military experience (gironda et al., 2006). a participant explained his receptiveness to using cannabis for pain ailments: but i feel like if someone's in pain, and this [cannabis] can help them out, i absolutely agree that they should do it. and that and i think that's for the most part, universally agreed upon kind of thing in the military [referring to other service members]”. –male, 25, navy, active duty. another participant shared her own experiences with using cannabis for pain, anxiety, and a traumatic brain injury: “well, from basically you know being hooked on percocet at a young age and almost you know destroying my life, and you know, the big opiate epidemic that you know we’re in that is an extremely huge problem, but then, a natural thing like you know marijuana, i don’t understand why it’s not legal already, because, you know for me it helps my anxiety which is, extremely bad, and you know on and off again depression which now that i have a traumatic brain injury, one of the long term side effects is even if you’re happy, your brain releases basically whatever it’s called that makes you feel really sad so now i have that too, so the anxiety, the depression and the pain that is very severe, it helps all that. so how many medications is that preventing me from having to be on.” –female, 25, marine corps, veteran. cannabis, a publication of the research society on marijuana 37 this participant mentioned how it helped her crucial pain ailment (i.e., traumatic brain injury), which impacts approximately 30,000 service members each year (bagalman, 2011). she also endorsed it for her mental health issues including anxiety and depression. many participants expressed their openness with utilizing cannabis for mental health problems. mental health issues ptsd was muttered numerous times throughout the interviews when discussing cannabis. multiple participants shared their thoughts on mental health tribulations: “people say like marijuana is better than drinking, and if veterans who have ptsd and they can use marijuana, i think that they should do that. like, you know, legalize it, like if medical marijuana can help those veterans become calm and like, like take care of anxiety or something like that, i think that would be good.”male, 29, army, active duty. “yeah, so, i think in a lot of ways medical marijuana is making big strides towards helping patients with like ptsd or tourette’s or like just different psychological disorders in stimulating different parts of your brain that your brain needs to function and sometimes over functioning and it helps kind of mediate that.” –male, 26, marine corps, active duty. “i definitely think it is a positive thing especially for ptsd” –male, 20, marine corps, active duty. “yeah, i mean i definitely think it is a positive thing for them, especially if they have ptsd, which individuals that have been deployed probably do or at least some sort of like issue.” –female, 26, air national guard, veteran. substitute to opioids and benzodiazepines opioids are commonly used to treat pain, and benzodiazepines are often used to treat anxiety, depression, and ptsd among veterans (american geriatrics society, 2009; national center for ptsd, 2019). many participants acknowledged negative consequences that often transpire from misusing prescription medications. others recognized benefits to using cannabis as an alternative to prescription medications. one participant discusses their thoughts: “yeah, i'm all for it [cannabis]. i think it's better than, you know, some of the medications that people are getting addicted to. i think it kind of makes me lazy and doesn't make think very logically, but in terms of like an alternative to some of the pain medications and anti-depressants that veterans are given, i'm not a pharmacist or anything, but i think it's, you know, a better alternative to those for sure. i'm all for it.” – male 26, marine corps, active duty. many participants recognized the negative repercussions associated with using opioids and benzodiazepines. two participants are familiar with veterans not keen on using prescription medications: “yeah, because most of the guys who are like taking prescriptions and stuff like don't want to, so i think like if you're like, hey, this [medical cannabis] is a legal way of potentially doing the same thing, you can try this out, blah, blah blah. if it works, great. if not like we can try the other stuff, i think it's healthier to probably smoke weed than take a bunch of prescriptions drugs, but i don’t know. –male, 26, marine corps, active duty. “i mean, you see these people in the military have chronic pain for the rest of their life and they're hooked on vicodin or hydrocodone and it affects, you know, the rest of their life. and sometimes they just can't get off it. my uncle was a pharmacist and he was telling me that, some people are so addicted to the medication that they're not really even actually in pain, but when they stop taking it, they just feel like they’re in pain, and they’re going to live the rest of their life that way.” –male, 26, marine corps, active duty. perceptions of cannabis benefits among mm & veterans 38 alternative to alcohol many participants discussed the negative consequences of using and misusing alcohol. research proposes veterans have higher rates of alcohol-related consequences than civilians (mitchell et al., 2007). participants believed using cannabis may have less consequences compared to alcohol. one participant explained: yeah, i have zero issues with cannabis use. i think it should be legal nationwide, personally, i'm not like, i'm not like a goodie two-shoes and like, to be honest, i love to smoke weed and get black out drunk, but that’s just me. so, i think i it could be a good, a good thing for veterans. i mean i've never seen someone really high try to fight somebody or like try to hurt themselves while high on weed. so, i think that it could be a good alternative to alcohol and weed could also help physical pain. –male, 29, navy, veteran. this participant notes fighting as a potential consequence from using alcohol, whereas with cannabis the negative consequences are less common. another participant acknowledged dui’s are consequently associated with using alcohol: “i also think that banning marijuana but then allowing people to drink and all that is kind of, i mean there's a lot of duis in the military and all that. so, i feel like that's kind of contradictory to like want your people to be safe, but allowing them to drink so much and possibly drive and promoting like alcohol use and all that. so, i think it's, um, i mean cannabis has a lot of medical benefits to it as well. so, people should choose that over alcohol. i mean, go for it. i think that cannabis should be available to them”. – female, 26, air national guard, veteran. regulations are needed participants discussed how regulations for cannabis are needed to reduce potential adverse outcomes and to make it more acceptable among veteran communities. while participants acknowledged the possibility of cannabis serving as a beneficial replacement, they also recognized the need for regulation. one participant exemplified the need for regulations like alcohol: “i would like it to be accepted. i think there'd be a lot, a lot of regulation would have to be put in place in order to make it accepted. i mean this might be out there, i don't know. but like me drinking, you know, if you drink you could do a blood alcohol tests, right? that's wiser. but if you smoke, like there's not a way to measure how high somebody is”. –male, 29, navy, veteran. while this is a suggestion for regulation, some participants acknowledged the dichotomy between military and civilian culture, recognizing the stark cultural and fundamental differences between the two environments (demers, 2011; 2013). this is further explained by participants exemplifying the perceptions of cannabis potentially negatively interfering with military job responsibilities. incongruence with military job responsibilities participants discussed how being under the influence of substances, specifically cannabis, does not prepare military members to fulfill their mission (e.g., job responsibilities). a few participants brought up the differences in perceptions of using cannabis in and outside of a military setting. most acknowledged it would be a long while, if ever, before the military accepted cannabis for active-duty members. this could be an example of recreational use of cannabis, for instance when it is differentiated or separated from work time it potentially exists in leisurespace time. two participants offered their opinion: “no, i don’t think cannabis will be allowed. well, because it goes back to the thing where like, you know, every marine, is like a rifleman. technically you're supposed to be able to go and fight at any time. knowing you're going to be able to concentrate if you're high, no. i think it's like one of those things too, they tell you it gets in the book. like if they allow it, people are just coming up to work high and stuff and shit won't get done. because like one mistake could kill cannabis, a publication of the research society on marijuana 39 somebody. you know what i mean? one mistake could kill somebody or more. your probability and your chance of making that mistake is much higher.” male, 20, marine corps, active duty. “so i think that medical marijuana can be beneficial to some, but not all. um, and i think the navy's perspective, i don't think that they have a definite standpoint, but i definitely know that it's completely prohibited, uh, when it comes to, uh, even cbd oil in the military you will pop and it's looked down upon, uh, to put forth the effort while you're in the military. uh, it's wrong. in their sense because it's physically, um, i don't want to say it deteriorating cause weed doesn't really do that. it's more of just like a health conscious thing where you have to be consciously active thinking that under the influence. uh, especially if you're called into work. um, it just creates a, uh, less, it creates an environment where things happen. like you're getting arrested less. so it's, it's a means of security and stuff.” –male, 25, marine corps, veteran. others discussed the perception in the military regarding cannabis, that may influence the military’s perceptions. these participants explained: “i think like big army or big military with what, what their perspective would be. is it basically you know, it clouds your judgment and the different ways that impairs your thinking process. you know, i think you're more clouding, you know, clouding your thoughts, clouding your judgment, to where you may not be able to function as you would, or as maybe as efficiently as you would not being influenced by marijuana.” – male, 26, army, active duty. “yeah, it definitely goes back to like whether or not like if you smoke, can you go to war? like, yeah. i mean anything can happen. right?... and it goes back to like for alcohol, you can test bac right ,easily with the breathalyzer and marijuana. they haven't come up with something that's so quick and accurate.” – male, 29, navy, veteran. discussion in this study, we add to the qualitative literature of perceived benefits and attitudes of cannabis with a sample of ea military members and veterans with self-reported high-risk substance use behaviors (i.e., alcohol and/or other substances). overall, participants were receptive to using cannabis for various conditions and did not mention identified risks associated with using cannabis, aligning with other reports indicating veterans are receptive to the utilization of cannabis for medical purposes and perceive cannabis as a safe substance (wilkinson et al., 2016). instead, they identified benefits for using it as a substitute to highly addictive prescription medications for pain, physical ailments, and mental health issues. moreover, most participants believe using cannabis in place of alcohol may decrease negative repercussions that alcohol is often associated with or causes. increase in substance use participants recognized an increase in substance use after transitioning out of the military, specifically with cannabis. research also reiterates this behavior (sayer et al., 2010). a longitudinal study found that approximately 40% of veterans received a mental health diagnosis, and that those who were younger than 25 had higher rates of ptsd and substance use problems compared to those who were 40 and older (seal et al., 2009). among veterans, cannabis is often used as a means of reducing ptsd symptoms (grant et al., 2016). when thinking about the use of cannabis, research should continue to evaluate if cannabis use is increasing because of the legality of it out of the military setting, so for recreational/leisure purposes, or for selfmedication (shadur et al., 2015) purposes for pain and mental health issues, or a combination of both factors. pain ailments and ptsd studies have found cannabis to be a useful to way to alleviate physical symptoms. recent advances in cannabis research have discovered cannabinoids to be a favorable way to relieve spinal cord injury-related symptoms (stillman et perceptions of cannabis benefits among mm & veterans 40 al., 2019), stiffness/spasm and pain among those with multiple sclerosis (clark et al., 2004), noncancer musculoskeletal pain (johal et al., 2020), fibromyalgia (habib & artul, 2018), and neuropathic pain (wilsey et al., 2013). musculoskeletal pain is also extremely prevalent among veterans. between 2000 and 2011, nearly 500 million u.s. veterans were diagnosed with one or more musculoskeletal disorders (monaghan, 2020), and some may benefit from medical cannabis. regarding ptsd, one recent qualitative study with seven veteran ptsd patients in the netherlands identified cannabis as a medicine to manage their symptoms and function more adequately (krediet et al., 2020). a recent study with 404 medical cannabis users self-reporting ptsd found that cannabis temporary relieved ptsd-related symptoms by up to 50% after use (lafrance et al., 2020). however, this study identified a risk of developing tolerance. further, a recent systematic review concluded that randomized controlled trials are needed to uncover evidence between cannabis, ptsd symptoms, and sleep disturbances, as there is “insufficient evidence to support the use of cannabinoids as a psychopharmacological treatment for ptsd” (hindocha et al., 2020, p. 133). because of these inconsistencies, research suggests that medicinal cbd and thc should not be recommended for treating patients with affective or anxiety disorders, or ptsd (stanciu et al., 2021). it seems as if there is a disconnect with research evidence, perceptions of veterans, and health service recommendations (i.e., ptsd serving as a qualifier for a medical cannabis card). alternative to alcohol participants in this study and other research (mitchel et al., 2007; cdc, 2018) recognized negative consequences often transpire from alcohol. an increasing number of veterans drove under the influence of alcohol (1.6 to 2.5%) over a recent two-year period (cdc, 2018). however, participants in this study reported that cannabis was a substitute or safer alternative to alcohol. it is important to mention that while cannabis may be perceived as a “safer” alternative to alcohol, there are still potential consequences and repercussions of driving while under the influence of cannabis (duic; borodovsky et al., 2020). research has found that there are groups of people that believe they can still safely drive while using cannabis, that cannabis is not responsible for impairing driving abilities, and cannabis may actually improve driving abilities (greene, 2018; fischer et al., 2009; swift et al., 2010; mccarthy et al., 2007). however, multiple experimental and epidemiological studies conclude cannabis does impair safe driving, as it adversely impacts cognitive and psychomotor skills (wood & dupoint, 2020). further, data suggests operating a motor vehicle while under the influence of cannabis is associated with significantly increased odds of a collision (rogeberg & elvik, 2016). sharing this information with ea military members and veterans to promote harm reduction approaches might be needed as medical and recreational cannabis opportunities continue to grow. substitute to prescription drugs many participants recognized the possibility of using cannabis as an alternative to prescription opioids and benzodiazepines. research recognizes due to the addictive nature of these medications, consistent and/or long-term use can attribute to addiction (bruckenthal et al., 2009; national center for ptsd, 2020). a sample of veterans reported using cannabis as an alternative to prescription medications significantly decreased their negative mood states and helped them cope better in stressful situations (elliott et al., 2015). however, limited research exists on cannabis use in ea veterans who are using it as a substitute or complement for prescription opioids and benzodiazepines. negative outcomes of cannabis while most participants acknowledged the benefits associated with using cannabis for pain ailments and mental health issues, they did not disclose perceived risks besides the suggestion for regulations to be made. to date, there is conflicting research about cannabis for assisting various health problems. there is a growing body of literature unveiling the spectrum of behavioral and neurobiological health risks associated with cannabis use such as risks for psychosis (bassir nia, 2016; charilaou et al., 2017; leweke & koethe, 2008; malone et al., 2010), anxiety cannabis, a publication of the research society on marijuana 41 (kedzior & laeber, 2014), depression (feingold et al., 2017), cognitive deficits and social impairments (crean et al., 2011), and subsequent drug addiction. many studies provide evidence that cannabis is not risk-free and emphasize the need for more rigorous scientific investigations to address the prospective long-term consequences of cannabis use. moreover, research suggests that cannabis is also addictive with possible withdrawal symptoms (volkow et al., 2014). approximately 1 in 9 individuals who use cannabis will develop dependency, and there is now a specific cannabis withdrawal syndrome that was formally recognized by the american psychiatric association in 2013 (american psychiatric association, 2014). however, there are studies that confirm veterans are reaping benefits from cannabis use for chronic pain, sleep difficulties, anger outbursts, anxiety, and ptsd (aston et al., 2018). while research studies have demonstrated some benefits derived from using cannabis for various medical reasons (institute of medicine, 2011), there is still inconsistent literature regarding the risks and benefits of cannabis use requiring further attention, specifically the utilization of experimental designs. implications the implementation of drug testing in the military began in 1971 with the plan to detect, rehabilitate, and return them to their jobs (bray et al., 1992). however, this drug enforcement is now more punitive through a zero-tolerance policy. detection of an illegal substance can result in separation of the military, exemplifying a negative connotation of substances. this policy is starkly different than many corporations or private sectors outside of the military. many substance use programming models, especially with eas, integrate a harm reduction approach. harm reduction is defined as “the recognition that treatment must start from the client’s needs and personal goals and that all change that reduces the harms associated with substance use can be regarded as valuable” (tatarsky, 2003, p.1). this paradigm-shift in treatment allows people to moderate their use to decrease consequences, without stopping all together. due to the mixed benefits and consequences associated with cannabis use among ea veterans, and the dichotomy of drug perceptions in and outside the military, health experts and helping professionals should work on incorporating harm reduction approaches with ea veterans to moderate the risks and benefits of cannabis. future research additional research is needed to fully understand the shortand long-term effects cannabis may have on veterans before recommendations for policies and regulations should be made. a deeper understanding of using cannabis as a complement or substitute for prescription opioids and benzodiazepines will allow us to understand potential risk factors for polysubstance use. consequences of polysubstance use and the implications cannabis has should also be considered. related to this idea, future research should consider where ea military members and veterans are purchasing their cannabis (i.e., street dealer who they trust, medical cannabis card, or recreational dispensary). this could shed light on veterans’ differences in using cannabis for primarily recreational, medical, or a combination of both purposes. however, teasing these things out may be difficult due to legality differences across state lines (grant et al., 2016). but greater understanding of these phenomenon could assist with harm reduction approaches and future education and programming on cannabis for ea military populations. limitations because of the qualitative nature of this study, this study is limited by its small sample size. there were a mix of veterans and military members in this study which makes it difficult to tease apart perceptions based on military status. moreover, there was a wide range of military branches that were included in the study which may influence one’s perceptions as we know each branch in the military often has their own substance use culture. perceptions of cannabis may differ depending on one’s military status, rank, geographic location, and branch. further, this sample met criteria for risky substance use, positioning them to potentially have nuanced experiences and perspectives regarding substance use behaviors including cannabis. lastly, because perceptions of cannabis benefits among mm & veterans 42 this study employed a purposeful sampling strategy with snowball recruitment methods, selection biases exist. future research should follow up on these findings using more generalizable methods. conclusion ea military members and veterans perceive cannabis as an attractive alternative to alcohol, as well as to opioid and benzodiazepine medications. further, this sample recognized cannabis as an effective treatment mechanism for physical ailments and mental health issues including ptsd. participants recognized limited risks, aligning with research on the increasing acceptability, accessibility, and use levels of cannabis. however, these perceptions do not align with research regarding potential consequences or health risk factors, specifically the inconsistent data regarding the effectiveness of using cannabis for ptsd and potential adverse effects of driving while under the influence of cannabis. future research should examine polysubstance use and the impacts cannabis has on consequences, pain ailments, and mental health issues, including ptsd. lastly, understanding cannabis as an alternative or substitute to alcohol, opiates, and benzodiazepines can inform substance use treatment strategies and modalities. references american geriatrics society panel on the pharmacological management of persistent pain in older persons. pharmacological management of persistent pain in older 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(2007). a comprehensive review of the psychometric properties of the drug abuse screening test. journal of substance abuse treatment, 32(2), 189-198. funding and acknowledgements: the development of this article was supported by the university of illinois at urbana-champaign’s career center’s robert p. larsen career development grant. the views, however, are those of the authors and do not reflect official positions of the uiuc career center. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i1a5_authors_v2 research article 42 ved abstract using ecological momentary assessment (ema), we assessed momentary patterns of alcohol and cannabis co-use in college students and whether state-level and baseline reports of anxiety varied based on type of substance(s) consumed. students (n=109) reporting regular cannabis use completed a baseline assessment and two-week signal-contingent ema, with three random prompts/day. at each ema instance, we categorized instances of substance “usage” as: 1) no use, 2) cannabis-only, 3) alcohol-only, or 4) co-use of alcohol and cannabis (i.e., reports of alcohol and cannabis use within the same prompt). using temporal sequenced data, we explored how state-level anxiety varied before and after usage type using multiple multilevel structural equation models (msems) and whether baseline factors (general anxiety, social anxiety, and sex) influenced the relation between usage type and state-level anxiety. participants were 63.3% white, 58.7% female, used cannabis near-daily, and commonly reported co-use. models examining whether usage type predicted subsequent state-level anxiety were predominantly significant, with the majority of relationships being more pronounced for participants with higher baseline general anxiety. in examining whether momentary state-level anxiety predicted usage type, in instances when participants reported higher levels of momentary anxiety, they were more likely to report no use compared to co-use and cannabis-only, with sex moderating some of the relationships. social anxiety did not moderate any of the within-person associations between state-level anxiety and usage type. this study provides preliminary evidence that report of momentary anxiety varies based on substance type. future research is needed to establish co-use related synergistic effects and correlates. key words: cannabis; alcohol; co-use; anxiety; ecological momentary assessment alcohol and cannabis are commonly used both singularly and together among college students (yurasek et al., 2017). varying terms have been used to describe the combined use of alcohol and cannabis, including “co-use or concurrent alcohol and cannabis use,” often used to describe asynchronous, independent use of both alcohol and cannabis within the past 30 days or some other timeframe and “simultaneous use,” defined as use of both substances at the same time with overlapping effects (jackson et al., 2020). approximately one-fourth of full-time college cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.005 momentary patterns of alcohol and cannabis co-use in college students: assessing the temporal association with anxiety corresponding author: kristina t. phillips, ph.d. center for integrated health care research (cihr), kaiser permanente hawai’i, 501 alakawa st., suite 201, honolulu, hi 96817. phone: 808-432-4687. fax: 808-432-5121. email: kristina.t.phillips@kp.org kristina t. phillips1, mark a. prince2, michael m. phillips3, trent l. lalonde4, & michael d. stein5 1center for integrated health care research (cihr), kaiser permanente hawai’i, 501 alakawa st., suite 201, honolulu, hi 96817 2department of psychology, 1876 campus delivery, colorado state university, fort collins, co 80523 3office of public health studies, university of hawai’i, 1960 east-west road, honolulu, hi 96822 4colorado department of human services, 1575 sherman st., denver, co 80203 5 school of public health, boston university, 715 albany street, boston, ma 02118 cannabis, a publication of the research society on marijuana 43 students report any cannabis use in the past month, with 5.9% reporting daily use (schulenberg et al., 2020). higher rates of past month cannabis use have been reported among students living in states with legal recreational cannabis use (38%) compared to students living in states without such laws (24%; pearson et al., 2017). although recent data shows that male and female students have similar rates of past month cannabis use, males are more likely (7.2%) to use daily compared to females (5%; schulenberg et al., 2020). in comparison, about 60% of college students report use of alcohol in the past 30 days, with 33% reporting heavy episodic drinking in the past 2 weeks (aka, binge drinking; 4-5+ drinks in one occasion), again with higher rates for males (schulenberg et al., 2020). a recent longitudinal study found a prevalence rate of 23% for simultaneous alcohol and cannabis use within the past year among emerging adults, with greater odds of simultaneous use for males (patrick et al., 2019). daily cannabis use in college students is associated with greater alcohol consumption and estimated blood alcohol concentration (gunn et al., 2018) and young adults have been shown to consume more alcohol on simultaneous days compared to days with singular alcohol use (lee et al., 2020). patterns of co-use may vary based on cannabis legality, with recent work finding that rates of cannabis use in college students increased from preto post-cannabis legalization in oregon, although only among those who used alcohol heavily (kerr et al., 2017). accumulating evidence suggests that co-use of alcohol and cannabis leads to more negative consequences than use of either substance alone (cummings et al., 2019; davis et al., 2019; egan et al., 2019; jackson et al., 2020; lee et al., 2020; linden-carmichael et al., 2020). it is possible that simultaneous alcohol and cannabis use (aka “crossfading”) may produce synergistic effects and hence greater feelings of intoxication (lee et al., 2017; patrick & lee, 2018). lab studies have shown that simultaneous use can alter the absorption and concentration of each substance, contributing to more significant impairment (hartman et al., 2015; lukas et al., 1992; lukas & orozco, 2001). those who engage in simultaneous use report greater negative cognitive and physiological subjective effects during simultaneous use compared to using alcohol or cannabis alone (lee et al., 2017). the interaction of the two substances is poorly understood and challenging to study due to a combination of regulatory barriers related to cannabis research and the numerous forms, potencies, and methods of cannabis ingestion that can impact findings (national academies of sciences & medicine, 2017; singh, 2019). past research has not examined whether simultaneous or co-use of cannabis and alcohol is associated with affective symptoms. as a means of understanding negative outcomes associated with co-use, the affective-motivational model of drug addiction suggests that substance use may serve as a means of negative reinforcement to self-treat affective symptoms (baker et al., 2004). though many persons using substances initiate substance use to experience positive effects (i.e., positive reinforcement), as individuals progress towards addiction, using to reduce negative affect, stress, and withdrawal become more prominent (robinson & berridge, 2003; wycoff et al., 2018). interoceptive or internal cues of anxiety may contribute to a momentary desire to use substances for symptom relief; alleviation of anxiety symptoms post-use subsequently increases the likelihood of future substance use (baker et al., 2004; dunn et al., 2010). it is possible that co-use of cannabis and alcohol may lead to specific anxiolytic effects, even above and beyond those of each substance alone. evidence supporting the affective-motivational model comes from a range of epidemiological and intensive longitudinal design (ild) studies. at the diagnostic level, epidemiological studies have shown relationships between specific anxiety disorders and cannabis use disorder (cud) or alcohol use disorder (aud; grant et al., 2015; hasin et al., 2016). of studies examining co-occurring anxiety disorders, evidence suggests co-morbidity between aud or cud and select disorders, such as generalized anxiety disorder (gad) and social anxiety disorder (social phobia; grant et al., 2015; hasin et al., 2016; schneier et al., 2010). metaanalytic work has shown that social anxiety is negatively associated with alcohol use, but positively associated with alcohol-related problems (schry & white, 2013), prompting work to examine possible moderators (adams et al., 2019). vulnerability for the development of anxiety disorders, cud, and aud is greater during young adulthood (substance abuse and mental health service administration [samhsa], 2019) and recent work with a psychiatric sample of emerging adults with predominantly anxiety and depressive disorders found that those engaging in frequent comomentary patterns of alcohol and cannabis co-use 44 use were more likely to have higher rates of cannabisand alcohol-related problems compared to groups who used or co-used less frequently (blevins et al., 2019). most of the past work examining these relations has focused on singular cannabis or alcohol use; more research is needed to better understand the complex relationship between underlying anxiety disorders and co-use of cannabis and alcohol or cud/aud. at the symptom level, individuals with underlying anxiety may use cannabis or alcohol to cope with their symptomatic distress (bakhshaie et al., 2020; blevins et al., 2019; villarosa et al., 2019). however, research has yet to explore whether decisions to co-use are prompted by momentary anxiety or nervousness. affect variables, such as anxiety, fluctuate considerably and have been related to use of individual substances when examined in the momentary context (dvorak et al., 2018; treloar padovano & miranda, 2018). ild studies, such as ecological momentary assessment (ema), are well-suited to study affect and co-use, can capture participants’ experiences around the time of the prompt, and can be useful to disentangle state-level versus (v.) underlying anxiety influences (bolger & laurenceau, 2013; shiffman, 2009). findings from studies assessing the relation between cannabis and state-level anxiety have been mixed, with most of the evidence looking at negative affect as an aggregate (e.g., combining anxiety, sadness, anger, etc.) rather than anxiety alone (wycoff et al., 2018). a recent systematic review (wycoff et al., 2018) of ild studies indicated that the association between cannabis use and negative affect in community samples is variable. however, in clinical samples, they found more consistent evidence that negative affect is higher before cannabis use and decreases following use. select studies have shown that anxiety is elevated prior to cannabis use (buckner et al., 2012) and reduced post-cannabis use (gruber et al., 2012), but other work has found no relation between cannabis use and state-level anxiety (swendsen et al., 2011; trull et al., 2016). cuttler et al. (2018) analyzed archival data from medical cannabis users who were tracking their use of cannabis in real-time to treat symptoms of anxiety, stress, and other symptoms. findings suggested reduced anxiety from preto post-cannabis use, with greater decreases for women. limited ild studies have examined associations between state-level anxiety or negative affect and alcohol use in young adults. in undergraduate students, tournier et al. (2003) found an association between lower state-level anxiety during periods of alcohol use compared to no alcohol use. dvorak and colleagues (2018) found that state-level anxiety was lower following alcohol use compared to anxiety level prior to drinking in college students. in a young adult sample, gorka et al. (2017) found that participants with greater anxiety symptoms reported reduced negative affect while drinking compared to not drinking, as compared to those with lower anxiety. contradictory to these studies, o’donnell and colleagues (2019) found no relation between negative affect and subsequent drinking in australian young adults. to our knowledge, no past ema studies have examined momentary anxiety in relation to alcoholcannabis co-use. the current paper was a secondary analysis of a larger ema study on cannabis with data collected in a state with legal recreational cannabis use (colorado). we examined two-week signal-contingent ema data collected from college students who reported regular cannabis use. the goal of the current paper was to explore the temporal association of momentary anxiety with alcohol and cannabis use, particularly co-use instances, while also examining the moderating effect of baseline general anxiety, social anxiety, and sex. specifically, we examined the following questions: 1) does momentary anxiety predict a next use instance of alcohol, cannabis, or co-use? and 2) does type of use (i.e., no use, alcohol-only use, cannabis-only use, co-use) predict momentary anxiety following a use episode? in addition, we sought to determine whether between-person levels of general anxiety, social anxiety, and sex might moderate state-level relationships between use and anxiety. due to mixed past literature on the association between momentary anxiety and singular cannabis or alcohol use, and the absence of data related to momentary anxiety and co-use, our analyses were primarily exploratory. however, in line with the affective-motivational model of addiction, we hypothesized that alcohol-only, cannabis-only, and co-use would predict lower momentary anxiety, as compared to no use. additionally, we expected male status and greater baseline general and social anxiety to moderate cannabis, a publication of the research society on marijuana 45 these comparisons due to prior literature which has shown that males and those with anxiety disorders either use alcohol or cannabis more frequently or are more prone to developing aud or cud. methods participants and procedures participants (n = 109) were recruited from 20162019 from a western four-year university for a study focused on cannabis use through flyers, class announcements, and emails. potential participants were screened by phone or in-person. flyers listed the study phone number and in-person screening session dates that potential participants could attend. to participate, students met these eligibility criteria: 1) enrollment at the university for at least one prior semester, 2) age over 18 years, 3) own a smartphone, 4) report using cannabis at least two days per week (with recent use within the last week), and 5) positive thc urine screen (single panel cannabis urine dip test; .50 ng/ml cutoff; redwood toxicology laboratory). over the course of the study, 210 students were screened for eligibility and 113 were eligible, consented, and completed the study. four participants had technical issues and were excluded from analyses, leaving 109 with usable data. eligible participants were scheduled for an in-person baseline appointment that took approximately two hours and included completion of the urine screen (which could serve as a rule-out), informed consent, cognitive testing (part of a different study aim), interview, and completion of self-report questionnaires through qualtrics. towards the end of the baseline appointment, participants downloaded the smartphone application (app; ©lifedata, reallife exp app; www.lifedatacorp.com/) and were trained on the two-week signal-contingent ema. participants were sent a series of practice questions prior to the end of the appointment to address questions about the app or how to respond. prior to leaving the lab, participants were reminded to respond promptly to the ema messages and were informed that compensation was based on their response rate. participants were compensated with either a $40 (under 80% response rate) or $50 (above 80% response rate) gift card at the end of the study period. ema questions (below) were sent to participants from the app beginning the day following the baseline appointment. based on past feasibility work (phillips et al., 2014), participants were given one hour to respond to prompts. a randomized prompt schedule was developed for each participant within three time blocks (morning, afternoon, and evening) over a two-week period, for a total of 42 prompts. responses were logged in the app, time stamped, and downloaded from the app server by the researchers. response rate over the two-week period was 79.7% and ranged from 70.6% to 88.7% per day across the 14-day period, and from 75.1% (sunday) to 84.5% (tuesday) per day across days of the week. the response rate was consistent and slightly higher than ema compliance rates reported in a recent meta-analysis (75%; jones et al., 2019). following the random prompt, participants completed the signal-contingent assessments on average 46.76 (sd = 91.85, mdn = 11 minutes) minutes after the signal occurred. all procedures were approved by the institutional review board at the university of northern colorado and a national institutes of health certificate of confidentiality was obtained. baseline measures as part of the larger study, participants completed a wide range of assessment measures. the current analysis focused on the following baseline assessments. background characteristics. participant sex, age, race/ethnicity, and year at the university were collected. alcohol use. to characterize the sample, we included single-item questions on participant alcohol use. participants who endorsed any alcohol use in the past month were asked to report the average number of standard alcohol drinks consumed on a typical drinking day and the number of heavy episodic drinking episodes (number of times participant consumed four+ [women] or five+ [men] drinks on one drinking occasion in a two-hour period) within the past month. cannabis use. to better characterize the sample, we used select items from the psychometrically validated daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017). specifically, we report on cannabis frequency (number of days cannabis was consumed in the past month), primary form (flower/bud, concentrates, momentary patterns of alcohol and cannabis co-use 46 edibles, and other), and primary method of ingestion (smoke, vape, oral, dab) currently used. beck anxiety inventory (bai). the bai is a psychometrically-validated (beck et al., 1988) 21item measure that assesses various dimensions of anxiety, such as feeling nervous, dizzy, or having difficulty breathing, over the last month (α = .94 for scores in the current sample). items are rated from 0-3 and total score was used. scoring ranges for the bai are as follows: 0-7 = minimal anxiety, 8-15 = mild anxiety, 16-25 = moderate anxiety, and 26-63 = severe anxiety (beck & steer, 1993). social interaction anxiety scale, short form (sias-sf). social anxiety/phobia was measured with the sias-sf (mattick & clarke, 1998), which is a six-item scale with items rated from 0-4 (not at all to extremely). the measure has strong internal consistency (α = .88 for scores in the current sample) and test-retest reliability in a college population (fergus et al., 2012). a suggested cutoff score of 9 has been shown to discriminate high v. low social anxiety (fergus et al., 2012). ema data sources the ema protocol consisted of 11 questions that were sent via the life data app and included items related to cannabis use, alcohol use, social context, anxiety, mood, cannabis craving, exercise, and academics. due to skip logic that included follow-up questions, some participants may have received only 8 questions. the same questions were assessed at each of the 42 prompts. three particular ema questions were used for this study as described below. types of substance use. for each ema time block, we assessed whether cannabis or alcohol were used (yes/no) since the last prompt and then categorized each response into the following groups: no substance use, alcohol-only, cannabis-only, or couse. “co-use” was defined as any report of both cannabis and alcohol during the same time block, but did not include information regarding the timing (when each substance was used) or ordering (which substance was used first) of use. therefore, we were unable to determine whether co-use was actual simultaneous use, i.e., if the effects of alcohol and cannabis overlapped. state-level anxiety. we modified a single question from buckner et al. (2012) to assess anxiety state. at each prompt, participants were asked: “please rate your current anxiety on a scale of 0-10, with 0 being “totally relaxed” and 10 being “extremely intense anxiety.” data analyses missing data were handled using full information maximum likelihood, commonly used for two-level data (schminkey et al., 2016). co-use was analyzed using a combination of descriptive statistics and multilevel structural equation models (msems; cf. curran, 2003; mehta & neale, 2005). to account for the repeated measures aspect of the ild data and to allow for simultaneous tests of effects, two sets of msems were conducted using mplus 8 (muthén & muthén, 1998–2017) to test the temporal association between anxiety and various categories of use. the first set of models were used to investigate the research question of whether momentary statelevel anxiety prior to use predicted the likelihood of different usage types (i.e., no use, alcohol-only, cannabis-only, or co-use) at the next timepoint. to examine these relations, the dataset was reorganized to address the time-lagged data. the second set of models examined whether usage type predicted state-level anxiety after use instances. in these models, the substance use ema variables were naturally time-lagged due to the usage type questions examining any use since the last timepoint, while anxiety was assessed as a rating in the current moment. it is important to note that because “usage type” is a categorical variable with four categories, dummy coded variables were created and the models were re-run redundantly to get different dummy effect estimates (i.e., pairwise comparisons). for example, table 2 is a combination of three models, with redundant information removed. model 1 used co-use as the referent group and compared each of the other usage types (i.e., no use, alcohol-only, cannabis-only) to co-use. then, in model 2, alcohol use was the referent group and there were two new comparisons (alcohol-only v. no use; alcohol-only v. cannabis-only) and one redundant comparison (alcohol-only v. co-use) that was not repeated in the table. in model 3, cannabisonly was the referent group with one new comparison (cannabis-only v. no use) and two redundant comparisons (cannabis-only v. alcoholonly; cannabis-only v. co-use) that were not shown. this procedure was repeated in table 3 presenting cannabis, a publication of the research society on marijuana 47 three models in one table and excluding redundant information. msems were utilized for both research questions to test all pairwise comparisons based on the use of dummy codes for the categorical variable of usage type. the key difference between the msems was the within-level random slopes. in table 2 the random slopes represent momentary anxiety modeling categorical usage type (with reference groups indicating the pairwise comparisons). in table 3 the random slopes represent dummy coded usage types modeling momentary anxiety. due to running multiple models for each research question, the absolute magnitudes of the parameter estimate values in tables 2 and 3 are difficult to compare across the models. however, because all pairwise comparisons are accounted for at each iteration, it is possible to draw conclusions about the relative ordering of the four usage types. these random slopes were then predicted by baseline time-invariant variables, including baseline anxiety (bai), baseline social anxiety (sias-sf), and sex (male as referent) to test the moderation hypotheses. this approach is a 2 x (1– 1) moderation msem (preacher et al., 2010; preacher et al., 2016) because the predictor (statelevel anxiety for question 1; usage type for question 2) and the outcome variables (usage type for question 1; state-level anxiety for question 2) were measured on the momentary level, and the moderators (i.e., baseline general anxiety, social anxiety, and sex) were measured once at baseline; this is called the random coefficient prediction method. dummy coding was utilized for usage type that allowed for all pairwise comparisons through multiple iterations of the models with varying reference groups. results sample characteristics participants’ age ranged from 18 to 46 (m = 20.21; sd = 3.48). the sample included 64 females (58.7%) and 45 males (41.3%), 69 (63.3%) who were white, and 40 (36.7%) who were underrepresented minorities, which included 21 (19.3%) latinx, 12 (11%) multiracial, and 7 (6.4%) african american individuals. participants included 47 (43.1%) firstyear, 31 (28.4%) second-year, 20 (18.3%) third-year, and 11 (10.1%) fourth-year students. descriptive statistics for baseline and ema substance-related and other model variables can be found in table 1. at the baseline appointment, participants self-reported near-daily cannabis use, on average. the majority of participants reported that flower was the primary form of cannabis used. smoking, via a bong/water pipe, hand pipe, or joint/blunt, was the primary method of ingestion. most participants reported alcohol use within the past 30 days at baseline, consuming a mean number of 4.3 (sd = 4.6) standard alcohol drinks on a typical drinking day in the past month. mean number of heavy episodic drinking occasions (consuming four/five+ drinks per drinking occasion for women/men in a two-hour period) in the past 30 days was 2.27 (sd = 3.58) times for females and 2.59 (sd = 3.56) times for males. mean levels of anxiety on the bai and sias-sf were above respective measure cut-off scores, indicating possible clinically significant anxiety. more specifically, 40.4% of participants scored higher than 16 on the bai and 79.8% had scores above 9 on the sias-sf. overall, 85 participants (78%) reported any couse within the 14-day ema period. out of all ema instances, 928 were missing from the total 4578 prompts. of those remaining, the majority were coded as no substance use (n = 1698, 46.5%), followed by cannabis-only (n = 1449, 39.7%), co-use (n = 298, 8.2%), and alcohol-only (n = 205, 5.6%). ema state-level anxiety ranged from 0 – 6, with an average of 2.49 (sd = 1.53). does momentary anxiety predict alcohol, cannabis, or co-use? state-level anxiety predicted the likelihood of subsequent substance use in two pairwise comparisons. in instances when participants reported higher levels of momentary anxiety, they were more likely to report no use compared to co-use (see table 2, s1, state-level) and cannabis-only (see table 2, s6, state-level). when examining baseline moderators (bai, sias-sf, and sex) of the random slope between momentary state-level anxiety and usage type, several random slopes were moderated by sex (see table 2, baseline level). specifically, we found a stronger relationship for women compared to men for momentary state-level anxiety predicting a higher likelihood no use episodes when compared to co-use (s1), alcohol-only (s4), and cannabis-only (s6). momentary patterns of alcohol and cannabis co-use 48 table 1. descriptive statistics for alcohol, cannabis, and other model variables (n = 109) variable n (%) range median mean standard deviation primary method of cannabis ingestiona smoke bong/water pipe hand pipe joint/blunt vape oral (edibles) dab rig other 36 (33%) 31 (28.4%) 10 (9.2%) 13 (11.9%) 8 (7.3%) 10 (9.17%) 1 (<1%) primary form of cannabis useda flower concentrates/dabs edibles other 74 (67.9%) 27 (24.8%) 7 (6.4%) 1 (<1%) any alcohol use, past montha standard alcohol drinks consumed on a typical drinking day, last monthac 93 (85.3%) 1 – 20 3 4.3 4.6 days used cannabis, last montha 3 – 30 25 22.6 7.5 beck anxiety inventory (bai)a social interaction anxiety scale, short form (sias-sf)a state-level anxiety (per subject)b substance use instancesbd no substance use cannabis-only use co-use alcohol-only use 1698 (46.5%) 1449 (39.7%) 298 (8.2%) 205 (5.6%) 0 – 48 6 – 30 0 – 6 10 12 2.5 14.1 12.8 2.49 12.6 5.2 1.53 note. if frequency or percentage < 109 or 100%, due to missing data. a = baseline variable, b = ema variable, c = out of those who reported drinking (n = 93), d = out of 3650 available ema responses. cutoff scores: bai, mild to severe anxiety = 7 or higher (beck & steer, 1993); sias-sf, high social anxiety = 9 or higher (fergus et al., 2012). cannabis, a publication of the research society on marijuana 49 table 2. summary of results from multilevel structural equation models examining the predictive nature of momentary anxiety on usage type. state-level random slope (s) anxiety predicting: estimates se t p no use v. co-use (s1) .318 .137 2.316 .021 cannabis-only v. co-use (s2) .153 .132 1.158 .247 alcohol-only v. co-use (s3) -.108 .201 -.534 .593 no use v. alcohol-only (s4) .176 .136 1.289 .197 cannabis-only v. alcohol-only (s5) -.273 .189 -1.444 .149 no use v. cannabis-only (s6) .415 .117 3.559 <.001 baseline level outcome predictor estimates se t p s1 on bai .002 .004 .420 .675 sias-sf -.014 .010 -1.447 .148 sex (male) -.293 .102 -2.875 .004 s2 on bai .006 .004 1.455 .146 sias-sf -.011 .009 -1.185 .236 sex (male) -.028 .082 -.339 .735 s3 on bai .004 .005 .884 .377 sias-sf -.015 .011 -1.413 .158 sex (male) -.014 .128 -.106 .915 s4 on bai .000 .004 -.097 .923 sias-sf .003 .008 .424 .672 sex (male) -1.82 .084 -2.159 .031 s5 on bai .006 .006 1.106 .269 sias-sf .013 .011 1.190 .234 sex (male) .068 .121 .559 .576 s6 on bai -.006 .004 -1.484 .138 sias-sf -.009 .009 -1.068 .286 sex (male) -.241 .087 -2.785 .005 note. this table represents 3 models with redundant information removed (see analysis plan for a full description). for comparisons by sex, male = 1, female = 0. s1 compared co-use to no use and no use was the more likely outcome, s4 compared alcohol-only to no use and no use was the more likely outcome. s2, s3, s5, and s6 usage types were statistically equivalently likely. the sign of the estimates is relative to the referent group coding in mplus. bai = beck anxiety inventory; sias-sf = social interaction anxiety scale, short form; estimates = unstandardized regression coefficients; se = standard error. p<.05 bolded. momentary patterns of alcohol and cannabis co-use 50 table 3. summary of results from multilevel structural equation models examining predictive nature type of usage type (i.e., no use, alcohol-only use, cannabis-only use, co-use) on momentary anxiety. state-level random slope (s) predicting anxiety estimates se t p no use v. co-use (s1) -1.523 .479 -3.180 .001 no use v. alcohol-only (s2) -1.773 .591 -2.999 .003 no use v. cannabis-only (s3) -1.859 .366 -5.078 .000 alcohol-only v. co-use (s4) -1.005 .536 -1.874 .061 alcohol-only v. cannabis-only (s5) -1.346 .449 -2.998 .003 cannabis-only v. co-use (s6) -1.090 .496 -2.199 .028 baseline level outcome (raw) predictor (raw) estimates se t p s1 on bai .058 .018 3.266 .001 sias-sf .006 .039 .151 .880 sex (male) .008 .367 .022 .983 s2 on bai .062 .020 3.104 .002 sias-sf .043 .045 .946 .344 sex (male) -.287 .447 -.643 .520 s3 on bai .055 .011 4.908 .000 sias-sf .043 .026 1.625 .104 sex (male) -.024 .259 -.093 .926 s4 on bai .058 .018 3.246 .001 sias-sf .006 .039 .143 .886 sex (male) .005 .370 .014 .989 s5 on bai .054 .011 4.901 .000 sias-sf .043 .026 1.646 .100 sex (male) -.027 .259 -.106 .916 s6 on bai .058 .018 3.262 .001 sias-sf .006 .039 .151 .880 sex (male) .007 .368 .018 .985 note. this table represents 3 models with redundant information removed (see analysis plan for a full description). in the state-level comparisons, the first usage type listed is the referent. for comparisons by sex, male = 1, female = 0. bai = beck anxiety inventory; sias-sf = social interaction anxiety scale, short form; estimates = unstandardized regression coefficients; se = standard error. p<.05 bolded. cannabis, a publication of the research society on marijuana 51 figure 1. pattern of usage types predicting momentary state-level anxiety note. this figure illustrates average state-level anxiety for each substance usage type across the two-week ema period. anxiety is the highest during episodes of no use, followed by cannabis-only and alcohol-only, followed by co-use, which had the lowest state-level anxiety levels. error bars represent the standard error around the means. does type of use (i.e., no use, alcohol-only, cannabis-only, co-use) predict momentary anxiety following a use episode? there was a consistent pattern of usage types predicting momentary state-level anxiety, with all comparisons except one (alcohol-only v. co-use) demonstrating statistically significant differences. as noted in table 3 (state-levels), based on the pairwise comparisons, there was a progression from higher to lower average state-level anxiety for no use, cannabis-only and alcohol-only (which had similar state-anxiety levels), followed by co-use, which had the lowest state-level anxiety levels. though the magnitude of differences were not compared statistically, figure 1 demonstrates this progression. examination of baseline moderators (bai, sias-sf, and sex) revealed that bai score impacted the usage type relation to state-level anxiety for all six comparisons (see table 3, baseline level). sias-sf and sex did not moderate any of the relationships. as demonstrated with negative slopes at the state-level (table 3, s1-s6, state-level), higher baseline anxiety (bai) contributed to a stronger relative effect of usage type predicting anxiety for all six comparisons. discussion the current analysis focused on examining the temporal association between state-level anxiety and different substance usage categories among a sample of college students who use cannabis regularly and live in a state with legal recreational cannabis. participants engaged in regular co-use of cannabis and alcohol, with a majority (78%) reporting at least one instance of co-use during the 2-week ema period. overall, findings provide partial support for the affective-motivational model of drug addiction. in our first set of models momentary patterns of alcohol and cannabis co-use 52 examining whether momentary anxiety predicted usage type, participants who reported higher levels of anxiety were more likely to report no substance use when compared to co-use or cannabis-only episodes. in our second set of models examining whether usage type predicted state-level anxiety, usage types largely predicted momentary statelevel anxiety, with all comparisons except one (alcohol-only v. co-use) demonstrating statistically significant differences. we found insufficient evidence that prior statelevel anxiety predicted usage type, with two exceptions. when anxiety level was high, participants were more likely to report no use compared to co-use and no use compared to cannabis-only. when examining baseline moderators, we found stronger associations for women compared to men for several of the pairwise comparisons (i.e., momentary anxiety and higher likelihood of no use compared to all three substance usage types). this finding suggests that women may be less likely than men to engage in substance use despite feelings of anxiety. past research has shown that women use substances less often than men; however, women have higher rates of anxiety disorders (mclean et al., 2011; schulenberg et al., 2020). one potential explanation for our finding is that women may be utilizing other coping strategies (e.g., reappraisal, distraction, problemfocused coping) to manage symptoms of anxiety and thus are less likely to use substances to cope (nolen-hoeksema et al., 2012). this finding needs to be further explored in future work. we also found that baseline social anxiety did not moderate any of the pairwise comparisons. this finding is contrary with other work (buckner et al., 2008) that suggests that persons with social anxiety may drink or use cannabis to decrease discomfort associated with social interaction. in a review of the literature, morris and colleagues (2005) found that studies examining the co-morbidity between social anxiety disorder (sad) and alcohol use disorder (aud) have been inconsistent and that mixed findings may be explained by unexamined moderating factors (e.g., alcohol expectancies, social context, sex). our findings are consistent with our hypothesis that alcohol-only, cannabis-only, and co-use would lead to lower state-level anxiety when compared to no use. this finding is also consistent with select ema studies that have shown that use of cannabis or alcohol independently are associated with lower levels of negative affect or anxiety following use (buckner et al., 2015; dvorak et al., 2018). co-use generally had the lowest levels of anxiety post-use across the different usage types, as shown in figure 1. one explanation for this finding is that co-use produces decreased anxiety due to direct, pharmacological effects. to our knowledge, no prior studies have examined the impact of co-use on anxiety. past research has shown that simultaneous cannabis and alcohol use may lead to increased intoxication effects, with more pronounced feelings of confusion, dizziness, clumsiness, and difficulty concentrating (hartman et al., 2015; lee et al., 2017; lukas et al., 1992; lukas & orozco, 2001). it is possible that enhanced feelings of intoxication, in-the-moment, may override sensations of anxiety, making it less noticeable. controlled lab-based studies would best address the impact of co-use on anxiety. in our data, relationships between usage types and lower anxiety were moderated by higher baseline general anxiety across all six comparisons. past work has found high rates of comorbidity between anxiety and substance use disorders (blevins et al., 2019; buckner et al., 2017). however, the relationship between anxiety and substance use in-the-moment among those with anxiety disorders is not well understood. it is possible that cannabis and/or alcohol use may differentially affect the momentary expression of anxiety in those with higher levels of baseline anxiety. specific anxiety symptoms may prompt coping-related substance use. we utilized the beck anxiety inventory to assess general anxiety symptoms, which focuses extensively on physiological/somatic (e.g., “heart pounding”) and cognitive (e.g., “fear of losing control”) aspects of anxiety. future research should explore how particular anxiety symptoms and coping motives relate to alcohol, cannabis, and co-use in-themoment for persons with higher levels of anxiety to drive future real-time interventions. furthermore, assessing outcome expectancies related to alcohol, cannabis, and co-use is warranted, as such beliefs may drive anxiety management and can be addressed as part of intervention. the relation between momentary anxiety and alcohol, cannabis, or co-use may also be a function of product type, dose used, specific substance use patterns, and tolerance. classic research has cannabis, a publication of the research society on marijuana 53 shown that a wide range of factors (e.g., dose, particular conditions) likely determine whether alcohol has any impact on anxiety (wilson, 1988). alcohol is known to have biphasic stimulatory and sedating effects, which may function differently in light and heavy drinkers (king et al., 2002). research on the anxiolytic effects of cannabis (including thc and cannabidiol) is ongoing, but thus far inconsistent (van ameringen et al., 2020). recent experimental work (childs et al., 2017) demonstrated that low-dose oral thc (7.5 mg) decreased anxiety associated with an experimental stress task, while high-dose oral thc (12.5 mg) increased anxiety. it is currently unclear how variations in cannabis form (e.g., edibles, concentrates), dose, potency level, and route of ingestion (e.g., vaping, dabbing) may influence the experience of anxiety. due to the complex and possibly synergistic effects of cannabis and alcohol, there is a need for additional research on the effects of these substances on anxiety in a laboratory setting. limitations and future directions there has been increased attention to alcohol and cannabis co-use due to the increased risk for negative consequences resulting from using both substances compared to using either substance alone (yurasek et al., 2017). the majority of co-use studies have been cross-sectional, suggesting a need for ild studies (e.g., daily or ema designs; yurasek et al., 2017). future ild studies should be designed to gather data specifically on episodelevel simultaneous use to better understand predictors and sequalae of simultaneous use. we did not assess negative consequences associated with co-use in-the-moment, which could be associated with coping-related alcohol or cannabis use and should be explored in future work. in addition, we did not assess other potentially important variables that might contribute to co-use behavior, such as trait impulsivity. the current study was a secondary analysis of data from a larger study focused on a cohort of college students using cannabis near-daily. findings may not generalize to those who use cannabis at low to moderate levels. though most participants also drank alcohol, examination of alcohol variables and measures were not an original study goal. we also did not assess the quantity/potency of cannabis or alcohol use in-the-moment, other substance use (e.g., prescription stimulants), or other potentially influential momentary factors, such as positive affect or motives for use (slavish et al., 2019), which may relate to co-use. it is unclear if participants used the same dose of alcohol and/or cannabis when using together v. during singular use; as such any differences across usage groups may reflect dose effects and not potentiation. in addition, we did not control for prelevel of anxiety in our analyses due to the time span between prompts. due to power concerns, we also did not control for other potentially important variables, such as time/day of study, baseline substance use, and the social context of one’s use (e.g., with others or alone). the majority (96%) of our participants were under age 24, but four were over age 28, which should be noted when considering generalizability. finally, this study should be replicated in a general population sample. while college students are an important and high-risk group in need of study, it is important for the purposes of generalizability to understand if correlates of co-use identified generalize to a general population sample. conclusions the present study provided an initial examination of the association between co-use and state-level/baseline anxiety. though our findings did not suggest that anxiety (conscious or not) broadly drives various types of substance use inthe-moment, we did find that participants largely experienced lower anxiety after cannabis-only, alcohol-only, or co-use as compared to no use, with general anxiety moderating these relationships. future research is needed to better understand couse, how it functions in different contexts, and whether it’s related to a wide range of affect variables, including positive affect. moving forward, it is important to recognize potential benefits that participants may experience as a result of substance use, as such factors could interfere with successful treatment completion. consequently, clinicians should consider assessing for underlying anxiety and potential motives for use in those seeking substance-related treatment services. future research, particularly lab-based studies, should explore the combined effects of cannabis and alcohol on participant outcomes, as well as factors that may moderate these relations. momentary patterns of alcohol and cannabis co-use 54 references adams, t., rapinda, k. k., frohlich, j. r., o'connor, r. m., & keough, m. t. 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184-193. funding and acknowledgements: this study was funded by the national institutes of health (r15da041656; phillips, k.; phillips, m.) copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources are not modified, and the source is not used for commercial purposes. v4i2a2_authors_v2 research article 17 abstract assessment reactivity involves changes to behaviours from self-monitoring those behaviours (nelson & hayes, 1981). in the substance use field, reactivity has been identified both as a potential confound in daily diary research (cohn et al., 2015) and as a possible intervention tool in clinical practice (cohn et al., 2018). reactivity to daily self-monitoring of alcohol and tobacco use has been inconsistent in prior research. reactivity to daily self-monitoring of cannabis use quantity has received far less study. this study involved secondary analyses of data from n = 88 females who self-monitored their cannabis use for 32 days. we examined objective reactivity of cannabis use to daily self-monitoring by assessing changes in daily cannabis use over 32 days. we also explored participants’ perceptions of the impact daily selfmonitoring had on their cannabis use at study completion (i.e., subjective reactivity). in hurdle models testing objective reactivity, neither probability of cannabis use, nor quantity of cannabis use, changed significantly over the study period. many respondents (45%) reported no subjective reactivity, though a slight majority (55%) reported some subjective reactivity. subjective reactivity did not moderate objective reactivity over time; however, higher subjective reactivity was significantly associated with increased variability (interquartile range [iqr]) in cannabis use across the self-monitoring period. overall, reactivity appears unlikely to confound research utilizing daily diary cannabis measures, and daily selfmonitoring of cannabis use may be unlikely to serve as a useful stand-alone intervention for reducing cannabis use in non-treatment-seeking individuals. potential clinical implications of the novel finding of a link between subjective reactivity and objective cannabis use variability are discussed. key words: = cannabis; cannabis use quantity; assessment reactivity; longitudinal; daily diary; hurdle models assessment reactivity refers to behavior change that occurs due to self-monitoring (nelson & hayes, 1981). in the addictions field, reactivity to daily self-monitoring has been identified as an intervention tool in clinical practice (cohn et al., 2018), that may also introduce measurement bias in daily diary research (cohn et al., 2015). reactivity to daily self-monitoring of substance use is thought to occur due to increased awareness of use (moos, 2008). objective reactivity to daily self-monitoring (i.e., systematic mean changes over time) has been demonstrated for alcohol and tobacco use. in an 8week intervention study with heavy drinkers, participants in the control condition, who had selfmonitored their alcohol use up to six times/day, significantly decreased their alcohol consumption over time (collins et al., 1998). in another study of treatment-seeking smokers randomized to selfmonitor cigarette craving either once or six times/day for four-weeks (mccarthy et al., 2015), higher frequency self-monitoring was associated with lower craving over time. however, other studies with both clinical and non-clinical samples have failed to identify alcohol reactivity during shorter self-monitoring intervals of two to four weeks (e.g., hufford et al., 2002; simpson et al., 2005). buu et al. (2020) investigated reactivity to cannabis use daily self-monitoring. threehundred-and-seven emerging adults selfmonitored their cannabis use daily or weekly for 90 days. while no evidence of reactivity to daily self-monitoring on probability of cannabis use or reactivity to daily selfmonitoring of cannabis use in biological females cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.002 jason y. isaacs1, sean p. mackinnon1, kayla m. joyce2, sherry h. stewart1 1department of psychology & neuroscience, dalhousie university 2department of psychology, university of manitoba corresponding author: jason y. isaacs, life sciences centre, dalhousie university, 1355 oxford street, po box 15000, halifax, ns, b3h 3z1. email: jason.isaacs@dal.ca. phone: 416-554-8676. cannabis reactivity 18 cannabis use frequency (number of use occasions/day) was found in either self-monitoring group, they did not examine quantity (i.e., how much or what dose of cannabis was used; day & robles, 1989; zeisser et al., 2012) – a cannabis outcome that warrants further exploration (asbridge et al., 2014). the focus on cannabis quantity in the present study represents a necessary addition to the reactivity literature given that quantity of cannabis consumed has been shown to have effects that are independent of cannabis frequency in predicting cannabisrelated problems (walden & earleywine, 2008). additionally, some have emphasized that definitions of risky or harmful substance use should not be predicated on frequency of use alone (e.g., rehm, 1998). subjective reactivity (i.e., participants’ selfrated perceptions of reactivity) is rarely investigated. in a study by hufford et al. (2002), a sample of heavy drinking undergraduates perceived mild reactivity effects to daily selfmonitoring of their drinking behavior (m=2.1 on a 0-10 scale, with “0” indicating “not at all” and “10” indicating “a great deal”). to our knowledge, subjective reactivity has not been examined for cannabis use, and researchers have not yet examined associations between subjective and objective reactivity. such an examination would clarify whether cannabis users are aware of the reactivity effects that are occurring, or whether such effects may be occurring without their conscious awareness. the objectives of the present study were to investigate: (1) objective cannabis reactivity by replicating buu et al.’s (2020) analysis of cannabis use probability and extending to quantity of cannabis used; (2) participants’ perceptions of the impact of daily self-monitoring on their cannabis use to assess if subjective reactivity exists; (3) if subjective reactivity moderated the rate of change over time (i.e., do people high in subjective reactivity display larger decreases in cannabis use over time on the daily self-monitoring?); and (4) whether people high in subjective reactivity have greater day-to-day variability in cannabis use. consistent with findings demonstrated by the limited existing research on daily diary cannabis reactivity (buu et al., 2020), we hypothesized that cannabis use (probability and quantity) would decrease significantly over the 32 days of daily self-monitoring. similarly, based on limited existing findings with alcohol (buu et al., 2020; hufford et al., 2002), we predicted that participants would perceive overall mild reactivity effects of daily self-monitoring on their cannabis use. regarding the hypothesized effect of subjective reactivity on daily self-reported rate of change, we expected that individuals reporting the greatest subjective reactivity would also be those with the greatest objective change, reflecting participant awareness of assessment reactivity effects (moos, 2008). finally, participants high in subjective reactivity were hypothesized to also demonstrate higher variability in use because we expected that when people subjectively report having experienced higher levels of assessment reactivity, what they may have been noticing was day-to-day variations in use. methods participants eighty-eight female1 cannabis users (mage=28.86 years, sd=6.11, range=19-45) were originally recruited via advertisement for a study on cannabis use across the menstrual cycle (joyce, 2019; joyce et al., 2021). eligibility criteria included: aged 19-45 years, access to a smart phone with a data/texting plan (daily diary surveys were sent to participants via text message and accessed through the internet), using cannabis >4 times/past month, and not attempting to abstain from cannabis or receiving cannabis treatment.2 participants could not have a current pain disorder diagnosis or a medicinal cannabis prescription as these might minimize reactivity to daily self-monitoring. most participants were identified as daily users and having hazardous use/a possible cannabis use 1participants for the original study (joyce, 2019; joyce et al. 2021) were required to have a menstrual cycle, and thus were biologically female by birth. information was not originally obtained on gender. as such, we do not use the term “woman/women” to describe participants, as participants may not have identified as women. 2additional inclusion criteria for the [deidentified study citation 1] study examining depressed mood and coping motive effects on cannabis use quantity across the menstrual cycle included: (1) no menstrual cycle interference (e.g., past 6 month/current pregnancy, past 3-month contraceptive use), (2) a menstrual cycle between 25 and 32 days long, and (3) no imminent plans of conceiving. while these additional inclusion criteria were not relevant for the current study on reactivity to daily self-monitoring of cannabis use, they are mentioned here since they may affect generalizability. cannabis, a publication of the research society on marijuana 19 disorder (see table 1). for the original study (joyce, 2019; joyce et al., 2021), 232 females were screened and 112 were deemed eligible. of those deemed eligible, 24 were scheduled but did not attend the first session, resulting in our final sample of 88 participants. the 88 participants in our study included the 69 participants analyzed in the original study, with an additional 19 participants included in our current analysis. data for all 88 participants was collected in the original study; however, the original analyses excluded participants (n = 19) who completed less than 70% of their daily diaries. we retained all 88 participants for our current study. while a 70% completion rates is typically required to be sufficient for daily diary data (gordon, 2002), we utilized statistical models for the current study that were well able to accommodate missing data. procedure this study consisted of four sessions. session one included telephone eligibility screening. once deemed eligible, participants were scheduled for session 2 which occurred during specific menstrual cycle days (joyce, 2019; joyce et al., 2021); this ensured reactivity effects would not be confounded by menstrual cycle phase. during session 2, informed consent was provided, a demographics questionnaire was completed, and participants were taught how to use their smartphone to answer surveys. the selfmonitoring period (session 3) started the next day. participants received daily text messages with an online survey link for 32 days. every day at 10:30 am, participants were asked the total quantity of cannabis used the prior day. participants completed two daily questions on their cannabis use quantity: one at 10:30am and another at 2pm (joyce, 2019). further, a daily reminder to complete the 2pm survey was sent at 6:30pm. the 2pm survey only included information on the participants most recent use of cannabis that day. the 10:30am assessment captured the total quantity of cannabis used the previous day, so we deemed the 10:30am survey to be the most appropriate for this study given our novel focus on quantity. following the self-monitoring period, participants completed session 4 where they answered a subjective reactivity questionnaire, were debriefed, and obtained compensation (up to $97.65/cnd). measures measures for the current study were chosen from among a broader set used in the original study (joyce, 2019; joyce et al., 2021) to focus solely on cannabis use reactivity effects over the self-monitoring period. demographics. a demographics questionnaire, including items assessing participant characteristics such as age, ethnicity, and education, was administered at baseline for sample description purposes. cannabis timeline followback (ctlfb; robinson et al., 2014). the ctlfb, a calendarbased retrospective measure, was administered at baseline to determine participants’ recent cannabis use habits (e.g., cannabis-using days during the past 30 days). the measure assessed various cannabis use behaviours such as type and amount of cannabis used (sobell & sobell, 1992). participants were shown a calendar and asked to provide information about salient occasions (e.g., birthdays or holidays) during the past 30 days to act as memory anchors for increasing the accuracy of their cannabis use self-reports. the ctlfb has been found to have high test-retest reliability over a 30-day period (r = .79 to .96; robinson et al., 2014) as well as high concurrent validity with biological measures over a 30-day period (percentage agreement = 87.4 to 91.9; hjorthøj et al., 2012). the cannabis use disorder identification test revised (cudit-r; adamson & sellman, 2003). the cudit-r is an eight-item measure used to assess cannabis use disorder symptoms amongst at-risk populations. it was administered at baseline to identify hazardous/disordered vs. non-problematic cannabis users. the cudit-r has demonstrated good internal consistency (α = .84) and test-retest reliability (between six and 12 months; r = .85 .87, respectively; adamson & sellman, 2003). in our sample, the cudit-r demonstrated an internal consistency of α = .66. while lower than in the validation study (adamson & sellman, 2003), our alpha was greater than .60 – a cut-off deemed to be acceptable for the internal consistency of short scales of less than 10 items (loewenthal, 2004). a score of 13 or more was the cut-off point used to establish problematic cannabis use on the cudit-r (adamson et al., 2010). cannabis reactivity 20 table 1. demographic information for full sample (n = 88) demographic variable valid n m (sd)/% range ethnicitya 87 caucasian 87.36% first nations 11.49% black 6.90% south asian 4.60% arabic/west asian 4.60% latin american 2.30% east or southeast asian 2.30% other 3.45% education level 87 college/university graduate or moreb 68.97% some college/university or lessc 31.03% cannabis use riskd 87 hazardous use or moree 58.60% non-problematic cannabis use 41.40% cannabis using days (30-days pre-study)f 88 24.53 (8.55) 2 – 30 cannabis using days (daily diary study)g 88 21.05 (9.38) 3 – 32 daily cannabis use (30-days pre-study)f 57.95% age (in years) 87 28.86 (6.11) 19 – 45 current mood-related disorder diagnosesh 87 pre-menstrual dysphoric disorder 27.5% persistent depressive disorder 17.6% cyclothymic disorder 8.8% hypomanic episode 1.5% manic episode 0.0% aethnic categories are not mutually exclusive as people could identify with more than one ethnic category (e.g., biracial individuals). bincludes: college/university graduate, some post-graduate, and post-graduate degree cincludes: some college/university, high school graduate, and some high school ddetermined by cannabis use disorder identification test-revised (adamson & sellman, 2003) eincludes: hazardous cannabis use and cannabis use disorder. a cutoff score of 13 and above was used to identify hazardous cannabis users (adamson et al., 2010). fdetermined by cannabis timeline followback (robinson et al., 2014) gdetermined by ecological momentary assessment hdetermined by the structured clinical interview for dsm-5 disorders – research version (first et al., 2015). the scid-5-rv is the gold standard for mood disorder diagnoses (first et al., 2015) with good testretest reliability across one week (r = .76) and very good-to-excellent inter-rater reliability (k = 0.62-0.82) for depressive disorders (tolin et al., 2018). cannabis, a publication of the research society on marijuana 21 table 2. missing data for full sample (n = 88) across all 32 days day missing (%) 1 56.8 2 44.3 3 59.1 4 54.5 5 54.5 6 58.0 7 61.4 8 61.4 9 65.9 10 60.2 11 63.6 12 68.2 13 68.2 14 64.8 15 70.5 16 61.4 17 60.2 18 67.0 19 69.3 20 64.8 21 70.5 22 72.7 23 68.2 24 65.9 25 65.9 26 71.6 27 71.6 28 68.2 29 70.5 30 72.7 31 69.3 32 73.9 daily self-monitoring. at the 10:30am daily assessment, participants were asked if they had used cannabis the previous day (yes/no). when participants reported previous day cannabis use, they were prompted to indicate the quantity of cannabis used via the number of standard joint equivalents. they were told a standard joint referred to .5 grams, five bong/pipe hits, and/or 10 puffs (zeisser et al., 2012). reported instances of cannabis edibles and concentrates (5 and 5 out of 2816 days, respectively) were eliminated from cannabis use quantity calculations due to a lack of research equating cannabis quantity across different types of cannabis (e.g., flower, edible, or concentrates). participants had until 11:59pm each day to record their responses, and failure to respond by the deadline resulted in missing data for that day. subjective perception of reactivity. at session 4, participants were asked to rate, on a 10-point scale, “to what extent did the monitoring impact your cannabis use behaviors” (1="not at all", 5="moderately", 10="a great deal") similar to previous alcohol research (hufford et al., 2002). data analysis the study design was repeated measures nested within participants. hurdle models were chosen to examine change in cannabis use both cannabis reactivity 22 betweenand within-participants over 32-days. day of study was entered as a linear predictor of cannabis use. nested model comparison was used to compare different distributional assumptions. models were run in r version 3.6 (r development core team) using the ‘glmmtmb’ package (brooks et al., 2017) where models are fit using maximum likelihood estimation (mle).3 mle is one way to help reduce bias of parameter estimates in the presence of missing data (65.8% of all our possible observations were missing). this approach assumes we can predict missingness from variables in the model. missing data was found to be higher for later days of data collection (see table 2), which supports the missing at random condition. results nested model comparison cannabis use was positively skewed with zeroinflation (figure 1). model fit was tested with zero-inflated negative binomial, zero-inflated poisson, and hurdle models.4 negative binomial models and the fixed slopes poisson models failed to converge. all models had random intercepts. three models were compared: random slopes zero-inflated poisson (aic = 6248.0), fixed slopes hurdle (aic = 6201.1), and random slopes hurdle (aic = 6180.3; best-fitting model). the hurdle model allowed us to examine zeros (i.e., using versus not using cannabis) and numerical differences in cannabis quantity separately in a single model. figure 1. histogram of cannabis scores note. scores are indicated by “standard joint equivalents”, reported by participants (n = 88) for the full period of data collection. there were 2226 total usable observations (79% of a possible 2816) across participants, including zero values. cannabis, a publication of the research society on marijuana 23 cannabis use over 32-days the hurdle model separates results into logistic regression on the zeros and a truncated poisson model on the non-zero data. cannabis use did not demonstrate a significant change in usage probability (irr = 1.01, 95% ci = [0.99, 1.02], p = 0.23; figure 2) or quantity (irr = 0.99, 95% ci = [0.98 1.00], p = 0.08; figure 2) over the 32-day measurement period. the original study narrowed the final sample to n = 69, only including participants with a >70% daily diary completion rate (joyce, 2019; joyce et al., 2021). we re-tested model fit for this narrowed sample. both negative binomial and poisson models failed to converge, and a hurdle model with random intercept and slopes again provided the best fit, similar to our model fit for n = 88. analyses on the narrowed sample demonstrated findings consistent with the full sample (n = 88) for both probability of use (irr = 1.01, 95% ci = [0.99, 1.03], p = 0.19) and quantity used (irr = 0.99, 95% ci = [0.98, 1.00], p = 0.10). it is notable that 83% of the total variance available to be explained was between-subjects (icc = 0.83), while only 17% was within-subjects. the marginal r2 = 0.004 further highlighted the small amount of variance accounted for by day of cannabis self-monitoring. comparison of cannabis measurements: daily diary and ctlfb a further set of exploratory research questions arose through peer review. primary study outcomes were quantity and probability of cannabis recorded using daily diary data; however, participants also estimated 30 prior days of usage on the ctlfb. after discovering zero-inflation in the daily diary data, we compared patterns for both cannabis assessments to explore their similarities and differences. figure 2. line plots of mean cannabis use/no use (top panel) and cannabis quantity (bottom panel) (figure continues) 3see supplemental material for the full r code. 4see hu, pavlicova, and nunes (2011) for a detailed example of the utility of (and the differences between) negative binomial, poisson, and hurdle models. cannabis reactivity 24 note. for the top panel, no use = 0 and use = 1. results shown over the 32-day study period. the graph demonstrates slightly more occasions of cannabis use as opposed to no use at the outset, with no significant change in probability of usage across the self-monitoring period. for the bottom panel, mean cannabis use quantity is displayed in joint equivalents (on cannabis using days) across the 32-day study period. the mean line is superimposed in black. the graph demonstrates no significant change in daily quantity of cannabis use across the 32-day self-monitoring period. we sampled the first 30 days of the daily diary data for each participant as a direct comparison to the 30 days reported for the ctlfb (i.e., excluding daily diary days 31-32). data were aggregated across all 30 days in creating one value per participant (n = 88) with four variables of interest: sum of non-use days (i.e., scores of zero), sum of days with missing data (out of 30), quantity used (per day), and probability of use (a proportion of cannabis use days: cannabis use days / days completed). wilcoxon signed-ranks tests indicated no significant differences between the daily diary and ctlfb on zero values (mdn ctlfb = 1, mdn daily = 2, p = 0.13), quantity used (mdn ctlfb = 1.7, mdn daily = 2.0, p = 0.12), or probability of cannabis use (mdn ctlfb = 0.97, mdn daily = 0.93, p = 0.29). the ctlfb was found to have significantly fewer missing datapoints than the daily diary data (mdn ctlfb = 0, mdn daily = 3.5, p < 0.0001). this is natural given that all 30 days of the ctlfb are completed in a single session. spearman correlations also demonstrated strong relationships between the daily diary and ctlfb data for zero values (r = .66, p < 0.0001), quantity used (r =.82, p < 0.0001), and probability of use (r = .74, p < 0.0001). subjective reactivity participants self-reported perceiving mild reactivity of cannabis use to daily self-monitoring of cannabis use behaviors (median = 2; iqr = 3; range = 1-10), on average. six datapoints were missing due to participant dropout. these six participants did not complete the subjective reactivity measure as they did not attend the debriefing, resulting in a sample of n = 82. this median represented a score falling between “not at all” and “moderately”. while many participants (45%) reported a “1” on this scale (no reactivity), the majority (55%) reported some degree of subjective reactivity with 24% scoring 5 or higher (at least moderate reactivity). cannabis, a publication of the research society on marijuana 25 subjective reactivity as a moderator of trajectories the impact of participants’ subjective reactivity on objective change in cannabis use over time was investigated with a three-step hierarchical linear regression. in the first step (n = 88), time was entered as the only predictor, with results as previously reported (i.e., no significant change in probability or quantity over time). in the second step (n = 82), subjective reactivity was entered as an additional predictor. cannabis still demonstrated no significant change over time for dichotomous use (95% ci or [0.99-1.02], p = .29), and the effect of subjective reactivity was nonsignificant (95% ci or [0.90-2.08], p = .14). in the count (quantity) portion of the model, time remained non-significant (95% ci irr [0.98-1.00], p = .11) and subjective reactivity was nonsignificant (95% ci irr [0.87-1.09], p = .65). in the third step (n = 82), the interaction (time x subjective reactivity) was explored; the interaction effects were non-significant for the logistic (95% ci or = [1.00-1.01], p = .32) and count (95% ci irr = [1.00-1.00], p = .80) portions of the hurdle model. thus, we did not find evidence of subjective reactivity as a moderator of the relationship between time and cannabis use. the relationship between subjective reactivity and day-to-day variability was then investigated using the within-person interquartile range (iqr). that is, iqr for cannabis use was calculated for each participant, and subjective reactivity was regressed on this within-person iqr score. there was a small significant relationship between self-reported subjective reactivity and variability of cannabis use across 32 days (b = .12, 95% ci = [0.02, 0.23], p = .02; figure 3). thus, greater subjective reactivity signalled greater variability in day-to-day cannabis use. figure 3. the relationship between subjective reactivity and day-to-day variability note. the relationship is demonstrated using the within-person interquartile range (iqr). iqr for cannabis use was calculated for each participant, and subjective reactivity was regressed on this withinperson iqr score. this figure demonstrates a small positive relationship between self-reported (subjective) reactivity and variability of cannabis use across 32 days. cannabis reactivity 26 discussion we are among the first to investigate reactivity to daily self-monitoring of the quantity of cannabis use. we examined female users’ reactivity to 32-days of twice daily cannabis use self-monitoring. results demonstrated no significant change in cannabis use over time for either probability or quantity of use. findings are similar to those of buu et al. (2020) who indicated no impact of daily selfmonitoring on cannabis use probability or frequency. prior findings on reactivity to daily self-monitoring of alcohol and tobacco have been mixed, demonstrating reactivity in some cases (e.g., collins et al., 1998), but not others (e.g., simpson et al., 2005). prior research on assessment reactivity for alcohol provides a helpful comparison for our cannabis findings in a related (but distinct) domain of addictive behaviours. findings for alcohol have been mixed, but nonetheless suggest a pattern of significant reactivity effects among treatment-seeking or treatment-involved samples (e.g., epstein et al., 2005; kaminer et al., 2008). however, this pattern has primarily been observed in studies that have investigated reactivity to baseline or periodic assessments as opposed to daily diary measurements. because participants in our study were not recruited to be treatment-seeking, our sample may not have had sufficient motivation to facilitate change in their cannabis use stemming from self-monitoring. thus, future research should investigate reactivity to daily selfmonitoring among treatment-seeking cannabis users, as results could have important implications for ways to enhance motivation and behavior change for cannabis users in treatment settings. while our sample was not overtly treatment-seeking, almost 60% of participants reported engaging in hazardous cannabis use (as shown in table 1); therefore, our failure to observe reactivity effects cannot be readily attributed to low levels of problematic use in our sample. similar to treatment-seeking status, age has been found to play a primary role in alcohol reactivity, with more research supporting reactivity effects in younger populations (schrimsher, 2011). again, it is worth noting that most of the existing research investigating age’s role in reactivity has utilized baseline or periodic assessments as opposed to daily diary measurements. thus, future studies would benefit from exploring the role of age in reactivity to daily self-monitoring (and to periodic/baseline assessment) in the cannabis field. future research might additionally focus on daily selfmonitoring in the context of goal setting as a mechanism for motivational enhancement and behaviour change in cannabis use (spinola et al., 2017). more research is needed to assess potential differences in reactivity effects between cannabis users who self-monitor with pre-set goals vs. those who engage in self-monitoring alone. reactivity has also been shown to fluctuate with factors such as length (buu et al., 2020) and intensity of measurement (mccarthy et al., 2015). while our study demonstrated no assessment reactivity for cannabis, we build on previous findings by buu et al. (2020) by demonstrating that among a sample of female participants, reactivity did not seem to exist for cannabis quantity and did not seem to be impacted when frequency of self-monitoring increases to twice per day. it is worth noting that buu et al. (2020) demonstrated some impact of reactivity on alcohol use, but no impact on cannabis use. the observed difference between alcohol and cannabis was explained as potentially resulting from the focus on frequency of cannabis use. our study overcame this limitation by including investigation of cannabis use quantity, yet still found no evidence of reactivity to daily self-monitoring of cannabis use. following the finding that the pattern of overall cannabis use was zero-inflated, we compared data on our primary outcome measure (daily diary surveys) to reports on a ctlfb (robinson et al., 2014). measures of zero scores, along with general cannabis use, were comparable on both measures, thereby strengthening support for the validity of our initial (daily diary) assessment. missing data was found to be lower on the ctlfb, likely resulting from participants completing the ctflb on a single occasion. additionally, less missing data may be explained by a potential tendency for participants to use cognitive heuristics (e.g., “digit bias”; nagi, stockwell, & snavley, 1973) to generate data on the ctlfb for days when they were not sure about their use. similar reports on both cannabis use assessments indicate that the potential use of such heuristics did not appear to impact accuracy. cannabis, a publication of the research society on marijuana 27 this study was the first that we are aware of to examine subjective reactivity to cannabis daily self-monitoring. in general, many participants experienced no subjective reactivity (45%) but there was wide variability in subjective reactivity across the remaining 55%. furthermore, we conducted a novel examination of the impact of subjective reactivity on objective reactivity to determine the degree to which participants who experienced reactivity were aware of this reactivity. while subjective reactivity did not moderate changes in objective cannabis use over time, participants who reported experiencing greater subjective reactivity exhibited greater within-person variability in cannabis use over time. this seems to suggest that cannabis users may notice and misinterpret day-to-day variability in cannabis use levels as reactivity to self-monitoring. a potentially important implication of this finding may be that those with higher perceived reactivity to self-monitoring may benefit from being matched with interventions that use self-monitoring to help increase awareness of cannabis triggers. this study has several strengths. first, this was only one of a few studies to investigate reactivity to daily self-monitoring of cannabis use (cf. buu et al., 2020) and among the first to examine reactivity effects on cannabis use quantity. additionally, our study included an evaluation of subjective reactivity and examined its impact on both objective reactivity and day-today variability in cannabis use over time. however, our study also had limitations, most of which highlight potentially beneficial future directions. first, with a female-only sample, our findings may not generalize to males (green, 2006; tuchman, 2010). however, as females are underrepresented in cannabis research (schlienz et al., 2017), our sample offers additional representation to females in this regard. additionally, we were unable to determine the impact of reactivity to daily self-monitoring among treatment-seeking individuals, as our study was not limited to treatment seekers. we also did not measure other potential moderators of cannabis use reactivity to self-monitoring such as perceived desirability/undesirability of cannabis use behaviour, cravings, or motivations to change (barta et al., 2012; wray et al., 2014). future research into relevant moderators can have implications for both treatment-seeking and non-treatment-seeking populations. each of these variables may contribute to cannabis use behavioural change in the context of daily selfmonitoring. including cudit-r scores as an additional moderator might appear meaningful at first glance, but such inclusion would confound predictor with outcome (given that the cudit-r includes items tapping cannabis use levels), making results relatively uninterpretable. moreover, since problems are so strongly related to use (pearson, 2019), we believe that it would no longer be clear what the outcome measure is in the multivariate model. that is, cannabis quantity with the shared variance of cannabis problems removed would likely not be interpretable as an outcome measure (i.e., conceptually, it is hard to imagine what this might represent). future research should additionally consider assessing subjective reactivity prior to objective monitoring (i.e., assessing expectations for reactivity), which would provide additional information on potential individual differences in reactivity susceptibility. finally, participants were not asked about directionality of subjective change to their cannabis use (i.e., did they perceive their cannabis use to be decreasing or increasing secondary to daily monitoring). by not inquiring about directionality, true relations between subjective and objective reactivity may have been obscured, since the objective reactivity measure, but not the subjective reactivity measure, did allow for quantification of reactivity effects involving (the rarer) increases in cannabis use over time. in future, we recommend that researchers ask not only about the degree of perceived reactivity of cannabis use to selfmonitoring, but also the direction of that perceived change (i.e., increase or decrease) rather than simply assuming the perceived change involves a perceived decrease. overall, our results suggest daily selfmonitoring of cannabis use among females does not significantly impact usage over time, and further suggest that this change is not moderated by subjective reactivity. however, participants who perceived greater reactivity of their cannabis use to daily self-monitoring were more likely to have variable cannabis use over time, though the effect was small. from a research standpoint, reactivity is likely not a major confounding factor in research studying cannabis use with daily diary cannabis reactivity 28 methods. clinically, self-monitoring cannabis is unlikely to provide standalone benefits, at least for non-treatment-seeking individuals; 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(2012). a ‘standard joint’? the role of quantity in predicting cannabis-related cannabis reactivity 30 problems. addiction research and theory, 20, 82-92. funding and acknowledgements: our project utilized archival data from a previous study. as such, there is no funding to declare for the submitted paper. funding for the original project was obtained from the department of psychiatry research fund provided by dalhousie university. the authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 139 ved abstract medical marijuana has a long history of use as an analgesic for chronic pain disorders, including dyspareunia (pain during intercourse), a hallmark of the rare chronic pain disorder vulvodynia. many women’s health topics remain under investigated. few studies address cannabis’s potential to treat vulvodynia symptoms despite their dramatic impact on quality of life. women who had used cannabis and who reported experiencing vulvodynia symptoms (n = 38) completed an online survey assessing symptoms, expectancies regarding cannabis-associated relief from vulvodynia symptoms, cannabis use, and cannabis-related problems. generally, women expected cannabis to have moderate to large effects on vulvodynia symptoms (d = .63-1.19). nevertheless, women expected greater relief for burning/stabbing pain than for itching and pain associated with tampon insertion, as well greater relief for dyspareunia than for pain associated with tampon insertion. those whose symptoms were worse expected more relief from cannabis treatment. expectations of cannabis-induced relief did not increase frequency of use or problems. these data support the idea that further work is warranted, including placebo-controlled randomized clinical trials to rule out any placebo effects and identify potential adverse side effects from a cannabis treatment for vulvodynia. key words: vulvodynia, vulvar pain, cannabis, expectancies, alternative treatment vulvodynia, a chronic pain disorder affecting the vulva, persists for at least three months and lacks a clear identifiable cause (borstein et al., 2016). the disorder affects up to 28% of women in their lifetime (groysman, 2010). the pain can be localized, affecting a specific area in the vulva (e.g., the vestibule), generalized (affecting the vulva as a whole), or mixed (both localized and generalized pain; borstein et al., 2016). patients often describe the pain as ‘knife-like’, burning, rawness, or itching (sadownik, 2014). both sexual (e.g., vaginal penetration) and non-sexual contact (e.g., clothing, tampon insertion) can elicit pain, but symptoms also appear spontaneously. mixed conditions also appear where both physical contact and the absence of contact can elicit pain. the pain might arise from the first attempts of vaginal penetration (i.e., primary vulvodynia) or appear after a period of pain-free sexual intercourse (i.e., secondary vulvodynia; bornstein et al., 2016). the exact cause of vulvodynia remains unknown, but is likely multifactorial (sadownik, 2014) with established links to inflammation (falsetta et al., 2015) and neuroproliferation of nociceptors (bohm-starke, hilliges, falconer, & rylander, 1999). current treatment options for vulvodynia proposed treatments include reducing potential irritants, administering topical analgesics, injections, oral medications, and cannabis 2020, volume 3 (2), 139-147 © author(s) 2020 researchmj.org doi: 10.26828/cannabis.2020.02.001 open access cannabis and vulvodynia symptoms: a preliminary report corresponding author: eliza barach, department of psychology, university at albany, state university of new york, 1400 washington ave., albany, ny, usa email: ebarach@albany.edu eliza barach1, melissa n. slavin2, mitch earleywine1 1 university at albany, state university of new york, albany, ny, usa 2 columbia university school of social work, new york, ny, usa cannabis and vulvodynia symptoms 140 surgery. reducing irritants often includes changing laundry detergent, switching to cotton underwear, and avoiding tight clothing. topical analgesics often include regular applications of lidocaine, especially prior to sexual contact, but many patients find this approach increases irritation for themselves or their male partners, and might not surpass placebo (foster et al., 2010). similarly, injections of botulinum toxin a have alleviated self-reported pain in one study (hansen, guildberg, & meinert, 2019), but failed to surpass placebo in another (petersen, giraldi, lundvan & kristensen, 2009). health professionals have turned to prescription tricyclic antidepressants (tcas), serotonin reuptake inhibitors (ssris), and anticonvulsants, (e.g., gabapentin) with some success (leo, 2013; leo & dewani, 2013), but attempts at replication show no advantage for either approach over placebo (brown, bachmann, wan, & foster, 2018; foster et al., 2010). the side-effects of some of these medications decrease adherence to the treatments too. in summary, none of these treatment options have uniform successes in reducing vulvodynia pain, with many failing to outperform reasonable placebos (miranda, soriano, silveira, & vale, 2018). finally, health professionals have recommended a vestibulectomy (e.g., partial or full removal of the vulvar vestibule; haefner et al., 2005) after more conservative treatments have failed. the surgery can improve localized provoked vulvodynia, but appears less effective for generalized vulvodynia (falsetta, foster, bonham, & phipps, 2017). potential complications include infection, increased pain, reduction in lubrication and sensitive scar tissue (tommola, unkila-kallio, & paavonen, 2010). the lack of randomized clinical trials (rcts) prevents reasonable estimates of rates of true success or complications of this procedure (stockdale & lawson, 2014). many women are reluctant to turn to surgery for this ailment. alternative treatments with better outcome and side-effect profiles would be a dramatic improvement. vulvodynia and cannabis historically, medical marijuana is most commonly used for chronic pain (parker, 2017). anecdotal reports suggest that marijuana can treat vulvodynia. cannabis offers significant analgesic effects with few side effects for a wide range of chronic pain conditions, including neuropathic pain, fibromyalgia, rheumatoid arthritis, and mixed chronic pain (lynch & campbell, 2011; lynch & ware, 2015). furthermore, cannabis exhibits potential antiinflammatory properties (blake, robson, ho, jubb, & mccabe, 2006) and at low doses can effectively treat chronic pain while avoiding the psychoactive side effects (wilsey et al., 2013). dyspareunia, a hallmark symptom of vulvodynia, decreases when patients consume marijuana prior to intercourse (lynn, lópez, miller, thompson, & campian, 2019). marijuana’s success with neuropathic and inflammatory pain (as well as dyspareunia) support its potential efficacy for vulvodynia. cannabis treatment expectancies: links to cannabis use and associated problems expectancies about a host of substances influence their subjective experience and subsequent use. cannabis use often increases as expectancies for positive effects increase. those who anticipate more enhanced social interactions, improved sexual functioning, or greater relaxation use cannabis more often or in greater amounts (e.g. metrik et al., 2009; schafer & brown, 1991). those who think cannabis will improve their symptoms are likely to consume cannabis more frequently or in greater quantities as well. for example, symptom severity for ptsd (earleywine & bolles, 2014), menopause (slavin, farmer, & earleywine, 2016), and pms/pmdd (slavin, barach, farmer, luba, & earleywine, 2017) correlated with individuals’ cannabis use. expectancies of cannabis-induced relief mediated the associations between symptom severity and use in these examples as well. comparable symptom-specific expectancies might exist for women who use cannabis for vulvodynia relief, and their consumption might covary with these expectancies. nevertheless, positive expectancies need not correlate with cannabis-related problems. for example, menopausal women and women suffering from pms/pmdd reported expecting cannabis to relieve these symptoms, but the expectancies varied inversely with problems (slavin et al., 2017; slavin et al., 2016). in contrast, regular and heavy users expectations of cannabis, a publication of the research society on marijuana 141 global negative effects did increase with problems (beraha, cousijn, hermanides, goudriaan, & wiers, 2013). ideally, expectations of relief from vulvodynia would not lead to inordinate or problematic use. current study because cannabis improves many different chronic pain conditions (lynch & campbell, 2011; lynch & ware, 2015) and reduces dyspareunia (lynn et al., 2019), we hypothesized that participants would expect cannabis to alleviate vulvodynia symptoms. in addition, we examined the relation between cannabis treatment expectancies, monthly cannabis use and vulvodynia pain symptom severity as well as their impact on cannabis-related problems. in order for cannabis to be considered a proper alternative treatment for vulvodynia, it is imperative that the potential medicinal benefits outweigh any associated increase in problems. method participants women who reported vulvodynia symptoms as well as lifetime cannabis use (n = 38) completed an online survey on symptoms, expectancies regarding cannabis-associated relief from vulvodynia symptoms, cannabis use, and cannabis related problems. participants responded to a facebook or vulvodynia support forum blog post advertisement to complete an internet survey on cannabis use and vulvodynia symptoms. to target women with vulvodynia the advertisement was posted monthly in different facebook groups that served as vulvodynia support groups as well as in the vulvodynia support forum webpage. the advertisement stated that participants experiencing vulvodynia and have used cannabis before are eligible to participate in an online research study. participants were informed that they would be entered into a raffle to win a free vaporizer if selected. participants had the option to send their email address and a secret number to be eligible for the prize. all procedures were in line with and approved by the local institutional review board. measures demographics. participants reported age, race, ethnicity, education and recent cannabis use. in addition, we asked about disorders frequently comorbid with vulvodynia, including fibromyalgia (sadownik, 2000), interstitial cystitis (rueda, 1986), and irritable bowel syndrome (sadownik, 2000). we also asked about rates of depression/anxiety because of suggested links between depression/anxiety and vulvodynia (khander et al., 2011) and because living with vulvodynia can have a marked influence on the quality of life (ponte, klemperer, sahay, & chren, 2009). see table 1 for participant demographics. vulvodynia symptoms. we assessed vulvodynia symptoms for generalized vulvodynia and localized vulvodynia as well as for provoked and spontaneous vulvodynia based on common patient self-reported descriptions of vulvodynia symptoms/pain (e.g., reed et al., 2012; sutton, bachmann, arnold, rhoads, & rosen, 2008). the 12 items addressed: (1) vulvar burning, (2) vulvar soreness, (3) vulvar stinging (4) vulvar rawness, (5) vulvar throbbing, (6) vulvar stabbing or sharp pain (7) vulvar itching (8) dyspareunia, (9) pain with tampon insertion (10) vulvar pain from prolonged sitting (11) vulvar pain from tight fitting pants (12) vulvar pain while exercising. participants were asked to rate the severity of each symptom on a likert scale from “none (0)” to “extremely severe (5)”. all symptoms were endorsed by most participants (see table 1). cronbach’s alpha for the total symptoms scale was .878. expectancies of cannabis-induced changes in vulvodynia symptoms. this scale was adapted from the scale used to assess vulvodynia symptoms and queried participants on their expectancies of how cannabis helps each of these symptoms. individuals were asked to rate how cannabis makes each of the symptoms feel on a five-point likert scale ranging from ‘extremely worse (-2)’ to ‘extremely better’. scores greater than zero on this scale are indicative of more positive expectancies toward cannabis treating vulvodynia symptoms; scores less than zero are indicative of no expectancies of cannabis treating symptoms or expectancies of cannabis worsening symptoms. cronbach’s alpha for the total expectancies scale was .916. cannabis and vulvodynia symptoms 142 table 1. characteristics of study sample characteristic n % age 34 89.5 19-29 19 50.0 30-39 6 15.8 40-39 4 10.5 50-59 4 10.5 60+ 1 2.6 race/ethnicity 38 100.0 caucasian 36 94.7 asian 1 2.6 hispanic/latino 1 2.6 comorbid illness/disorders (items not mutually exclusive) 38 100.0 fibromyalgia 3 7.9 interstitial cystitis 4 10.5 irritable bowel syndrome 6 15.8 depression/anxiety 24 63.2 none 12 31.6 education 38 100.0 some high school 1 2.6 finished high school/ged 4 10.5 some college 11 28.9 associates degree 2 5.3 bachelors degree 9 23.7 some graduate training 4 10.5 advanced degree 7 18.4 recent cannabis use (items not mutually exclusive) 38 100.0 past year 38 100.0 past month 34 89.5 past week 30 78.9 vulvodynia symptoms (items not mutually exclusive) 38 100.0 vulvar burning 36 94.7 vulvar soreness 33 86.8 vulvar stinging 32 84.2 vulvar rawness 31 81.6 vulvar throbbing 25 65.8 stabbing or sharp pain 32 84.2 vulvar itching 27 71.1 dyspareunia 37 97.4 tampon insertion 29 76.3 vulvar pain from prolonged sitting 29 76.3 vulvar pain from tight fitting pants 31 81.6 vulvar pain while exercising 32 84.2 cannabis, a publication of the research society on marijuana 143 cannabis use per month. participants reported how many days they used cannabis in the previous month, from zero to 31 days. average monthly usage was 17.26 days. cannabis-related problems. participants completed the marijuana problems scale by rating 19 items from 0 (none) to 5 (a serious problem) based on the previous 90 days. items included: (1) problems with partner, (2) problems in family, (3) neglect of family, (4) problems with friends, (5) missing days at work or school, (6) losing a job, (7) lowering productivity, (8) medical issues, (9) withdrawal symptoms, (10) blackouts or flashbacks, (11) memory loss, (12) difficulty sleeping, (13) financial difficulties, (14) legal problems, (15) low energy levels, (16) feeling bad about use, (17) lowered self-esteem, (18) procrastination, and (19) lack of self-confidence. cronbach’s alpha was .863. data analysis we performed a series of one-sample t -tests to see if mean expected relief differed from zero for each expectancy. we then performed paired ttests to determine whether women expected greater cannabis-associated relief for some vulvodynia symptoms than others. due to the number of analyses we used a modified bonferroni approach to balance power and type i error (wilcox, 2013). each category of analyses received a family-wise error rate of p < .05 (two-tailed). for the 12 analyses addressing if the expectancy exceeded zero, corrected p values were set to p < .004 (.05/12). lastly, we compared correlations between frequency of cannabis-usage, cannabisassociated problems, vulvodynia symptoms and cannabis-associated relief expectancies. given the rarity of the disorder, sample sizes in vulvodynia research are frequently small. power analysis revealed that with n = 38, and alpha at .05 (twotailed), we have power of 0.80 to detect a pearson's r of 0.40. t -tests to assess significant difference from 0 under the same conditions could detect effects of d = 0.47 or larger. paired t-tests for comparing symptom expectancies could detect d = 0.46 or larger (faul, erdfelder, buchner, & lang, 2009). given the limited amount of research on this topic and the social desirability bias associated with these symptoms (and cannabis consumption), we were eager to examine even a small sample in an effort to discover if further work on this topic appeared justified. results expectancies of vulvodynia symptom relief one sample t-tests revealed that all expectancies were significantly different from 0 (see table 2 for means, ts, ps and the effect size d). paired ttests revealed that participants endorsed greater cannabis-induced relief for sharp/stabbing pain compared to itching (t(33) = 3.27, p = .002) and tampon insertion (t(33) = 3.78, p =.001). in addition, participants reported greater cannabisinduced relief for dyspareunia compared to tampon insertion (t(34) = 3.43, p = .002). the remaining paired t-tests did not reveal any difference among the symptoms for expectancies of cannabis-associated relief (all ps > .004). bivariate correlations among expectancies, use, and problems correlations among the severity of symptoms, expectancies for cannabis-induced relief, and cannabis problems appear in table 3. as symptom severity increased, expectancies regarding cannabis-induced relief increased. no other correlations were significant. discussion given the diverse range of efficacy and frequent negative side-effects for treatment for vulvodynia, we examined self-reported responses to cannabis in a sample of women suffering from the disorder. women reported the severity of their symptoms, expectancies regarding cannabisinduced symptom relief, frequency of cannabis consumption, and cannabis-related problems. women endorsed cannabis-induced relief for all symptoms. women expected cannabis to reduce dyspareunia—a hallmark of vulvodynia. these results suggest that cannabis might serve as a promising alternative treatment to add to the arsenal of potential interventions. in addition, participants expected more cannabis-induced relief for sharp/stabbing symptoms compared to itching and tampon insertion as well as greater expectancies of relief for dyspareunia compared to tampon insertion. cannabis and vulvodynia symptoms 144 table 2. mean expectancies for vulvodynia symptoms vulvodynia symptom mean (sd) significance (2tailed). effect size (d) sharp/stabbing .64 (.54) t(35) = 7.06, p <.001 1.19 dyspareunia .62 (.49) t(36) = 7.69, p <.001 1.24 soreness .54(.56) t(36) = 5.90, p <.001 0.96 sitting .53 (.51) t(33) = 6.09, p <.001 1.03 burning .50 (.60) t(37) = 5.10 , p <.001 0.83 stinging .50 (.56) t(37) =5.53 , p <.001 0.89 throbbing .47 (.56) t(33) = 4.87 , p <.001 0.84 rawness .42 (.55) t(35) = 4.51 , p <.001 0.76 exercise .35 (.49) t(33) = 4.24 , p <.001 0.71 tight pants .34 (.59) t(34) = 4.24 , p = .002 0.58 itching .31(.47) t(34) = 3.95 , p <.001 0.70 tampon insertion .29 (.46) t(34) = 3.69 , p = .001 0.63 note. expectancies are ordered from highest (most expected cannabis-induced relief) to lowest. table 3. table of correlations mean (sd) 1 2 3 1 monthly use 17.26 (11.62) 2 symptoms 24.47 (10.11) r = .22 , p = .187 3 expectancies 5.25 (4.57) r = .20, p = .232 r = .40, p = .013 4 problems 6.64 (7.83) r = .20, p = .240 r = .17, p = .299 r = -.04, p = .791 note. the degrees of freedom are 36 and significance is 2-tailed. significant correlations are shown in bold. monthly use = average number of days of cannabis use per month; symptoms= severity of vulvodynia symptoms; expectancies = expected cannabis-induced relief of vulvodynia symptoms; problems= cannabis-related problems. these results suggest that cannabis might be better suited for some vulvodynia symptoms, specifically pain. for the remaining symptoms there was no difference in the endorsement of cannabis-relief, suggesting that women expect marijuana to equally help the remaining symptoms associated with vulvodynia. these results are consistent with other work on medical cannabis and chronic pain (parker, 2017; lynch & campbell, 2011; lynch & ware, 2015). the absence of a significant link with cannabis-related problems might allay concerns about the development of negative consequences from this treatment approach. although the current data are preliminary, further work on this topic appears justified. limitations the current study carries important limitations related to sample size, self-report bias and the scope of the assessed constructs. these data appear to be the first to address this aspect of cannabis expectancies in women’s health. the current sample is small (n = 38), but in light of the relative infrequency of vulvodynia (harlow et al., 2014; reed et al., 2012), the prevalence of cannabis use, and the low rate of volunteering for cannabis research (mian, altman, & earleywine, 2019), the target population proved relatively small despite cannabis’s potential as a treatment. the current sample is actually larger than many in the published literature on vulvodynia, and these results appear to justify further work on this topic. the potential for self-report bias, particularly given this combination of sensitive cannabis, a publication of the research society on marijuana 145 topics (drug use and symptoms that affect the genitals), seems high, but the anonymity of internet responding might have helped keep systematic overor under-reporting to a minimum. lastly, to avoid increasing the respondent burden, we limited our questionnaire to the items most relevant to participants’ vulvodynia symptoms, marijuana consumption and their expectancies regarding whether they believed marijuana could help reduce their vulvodynia symptoms. nevertheless, future work should consider additional items regarding participant’s source of obtaining marijuana, the timing of consumption relative to the onset of symptoms, additional drug use (e.g., alcohol consumption), as well as their current vulvodynia treatments. future work also could attempt to recruit women from vulvovaginal clinics or doctor’s offices that specialize in the treatment of vulvodynia. alternatively, researchers might cast a wide net among large samples of women and ask them about individual symptoms and their expectations of cannabis-induced relief. prohibition also limits the number of women who might know about the impact of cannabis on 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(2013). low-dose vaporized cannabis significantly improves neuropathic pain. the journal of pain, 14(2), 136-148. funding and acknowledgements: mns was supported by the national institutes of health under award number: 2t32da037801-06. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 148 abstract the cannabis use disorders identification test revised (cudit-r) is an 8-item screening instrument designed to identify recent problematic cannabis use over the past 6 months. the purpose of the present study was to investigate the factor structure of the cudit-r separately for male and female college students. participants included 1,390 male and female college students recruited from three state universities (61% female; age: m = 19.8, sd = 1.3). we conducted exploratory and confirmatory factor analyses followed by tests of measurement invariance including configural invariance, metric invariance and scalar invariance across men and women. results confirmed a one-factor structure for the cudit-r. the number of factors and item loadings were invariant between men and women. however, intercepts were non-invariant for an item asking about consumption of cannabis use indicating that the endorsement of this item varied between men and women. follow-up validation tests indicated that using a sum score for analyses is appropriate despite non-invariance. however, more research is needed to determine if the cut-off scores of the cudit-r should be reevaluated by gender. key words: cannabis, cudit-r, college students, assessment the 20-item cannabis use disorders identification test (cudit; adamson & sellman, 2003) was developed to screen for cannabis abuse or dependence by modifying the alcohol use disorders test (audit; saunders, aasland, babor, de la fuente, & grant, 1993). the initial cudit was revised (cudit-r; adamson et al, 2010) and contains eight items consisting of four items from the original cudit and four new items that assess consumption, problems, dependence, and psychological features. although the cudit-r has been validated in clinical (adamson et al., 2010) and non-clinical (loflin, babson, browne, & bonn-miller, 2018; schultz, bassett, messina, & correia, 2019) samples, it is not known whether the cudit-r operates differently across salient demographic groups, such as men and women. men and women differ in rates of cannabis use and progression to cannabis use disorder (cud). reporting of lifetime cannabis use is about 53.1% in men and 43.7% in women (substance abuse and mental health services administration, 2018). recent research indicates that men also have higher rates of cud than women (3.5% versus 1.7%, respectively; hasin et al, 2016). cannabis 2020, volume 3 (2), 148-156 © author(s) 2020 researchmj.org doi: 10.26828/cannabis.2020.02.002 open access factor structure of the cannabis use disorders identification test revised (cudit-r) for men and women megan m. risi1, alexander w. sokolovsky2, helene r. white3, kristina m. jackson2 1 department of psychology, university of rhode island, south kingston, ri, usa 2 center for alcohol and addiction studies, school of public health, brown university, providence, ri, usa 3 department of sociology and center of alcohol studies, rutgers, the state university of new jersey, piscataway, nj, usa corresponding author: megan m. risi, department of psychology, university of rhode island, 142 flagg road, kingston, ri, usa 02881, email: mrisi@uri.edu factor structure of cudit-r by gender 149 nonetheless, women appear to have a faster trajectory from first cannabis use to cud relative to men (hernandez-avila, rounsaville, & kranzler, 2004; khan, 2013). the reason for this telescoping effect is not well known; however, women demonstrate greater subjective intoxication to cannabis than men, which may contribute to maintained use (cooper & haney, 2014). the validity of the cudit-r across gender has not, to our knowledge, been investigated. thus, current research utilizing the cudit-r relies on the assumption that this measure assesses the same construct in men and women across a common metric. without examining measurement invariance, we do not have evidence that differences among men and women in the cudit-r scores represent true differences in problematic use or are merely artifacts of other processes, such as the interpretation of questions. the purpose of the present study was to explore the psychometric qualities of the cudit-r separately for young adult men and women. method participants and procedures as part of a larger study, students ages 18-24 from three state universities were randomly chosen by each school’s registrar and sent email invitations to participate in an online screening survey. eligible participants were then invited to participate in a 30to 40-minute online baseline survey asking questions related to alcohol and cannabis use. eligibility criteria included being a past-year alcohol and cannabis user between ages 18 and 24 and a full-time student invited to participate at one of the three universities. those who responded to the screening surveys were fairly representative of those invited based on demographic information provided by the registrars. (for greater detail on recruitment and participation, see white et al., 2019.) participants were 1,390 eligible students from the three universities. gender identity of the sample was 61% women, 38.1% men, and 0.9% transgender, genderqueer, or gender non-binary, with a mean age of 19.8 (sd = 1.3). the sample was 63.8% non-hispanic white, 2.7% nonhispanic black, 12.5% asian, 12.2% hispanic/latinx, 0.2% native hawaiian or other pacific islander, 0.1% american indian or alaskan native, 0.8% other not listed, and 7.7% more than one race/ethnicity. measures the cudit-r (adamson et al, 2010) contains items designed to assess criteria related to cannabis abuse and dependence during the past 6 months and has been validated to screen for dsm5 criteria for cud (schultz et al., 2019). see table 1 for questions and item-level means. item one had response options of 0 = “never,” 1 = “monthly or less,” 2 = “2-4 times a month,” 3 = “2-3 times a week,” and 4 = “4 or more times a week.” item eight used response options 0 = “never,” 2 = “yes, but not in the past 6 months,” and 4 = “yes, during the past 6 months.” the remaining six items used a five-point likert-type scale ranging from 0 = “never” to 4 = “daily or almost daily.” total scores range from 0 to 32 with scores of 8 or more indicating hazardous cannabis use and scores of 12 or more indicating possible cud (adamson et al., 2010). in addition, demographic information including gender identity was collected. response options included male, female, tans male/trans man, trans female/trans woman, genderqueer/gender non-conforming, different identity (check all that apply). for the analyses, we included persons who identify as either men or women. thus, those who identified as transgender men were combined with those who identified as men (total n = 547) and those who identified as transgender women were combined with women (total n = 831). we excluded participants who identified as genderqueer and gender nonbinary if they did not also identify as a man or woman as the sample size was too small (n = 9). further, we excluded participants who identified as both a man and woman (n = 3). the final sample size for the efa was 488 (men n = 199, women n = 289) and the final sample for the cfa was 890 (men n = 348, women n = 542). students were asked whether or not they experienced 28 different negative consequences in the past 3 months “due to their marijuana use” (see table 2). we summed these dichotomous items (yes/no) to create a score of total number of consequences experienced. the consequence items were from the 21-item brief marijuana consequences questionnaire (macq; simons, dvorak, merrill, & read, 2012) and the 24-item cannabis, a publication of the research society on marijuana 150 table 1. descriptive information for cudit-r (n = 1390) item mean (sd) range frequency of cannabis use 1.32 (1.54) 1-5 hours stoned on a typical day 1.32 (0.88) 1-5 past 6 months unable to stop using cannabis once started 0.23 (0.73) 1-5 past 6 months failed to do what’s expected because of cannabis use 0.35 (0.69) 1-5 past 6 months devoted time spent recovering from cannabis use 0.34 (0.82) 1-5 past 6 months problem with memory or concentrating because of cannabis use 0.59 (0.94) 1-5 cannabis use in risky or hazardous situation 0.43 (0.89) 1-5 thought about cutting down or stopping cannabis use 1.82 (1.89) 1-3 note. the cudit-r asks “how often in the past 6 months have you…”; item one had response options of 0=“never,” 1=“monthly or less,” 2=“2-4 times a month,” 3=“2-3 times a week,” and 4=“4 or more times a week.” item eight used response options 0=“never,” 2=“yes, but not in the past 6 months,” and 4=“yes, during the past 6 months.” the remaining six items had responses of 0=“never,” 1=“less than monthly, 2=“monthly,” 3=“weekly,” and 4=“daily or almost daily.” sd = standard deviation table 2. negative consequences for cannabis use experienced over the past 3 months item 1. had a hangover or felt in a fog the morning after i had been using 2. my school work has suffered because of my use 3. i had less energy or felt tired because of my use 4. have often ended up using on nights when i had planned not to use 5. while using, i have said or done embarrassing things 6. have missed classes because of use, hangover, or illness caused by my use 7. when using, i have done impulsive things i regretted later 8. my use has created problems between myself and my romantic partner or parents 9. have felt like i needed to use after i'd gotten up (i.e., before breakfast) 10. have neglected my obligations to family, work, or school because of my use 11. have often found it difficult to limit how much i use 12. have become very rude, obnoxious, or insulting after use 13. have felt very sick to my stomach or thrown up after using 14. have taken foolish risks when i have been using 15. have passed out from using 16. could no longer get high on the amount that used to get me high 17. my use has gotten me into sexual situations that i later regretted 18. have woken up in an unexpected place after using heavily 19. have driven a car while under the influence 20. have gotten into physical fights because of my use 21. have been less physically active because of my use 22. have had trouble sleeping after stopping or cutting down on use 23. have awakened the day after using and found i could not remember a part of the evening before 24. haven't been as sharp mentally because of my use 25. have received a lower grade on an exam or paper than i normally would have because of my use 26. have tried to quit using because i thought i was using too much 27. have felt anxious, irritable, lost my appetite or had stomach pains after stopping or cutting down use 28. have lost motivation to do things because of my use note. all questions were asked as yes or no factor structure of cudit-r by gender 151 brief young adult alcohol consequence questionnaire (byaacq; kahler, strong, & read, 2005); collapsing the two scales yielded 28 unique items. both scales have been used reliably with college students (kahler et al., 2005; simons et al., 2012). data analysis a random subset of 488 participants was first used for exploratory factor analysis (efa), which was further split by gender. we conducted the efa using r version 3.1.4 (r core team, 2017) on the cudit-r and factor extraction was based on parallel analysis (hayton, allen, & scarpello, 2004). factor analysis was justified using bartlett’s test of sphericity and the kaiser meyeroklin (kmo) measure of sampling adequacy (bartlett, 1950; kaiser, 1970). a significant bartlett’s test (p<.05) and a kmo index of at least 0.50 indicated the data were suitable for factor analysis (williams, onsman, & brown, 2010). the remaining 890 participants were used to conduct the cfa and measurement invariance. table 1 shows descriptive statistics for individual cudit-r items. the cfa was completed using lavaan (rosseel, 2012) for r version 3.1.4 (r core team, 2017). missing data were accounted for using diagonally weighted least squares (dwls), which results in less biased factor loadings for ordinal data (li, 2016). the comparative fit index (cfi) and tucker lewis index (tli) ≥.95, the root mean square error of approximation (rmsea) ≤ .06, and the standardized root mean squared residual (srmr) ≤ .08 were used as indicators for good model fit (hu & bentler, 1999; yu, 2002). modification indices were evaluated to determine whether residuals of items should be correlated based on overlapping constructs (sörbom, 1989). next, measurement invariance was tested by sequentially constraining parameters across genders. configural invariance of the cudit-r was evaluated by first fitting separate confirmatory models in men and women. a test of configural invariance examines whether the basic organization of the constructs (i.e., latent factors) is supported across genders. once configural invariance is established, the next step is metric invariance, or invariance of the item loadings. when factor loadings are invariant across groups, this indicates that each item contributes to the latent construct to a similar degree. if metric invariance holds across groups, scalar invariance is tested. scalar invariance is the equivalence of item intercepts. if all previous invariances are supported, strict invariance is tested. strict, or residual, invariance tests whether the sum of specific variance and error variance is similar across groups (byrne, 2010; kline, 2011; putnick & bornstein, 2016). the marijuana consequences score was used to validate the cudit-r. results the criteria of sphericity and normality were met as checked by a significant bartlett’s sphericity test (p<.001) and kmo value of 0.85. parallel analysis and efa suggested a one-factor solution for the cudit-r for both men and women with 83% of variance explained for both samples (see table 3). next, we tested goodness of fit of the one-factor structure using cfa. the final sample for the cfa (n = 890) consisted of 348 men and 542 women. there was no significant difference in gender by site, χ2(2) = 1.36, p = .506. a one-factor model with no correlated residuals showed poor to adequate fit (i.e., χ2(20) = 92.431, p < .001, cfi = .964, tli = .950, rmsea[90%ci] = .064[.051, .077], srmr = .034). evaluation of the modification indices showed strong evidence of a correlated residual between item one (“how often do you use cannabis?”) and item seven (“how often do you use cannabis in situations that could be physically hazardous, such as driving, operating machinery, or caring for children?”). given that these two items tapped similar content (frequency of use), we made the decision to correlate the residuals. the model with these correlated residuals resulted in significant improvement in model fit, ∆χ2 = 21.597, ∆df = 1, p < .001. modification indices were reevaluated and suggested that the covariance of item one and item two (“how many hours were you ‘stoned’ on a typical day when you had been using cannabis?”) also overlapped, likely because both items are indicators of consumption (as opposed to problems). adding these correlated residuals resulted in significant improvement in model fit, ∆χ2 = 21.229, ∆df = 1, p < .001. cannabis, a publication of the research society on marijuana 152 table 3. factor loadings of the individual cudit-r items on the factor for men and women separately from exploratory factor analysis. item men women (n = 199) (n = 289) frequency of cannabis use 0.59 0.66 hours stoned on a typical day 0.31 0.39 past 6 months unable to stop using cannabis once started 0.62 0.58 past 6 months failed to do what’s expected because of cannabis use 0.56 0.52 past 6 months devoted time spent recovering from cannabis use 0.65 0.62 past 6 months problem with memory or concentrating because of cannabis use 0.74 0.81 cannabis use in risky or hazardous situation 0.63 0.48 thought about cutting down or stopping cannabis use 0.53 0.57 note. the cudit-r asks “how often in the past 6 months have you…”; item one had response options of 0=“never,” 1=“monthly or less,” 2=“2-4 times a month,” 3=“2-3 times a week,” and 4=“4 or more times a week.” item eight used response options 0=“never,” 2=“yes, but not in the past 6 months,” and 4=“yes, during the past 6 months.” the remaining six items had responses of 0=“never,” 1=“less than monthly, 2=“monthly,” 3=“weekly,” and 4=“daily or almost daily.” modification indices were reevaluated once again but suggested no correlations with overlapping constructs. the final model showed good to excellent fit, χ2(17) = 49.605, p < .001, cfi = .984, tli = 0.976, rmsea[90%ci] = .044[.030, .059], srmr = 0.025. the final one-factor cfa model was run for men and women separately. the one-factor cfa showed good fit for men, χ2(18) = 44.403, p = .001, cfi = .969, tli = 0.951, rmsea[90%ci] = .066[.041, .090], srmr = 0.039; and women, χ2(18) = 36.489, p = .006, cfi = .984, tli = 0.975, rmsea[90%ci] = .026[.022, .063], srmr = 0.026 (see figure 1 final model by gender). table 4 shows the results from invariance testing. after establishing configural invariance, we tested group invariance by entering the configural model as the baseline step (step 1), and constraining factor loadings to be equal across groups (metric invariance; step 2). we found that the strengths of the factor loadings were invariant across men and women. we then evaluated scalar invariance by further constraining item intercepts to be equal across groups (step 3). we found noninvariant intercepts for item one suggesting that scalar invariance did not hold between men and women. specifically, men had a higher unstandardized item intercept than women (intercept = 2.91, se = 0.083 and intercept = 2.41, se = 0.062, respectively). we further evaluated whether a sum score for the cudit-r reliably indexed the measure for both men and women, by computing factor scores for each individual and correlating this score with the cudit-r sum score. pearson correlation revealed that the cudit-r factor score was strongly correlated with the sum score (r = .991, p < .001), suggesting that the variance in these indices was largely overlapping. finally, to determine whether differences observed in our test of scalar invariance would have practical implications for the cudit-r at a substantive level, we investigated the concurrent validity of both index measures (sum scores and factor scores) and found that they were both significantly correlated with cannabis use consequences with relatively equivalent magnitude (r = .711, p < .001 and r = .711, p < .001, respectively). when split by sex, both index measures correlated significantly with men (r = factor structure of cudit-r by gender 153 figure 1. model with standardized estimates for men (left) and women (right) separately. table 4. invariance testing across gender for the one-factor model of the cudit-r (n = 890) model χ2(df) cfi rmsea ∆χ2(∆df) ∆cfi p step 1: configural model 80.270 (36) .978 .053 step 2: metric invariance (all factor loadings held invariant across groups) 85.998 (43) .979 .047 5.728 (7) 0.001 0.572 step 3: scalar invariance (all factor loadings and item intercepts held invariant across groups) 134.182 (50) .958 .062 48.184 (7) 0.020 < .001 .684, p < .001 and r = .689, p < .001, respectively) and women (r = .724, p < .001 and r = .720, p < .001, respectively). discussion the present study sought to replicate the factor structure of the cudit-r items proposed by adamson et al. (2010) in a nonclinical young adult sample of cannabis users and to extend previous studies by examining gender invariance in the cudit-r. in line with the conceptualization of the cudit-r, our model confirmed a one-factor structure. our test of whether the cudit-r factor structure was the same across men and women indicated that the number of factors and item loadings were invariant between men and women. although our model replicated the factor structure of the cudit-r, we used modification cannabis, a publication of the research society on marijuana 154 indices to identify items with shared variance. specifically, item one (“how often do you use cannabis”) was correlated with items two (“how many hours were you ‘stoned’ on a typical day when you had been using cannabis”) and seven (“how often do you use cannabis in situations that could be physically hazardous, such as driving, operating machinery, or caring for children”). these items strongly overlapped in asking about consumption patterns. invariance testing of the cudit-r held across factor loadings (i.e., metric invariance). this finding indicates that the relationship between cudit-r items and the underlying latent construct is the same for men and women and suggests that these items are interpreted consistently by both genders. in this sample, item one intercept (“how often do you use cannabis?”) was non-invariant across groups, indicating that the endorsement of the items varied between men and women. knowing that there are gender differences in cannabis use including prevalence (cuttler, mischley, & sexton, 2016) and rates of and progression to cud (hasin et al., 2016; hernandez-avila et al., 2004; khan, 2013), differences in endorsement of cudit-r items was expected. specifically, we found that men had higher endorsement of item one (“how often do you use cannabis?”). this difference is in line with previous research indicating that men use cannabis more frequently than women (cuttler et al., 2016). due to the gender differences in the cudit-r above, we compared the traditionally derived cudit-r sum score to a cudit-r factor score based on our psychometric models. factor scores are composite scores which identify an individual’s placement on a latent factor. when we compared the factor score with the sum score, results indicated both scores measured virtually the same thing (i.e., they were correlated at .99). this finding suggests that despite non-invariance at item one intercepts, the sum score is still appropriate to use for both young adult men and women. however, more research is needed to determine if clinical implications of the cudit-r, such as cut-off scores, should be reevaluated by gender. the results of the study need to be considered within the context of some limitations. the cudit-r is a self-report measure; thus, responses may be overor under-reported. the present study results were based on a sample of university students who reported using both alcohol and cannabis in the past year and may not generalize to other college students or to nonstudent samples. the cudit-r may perform differently in other samples such as older adults or those with less regular cannabis use who may endorse items related to frequency at lower levels. nonetheless, our sample represents an important age group given that the annual prevalence of cannabis is highest among 19to 30-year-olds (38%) with highest use at ages 21-22 (44%; schulenberg et al, 2019) and odds of cud diagnosis are highest in young adults aged 18-24 (hasin et al., 2016). our sample had a small number of non-white students and analyses were limited to those who identified either as men or women; replication in more diverse samples and across non-binary gender groups is an area of future research. due to the self-report nature of the assessment and the lack of a diagnostic measure of cud in the data set, we were unable to determine potential cutoff scores for hazardous use and probable cud. future research should work to determine appropriate cutoff scores for men and women. despite these limitations, this is the first study that has evaluated the factor structure of the cudit-r separately for men and women. this study makes a significant contribution through the evaluation of this screening tool across genders, which could have clinical implications for the identification of problematic cannabis use and cud. with recent legislative changes in cannabis legalization as well as increased prevalence of cannabis use, identifying problematic use will be imperative. references adamson, s.j. & sellman, j.d. 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(2002). evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes (vol. 30). los angeles: university of california, los angeles. doi: 10.1.1.310.3956 funding and acknowledgements: the writing of this paper was supported by the national institute on drug abuse (r01 da040880, mpis: jackson and white). alex w. sokolovsky is funded by the national institute on drug abuse (t32 da016184, pi: rohsenow). points of view in this document are those of the authors and do not necessarily represent the official position or policies of the national institutes of health. the funding sources had no role in the analysis or interpretation of the data, the preparation of this manuscript, or the decision to submit the manuscript for publication. copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. http://monitoringthefuture.org/pubs.html%23monographs http://monitoringthefuture.org/pubs.html%23monographs https://creativecommons.org/licenses/by/4.0/ research article 1 abstract trends toward the legalization of cannabis are raising concerns about driving under the influence of cannabis (duic). the goal of this study was to examine the percentage of cannabis users who believe duic is safe, who drive within one hour of using cannabis, and who have experienced a duic-related incident (i.e., ticket/accident). we further sought to compare these percentages in exclusively medical versus exclusively recreational versus mixed cannabis users and in participants surveyed before versus after legal sales of recreational cannabis. finally, we examined predictors of duic beliefs, practices, and incidents. an anonymous online survey was administered to cannabis users across the 50 united states (n=1773; 54% male) to assess duic beliefs, practices, and incidents. 52.4% reported believing duic is safe, 52.1% admitted to driving within one hour of using cannabis, but only 3.9% reported experiencing a duic-related incident. no significant differences were found in exclusively medical, exclusively recreational, and mixed cannabis users or in wa respondents surveyed beforeand after-legal sales in wa state. older age, less education, higher frequency and quantities of use, and driving within one hour of use predicted beliefs duic is safe. younger age, more education, higher frequency and quantities of use, younger age of first use, and beliefs duic is safe predicted driving within one hour of using cannabis. male gender, lower income, and higher frequency of use predicted duic-related incidents. rates of duic are high among cannabis users but self-reported accidents/tickets are low. recreational cannabis sales do not appear to be exacerbating these rates. key words: driving; driving under the influence; recreational cannabis; medical cannabis; recreational cannabis legalization cannabis use is presently at an all-time high in the united states (u.s.), with 44% of americans admitting that they have tried cannabis and 11% reporting current cannabis use (gallup, 2015). trends toward the legalization of cannabis for recreational purposes are not only increasing the availability of cannabis but they are also decreasing stigma and perceptions of risks (okaneku, et al., 2015; palamer, 2014). as such, fears are being expressed that increased rates of cannabis use combined with decreased perceptions of risks will exacerbate rates of driving under the influence of cannabis (duic), which may in turn pose a public health threat. results of experimental research on the acute effects of cannabis on psychomotor and cognitive cannabis 2018, volume 1 (2), 1-13 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.001 open access driving under the influence of cannabis: an examination of driving beliefs and practices of medical and recreational cannabis users across the united states corresponding author: carrie cuttler, department of psychology, washington state university, p.o. box 644820, pullman, wa, 99164-4820, u.s.a., email: carrie.cuttler@wsu.edu carrie cuttler*1, michelle sexton*2, laurie k. mischley3 *co-first authors 1 department of psychology, washington state university, pullman, wa, usa 2 university of california san diego, san diego, ca, usa 3 bastyr university research institute, seattle, wa, usa http://dx.doi.org/10.26828/cannabis.2018.02.001 driving under the influence of cannabis 2 test performance justify fears that duic may represent a public health threat. as reviewed by ramaekers, berghaus, van laar, and drummer (2004), the results of numerous experimental studies have generally revealed dose dependent reductions in performance on tests of memory, divided attention, sustained attention, reaction time, tracking, and motor control. this review also describes a meta-analysis (berghaus, schultz, & szegedi, 1998) that indicated that the percentage of psychomotor tests impaired by thc was highest during the first hour after smoking and sharply declined to zero 3-4 hours after use. moreover, dose dependent effects were detected with higher doses of thc increasing the percentage of tests impaired and increasing the duration of impairments. of course, one limitation of these experimental studies is that the degree to which impairments on these laboratory tests of psychomotor and cognitive abilities translates to actual driving ability is largely unknown. indeed, many of these tests are far more simplistic than driving, which requires a much more complex integration of these skills. recent research (hartman et al., 2016) utilizing a state-of-the-art full-motion driving simulator and vaporized cannabis found that higher levels of tetrahydrocannabinol (thc) were significantly associated with decreased speed and increased headway (i.e. distance) behind a lead vehicle. these results are consistent with the findings of other driving simulator studies, which showed significant decreases in speed (anderson et al., 2010; leené et al., 2010; ronen et al., 2008; ronen et al., 2010) increased headway (leené et al., 2010), and refusal of more opportunities to pass (ramaekers et al., 2004) under the influence of inhaled cannabis or thc, relative to placebo. previous researchers have interpreted these findings to suggest that slower speed and increased headway allow drivers more time to react to changes (hartman et al., 2016), which may be important in light of evidence that reaction time (e.g. leené et al., 2010; ronan et al., 2008) and lateral positive variability (ramaekers et al., 2004) shows significant increases during cannabis intoxication. moreover, findings of increased caution when duic are commonly interpreted to reflect awareness of impairment and attempts to compensate (anderson et al., 2010; hartman et al., 2016; leené et al., 2010; ronen et al., 2010). research quantifying levels of thc and its metabolites in drivers involved in traffic accidents has also been heavily relied upon to assess the extent of the duic problem and to infer risks associated with duic. reviews of this literature have generally converged on the notion that accidents are roughly doubled in those with thc detected in their systems (asbridge, et al., 2012; hartman & huestis, 2013; li et al., 2011). however, there is substantial variability in these results, with a recent controlled meta-analysis suggesting that accident risk in those with thc in their system is substantially lower (odd ratio [or] = 1.36; rogeberg & elvik, 2016). of greater concern, this research is confounded by the fact that thc and its metabolites can be detected in the bodily fluids of regular cannabis users after a month or more of abstinence (bergamaschi et al., 2013; kapur, 1994; karschner et al., 2015). as such, these estimates would include individuals who used cannabis regularly and/or recently but who were not acutely intoxicated at the time of the accident. therefore, risks of duic may actually be higher than these studies would suggest (gjerd & mørland, 2016). another problem with inferring risks of duic in this manner is that most drivers with thc detected in their system, test positive for alcohol or other drugs (hoff, 2016; rogeberg & elvik, 2016). these problems are further muddied by the current lack of any standardized, valid, and reliable assay/instrument for detecting acute cannabis intoxication. these impediments hinder the ability to determine whether drivers who test positive for thc are intoxicated by cannabis at the time of the accident (acmd, 2000) and obscure our understanding of the magnitude of the duic problem. given the barriers to detecting acute cannabis intoxication, it is important to explore complementary methods of examining the issue of duic. one avenue of research that is less developed is the examination of cannabis users’ perceptions of the effects of cannabis on driving ability and their self-reports of duic, which may help shed light on the degree of the problem at hand. that is, if acute cannabis intoxication significantly increases the risk of accidents, but only a small proportion of cannabis users engage in this behavior, the public health risk would seem less concerning. in contrast, if a large proportion of cannabis users admit to duic then the cannabis, a publication of the research society on marijuana 3 importance of understanding the risks of duic would be underscored. only a few studies have examined cannabis users’ perceptions of the effects of cannabis on driving ability. specifically, aitken and colleagues (2000) found that a small group of australian cannabis users unanimously perceived cannabis to be very safe for driving; while lenné and colleagues (2001) found that 57% of australian cannabis users reported that duic does not increase their accident risk. similarly, a study conducted in england found that 58% of regular cannabis users believed cannabis only slightly impairs their driving ability (terry & wright, 2005). collectively, these results indicate that the majority of cannabis users do not believe that cannabis significantly impairs their driving ability. consistent with these findings, previous research has revealed that 90% of australian cannabis users (reilly et al., 1998) and 82% of english cannabis users (terry & wright, 2005) reported duic at least once in their lives. moreover, 28.5% of australian users (jones et al., 2003), 23% of canadian cannabis users (walsh & mann, 1999), and 9.7% of cannabis users from spain (alverez et al., 2007) reported duic in the past year. to our knowledge only two studies of self-reported duic have been conducted in the u.s. the first found that approximately 50% of a small sample of young adult (18-21 yrs.) cannabis users reported duic (johnson & white, 1989). a more recent study found that 43.6% of a large sample of cannabis users from colorado and washington (wa) state reported duic in the past year, and 23.9% reported driving within one hour of using cannabis at least five times in the past month (davis et al., 2016). these results suggest that duic is common among regular cannabis users; however, rates appear to vary somewhat across countries. in summary, a limited body of research indicates that a substantial proportion of cannabis users believe that duic is safe and engage in the practice. however, this research has largely been conducted outside of the u.s. or in small samples of young adults, and we are aware of only one study that has focused on a broader u.s. sample. moreover, to our knowledge no research has been conducted to compare the driving beliefs and practices of exclusively recreational vs. exclusively medical vs. nonexclusive medical/recreational cannabis users or to compare driving beliefs and practices before and after recreational marijuana stores opened their doors to the public. exploring the impact of the legal sales of recreational cannabis on duic perceptions and practices may help address growing concerns about the influence of the new legal cannabis market on rates of duic. further, information on the characteristics that predict duic beliefs and practices will help identify those at greatest risk, thereby aiding in targeting campaigns against duic. therefore, the aims of the present study were to: i) examine the percentage of cannabis users in the u.s. who believe that duic is safe, who report driving within one hour of using cannabis, and who report having been in an accident or receiving a ticket when duic, ii) compare these percentages in exclusively medical vs. exclusively recreational vs. non-exclusive medical/ recreational cannabis users, iii) explore whether these beliefs and practices differ in residents of wa state surveyed before and after recreational cannabis became commercially available for legal purchase, and iv) determine which demographic characteristics, cannabis use patterns, and beliefs/practices predict duic beliefs, practices, and incidents. method participants participants were recruited via word-of-mouth and links on advertisements posted on various websites and in wa state cannabis dispensaries. a total of 1773 participants who had used cannabis in the past 90 days, were 16 years of age or older, and resided in the u.s. completed the survey. there were respondents from all 50 states but a disproportionate percentage of respondents (22.4%) resided in wa state (where the survey was housed). table 1 displays the complete demographic characteristics of the sample. procedures bastyr university’s institutional review board approved the study. as part of a larger anonymous online survey designed to assess cannabis use patterns, beliefs, and effects, participants answered the question described in driving under the influence of cannabis 4 table 1. sample characteristics gender n = 1759 male female 54% (n = 950) 46% (n = 809) age n = 1773 m = 34.23 (sd =13.18) race/ethnicity n = 1758 caucasian african american hispanic native american asian/pacific islander other 87.7% (n = 1541) 1.0% (n = 18) 3.4% (n = 60) 1.5% (n = 26) 1.6% (n = 28) 4.8% (n = 85) highest level of education n = 1769 < high school high school/ged technical school associate bachelors masters doctorate 2.3% (n = 40) 29.5% (n = 522) 9.3% (n = 164) 16.1% (n = 285) 29.3% (n = 518) 9.0% (n = 159) 4.6% (n = 81) current employment n = 1759 full time part time unemployed retired disabled 52.8% (n = 928) 21.7% (n = 382) 12.3% (n = 216) 3.9% (n = 68) 9.4% (n = 165) income: last 12 months n = 1756 <$20,000 $20-40,000 $40-60,000 $60-80,000 $80-100,000 $100-150,000 >$150,000 21.0% (n = 364) 24.0% (n = 416) 17.4% (n = 301) 10.8% (n = 188) 9.6% (n = 166) 9.6% (n = 166) 7.6% (n = 132) relationship status n = 1767 married domestic partnership divorced single other 32.8% (n = 579) 12.8% (n = 230) 5.5% (n = 98) 42.4% (n = 749) 6.5% (n =114) cannabis use purpose n = 1767 exclusively recreational exclusively medical recreational & medical exclusively religious 37.6% (n = 664) 30.6% (n = 541) 31.5% (n = 557) 0.3% (n = 5) cannabis use frequency n = 1770 < 2 times per year 1 time every 4-6 months 1 time every 2-3 months 1 time per month 2-3 times per month 1-3 times per week 3-6 times per week 1-4 times per day 5-10 times per day all day, every day 1.2% (n = 22) 1.1% (n = 19) 1.9% (n = 34) 2.0% (n = 36) 4.8% (n = 85) 10.6% (n = 187) 14.8% (n = 262) 42.4% (n = 751) 12.5% (n = 221) 8.6% (n = 153) quantity used per week n = 1760 <1 gram 1-2 grams 3-5 grams 6-7 grams 1 ounce more than 1 ounce 20.7% (n = 365) 22.3% (n = 393) 30.3% (n = 533) 20.4% (n = 359) 4.1% (n = 73) 2.1% (n = 37) age of first use n = 1770 <10 11-13 14-16 17-18 19-20 21-25 26-30 31-35 35-40 over 40 1.5% (n = 26) 13.3% (n = 236) 36.7% (n = 649) 23.3% (n = 413) 11.1% (n = 197) 8.8% (n = 155) 2.6% (n = 46) 1.0% (n = 17) 0.6% (n = 10) 1.2% (n = 21) cannabis, a publication of the research society on marijuana 5 the measures section. participants were not compensated. measures demographics. participants were asked to input their age, country, and state/province of residence. only respondents residing in the u.s. were considered. participants were also asked to indicate their gender, ethnicity, employment, relationship, education, and family income. cannabis use patterns. participants were asked to indicate whether or not they used cannabis for recreational, medicinal, and/or religious purposes. they were also asked to indicate the frequency they use cannabis, the quantity of cannabis used per week, and their age when they first tried cannabis. duic beliefs, practices, and incidents. to assess duic beliefs, participants were asked whether or not they believe cannabis impairs their ability to drive safely. to assess duic practices, participants were asked whether they drive within one hour of using cannabis. finally, to assess duic-related incidents, participants were asked whether they had ever been in an accident, or received a ticket, while duic. all responses were dichotomized into yes/no [1/0] responses. data analysis the percentages of participants who reported believing duic is safe, who reported driving within one hour of using cannabis, and who reported having a duic-related incident were computed. chi-square tests were used to compare these percentages among exclusively medical cannabis users, exclusively recreation cannabis users, and non-exclusive medical/recreational cannabis users. additional chi-square tests were used to compare wa state respondents’ duic beliefs, practices, and incidents preand postlegal sales. wa state residents were selected because only one respondent resided in alaska, only six colorado residents completed the survey prior to legal sales, and no oregon residents completed the survey after recreational cannabis became available for purchase. a series of logistic regression analyses were used to determine which demographic characteristics, cannabis use patterns, and duic beliefs, practices and incidents, predicted duic-related beliefs, practices, and incidents. results overall results a total of 52.4% of the sample indicated that cannabis does not impair their ability to drive safely. consistent with this perception, 52.1% of participants indicated that they drive within one hour of using cannabis. however, only 3.9% of participants reported that they had received a ticket or been in an accident while duic. interestingly, 29.6% of the participants who reported believing that cannabis impairs their ability to drive safely, also reported that they drive within one hour of using cannabis. medical vs. recreational vs. non-exclusive medical/recreational users to compare medical cannabis users, recreational cannabis users, and mixed recreational/medical cannabis users’ duic beliefs, practices, and incidents, participants who reported using cannabis for exclusively recreational purposes (n = 664; 37.6%), for exclusively medical purposes (n = 541; 30.6%), or for both medical and recreational purposes (n = 557; 31.5%), were selected. respondents (n = 5; 0.3%) who reported use for religious purposes were excluded from these analyses. as depicted in figure 1, there were no significant differences in the percentages of exclusively medical, exclusively recreational, and non-exclusive medical/recreational cannabis users’ beliefs about the safety of duic, χ2(2) = 5.12, p = .08, practices of driving within one hour of using cannabis, χ2(2) = 2.66, p = .26, or in their self-reported accidents/tickets when duic, χ2(2) = 1.04, p = .59. preand post-legal sales of recreational cannabis to explore potential impacts of the legal sales of recreational cannabis on duic beliefs, practices, and incidents, participants who indicated residing in wa were selected (n = 398). those who completed the survey before the first recreational cannabis store opened in wa state driving under the influence of cannabis 6 figure 1. comparisons of exclusively medical, exclusively recreational, and non-exclusive medical/recreational cannabis users’ duic-related beliefs, practices, and incidents. no significant differences were found across groups. figure 2. comparisons of duic-related beliefs, practices, and incidents before and after legal sales of recreational cannabis in wa state. no significant differences were detected between groups. cannabis, a publication of the research society on marijuana 7 (11/4/2013 – 07/08/2014) were identified as prelegal sales respondents (n = 279), while those who completed the survey after this date (07/09/2014 – 12/15/2014) were identified as post-legal sales respondents (n = 119). as depicted in figure 2, there were no significant differences in the two groups’ beliefs about the safety of duic, χ2(1) = 2.76, p = .10, practices of driving within one hour of using cannabis, χ2(1) = 3.68, p = .055, or in their self-reported duic-related incidents, χ2(1) = 1.39, p = .24. however, there was a trend for a higher percentage of pre-legal sales respondents than post-legal sales respondents (44.4% vs. 35.3%; p = .055) to report driving within one hour of using cannabis. predictors of driving perceptions and practices as shown in table 2, logistic regression analysis revealed that older age, less education, higher frequency of cannabis use, higher quantity of cannabis use, and driving within one hour of use were significant predictors of beliefs that duic is safe. a second logistic regression analysis revealed that younger age, higher education, higher frequency of cannabis use, higher quantity of cannabis use, lower age of first use, and beliefs that duic is safe were significant predictors of driving within one hour of using cannabis (table 2). a final logistic regression analysis revealed that male gender, lower income, and higher frequency of use were significant predictors of duic-related incidents (table 2). discussion the results of this large-scale anonymous survey of cannabis users across the 50 united states indicate that over 50% of cannabis users report believing that duic is safe and over 50% admit to driving within one hour of using cannabis. these findings suggest that some ambiguity remains about the perceived safety of duic among cannabis users and underscores the need for additional research on the risks of duic and of disseminating the results of this research to the general population. it was somewhat surprising that 29.6% of the cannabis users who reported believing that cannabis impairs their ability to drive safely, also admitted that they drive within one hour of using cannabis. this indicates that a substantial proportion of cannabis users are duic despite their personal belief that this is not a safe practice. this suggests that there are other motivating factors at play (e.g., proneness to risk-taking behaviors) in the decision to duic. future research should further explore the reasons for why individuals report duic in order to assist in better targeting anti-duic campaigns and other interventions. results of the current study also suggest that self-reported accidents and tickets when duic are rather low (3.9%). this finding is remarkably consistent with johnson and white’s (1989) finding that 4% of young adults in the u.s. reported smoking cannabis before an accident. it is highly likely that these selfreported rates are lower than actual rates due to self-report bias (including a potential desire to try to decrease perceptions of harm associated with cannabis use and instances of memory failures) as well as by the fact that those who have been killed when duic would not be represented in our survey. also without knowledge of the percentage of time respondents drive sober versus under the influence of cannabis and their rates of accidents while sober versus intoxicated, it is not possible to interpret this statistic with respect to elevated risks associated with duic. therefore, future research should attempt to gather this information to better understand the potential risks of duic. nevertheless, the results suggest that a substantial proportion of cannabis users are duic without incident. the results of comparisons of exclusively medical, exclusively recreational, and nonexclusive medical/recreational cannabis users indicated no significant differences in duic beliefs, practices, and incidents. similarly, there were no significant differences in the beliefs, practices, and incidents of wa state residents surveyed before and after driving under the influence of cannabis 8 table 2. logistic regression analyses using demographic variables, cannabis use patterns, and duic beliefs, practices, and incidents to predict duic predict beliefs, practices and incidents note. r2 = nagelkerke r2, or = odds ratio, bolded values indicate p < .05 beliefs duic is safe drive within one hour duic-related incidents model statistics model statistics model statistics χ2 r2 p χ2 r2 p χ2 r2 p 407.47 .29 < .001 499.69 .35 < .001 39.43 .08 < .001 predictors predictor statistics predictor statistics predictor statistics wald χ2 or p wald χ2 or p wald χ2 or p age 16.77 1.02 < .001 20.92 0.98 < .001 0.65 1.01 .42 gender (f=0; m=1) 1.41 1.15 .23 1.26 1.14 .26 8.53 2.31 .004 education 9.14 0.89 .002 16.91 1.18 .001 0.25 1.05 .62 income 0.18 0.99 .67 0.01 1.00 .93 4.13 0.86 .04 frequency of cannabis use 4.39 1.10 .04 21.10 1.26 < .001 4.20 1.31 .04 quantity of cannabis use 11.73 1.25 < .001 23.87 1.39 < .001 0.00 1.00 .99 age cannabis first used 2.02 0.95 .16 22.08 0.83 < .001 3.34 0.83 .07 beliefs duic safe ---------------185.26 2.24 < .001 0.62 0.89 .43 drive within one hour 186.40 5.04 < .001 ---------------3.35 1.76 .07 duic-related incident 0.44 0.82 .51 3.06 1.73 .08 --------------- cannabis, a publication of the research society on marijuana 9 recreational cannabis sales. the latter results are consistent with a recent study which utilized the u.s. fatality analysis reporting system and found that the changes in motor vehicle crash fatality rates since legalization for washington and colorado are comparable to those from similar states that have not legalized recreational marijuana (aydelotte et al., 2017). however, it is important to note that the survey data utilized for the present study do not extend beyond december, 2014 (5 months after legal sales commenced in wa). given that beliefs, practices, and incidents may take more time to change, it is important that future research continue to monitor the potential impacts of legal sales of recreational cannabis on attitudes, practices, and incidents related to duic. although not statistically significant in the reduced sample, there was a 9.1% decline in the percentage of people reporting that they believe duic is safe and a 10.6% decrease in the percentage of people reporting driving within one hour of using cannabis after recreational cannabis became legally available for purchase. it is possible that changes in legislation may be increasing awareness of cannabis policies in the general public, increasing concerns about enforcement of drugged driving, and/or that labeling of recreational cannabis may be having its intended effects. for instance, all recreational cannabis sold in wa state must contain a label with the following message, “marijuana can impair concentration, coordination, and judgment. do not operate a vehicle or machinery under the influence of this drug" (washington state legislature, title 314, chapter 55-105). such messages may be helping to deter people from duic. regardless, preliminary results of the present study are encouraging and indicate that the legalization of recreational cannabis may not be intensifying rates of duic. nevertheless, it will be important for future more controlled research to verify these findings, extend them to other states preparing to legalize recreational cannabis, and continue to examine changes across longer periods of time. the logistic regression analysis used to examine predictors of beliefs that duic is safe revealed that participants’ age, education, frequency of cannabis use, quantity of use, and driving within one hour of using cannabis are significant predictors, with admitting to driving within one hour of using cannabis emerging as the strongest predictor of these beliefs. the odds ratio associated with participants’ age, frequency, and quantity of use indicate that as these variables increase so do the chances that the individual will report believing that duic is safe. these findings appear to indicate that older, more experienced cannabis users are more likely to believe that duic is safe. it is possible that those who frequently use high quantities of cannabis are motivated to endorse such beliefs in order to justify the potential necessity of combining the routine behaviors of using cannabis and driving. while research examining motivations for duic and how these vary as a function of age and cannabis use history is needed to fully understand these results, it is also possible that older more experienced users perceive cannabis to be more benign as they have grown more accustomed to its effects. however, it is important to note that recent research suggests that there are no tolerance effects to the acute administration of thc and even regular users are adversely affected by the psychomotor effects of thc (ramaekers et al., 2016). as such, it will be important to identify, and if necessary correct, cannabis users’ beliefs about tolerance effects and the safety of duic. the odds ratios generated from the logistic regression analysis used to predict driving within one hour of using cannabis, indicate that younger age, higher education, higher frequency of use, higher quantity of use, lower age of first use, and beliefs that duic is safe predict driving within one hour of using driving under the influence of cannabis 10 cannabis. given that beliefs that duic is safe was the strongest predictor of driving within one hour of using cannabis, it is somewhat unclear why younger age and higher education predicted driving within one hour of using cannabis despite the finding that older age and lower education predicted beliefs that duic is safe. one possible explanation is that younger individuals may be more likely to engage in known risks. in other words, while it appears that older individuals are more likely to believe that duic is safe, they may be more cautious in their actual behavior. the results of the regression analysis used to predict self-reported tickets/accidents when duic revealed that gender, income, and frequency of cannabis use, were significant predictors. the odds ratio for frequency of use indicates that those who use cannabis more frequently are more likely to report receiving a ticket or being in an accident when duic. the odds ratio for income indicate that lower income is associated with reporting a duicrelated incident. finally, gender showed the strongest relationship, with the odds ratio indicating that men are 2.31 times more likely to report a duic-related incident. there are numerous hurdles to examining the issue of duic. as previously described, these include the lack of any valid and reliable index of acute cannabis intoxication, the confounding effects of polysubstance use, and individual differences in drug metabolism and tolerance that can vary as a function of the frequency, quantity, and duration of cannabis use. the present study is also limited by several factors, including potential self-report bias, which may include underreporting of duic-related incidents, desire to decrease perceptions of harm associated with cannabis use, failure to disclose driving within one hour of using cannabis, and instances of memory failure. however, the anonymous nature of the survey should have diminished these biases. other limitations include self-selection bias associated with the use of a convenience sample, lack of ethnic diversity in the sample, and the sample’s heavy use of cannabis (over 50% were daily users and used more than 3 grams per week). given that frequency and quantity of use predicted duic beliefs and practices, these sample characteristics may have inflated the reported percentages. nevertheless, while data from the present study may not reflect the general population, they do capture the beliefs and practices of the population most relevant to the discussion about duic and public health (i.e., frequent cannabis users). moreover, the large sized sample increases confidence in the generalizability of the results to similar populations of cannabis users across the u.s. and helps to increase confidence in the veracity of the findings. finally, it is important to note that the cross-sectional nature of the survey prohibits the ability to arrive at causal conclusions. as such the predictors identified in the logistic regression analyses should not be considered causal agents in duic-related beliefs, practices, and incidents. nevertheless, identification of these predictors may help to guide future campaigns against duic. similarly, while the results from the present study failed to garner any evidence for concerns that the legal sales of recreational cannabis would exacerbate the duic problem, the causal role of this new legal market cannot be definitively determined using the present cross-sectional design. rather, results from the present study merely provide encouraging preliminary evidence that the legal sales of recreational cannabis do not appear to be associated with immediate changes in duic-related beliefs, practices, and incidents. once again, these results should be used to encourage future, more controlled, longitudinal investigations into the impact of changing cannabis laws on the duic problem. 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(1999). on the high road: driving under the influence of cannabis in ontario. canadian journal of public health, 90, 260-263. cannabis, a publication of the research society on marijuana 13 washington state legislature, title 314, chapter 55-105. retrieved from: http://apps.leg.wa.gov/wac/default.aspx?cite= 314-55-105 copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 135 abstract research on cannabis users has the potential to suffer from volunteer bias. the sensitive nature of substance use might play an influential role in studies investigating cannabis consumption, particularly in the emerging adult population. the present study examined cannabis use and willingness to participate in cannabis-related research in emerging adults. undergraduates enrolled in a psychology course (n = 262) reported frequency of use and willingness to participate in hypothetical research studies on cannabis that varied in type and compensation. logistic regression analyses revealed that women were more likely to participate in a survey for a prize, and both women and non-cannabis users were less likely to participate in a lab study for science. in addition, those who used cannabis less frequently were less willing to participate in an ingestion study for science and an ingestion study for pay. these findings reveal important trends exist in potential participation for cannabis-related research in the emerging adult population, specifically around gender and cannabis use. the results suggest cautious interpretation for the generalizability of studies on cannabis in undergraduate students. most work might be free of bias but the results of laboratory administration of cannabis might prove difficult to generalize to women and infrequent users of cannabis. key words: cannabis, participation bias, emerging adults, gender differences, research participation representative samples are essential to generalizable research, but recruitment practices, perception of risk, and incentives might create participation bias. biased participation patterns generate concern for several sensitive research areas, including substance use. due to the illicit nature of many substances, coupled with the social taboo around use and addiction, several barriers might inhibit individuals from volunteering for research. numerous factors impact participation in substance use studies, including current user status, history of use, study location site, perceived risk, race, age, informed consent, psychopathology, and gender (bandyopadhyay, desantis, korte, & brady, 2011; brown & topcu, 2003; carter & hall, 2013; mariani, haney, hart, vosburg, & levin, 2009; orsi, chapman, & edwards, 2010; potter et al., 2011; ray et al., 2011; rojas, sherrit, harris, & knight, 2008; strickland & stoops, 2015). motivation to participate in sensitive psychological research might vary across potential participants, which can contribute to sample characteristics and generalizability. cannabis 2019, volume 2 (2), 135-143 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2019.02.003 open access who volunteers for cannabis research? examining potential research participation in cannabis research among emerging adults corresponding author: maha n. mian, department of psychology, university at albany, state university of new york, 1400 washington ave., albany, ny 12222, email: mmian@albany.edu maha n. mian1, brianna. r. altman1, mitch earleywine1 1 department of psychology, university at albany, state university of new york, albany, ny, usa volunteering for cannabis research 136 studies likely entice individuals who find the research insightful and useful (fry & dwyer, 2001; hasking, tatnell, & martin, 2015). the compensation for participation can also motivate individuals to partake in research, particularly if the study tasks are burdensome or highly sensitive (frankel & sharp, 1981; holland, ritchie, & du bois, 2015; ulrich, wallen, feister, & grady, 2005). while providing monetary incentives for substance-using individuals has inspired heated debate, these incentives are often necessary to attract, retain, and fairly compensate participants (pollastri, pokrywa, walsh, kranzler, & gelernter, 2005; slomka, mccurdy, ratliff, timpson, & williams, 2007; van horn et al., 2011; wilcox, bogenschutz, nakazawa, & woody, 2012). perceptions of research burden, risks, benefits, and the drug of interest can influence participation rates and variability (strickland & stoops, 2015). additionally, participation might vary with procedures. potential disclosure of sensitive personal information alters volunteering among college students (rosenbaum, rabenhorst, reddy, fleming, & howells, 2006). the perception of risk associated with data collection might also influence an individual’s decision (coors & raymond, 2009; ray et al., 2011). surveys are common in psychological research. they can provide anonymity to a large sample; however, concerns around consent and representativeness remain (buchanan & hvizdak, 2009; groves, cialdini, & couper, 1992). in contrast, clinical research might require more risk and engagement. those who seek treatment are more likely to engage in intervention studies, depending upon the drug of interest (souleymanov et al., 2016; strickland & stoops, 2015; thrul, stemmler, goecke, & bühler, 2015; uhlmann et al., 2015). bias likely stems from sampling procedures that systematically target some people but not others. the historical lack of racial, socioeconomic, and geographic representation in psychological research remains troublesome (george, duran, & norris, 2014; hussaingambles, atkin, & leese, 2004; miranda, nakamura, & bernal, 2003). the exclusion of certain individuals leaves researchers, and the public, poorly informed on the prevalence of clinical problems and efficacy of treatments. limited range of research sites coupled with the ease of convenience sampling has led many researchers to draw from undergraduate populations in a university setting. this practice has facilitated a surge of findings, particularly for a population considered to be vulnerable to drug problems (arnett, 2008; hanel & vione, 2016; knight et al., 2002; o’malley & johnston, 2002). nevertheless, few studies examine patterns of participation in emerging adults, particularly in the cannabis literature. the objective of this study was to examine willingness to participate in hypothetical research studies on cannabis, differing in methodology and incentive. clinical intuitions and previous work generated exploratory hypotheses that gender, cannabis use, and the demands of the study would contribute to willingness to participate in research on the plant. method participants students in an undergraduate-level psychology course at a public university in the northeast (n = 262) provided data by anonymously opting-in to a brief web-based survey. preliminary analyses provided demographic information on the participating sample (median = 18-22 years old, 71.4% female). survey administration questions appeared on kahoot!™, an online platform that allows users to create custom quizzes. each quiz has a unique sign-in code where invited participants may use a personal electronic device, such as a smartphone, tablet, or laptop, to enter the code once they have accessed the online site. participants may provide a temporary non-identifying username in the quiz, and following each question, responses are aggregated. for this survey, all questions had up to four multiple choice options, and each question was timed for one minute, at which point responses for the question were closed. all procedures were in accordance with and approved by the local institutional review board. cannabis, a publication of the research society on marijuana 137 cannabis use participants reported cannabis use with three items: lifetime use (“how many days in your life have you used cannabis?”), past year use (“how often in the last 365 days have you used cannabis?”), and weekly use (“how many days per week did you use cannabis in the last year?”). response options for lifetime use were: 0, less than 10,11-50 and over 50 for lifetime use; for past year use: once a week, 2-3 times per month, about once a month, and less than once a month,; and for weekly use: 1-2, 3-4, 5-6, and every day. for yearly and weekly use, participants learned to leave the response blank to indicate “no use.” potential research participation measures participants viewed six unique hypothetical research opportunities, varying in type (online survey, laboratory experiment, or thc ingestion), and compensation (a prize, pay, or no compensation/simply for helping science), and provided a binary choice as to whether they would be willing to participate in such a study or not (“yes” or “no”) (table 1). table 1. potential research participation measures. would you complete a 30 min online survey about cannabis for a chance at a prize? would you complete a 30 min online survey about cannabis simply to help science? would you come to a lab to spend 1 hour on a cannabis lab experiment to help science (no thc)? would you come to a lab to spend 1 hour on a cannabis lab experiment for pay (no thc)? would you ingest thc in a lab experiment to help science? would you ingest thc in a lab experiment to for pay? data analysis descriptive analyses revealed details on demographics, and cannabis use measures. cannabis use items were consolidated into a single use variable (no use, less than once a month, 1-2 times a week, 3-4 times a week, 5-6 times a week, and everyday use). we regressed willingness to participate in each type of research on gender and cannabis measures. due to the low sample size for one subpopulation of the model for willingness to come into the lab for pay, we performed a chi-square analysis to examine the association of participation with gender and cannabis use. results demographics participants could report age through one of four items (“younger than 18 years old,” “18-22 years old,” “23 years and older,” or “rather not say.”) in this sample, (n = 262), over 90% participants reported an age between 18-22, followed by around 7% reporting 23 or older, less than 1% under 18, with the remaining sample not disclosing; the majority of sample participants identified as female (median = 18-22 years old, 71.4% female). cannabis use we found that 29.7% of participants reported using cannabis 1-2 times a week, followed by 20.3% reporting everyday use, 14.4% reporting less than once a month use, 13.4% reporting 3-4 times a week, and 7.9% reporting 5-6 times a week, while the remaining participants reported no use in their lifetime (14.4%). among women, the modal response for use was 1-2 times a week (35.6%), while the modal response for men was daily use (30.2%) (table 2). table 2. cannabis use in male and female undergraduates (percentage). cannabis use male female 0 15.1 27.8 less than once a month 7.5 16.8 1-2/week 13.2 35.6 3-4/week 15.1 12.8 5-6/week 18.9 4.0 daily 30.2 16.8 volunteering for cannabis research 138 table 3. logistic regression analysis of cannabis use from gender. < 1/week 1-2/week 3-4/week 5-6/week daily β se or [ci] β se or [ci] β se or [ci] β se or [ci] β se or [ci] constant -.69 .61 -.13 .52 .00 .50 .22 .47 -.69 .43 gender -.87 .68 2.38 [.639.03] 1.06 .58 2.88 [.938.96] -.10 .59 .91 [.282.89] -1.48 .66 .23 [.06.84]* .52 .53 .60 [.211.66] note. reference category=no use. gender coded as -1 for female, and 1 for male. β = unstandardized regression coeffiicent, se = standard errors of regression coefficients, or = odds ratio , ci = confidence interval for odds ratios, * p < .05. a logistical regression analysis was performed to examine gender and cannabis use. overall, use was predicted by gender (χ2 (5, n = 202) = 23.023, p < .001). females were only .60 times as likely to report use 5-6 times a week. nagelkerke’s r2 of .111, and cox and snell’s r2 of .108 indicated a small relationship between gender and use. the full set of analyses appears in table 3. potential research participation logistic regressions addressed the role of cannabis use and gender in predicting research participation. survey for prize. a test of the model for willingness to complete a survey for a prize was significant (2 (6, n = 201)=13.880 p < .05). willingness to participate in a survey for a prize was significantly predicted by gender, with women 4.19 times more likely to participate (2 (1, n = 201) = 7.330, p < .01). nagelkerke’s r2 of .137, and cox and snell’s r2 of .067 indicated a small relation between the predictor and willingness to participate, and overall classification accuracy at 89.6%. lab for science. a test of the model for willingness to come into the lab for science was significant (2 (6, n = 201) = 21.731 p < .01). both gender (2 (1, n = 201) = 5.884 p < .05) and use (2 (5, n = 201) = 11.345 p < .05) were predictive of willingness to participate in a lab study to contribute for science, with women only .42 times as likely to participate. daily users were 3.53 times more likely to participate in this kind of study, as were those who used cannabis 3-4 times a week and 5-6 times a week (3.94 and 4.55 times more likely, respectively). nagelkerke’s r2 of .137, and cox and snell’s r2 of .102 indicated a small relation between predictors and willingness to participate, and overall classification accuracy at 65.2%. ingest for science. a test of the model for willingness to ingest cannabis for science was significant (2 (6, n = 202) = 71.965, p < .001). cannabis use was a significant predictor (2 (5, n = 202) = 65.969 p < .001), with all users more likely to participate, including daily users who were 76.57 times more likely to participate in such a study. nagelkerke’s r2 of .426, and cox and snell’s r2 of .300 indicated a moderate relation between the predictor and willingness to participate, and overall classification accuracy at 80.2%. ingest for pay. a test of the model for willingness to ingest cannabis for pay was significant (2 (6, n = 198) = 51.497, p < .001). cannabis use was a significant predictor (2 (5, n = 198) = 61.389, p < .001), with daily users 53.05 times more willing to ingest cannabis for pay. individuals using cannabis 1-2 times a week, 3-4 times a week and 5-6 times a week were also all more likely to participate in this study (11.67, 34.86, 18.54 times more likely, respectively). nagelkerke’s r2 of .367, and cox and snell’s r2 of .229 indicated a moderate relation ship between the predictor and willingness to participate, and overall classification accuracy at 82.8%. lab for pay. due to the low cell size, the model was unable to compute betas for specific levels of each predictor. a chi square test for independence revealed a significant relation between cannabis use and willingness to ingest cannabis for pay, (2 (5, n = 198) = 54.234 p < .001, cramer’s v = .523). neither gender nor use altered willingness to participate in a survey for science, with none of cannabis, a publication of the research society on marijuana 139 the predictors reaching statistical significance. the full set of analyses appear in table 4. table 4. logistic regression analysis of willingness to participate in research from cannabis use and gender survey for prize lab for science β se or [ci] β se or [ci] constant .93 .62 -.37 .48 cannabis use < 1 month -.75 .75 .47 [.11 – 2.04] 030 .59 1.35 [.43 – 4.30] 1-2/week .56 .78 1.76 [.38 – 8.02] .68 .51 1.97 [.73 – 5.33] 3-4/week -.03 .79 .97 [.21 – 4.59] 1.37 .58 3.94 [1.26 – 12.33] 5-6/week 1.43 1.20 4.18 [.40 – 43.56] 1.51 .70 4.55 [1.16 – 17.85] daily 1.40 .93 4.05 [.66 – 24.90] 1.26 .53 3.53 [1.24 – 10.01]** gender 1.43 .53 4.19 [1.50 – 11.75]** -.86 .36 .42 [.21 – .85]* ingest for science ingest for pay β se or [ci] β se or [ci] constant -.74 -.42 1.09 cannabis use < 1 month 1.31 .61 3.69 [1.11 – 12.30]* .47 .54 1.60 [.56 – 4.61] 1-2/week 2.56 .58 12.99 [4.21 – 40.06]*** 2.46 .58 11.67 [3.74 – 36.43]*** 3-4/week 3.96 .88 52.56 [9.36 – 295.07]*** 3.55 1.09 34.86 [4.13, 294.53]** 5-6/week 3.87 1.14 47.99 [5.15 – 447.35]** 2.92 1.13 18.54 [2.04 – 168.57]* daily 4.34 .87 76.57 [13.97 – 419.61] 3.97 1.09 53.05 [6.33 – 444.85*** gender -.90 .54 .41 [.14 – 1.17] .18 .530 1.20 [.42, 3.40} note. reference category=no use. gender coded as -1 for female, and 1 for male. β = unstandardized regression coeffiicent, se = standard errors of regression coefficients, or = odds ratio , ci = confidence interval for odds ratios, *p < .05, **p < .01, ***p < .001 discussion in an effort to identify if volunteer bias contributes to the generalizability of cannabis research on young adults, we looked at links among gender, cannabis use, and willingness to participate in varied studies and experiments. gender and frequency of cannabis use covaried. women were less likely to report using cannabis 5-6 times a week. in addition, women were more likely to participate in a survey study for a prize, though less likely to participate in a lab study for science. cannabis use was predictive of willingness to participate in an ingestion study both for science and for pay. specifically, those who used cannabis more frequently were more likely to participate in these studies. these results are consistent with previous literature on participation trends in substance use research. high risk users are more likely to participate in substance-use-related research more generally, and these new data extend the idea to cannabis research in particular (thrul et al., 2015; uhlmann et al., 2015). while other work has focused on monetary incentives as motivation for participation, the findings reported here suggest that users are just as willing to take part in risky research for scientific contribution rather than pay (fry & dwyer, 2001; pollastri et al., 2005; slomka et al., 2007; van horn et al., 2011; wilcox et al., 2012). future studies might benefit by emphasizing the altruistic and empowering aspects of drug research, which might mitigate ethical issues associated with monetary compensation (daley, 2015). substance users might also recognize the potential benefits of participating in research, contributing to willingness to participate without monetary compensation. such benefits include reduction of use, increased knowledge, higher self-esteem, validation, and other positive gains (daley, 2015; desantis, bandyopadhyay, back, & brady, 2009; tross et al., 2018). recruiting undergraduate samples might stem from convenience, but the volunteering for cannabis research 140 practice can potentially neglect higher risk individuals (billett, 2012). generalizing from student samples does not always yield an accurate representation of the wider public; the current work highlights the importance of understanding the emerging adult population as a distinct group of users (hanel & vione, 2016). in addition, those emerging adults who are willing to participate in cannabis research likely differ from those who are not. nevertheless, those who appear willing to volunteer appear more involved with cannabis. perhaps they are the population we are most interested in generalizing to. this study revealed important findings about potential gender differences in research participation. women are more likely to participate in survey-based research, but men are more likely to come into the lab. several possible factors might contribute to these results. participation in a lab study might appear riskier than survey work, and men are more likely to engage in risky behaviors (byrnes, miller, & schafer, 1999; harris, jenkins, & glaser, 2006; langhinrichsen-rohling, arata, o’brien, bowers, & klibert, 2006). additionally, women might be more hesitant to disclose substance use in a more public setting because of marginalization, existing social norms around substance use, or genderrelated pathologizing (salmon, browne, & pederson, 2010). recruitment of female participants may be more successful if discomfort can be reduced by targeting safe and known environments (cooper & tempalski, 2014). in this sample, female users had a higher prevalence of cannabis use 1-2 times a week compared to men, who endorsed daily use more often. this suggests that while both men and women do use cannabis, they differ in frequency. future studies should develop recruitment methods to accurately capture both male and female users, particularly if studies may be perceived as risky, in order to obtain a more representative sample. the present study had several limitations. given the nature of the survey tool, response options were limited to four multiple choice answers. while this tool was useful for quickly gathering data in this population anonymously, future survey work should provide participants with more nuanced choices, and the opportunity to elaborate on responses. the sample was drawn from an undergraduate course on addictive behaviors, which might attract individuals who are more likely to be users and who are more partial to drug research compared to a general psychology course. additionally, this study focused on willingness to participate in research, but did not examine the motivation behind participation interest or lack thereof. follow up studies should investigate attitudes and perceptions around research that might influence willingness to participate. finally, the current study presented participants with a survey of hypothetical scenarios; future work should utilize a diverse range of methods to examine 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(2012). compensation effects on clinical trial data collection in opioiddependent young adults. american journal of drug and alcohol abuse, 38(1), 81–86. https://doi.org/10.3109/00952990.2011.600393 funding: the author(s) received no specific funding for this work. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ microsoft word v3i1a1_final.docx research article 1 abstract cannabis consumption, already legal in several american states and other jurisdictions around the world, became legal in canada in october 2018. the present study examines the patterns of cannabis use in canada among those born between 1946 and 1964, the so-called “baby boom” generation. this study was undertaken in order to better understand the motivations or inhibitions of baby boomer with respect to cannabis use decisions, as well as to explore their opinions about the effects of cannabis use on their health and cognitive and physical well-being. a voluntary, anonymous on-line survey was circulated using social media and flyers. the survey questions were on general health, cannabis use and effects, and other drug consumption. one hundred and forty-two responses were collected from june 2016 to may 2017. a majority (87.6%) had used cannabis although 42.5% had not consumed it for over a year. most respondents first used cannabis in their teens (59%) or as young adults (38.4%). about 42% have continued to consume cannabis (daily (16.4%), weekly (20%), or monthly (5.5%). the majority of respondents (48.5%) were found to use cannabis for recreational purposes only, while 19.2% use it for both recreational and medicinal purposes, and 7.1% for assistance with their physical health. the most common conditions for which the respondents have used cannabis are pain (32.9%), sleeplessness (27.4%), and anxiety (24.7%). baby boomers report that they make conscious and informed decisions about their cannabis use, and for the majority, their use causes them no harms in their overall functioning, learning, or relationships. for some, cannabis provides a reduction in physical pain and sleeplessness, which improves their abilities to participate in activities that are important to them. more frequent users reported a higher rate of concerns with short-term memory, but overall, users reported their functioning was enhanced by their cannabis use. key words: cannabis, baby boomers, drug use, marijuana cannabis is the most commonly used illegal (note: legalization occurred october 2018 in canada) drug in canada and worldwide (canadian centre on substance abuse, 2017; haines-saah et al., 2014). despite its historically prohibited status, large numbers of canadians continue to consume it (osborne & fogel, 2008, p. 540). according to a 2005 health canada addiction survey, 45% of canadian adults have used cannabis at least once in their lifetime (adlaf, begin, & sawka, 2005). in 2013, the latest year for which government statistics are available, 8% of canadian adults aged 25+ reported using cannabis in the past year. british columbia, on canada’s west coast, has a past-year cannabis use prevalence (for ages 15 +) of 13.3%, significantly higher than the canadian average of cannabis 2020, volume 3 (1), 1-10 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.001 open access cannabis use and baby boomers: attitudes and patterns of consumption corresponding author: janet douglas, social service worker department, langara college, 100 west 49th avenue, vancouver, bc, v5y 2z6, canada, email: jdouglas@langara.ca janet douglas1, d. margo nelson2, paul s. sunga2, daryl j. smith3 1 social service worker department, langara college, vancouver, bc, canada 2 department of health sciences, langara college, vancouver, bc, canada 3 department of biology, langara college, vancouver, bc, canada cannabis use and baby boomers 2 11% (canadian centre on substance abuse, april 2016). “baby boomers” those born between 1946 and 1964 are a unique demographic with respect to the evolution of cannabis consumption in canada. people in this age group were children and teens during the 1960’s, a time in canada when more than half the population was under the age of 25 and youth culture was strongly influenced by the hippie movement. cannabis use was widespread, particularly on the west coast and in urban areas. social (if not legal) acceptance of cannabis consumption became a part of a culture that was permissive towards the drug (black & joseph, 2014). challenges to drug policies, debates in the scientific community over harm, a gradual relaxation of police enforcement for minor drug crimes in some jurisdictions (canadian centre on substance abuse, 2016; levasseur, marcoux, & kubinec, 2015) and, more recently, legislation to legalize cannabis use, have all happened as the baby boomer generation has proceeded through their adult lives. baby boomers are heading into their retirement years on the wave of cannabis legalization in canada. as attitudes towards cannabis use have become more tolerant, and access and availability to the drug increase, there has been a shift away from an association with deviant subcultures and a move towards normalization and acceptance of cannabis use as a lifestyle choice for many canadians (erickson, 1999; duff et al., 2012; osborne & fogel, 2008; parker, 2005). many baby boomers have carried over the pro-cannabis norms and values they adopted in their youth into their adulthood (black & joseph, 2014; salaswright et al., 2014). han et al. (2016) point out that the baby boomer generation differs significantly from previous cohorts with respect to attitudes toward substance use as well as substance use behaviours. at the political level, the federal liberal party of canada campaigned in 2015 on a platform that included the legalization of cannabis. legislation was introduced in the spring of 2017, and legalization occurred in october 2018. bergen-cico and cico (2012) point out that the likelihood of cannabis use in adults is associated with social norms surrounding cannabis use among particular birth cohorts. in turn, this is linked to higher prevalence of cannabis use by adults over the age of 50. while some baby boomers abandoned cannabis consumption in their youth, others continued to use it, and some resumed cannabis use in later years. similar patterns of lifetime use have been observed in the us, europe, and australia (bergen-cico & cico, 2017; kortaba, 2012). the percentage of older adults in the us who use cannabis has tripled in the period from 2003-2014, reflecting generational differences in experiences of and attitudes toward cannabis use (salas-wright et al., 2017). the degree to which cannabis consumption has become normalized in canada is the subject of some discussion (duff et al., 2012; lau et al., 2015). the acute effects of cannabis are well understood, while the mechanisms of effects through the endogenous cannabinoid system in humans have begun to be elucidated during the last decades. longer term impacts on physical and mental functioning, and as a risk factor for chronic disease and mental function, are less well understood, with a wide variety of studies showing a range of possible effects including cognitive deficits, lack of motivation, and psychosis (volkow, et al., 2016). the reversibility of these impacts is also controversial (filbey et al., 2014; jager, kahn, van den brink, van ree, & ramsey, 2006; szutorisz & hurd, 2016). the extent to which these may be a problem for older adults in particular is poorly understood, although very few older adults report cannabis abuse or dependence (bergen-cico & cico, 2017). research on cannabis and cognitive function has focused largely on youth and young adults (mcketin, parasu, cherbuin, eramudugolla, & anstey, 2016). in a meta-analysis of the neurocognitive effects of cannabis use on adults, researchers found no significant effect on cognition except for a small effect in the learning and forgetting domains in chronic users (grant, gonzalez, carey, natarajan & wolfson, 2003). in a study of mid-life adults, there was no evidence that cannabis was related to early decline in verbal recall, however researchers questioned whether their sample was too young to exhibit any effects of cannabis on their cognitive abilities (mcketin, et al, 2016). the reasons for cannabis use can be considered to fall into three categories: recreational (used without medical justification), medical (used to alleviate symptoms of certain conditions or diseases), or a combination of both. access to cannabis, a publication of the research society on marijuana 3 cannabis for medical purposes has been legal in canada since 2001, although it is highly regulated. the number of medical marijuana dispensaries is increasing across the country, offering a variety of cannabis products and alternatives to traditional ‘bud’ for those who do not want to smoke (murphy et al., 2015). studies suggest that older cannabis-using adults who are dispensary customers are more likely to report that they are using cannabis for the treatment of chronic illnesses, including pain, nausea, glaucoma and cancer (bergen-cico & cico, 2017; haug et al., 2017). although there is some evidence that cannabis is effective for the treatment of medical conditions including seizure disorders, chronic pain, and inflammatory conditions (mccall, 2015), cannabis has physiological effects which may be particularly salient for older adults. han et al. (2016) discuss cardiovascular, pulmonary, and cerebrovascular effects for which age is also a risk factor, and point out that a better understanding of cognitive effects on the aging brain is required, given the significant increase in the percentage of older adults who are using cannabis. the present study examined the role of cannabis in the lives of the 'baby boomer' generation. the specific purpose was to explore the prevalence, usage patterns, and attitudes toward cannabis among this age cohort, with a focus on associations between cannabis use and social, mental, and physical health. this was a small, non-representative sample, and this research was intended to identify attitudes about use and associations between cannabis use and health that could point the research team towards topics warranting additional exploration. method participants there were 142 respondents to the survey. slightly more females (55%) than males (44%) participated; one respondent identified their gender as ‘other’. almost three-quarters identified as caucasian. the average age of respondents was 63 years (sd = 4.6). sampling several different sampling strategies were used: the survey link was posted on facebook and emailed to researchers’ contact lists, and invitations to participate were placed in faculty workplace mailboxes. a snowball sampling technique was also used, as respondents were encouraged to forward the survey to their own contacts. both cannabis users and non-users were recruited. data collection this research involved the collection of data through the use of an electronic survey developed specifically for this study. the study variables were based on a review of existing literature on cannabis, adults, learning, and mental health. variables were organized to gather responses in the following areas: demographics; cannabis use habits; attitudes towards cannabis use in society; perceived effects of cannabis on personal, physical, mental, and social functioning; perceived effects on learning. measures in order to achieve the most comprehensive findings possible, both fixed and open-ended questions were used in the survey. respondents were given opportunities to provide qualitative information in addition to answering the fixed response survey questions. measures included multiple choice (single and multiple response), matrix/ranking, and likert scale (6 pt). data analysis frequencies were calculated on all variables to provide a descriptive representation of the adults included in the study. cross tabulations were utilized to examine the relationship between key variables as identified by the literature. the qualitative data was analyzed for themes and recoded where possible. as the sample is nonrandom and non-representative, more extensive analysis was not warranted. all data management and analysis were conducted using fluid survey, excel and spss. cannabis use and baby boomers 4 results of the 142 respondents to the survey, 85% lived in british columbia and 72% lived in vancouver and/or the lower mainland of bc. the majority of respondents (87.6%) had used cannabis at some point in their lives, although 42.5% had not used for over one year and 27.2% indicted they no longer use marijuana. consistent with the literature (centre for addiction and mental health, 2013), most respondents first used cannabis in their teens (59%) or as young adults (38.4%). baby boomers report that they used daily (16.4%), weekly (20%), or monthly (5.5%), with the remainder stating they no longer used, or used rarely. most users felt they used just the right amount of cannabis (87.9%), some felt they used too much (4.4%), and others reported they felt they did not use enough (7.7%). dried bud was the most frequently used form of cannabis (77.9%). cannabis oil (4.2%) and edible baked good containing cannabis (3.2%) were both used at a much lower rate. smoking cannabis was the most popular method of consumption reported, whether in a traditional ‘joint’ (52.3%), smoking a pipe (11.6%), a ‘bong’ or water pipe (8.1%), or using a vaporizer (14%). the majority of respondents (48.5%) were found to use cannabis for recreational purposes only while 19.2% used it for both recreational and medicinal purposes, and 7.1% for assistance with their physical health. the most common conditions for which the respondents have used cannabis were pain (32.9%), sleeplessness (27.4%), and anxiety (24.7%). other reasons cited by single (1) respondents included menopause, depression, stress, inflammation, stomach upset, migraine, and sexual stimulation. daily cannabis users used equally for recreational reasons or a combination of recreational and medicinal reasons (33.3%). they used less for solely recreational purposes than the total sample (48.5%), and used at a higher rate for pain, sleeplessness and anxiety. over half of the daily cannabis users (52.9%) reported that their use has improved their physical well-being by allowing them to cope with their pain and sleep and relax better. the larger sample had a much lower physical well-being improvement rating of 21.9%. early onset of use (age 13-15) for the subset of 33 respondents who started using cannabis between ages 13 and 15, they were more likely than the full sample to report that they were “more motivated to learn” than their peers and that they are better at learning new things than same-age peers (see table 1). this same group of early users also reported more frequent use of cannabis. there were also differences between the two groups with respect to the conditions they reported using cannabis to address. learning baby boomers were asked to reflect on how cannabis use affects their ability to learn. as can be seen in table 2, the majority of respondents indicated that cannabis use had no effect on their learning. for those who did report an impact, it table 1. comparisons between early onset cannabis users and the total sample early onset of use (age 13-15) total sample i learn new things better than people my age 60.6% 46.1% i am more motivated to learn than people my age 63.6% 56.3% i use cannabis daily 21.9% 17.1% i use cannabis weekly 15.6% 9.9% i use cannabis monthly 9.4% 5.4% conditions: pain 33.3% 33.9% sleeplessness 37% 27.4% anxiety 37% 24.7% cannabis, a publication of the research society on marijuana 5 table 2. perceptions of the effects of cannabis use on learning among baby boomers who use cannabis and among baby boomers who use cannabis daily all baby boomers who use cannabis positive effect somewhat positive effect no effect somewhat negative effect negative effect total responses short term memory 2 (2.2%) 2 (2.2%) 66 (72.5%) 7 (7.7%) 14 (15.4%) 91 reading comprehension 2 (2.2%) 4 (4.4%) 66 (73.3%) 6 (6.7%) 12 (13.3%) 90 learning new things 5 (5.6%) 13 (14.4%) 61 (67.8%) 3 (3.3%) 8 (8.9%) 90 concentration 5 (5.6%) 13 (14.4%) 51 (56.7%) 4 (4.4%) 17 (18.9%) 90 motivation to learn 4 (4.5%) 13 (14.6%) 58 (65.2%) 2 (2.2%) 12 (13.5%) 89 baby boomers who use cannabis daily positive effect somewhat positive effect no effect somewhat negative effect negative effect total responses short term memory 1 (5.9%) 0 (0%) 11 (64.7%) 1 (5.9%) 4 (23.5%) 17 reading comprehension 1 (6.3%) 2 (12.5%) 12 (75%) 1 (6.3%) 0 (0%) 16 learning new things 2 (12.5%) 4 (25%) 10 (62.5%) 0 (0%) 0 (0%) 16 concentration 2 (12.5%) 3 (18.8%) 8 (50%) 2 (12.5%) 1 (6.3%) 16 motivation to learn 2 (12.5%) 13 (18.8%) 11 (68.8%) 0 (0%) 0 (0%) 16 was more negative than positive for short-term memory, reading comprehension, and concentration, and slightly more positive for learning new things and motivation to learn. daily cannabis users reported a slightly different impact on their learning ability than all users surveyed. although the sample was smaller, they reported higher ratings of positive effects on their learning in all five areas, but also higher negative effects on their short-term memory (23.5% v 15.4%). with the exception of short-term memory, the ratings for no effect were similar between the two groups. consistent with the reported effects on learning (mcinnis & porath-waller, 2016), the majority of baby boomers (60.5%) stated that their mental state remained unchanged the day after consuming cannabis. among those who reported differences in mental state the day after consuming cannabis, similar numbers reported difficulty focusing the next day (20.9%) or reported increased ability to focus (18.6%). baby boomers were asked about their reactions to using cannabis. relaxed and happy (74.7%), lively and talkative (37.9%), and a reduction in aches and pains (37.9%) were the most frequently reported reactions, however 12.6% reported feeling paranoid and 2.3% reported they had experienced hallucinations. while the majority of respondents (63.6%) reported that their cannabis use had no impact on their physical well-being, 21.6% indicated their physical well-being had improved. this included an increased ability to cope with or a reduction in pain (54.3%), and improvement in sleep and relaxation (45.7%). a smaller number of respondents, all of whom started using cannabis when they were aged 13-15, indicated their cannabis use had harmed their physical wellbeing (3.4%), including coughing or lung problems and overall feelings of being tired and/or unmotivated. most baby boomers reported that their cannabis use has no impact on their ability to manage tasks (73%), no impact on their friends or social life (79.8%), no impact on their financial situation (94.3%), and no impact on their home life (82%). for those who indicated a positive impact, cannabis use and baby boomers 6 they reported being calm and focused, connected to their friends, and in a better mood as they experience less pain. negative outcomes include problems focusing, being reclusive, and experiencing the disapproval of family. while the majority of baby boomers (68.1%) stated that their cannabis use did not impact their relationship with an intimate partner, positive impacts included improved sex (47.8%) and increased sensitivity and empathy. harms centred on their partner disapproving of their cannabis use. social attitudes concerning cannabis legalizing recreational cannabis would have an impact on the usage of 26.1% of the respondents, who reported they would be more relaxed about their use if it were legal, and feel there would be more choice and better quality control. the current lack of legal status of the drug is not a determinant of use for 14.3% of respondents. of the baby boomers surveyed, 60.9% feel it should be legalized, 23.6% prefer decriminalization, 10% support medical cannabis, and 5.5% believe the laws should stay the way they are. the majority (58.6%) believe it should be regulated, taxed and sold like alcohol; 13.5% feel it should be treated the same as tobacco, while the minority would like it to be treated as a medicinal product: herbal medicine 3.6%; over the counter 7.2%, and available by prescription 8.1%. despite the above data that shows little or no reported impact on a number of different areas of functioning, one-third of the baby boomers surveyed indicated that cannabis is dangerous or somewhat dangerous. one-fifth believe it is beneficial, while 22.5% feel it is harmless or somewhat harmless. baby boomers indicated that the message they give young people is that cannabis is dangerous or somewhat dangerous (50.2%), although 18.2% stated they do not give them any messages about cannabis. baby boomers were asked their opinion of cannabis use by different age groups. as might be anticipated based on our society’s views of drug use, the younger the age group being considered, the higher the disapproval was for their drug use. for children aged 12-15 years, 92.7% disapproved (‘somewhat disapprove’ to ‘strongly disapprove’) of their cannabis use. for older teens (16-18 years), the disapproval rating dropped to 80.9%, with more respondents indicating only ‘somewhat disapprove’ compared to the younger teen group (27.3% vs. 8.2%). for adults, the approval/disapproval ratings were reversed: only 22.7% disapproved of adult cannabis use. there was no significant difference between the results in these categories from the entire sample and those from the early onset users (age 13-15). the data in this study are consistent with research on “normalization” of cannabis use among older canadians which shows that although adults acknowledge potential harms, and differentiate between moderate and problematic patterns of use, cannabis use is more likely to be viewed as “a normal and largely harmless practice” (duff et al., 2012). use of other drugs baby boomers were asked about their use and frequency of us of other drugs. over half of the respondents had used tobacco (58.2%), however only 34.4% of them had used in the past year and only 5.8% were daily smokers. the numbers for alcohol use were much higher: 95.4% had used alcohol in their lifetime, and 96.2% of those who had ever used alcohol had used in the past year. they described their patterns of alcohol use as: daily drinkers (19%), weekly drinkers (23%), a few times per week (31%), monthly drinkers (8%) and drinking less than once per month (19%). stimulant use (i.e. cocaine, speed, ice, crank, crystal, methamphetamine, uppers) was reported by 31.8% of respondents, but only 8.6% of those persons had used in the past year. a small number of respondents (15.5%) had used opioids that were not prescribed for them (i.e. hydrocodone, oxycontin, oxycodone, hydromorph, percocet, heroin, opium, morphine). most of those people (80%) had not done so for more than one year; one person used other people’s opioids daily. hallucinogens (i.e. lsd, mushrooms, psilocybin, mescaline, pcp, meda, mdma, ecstasy) had been used by over half the respondents (56.4%), but most of those people had not used in over one year (95.2%). over-thecounter or prescribed medications were used for non-medicinal purposes by 15.5% of respondents, with 35.3% having done so within the past year. lifetime inhalant use was low (12.7%), with only 15.4% of those who had ever used inhalants reporting use within the past year. cannabis, a publication of the research society on marijuana 7 early onset cannabis users were more likely to have used tobacco in their lifetime (80.6% compared to 58.2% for total sample), and had higher lifetime use of stimulants (54.8% v. 31.8%), opioids (29% v. 15.4%), hallucinogens (90.3% v. 56.4%), over-the-counter medications or prescribed medications for nonmedical uses (25.8% v. 15.5%), and twice as likely to have ever used inhalants (22.6% v. 12.7%). tobacco users were more likely to have tried stimulants (43.8% v 31.8%) or hallucinogens (71.9% v 56.4%) during their life, however there was no significant difference in past year use (<9%). for other drugs (non-prescribed opioids, misuse of over-the-counter drugs, inhalants) there was no difference in lifetime use between tobacco users and non-users. one respondent noted they turned to cannabis instead of prescription drugs to get through the pain of emotional trauma, in part because cannabis is less costly than prescription drugs for which they have no extended health care coverage. discussion this study presented a broad range of characteristics, attitudes and patterns of cannabis use by adults born between 1946 and 1964. many of the findings are consistent with previous studies. in a 2015 study by lau et al., it was noted that older cannabis users made informed decisions on the types of cannabis products they used, as well as the circumstances under which they used (why, when, where, and with whom). in research funded by the national institute of drug abuse, murphy et al. (2015) determined that although baby boomers are using alternative cannabis products rather than smoking to relieve physical ailments and improve their mental health, many still use for solely recreational purposes. there are a range of medical conditions for which cannabis users seek relief. chronic pain, insomnia, anxiety, and depression are most-often reported as the primary reasons for cannabis use among medical cannabis users (bonn-miller, boden, bucossi & babson, 2014). concerns have been raised that an increase in cannabis use by baby boomers may result in adverse health consequences for this population as they opt for a familiar drug to meet their recreational and medicinal needs (colliver, compton, gfroerer & condon, 2006). while this study did not specifically ask respondents to comment on the role cannabis plays in their sexual experiences, many noted that it has a positive impact. cannabis users have long maintained that the drug has a significant role in enhancing their sexual experiences (goode, 1970; tart, 1971), with some claiming it raises sex to an ‘art form’ (ford, 2003). in a more recent study, one third of participants reported that sex was a very important or important reason to use cannabis (hathaway, 2003). in osborne & fogel’s study (2008), participants reported that cannabis enhanced their ability to concentrate, reduced their inhibitions and insecurities, and contributed to their ‘creativity and capacity for original thought’ (p. 558). they found daily chores more tolerable, and their relaxed state allowed them to focus on nature and physical sensations (associated with sexual activity) (p. 563). a recent report by the canadian centre on substance abuse on the effects of cannabis use on cognitive functioning noted that ‘continued chronic cannabis use does not produce severe or grossly debilitating impairment of memory, attention, psychomotor and other cognitive functioning; the effects on these cognitive abilities are generally more subtle’ (mcinnis, & porathwaller, 2016, p. 2). there were very few statistically significant differences between the male and female responses in this study. due to the small number of responses to some of the choices in each question, we were not able to draw any meaningful conclusions based on gender. limitations the data set consists of only those who voluntarily participated in the study. there is no data available on the attitudes and use of cannabis of those who did not participate, therefore the present findings cannot be generalized to the general population. this study did not ask respondents about their lifetime patterns of cannabis use. in hindsight, it would have been beneficial to gather data on respondents’ reasons for continuing cannabis use, stopping use, and/or resuming use. those results cannabis use and baby boomers 8 may have assisted with the analysis of the existing data. conclusion baby boomers report that they make conscious and informed decisions about their cannabis use, and for the majority, their use causes them no harms in their overall functioning, learning, or relationships. for some, cannabis provides a reduction in physical pain and sleeplessness, which improves their abilities to participate in activities that are important to them. more frequent users reported a higher rate of concerns with short-term memory, but overall, users reported their functioning was enhanced by their cannabis use. baby boomers perceive cannabis as a low-risk and familiar drug that can assist with some of the mental and physical problems that emerge as they age (black & joseph, 2014). they are at a different stage of life where the benefits of using cannabis to deal with their ‘stress and strains’ outweigh the risks, especially in light of medicalization and legalization (black & joseph, 2014). the self-perceptions of participants provide useful information about the harms and benefits they experience and should be a key consideration in the development of health and social policies that impact the choices available to rational adults with respect to their cannabis use. references adlaf, e. m., begin, p., & sawka, e. 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(1971). on being stoned: a psychological study of marijuana intoxication. palo alto, ca: science and behavior books volkow, n. d., swanson, j. m., evins, a. e., delisi, l. e., meier, m. h., gonzalez, r., ... & baler, r. (2016). effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review. jama psychiatry, 73(3), 292-297. doi:10.1001/jamapsychiatry.2015.3278 funding: there are no known conflicts of interest for any of the authors of this paper and no external funding sources were used to support this research. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 29 abstract previous research has uncovered a link between stress and cannabis. the overall goal of the present study was to further elucidate the nature of this link by examining whether cannabis use motives (e.g., using cannabis to cope with negative affect) mediate the putative associations between stress (early life stress, chronic stress) and cannabis (frequency of cannabis use, problematic cannabis use). a sample of 578 cannabis-using college students completed an anonymous online survey designed to measure early life stress, chronic stress, frequency of cannabis use, and problematic cannabis use. the results indicated that early life stress was significantly associated with more frequent cannabis use and that both early life stress and chronic stress were significantly associated with more problematic cannabis use. the results of a series of parallel multiple mediation models further revealed that cannabis coping motives (i.e., using cannabis to cope with negative affect and other problems) was a significant mediator of all three of these relationships. these findings suggest that both early life stress and chronic stress may lead to the use of cannabis to cope with stress, and that the use of cannabis for this purpose may, in turn, increase problematic cannabis use. we propose that enhancing cannabis users’ coping skills, so that they are not reliant on cannabis for coping, may help sever the connection between stress and problematic cannabis use. key words: cannabis, coping, chronic stress, early life stress, motives according to a recent survey, 63% of americans do not believe they can manage their stress adequately (american psychological association [apa], 2013), and young adults (particularly college students) report some of the highest levels of stress and stress-related symptoms (apa, 2015). for example, students surveyed at one major us university felt “more than average” or “tremendous” levels of stress at some point in the past 12 months, and 86% felt overwhelmed by all they had to do (american college health association, 2015). this is particularly concerning because unmanaged stress can lead to a broad array of negative outcomes (e.g., depressed mood, digestive problems, viral infections; national institute of mental health, n.d.) as well as to substance abuse and substance-related problems (e.g., fishbein et al., 2007; labouvie, 1986; sinha, 2001; sinha, 2008; windle & wiesner, 2004). many people turn to cannabis to cope with their stress. indeed, one of the most commonly reported reasons for cannabis consumption is for relaxation and tension reduction (copeland, swift, & rees, 2001; green, kavanaugh, & young, 2003; hathaway, 2003; reilly, didcott, swift, & hall, 1998). further, cannabis is cited as a coping tool for dealing with negative affect and problems in life more than any other drug (green, kavanaugh, & young, 2003). while recent research suggests that sober cannabis users demonstrate a blunted stress response compared cannabis 2019, volume 2 (1), 29-38 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.01.003 open access problems associated with using cannabis to cope with stress corresponding author: alexander spradlin, department of psychology, washington state university, p.o. box 644820, pullman, wa 99164-4820, email: a.spradlin@wsu.edu, phone: (509) 335-1592 alexander spradlin1, carrie cuttler1 1 department of psychology, washington state university, pullman, wa, usa motives and the stress-cannabis link 30 to non-users (cuttler et al., 2017), the acute effects of cannabis on stress and the long-term consequences of using cannabis to cope with stress are not well understood. previous research has highlighted the role of coping motives (i.e., using cannabis to cope with negative affect and other problems) in the relationship between various states of negative affect and cannabis. for example, bujarski and colleagues (2012) discovered a relationship between distress intolerance and problematic cannabis use that was mediated by coping motives. similarly, brodbeck and colleagues (2007) found significantly higher psychosocial distress (i.e., unpleasant feelings that occur in response to stress) in young adults who used cannabis primarily for coping motives but not in those who used cannabis primarily for social reasons. johnson and colleagues (2009) found that coping motives mediated the relationship between anxious arousal (i.e., somatic tension and arousal) and cannabis use. finally, spradlin, mauzay, and cuttler (2017) provided evidence that coping motives mediate the relationship between symptoms of obsessive-compulsive disorder and cannabis misuse. to our knowledge, only one previous study has attempted to model mediators of the link between stress and cannabis. specifically, ketcherside and filbey (2015) found that both early life stress and chronic stress were linked to increased problematic cannabis use, and these relationships were mediated by negative affect. no known research has examined the role of cannabis use motives in the link between stress and cannabis. as such, there are significant gaps in our understanding of the nature of the link between stress and cannabis and the mechanisms that may be driving that link. therefore, the primary aim of the present study was to test the role of various cannabis use motives as mediators of the stress-cannabis link. in order to provide a thorough examination of this link, we assessed two forms of stress (early life stress and chronic stress) and two cannabis outcome variables (frequency of cannabis use and problematic cannabis use). we hypothesized that both early life stress and chronic stress would be related to increased frequency of cannabis use and to problematic cannabis use and that coping motives would mediate these links. method participants a total of 1,334 undergraduate students participated in the present study. after data collection was completed, the data were filtered to ensure the sample met several criteria. first, the 10 items of the deviant responding validity subscale of the psychopathic personality inventory (ppi; lilienfeld & andrews, 1996) were randomly interspersed throughout our survey to detect random responders, and 80 participants who endorsed more than four ppi items in an aberrant manner were excluded from all analyses. second, participants must have used cannabis within the past 30 days. this criterion was chosen to ensure that a wide range of cannabis use was available for analysis while also removing the influence of the large percentage of non-users who completed the study. a final sample of 578 undergraduate students was included in the analyses. this sample comprised primarily females (65.6%) and individuals who identified as white (68.2%), followed by hispanic or latino (11.9%), black (6.9%), asian (5%), pacific islander (2.8%), and native american (1.4%). approximately 3.6% of participants indicated their ethnicity was something other than the answer choices available. among the participants, the average age was approximately 20 years old (sd = 1.71). participants reported using cannabis, on average, 10.1 days (sd = 6.51) of the past month, and 18.7% of the participants reported using cannabis once a day or more. the average age of first cannabis use among participants was approximately 16.4 (sd = 2.12). materials demographic information. a short demographics questionnaire was included in the survey to assess age, sex, ethnicity, and other demographic characteristics. early life stress questionnaire (elsq). early life stress was assessed using the elsq. the elsq is a self-report inventory used to measure exposure to potentially traumatic events before the age of 18 (cohen et al., 2006). participants use a yes/no scale to respond to 19 items to indicate whether they experienced each specific event cannabis, a publication of the research society on marijuana 31 during their childhood (e.g., sexual abuse, the death of a sibling, premature birth or other birth complications). the initial version of the questionnaire has shown high internal consistency (α = .90) and test-retest reliability at a sixto eight-week follow-up (r = .89; sanders & becker-lausen, 1995). the elsq also has significant correlations with other measures, such as depression (r = .40) and stressful life events (r = .29; sanders & becker-lausen, 1995). total scores were computed by summing the number of traumatic events each participant experienced. scores could range from 0 to 19 with higher scores indicating more exposure to potentially traumatic events during childhood and adolescence. perceived stress scale (pss). chronic stress was measured using the pss, a 10-item selfreport inventory for measuring the severity of symptoms of stress in the last month (i.e., levels of chronic stress; cohen, 1988). participants rate how often they have experienced stress (e.g., “how often have you been upset because of something that happened unexpectedly”) on a 5-point scale with anchors as follows: 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often. the psychometric properties of the measure are sound among college students and include high internal consistency (α ≥ .70) and high testretest reliability (r ≥ .70; see lee, 2012 for review). scores for each participant were computed by summing all 10 items of the measure. scores could range from 0 to 40, with higher scores indicating more chronic stress. daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu). cannabis use frequency was assessed using the dfaq-cu, a 33-item self-report inventory for measuring cannabis use across six factors: number of sessions of cannabis use per day, frequency of cannabis use, age of onset of cannabis use, quantity of loose-leaf cannabis typically consumed, quantity of cannabis concentrates typically consumed, and quantity of cannabisinfused edibles typically consumed (cuttler & spradlin, 2017). only the frequency subscale was utilized in the present study. this subscale has demonstrated excellent reliability (α = .87) and good predictive validity with measures of cannabis use disorders (r = .59), cannabis abuse (r = .60), cannabis dependence (r = .21), and problems associated with cannabis use (r = .74; cuttler & spradlin, 2017). the frequency subscale has also shown sound concurrent validity with other measures of cannabis consumption (e.g., r = .81 for the dfaq-cu frequency subscale with the marijuana smoking history questionnaire frequency subscale; cuttler & spradlin, 2017). total scores were computed by summing the items of the frequency subscale of the dfaq-cu after standardizing those items and adjusting outliers to the highest non-outlying value (cuttler & spradlin, 2017). because all items were standardized, there were no limits to the potential range of scores. higher scores on the frequency subscale indicate more frequent cannabis use. marijuana problems scale (mps). problematic cannabis use was measured using the mps, a selfreport measure of the manner and degree to which marijuana use interferes with day-to-day functioning (e.g., by causing problems with one’s partner, by causing one to procrastinate; stephens, roffman, & curtin, 2000). participants respond to 19 items based on whether the statement represents a problem they have experienced in the last month, with 0 = no problem, 1 = minor problem, and 2 = serious problem. previous research has shown that the mps has high internal consistency (α = .86) and significant correlations with depression (r = .26) and distress tolerance (r = -.18; buckner, keough, & schmidt, 2007). a total mps score was computed for all participants. scores could range from 0 to 38, with higher scores indicative of more problems caused by marijuana use. marijuana motives measure (mmm). cannabis use motives were assessed using the mmm. the mmm is a self-report measure designed to assess the reasons people use cannabis (simons, correia, carey, & borsari, 1998). it measures five distinct motives to use cannabis: coping motives (e.g., “to forget my worries”), enhancement motives (e.g., “because it’s fun”), social motives (e.g., “because it helps me enjoy a party”), conformity motives (e.g., “because my friends pressure me to use marijuana”), and expansion motives (e.g., “to know myself better”). participants respond to 25 items using a 5-point response scale with anchors as follows: 1 = almost never/never, 2 = some of the time, 3 = half of the time, 4 = most of the time, and 5 = almost always/always. the factor structure of the mmm has been evaluated and confirmed in both student (e.g., chabrol, ducongé, casas, roura, & carey, 2005; simons, correia, carey, & borsari, 1998; motives and the stress-cannabis link 32 zvolensky et al., 2007) and broader young adult samples (benschop et al., 2015). the factors have shown good internal consistency in previous research (e.g., α = .85 for coping motives; benschop et al., 2015). total scores for each factor were computed. scores could range from 5 to 25 for each motive, with higher scores representing stronger endorsement of that particular motive for cannabis use. procedure participants completed an anonymous online survey that included the measures described above. the survey required 40-50 minutes to complete, on average, and participants were compensated with one credit that they could apply to an eligible psychology course. prior to analysis, the data were screened per the inclusion/exclusion criteria described in the participants section above. all variables were standardized and screened for outliers, defined as scores falling more than 3.29 standard deviations (sds) from the sample mean. the small number detected (< 1%) were converted to a score equivalent to 3.29 sds from the mean (tabachnick, fidell, & osterlind, 2001). all data screening and cleaning took place in ibm spss (version 24), and all analyses were run using this same software program. a conservative alpha of .01 was used to determine statistical significance in all analyses. this more conservative level was selected to reduce inflation in type i error rate as a result of the robust sample size and multiple analyses. all mediation models were tested in ibm spss using the process macro (version 2.15; hayes, 2013). all scores were standardized prior to entry into the models. the significance of indirect effects was tested using 99% biascorrected confidence intervals (cis). these confidence intervals were generated via bootstrapping with 10,000 iterations (see hayes, 2013; jose, 2013). results descriptive statistics and bivariate correlations the means (m) and standard deviations (sd) for all measures are provided in table 1, and the bivariate correlations between these variables are provided in table 2. as shown in the table, early life stress was significantly associated with frequency of cannabis use and problematic cannabis use. chronic stress was significantly correlated with problematic cannabis use but not with frequency of cannabis use. mediation analyses several parallel multiple mediation models were tested to determine if (and which) cannabis use motives mediate the relationships between early life stress and cannabis use frequency, early life stress and problematic cannabis use, and chronic stress and problematic cannabis use. all cannabis use motives were entered into the models simultaneously to determine which specific indirect pathway(s) best accounted for the observed relationships between our variables. a mediation model of the relationship between chronic stress and frequency of cannabis use was not tested because chronic stress and cannabis use frequency were not significantly correlated with each other. table 1. descriptive statistics and reliability for all measures measure m sd range skew α early life stress 2.86 2.66 0 – 11.61 1.03 .72 chronic stress 17.24 5.98 0 – 36.91 0.09 .82 cannabis use frequency 0.00 0.72 -1.21 – 2.25 0.46 .91 problematic cannabis use 3.18 4.13 0 – 16.77 1.71 .88 conformity motives 6.59 3.06 5 – 16.66 2.27 .88 coping motives 7.79 3.81 4 – 20 1.13 .86 enhancement motives 16.53 5.31 5 – 25 -0.37 .86 expansion motives 9.33 4.88 5 – 25 1.22 .92 social motives 9.38 4.56 5 – 24.38 1.03 .87 cannabis, a publication of the research society on marijuana 33 table 2. correlations among all measures measure 1 2 3 4 5 6 7 8 1. early life stress - 2. chronic stress .18** - 3. cannabis use frequency .14* -.09 - 4. problematic cannabis use .22** .18** .31** - 5. conformity motives -.05 .09 -.001 .19** - 6. coping motives .20** .27** .42** .37** .20** - 7. enhancement motives .15* -.02 .39** .19** -.04 .35** - 8. expansion motives .21** .05 .39** .28** .32** .47** .40** - 9. social motives .16** .13* .29** .25** .34** .43** .47** .51** note: * = p < .01, ** = p < .001. in the first mediation analysis, cannabis use motives were tested as mediators of the relationship between early life stress and frequency of cannabis use. results revealed significant indirect effects of early life stress on frequency of cannabis use via coping motives (β = .06), via enhancement motives (β = .03), and via expansion motives (β = .04; see figure 1, model a). confidence intervals generated for pairwise contrasts of the significant indirect pathways revealed no significant differences in their sizes. in the second mediation analysis, cannabis use motives were modeled as mediators of the relationship between early life stress and problematic cannabis use. results revealed a significant indirect pathway from early life stress to problematic cannabis use via coping motives only (β = .07; see figure 1, model b). we also tested this model while controlling for frequency of cannabis use and found the same pattern of results: the only significant indirect pathway was through coping motives, β = .07, ci = .02 to .17. for the third and final mediation analysis, all cannabis use motives were once again tested as mediators in parallel, this time in the relationship between chronic stress and problematic cannabis use. in this path model, there was only a significant indirect effect of chronic stress on problematic cannabis use through coping motives (β = .07; see figure 2). we also tested this model while controlling for frequency of cannabis use and found the same pattern of results: the only significant indirect pathway was through coping motives, β = .06, ci = .01 to .15. discussion the goal of the present study was to elucidate the nature of the relationship between cannabis and stress by testing the role of cannabis use motives as mediators of the relationships between multiple aspects of stress and cannabis use. findings revealed small but significant positive associations between early life stress and frequency of cannabis use, early life stress and problematic cannabis use, and chronic stress and problematic cannabis use. mediation analyses further revealed a consistent mediating role of coping motives in the stress-cannabis link, largely supporting our hypotheses. findings from the present study build upon previous research in several ways. first, the present study examined the stress-cannabis link in a comprehensive manner by evaluating both early life stress and chronic stress, as well as both frequency of cannabis use and problematic cannabis use. while the observed effects were small, they suggest that experiencing more early life stressors is related to using cannabis more and having more long-term problems from use, and that experiencing more chronic stress is related to having more long-term problems from cannabis use. these results are consistent with previous research describing a link between stress and cannabis more broadly (see hyman & sinha, 2009 and scholssarek, kempkensteffen, reimer, & verthein, 2016 for review), as well as between chronic stress, early life stress, and problematic cannabis use specifically (ketcherside & filbey, 2015). there are many factors that may contribute to problematic cannabis use in particular (e.g., affect dysregulation [simons & carey, 2002]; social anxiety [buckner, heimberg, motives and the stress-cannabis link 34 figure 1. effects of early life stress on cannabis use frequency (a) and problematic cannabis use (b) via cannabis use motives. note. all effects are standardized with standard errors in parentheses; ci = 99% confidence interval with significant indirect paths bolded; * p < .01, ** p < .001. figure 2. effects of chronic stress on problematic cannabis use via cannabis use motives. note. all effects are standardized with standard errors in parentheses; ci = 99% confidence interval with significant indirect paths bolded; * p < .01, ** p < .001 cannabis, a publication of the research society on marijuana 35 & schmidt, 2011]), and the results of the present study provide evidence that chronic stress and early life stress may also contribute. our results also provide novel evidence that cannabis use for coping with negative affect and other problems in life is one of the driving factors behind the link between cannabis and stress. for all significant relationships between stress and cannabis, an indirect pathway through coping motives accounted for a significant amount of that relationship. these findings indicate that experiencing either chronic stress or early life stress may increase the use of cannabis to cope with problems, and using cannabis for that purpose may contribute to more negative outcomes from cannabis use. this finding adds to a growing body of literature that points to cannabis coping motives as a significant explanatory factor behind a variety of cannabisrelated outcomes, such as mediating the relationship between negative attitudes toward mental health and cannabis use (fanale, maarhuis, wright, & caffrey, 2017) between distress intolerance and problematic cannabis use (bujarski et al., 2012) and between symptoms of obsessive-compulsive disorder and problematic cannabis use (spradlin, mauzay, & cuttler, 2017). together, these studies indicate that the motives for using cannabis are important to consider when working with people who are showing signs of cannabis misuse. there are several limitations of the present study that should be considered when interpreting the findings. first, all measures were exclusively self-report instruments, which are subject to retrospective recall and other biases. second, a cross-sectional design was used, meaning that inferences regarding the causal order of the variables in all models (i.e., their directionality) should be made with caution. while the temporal order of early life stress and problematic cannabis use supports the hypothesis that early life stress leads to problematic cannabis use, the direction of the relationship between chronic stress and problematic cannabis use is more difficult to ascertain. it is possible, for example, that chronic stress leads to increased coping motives, and then to more problematic cannabis use. alternatively, cannabis-related problems may lead to increased coping motives and then increased chronic stress. there may also be a feedback loop between the variables such that chronic stress leads to using cannabis to cope, which then leads to increased problematic cannabis use, which contributes to further increases in chronic stress. though the present study represents an important step toward elucidating the nature of the relationship between stress and cannabis, longitudinal studies are needed to provide more clarity regarding the direction of the observed effects. a third limitation is that the sample comprised college students who used cannabis occasionally. though the entire sample endorsed using cannabis at least once within the past 30 days, it is important to investigate samples with different usage rates (e.g., strictly daily users, medical cannabis users) to establish whether the pattern of results from the present study generalizes to other populations. nonetheless, we intentionally sought a sample of college students for the present study because college-aged individuals are particularly vulnerable to stress (apa, 2015), and they are also more likely to use cannabis than other age groups (johnston, o’malley, bachman, & schulenberg, 2013). as such, understanding the link between stress and cannabis in this population is of particular importance. in conclusion, the results of the present study provide novel insights into the nature of the link between stress and cannabis. overall, the findings suggest that the use of cannabis to cope with negative affect and other problems explains a substantial portion of the relationship between stress and cannabis. from a health standpoint, these findings have important implications. stress is a pervasive aspect of life, and in many cases, stress is unpredictable and unavoidable. therefore, targeting the stress component of the cannabis-stress link may be difficult. for example, quitting school may reduce stress in the short-term, but it may cause long-term issues (such as an inability to find work, advance in one’s career, etc.). further, there is no way to reverse the effects of early life stress on 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(2004). trajectories of marijuana use from adolescence to young adulthood: predictors and outcomes. development and psychopathology, 16, 10071027. doi: 10.1017/s0954579404040118 zvolensky, m. j., vujanovic, a. a., bernstein, a., bonn-miller, m. o., marshall, e. c., & leyro, t. m. (2007). marijuana use motives: a confirmatory test and evaluation among young adult marijuana users. addictive behaviors, 32, 3122-3130. doi: 10.1016/j.addbeh.2007.06.010 funding: there is no funding to declare. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ microsoft word v3i1a6_final.docx research article 52 abstract people who endorse using cannabis for medicinal vs. recreational purposes exhibit several important differences in terms of cannabis use quantity and frequency, cannabis-related problems, and other critical factors. however, there is currently little research on different motivations for use in these groups. the present study identifies specific cannabis use motives (using the comprehensive marijuana motives questionnaire) that distinguish medicinal (n = 283) from recreational (n = 462) users in a large, geographically-diverse sample recruited through amazon’s mechanical turk. logistic regression analyses indicated that sleep, social anxiety, and coping motives were associated with greater odds of medicinal use. conversely, motives related to boredom, enjoyment, simultaneous alcohol use, and celebration were associated with greater odds of recreational use. the results indicate that specific motives differentiate types of cannabis users such that positive reinforcement may primarily drive recreational use, and negative reinforcement may primarily drive medicinal use. key words: cannabis, motives, recreational, medicinal cannabis use has been linked to a number of harms and detrimental outcomes, including cognitive deficits (e.g., impaired short-term memory, impaired motor coordination), increased risk for mental health disorders (e.g., depression, anxiety, psychosis), and physical health problems (e.g., bronchitis, respiratory infections) (volkow, baler, compton, & weiss, 2014). despite these potential negative consequences, cannabis is currently the most commonly used drug in the united states (aside from alcohol and tobacco), with an estimated 26 million americans aged 12 and older reporting cannabis use in 2017 (substance abuse and mental health services administration, 2018). the legal status of cannabis in the united states is rapidly changing, with cannabis laws varying by state. currently, the recreational use of cannabis by adults over the age of 21 is legal in 10 u.s. states and the district of columbia (national conference of state legislature, 2019). while the majority of cannabis users use for solely recreational purposes (i.e., for enjoyment or for intoxication), estimates of cannabis users who report using for medicinal cannabis 2020, volume 3 (1), 52-63 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.006 open access differentiating medicinal and recreational cannabis users via cannabis use motives corresponding author: michael amlung, peter boris centre for addictions research and michael g. degroote centre for medicinal cannabis research, department of psychiatry and behavioural neurosciences, mcmaster university & st. joseph’s healthcare hamilton, 1280 main street west, hamilton, on l8s 4l8, canada, email: amlungm@mcmaster.ca lana vedelago1, jane metrik2, michael amlung3 1 peter boris centre for addictions research, neuroscience graduate program, mcmaster university & st. joseph’s healthcare hamilton, hamilton, on, canada 2 center for alcohol and addictions studies, brown university, and providence va medical center, providence, ri, usa 3 peter boris centre for addictions research and michael g. degroote centre for medicinal cannabis research, department of psychiatry and behavioural neurosciences, mcmaster university & st. joseph’s healthcare hamilton, hamilton, on, canada differentiating medicinal and recreational cannabis users 53 purposes (either concurrently with recreational use, or medicinal use alone) range from 9.8% to 17% (compton, han, hughes, jones, & blanco, 2017; lin, ilgen, jannausch, & bohnert, 2016). medicinal and recreational users exhibit several important differences in terms of cannabis use, cannabis-related problems, and other key health and safety factors. for instance, medicinal users tend to use cannabis more frequently than recreational users (lin et al., 2016). a recent study among u.s. veterans examined differences between medicinal and recreational cannabis users and showed elevated levels of posttraumatic stress disorder and worse physical and mental health functioning for medicinal users compared with recreational users (metrik, bassett, aston, jackson, & borsari, 2018). studies from primary care and emergency department settings have shown that medicinal users not only use cannabis more often than recreational users, they also tend to have lower income and experience poorer physical health (e.g., furler, einarson, millson, walmsley, & bendayan, 2004; lin et al., 2016; roy-byrne et al., 2015; woodruff & shillington, 2016). another potentially important factor that might differentiate these groups is specific motivations for using cannabis. motives for using drugs or alcohol are commonly described as the particular reasons individuals engage in use of a substance, and often include positive reinforcement (e.g., to enhance mood, to facilitate social interaction) and negative reinforcement (e.g., as a coping mechanism for stress, to improve sleep) (cooper, 1994; cooper, kuntsche, levitt, barber, & wolf, 2016). in the case of cannabis, common motives for use include enjoyment, experimentation, boredom, conformity, social anxiety, sleep, and coping, among others (lee, neighbors, hendershot, & grossbard, 2009). a study by metrik at al. (2018) comparing medicinal and recreational cannabis use among u.s. veterans found significant differences in cannabis use motives, with medicinal users reporting using cannabis to manage sleep to a greater extent than recreational users, and recreational cannabis users more likely to report concurrent alcohol use relative to medicinal users. in a follow-up study using prospective data to examine associations between cannabis and alcohol use among medicinal and recreational users, veterans who used cannabis recreationally were at greater risk for increased drinking when co-using cannabis at the daily level. medicinal users, particularly those who endorsed motives for using cannabis as a substitute for alcohol, were found to be at lower risk for increased drinking on days when cannabis was also used (gunn, jackson, borsari, & metrik, 2019). the studies by metrik and colleagues examined a specific group of cannabis users (i.e., veterans) and it is unclear if the findings generalize to a sample of community cannabis users (gunn et al., 2019; metrik et al., 2018). apart from these studies, research comparing motives for use between medicinal and recreational users remains limited, particularly in general population samples. this is an important gap in the literature since motives for use have been shown to have clinical relevance. differences in reasons for using cannabis can help predict when, where, and how often use will occur, and may have important implications for the efficacy of substance use disorder treatment (blevins, banes, stephens, walker, & roffman, 2016). for instance, a study of treatment-seeking adolescent cannabis users found that several cannabis motives decreased following treatment, and the magnitude of this reduction predicted reduction in cannabis problems and frequency of use over time (blevins et al., 2016). similar findings also have been reported in adult samples, with greater reductions in coping motives associated with better treatment outcomes (banes, stephens, blevins, walker, & roffman, 2014). the present study sought to replicate and extend the findings of metrik et al. (2018) by examining general cannabis use motives and medicinal-specific motives in a large sample of regular recreational and medicinal cannabis users who were recruited via an online crowdsourcing platform from u.s. states with legalized recreational cannabis use. this study also extends the work of metrik et al. (2018) by examining which cannabis-related motives uniquely predict medicinal vs. recreational use in a comprehensive multivariate model. consistent with the findings of metrik et al. (2018), we predicted that people who use cannabis for medicinal purposes will report more salient sleep-related motives whereas recreational users will report elevated simultaneous alcohol-related motives. cannabis, a publication of the research society on marijuana 54 method participants participants for the study were recruited through the amazon mechanical turk (mturk) crowdsourcing portal (www.mturk.com). mturk’s platform allows for surveys and tasks to be posted by “requesters” (researchers) and completed by “workers” given that the “workers” (participants) meet certain criteria (stewart, chandler, & paolacci, 2017). the survey was posted on mturk between september and december, 2017. participants had to be at least 18 years of age, geographically located in u.s. states with legalized recreational cannabis at the time of data collection, and have previously completed at least 100 mturk surveys with minimum 95% approval rating on prior surveys to ensure valid data. only one response per ip address was permitted. we recruited a large general sample of adults (n = 3,024) to complete the first survey. participants from this sample who reported cannabis use in the past 6 months were identified (n = 778) and invited to participate in stage two of the study. stage two consisted of another survey on mturk focusing on recreational and medicinal cannabis use and reasons for use, among other variables. excluding for missing data on the comprehensive marijuana motives questionnaire (cmmq), the final sample consisted of 745 participants. these participants were divided into two groups based on their reasons for using cannabis on the cannabis use patterns questionnaire (see specific items below): (a) recreational use only (n = 463) and (b) any medicinal use, including co-occurring with recreational use or solely medicinal use (n = 283). the study was approved by the hamilton integrated research ethics board (project #3566) and all participants completed informed consent. participants received $7 for completing both stages of the study. measures part one of the mturk survey consisted of selfreport questionnaires assessing substance use, personality, and other lifestyle behaviors. part two specifically assessed cannabis use patterns, history, and motives. demographics. demographic variables such as sex, age, race, years of education, and income were assessed using a self-report questionnaire. cannabis use patterns. a self-report questionnaire based on previous research (cuttler & spradlin, 2017; metrik et al., 2009) was used to assess history of cannabis use, current quantity and frequency of cannabis consumption, and reason for cannabis use (i.e., recreational or medicinal). cannabis use quantity was assessed by self-reported grams of cannabis consumed for personal use in a typical week. cannabis use frequency was assessed using the first item of the cannabis use disorder identification testrevised (cudit-r) (adamson et al., 2010). specifically, participants reported how often they used cannabis in the last 6 months, with responses ranging from “never” to “4 or more times a week”. due to established validity issues with the cudit-r in medicinal users (loflin, babson, browne, & bonn-miller, 2018), only the first item related to frequency was used as a covariate in the analyses; cudit-r total scores are reported for descriptive purposes. finally, the following question was used to bifurcate the sample into the medicinal vs. recreational groups: “are you currently taking marijuana for medicinal purposes?” participants who responded “no” were classified as recreational use only; participants who responded “yes” were classified as medicinal use. for inclusion in the medicinal group, it was not necessary that participants had been prescribed cannabis by a medical professional. motives and reasons for using cannabis. motives for cannabis use were assessed using the comprehensive marijuana motives questionnaire (cmmq) (lee et al., 2009), on which participants rated how often they use cannabis for each of 36 reasons on a 1 = “almost never/never” to 5 = “almost always/always” scale. composite scores were derived for 12 subscales (listed in table 1; α’s = .76 to .92). medicinal cannabis users completed the reasons for medical marijuana questionnaire (rfumm) (reinarman, nunberg, lanthier, & heddleston, 2011), a 25item questionnaire assessing how often medicinal users use cannabis to improve, relieve, or prevent certain conditions (e.g., pain, sleep, seizures, etc.), with additional items on ptsd and how often cannabis is used as a drug substitute from the modified rfumm used in the metrik et al. (2018) differentiating medicinal and recreational cannabis users 55 table 1. sample characteristics overall sample (n = 745) recreational only (n = 462) medicinal use (n = 283) variable n (%); m(sd) n (%); m(sd) n (%); m(sd) χ2/f p fdr η2 sex (female) 382 (48.7%) 210 (45.5%) 172 (60.8%) 16.49 <.001 race 3.91 .048 white 546 (73.3%) 327 (70.8%) 219 (77.4%) black/african american 38 (5.1%) 23 (5.0%) 15 (5.3%) aboriginal 1 (.1%) 1 (.2%) 0 (.0%) asian 67 (9.0%) 54 (11.7%) 13 (4.6%) native hawaiian/pacific islander 53 (7.1%) 36 (7.8%) 17 (6.0%) more than one race 38 (5.1%) 21 (4.5%) 17 (6.0%) another race 2 (.3%) 0 (.0%) 2 (0.7%) age 33.69 (10.06) 33.09 (10.25) 34.66 (9.70) 4.26 .039 .006 education 15.16 (2.20) 15.32 (2.18) 14.90 (2.23) 6.37 .012 .009 audit 7.12 (6.42) 7.52 (6.23) 6.46 (6.67) 4.78 .029 .006 cannabis use per week (grams) 5.28 (12.55) 4.37 (12.18) 6.77 (13.01) 6.46 .011 .009 use frequency (cudit-r item 1) 143.81 <.001 .162 4 or more times a week 285 (38.3%) 109 (23.6%) 176 (62.2%) 2-3 times a week 82 (11.0%) 54 (11.7%) 28 (9.9%) 2-4 times a month 116 (15.6%) 78 (16.9%) 38 (13.4%) monthly or less 262 (35.2%) 221 (47.8%) 41 (14.5%) cudit-r total 8.40 (6.12) 7.15 (5.79) 10.43 (6.12) 53.83 <.001 .068 phq-9 7.62 (6.51) 7.17 (6.18) 8.35 (6.97) 5.73 .008 .008 gad-7 6.86 (5.79) 6.22 (5.46) 7.91 (6.17) 15.16 <.001 .020 cmmq subscales enjoyment 7.52 (3.21) 7.72 (3.16) 7.19 (3.26) 18.03 <.001 sig. .024 conformity 1.15 (2.13) 1.42 (2.31) .71 (1.71) 2.58 .109 n.s. .003 coping 3.30 (3.22) 2.98 (3.11) 3.82 (3.33) 3.12 .078 n.s. .004 experimentation 2.43 (2.70) 2.65 (2.72) 2.08 (2.63) 1.08 .297 n.s. .001 boredom 3.69 (3.19) 4.03 (3.23) 3.13 (3.05) 17.58 <.001 sig. .023 alcohol 1.60 (2.41) 2.01 (2.65) .94 (1.78) 8.41 .004 sig. .011 celebration 4.06 (3.13) 4.29 (3.14) 3.70 (3.10) 4.23 .040 n.s. .006 altered perceptions 4.70 (3.71) 4.45 (3.70) 5.11 (3.70) .63 .428 n.s. .001 social anxiety 3.12 (3.26) 2.57 (3.03) 4.00 (3.43) 14.51 <.001 sig. .019 relative low risk 5.13 (3.57) 4.88 (3.59) 5.55 (3.73) 0.81 .368 n.s. .001 sleep 4.79 (3.70) 3.80 (3.47) 6.41 (3.49) 39.94 <.001 sig. .051 availability 4.35 (3.13) 4.74 (3.15) 3.72 (3.01) 15.69 <.001 sig. .021 note. audit = alcohol use disorder identification test, cudit = cannabis use disorder identification test, phq-9 = patient health questionnaire-9 (depression symptoms), gad-7 = generalized anxiety disorder (anxiety symptoms). fdr = false discovery rate correction (q < .05). study. response options ranged from 1 = “almost never/never” to 4 = “most of the time” (α = .86). mental health symptoms and alcohol use related variables. mental health symptoms and alcohol misuse were assessed for the purposes of including as covariates in analyses. symptoms of depression and anxiety were assessed using the patient health questionniare-9 (phq-9; α = .92) cannabis, a publication of the research society on marijuana 56 (spitzer, kroenke, & williams, 1999) and the generalized anxiety disorder scale (gad-7; α = .93) (spitzer, kroenke, williams, & lowe, 2006), respectively. alcohol use and severity of associated problems over the past 12 months were assessed using the alcohol use disorder identification test (audit; α =.88) (saunders, aasland, babor, de la fuente, & grant, 1993). results preliminary analyses prior to analysis, the data were screened for outliers (zs > 3.29) (tabachnick & fidell, 2013). only a small number of outliers were identified (0.4%), and these values were windsorized. sample characteristics for the overall sample and by group are presented in table 1. using a standard significance level of p < .05, significant group differences between recreational and medicinal users were noted for sex, race, age, and education. groups were also different with respect to alcohol use (audit; p = .029), depressive symptoms (phq-9; p = .008), and anxiety symptoms (gad-7; p < .001). medicinal cannabis users reported significantly greater frequency of cannabis use (p < .001), greater grams consumed per week (p = .011), and higher cudit-r total scores (p < .001). mean ratings on the rfumm in the medicinal group are presented in table 2. medicinal cannabis users reported using cannabis most frequently to improve relaxation and sleep, to relieve pain and anxiety, and as a substitute for prescription medication. cannabis use motives mean scores on the 12 cmmq subscales for the recreational only and medicinal cannabis groups are presented in table 1. bivariate correlations among the cmmq subscales are presented for recreational only users in table 3 and medicinal users in table 4, with r values ranging from .01 to .61 for recreational users and .09 to .70 for medicinal users. cmmq subscale correlations for the total sample is presented in supplemental materials. differences in cannabis use motives on the 12 cmmq subscales were examined using separate analyses of covariance (ancova) models controlling for demographic variables (sex, age, race [white/non-white], education) and quantity/frequency of cannabis use. to reduce the risk of type-i error due to multiple comparisons, the ancova models were corrected using a false discovery rate of q < .05 (benjamini & hochberg, 1995). significant differences between groups were found for six of twelve subscales of the cmmq after fdr correction, fs = 4.23-39.94, ηp2 = .006-.051. the recreational use only group reported more often using cannabis for enjoyment, to counter boredom, simultaneous with alcohol, and because table 2. reasons for using medicinal marijuana (rfumm; n = 283) m sd to relieve: pain 2.94 1.07 muscle spasms 1.93 1.18 headaches 2.08 1.09 anxiety 2.93 1.16 nausea/vomiting 1.94 1.12 depression 2.61 1.22 cramps 1.92 1.04 panic attacks 2.05 1.17 diarrhea 1.28 .71 itching 1.22 .65 anger 1.92 1.08 ptsd 1.93 1.24 to improve: sleep 3.04 1.01 relaxation 3.13 .96 appetite 2.14 1.11 concentration/focus 1.92 1.06 energy 1.75 .97 to prevent: medication side effects 1.67 1.01 anger 1.81 .98 involuntary movements 1.35 .80 seizures 1.19 .64 ptsd 1.76 1.10 as a substitute for: prescription medication 2.69 1.19 alcohol 1.85 1.08 another drug 1.51 .98 note. mean scores can range from 1 to 4. differentiating medicinal and recreational cannabis users 57 table 3. bivariate correlations among cannabis motive subscales – recreational only use 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 1. enjoyment 2. conformity .01 3. coping .33 .32 4. experimentation .17 .52 .34 5. boredom .46 .36 .61 .33 6. alcohol .02 .50 .20 .34 .22 7. celebration .36 .29 .36 .34 .38 .16 8. altered perceptions .45 .20 .46 .36 .44 .11 .36 9. social anxiety .30 .37 .61 .43 .46 .25 .43 .46 10. relative low risk .47 .25 .30 .30 .36 .09 .34 .43 .35 11. sleep .27 .20 .45 .25 .42 .13 .33 .35 .56 .36 12. availability .35 .36 .37 .34 .56 .38 .36 .26 .32 .33 .24 note. n = 462. table 4. bivariate correlations among cannabis motive subscales – medicinal use 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 1. enjoyment 2. conformity .06 3. coping .35 .35 4. experimentation .31 .43 .28 5. boredom .50 .44 .45 .43 6. alcohol .14 .70 .34 .42 .44 7. celebration .46 .31 .24 .53 .39 .29 8. altered perceptions .57 .18 .45 .42 .46 .20 .43 9. social anxiety .39 .17 .49 .29 .31 .18 .39 .49 10. relative low risk .52 .11 .34 .28 .33 .11 .38 .50 .46 11. sleep .28 .09 .29 .23 .27 .17 .26 .27 .39 .42 12. availability .43 .32 .35 .36 .66 .36 .43 .38 .29 .39 .24 note. n = 283. of availability when compared to the medicinal use group. conversely, the medicinal use group tended to report using cannabis more often for sleep difficulties and to relieve social anxiety when compared with the recreational use only group. we then conducted a hierarchical binary logistic regression model to determine which of the 12 cmmq subscales uniquely predicted group membership (recreational use only (0) vs. medicinal (1)) when the subscales were entered simultaneously. specifically, demographic and cannabis use variables were entered in the first step of the model, followed by the 12 cmmq subscales in the second step. results of the logistic regression are presented in table 5. the final model was significant, χ2 (df = 18) = 280.71, p < .001, nagelkerke r2 = .43. the odds of being a medicinal cannabis user were significantly (p < .05) greater for participants with higher sleep, coping, and social anxiety motives. conversely, the odds of being a recreational only user were significantly greater for participants with higher enjoyment, boredom, simultaneous alcohol, and cannabis, a publication of the research society on marijuana 58 table 5. binary logistic regression analysis predicting medicinal or recreational cannabis use variable b se or 95% ci wald statistic p model χ2 r2 step 1 151.58*** .25 sex (female) -0.37 0.20 0.69 [0.47, 1.01] 3.57 .059 race (white/non-white) 0.11 0.22 1.12 [0.72, 1.73] 0.25 .614 age 0.01 0.01 1.01 [0.99, 1.03] 1.52 .217 education 0.00 0.04 1.00 [0.92, 1.09] 0.00 .995 frequency of use (cudit-1) 0.58 0.04 1.78 [1.51, 2.10] 46.52 <.001 use per week (grams) 0.00 0.01 1.00 [0.99, 1.02] 0.06 .811 step 2 280.71*** .43 cmmq subscales enjoyment -0.16 0.04 0.854 [0.79, 0.93] 14.06 <.001 conformity -0.02 0.07 0.980 [0.86, 1.12] 0.09 .760 coping 0.08 0.04 1.087 [1.00, 1.18] 4.22 .040 experimentation 0.01 0.05 1.010 [0.92, 1.10] 0.05 .832 boredom -0.17 0.05 0.844 [0.77, 0.93] 12.35 <.001 alcohol -0.14 0.06 0.873 [0.78, 0.98] 5.48 .019 celebration -0.08 0.04 0.924 [0.85, 1.00] 3.86 .049 altered perceptions 0.06 0.03 1.065 [1.00, 1.14] 3.51 .061 social anxiety 0.10 0.04 1.104 [1.02, 1.20] 5.76 .016 relative low risk 0.03 0.03 1.031 [0.97, 1.10] 0.91 .340 sleep 0.19 0.03 1.214 [1.14, 1.29] 35.94 <.001 availability -0.04 0.04 0.962 [0.89, 1.04] 0.87 .350 note. logistic regression coding: 0 = recreational; 1 = medicinal. cudit = cannabis use disorder identification test. celebration motives. across all cmmq subscales, the largest odds ratios were present for sleep, boredom, enjoyment, and simultaneous alcohol motives. discussion the current study investigated differences in cannabis use motives among individuals endorsing cannabis use for recreational or medicinal reasons. relative to recreational only users, medicinal users tended to report more often using cannabis for reasons related to social anxiety and sleep. recreational only users, however, reported more often using cannabis for enjoyment, boredom, simultaneous with use of alcohol, and because of availability relative to medicinal users. the combined logistic regression model results were largely similar to the group comparisons for individual motives, but with some notable differences. while social anxiety and sleep motives remained associated with greater odds of medicinal use, coping motives emerged as an additional significant predictor of medicinal use. for recreational use, enjoyment, boredom, and alcohol motives were once again associated with greater odds of recreational use, but availability was no longer significant in the combined model. celebration also significantly uniquely predicted recreational use in the combined model. importantly, motives related to conformity, experimentation, altered perceptions, or relative low risk did not differentiate groups in any of the analyses. taken together, these results suggest that recreational and medicinal cannabis users report distinct reasons for use. interestingly, these results replicate two important findings among veterans in metrik et al. (2018) within a community sample – community recreational cannabis users were more likely to report alcoholdifferentiating medicinal and recreational cannabis users 59 related motives while medicinal cannabis users were more likely to report sleep-related motives. the motives distinct to recreational cannabis users have several implications for potential negative outcomes and interventions for cannabis-related problems. first, alcohol-related cannabis use motives (e.g., using cannabis “because you were drunk”) significantly predicted recreational cannabis use. prior research has investigated motives for and outcomes of concurrent and simultaneous cannabis and alcohol use (i.e., concurrent users use both cannabis and alcohol but during separate episodes, simultaneous users use cannabis and alcohol during the same episode) (subbaraman & kerr, 2015). patrick and colleagues (2018) characterized four primary motives for simultaneous alcohol and cannabis use: conformity, positive subjective effects, coping, and social motives. elevated social and calm/coping motives for simultaneous use was found to be correlated with greater odds of simultaneous alcohol and cannabis use, a pattern of use that may be more dangerous or risky compared with use of either substance alone (brière, fallu, descheneaux, & janosz, 2011; patrick, fairlie, & lee, 2018). simultaneous use is associated with a number of negative outcomes, including unsafe driving, social consequences and harms to self, and substance-related problems (brière et al., 2011; subbaraman & kerr, 2015; terry-mcelrath, o’malley, & johnston, 2014). individuals who use alcohol and cannabis concurrently or simultaneously also report elevated motivation for alcohol on behavioral economic measures of alcohol demand relative to people who use alcohol only (morris et al., 2018). this includes significantly greater overall purchases on alcohol (i.e., maximum expenditure) and continuing to consume alcohol despite higher costs. taken together, an expanding body of research suggests that combined use of alcohol and cannabis is an especially problematic pattern. the present findings suggest that including a measure of alcohol-related cannabis use motives in treatment settings may help to identify individuals who are at increased risk of experiencing negative consequences of combined use. however, these findings must be interpreted with caution given that recreational users had significantly higher audit scores than medicinal users. a future direction will be to investigate the impact of higher levels of alcohol use on alcohol-related cannabis use motives. second, when the other motives distinct to recreational users are examined collectively (i.e., boredom, enjoyment, availability), they appear to paint a picture of these individuals using cannabis when bored (e.g., “because you had nothing better to do”) and seeking stimulation, especially when cannabis is readily available. behavioral economic theory indicates that consumption of a substance is predicated upon access and availability of the substance as well as the individual’s subjective valuation of the substance (bickel, johnson, koffarnus, mackillop, & murphy, 2014). this may be important when considering how to identify and tailor interventions for those individuals whose recreational cannabis use has reached a problematic level. in line with behavioral economic theory, one way to decrease cannabis use is to increase the cost of the drug, thereby reducing ease of access. another potential avenue of intervention is promoting engagement in substance-free alternatives that are reinforcing for the individual. currently, one supplemental intervention has been developed to encourage participation in these alternative activities (i.e., the substance-free activity session; sfas) (murphy et al., 2012; yurasek, dennhardt, & murphy, 2015). although initially developed as an intervention for problematic alcohol use in college drinkers (murphy et al., 2012), the sfas protocol has been demonstrated to significantly reduce cannabis use among college students. the current results suggest that motives may be useful to identify ideal candidates for a sfas intervention (i.e., those individuals who report using cannabis due to enjoyment and availability may benefit from an intervention that specifically increases engagement in enjoyable substance-free alternatives). ultimately, it may be useful for future research to consider recreational users’ motives for use as predictors of intervention response to the sfas or related programs. in contrast to recreational users using cannabis as positive reinforcement, our data suggest that medicinal users tend to endorse use for negative reinforcement (i.e., to cope with various problems). first, medicinal users use cannabis for sleep-related motives more often than recreational users. this finding aligns with prior research reporting improvements in sleep as cannabis, a publication of the research society on marijuana 60 a primary reason for medicinal use (e.g., metrik et al., 2018). a recent systematic review of the effects of cannabis on sleep-related variables reported that many studies show subjective improvements in sleep; however, there is currently a lack of consistency between data on subjective (i.e., selfreport) and objective measures of sleep quality (e.g., decreases in sleep disturbances; decreases in sleep onset latency) (kuhathasan et al., 2019). also in line with previous research is the reported medicinal use of cannabis for social anxiety – a number of studies have suggested that cbd, a major constituent of cannabis, may be useful in reducing anxiety symptoms in participants with social anxiety disorder (bergamaschi et al., 2011; crippa et al., 2011). prior research has identified coping motives as potentially playing a mediational role between cannabis use/problems and anxiety (buckner, bonn-miller, zvolensky, & schmidt, 2007; johnson, mullin, marshall, bonnmiller, & zvolensky, 2010). of note, relief of anxiety was one of the most highly endorsed reasons for medicinal cannabis use in our sample. several limitations must be taken into consideration when interpreting the results of the current study. first, because assessments were administered using amazon’s mturk and completed at the participants’ convenience, data quality may have been impacted due to lack of experimental control. however, rigorous inclusion criteria commonly used in mturk studies were implemented. additionally, there has been an increasing body of literature supporting the validity of mturk for behavioral science research in general (e.g., hauser & schwarz, 2016) and addictions research in particular (kim & hodgins, 2017). while our sample was geographicallydiverse, the majority of the sample identified as white which limits the generalizability of our findings to other racial and ethnic groups. moreover, our sample was only drawn from u.s. states with legalized recreational and medicinal cannabis – a future direction will be to collect data from u.s. states that currently only have legalized medicinal cannabis programs. an additional future direction is to collect data from other countries such as canada, where recreational cannabis use was federally legalized in 2018. another limitation involves the inclusion of both prescribed and non-prescribed medicinal cannabis users in the medicinal group. an area of future work is to investigate factors that differentiate medical cannabis card holders from those that self-report using cannabis for medicinal purposes. a final limitation is the relatively small number of individuals in this sample who reported solely medicinal use (5.8% of sample), which restricts our ability to draw comparisons between solely medicinal users and those who use for dual reasons (i.e., medicinal and recreational). this may also reflect a lack of precision in measurement of recreational and medicinal cannabis use that does not account for the multifaceted reasons someone might use cannabis (i.e., for both recreational and medicinal reasons). in conclusion, the present study contributes to a relatively limited literature comparing cannabis motives between specific subgroups of users. specifically, our results further illustrate differences in cannabis use motives between people who use cannabis recreationally vs. medicinally. our results indicate that recreational use is primarily driven by positive reinforcing aspects of cannabis – including enjoyment, celebration, and co-use with alcohol – whereas medicinal use is primarily driven by negative reinforcing aspects such as sleep and social anxiety. given that motives are important predictors of when, where, and how often cannabis use will occur, along with predicting the efficacy of substance use disorder interventions (blevins et al., 2016), exploring specific motives for use among distinct subgroups of users has clear clinical relevance. also considering the expanding role of behavioral economic-based interventions for substance use (e.g., sfas), this study suggests that programs using those interventions might benefit from selectively screening clients based on specific profiles of cannabis use motives. references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2015). a randomized controlled trial of a behavioral economic intervention for alcohol and marijuana use. experimental and clinical psychopharmacology, 23(5), 332–338. https://doi.org/10.1037/pha0000025 funding and acknowledgements: this research was funded, in part, by the michael g. degroote centre for medicinal cannabis research at mcmaster university and the peter boris centre for addictions research at mcmaster university/st. joseph’s healthcare hamilton. dr. metrik was supported by nih grant r01aa024091. the authors acknowledge that this work was conducted on the traditional territory of the mississauga and haudenosaunee nations, and within the lands protected by the dish with one spoon wampum agreement. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 35 abstract marijuana use is a prevalent behavior among college students. little is known regarding edible marijuana use among this population. further, limited research on attitudes towards legalization among edible users is available. the present study examines edible marijuana use among college students and attitudes towards use and legalization. a survey instrument was developed by the research team to investigate the study purpose. participants included a total of 291 students at one midwestern, urban university. results indicated that one in four (26.3%) college students reporting using edible marijuana in their lifetime. no significant differences were found based on sex and race/ethnicity. significant differences were found based on driving behaviors, family use of marijuana, and friends’ use of marijuana. in addition, edible users were significantly more likely than non-users to want marijuana to be legal for recreational and medicinal purposes and were more likely to vote in an upcoming election due to marijuana being on the ballot. such high rates of edible marijuana use may be a cause for concern for health professionals. prevention and risk reduction programs may be warranted. key words: marijuana, edibles, college student, legalization, voting intention research trends indicate that marijuana use among college students is increasing in the us (substance abuse and mental health services administration, 2015). national studies found almost half (48.5%) of college students used marijuana in their lifetime whereas one in five (20.8%) reported using in the past 30 days (johnston, o'malley, bachman, schulenberg, & miech, 2015). although smoking marijuana remains the most common route of administration, variant forms of marijuana use also exist (higher education center for alcohol and drug misuse prevention and recovery, n.d.). additional forms include edible marijuana, drinkable marijuana, marijuana vaporizers, and dabbing of marijuana. edible marijuana may be increasing in popularity. specifically, edible marijuana refers to any food item that includes cannabis (gourdet et al., 2017). typical items consumed include brownies, cookies, other baked goods, suckers and hard candies, and gummy candies among others. research indicates that approximately 30% of marijuana users have consumed an edible form of marijuana (schauer, king, bunnell, promoff, & mcafee, 2016). additional trends demonstrate higher rates of edible marijuana in states that have legalized marijuana for medical purposes (borodovsky et al., 2016). some researchers speculate edible marijuana users choose to eat rather than smoke marijuana to avoid negative consequences associated with inhaling marijuana smoke (university of wisconsin colleges, 2014). corresponding author: dr. rebecca a. vidourek, health promotion and education program, university of cincinnati, cincinnati, oh 45221-0068, phone 513-556-3857, fax, 513-556-3898 email: rebecca.vidourek@uc.edu cannabis 2018, volume 1 (1), 35-43 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.01.003 open access beyond the bong: edible marijuana use among college students rebecca a. vidourek1, keith a. king1, michelle burbage1 1 university of cincinnati, cincinnati, oh http://dx.doi.org/10.26828/cannabis.2018.01.003 edible marijuana use 36 others hypothesize that consuming edibles is less noticeable than smoking marijuana (higher education center for alcohol and drug misuse prevention and recovery, n.d.). however, limited information is available regarding the extent of edible marijuana use among students. in colorado and washington, the selling of edibles has been robust ever since the legalization of recreational marijuana (gourdet et al., 2017). in 2014, almost 50% of total marijuana sales in colorado were of edibles with almost 3 million units of edibles and nearly 2 million units of medicinal edibles being bought at medical marijuana shops (brohl, kammerzell, & koski, 2015). as multiple states have legalized medical marijuana and several legalized marijuana for recreational purposes, increasing attention has been placed on marijuana use and policy initiatives (schuermeyer et al., 2014). greater than half (53%) of us citizens support decriminalizing marijuana whereas 2 in 3 americans (63%) report marijuana as less harmful than alcohol (pew research center, 2015). of the 4 states and the district of columbia to legalize marijuana for recreational use, individuals in those areas must be 21 or older to legally purchase and use marijuana. however, research indicates that diversion of medical marijuana to adolescents as well as increases in overdoses of children exists (16 to 22). furthermore, studies indicate adolescents in states that passed medical marijuana laws are more likely to perceive marijuana as less harmful (keyes, et al., 2016). thus, it is important to investigate use patterns among college students as well as attitudes towards legalization. negative consequences of marijuana use exist and affect both physical and mental health status. cognitive deficits and deleterious impact on brain development have been identified and particularly affect youth and young adults (griffith-lendering, huijbregts, vollebergh, & swaab, 2012). marijuana smoking has been linked to respiratory problems and other chronic diseases such as cancer (owen, sutter, & albertson, 2014). additional research found correlates between marijuana use and psychological issues including depression and anxiety (crippa et al., 2009; degenhardt, hall, & lynskey, 2003; lev-ran et al., 2014; moore et al., 2007; richardson, 2010). individuals who are heavy marijuana users report lower levels of life satisfaction and greater relationship difficulties than light users or those who never use marijuana (fergusson & boden, 2008). moreover, home preparation of thc, which results in edible hash oil, involves the use of butane, or lighter fluid, which has resulted in home fires and explosions, and subsequent serious burns (romanowski et al., 2017). less is known about effects of consuming edible marijuana. whereas smoking marijuana tends to produce the same physical effect for users, the physical effects of consuming marijuana vary (university of wisconsin colleges, 2014). in edibles, levels of tetrahydrocannabinol (thc) may vary producing differing psychoactive effects (washington poison center, n.d.). on average, the effects of edible marijuana tend to last longer than inhaled marijuana. it may also take up to 4 hours for an edible user to feel the effects of marijuana compared to immediately for users who smoke marijuana (colorado department of public health & environment, 2015; washington poison center, n.d.). this can result in the user over consuming edibles, as the effect is not immediate, and therefore the increase in thc can cause a state of psychosis until the drug wears off (hudak, severn, & nordstrom, 2015). purpose of the present study limited research on edible marijuana use among college students is available. identifying the extent and potential trends in use is important for prevention specialists and others to reduce negative consequences associated with use. therefore, the purpose of the present study was to investigate edible marijuana use and identify potential correlates to use. a 2015 ballot initiative was introduced to ohio voters to legalize marijuana for recreational and medical use. primarily, one political action committee, responsible ohio, lead the efforts to legalize marijuana in ohio (lucy burns institute, 2015). a secondary aim of the study was to examine attitudes of edible marijuana users towards legalization. more specifically, the following research questions were assessed: 1) what percent of students used edible marijuana in their lifetime? past year? past 30 days?, 2) is edible marijuana use associated with risky driving cannabis, a publication of the research society on marijuana 37 behaviors?, and 3) does edible use differ based on sex, grade, race/ethnicity, perceived harm, parents and friends’ use, intention to vote, and knowledge of responsible ohio? method participants study participants included students in general education classes at one midwestern urban university. all student participation was voluntary. the institutional review board (irb) granted approval for the current study. instrumentation to assess research questions, a survey was developed to determine participants’ edible marijuana use and attitudes towards marijuana use and attitudes towards voting. the survey was also created to assess risky driving behaviors, which is defined as driving while using marijuana as well as riding in a car with a driver who is intoxicated via this drug. the first section assessed student edible marijuana use including lifetime, past year, and past month use. the next section of the survey examined risky behaviors associated with marijuana use including unsafe driving behavior including: (1) in your lifetime, have you ever used marijuana and driven a car?; (2) during the past 30 days, did you use marijuana and drive a car?; (3) during the past 30 days, did you ride in a car with a driver who had been using marijuana? the next section assessed family and friends use of marijuana, items included: (1) i have a family member that uses marijuana; (2) i have a friend who uses marijuana; (3) my group of friends uses marijuana. the fourth section examined student knowledge and involvement with responsible ohio, the political action committee leading legalization efforts in ohio. this section included the following items: (1) i am familiar with responsible ohio; (2) i attended a responsible ohio event; (3) i have seen responsible ohio campaign materials. each section of the survey instrument requested students to respond by checking the appropriate box (yes/no). the attitudes towards marijuana and marijuana legalization included two items and requested students to respond using a likerttype scale (1 = strongly disagree; 5 = strongly agree). attitudes towards voting and harm included four items and required students respond via the same five point, likert-type scale. these items include: (1) medical marijuana should be legal in ohio; (2) marijuana should be legal in ohio; (3) in general, marijuana is harmful to your health; (4) i usually vote in elections; (5) i intend to vote in november; (6) i intend to vote in november because there is a marijuana law on the ballot. lastly, students were asked to provide demographic and background information including grade, sex, race/ethnicity, grades received, and living location. students were asked to check the box next to the appropriate response. procedures to establish reliability, the survey was distributed in one classroom two weeks apart. kendall’s tau-b correlation coefficients were computed for non-parametric items, which resulted in coefficients greater than .70. similarly, cronbach alphas were computed to establish reliability for each of the parametric data, which yielded coefficients greater than .70. lastly, internal consistency reliability analyses were also calculated resulting in a coefficient greater than .80. for the study, in each class one member of the research team explained the purpose of the study and informed students that all responses would be anonymous. students were also informed that by completing the survey and turning it in, participants granted approval to participate in the study. the survey took approximately 5 to 10 minutes. the survey was distributed to a panel of five experts including three survey researchers and two college health professionals to establish content validity. each panel member was asked to review the survey and provide feedback. all comments were subsequently reviewed by the research team and incorporated into the final instrument. edible marijuana use 38 data analysis data was analyzed using the statistical package for the social sciences (spss) (version 23.0). descriptive statistics (frequencies, means, standard deviations, ranges) were used to describe the demographic information. logistic regression was also conducted to determine if edible marijuana use differed based on demographic and background characteristics. in addition, a series of multivariate analysis of variance (manova) were calculated to determine whether edible marijuana use differed based on attitudes towards marijuana and marijuana legalization, and attitudes towards voting. results sample description the present study included 291 students at a midwestern, urban, public university (see table 1). of 295 students approached to participate, only four declined to complete the survey, resulting in a response rate of 98%. extent of edible marijuana use and use based on demographic characteristics of the students who participated in the study, 26.3% reported using edible marijuana in their lifetime. moreover, 15.5% cited using edibles in the last year and 5.8% stated they used in the last month. results were not significant for edible marijuana use based on sex with 31.9% of males and 22.5% of females reporting edible use in their lifetime (see table 2). results also indicated there were no significant differences based on grade with 25.1% of freshman/sophomores reporting use compared to 34.1% juniors/seniors/graduate students. the results also found no significant differences based on race/ethnicity with 28.1% of white students reporting edible use compared to 20.3% of nonwhite students. extent of risky driving behaviors the data revealed that students who had ever consumed edible marijuana were more likely to use marijuana and drive (55.3%) than table 1. demographic and background characteristics of participants item n (%) sex male 175 (60.1) female 116 (39.9) grade level freshman 183 (63.1) sophomore 66 (22.8) junior 27 (9.3) senior 12 (4.1) graduate student 2 (0.7) race/ethnicity african american 28 (9.8) asian 18 (6.3) white 222 (77.6) hispanic 2 (2.8) multiracial 10 (3.4) living location on campus 163 (56.2) off campus 87 (30.0) at home with parents 38 (13.1) other 2 (0.7) grades received mostly as 132 (46.3) mostly bs 130 (45.6) mostly cs 23 (8.1) notes: n = 291 choose to not engage in that particular risky driving behavior (44.7%). significant differences on lifetime edible use was found based on using marijuana and driving χ2 (1, n = 291) = 59.588, p < .001. findings also revealed that of the students who ever consumed edibles, 21.1% used marijuana and drove in the past 30 days and 43.4% rode with a driver who used marijuana within the last month of survey distribution. results indicated significant differences for use based on recently using marijuana and driving χ2 (2, n = 291) = 35.098, p < .001, as well as recently riding in a vehicle with a driver who has been using this drug χ2 (2, n = 291) = 23.715, p = p < .001. edible marijuana use based on parent and peer use of marijuana the majority of participants that reported ever using edibles also cited having a family member that uses marijuana (55.3%) in contrast cannabis, a publication of the research society on marijuana 39 table 2. odds ratios for ever used edible marijuana based on background and demographic characteristics, family and friend use, and awareness of responsible ohio item or (95% ci) χ 2 p sex male a .621 (.366, 1.054) 3.134 .077 female grade freshman/sophomore a 1.547 (.763, 2.137) 1.481 .224 junior/senior race white a .654 (.333, 1.285) 1.534 .216 nonwhite family use no a 1.0 yes 2.524 (1.478, 4.309) 11.840 .001 group of friends use no a 1.0 yes 4.839 (2.618, 8.944) 27.993 <.001 awareness of responsible ohio no a 1.0 yes 3.245 (1.30, 5.753) 17.114 <.001 note. a indicates referent. to having family members that did not use this substance (44.7%) (see table 2). significant differences on edible use was found based on family’s use of marijuana χ2 (1, n = 291) = 11.840, p = .001. comparably, lifetime edible use was higher among students who had a group of friends that use edibles (78.9%) than those who did not have a group of friends who use this particular substance (21.1%). significant differences were found based on group of friends use χ2 (1, n = 291) = 27.993, p < 0.001. knowledge of responsible ohio concerning responsible ohio, results indicate that individuals who ever used edibles accounted for 42.1% of those who are familiar with this campaign, whereas only 18.3% of those who did not use the substance were aware of the campaign (see table 2). findings denoted significant differences for knowledge based on lifetime use χ2 (1, n = 291) = 17.114, p < .001. in addition, 6.6% of the students who used this drug and 2.3% who do not use attended a responsible ohio event. students who use edibles accounted for 43.4% of those who have seen materials related to the campaign as opposed to 23.5% of non-users citing they had seen campaign materials. significant differences were not found for attending an event based on use χ2 (1, n = 291) = 3.002, p = .083 although significant differences were indicated for seeing materials based on use χ2 (1, n = 291) = 10.887, p = .001. differences based on attitudes towards marijuana use and legalization and typical voting behaviors and intention to vote results of the study indicated that students who ever used edible marijuana were more likely to want marijuana to be legal (m = 3.97, sd = .979) than those who never used edibles (m = 2.97, sd = 1.209) (see table 3). moreover, students who ever used edibles were more likely to want medical marijuana to be legal (m = 4.36, sd = .860) than those who never used (m = 3.75, sd = .961). significant differences were found based on attitudes edible marijuana use 40 table 3. ever used edible marijuana based on attitudes towards legalization item have not used in lifetime have used in lifetime m (sd) m (sd) f p marijuana should be legal in ohio 2.97 (1.209) 3.97 (.979) 42.507 <.001 medical marijuana should be legal in ohio 3.75 (.961) 4.36 (.860) 23.337 <.001 note. n = 291. table 4. ever used edible marijuana based on intention to vote item have not used in lifetime have used in lifetime m (sd) m (sd) f p i usually vote in elections 2.96 (1.136) 3.05 (1.118) .399 .528 i intend to vote in november 3.49 (1.123) 3.62 (1.243) .709 .400 i intend to vote because marijuana is on the ballot 2.56 (.999) 2.96 (1.238) 7.856 .005 note. n = 291. towards marijuana becoming legal in ohio, f(1, 291) = 42.507, p < .001 as well as medical marijuana becoming legal in ohio, f(1, 291) = 23.337, p < .001. students who ever used edibles were slightly more likely (m = 3.05; sd = 1.118) to usually vote than their peer counterparts (m = 2.96; sd = 1.136) (see table 4). no significant differences in students’ use based on voting behaviors were found, f(1, 291) = .399, p = .528. students who used were also slightly more likely to intend to vote in november (m = 3.62; sd = 1.243) than nonusers (m = 3.49; sd = 1.123). no significant differences in students’ use based on intention to vote were found, f(1, 291) = .709, p = .400. in line with these results, student who have used this substance were slightly more likely (m = 2.96; sd = 1.238) to plan to vote due to marijuana being on the ballot as opposed to students who have not used this substance (m = 2.56; sd = .999). significant differences in students’ use based on intention to vote due to marijuana being on the ballot were found, f(1, 291) = 7.856, p = .005. discussion study findings revealed greater than one in four college students ever used edible marijuana. regarding past year, approximately 15% used whereas approximately 5% used in the past 30 days. in comparison, previous research found 5% of colorado youth had used edible marijuana products in their lifetime (johnson, et al., 2016). such high rates of edible marijuana use in this sample are cause for concern as limited research exists on the determinants and consequences of use. few studies have examined the extent of edible marijuana use; therefore, the present study has identified high rates of use and provides insight into this behavior. it is apparent intervention is needed to educate this population on edible marijuana use, increasing awareness and enabling students to make informed decisions regarding use of marijuana edibles. the present study found no differences in edible marijuana use based on sex, grade, or race/ethnicity. it appears edible marijuana use may be popular among college students across varying demographics and backgrounds. this is contrary to previous research, which indicates male college students are more likely than female college students to use marijuana (johnston, o’malley, bachman, schulenberg, & miech, 2015). similarly, a qualitative study of teen edible marijuana use found females were more likely to use edibles (friese, slater, annechino, & battle, 2016). there is a lack of research specifically on edible marijuana use. it is clear additional research on characteristics of edible marijuana users are needed. similar to other drugs, family and friends use of drugs was found to place students at risk for edible use. students were more likely to use edible marijuana if a family member used marijuana. regarding friends, students were almost 5 times as likely to use edibles if friends used marijuana. additional research suggests that parent behavior has an impact on friend cannabis, a publication of the research society on marijuana 41 choice among adolescents and emerging adults (loke & wong, 2010). additionally, adolescents and emerging adults tend to choose peer groups based on common attitudes and beliefs (alexander et al., 2001; andrews et al., 2002; simons-morton, 2007). thus, it is not surprising that parent and peer use is associated with increased odds of use. concerningly, students who ever used marijuana and drove in a car were 10 times more likely to use edibles than students who did not ever use and drive a car. students who rode with a driver who used marijuana were over 4 times more likely than their counterparts to use edible marijuana. it is possible that students in this group may feel as if marijuana use is not a risky behavior. conversely, it is also possible this group is also simply at high risk and engages in risky behaviors. additional research is warranted to investigate student perceptions of marijuana use and driving. similarly, edible users’ perceived harm of marijuana use should also be investigated. in the present study, edible users were less likely than non-users to feel marijuana is harmful. it is possible edible users may be sensation-seekers or willing to experiment with a variety of behaviors. perhaps, as a group, these users perceive behaviors as less likely to be risky or harmful. based on study findings, additional research is warranted to investigate psychosocial factors that may be associated with edible marijuana use. in the present study, edible marijuana users were less likely than non-users to feel marijuana is harmful. perceived harm of marijuana use is decreasing among young adults (johnston et al., 2015). long-term studies of the health effects of edible marijuana use are needed. if consequences are found, then harm reduction approaches and educational campaigns educating the public on harmful effects can be utilized. students familiar with responsible ohio were 3 times more likely to have used edible marijuana than their counterparts who were not familiar with that organization. it may be possible that responsible ohio was successful in targeting current marijuana users with their initiatives yet failed to target non-users. it may be interesting to assess future campaigns and successes in directing campaign materials and events to marijuana and non-marijuana users. not surprisingly, edible users were more likely than non-users to believe marijuana should be legal for both medicinal and recreational purposes. interestingly, study findings also revealed that edible marijuana users were slightly more likely than non-users, to vote, vote in the upcoming election, and to vote because marijuana was on the ballot. research on voting behaviors indicates that prominent issues and events may effect voting behavior (south university, 2016). it may be that edible users were more interested in the election due to marijuana legalization appearing on the ballot. previous research of college students found that holding a positive attitude regarding marijuana use increased the odds of voting for marijuana legalization (moreno et al., 2016). the present study found that use contributed to intention to vote as well as intention to vote specifically due to a marijuana initiative being on the ballot. limitations the following are study limitations. in this study, participants included students enrolled in one midwestern, urban university in ohio, and therefore it may not be possible to generalize these findings to other populations. second, study findings are limited by the honesty and selfreporting accuracy of the participants. third, as this was a cross-sectional study, cause and effect cannot be determined. next, this study only examined marijuana users who reported consuming edible marijuana. no comparisons were made between marijuana users who consume via smoking versus marijuana users who consume edibles. future studies should seek to examine differences based on marijuana route of administration. conclusions marijuana use is commonly reported among college students; however, limited information is available specifically on edible marijuana use. the present study found 26.3% of students ever used edible marijuana in their lifetime. with greater than one in four students reporting using edible marijuana, attention is needed to this behavior on college campuses. additionally, potential negative consequences for college students should be explored. future research on edible marijuana should compare students who smoke marijuana with edible marijuana use 42 those who use edible products. perhaps, there are differences in these two populations. additionally, identifying the types and quantity of edible marijuana consumed may be an important step. edible marijuana may be increasing in popularity and research is necessary to explore this health behavior among college students. references alexander, c., piazza, m., mekos, d., & valente, t. 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(2014). effects of cannabis on impulsivity: a systematic review of neuroimaging findings. current pharmaceutical design, 20(13), 21262137. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 1 abstract higher levels of coping motives are associated with higher frequency and quantity of alcohol and marijuana use, and higher levels of stress may exacerbate this association. in this study, we examined whether perceived level of stress moderated the association between coping motives and alcohol and marijuana use in a sample of young adult men. data came from men who were interviewed at mean age 26 (n = 425) and again at mean age 29 (n = 400). past year frequency and quantity of drinking and past year frequency of marijuana use were assessed as outcomes. enhancement motives and race were controlled in the analyses. hierarchical regression analyses indicated that stronger alcohol coping motives were significantly related to greater frequency and quantity of alcohol use at ages 26 and 29 and stronger marijuana coping motives were significantly related to greater frequency of marijuana use at age 26 but not 29. coping motives at age 26 were not predictive of alcohol or marijuana use at age 29. enhancement motives attenuated the effects of coping motives concurrently and were significantly related to all substance-specific outcomes at the same wave. crossover effects from alcohol coping motives to marijuana use and from marijuana coping motives to alcohol use were not significant at ages 26 or 29. stress did not moderate the effects of coping on any outcome. although coping motives were significant substance-specific predictors of alcohol and marijuana use in young adulthood, most of these associations were no longer significant once enhancement motives were controlled. interventions to challenge both enhancement and coping motives are needed for young men throughout young adulthood. key words: alcohol use, marijuana use, stress, coping motives, enhancement motives it is imperative to understand reasons why individuals use substances in order to develop effective interventions to reduce use and related problems. coping motives, which involve using substances to escape from or avoid unpleasant emotional states, have been identified as the type of motives most directly associated with the experience of negative consequences for both alcohol and marijuana use (cooper, kuntsche, levitt, barber, & wolf, 2016). furthermore, in accord with a stress-coping model (wills & shiffman, 1985), some individuals use substances specifically as a coping response to stress to either increase positive affect and/or decrease negative affect. thus, higher levels of stress might exacerbate the association between coping motives and negative substance use outcomes. in this study, we examine whether perceived level of stress moderates the association between coping corresponding author: helene r. white, center of alcohol studies and department of sociology, rutgers, the state university of new jersey, 607 allison road, piscataway, nj 08854-8001, u.s.a., email: hewhite@smithers.rutgers.edu cannabis 2018, volume 1 (1), 1-13 © author(s) 2017 researchmj.org doi: 10.26828/cannabis.2018.01.001 open access stress as a moderator of the effects of coping motives on alcohol and marijuana use in young adulthood helene r. white1, kristen g. anderson2, jordan beardslee3 1 center on alcohol studies and department of sociology, rutgers, the state university of new jersey, piscataway, nj 2 department of psychology, reed college, portland, or 3 department of criminology and criminal justice, arizona state university, phoenix, az http://dx.doi.org/10.26828/cannabis.2018.01.001 stress, coping, and substance use 2 motives and alcohol and marijuana use in a sample of young adult men. motives for substance use substance use motives are reasons that individuals endorse for using substances and are proximal predictors of consumption (cox & klinger, 1988; kuntsche, knibbe, gmel, & engels, 2005). cooper’s (1994) four-factor framework of drinking motives has been the most frequently studied in the alcohol literature. in this framework, social motives involve reasons to drink associated with social facilitation; enhancement motives capture reasons associated with fun and pleasure; coping motives indicate drinking to reduce negative affect; and conformity motives relate to drinking to fit-in with peers. cooper’s model fits well for alcohol use among adolescents and young adults (cooper et al., 2016). overall, most individuals endorse social and enhancement motives with fewer indicating coping and conformity motives (cooper et al., 2016; crutzen, kuntsche, & schellemanoffermans, 2013; kuntsche et al., 2005). in general, social motives are associated with moderate alcohol use, enhancement motives with heavy drinking, and coping motives with heavier drinking and alcohol-related problems (cooper et al., 2016; kuntsche et al., 2005; schellemanoffermans, kuntsche, & knibbe, 2011). findings for conformity motives have been less consistent (cooper et al., 2016; kuntsche et al., 2005). simons, correia, carey, and borsari (1998) developed the marijuana motives measure (mmm) by adding a fifth type of motive to the cooper framework. the fifth factor, expansion, was added to account for the “psychedelic” effects of marijuana. this framework has been supported in samples of college students and emerging adults (e.g., bonn-miller & zvolensky, 2009; simons, correia, & carey, 2000; zvolensky et al., 2007). in contrast to alcohol, enhancement motives are most strongly endorsed for marijuana followed by social motives (cooper et al., 2016). although less frequently endorsed, marijuana coping motives have been related to more frequent marijuana use and negative consequences (cooper et al., 2016). for example, in a sample of adult marijuana smokers from the community, bonn-miller, zvolensky, and bernstein (2007) found that coping motives were uniquely associated with last month marijuana use, even after controlling for number of years of marijuana use and current alcohol and tobacco use (see also foster, buckner, schmidt, & zvolensky, 2016; johnson, bonn-miller, leyro, & zvolensky, 2009). furthermore, coping motives have been found to predict marijuana-related problems, even after controlling for use (buckner, 2013; lee, neighbors, & woods, 2007; moitra, christopher, anderson, & stein, 2015; patrick, bray, & berglund, 2016), although some studies have not found an association between marijuana coping motives and marijuana-related problems (e.g., zvolensky et al., 2007). stress, coping, and substance use research has consistently demonstrated that use of certain substances, such as alcohol, serves a stress-reduction function (wills & shiffman, 1985). this type of coping is motivated by a desire to reduce tension, promote relaxation, and avoid problems. labouvie (1986) found that adolescents who used alcohol and drugs to cope with problems reported the highest frequency and quantity of alcohol and marijuana use. in addition, these same adolescents experienced heightened levels of social and life stress. wills (1985) also found that problematic drinking was related to subjective stress among adolescents, consistent with the notion of a reciprocal process between stress and coping-related use (marlatt, 1985). marijuana use has also been linked to stress and coping. for example, in a sample of emerging adults, moitra et al. (2015) found a strong relationship between using marijuana to cope and perceived stress. in a study of adolescents, fox, towe, stephens, walker, and roffman (2011) found that frequency of marijuana use, internalizing problems, and marijuana coping motives explained the most unique variance in cannabis use dependence (cud) symptoms. researchers have found that individual internalizing factors moderate the association between coping use of substances and higher levels of use and problems. for example, in several studies, young adults who used marijuana to cope, compared to those who did not, experienced greater psychological distress and negative affect (beck et al., 2009; fox et al., 2011; mitchell, zvolensky, marshall, bonn-miller, & vujanovic, 2007; moitra et al., 2015; zvolensky et al., 2009). fox et al. (2011) found a significant interaction effect between internalizing behavior cannabis, a publication of the research society on marijuana 3 problems and using marijuana to cope with negative affect on cud symptoms. specifically, those adolescents who reported lower, rather than higher, levels of internalizing behavior problems and used marijuana to cope reported more symptoms of cud. similarly, holahan, moos, holahan, cronkite, and randall (2001) found that, over a 10-year period, the associations of anxiety and depression with alcohol consumption and alcohol-related problems were stronger for individuals who used alcohol to cope at baseline (ages 18-88 at baseline) compared to those who did not (see also holahan, cronkite, & randall, 2003). in a cigarette smoking treatment-seeking sample, foster and colleagues (2016) examined the extent to which psychological factors (depressive affect, social anxiety) moderated the associations between coping motives and multiple types of substance use (alcohol use, marijuana use). their study is also unique because they examined the crossover effects of marijuana coping motives on alcohol use as well as alcohol coping motives on marijuana use. this study found that alcohol coping motives were associated with heavier drinking; however, this association was moderated by a significant 3-way interaction between alcohol coping motives x social anxiety x depressive symptoms. the authors’ posthoc probing of the interaction suggested that the association between alcohol coping motives and heavier drinking among those with lower social anxiety was only significant among those with high depressive symptoms. however, among those with high social anxiety, alcohol coping motives was significantly associated with heavier drinking for individuals with low or high depressive symptoms. these same three-way interactions did not reach statistical significance for marijuana use. however, marijuana coping motives were marginally associated with greater drinking among those with higher social anxiety and high depressive symptoms. thus, it appears that negative affect and internalizing problems moderate the association between coping motives and substance use. it is also possible that levels of stress may moderate this association, that is, that individuals with higher coping motives may drink or use drugs more heavily than their peers with lower coping motives when exposed to stress. several experimental studies have demonstrated differential responses to stress between participants high and low in drinking coping motives and interactions between coping and stress or negative mood induction on drinkingrelated outcomes, such as attentional bias for alcohol cues, craving, and reinforcement value of alcohol (e.g., birch et al., 2004; field & powell, 2007; field & quigley, 2009; grant, stewart, & birch, 2007; rousseau, irons, & correria, 2011). only one laboratory study that we are aware of examined whether response to stress interacted with coping motives to predict alcohol consumption. thomas, merrill, hofe, and magid (2014) found that, although participants high, compared to low, on drinking coping motives differed in their response to stress (those higher showed less of a response), there were no effects of stress on alcohol consumption and no differential effects for the two groups. only a few survey studies have empirically tested this stress moderation hypothesis and only for alcohol. abbey, smith, and scott (1993), in a cross-sectional study of adults, found that coping use of alcohol was more strongly associated with heavy drinking among individuals with moderate or high levels of stress compared to individuals with lower levels of stress. in a longitudinal study of middle-aged adults, windle and windle (2015) examined moderating effects among alcohol use, coping motives, and stress on later drinking behavior. they found one significant interaction of stress and coping for men but not for women. specifically, higher levels of coping motives interacted with higher levels of stress to predict increases in alcohol problems over time and lower levels of coping motives interacted with higher stress to predict lower levels of alcohol problems over time. there were no significant interactive effects of stress by coping on drinking patterns (quantity-frequency and heavy drinking) for men or women. in contrast, there were several significant interactions between earlier drinking and stress and between earlier drinking and coping for both men and women. when the same sample was studied as adolescents, the interaction between major stressful life events and coping drinking motives was not related to alcohol use or alcohol problems (windle & windle, 1996). current study stress, coping, and substance use 4 foster et al. (2016) point to the scarcity of studies that have examined the interactive relations between coping motives and psychological factors across multiple substances. in fact, to our knowledge, their study is the only one to examine psychological moderators (i.e., depressive symptoms, social anxiety) in the context of crossover effects of alcohol and marijuana coping motives on different types of substance use. in this study, we examine the substance-specific and crossover effects of coping motives for alcohol and marijuana examining stress as the moderator. specifically, we test whether perceived stress moderates the associations between alcohol and marijuana coping motives and alcohol and marijuana frequency use as well as alcohol quantity in a community sample of young adult men. we hypothesize that: 1) stronger coping motives will be associated with higher levels of substance use; 2) for those men with higher, compared to lower, levels of stress, the association between coping motives and greater substance use will be stronger; and 3) substance-specific associations will be stronger than crossover associations. method design and sample we used data from the pittsburgh youth study (pys), which is a prospective study of the development of delinquency, substance use, and mental health problems (loeber, farrington, southamer-loeber, & white, 2008). the pys recruited three cohorts of boys from the pittsburgh public schools in 1987-1988; only boys were included because of the original focus of the study on delinquency. in this study, we included only the youngest cohort, which was recruited from the incoming first grade class. a random sample of 849 boys were screened for early conduct problems as assessed by self-report, primary caretakers’ reports, and teachers’ reports. boys who scored in the top 30% on conduct problems and an approximately equal number randomly selected from the remaining sample were selected for follow-up (n = 503; mean age = 6.9; sd = 0.5). the follow-up sample did not differ significantly from the screening sample on race, family composition, and california achievement test reading scores (pardini et al., 2015). the sample was comprised of predominately black (55.7%) and white (40.6%) boys. most primary caregivers were biological mothers (92%) and more than half of the families (61.3%) were receiving public financial assistance (see loeber et al. [2008] for details). after screening, youths were interviewed at 6month intervals for 4 years and then annually for 9 years until mean age 20 (sd = 0.61), with an average completion rate above 90% across the 14 years of data collection. in 2006-2007, follow-up interviews were conducted at mean age 26 (sd = 1.0; n = 427), and in 2009-2010 at mean age 29 (sd =1.1; n = 402). eleven men were deceased before the age 26 follow-up (2.2%), and a total of 16 men were deceased before the age 29 assessment (3.2% of initial sample). of the men who were alive at the time of the age 26 follow-up (n = 492), 89.8% provided data at either the age 26 or age 29 assessment (n = 442). men who did not provide data at either follow-up (including those who died) did not differ from men who participated in at least one young adult interview on average alcohol frequency and marijuana frequency between ages 14-17. for this study, we focused on the age 26 and age 29 assessments because the coping scales from the cooper (1994) drinking motivation questionnaire revised (dmq-r) and the simons et al. (1998) mmm were only available at those two time points. at each age only alcohol and/or marijuana users were included in the analysis. in adulthood, most interviews were conducted in-person using a laptop computer and written consent was obtained from the men. all study procedures were approved by the university of pittsburgh institutional review board. measures substance use. participants reported the number of times (continuous scale from 0 to 365) they used alcohol and marijuana in the last year at age 26 and at age 29. alcohol users were also asked the typical quantity they consumed on days when they drank (5-point scale from 1 = less than one drink to 5 = six plus drinks). nonusers were coded as 0. means and standard deviations for all measures are shown in table 1. coping motives. the men completed the coping scales from the dmq-r (cooper, 1994) and mmm (simons et al., 1998). these scales ask how often (5-point scale: 1 = almost never/never, 2 = some of the time, 3 = half of the time, 4 = most of cannabis, a publication of the research society on marijuana 5 the time, 5 = almost always/always) participants used a substance for a particular reason when they used that substance in the past year. the same five items were asked for alcohol and marijuana: “to forget your worries,” “because it helps when you feel depressed,” “to cheer you up when in a bad mood,” “to forget your problems,” and “to feel more self-confident and sure of yourself.” cronbach alpha was .87 for alcohol coping at age 26 and .87 at age 29 and .87 for marijuana coping at age 26 and .82 at age 29. stress. stress was measured with 13 items from the perceived stress scale (cohen & williamson, 1988), which measures perceptions of stress level and ability to handle problems. respondents reported on the frequency (5 point scale: 1 = never, 2 = almost never, 3 = sometimes, 4 = fairly often, and 5 = often) in the month prior to the assessment. example items included: “upset because of something that happened unexpectedly,” “felt nervous and ‘stressed’,” “inability to cope with things you had to do,” and “unable to control important things in your life.” in this sample, the alpha was .86 at age 26 and .87 at age 29. control variables. enhancement motives were controlled in the analysis because in some studies they have attenuated the association between coping motives and substance use (see cooper et al., 2016). we could not control for social and conformity motives because they were not assessed in this study. enhancement motives were assessed by the dmq-r (cooper, 1994) and mmm (simons et al., 1998) using the same response options as for coping motives. the same five enhancement motives were asked for alcohol and marijuana: “i like the feeling,” “it’s exciting,” to “get high,” “it gives me a pleasant feeling,” and “it’s fun.” chronbach alpha was .86 for alcohol enhancement at age 26 and age 29 and .82 for marijuana enhancement at age 26 and .80 at age 29. . table 1. correlations among variables at ages 26 (above the diagonal) and 29 (below the diagonal) and sample descriptive statistics at ages 26 and 29 stress acope falc qalc aenh mcope fmar menh stress .37*** .04 -.07 .11* .48*** .18*** .15 acope .40*** .26*** .22*** .40*** .61*** .13* .13 falc .07 .28*** .46*** .34*** .15 .25*** .11 qalc .07 .28*** .41*** .46*** -.01 .18*** .09** aenh .18** .41*** .27*** .50*** .17* .24*** .51*** mcope .44*** .62*** .02 .07 .17 .25** .42*** fmar .12* .11 .26*** .26*** .15** .20* .41*** menh .09 .05 .07 .08 .42*** .30*** .27** mean at 26 28.72 7.85 66.07 3.12 13.04 10.13 60.0 17.40 sd at 26 7.21 3.52 79.68 1.76 4.92 4.90 121.76 4.78 (n) at 26 (425) (344) (425) (425) (344) (159) (425) (159) mean at 29 29.95 7.83 62.27 3.11 12.78 9.12 58.11 17.34 sd at 29 7.89 3.65 79.78 1.65 4.85 4.10 116.60 4.80 (n) at 29 (399) (332) (400) (399) (332) (138) (400) (138) note. acope = alcohol coping motives; falc = frequency of alcohol use; qalc = quantity of alcohol use; aenh = alcohol enhancement motives; mcope = marijuana coping motives; fmar = frequency of marijuana; menh = marijuana enhancement motives; sd = standard deviation; (n) = sample size for that variable. *p < .05; **p < .01; ***p < .001. stress, coping, and substance use 6 we also controlled for race in the analyses due to race differences in substance use (white, loeber, & chung, 2016). in this sample, black, compared to white, men reported significantly higher alcohol frequency at age 26 (t = 2.83, df = 326, p < .01), higher marijuana frequency at age 26 (t = 3.99, df = 149, p < .001) and age 29 (t = 2.84, df = 130, p < .01), and lower alcohol quantity at age 26 (t = -3.60, df = 326, p < .001). race was included as two dummy variables, white and other, with black as the reference group analytic plan first, we examined correlations among the variables separately at age 26 and age 29. next, we tested hierarchical ols regression models. the first model regressed substance use on coping motives and level of perceived stress. the second model added enhancement motives to the first model. the third model added the interaction term between stress and coping to the second model. all independent variables were standardized. these models were conducted separately for alcohol and marijuana outcomes cross-sectionally at age 26 (n = 344 and n = 159, respectively) and age 29 (n = 332 and n = 138, respectively), controlling for race. in addition, longitudinal models were tested by including age 26 stress and motives to predict age 29 substance use outcomes (n= 317 for alcohol and n = 149 for marijuana), while controlling for age 26 substance use as well as race. analyses were run examining the association of alcohol coping with alcohol frequency and quantity and marijuana frequency as well as the association of marijuana coping with these three outcomes. because we examined three outcomes (alcohol frequency, alcohol quantity, and marijuana frequency) at three time frames (age 26, age 29, and from age 26 to age 29), a bonferroni correction was applied (p < .0056). results descriptive analyses table 1 shows the correlations among each of the measures and their means and standard deviations. at both ages, there was a strong association between alcohol coping motives and marijuana coping motives. in addition, at both ages, stress was strongly associated with both alcohol and marijuana coping. at age 26 and age 29, alcohol coping motives were modestly associated with alcohol frequency and quantity, and marijuana coping motives were modestly associated with marijuana frequency. alcohol and marijuana enhancement motives were strongly correlated with each other as well as moderately correlated with their substance-specific coping motives. substance-specific analyses table 2 shows the results from the main effects models examining the associations between alcohol coping and alcohol outcomes and between marijuana coping and marijuana outcomes. none of the interactions of coping motives and stress was significant; thus, the results from these models are not included in the table (but are available from the first author upon request). without substance-specific enhancement motives in the model (model 1), stronger alcohol coping motives were significantly related to higher alcohol frequency and quantity at both ages. stress was not significantly related to alcohol frequency at either age. higher stress was related to higher alcohol quantity at age 29 but not at age 26. with controls for age 26 alcohol frequency, alcohol coping motives and stress at age 26 did not significantly predict alcohol frequency at age 29. with controls for age 26 alcohol quantity, neither alcohol coping nor stress at age 26 significantly predicted age 29 alcohol quantity. in model 1, coping motives for marijuana use were concurrently related to marijuana frequency at age 26 but not age 29. stress was not significantly related to marijuana frequency at either age. with controls for age 26 marijuana frequency, neither marijuana coping motives at age 26 nor stress at age 26 significantly predicted marijuana frequency at age 29. when substancespecific enhancement motives were added to the models (model 2), the association between alcohol coping and alcohol frequency remained significant at age 29 but not at age 26 and the association between alcohol coping and alcohol quantity lost significance at both ages. stress at age 29 remained a significant predictor of alcohol quantity at age 29. alcohol cannabis, a publication of the research society on marijuana 7 table 2. results from main effectsa models for substance-specific analyses, with and without enhancement motivesb alcohol frequency alcohol quantity marijuana frequency at age 26 (n=344) model 1 b (se) model 2 b (se) at age 26 (n=344) model 1 b (se) model 2 b (se) at age 26 (n=159) model 1 b (se) model 2 b (se) alcohol coping 21.18*** (4.56) 11.62 (4.78) alcohol coping 0.25*** (0.05) 0.06 (0.05) marijuana coping 39.26** (13.08) 14.55 (13.49) stress -0.99 (4.62) .15 (4.46) stress -0.01 (0.06) 0.01 (0.05) stress -9.68 (12.08) -5.30 (11.42) alcohol enhancement 22.62*** (4.44) alcohol enhancement 0.44*** (0.05) marijuana enhancement 53.77*** (11.91) r2 .09*** .15*** r2 .11*** .27*** r2 .15*** .25*** at age 29 (n=331) at age 29 (n=331) at age 29 (n=138) alcohol coping 22.65*** (4.74) 16.59** (5.04) alcohol coping 0.21*** (0.05) 0.03 (0.05) marijuana coping 30.03 (13.48) 18.44 (13.77) stress -2.38 (4.79) -2.65 (4.73) stress 0.19*** (0.06) 0.18*** (0.05) stress -20.44 (14.26) -18.73 (13.91) alcohol enhancement 14.93** (4.68) alcohol enhancement .44*** (.05) marijuana enhancement 34.45** (12.20) r2 .09*** .12*** r2 .12*** .30*** r2 .10 .15*** age 26 to 29 (n=317) age 26 to 29 (n=316) age 26 to 29 (n=149) alcohol coping 0.88 (4.56) -0.25 (4.83) alcohol coping -0.07 (0.08) -0.12 (0.08) marijuana coping -8.55 (13.23) -13.42 (14.15) stress -2.21 (4.50) -2.12 (4.50) stress 0.15 (0.08) 0.16 (0.08) stress 11.01 (11.86) 12.03 (11.90) alcohol frequency 39.65*** (4.16) 38.82*** (4.32) alcohol quantity 0.51*** (0.08) 0.45*** (0.08) marijuana frequency 42.10*** (9.80) 38.64*** (10.43) alcohol enhancement 3.31 (4.64) alcohol enhancement 0.15 (0.09) marijuana enhancement 13.05 (13.42) r2 .25*** .25*** r2 .14*** .15*** r2 .15*** .15*** note. a only main effects models are shown because none of the interactions was significant. b race was controlled in all models and was coded as two dummy variables (white and other) with black as the reference group; results for race are not shown to simplify the presentation. **p < .0056; ***p < .001. stress, coping, and substance use 8 enhancement motives were significantly related to alcohol frequency and quantity at both ages. after controlling for age 26 alcohol use, coping and enhancement motives and stress at age 26 were not significant predictors of alcohol frequency or quantity at age 29. when substance-specific enhancement motives were added to the models (model 2), the association between alcohol coping and alcohol frequency remained significant at age 29 but not at age 26 and the association between alcohol coping and alcohol quantity lost significance at both ages. stress at age 29 remained a significant predictor of alcohol quantity at age 29. alcohol enhancement motives were significantly related to alcohol frequency and quantity at both ages. after controlling for age 26 alcohol use, coping and enhancement motives and stress at age 26 were not significant predictors of alcohol frequency or quantity at age 29. in model 2, marijuana enhancement motives significantly predicted marijuana frequency at both ages, whereas marijuana coping motives and stress did not. with control for marijuana frequency at age 26, coping and enhancement motives and stress at age 26 were not significantly related to marijuana frequency at age 29. crossover analyses table 3 shows the same main effects models for crossover effects, that is, marijuana motives predicting alcohol use and alcohol motives predicting marijuana use. again, none of the interactions was significant and, thus, these models are not shown (but are available from the first author). at both ages marijuana coping was not related to alcohol frequency or quantity and alcohol coping was not significantly related to marijuana frequency, with and without control for enhancement motives (model 2 and model 1, respectively). in both models 1 and 2, stress at age 26 was significantly related to marijuana frequency at age 26 but this association was not significant at age 29. alcohol enhancement motives were significantly related to marijuana frequency at age 26 but not 29. in the longitudinal models marijuana coping was negatively related to alcohol frequency but none of the other crossover effects was significant. discussion consistent with previous studies (for reviews see cooper et al., 2016; kuntsche et al., 2005), there were significant concurrent associations between alcohol coping motives and alcohol frequency and quantity. marijuana coping motives were also significantly related to marijuana frequency at age 26 but not 29. these associations were not statistically significant when enhancement motives were included in the model (except for alcohol coping motives predicting alcohol frequency at age 29), and instead substance-specific enhancement motives were the strongest predictors of use outcomes in all cross-sectional analyses. thus, it appears that frequent and heavy use, at least during the midto-late 20s, is more strongly related to enhancement motives than coping motives. in some ways this is not surprising given that coping motives have more consistently been associated with substance use-related problems than with use (cooper et al., 2016). future research should examine coping and enhancement motives as predictors of substance use problems. unfortunately, we only obtained diagnostic information and base rates of substance use disorders were too low for analysis in the present study. despite strong bivariate associations between alcohol and marijuana coping motives at both ages, the cross-sectional crossover effects from alcohol coping motives to marijuana use and from marijuana coping motives to alcohol use were not significant. these findings are consistent with other studies of crossover effects of coping motives (e.g., foster, allan, zvolensky, & schmidt, 2015; foster et al., 2016). because alcohol and marijuana have different psychopharmacological effects, some people may prefer one drug over the other for relief from negative affect, and, thus, crossover effects for coping motives may not be strong. similarly, there was only one crossover effect for enhancement motives, from alcohol enhancement to marijuana frequency at age 26. perhaps during the peak years of use, those youths who use alcohol for fun and to get high may also be likely to use marijuana for these same reasons. cannabis, a publication of the research society on marijuana 9 table 3. results from main effectsa models for crossover analyses, with and without enhancement motivesb alcohol frequency alcohol quantity marijuana frequency at age 26 (n = 159) model 1 b (se) model 2 b (se) at age 26 (n = 159) model 1 b (se) model 2 b (se) at age 26 (n = 344) model 1 b (se) model 2 b (se) marijuana coping 13.79 (8.35) 11.33 (9.16) marijuana coping 0.05 (0.12) -0.03 (0.13) alcohol coping 6.45 (7.08) -5.88 (7.52) stress -1.23 (7.71) -0.80 (7.75) stress -0.07 (0.11) -0.06 (0.11) stress 20.15** (7.17) 21.62** (7.01) marijuana enhancement 5.36 (8.09) marijuana enhancement 0.17 (0.12) alcohol enhancement 29.19*** (6.98) r2 .02 .03 r2 .06 .07 r2 .14*** .18*** at age 29 (n = 138) at age 29 (n = 137) at age 29 (n = 331) marijuana coping -2.25 (9.24) -4.79 (9.68) marijuana coping -0.09 (0.11) -0.14 (0.11) alcohol coping 6.38 (7.28) 0.13 (7.82) stress 3.25 (9.77) 3.62 (9.79) stress 0.10 (0.11) 0.11 (0.11) stress 9.06 (7.37) 8.79 (7.33) marijuana enhancement 7.53 (8.58) marijuana enhancement 0.13 (0.10) alcohol enhancement 15.39 (7.26) r2 .01 .02 r2 .07 .08 r2 .06*** .08*** from age 26 to 29 (n = 149) from age 26 to 29 (n = 138) from age 26 to 29 (n = 317) marijuana coping -22.36** (7.65) -23.18** (8.39) marijuana coping -0.23 (0.12) -.024 (0.14) alcohol coping -2.61 (6.22) -7.69 (6.70) stress 4.32 (6.99) 4.51 (7.05) stress 0.18 (0.11) 0.18 (0.12) stress 4.59 (6.39) 5.43 (6.37) alcohol frequency 42.11*** (5.82)*** 42.06*** (5.84) alcohol quantity 0.37** (0.12) 0.36** (0.13) marijuana frequency 51.34*** (5.82) 48.76*** (5.94) marijuana enhancement 1.82 (7.48) marijuana enhancement 0.03 (0.13) alcohol enhancement 12.67 (6.40) r2 .29*** .29*** r2 .10 .10 r2 .26*** .27*** note. a only main effects models are shown because none of the interactions was significant. b race was controlled in all models and was coded as two dummy variables (white and other) with black as the reference group; results for race are not shown to simplify the presentation. **p < .0056; ***p < .001. stress, coping, and substance use 10 stress was not related to frequency of use in the substance-specific analyses. this finding is in accord with previous research on alcohol use, which has failed to consistently find a significant association between stress and drinking outcomes, possibly due to differential measures of stress (corbin, farmer, & koekesman, 2013; thomas et al., 2014). the lack of a strong association between stress and use frequency in this study may also reflect a mediating effect of coping motives on the association between stress and use (see corbin et al., 2013). that is, the association between stress and substance use may be indirect. we did not examine this possible mediation model due to our focus on a theoretically different question (i.e., whether stress exacerbates the effects of coping motives) and also due to an inability to ensure temporal order among variables in this design. future longitudinal studies with more time frames of assessment should explore such mediating models where temporal precedence can be more clearly demonstrated. whereas, in the substance-specific analyses, stress was not related to alcohol or marijuana frequency, it was related to alcohol quantity at age 29. the fact that the stress-alcohol quantity association was significant at age 29 but not at age 26 may reflect developmental changes in drinking behavior. drinking large quantities of alcohol is normative during emerging adulthood, but many youths mature out of heavy drinking as they approach young adulthood (white, labouvie, & papadaratsakis, 2005). thus, it may be that higher stress may interfere with the normative maturation out of heavy drinking and that those individuals who experience the most stress drink heavily to alleviate it. alternatively, the difference may reflect differential exposure or vulnerability to stress between ages 26 and 29. this study was not without limitations. although this study followed participants from childhood through young adulthood prospectively, we were limited to the age 26 and 29 assessments because those were the only two when a validated measure of coping motives was included. as such, it is unclear whether findings would extend to adolescents or to older adults. all measures were based on self-report, although this is common for substance use as well as coping motives and perceived stress. also, as mentioned previously, we did not include a measure of substance-related problems as an outcome. furthermore, because we only assessed coping and enhancement motives, we could not control for social and conformity motives. the sample was limited to young adult men from one geographic area. future research is needed to replicate these findings with women and individuals from varying locations. despite these limitations, the study had several strengths. it used validated measures of coping motives and perceived stress; 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(2007). marijuana use motives: a confirmatory test and evaluation among young adult marijuana users. addictive behaviors, 32, 3122-3130. cannabis, a publication of the research society on marijuana 13 funding: manuscript preparation was supported by grants from the national institute on drug abuse (r01da034608; r01da040880) and national institute on alcohol abuse and alcoholism (r01aa012171). data collection was supported by grant awards from the national institute on drug abuse (r01da011018), national institute of mental health (p30mh079920; r01mh048890; r01mh050778), the office of juvenile justice and delinquency prevention (86-jn-cx-0009), pew charitable trusts, and the pennsylvania state department of health (sap 4100043365). points of view in this document are those of the authors and do not necessarily represent the official position or policies of the u.s. department of justice or national institutes of health. the funding sources had no role in the analysis or interpretation of the data, the preparation of this manuscript, or the decision to submit the manuscript for publication. copyright: © 2017 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ microsoft word v3i2a4_authors_final.docx research article 173 abstract with the increase in the number of states legalizing cannabis, driving after cannabis use (dacu) has become a significant public health concern nationwide and is one of the riskiest cannabis-related behaviors. prior research has linked dacu with cannabis outcome expectancies, the positive and negative beliefs one holds about the effects of cannabis. the present study examined the relationships between cannabis expectancies and dacu in a sample of college cannabis users who have engaged in recent dacu. participants were 85 college students who reported driving after cannabis use at least three times in the past three months. participants completed measures that assessed positive and negative cannabis expectancies, perceived peer approval and dangerousness of dacu, and driving after cannabis use. in a negative binomial regression model, negative expectancies, perceived peer approval, and perceived dangerousness were significantly associated with dacu (p’s <.05). positive expectancies of cannabis use were not significantly associated with dacu. these results provide evidence that negative expectancies of cannabis use are associated with dacu. in addition to perceptions of dangerousness and peer approval, cannabis expectancies may be an important prevention and intervention target. key words: cannabis, impaired driving, expectancies, peer norms, dangerousness, college driving after cannabis use (dacu) is a significant public health concern and represents one of the riskiest cannabis-related behaviors (li et al., 2011). rates of dacu have been steadily increasing over time as the number of states legalizing cannabis for medical and recreational use has increased (ramaekers, 2018). though overall rates of driving after alcohol and cannabis use among college students are similar, rates of dacu among cannabis users have been shown to be significantly higher than rates of driving after drinking among drinkers (o’malley & johnston, 2003). whitehall and colleagues (2014) found that among first-year college students, 31.3% of cannabis users drove after using cannabis, while 6.8% of alcohol users drove after drinking alcohol. while several studies have demonstrated that cannabis impairs a number of functions imperative to driving ability, a large percentage of cannabis users continue to drive after using cannabis (asbridge et al., 2012; hartman & huestis, 2013). prior research has shown that cognitive perceptions associated with using cannabis are related to level of cannabis use and cannabis-related consequences (aarons et al., 2001). specifically, perceived dangerousness and perceived peer approval contribute to cannabis use. in the context of dacu, individuals more likely to drive after cannabis use include those who perceive it to be less dangerous and those who believe that friends or other students are accepting of dacu (mccarthy et al., 2007). cannabis 2020, volume 3 (2), 173-179 © author(s) 2020 researchmj.org doi: 10.26828/cannabis.2020.02.004 open access negative cannabis expectancies are associated with driving after cannabis use shelby a. king1, sarah n. elder1, jenni b. teeters1 1 department of psychological sciences, western kentucky university, bowling green, ky, usa corresponding author: jenni b. teeters, department of psychological sciences, western kentucky university, 1028 kelly thompson hall, 1906 college heights blvd, bowling green, ky, usa, phone: 270745-3918, fax: 270-745-3475, email: jenni.teeters@wku.edu negative cannabis expectancies 2 another factor that has been shown to be related to dacu is outcome expectancies (arterberry et al., 2013). outcome expectancies are beliefs regarding the positive and negative effects of a substance. a large body of literature has linked alcohol expectancies to alcohol use and consequences (blume & guttu, 2015; goldman, 1994; lac & luk, 2019). this body of research suggests that expectancies are key determinants of alcohol-related behaviors. similarly, cannabis expectancies, beliefs regarding the positive and negative effects of cannabis use, have been linked to cannabis use and act as predictors of use (schafer & brown, 1991; vangsness et al., 2005). specifically, positive expectancies, for example the belief that cannabis helps a person relax, are associated with increased use of cannabis. whereas, negative expectancies, such as the belief that cannabis makes it harder to think, act as protective factors and have been linked to decreased levels of cannabis use (schafer & brown, 1991). despite these relationships, only two previously published studies have examined the role of cannabis expectancies in the context of dacu. in a sample of college students reporting any lifetime cannabis use, arterberry and colleagues (2013) found that greater negative cannabis expectancies were associated with decreased likelihood of driving while under the influence of cannabis. conversely, in a community sample of weekly cannabis users, aston and colleagues (2016) found no association with either negative or positive expectancies and dacu when perceptions of danger and peer approval were included in the model, suggesting that cognitive factors, such as perceived dangerousness and perceived peer approval may be more important predictors of dacu than cannabis expectancies in heavier using samples. these mixed findings highlight the necessity for further research on cannabis expectancies and dacu. the present study aims to add to the research by examining the relationships between cannabis expectancies and dacu in a sample of college cannabis users who have engaged in recent cannabis-impaired driving. based on previous research, it was hypothesized that stronger negative cannabis expectancies would be significantly associated with a decreased likelihood of dacu. additionally, the present study examined whether a significant association between negative cannabis expectancies and dacu remains when perceived dangerousness of dacu and perceived driving-related peer approval are included in the model. based on aston and colleagues (2016) findings in a sample with similar cannabis use frequencies, it was hypothesized that negative cannabis expectancies would not be associated with decreased likelihood of dacu when perceived dangerousness and perceived peer approval were included in the model. method participants participants were 85 undergraduate students from a large public university in the southern united states recruited to participate in a larger intervention study aimed at reducing driving after substance use. students were eligible to participate in the intervention study if they were at least 18 years old, had access to a motor vehicle, and reported driving after drinking two or more drinks or after using cannabis at least three times in the past three months. all data analyzed in the present manuscript comes from the baseline data of the participants who reported dacu. participants were 66.7% women, 31.0% men, 1.2% transgender, and 1.2% “other”, and 89.4% caucasian, 8.2% african american, 3.5% hispanic or latino, 1.2% american indian, and the remainder not specifying their ethnicity. note that percentages do not add to 100% due to option to select multiple choices and “other” choice for race/ethnicity. the average age of participants was 21.5, sd = 4.20. measures demographics. participants completed a brief questionnaire regarding age, race/ethnicity, and gender. cannabis use. a modified, brief computerdelivered timeline follow-back (tlfb; sobell and sobell, 1992) was used to assess cannabis use during the past 7-days prior to the baseline appointment. additionally, participants were asked to report the number of days they used cannabis in the past month. driving after cannabis use. driving after cannabis use was assessed with a question cannabis, a publication of the research society on marijuana 3 adapted from prior studies that asked students how many times they have driven after using cannabis in the past 3 months (arterberry et al., 2013, 2017). perceived peer approval and perceived dangerousness. questions assessing perceived peer approval and perceived dangerousness of dacu were adapted from previous studies assessing cognitions about cannabis and driving (mccarthy et al., 2007). perceived peer approval beliefs related to dacu were assessed by asking participants to indicate “how much do you think a typical college student approves of driving a car after using marijuana?” on a 7-point likert scale from 1 (strongly disapprove) to 7 (strongly approve). perceived dangerousness related to dacu was assessed by asking participants to indicate, “how dangerous do you believe it is to drive after marijuana use?” on a 4-point likert scale from 1 (not at all dangerous) to 4 (very dangerous). cannabis expectancies. cannabis expectancies were assessed using the marijuana expectancies questionnaire-brief (meeq-b; torrealday et al., 2008). the meeq-b consists of 6-items that measure participants’ level of agreement with assertions about marijuana’s effects and has two subscales: positive expectancies and negative expectancies (derived from the mean composite score of the 3 corresponding items). participants rated items on a 5-point likert scale from 1 (disagree strongly) to 5 (agree strongly). an example item from the negative expectancies subscale is, “marijuana makes it harder to think and do things (harder to concentrate or understand; slows you down when you move).” an example item from the positive expectancies subscale is, “marijuana helps a person relax and feel less tense (helps you unwind and feel calm).” procedures all procedures were approved by the university institutional review board and participants were assured that all data would be kept anonymous and confidential. participants were recruited via a mass, university-wide email, the psychology subject pool for research participation, and flyers posted around campus. interested students were invited to complete a brief screening survey online to determine their eligibility. if eligible, they were invited to enroll in a mobile phone-based brief intervention trial aimed at reducing driving after substance use. eligible participants completed baseline measures on their mobile phones via a secure web platform. all data used in the present analyses came from the baseline survey prior to intervention delivery. data analysis plan data were examined for outliers using standard scores, with a criterion of z = 3.29 to retain maximum data. no outliers were identified. alpha was set at .05 for all analyses. bivariate correlations were examined between cannabis use frequency, the positive and negative cannabis expectancy subscales, frequency of cannabis use in the past month, perceived dangerousness, perceived peer approval and dacu. to examine whether positive and negative expectancies were associated with dacu, a negative binomial regression analysis controlling for frequency of past month cannabis use was utilized with number of times dacu as the dependent variable and the positive and negative expectancy subscales as the independent variables. negative binomial regression was chosen because our dependent variable, number of times driving after cannabis use, is an overdispersed count variable (i.e., the variance exceeds the mean). perceived peer approval and dangerousness were then added to the model to determine whether positive and negative cannabis expectancies were associated with dacu above and beyond perceived dangerousness and perceived peer approval. results descriptive statistics on average, participants reported 19.3 days of cannabis use in the past month (sd = 10.4). for number of times driving after cannabis use in the past month, 25.9% reported dacu between 1-5 times, 17.6% reported dacu 5-10 times, 23.5% reported dacu 10-20 times, and 32.9% reported dacu 20 or more times. negative cannabis expectancies 4 associations between dacu, expectancies, perceived peer norms, and perceived dangerousness bivariate correlations were examined between cannabis use frequency, cannabis expectancy subscales, perceived dangerousness, perceived peer approval, and dacu (see table 1). cannabis use frequency and the negative expectancies subscale were associated with dacu frequency (r’s = .54 and -.37, respectively). notably, positive expectancies of cannabis use were not significantly correlated with driving after cannabis use. additionally, perceived peer approval and perceived dangerousness were significantly associated with dacu (r’s = .32 and -.36, respectively). a negative binomial regression analysis controlling for the frequency of past month cannabis use was run with number of times dacu as the outcome variable and positive and negative expectancy subscales as the predictor variables. stronger negative expectancies were significantly associated with a decreased likelihood of driving dacu (p = .001). an additional negative binomial model regression including perceived dangerousness and perceived peer approval of dacu revealed that stronger negative expectancies (p = .006), less salient perceptions of peer approval (p = .045), and greater perceived dangerousness of dacu (p = .014), were significantly associated with a decreased likelihood of dacu in the negative binomial regression model. table 2 contains the results of the negative binomial model. table 1. correlations between dacu, expectancy subscales, perceived dangerousness, perceived peer norms, and cannabis use frequency variable 1 2 3 4 5 6 1. dacu 1 2. negative expectancy subscale -.37** 1 3. positive expectancy subscale -.01 .02 1 4. perceived dangerousness -.36** .34** .23* 1 5. perceived peer norms .32** -.09 -.06 -.25* 1 6. cannabis use frequency .54** -.29** -.03 -.29** .28* 1 note. dacu = driving after cannabis use. *p < .05. **p < .01. table 2. negative binomial regression results for number of times dacu model predictor variable b se ci number of times dacu meeq-b negative subscale** -0.328 .118 [-0.560, -0.096] meeq-b positive subscale 0.185 .141 [-0.091, 0.462] perceived dangerousness* -0.377 .154 [-0.679, -0.075] perceived peer norms* 0.106 .053 [0.003, 0.208] cannabis use frequency*** 0.047 .008 [0.032, 0.063] df 1 note. ci = confidence interval *p < .05. **p < .01. ***p < .001 cannabis, a publication of the research society on marijuana 5 discussion the present results suggest that among college students reporting recent dacu, negative expectancies of cannabis use play an important role in the decision to drive after cannabis use. more specifically, the present findings indicate that holding stronger negative expectancies of cannabis use, stronger perceptions of dangerousness of dacu, and less salient perceptions of peer approval of dacu are associated with decreased likelihood of dacu. with the increase in the number of states adopting legalization of recreational and medical cannabis, it is becoming increasingly important to understand the factors that are related to driving after cannabis use in order to reduce this risky behavior. these results add important information to the mixed findings obtained in previous studies examining expectancies and cognitive factors related to dacu. similar to results obtained in the present study, arterberry and colleagues (2013) found that college students that had stronger negative expectancies and stronger perceptions of dangerousness of dacu were less likely to drive while high. conversely, aston and colleagues (2016) found that after accounting for perceived peer disapproval and perceived dangerousness, negative expectancies no longer significantly predicted driving after smoking cannabis. results of the present study suggest that among college cannabis users reporting recent dacu, negative expectancies remain a significant predictor of dacu even when frequency of cannabis use, perceived dangerousness, and perceived peer approval are included in the model. though reasons for discrepant findings remain unclear, the target samples may have contributed to differential results. although participants in aston and colleagues study had similar dacu frequency, participants were recruited from a community rather than a college student sample. many universities have implemented drug and alcohol education programs into their freshman orientation itineraries that focus on the potential consequences of misusing drugs and alcohol. due to the information gained from these programs, college students may be more aware of negative cannabis expectancies compared to individuals in community samples. additionally, aston et al. examined the relationship between expectancies and driving after smoking cannabis. thus, other methods of administration (e.g., vaping, edibles, potables, concentrates, etc.) were not tested. the present study and arterberry et al. asked more generally about driving while high and driving after cannabis use. limitations of the present study include that cannabis use data were collected via retrospective self-reports and may have been subject to biases. previous research is mixed regarding the accuracy of retrospective self-reports of substance use with some researchers indicating that self-report assessments of substance have been shown to be valid and reliable (martens et al., 2012), while others indicate that young adults are often inaccurate when estimating how much of a substance they consumed (williams & nowatzki, 2005). in the present study we attempted to reduce potential self-reporting biases by reassuring confidentiality and anonymity multiple times throughout the consent process and emphasizing that participants could not get into any trouble for responding truthfully. future studies should use ecological momentary assessment (ema) or daily diary reporting to track dacu. additionally, a lot of nuance is missing when asking only about the number of times someone has driven after using cannabis. this measurement does not account for how much cannabis was used, the timeframe of use, method of administration, type of product, or potency of the cannabis used. though assessment of cannabis use frequency is a commonly cited issue in the literature (cuttler & spradlin, 2017), more of these factors should be included to gain a better estimate of impairment rather than just how many times the behavior has occurred. lastly, it is speculative to suggest that targeting cannabis expectancies will lead to decreases in dacu. prospective research is necessary to determine whether changing cannabis expectancies leads to decreases in dacu. despite these limitations, this study has public health relevance as it identifies negative cannabis expectancies, perceptions of dangerousness of dacu, and perceptions of peer approval of dacu as potential prevention and intervention targets. greater public awareness of the negative consequences of cannabis, especially in relation to cannabis’ physical and cognitive negative cannabis expectancies 6 effects related to driving ability, needs to be a priority in drug education and prevention services. many studies have utilized brief interventions (bis) containing personalized feedback to reduce cannabis use and related problems by identifying and correcting faulty normative beliefs in order to increase motivation to change a problematic substance-related behavior (halladay et al., 2019). personalized feedback elements that address negative expectancies of cannabis use, perceived dangerousness of dacu, and perceived peer approval of dacu have the potential to reduce incidences of dacu. prospective research that examines whether changes in negative expectancies, perceived dangerousness, and perceived peer approval mediate changes in dacu is warranted. references aarons, g. a., brown, s. a., stice, e., & coe, m. t. 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(2005). validity of adolescent self-report of substance use. substance use & misuse, 40(3), 299–311. https://doi.org/10.1081/ja-200049327 funding and acknowledgements: this project was supported by the national institute of general medical sciences (#8p20gm103436). copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 157 abstract the impacts of recently legalized cannabis retail markets on urban neighborhoods are largely unknown. more cannabis retailers may be operating in neighborhoods experiencing deprivation because of regulations that limit where cannabis businesses can operate. increased exposure to cannabis retailers in deprived neighborhoods could have negative consequences on the perceived safety and social cohesion within neighborhoods, and the availability of commercialized cannabis could have negative health impacts for both youth and adults if it promotes risky use. on the other hand, cannabis businesses potentially provide for economic growth in deprived areas and divert illicit activities. this study uses integrated nested laplace approximation (inla) spatial regression to estimate the association between neighborhood deprivation and the distribution of cannabis retailers in city-defined neighborhoods in portland, oregon, september 2017. across portland, 66% of 117 neighborhoods had at least one cannabis retailer (range 0-8 retailers). model results indicated that a one-standard deviation increase in neighborhood deprivation corresponded with 73% more cannabis retailers (arr 1.73, 95% ci: 1.32–2.27) after adjusting for availability of eligible commercial property, population density, and neighborhood size. findings of this study support the hypothesis that cannabis retailers are more likely to be located in relatively deprived neighborhoods, suggesting the need to consider spatial equity in cannabis policies to mitigate disproportionate exposure to retailers, particularly if retailer exposure is associated with negative consequences. key words: cannabis retailers, inequity, neighborhood area deprivation, spatial epidemiology, cannabis policy, built environment, land use, cannabis legalization, marijuana legalization, equity by the summer of 2019, eleven u.s. states and the district of columbia have legalized nonmedical cannabis use for adults, and a majority of states have legalized some form of cannabis for medical use; however, cannabis use, possession and sales remain illegal at the federal level. some common features across legalized states include the adoption of a market-oriented, for-profit cannabis 2020, volume 3 (2), 157-172 © author(s) 2020 researchmj.org doi: 10.26828/cannabis.2020.02.003 open access what about equity? neighborhood deprivation and cannabis retailers in portland, oregon caislin l. firth1,2, beatriz h. carlini3, julia a. dilley4, jon wakefield5, anjum hajat1 1 department of epidemiology, school of public health, university of washington, seattle, wa, usa 2 faculty of health sciences, simon fraser university, burnaby, bc, canada 3 alcohol & drug abuse institute, university of washington, seattle, wa, usa 4 program design and evaluation services, multnomah county health department and oregon public health division, portland, or, usa 5 department of biostatistics, school of public health, university of washington, seattle, wa, usa corresponding author: caislin l. firth, faculty of health sciences, simon fraser university, 2635 laurel st, vancouver, bc, v6h 3z6, canada email: caislin_leah_firth@sfu.ca neighborhood deprivation and cannabis retailers 158 cannabis industry that allows for the production, distribution, and sale of cannabis products to adults ages 21 or older (alcohol policy information system, 2019). there is growing concern that exposure to cannabis retailers and storefront advertisement could have detrimental effects at both the individual and neighborhood level. legalization of medical and retail cannabis in the u.s. has exposed vulnerable communities to storefront marketing of cannabis retailers (cao, carrillo, zhu, & shi, 2019; fiala, dilley, firth, & maher, 2018). the legalization of cannabis has also resulted in increased availability of high potency products (concentrates and edibles) which could have negative health impacts for both youth and adults (carlini, garrett, & harwick, 2017). specifically for youth, exposure to cannabis retailers may alter social norms by reducing the perceived harm of cannabis use and lead to an increase in cannabis consumption and further criminal prosecution of minors who use cannabis (ammerman, ryan, & adelman, 2015). for adults, proximity to cannabis retailers has been associated with both an increase in any cannabis use and frequent use (everson, dilley, maher, & mack, 2019). at the neighborhood level, the nature and direction of the impacts of legalization and the opening of commercial cannabis markets on social cohesion, perceived safety, and local economies are unknown, but could prove to have a destabilizing effect on vulnerable neighborhoods. research on alcohol outlets found that off-premise liquor outlets have negative impacts on the social capital of neighborhoods, drinking behaviors, hospital admissions, and violent crime (fone et al., 2016; theall et al., 2009). further, increases in neighborhood socioeconomic status was associated with decreases in alcohol use (brenner, borrell, barrientos-gutierrez, & diez roux, 2015). the opening of cannabis retailers may impact neighborhoods in a similar manner as liquor stores (berg, henriksen, cavazos-rehg, haardoerfer, & freisthler, 2018). in colorado, cannabis retailers were disproportionately located in census tracts with lower household incomes and higher proportions of racial/ethnic minorities (shi, meseck, & jankowska, 2016), cannabis outlets in washington state were more likely to be co-located in census tracts with liquor stores (tabb, fillmore, & melly, 2018) and areas experiencing the greatest disadvantage (amiri, monsivais, mcdonell, & amran, 2019), and census tracts with shorter life expectancy were more likely to have unlicensed cannabis retailers but not licensed retailers in los angeles county (nicholas et al., 2019). prior research on the distribution of medical dispensaries in california found that dispensaries were concentrated in areas of poverty, racial/ethnic minorities, and alcohol outlets (morrison, gruenewald, freisthler, ponicki, & remer, 2014; thomas & freisthler, 2017), and dispensaries in denver, colorado were more likely in areas of high crime rates (boggess, pérez, cope, root, & stretesky, 2014). in light of evidence, there is reason to believe that commercial cannabis markets will be disproportionately distributed across urban areas and concentrate in neighborhoods experiencing disadvantage. a limitation of these previous studies, however, is that they did not consider the state-specific regulations that determine where cannabis retail stores can operate and the availability of this eligible property. not accounting for the influence of business regulations on where cannabis retailers can operate will ultimately bias associations between neighborhood characteristics and cannabis retailers. the state of oregon legalized the local production, processing, and sale of cannabis to persons 21 and older for non-medical use by voter initiative in 2014. early restricted retail sales of cannabis products began in october 2015 in existing medical dispensaries and full retail sales commenced in january 2017. by the end of 2017, 486 retail cannabis stores were operating across oregon (oregon liquor control commission, 2017); 31% of these retailers (150 stores) were operating in the city of portland, oregon’s most populous city. we use an interdisciplinary approach and innovative methods to address our research question: site suitability assessments, a technique from urban planning, and spatial epidemiological methods. this study aims to assess the relationship between neighborhood area deprivation and the distribution of cannabis retailers while accounting for cannabis business regulations that restrict where retailers can operate. we hypothesize that licensed cannabis retailers will be more likely to operate in neighborhoods experiencing disadvantage even cannabis, a publication of the research society on marijuana 159 when adjusting for availability of eligible commercial property. findings from this study will further our understanding about where cannabis retailers are located in one urban area that has legalized cannabis and provide insights to support equity-focused cannabis policies in other urban areas with emerging retail cannabis markets. method study design we conducted an ecological cross-sectional spatial analysis of the association between neighborhood deprivation and distribution of cannabis retailers in portland, oregon. neighborhood area definition areas within portland that have registered with the office of neighborhood involvement and have an established neighborhood association with clearly defined geographic boundaries are considered neighborhoods for the purposes of our study. locally-defined neighborhood boundaries are more relevant to policy makers and communities than census tracts which often do not align with conceptions of a neighborhood (sperling, 2012). in the city of portland, neighborhood coalitions are well established and positioned to influence business operations – including cannabis retailers—within their neighborhood boundaries (city of portland office of neighborhood involvement, 2005). our results will provide stakeholders with more representative data and support policy solutions to ensure equitable impacts of cannabis legalization. in addition to the 92 registered neighborhoods, portland has 21 areas where multiple neighborhoods share jurisdiction of an area, and 4 unclaimed areas of land (the city of portland, n.d.). shared regions and unclaimed land were considered as neighborhoods in our analysis in order to provide contiguous, mutually exclusive, and full coverage of our study area. this resulted in 117 neighborhood areas included in analysis (see figure 1). figure 1. cannabis retailers in portland, oregon neighborhoods, 2017 neighborhood deprivation and cannabis retailers 160 exposure: neighborhood deprivation index a neighborhood deprivation index (ndi) was constructed from american community survey (acs) 2012–2016 5-year estimates at the census block group-level. this data were the most current available during september 2018 when analysis was conducted. thirty-three acs variables were included in a principal component analysis (pca) to calculate a portland-specific deprivation index. variables included in the pca draw from the domains of income/poverty, demographics, occupation, education, housing, and assets (supplemental table 1). these domains represent aspects of the neighborhood context intrinsically tied to economic disadvantage, increases in health risk behaviors, and poor health outcomes (messer et al., 2006). variables included in the pca are consistent with other survey-based estimations of neighborhood socioeconomic status or deprivation indices (powell-wiley et al., 2014). we implemented a three-step pca approach that uses data mining techniques to reduce variable redundancy and optimize the proportion of variance explained by the first component (sesindexcreator version 1.0 and factominer version 1.41 statistical packages in r software (lalloué et al., 2015, 2013)). the sesindexcreator procedures have been described in detail elsewhere (lalloué et al., 2013). three successive steps were followed to create the portland ndi: 1) reduction of redundant variables through pca. for variables that represented a similar construct, a pca was performed on each group of similar variables. one variable was selected from each pca that had the largest correlation with the first component of the pca. each selected variable was then used in subsequent steps. five variable groups were candidate for variable reduction: occupation categories, education attainment, health insurance, active transportation, and food stamps (see table 1). the correlation coefficients from the first component of the pca were reported in table 1, column 2 for each variable. the five selected variables (one from each pca) were: percent of residents with a management-level occupation, adults 25+ years with a high school diploma, percent of residents without health insurance, percent of residents who bike or walk to work, and percent of residents who received food stamps. 2) preliminary pca was conducted. the goal of the preliminary pca was to identify variables that were best correlated with the first component. variables that had an above average correlation with the first component were used in the final step. the preliminary pca included 23 variables (5 selected variables from step one and 18 remaining variables). the first component of this pca had an eigenvalue of 9.78 and explained 43% of the variance in the data. twelve variables that had a correlation with the first component >0.6 or < -0.60 were included in the final pca (step 3) and reported in figure 2. correlation coefficients from the first component were reported table 1, column “step 2: preliminary pca” for each variable. 3) a final pca was conducted to construct the neighborhood deprivation index. the first component of this final pca was interpreted as the neighborhood deprivation component and was used to calculate the ndi for each census block group. the first component had an eigenvalue of 8.27 and explained 69% of the variance in the data. correlation coefficients from the first component were reported table 1, column “step 3: final pca” for each variable. factors most positively correlated with neighborhood deprivation included: receipt of food stamps, household income < $50,000, no health insurance, poverty, no post-secondary education, single female head of household, rental housing, and limited english spoken at home. to estimate ndi for each locally-defined neighborhood, area-weighted estimation was used to assign census block groups to portland neighborhoods. area-weighted estimation is a gis technique that overlays neighborhood boundaries on census block groups to determine which portions of each block group are contained within a particular neighborhood. for example, if the geographic area of a neighborhood contains 30% of block group a and 70% of block group b then the population of the neighborhood (np) would be the sum of weighted block groups estimates (np = 0.3(population of block group a) + 0.7(population of block group b). therefore, every neighborhood population or prevalence estimate is the sum of weighted census block group estimates. areaweighted estimation was conducted using the sf statistical package version 0.7-1 in r software (edzer pebesma, 2018). the number of block groups within each portland neighborhood varied http://publications.sciences.ucf.edu/wp-content/uploads/2020/07/v3i2a3_supplemental.docx cannabis, a publication of the research society on marijuana 161 table 1. variables included in principal component analysis of neighborhood deprivation, from american community survey, 2012-2016 five-year census block group estimates indicators step 1: reduce redundancy with pcas step 2: preliminary pca step 3: final pca income & poverty median household income (in dollars)1 -0.87 -0.87 percent of households making <50k 0.94 0.93 percent of families in poverty with children < 18 years old2 0.84 0.83 percent of individuals in poverty 0.90 0.89 food stamps: percent who receive food stamps 0.98 0.93 0.94 percent who are on disability and receive food stamps 0.98 percent of income attributed to public assistance 0.72 0.75 dividends, interest, or net rental income (in dollars) -0.86 -0.88 occupation3 percent of unemployed 0.61 percent in labor force -0.19 occupation type: percent with an occupation in a management role 0.93 -0.51 percent with an occupation in the business sector 0.91 percent with an occupation in food service -0.39 demographics population density 0.16 percent of single female head of households 0.72 0.72 percent of single female head of households with children < 18 years old2 0.60 percent of households where limited english is spoken 0.67 0.67 percent of households that have move at least once in the past year 0.42 health insurance: percent of all persons not covered by health insurance 0.98 0.88 0.90 percent of adults 18-34 years covered by health insurance 0.88 percent of adults 35-64 years covered by health insurance 0.93 education percent of adults 25+ years with less than a high school diploma 0.90 percent of adults 25+ years with a high school diploma 0.96 0.79 0.8 percent of adults 25+ years with some college 0.85 percent of adults 25+ years with a college degree -0.92 percent of adults 25+ years with graduate school education 0.95 housing number of housing units 0.08 percent of households in rental housing 0.71 0.70 median contract rent (in dollars) -0.44 percent of households in new homes (2014 or newer construction) 0.20 neighborhood deprivation and cannabis retailers 162 transportation percent of households with no vehicle 0.39 active transportation: percent of person who use active transportation (bike or walk) to get to work 0.85 0.10 percent of persons who use public transportation to get to work 0.85 note. 1 for 5 census block groups the sample size was too small for acs to provide an estimate of median income. estimates were imputed by assigning the corresponding census tract’s median income value to the block group. 2 for 3 block groups were no families lived, estimates were imputed with census tract estimates. 3 occupation type was restricted to occupations that were common in portland, oregon, and showed variety in type of occupation. figure 2. creation of neighborhood deprivation index using a three-step principal component analysis approach. cannabis, a publication of the research society on marijuana 163 from 1 to 28. for analysis, the neighborhood-level ndi was transformed into a z-score and the mean score was 0 with a 1-unit difference representing one standard deviation away from the mean. higher values of the ndi indicate more deprived neighborhoods. outcome: count of cannabis retailers the outcome of interest was the count of observed cannabis retailers within a defined portland neighborhood (see figure 1). to calculate the count of cannabis retailers within each neighborhood, each of the 150 active cannabis retailers registered with the oregon liquor control commission (olcc) on september 28th 2017 were geocoded and spatially assigned to a neighborhood. covariate: availability of eligible commercial property cannabis business regulations determine where cannabis retailers can operate. criteria for operating a cannabis business are mandated by state legislature and the city of portland cannabis program (city of portland office of neighborhood involvement, 2018). regulations require that properties 1) must be zoned for commercial use, 2) maintain a minimum 1,000 foot buffer from primary and secondary schools, and 3) must be at least 1,000 foot buffer between all established cannabis retailers (city of portland office of neighborhood involvement, 2018). in order to assess the association between neighborhood deprivation and the distribution of cannabis retailers, we needed to account for the availability of properties that could operate as licensed cannabis businesses in each neighborhood. the number of eligible commercial properties in each neighborhood was estimated by conducting site suitability assessments. this is a common practice in real estate and urban planning disciplines to inform where particular business can operate (meyer & grabaum, 2008). we analyzed all properties within the city that were recorded in multnomah county tax assessor data. our data file was compiled during the spring of 2018 (metro regional government, 2017). the first step was to determine the universe of possible locations where cannabis retailers could legitimately open. using a gis approach, the number of suitable sites within each neighborhood was reduced in stepwise fashion. among the 13,844 commercial properties with an existing structure in portland, 807 were deemed eligible to open as a cannabis retailer based on the criteria described above (and summarized in supplemental table 1). seven eligible properties (0.9%) had structures built in 2017. we then estimated the number of eligible cannabis retailers within each neighborhood based on the reference probability of an eligible commercial property becoming a cannabis retailer. the reference probability was the proportion of total number of current cannabis retailers out of the total number of eligible sites in the city (150/807). the sum of eligible cannabis retailers within portland was 148 and ranged from 0 to 13 within each neighborhood, and 77 of 117 (66%) neighborhoods were eligible to have least one cannabis retailer. all gis analyses were performed in arcgis pro 2.1.2. covariate: adult population the number of adults (21+ years) living in each neighborhood was a covariate in our analysis. in analysis, the number of adults was log transformed to address its non-normal distribution. adults serve as the customer base for cannabis retailers and thus neighborhoods with a larger adult population may attract more retailers. covariate: expected value in the absence of cannabis business regulation, the expectation is that cannabis retailers would be evenly distributed across neighborhoods in portland. the expected value for each neighborhood was calculated by multiplying the probability of the proportion of operating cannabis retailers out of total land area for the city of portland (150 retailers/149.8 square miles) by the area of each neighborhood (in square miles). the median neighborhood expected value was 0.80 retailers with a range from 0.01–12.29 retailers. the expected value was used as the reference risk in statistical models. http://publications.sciences.ucf.edu/wp-content/uploads/2020/07/v3i2a3_supplemental.docx neighborhood deprivation and cannabis retailers 164 statistical analysis data processing and mapping of cannabis retailers and neighborhood deprivation in portland were conducted in arcgis pro 2.12. we fit statistical models with spatial smoothing for observed counts of cannabis retailers to test the association with neighborhood deprivation. this method allowed us to assess the risk surface of cannabis retailers at the neighborhood-level by neighborhood deprivation. in models, the primary independent variable is the neighborhood deprivation index (ndi). the dependent variable was the count of observed cannabis retailers within each neighborhood. availability of eligible commercial property and log-transformed population density (adults 21+ years) were included as covariates in analysis. we fit a series of poisson models and used as an offset the natural log of the expected value of cannabis retailers within each neighborhood. an offset (or reference risk) was included to estimate the relative risk within each neighborhood. (model 1) { 𝑌𝑖 = 𝜇𝑖 log(𝜇𝑖) = log(𝐸𝑖) + 𝛽0 + 𝛽1𝒙𝑖 + 𝛽2𝒙𝑖 + 𝛽3𝒙𝑖 + 𝑆𝑖 + 𝑖 𝑌𝑖 count of cannabis retailers within a neighborhood (outcome) 𝜇𝑖 marginal mean 𝐸𝑖 expected value 𝛽0 intercept 𝛽1 neighborhood deprivation index (exposure) 𝛽2 availability of eligible commercial property (covariate) 𝛽3 log-transformed adult population (21+ years) (covariate) 𝒙𝑖 unit of analysis, measurement at the neighborhood level 𝑆𝑖 spatial random effects 𝑖 non-spatial random effects first, we fit a quasi-poisson model to estimate the amount of overdispersion in the data. to address overdispersion, we then fit a series of poisson models with neighborhood random effects and spatial smoothing using integrated nested laplace approximation (inla) (lindgren & rue, 2015; rue, martino, & chopin, 2009). inla is an efficient bayesian estimation approach for areal spatial data that produces estimates of the marginal posterior distributions of the parameters (taylor & diggle, 2014). incorporating a spatial component into the model controls for spatial confounding that may be present if an association is isolated to a particular region within the study area. spatial effects were specified using a modified besag-york-molli´e model (bym2) that calculated both spatial and non-spatial random effects (model 1) (riebler et al., 2016). the bym2 was chosen because it allows two contributions to the residuals in each area: one allows for "shocks" in each area that are independent of the residuals in other areas while the other allows dependence between residuals of neighboring areas. the spatial contribution of the bym2 model allows for the count of cannabis retailers within each neighborhood to depend on the values of the counts in neighboring areas (defined as areas that share boundaries). this approach allows us to examine whether there is spatial structure in the counts of cannabis retailers across neighborhoods. the regression part of the model estimated the log relative risk between neighborhood deprivation and the distribution of cannabis retailers. we reported the 95% credible interval, similar to a confidence interval, for neighborhood-area residual relative risks along with the proportion of residual variability explained by spatial dependence. all analyses were conducted in r studio using inla version 18.07.12 package and spatialepi version 1.2.3 package. analysis was conducted december 2018 and revised in summer of 2019. results descriptive statistics across the 117 neighborhood areas within portland, 66 had at least one cannabis retailer operating by september 2017. the range of cannabis retailers within each neighborhood was 0 to 8. the city of portland is sometimes described in terms of east or west portland, as divided by the willamette river. the majority of cannabis retailers (122, 81%) were located in the 79 neighborhoods in east portland (map 1) and the remaining 28 retailers (19%) were within the 38 neighborhoods of west portland. cannabis, a publication of the research society on marijuana 165 neighborhood deprivation varied greatly across portland. areas experiencing the most deprivation were predominately located in outer south east portland and the least deprived neighborhoods were in north east and west portland. neighborhood characteristics included in the ndi are summarized in table 2 for areas with the highest (glenfair) and lowest (bridlemile) ndi score (see figure 3). within the most deprived neighborhood, glenfair, the median income was $48,000, over half (54%) of residents lived in households that earn less than $50,000 annually, 21% of residents lived in poverty, and the majority of residents (64%) lived in rental housing. across the city in west portland, bridlemile residents earned a median household income of $167,000 annually, 14% of residents lived in households earning less than $50,000, only 1% of residents lived in poverty or received food stamps, and 3% of households lived in rental housing. spatial regression models the quasi-poisson model found overdispersion in the data: the variance exceeded the marginal mean by 67%. given the presence of overdispersion, the spatial regression models used a poisson model with neighborhood-level random effects (model 1). across neighborhoods, a oneunit (or one standard deviation) increase in neighborhood deprivation was associated with 81% more cannabis retailers (rr 1.81, 95% ci: 1.38–2.40) than the expected value in crude analysis (table 3). when the count of eligible commercial properties within each neighborhood was adjusted for, the effect of neighborhood deprivation increased such that a one-unit change corresponded to 87% more retailers (arr 1.87, 95% ci: 1.44– 2.45). though, when adult population was also adjusted for, the effect of neighborhood deprivation was slightly attenuated towards the null (arr 1.73, 95% ci: 1.32–2.27). both adult population density and eligible commercial property were associated with the count of cannabis retailers beyond the expected value. greater adult population density (on the log scale) was associated with more cannabis retailers (arr 1.54, 95% ci: 1.15–2.14). while, availability of eligible commercial property was associated with fewer cannabis retailers when holding neighborhood deprivation and adult population density constant (arr 0.85, 95%ci: 0.75–0.95). table 2. neighborhood characteristics among the most and least deprived neighborhoods, portland, oregon ndi score food stamps poverty high school diploma female head of household most deprived: glenfair 2.44 44% 21% 29% 45% least deprived: bridlemile -1.70 1% 1% 4% 10% annual income <$50k median income no health insurance rental housing limited english spoken most deprived: glenfair 54% $48k 18% 64% 12% least deprived: bridlemile 14% $167k 2% 3% 0% neighborhood deprivation and cannabis retailers 166 table 3. association between neighborhood deprivation and distribution of cannabis retailers, portland, oregon 2017 neighborhood deprivation count of eligible commercial property locations log(population 21+ years) rr (95% ci) rr (95% ci) rr (95% ci) 1.81 (1.38–2.40) 1.87 (1.44–2.45) 0.92 (0.82–1.02) 1.73 (1.32–2.27) 0.85 (0.75–0.95) 1.54 (1.15–2.14) note. spatial models used integrated nested laplace approximation and incorporated both spatial and non-spatial random effects that were specified with a modified besag-york-molli´e model. rr=relative risk. figure 3. neighborhood deprivation in the city of portland, oregon, 2012-2016. note. neighborhood deprivation index was derived from the american community survey data at the census block group-level and spatially weighted to neighborhood boundaries, 2012-2016. higher values indicate more deprivation. cannabis, a publication of the research society on marijuana 167 discussion to date, no study had considered the spatial restrictions that cannabis siting regulations impose when examining the distribution of cannabis retailers in a fully legalized market. a previous study analyzed changes in the count of medical marijuana dispensaries in los angeles (2012–2014) and considered percent of commercially-zoned area, restaurants, bars, and off-premise alcohol outlets in their analysis (thomas & freisthler, 2017). though, the study was conducted prior to california’s legalization of retail markets and regulations for medical marijuana dispensaries did not include zoning and buffer requirements like those incorporated in our site suitability assessment. considering the spatial implications of cannabis business regulations is an improvement upon previous methods when describing the distribution of cannabis retailers (shi et al., 2016; tabb et al., 2018). another improvement from previous research is that this study used geographic neighborhood boundaries defined by the city of portland office of neighborhood involvement instead of using census-defined areas. using locally-defined neighborhood boundaries provided relevant neighborhood deprivation data to neighborhood coalitions and city planners. this study identified that neighborhoods experiencing disadvantage in portland were more likely to have higher concentrations of cannabis retailers than neighborhoods that experienced less disadvantage. if two neighborhoods had the same number of adults and amount of eligible commercial property, but they differed by oneunit on the deprivation index, the more deprived neighborhood would have 73% more cannabis retailers. our results are consistent with recent studies in other legalized states that found cannabis retailers to be more likely to be located in census tracts with greater poverty in both washington state and colorado (shi et al., 2016; tabb et al., 2018), and retailers were more prevalent in the most deprived census tracts in washington state (amiri et al., 2019). further, there is consistency between the washington state area deprivation index (amiri et al., 2019) and the portland neighborhood deprivation index that both include domains of poverty, housing, employment, and education. neighborhoods with more available commercial property were less likely to have operating cannabis retailers. in other words, areas with the greatest amount of available commercial property, which tend to be located on the outskirts of the city, were not enticing for cannabis retailer businesses. such business characteristics like business size (square footage), parking lots, and road visibility may be important factors for retailer owners and were not considered in this analysis. this finding is similar to a spatial analysis conducted on medical marijuana dispensaries in los angeles, california, that identified dispensaries were more likely to be located in census tracts of more african american residents and fewer in areas zoned for commercial use (thomas & freisthler, 2017). similarly, redevelopment zones and urban revitalization in historically deprived neighborhoods could contribute to the placement of cannabis retailers and targeting business development in specific deprived neighborhoods. impliciations for future research the effects that disproportionate exposure to cannabis retailers will have on neighborhoods remains unclear. studies are needed to identify both positive and negative effects that cannabis regulatory policies have on the placement of cannabis retailers and the subsequent impacts on neighborhoods and residents. individuals living in deprived areas with more exposure to cannabis retailers may be at greater risk of increasing cannabis use, particularly use of high potency products sold in cannabis retailers, that put youth and naïve users at heightened risk for poisoning and emergency department visits (allen et al., 2017; barrus et al., 2016). at the neighborhood level, the presence of cannabis retailers may disrupt neighborhood social cohesion or increase crime. on the other hand, cannabis businesses may build the local economy and reduce illicit cannabis enterprises. the city of portland recently implemented a cannabis social equity grant program (april 2019) that has reserved a proportion of local cannabis sales tax for minority-owned businesses (office of community & civic life, 2019). other legalized urban areas that have implemented similar social equity programs (oakland (city of oakland, 2018), los angeles (department of cannabis neighborhood deprivation and cannabis retailers 168 regulation, n.d.), and the state of massachusetts (cannabis control commission, 2018)) prioritize cannabis business licenses for low income residents who have been formally convicted of a cannabis crime or live in a low socioeconomic area. such initiatives help alleviate barriers that have prevented small business owners and communities disproportionately affected by previous cannabis laws from entering into the cannabis industry. to date, no evaluation has been conducted on the impacts that these equity programs have on neighborhood economies and population health. this study provides a methodological framework for measuring disproportionality of cannabis retailers in other urban areas. methods should be replicated in other areas that are establishing retail cannabis markets. variations in cannabis policies between urban areas, legalized states, provinces, and countries may offer insight into policies that effectively mitigate the disproportionate burden of cannabis retailers across neighborhoods. as more areas continue to liberalize cannabis laws, local policy efforts should consider how zoning restriction will contribute to the concentration of cannabis retailers in deprived areas. limitations the ecological cross-sectional design of our study limits the ability to infer a causal relationship between neighborhood deprivation and the establishment of cannabis retailers. further, our results did not assess changes in the distribution of cannabis retailers over time. given that the cannabis industry is still in its infancy, it may be that retailers are first opening stores in areas perceived as ‘low risk’ where community resistance is minimal. in the future, retailers may begin to move into more advantaged neighborhoods and the distribution of cannabis retailers across neighborhoods may change. longitudinal data will be needed to assess future changes. further, we only assessed the potential confounding effects of eligible commercial property and neighborhood population, unmeasured confounding could have inflated our estimated effect of neighborhood deprivation on the distribution of cannabis retailers. for instance, accounting for all commercially-zoned property within a neighborhood –not just commercial property eligible to operate as a cannabis retailer—could contribute to our understanding of why retailers open within particular neighborhoods. our study was interested in assessing ‘who’ was most exposed to cannabis retailers and future research could assess built environment characteristics to identify ‘how’ or ‘why’ cannabis retailers operate within particular neighborhoods. the measure of neighborhood deprivation used in analysis was specific to portland and captured neighborhood characteristics that are most relevant to deprivation within the city. though this is a strength of our analysis, the index created may not translate well to other urban areas that have legalized cannabis. further, the index was compiled with the most current available acs data at the time of analysis (2012–2016). therefore, the possibility exists that neighborhood deprivation could have changed between the time when ndi data were collected and our sample of cannabis retailers was compiled in september 2017. prior to retail cannabis legalization, the siting of legitimate medical cannabis dispensaries across the city may have influenced the location of cannabis retailers included in our study. though the exact number is unknown, many cannabis retailers operating in portland during 2017 were believed to be previously operating as licensed medical dispensaries (oregon liquor control commission, 2016; oregon medical marijuana program, 2018). if the earlier siting practices for medical dispensaries had influenced the location of currently operating retail cannabis stores and these previous dispensary practices are different from current retailer regulations, this could have affected the results of our adjusted models. in other words, the estimates of the number of available properties to operate as cannabis retailers within each neighborhood may not be relevant to some retailers if the shops were previously operating under medical dispensary regulations. though, the impact of this bias appears to be minimal because both crude and adjusted models found a similar magnitude in the association between neighborhood deprivation and cannabis retailers. cannabis, a publication of the research society on marijuana 169 conclusion neighborhood deprivation was associated with more cannabis retailers in the city of portland, oregon regardless 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(2017). evaluating the change in medical marijuana dispensary locations in los angeles following the passage of local legislation. journal of primary prevention, 38, 265–277. https://doi.org/10.1007/s10935-017-0473-8 neighborhood deprivation and cannabis retailers 172 funding and acknowledgements: this research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. the authors would like to thank phil hurvitz, phd, for his advice on spatial weighting; rebecca walter, phd, for her guidance on conducting site suitability assessments and reviewing our manuscript; and steve mooney, phd, for his input on the framing of our research question and reviewing our manuscript. metro’s data resource center and brendon haggerty for providing access and support using multnomah county tax assessors data. copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v4i1a5_authors_final research article 69 abstract background: little is known about the factors influencing use among frequent cannabis users, defined here as using at least three times per week. outcome expectancies and motives for cannabis use have been independently examined in relation to cannabis use, but not among frequent users. further, the associations among distinct expectancies and motives for cannabis use have yet to be explored. the current study examined whether expectancies influence cannabis use through cannabis use motives among frequent users. additionally, we examined more nuanced relationships among three cannabis outcome expectancies (relaxation/tension reduction, social, perceptual/cognitive) and four motives (enhancement, social, coping, expansion). method: bayesian path analysis with informative priors was used to examine associations among expectancies, motives, and outcomes in a sample of 54 (63% male) young adult frequent users (i.e., at least three times per week; 65% used daily). participants were recruited from the community and completed self-report questionnaires assessing cannabis use, expectancies, and motives. results: findings support hypotheses that cannabis use expectancies were associated with unique motives for frequent cannabis users. perceptual/cognitive enhancement expectancies were the only expectancy to consistently relate to all four cannabis use motives. social expectancies were related to enhancement, social, and expansion motives for use, and relaxation/tension reduction expectancies were associated with coping motives. conclusions: results extend previous work examining direct and indirect effects of expectancies and motives among frequent using young adults. findings support the potential clinical utility of exploring the perceived functional benefits of cannabis use for individual frequent users as well as potential alternatives that might serve similar functions with fewer risks and consequences. key words: = cannabis use, cannabis expectancies, cannabis motives, bayesian methods rates of cannabis use have remained relatively consistent over the past five years, with 33-39% of adults between the ages of 22 and 29 reporting past-year use in the united states in 2019 (substance abuse and mental health services administration [samhsa], 2021). of these, approximately 5-7% report daily use (samhsa, 2021). frequent cannabis use in large doses has been associated with more negative consequences, such as increased risk of cancer (e.g., hall, 2015) and neurocognitive impairments (figueiredo et al., 2020), yet most research on cannabis use is conducted with lowor moderateusing participants. thus, there is a need to understand factors that contribute to frequent cannabis use to inform treatment development and intervention efforts. in the present study, frequent cannabis use is defined as using three or more days each week (benschop et al., 2015). beliefs that drinking results in positive effects (i.e., alcohol expectancies), such as becoming more sociable, relaxed, or sexually appealing, are strong predictors of alcohol use (e.g., read et al., 2003; jones et al., 2001). however, self-reported cannabis outcome expectancies, cannabis use motives, and cannabis use among a small sample of frequent using adults cannabis 2021, volume 4 (1) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.01.005 amber m. anthenien1, mark a. prince2, gemma wallace2, tiffany jenzer3, clayton neighbors1 1university of houston, houston, tx 77004 2colorado state university, fort collins, co 80521 3university at buffalo, the state university of new york, buffalo, ny 14260 corresponding author: mark prince, phd, colorado state university, 1876 campus delivery, fort collins, co 80523. email: mark.prince@colostate.edu cannabis expectancies and motives 70 reasons for using alcohol (i.e., alcohol use motives) are often more robust predictors of alcohol use than expectancies (see kuntsche et al., 2005 for review). when examined concurrently, expectancies emerge as predictors of alcohol use motives, and mediation models have suggested the effects of expectancies on alcohol may be attributable to alcohol use motives (cooper et al., 1995; fischer et al., 2004; kuntsche et al., 2007). in other words, motives appear to be most the proximal factors influencing alcohol use, and relations between alcohol use and distal factors, including alcohol expectancies, are mediated by motives (e.g., hasking et al., 2011; madden & clap, 2021). this phenomenon has been explained through motivational theory, in which an individual’s combined expectancies for drinking influence their decision about whether or not, and how much, to drink based on what they aim to achieve by drinking (i.e., the motive) (kuntsche et al., 2010). theoretical models of use expectancies and motives have been applied to cannabis use, resulting in the development of measurement instruments for cannabis-specific expectancies and motives (aarons et al., 2001; benschop et al., 2015; schafer & brown, 1991; simons et al., 1998). however, few studies have simultaneously examined relations between cannabis use expectancies and motives for use, and it is unclear if the mediation effects typically observed in alcohol research are relevant to cannabis expectancies, motives, and use. thus, the aim of the current investigation is to examine specific pathways through which cannabis effect expectancies are associated with use indirectly through specific motives among frequent users. cannabis effect expectancies and cannabis use motives cannabis expectancies are perceived physical, cognitive, or behavioral effects anticipated to occur after using cannabis (schafer & brown, 1991; kristjansson et al., 2012). positive expectancies can include relaxation/tension reduction (e.g., to unwind), social facilitation (e.g., feel more romantic), and perceptual/cognitive enhancement (e.g., become more creative). negative expectancies, alternatively, refer to the perceived negative consequences of cannabis use, and can include global negative effects (e.g., becoming careless) and sometimes cravings and physical effects (e.g., getting the “munchies”). while positive and negative outcome expectancies have been associated with frequency and quantity of use and dependence criteria, positive expectancies generally demonstrate larger effects on use and were therefore the focus of the present study (e.g., altman et al., 2019; brackenbury et al., 2016; kristjansson et al., 2012; lauritsen & rosenberg, 2016). cannabis use motives describe self-reported reasons for using cannabis. motives most commonly associated with cannabis use and problems include enhancement (e.g., because i like the feeling; to get high), social (e.g., be social; makes social gatherings more fun), coping (e.g., forget problems; cheer me up when i’m in a bad mood), and expansion (e.g., expand awareness; be more open to experiences) (blevins et al., 2016; bonar et al., 2017; bonn-miller & zvolensky, 2009; lee et al., 2009; patrick et al., 2011). while a fifth motive, conformity, has also been proposed, this is previously failed to demonstrate associations with cannabis use (e.g., bonn-miller et al., 2007) and was not included in the current study. coping motives, in particular, are associated with problematic use and cannabisrelated negative consequences (bravo et al., 2019; kuntsche et al., 2005; lee et al., 2009; phillips et al., 2017). coping motives have also been associated with lower distress tolerance (semcho et al., 2016), higher anxiety sensitivity (johnson et al., 2010), higher pain-related anxiety (hogan et al., 2010), and higher depressive symptoms (bravo et al., 2019). in models of alcohol use, motives have typically been found to mediate associations between expectancies and drinking (e.g., cooper et al., 1995; fischer et al., 2004; kuntsche et al., 2007). although cannabis use expectancies and motives have both been independently associated with use, relatively little work has focused on integrating these constructs. in one study, foster et al. (2016) found negative cannabis expectancies were more strongly associated with cannabisrelated outcomes when accompanied by higher coping motives. however, this study did not examine positive expectancies and only examined one motive (i.e., coping). buckner (2014) examined the unique predictive values of cannabis expectancies and motives on cannabis use and problems among college students, in addition to perceived cannabis use norms, but did not cannabis, a publication of the research society on marijuana 71 examine associations among expectancies and motives. amiet et al., (2020) found higher general endorsement of both cannabis motives and expectancies was associated with poorer psychosocial functioning, but this study did not examine interrelations between expectancies and motives. thus, research has yet to consider cannabis motives as potential mediators of expectancy effects on cannabis-related outcomes. the present investigation seeks to fill these empirical and theoretical lacunae in a sample of frequent users. effects of experience with cannabis on expectancies and motives cannabis use expectancies have been prospectively associated with changes in cannabis use among adolescents over a two-year period (skenderian et al., 2008). similarly, motives for cannabis use have been found to fluctuate between the ages of 18 and 30 (patrick et al., 2011). exposure to cannabis may also influence perceptions of risk associated with use as college students who use cannabis report lower perceived risk than non-users whereas risk perception did not differ between cannabis heavy users and everusers (kilmer et al., 2007). the existing literature on cannabis expectancies and motives have primarily focused on relatively light/infrequent users and college student samples. while this is understandable given the difficulty in recruiting individuals who use cannabis daily or almost daily, conclusions from light using samples may not generalize to those for whom effective intervention and treatment strategies are most needed (benschop et al., 2015). for example, sensation-seeking may be a strong predictor of experimenting with cannabis, but it may have little to do with use among daily users. similarly, treatment strategies developed based on findings from light using samples may have little impact among frequent users. given the difficulty and expense associated with recruitment of frequent users, novel statistical methods which have fewer assumptions relative to traditional methods and are better suited for smaller samples (e.g., bayesian approaches) may be useful in studying frequent cannabis users. using bayesian methods with small samples small sample sizes constrain researchers’ ability to evaluate effects using traditional null hypothesis testing, known as the frequentist approach, in which parameters are considered fixed values with random error that reflect probabilistic determinants of a true effect. the frequentist approach considers the frequency of an occurrence over many trials, and is translated to the probability of observed attributes in a given sample relative to expected values from large number of samples drawn from a theoretical population with a given distribution. increasing sample sizes reduces random sampling error, therefore increasing statistical power and resulting in higher t statistics and smaller pvalues. thus, sample size has considerable influence on the chance of finding statistically significant effects using traditional null hypothesis testing approaches. alternatively, the bayesian approach incorporates knowledge of one’s data and prior research to determine the probability of the theoretical model given the observed data (dienes, 2011). bayesian inference differs from the frequentist approach in that it incorporates prior information based on previous research findings, which vary in the degree of confidence attributed to them (gelman et al., 2014). prior distributions, often referred to as priors, are probability distributions that reflect the amount of uncertainty about a given parameter before data are examined. priors can be either informative or non-informative. informative priors are theoretically or empirically derived such that the researchers incorporate prior knowledge of the constructs and hypothesized relationships into the models. the extent to which the literature, both theoretical and empirical, used to specify priors is well-developed and robust reflects the strength of the priors selected to be incorporated into the model. uninformative, or diffuse, priors are used when research and/or theory is limited and the researcher chooses to rely on observed associations within the data. these are uninformative because they place little emphasis on prior knowledge or findings, and have received cautionary recommendations as uninformative priors can have minimal impact on the results (gelman, 1996) and using diffuse priors will often result in parameter estimates cannabis expectancies and motives 72 that are similar to maximum likelihood estimates derived from the sample data (clark, 2005). as sample size increases, the impact of priors on results diminishes (gelman et al., 2004; wang & gelfand, 2002). therefore, bayesian methods are well suited for assessing the boundaries of the burgeoning body of theoretical and clinical research questions related to frequent cannabis use. despite their strong applicability to this research area, bayesian approaches have rarely been applied to cannabis research. thus, an additional aim of the present study was to demonstrate how bayesian methods can be used to evaluate complex theoretical models of cannabis use when sample sizes are small. the overall purpose of this study was to determine the extent to which specific positive cannabis effect expectancies are associated with cannabis use motives using a bayesian approach. in addition, the current research sought to determine whether cannabis use expectancies indirectly influence the likelihood of being a daily cannabis user and average number of joints used through cannabis use motives in a small sample of frequent cannabis users. we hypothesized that indirect pathways between cannabis expectancies and motives would align with alcohol use research (e.g., hasking et al., 2011; kuntsche et al., 2007), such that relaxation/tension-reduction expectancies would be mediated by enhancement, social, and coping motives, social facilitation expectancies would be mediated by enhancement and social motives, and perceptual/cognitive enhancement expectancies would be mediated enhancement and expansion motives. methods participants and procedures secondary data analyses were conducted using data from a broader mixed-methods study that included focus groups and a short survey (prince et al., 2019). the present study used the survey data and the sample consisted of frequent cannabis users (n = 54; 63% male; 44.4% caucasian; mage = 24.33 sd = 3.07), recruited from the community through local facebook advertisements and received $50 as remuneration for participation. participants had to be between the ages of 18-30, had to use cannabis as their drug of choice at least three times a week, and provide written consent. participants were excluded if they had serious or ongoing legal problems, or had signs of severe mental illness. all procedures were approved by the university’s irb. measures cannabis use. a modified version of the timeline followback specific to cannabis use was used to assess cannabis use (tlfb; collins et al., 2008). participants were shown a past 30-day calendar, as well as pictures of what constituted a standard cannabis joint (1/2 gram), and indicated whether they used cannabis (yes/no) and how many joints they had used on each day. average number of joints used per day was used to assess quantity of use. this method has been shown to be a valid method of assessing use (hjorthoj et al., 2012). cannabis effect expectancies. the marijuana effect expectancy questionnaire (meeq; aarons et al., 2001; schafer & brown, 1991) includes 48 items and six subscales. the three positive subscales were examined in the current study: relaxation/tension reduction, perceptual and cognitive enhancement, and social facilitation. additional subscales include global negative effects (i.e., consequences), craving and physical effects, and cognitive/behavioral impairment. these subscales were not included as they are either negatively associated with use, as previously discussed, or were not hypothesized to relate to motivations for use (i.e., craving and physical effects) in the current study. participants rated each item on a scale of 1 (strongly disagree) to 5 (strongly agree). the social facilitation scale included seven items and was revised from the nine-item social facilitation scale. two of the nine items were uncorrelated with the rest of the items: “i am less motivated when i smoke marijuana” and “marijuana does not make me feel more romantic or attracted to members of the opposite sex.” these were the only items of the subscale that were reverse coded and one of the items was the only item that specifically referred to sex. removal of these two items improved alpha from .595 to .771. no modifications were made either of the other two subscales. example items included “it helps me to unwind” (relaxation/tension reduction), “i become more creative or imaginative on marijuana” (perceptual/cognitive enhancement), “marijuana makes me talk more” cannabis, a publication of the research society on marijuana 73 (social facilitation). see table 1 for reliability estimates. cannabis use motives. the marijuana motives questionnaire (mmq; simons et al., 1998) comprises 25 items assessing motives. four of the five 5-item subscales were examined, including enhancement, social facilitation, coping, and expansion motives. conformity motives have previously failed to demonstrate associations with cannabis use in previous studies (e.g., bonnmiller et al., 2007), and initial analyses confirmed that conformity motives were not related to use or correlated with the remaining subscales using the bayesian framework. therefore, conformity motives were not included in analyses. participants indicate how often they used cannabis for each reason presented on a scale of 1 (almost never/never) to 5 (almost always/always). example items included “because it gives me a pleasant feeling” (enhancement), “because it helps me enjoy a party” (social facilitation), “to forget my worries” (coping), and “because it helps me be more creative and original” (expansion). cronbach’s alphas can be found in table 1. analysis plan bayesian analyses were used to tests hypotheses using mplus 7.4. four markov chain monte carlo (mcmc) chains were used, running 50,000 iterations and thinning by 1 (i.e., retaining every other sample from mcmc simulations). multiple imputation was used to replace missing values based on 20 generated datasets. multiple fit indices were consulted to evaluate model fit, including deviance information criteria (dic; spiegelhalter et al., 2002), bayesian information criteria (bic; schwarz, 1978), p-value for posterior predictive checking, and confidence limits for the differences between the observed and replicated chi-square values. lower dics and bics were indicative of better fitting models. nonsignificant p-values for posterior predictive checking indicate that the differences between the observed and replicated posterior means and posterior standard deviations are not greater than chance. models with various informative and noninformative priors were estimated to test model sensitivity following recommendations by gelman et al. (2004). although definitions of degrees of informative priors vary among researchers, we adopted the use of definitions that reflect the strength of the literature used to inform prior distributions’ specifications. informative priors for associations of relaxation/tension reduction expectancies with enhancement and coping motives, as well as associations of expectancies and motives for use with cannabis use, were aggregate scores of standardized coefficients across studies (gelman, 2002). weakly informative priors derived from single study scores and results from studies on alcohol use were used to examine remaining parameters between expectancies and motives (gelman, 2002). relationships between expectancies and motives indicated in the alcohol use literature were used to inform priors for the relationship between cannabis use motives and expectancies (cooper et al., 1995; haskin et al., 2011; read et al., 2003). similarly, empirically-based priors were for specified relationships between motives and cannabis use (bonn-miller et al., 2007; simons et al., 1998; 2005; zvolensky et al., 2007). for relationships between expectancies and motives unique to cannabis use, perceptual/cognitive enhancement expectancies and expansion motives, priors were theoretically-based. results descriptive information can be found in table 1. approximately 64.8% of the sample reported using cannabis on all 30 days in the past month, and remaining responses were evenly distributed across 14 to 29 days, although two individuals reporting using on zero days. the average number of joints reported per smoking day was 2.75, and ranged from 1 to 7. thus, frequency was dichotomized to represent those who reporting using on all 30 days (1) and those who reported using fewer than 30 days (0). correlations were evaluated using standard effect size criteria (i.e., .1 = small, .3 = medium, .5 = large; cohen, 1992) rather than null hypothesis significance testing. correlations among cannabis effect expectancies subscales and cannabis motives subscales suggested strong and positive associations between these cognitions. additionally, expectancies and motives were positively associated with cannabis use. more specifically, correlations between motives and expectancies with cannabis use frequency were small in size for cannabis expectancies and motives 74 table 1. variable statistics and correlations correlations α mean sd 1 2 3 4 5 6 7 8 9 1. relaxation/tension reduction .79 4.02 0.75 2. per/cog enhancement .75 3.74 0.74 .650 3. social facilitation .77 3.72 0.59 .600 .671 4. enhancement motives .89 4.03 1.04 .546 .650 .600 5. social facilitation motives .88 3.59 1.08 .618 .749 .764 .794 6. coping motives .89 3.42 1.20 .616 .631 .609 .659 .746 7. expansion motives .92 3.64 1.25 .435 .717 .640 .581 .690 .609 8. average joints used 2.75 1.51 .096 .087 .049 .124 .055 .277 .129 9. frequency 0.65 0.48 .163 .159 .197 .176 .299 .157 .059 .285 note. frequency is dichotomous (i.e., 1 = all 30 days, 0 = < 30 days) and polychoric correlations are reported. α = cronbach's alpha estimate. per/cog = perceptual and cognitive. sd = standard deviation. cannabis, a publication of the research society on marijuana 75 all but expansions motives for which the correlation was positive but trivial in size. regarding average number of joints, all correlations with expectancies were trivial, and only enhancement, coping, and expansion motives were associated with use quantity and these effects were small to moderate in size. model building and sensitivity analyses informative priors found in model 3 of table 1 (effects retained in final analyses) and supplemental table 1 (direct effects and all a paths) were initially specified to examine model fit. models tested seven pathways between cannabis expectancies and motives: pathways between relaxation/tension-reduction expectancies and enhancement, social, and coping motives; pathways between social facilitation expectancies and enhancement and social motives; and pathways between perceptual/cognitive enhancement expectancies and enhancement and expansion motives. each of the cannabis motives were hypothesized to be associated with cannabis use frequency and average number of joints used. to these models, the remaining five associations between expectancies and motives (i.e., relaxation/tension reduction expectancies with expansion motives; social facilitation expectancies with coping and expansion motives; perceptual/cognitive enhancement expectancies with social and coping motives) were also added. direct effects of expectancies on cannabis use were then added to models of frequency and quantity of use, and all priors can be found in supplemental table 1. the added parameters, and thus reduced degrees of freedom, of the direct effects included for frequency of use did not improve model fit for frequency of use (reduced model: posterior predictive p-value = .500, 95%ci[-14.54, 27.47]; direct effects model: posterior predictive p-value = .455, 95%ci[-26.83, 43.41]). inclusion of direct effects for average joints used were also not determined to improve model fit (reduced model: posterior predictive p-value = .333, 95%ci[-17.75, 37.61], bic = 1025.05, dic = 921.20; direct effects model: posterior predictive p-value = .333, 95%ci[-9.41, 25.30], bic = 1028.22, dic = 917.82), therefore, direct effects were not retained in the models. the first set of priors used point estimates that were empiricallyand theoretically-derived with modest and uniform variances of 0.10, which represented approximately 15% to 43% (average of 30%) of the estimates’ magnitudes (model 1). variances were then adjusted to be very narrow (0.001) to represent highly precise estimates (model 2), and relatively wide (0.40) to reflect a greater amount of variability and uncertainty (model 3). finally, model estimates were increased by two times in order to test whether the associations between expectancies and motives, as well as motives and use, were greater within the current sample of frequent users than those suggested in previous research (model 4). table 2 presents model fit results for selected models, and table 3 presents the priors specified for each model. across models, all pathways between expectancies and motives emerged. in model 1, no effects of motives on frequency of use and average number of joints used were observed. however, all motives were associated with both frequency and average joints in model 2. in both models 3 and 4, only social motives were associated with use for frequency, and only coping motives emerged for average joints used. relationships between relaxation expectancies and enhancement motives (b = 0.13, 95%ci[-0.27, 0.58]), coping motives (b = 0.41, 95%ci[-0.03, 0.84]), and social motives (b = 0.06, 95%ci[-0.18, 0.39]), in addition to social expectancies and enhancement motives (b = 0.36, 95%ci[-0.07, 0.89]), were not indicated in models of frequency. relationships between relaxation expectancies and enhancement motives (b = 0.14, 95%ci[-0.29, 0.65]), social motives (b = 0.11, 95%ci[-0.18, 0.49]), and expansion motives (b = 0.30, 95%ci[-0.75, 0.19]), as well as between social expectancies and coping motives (b = 0.38, 95%ci[-0.15, 0.87]) and enhancement expectancies and coping motives (b = 0.43, 95%ci[-0.03, 0.80]) failed to emerge in models of average use. these pathways were thus removed from the model. cannabis expectancies and motives 76 table 2. bayesian path analysis model fit comparisons outcome priors bic dic posterior predictive checking 95% ci [ll, ul] frequency model 1 0.500 -14.54 27.47 model 2 0.083 -3.23 35.67 model 3 0.500 -16.08 28.51 model 4 0.500 -16.01 29.68 average joints used model 1 1025.05 921.20 0.333 -17.75 37.61 model 2 1056.49 940.04 < .001 9.25 65.44 model 3 1017.81 919.74 0.417 -18.61 33.68 model 4 1019.71 920.29 0.333 -17.61 34.70 note. frequency of use is dichotomous (i.e., all 30 days vs. < 30 days). selected models are highlighted. bic and dic model fit statistics are not available for bayesian analyses using categorical outcomes. bic = bayesian information criteria. ci = credibility interval for the difference between the observed and replicated chi-square values. ll = lower limit. ul = upper limit. table 3. prior distributions for selected models model 1 model 2 model 3 model 4 expectancy motive µ σ2 µ σ2 µ σ2 µ σ2 relaxation → enhancement 0.24 0.10 0.24 0.001 0.24 0.40 0.48 0.40 social facil → enhancement 0.65 0.10 0.65 0.001 0.65 0.40 1.30 0.40 relaxation → coping 0.52 0.10 0.52 0.001 0.52 0.40 1.04 0.40 social facil → social 0.42 0.10 0.42 0.001 0.42 0.40 0.84 0.40 relaxation → social 0.30 0.10 0.30 0.001 0.30 0.40 0.60 0.40 enhancement → coping 0.30 0.10 0.30 0.001 0.30 0.40 0.30 0.40 enhancement → social 0.50 0.10 0.50 0.001 0.50 0.40 1.00 0.40 enhancement → expansion 0.50 0.10 0.50 0.001 0.50 0.40 1.00 0.40 social facil → expansion 0.50 0.10 0.50 0.001 0.50 0.40 1.00 0.40 motive outcome enhancement → mj use 0.38 0.10 0.38 0.001 0.38 0.40 0.76 0.40 social → mj use 0.29 0.10 0.29 0.001 0.29 0.40 0.58 0.40 coping → mj use 0.23 0.10 0.23 0.001 0.23 0.40 0.46 0.40 expansion → mj use 0.29 0.10 0.29 0.001 0.29 0.40 0.58 0.40 expectancy outcome relaxation → mj use 0.38 0.10 0.38 0.001 0.38 0.40 0.76 0.40 social facil → mj use 0.29 0.10 0.29 0.001 0.29 0.40 0.58 0.40 enhancement → mj use 0.23 0.10 0.23 0.001 0.23 0.40 0.46 0.40 note. social facil = social facilitation. µ = posterior mean. σ2 = variance. cannabis, a publication of the research society on marijuana 77 final model results model selection was based on model fit indices, which can be found in table 2. model 4 was selected for frequency of use given results of posterior predictive checking, which suggested this model demonstrated the smallest differences between the observed and replicated chi-square values with the narrowest credibility interval. however, model fit did not vary greatly across the models, with the exception of narrow variances (model 2). similarly, interpretations and results for expectancies and motives in model 4 differed minimally from those indicated in models 1 and 3, and relationships between motives and frequency of use were similar to those indicated in model 3. model 3 was selected for both frequency of use and average number of joints used based results indicating this model had the largest posterior predictive p-value, as well as the lowest dic and bic values. path estimates and posterior standard deviations for the final model assessing frequency of use are reported in table 4 and figures 1 & 2. estimates and posterior standard deviations for average number of joints used can be found in table 5. across frequency and average number of joints used, results suggested increases in perceptual/cognitive enhancement cannabis effect expectancies were positively associated with greater social, enhancement, and expansion motives. finally, social facilitation expectancies were positively associated with enhancement, social, and expansion motives. with regard to associations between cannabis motives and cannabis use, coping motives were associated with average number of joints used, and social motives were associated with frequency of use. no effects emerged for the remaining motives and either of the two cannabis use outcomes. table 4. path model results for frequency of use 95% ci expectancy motive est. p(sd) ll ul social facil → social 0.55 *** 0.13 0.33 0.80 enhancement → social 0.63 *** 0.13 0.32 0.87 enhancement → enhancement 0.82 *** 0.13 0.54 1.05 enhancement → expansion 0.82 *** 0.20 0.45 1.17 relaxation → expansion -0.22 0.17 -0.57 0.12 social facil → expansion 0.55 *** 0.19 0.18 0.90 social facil → coping 0.44 * 0.20 0.04 0.79 enhancement → coping 0.57 ** 0.18 0.24 0.90 motive outcome enhancement → frequency 0.09 0.21 -0.33 0.48 social → frequency 0.41 * 0.21 -0.05 0.81 coping → frequency 0.00 0.19 -0.39 0.31 expansion → frequency -0.11 0.18 -0.49 0.23 note. priors noted in model 3 of table 3 are specified. social facil = social facilitation. ci = credibility interval. ll = lower limit. ul = upper limit. *p < .05. **p < .01. ***p < .001. cannabis expectancies and motives 78 table 5. model results for average number of joints used. 95% ci expectancy motive est. p(sd) ll ul relaxation → coping 0.75 *** 0.16 0.43 1.07 social facil → enhancement 0.41 *** 0.16 0.15 0.73 enhancement → enhancement 0.50 *** 0.16 0.19 0.76 social facil → social 0.64 *** 0.14 0.39 0.89 enhancement → social 0.50 *** 0.12 0.27 0.72 enhancement → expansion 0.68 *** 0.16 0.37 0.98 social facil → expansion 0.48 ** 0.16 0.14 0.73 motive outcome enhancement → avg joints 0.15 0.21 -0.26 0.54 social → avg joints -0.28 0.27 -0.80 0.23 coping → avg joints 0.42 * 0.19 -0.03 0.76 expansion → avg joints 0.09 0.18 -0.27 0.40 note. social facil = social facilitation. ci = credibility interval. ll = lower limit. ul = upper limit. *p < .05. **p < .01. ***p < .001. figure 1. final bayesian path analysis model for expectancies predicting frequency of use through three different forms of cannabis use motives. dashed lines represent indirect pathways. frequency is coded 0 (< than 30 days) and 1 (all 30 days). social facilitation and perceptual/cognitive enhancement cannabis effect expectancies were indirectly related to average number of joints used on days when cannabis was used through social motives. cannabis, a publication of the research society on marijuana 79 figure 2. final bayesian path analysis results for expectancies predicting average number of joints used through three different forms of cannabis use motives. dashed lines represent indirect pathways. perceptual/cognitive enhancement cannabis effect expectancies were indirectly related to average number of joints used on days when cannabis was used through coping motives. table 6. indirect effects of cannabis expectancies on cannabis use through motives for use. 95% ci expectancy a motive b outcome ab ll ul social facil → expansion → frequency -0.05 -0.31 0.12 social facil → coping → frequency 0.00 -0.19 0.18 social facil → social → frequency 0.21 * -0.03 0.49 enhancement → enhancement → frequency 0.07 -0.27 0.39 enhancement → coping → frequency 0.00 -0.24 0.19 enhancement → social → frequency 0.24 * -0.03 0.57 enhancement → expansion → frequency -0.09 -0.39 0.19 relaxation → expansion → frequency 0.01 -0.08 0.17 relaxation → coping → average joints 0.29 * -0.09 0.27 social facil → enhancement → average joints 0.06 -0.12 0.27 social facil → social → average joints -0.19 -0.60 0.14 enhancement → enhancement → average joints 0.07 -0.12 0.27 enhancement → social → average joints -0.13 -0.49 0.13 enhancement → expansion → average joints 0.06 -0.23 0.27 social facil → expansion → average joints 0.04 -0.11 0.27 note. social facil = social facilitation. ci = credibility interval. ll = lower limit. ul = upper limit. * p < .05. cannabis expectancies and motives 80 indirect effects eight indirect effects were specified for each of the cannabis use expectancies on frequency of use and seven indirect effects were specified for average number of joints used through each of the cannabis use motives. the product of coefficients method was used to examine indirect effects; specifically, a paths between each expectancy and each motive were multiplied by the b paths assessing the effects of each respective motive on cannabis use. all indirect effects can be found in table 6. two indirect effects emerged as significantly greater than zero for frequency of use: social facilitation expectancies had a significant indirect effect on frequency through social motives. in addition, perceptual/cognitive enhancement expectancies were also indirectly related to frequency of use through social motives. one indirect effect was determined to be significantly different than zero for average number of joints used: relaxation/tension reduction expectancies were indirectly related to average joints used through coping motives. discussion the current study aimed to extend prior research demonstrating unique associations between expectancies and motives for alcohol consumption to cannabis use, an area of work with important theoretical and practical utility. we were also interested in examining the associations between the different types of motives and expectancies. furthermore, we aimed to report on and demonstrate how bayesian methods can be used to examine complex theoretical models with modest sample size. results revealed similar positive relationships between expectancies and motives suggested in alcohol use literature (e.g., hasking et al., 2011; kuntsche et al., 2007). notably, across all expectancies, perceptual/cognitive enhancement expectancies were the only expectancy determined to be consistently related to all four cannabis use motives. social facilitation expectancies were related to enhancement, social, and expansion motives, and relaxation/tension reduction expectancies were determined to be associated with coping motives. perceptual/cognitive enhancement expectancies were consistently associated with enhancement, social, and expansion motives. furthermore, perceptual/cognitive expectancies and social expectancies were both indirectly related to frequency through social motives. relaxation/tension reduction expectancies, conversely, were indirectly related to average number of joints used through coping motives. of the four motives examined, only social motives were directly related to frequency of past 30-day use, whereas coping motives were associated with average amount of use. two unanticipated relationships emerged within the data: social facilitation expectancies were associated with expansion motives and perceptual/cognitive enhancement expectancies were associated with social motives. both perceptual/cognitive enhancement expectancies and expansion motives describe perceptions that cannabis increases one’s ability to be creative, increase awareness, and increase openness to new ideas and experiences. that social expectancies and motives were associated with these cognitions indicates something distinctive about cannabis use that may be inherently social in nature to our frequent using participants. it is possible these individuals are highly embedded within social networks comprised of other frequent using adults, and consuming cannabis in such situations may facilitate social bonding. our results suggest motivational pathways may vary across outcomes. social and cognitive perceptual expectancies were indirectly associated with daily use through social motives whereas tension reduction and cognitive/perception expectancies were indirectly associated with quantity through coping motives. the differential effects of social and coping motives on daily use frequency and quantity are somewhat analogous to motivational effects on drinking, where social motives have been associated more with consumption relative to coping motives, which have been more associated with problems (e.g., kuntsche et al., 2007; read, et al., 2003). findings provide general support for motives as mediators of associations between expectancies and cannabis use, at least among frequent users. subsequent research should examine whether motivational pathways may vary with use history and use patterns. clinical implications our findings provide important clinical implications for prevention and intervention approaches. interventions targeting perceptions cannabis, a publication of the research society on marijuana 81 that cannabis enhances one’s awareness and improves cognitive facilities may be ideal for interventions for frequent users (figueiredo et al., 2020), as this was the only expectancy demonstrating associations with all four motives, as well as indirectly related to both frequency and quantity through cannabis social and coping motives, respectively. further, intervening on social facilitation and relaxation/tension reduction cognitions may thwart the effects of these expectancies on subsequent use. interventions focused on challenging positive alcohol use expectancies have indicated significant decreases in alcohol use at follow-up (e.g., darkes & goldman, 1993; larimer & cronce, 2007), although meta-analyses have suggested these effects are rarely sustained beyond 30-day follow-ups (scott-sheldon et al., 2012). thus, potentially altering positive expectancies for cannabis use may be one way to reduce use. more recently, researchers have demonstrated that interventions challenging coping motives for cannabis use can be used to significantly decrease use (blevins & stephens, 2016; banes et al., 2014; blevins et al., 2016). similar methods may be applied to frequent users as our results indicated coping motives mediated the effects of expectancies (i.e., relaxation/tension reduction and perceptual/cognitive enhancement) on the amount of cannabis consumed. programs altering the content of these strategies to target these specific expectancies and motives for cannabis use may be especially efficacious for frequent users. limitations and future directions a number of limitations should be considered and provide important directions for future research. given our focus on frequent cannabis using young adults, our findings may not extend to light or moderate users. moreover, we had participants report cannabis use frequency relative to the number of standard joints used per day, which may not be the best approach for individuals who primarily used edibles, topicals, or other concentrated cannabis products. replication of these models is needed to determine the extent to which similar relationships emerge and provide additional support for the theoretical model proposed. replication within larger samples of frequent users would greatly bolster confidence in our findings as even bayesian analyses cannot correct sampling error, as well as other concerns related to conservative sample sizes. additionally, our findings are crosssectional. mediational analyses are best applied to samples with two or more time points during which mediators and outcomes are manipulated or assessed longitudinally (preacher & hayes, 2008). if these relationships are found in larger samples of cannabis users across multiple time points, greater confidence can be placed in our findings. lack of associations between reported use and most cannabis expectancies and motives (i.e., enhancement, coping, and expansion) in the present study diverge from those reported in previous studies involving frequent cannabis users (simons et al., 2000), limiting the generalizability of the findings. however, one reason for the lack of association between motives and cannabis use may be the small sample size included in the current study as modest correlations were suggested across frequency and average joints, ranging from .11 to .36 with an average correlation of .21 when removing social facilitation motives (r = .05). additional research is needed to replicate these effects in larger samples, samples with greater diversity, and samples of varying amounts of cannabis use prior to participation. although originally designed for use with adolescents, the meeq has been used in a large number of studies of adolescents and young adults. most samples in which the meeq has been used have consisted of a relatively small proportion of daily or nearly daily users. this may account for the poor reliability of the social facilitation subscale and the need to drop two of the items. the fact that both of the items were reversed and that they were the only two that were reversed on this subscale could suggest that reversed items are more difficult to understand for frequent users. it also seems plausible that frequent users who may use multiple times every day or nearly every day may not associate use with sexual activity. in a review of self-reported effects of cannabis, green, kavanagh, and young (2003) noted relatively frequent endorsement of enhanced sexual pleasure and sexual arousal but only when experiences were reported from a list of effects provided by researchers. in studies where responses were open ended, sexual effects were cannabis expectancies and motives 82 not mentioned in any of the studies reported. studies using open ended responses included heavier users than most of the studies where lists of possible effects were provided. future research is needed to determine the extent to which the nature of expectancies differ markedly for very frequent users. conclusion collectively, results of the present study suggest expectancies have indirect effects on cannabis use through motives. to date, cannabis expectancies and motives have typically been evaluated separately. our findings provide an initial foundation for more systematically examining how expectancies and motives operate in unison to predict cannabis use among frequent using adults. 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(2002). a simulationbased approach to bayesian sample size determination for performance under a given model and for separating models. statistical science, 193-208. funding and acknowledgements: research reported in this manuscript was supported by the howard t. blane director’s award for the development of innovative research in the addictions (bdaa) by the research institute on addictions awarded to mark a. prince. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i1a3_authors_v2 research article 53 abstract androgenetic alopecia (aga) is the most common cause of hair loss. several fda approved medications are available but offer limited results. studies have shown that the endocannabinoid system (ecs) is a key player in hair follicle cell growth. the ecs cannabinoid type one (cb1) receptors are well expressed in the hair follicle cells. cannabidiol cbd is a negative allosteric modulator of the cb1 receptor and has been shown to result in hair shaft elongation. in addition, the hair follicle cycle phases are controlled by the ecs vanilloid receptor-1 (trpv1). cbd has also been shown to increase wnt signaling pathways that are involved in the differentiation of dermal progenitor cells into new hair follicles and maintaining the anagen phase of the hair cycle. the effects of cbd on hair growth are dose dependent and higher doses may result in premature entry into the catagen phase via a receptor known as vanilloid receptor-4 (trpv4). topical application of cbd reaches hair follicles where it is a cb1 negative modulator, and trpv1, and trpv4 agonist. a study was done of 35 subjects with aga using a once daily topical hemp oil formulation, averaging about 3-4 mg per day of cbd and minimal amounts of other cannabinoids for six months. a hair count of the greatest area of alopecia was carried out before treatment and again after six months. the results revealed that men did slightly better than women, and the vertex area did better than the temporal areas. on average there was statistically significant 93.5% increase in hair after 6 months. all subjects had some regrowth. there were no reported adverse effects. since the cbd works through novel mechanisms different from finasteride and minoxidil it can be used in conjunction with these current drugs and would be expected to have synergistic effects. key words: = cannabidiol (cbd). cannabinoid one receptor (cb1), vanilloid receptor-1 (trpv1), androgenetic alopecia (aca) androgenetic alopecia (aga) is a very common condition, that occurs in both men and women, and increases in prevalence with age. it is by far the most common cause of baldness and hair thinning. it generally starts in the third and fourth decades of life and significantly increases in prevalence in women after menopause. is it estimated that 50% of caucasian men and 19% of caucasian women are affected by age 50 (shankar et al., 2009). there is a lower prevalence and severity of the condition in asian and black men. aga may adversely impact a person both psychologically and socially, especially in women (levy & emer, 2013). the condition is characterized by follicular miniaturization in a specific pattern due to the effects of systemic androgens and genetic factors (salman et al., 2017). in the male pattern phenotype, the hairline regresses at the bitemporal regions and at the vertex. in the female pattern then is a diffuse thinning with preservation of the frontal hairline. however, the pathogenesis is the same (levy & emer, 2013). aga develops due to a disturbance in the cyclic transformation of hair follicles from active hair shaft growth and pigment production (anagen) to apoptosis-driven (cell death) hair follicle involution (catagen). current treatment two medications, minoxidil topical and oral finasteride are fda approved for the treatment of aga. unfortunately, these medications offer limited results (gupta & charrette, 2015; shapiro & kaufman, 2003). the new combination of hair regrowth with cannabidiol (cbd)-rich hemp extract – a case series cannabis 2021, volume 4 (1) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.01.003 gregory l. smith1 and john satino2 1medical director, medical life care planners, st. petersburg, fl, usa. 2laser hair center, clearwater, fl, usa. corresponding author: gregory l. smith, md, mph, medical life care planners, 3052 west vina del mar blvd, st. pete beach, fl 33706. tel: 404-451-4045, e-mail: medicalmarijuana@mail.com hair regrowth with cbd-rich hemp extract 54 topical minoxidil and topical finasteride has shown more promising results (suchonwanit et al., 2018). hair transplantation is the only current successful permanent option, and it requires surgical procedures. several other medical options, such as antiandrogens such as spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride, prostaglandin analogs and ketoconazole are reported to be beneficial (levy & emer, 2013). however, they can be associated with significant adverse effects, such as depression and elevated liver enzymes. laser and light therapies have also become popular despite the lack of documented profound benefit.(levy & emer, 2013). minoxidil was first evaluated for treatment of hair loss in 1984 as a 1% topical solution (olsen & weiner, 1987). it became clear that higher concentrations were needed. a 12-month doubleblind trial was done on 60 subjects with aga. the use of twice-daily topical 2% and 3% minoxidil revealed that at month 4 the average total nonvellus hair counts had increased from a baseline mean of 158.2 to 270.2 (71% increase) in the 2% minoxidil group, from 156.6 to 287.0 (83% increase) in the 3% minoxidil group (roberts., 1987). at month 12 the means were 415.6 (163% increase) and 448.5 (186% increase) for 2% minoxidil, 3% minoxidil, respectively. the increases from month 4 to month 12 were highly significant for each group (p = 0.0001). more recently, a 5% once-a-day foam has been shown to be equally effective to twice-daily application of lower concentration topical minoxidil (blumepeytavi et al., 2011). finasteride, a type 2-selective 5α-reductase inhibitor, was approved in 1997 as the first oral pharmacologic therapy for the treatment of men with aga. it was originally developed for the treatment of men with benign prostatic hyperplasia (bph) at a dose of 5 mg/day. subsequent studies demonstrated that finasteride was an effective treatment for men with aga at an optimal dose of 1 mg/day. the net improvement in hair count (finasteride vs. placebo) was 14% at 1 year and 16% at 2 years (shapiro & kaufman, 2003). a 48-week-long clinical trial of men with aga was started in november 2018. (https://www.clinicaltrials.gov/ct2/show/nct0374 2518). the study used an investigational new topical drug called sm04554. phase iii trials were completed in january 2021; however, no results are published at this time. it has shown some promising results in early phase i and ii trials and works by modulating the wnt pathway that is postulated to initiate and maintain the anagen phase of the hair cycle. wnt signaling also causes dermal progenitor cells to differentiate into new hair follicles. it is interesting to note that cbd has also been shown to increase wnt signaling (vallée et al., 2017).. however, to date there is little basic science or clinical research on cbd and wnt signaling. recently, with the increasing acceptance of cannabis sativa-based therapies, cannabidiol (cbd) has come under consideration as a possible, effective, safe, inexpensive non-prescription, topical aga therapy (expert committee on drug dependence, 2018). cbd works through the endocannabinoid system (ecs) in the body and has novel effects on hair follicle elongation and hair matrix keratinocytes activated through ecs receptors in the hair follicle cells (bíró et al., 2009). as such, the therapeutic effects of cbd would complement the physiologic effects of minoxidil, finasteride and antiandrogen therapies. ecs and hair follicles the ecs was only discovered in the 1990s. in essence, it is a system involved with maintaining cellular homoeostasis in response to excess oxidative stress. it down-regulates the damaging inflammatory response, and up-regulates regenerative processes. it is comprised of two receptors, cannabinoid receptor 1 and 2 (cb1 and cb2) and has two messenger molecules known as the endocannabinoids, anandamide (aea) and 2arachidonylglycerol (2-ag). one of the many systems that the ecs is involved with is thermoregulation within the skin. there are a substantial number of cb1 and cb2 receptors on various cell lines within the skin (tóth et al., 2019). cb1 receptors are well expressed in the hair follicle cells. stimulation of the cb1 receptor with the endocannabinoids leads to decreased hair shaft elongation (telek et al., 2007). studies have shown that the ecs is a key player in hair follicle cell growth control. (bíró et al., 2006; telek et al., 2007; tóth et al., 2019). the hair follicle cycle (anagen, catagen, telogen phases) is controlled by the vanilloid receptor-1 cannabis, a publication of the research society on marijuana 55 (trpv1; bíró et al., 2006).trpv1 receptors are found on the hair matrix keratinocytes. mouse studies have shown that activation promotes hair follicle regression (catagen) and hair matrix keratinocyte apoptosis (cell death) thru retarding hair shaft elongation. (bíró et al., 2006). endocannabinoids, and cannabis-derived phytocannabinoids, such as thc and cbd message trpv1 receptors. it is postulated that cbd has therapeutic effects via trpv1 receptors by excessive activation of the receptor that they become desensitized. (muller et al., 2019). tetrahydrocannabinol (thc) is a cb1 receptor partial agonist, and it has been shown to dose-dependently inhibit hair shaft elongation, decrease proliferation of hair matrix keratinocytes and induce intraepithelial apoptosis and premature hair follicle regression (catagen). these effects which occur with our innate endocannabinoid anandamide and with plant-based thc were inhibited by a selective cb1 antagonist. furthermore the studies revealed that cb1 receptors were expressed in a hair cycle-dependent manner on the hair follicle. (bíró et al., 2006; telek et al., 2007). the available research suggests that thc and other cb1 agonists can be used to manage unwanted hair growth, and likewise, cb1 antagonists, such as cbd and tetrahydrocannabivarin (thcv) and cannabidivarin (cbdv) can be used to promote hair growth (telek et al., 2007). cbd is a cb1 antagonist that likely has its effects via negative allosteric modulation of the cb1 receptor (chung et al., 2019; laprairie et al., 2015). thcv and cbdv have more potent direct antagonistic effects on the cb1 receptor. a more recent study of human hair follicle cultured cells (szabó et al., 2017) revealed that use of lower doses of cbd resulted in hair shaft elongation, likely via cb1 antagonism. however, much higher doses resulted in premature entry into the catagen phase, probably via a different receptor, the vanilloid receptor-4 (trpv4). therefore, the dosing of the topical cbd needs to be evaluated in order to obtain positive hair regrowth. cbd over the past decade cbd has been extensively researched for a myriad of therapeutic benefits (expert committee on drug dependence, 2018). cbd does not cause euphoria or addiction. it has a wide therapeutic window and few adverse effects. topical application of cbd has not been associated with any significant adverse effects (bíró et al., 2009; tóth et al., 2019). cbd in an oral form has been fda approved for treatment of recalcitrant epilepsy and is now an over-thecounter drug (www.epidoloex.com). cbd in sublingual, oral, inhaled and topical versions are relatively inexpensive and widely available as nutraceuticals. it is estimated that as many as 14% of the united states population has tried cbd products. (corroon & phillips, 2018). cbd is fat-soluble and poorly absorbed past the epidermis, but topical application of cbd easily reaches hair follicles where it is a cb1 antagonist, and trpv1, and trpv4 agonist (szabó et al., 2017). the present study the study was conducted to evaluate the efficacy of daily topical application of a cbd-rich hemp oil formation on aga. secondary goals of the study were to look for adverse effects associated with the daily topical application. based on the pre-clinical evidence of the hair regrowth benefits of antagonizing the cb1 receptors, and from over stimulating trpv1 receptors we would expect a significant increase in hair follicles in the treated areas. methods the study is a case series of adults presenting to a ‘hair and scalp’ center in clearwater florida. adult subjects, not currently using minoxidil or finasteride were offered the opportunity to receive the hemp oil extract free of charge through facebook advertising. the first thirty-five subjects who responded were selected (28 males, 7 females). all were caucasian and were diagnosed with aga based on the presence of gradually progressing bitemporal and/or vertex alopecia. clinical diagnosis of aga with norwoodhamilton classification score of 3v or 4. the norwood-hamilton classification is used to score stages of male pattern baldness, from 1 7. stage 3v vertex: there is slight recession of the hairline around the temples, but there is significant hair loss on the top of the scalp (the vertex). stage 4: the hairline recession is more than slight recession of the hairline around the hair regrowth with cbd-rich hemp extract 56 temples, and there is sparse hair or no hair on the vertex. the two areas of hair loss are separated by a band of hair that connects to the hair remaining on the sides of the scalp. the predefined endpoints were hair counts obtained in a defined, representative area of scalp hair loss, and investigator clinical assessment of hair growth. the females were ages 46-76 (average age 61) and the males 28-72 (average age 43). the subjects gave their written informed consent for this six-month trial. the study adhered to the helsinki guidelines and was institutionally approved. each participant was provided with an informed consent form that they signed. none of the subjects were currently using minoxidil or finasteride. no other hair loss treatments were used during the six months of the research. the subjects were given a topical extract in a 2 oz jar once a month and advised to apply a thin layer once each morning to the areas of baldness. the subjects were advised that she could use blow dryers, conditioners and other hair preparations. the 2 oz topical was replaced as needed at monthly visits at throughout the six-month trial. the amount used varied significantly based on the area of the scalp to be treated. none of the subjects used more than 2 oz in any one-month period. the topical extract was made of high cbd cannabis sativa (hemp) flower that had been ultrapulverized into a fine powder. this chalk-like green powder was independently analyzed by cannalysis labs in santa ana, ca. it was found to contain 10.78% cbd, and 0.21% thc, and there was no detectable thcv or cbdv. this powder was infused into a lanolin base paste and natural emu oil carrier. each 2 oz jar contained 1000 mg of the power, or 108 mg of cbd. the subjects were advised to apply thin layer of the paste over all bald or balding areas once each morning. the 2 oz jar lasted approximately one month, which is an average daily dose of 3-4mg of topically applied cbd. a hair count of the greatest area of alopecia was carried out before treatment was started and again after six months of treatment. to facilitate consistent hair count analysis, a clear acrylic mold was made of each subject’s head. the front of the mold was positioned at the hair line, with additional measurements from the tip of the nose to the front of the mold. a one-centimeter square was removed from the mold in the area of greatest alopecia, which was either in the temporal or vertex region. the hair count was done within the 1 cm area. the nonvellus hairs within the one square centimeter were pulled through the opening with a surgical skin hook. a bodelin proscope with fifty times magnification was used to perform hair counts. results the specific data and hair count for each subject is demonstrated in table 1. temporal area. this table reveals that hair counts in the temporal area increased an average of 74.1% in men, and 55.2% in women. in men the number of hairs increased from baseline of 20.6 to 33.7 (paired t-test p< 0.01) in the temporal area, and in women from 20.3 to 30.5 (paired t-test p< 0.01) vertex area. in the vertex area the hair counts increased an average of 120.1% for men, and 64.9% for women. in men, the number of hairs increased from baseline of 16.8 to 32.9 (paired ttest p < 0.01) in the temporal area, and in women from 18.7 to 30.7 (paired t-test p < 0.01). for all males, the baseline hair count was 18.28 (95% confidence interval +/3.02) and at six months it was 33.21 (95% confidence interval +/ 4.86). for all females, the baseline hair count was 19.57 (95% confidence interval +/4.83) and at six months it was 30.57 (95% confidence interval +/ 7.51). the paired samples t-value for men before and after difference was 7.38 (p <0.00001). the paired samples t-value for women before and after difference was 5.56 (p =0.0014). the hair count increased 93.5%, from 18.5 to 32.7 (p < 0.001) when temporal and vertex areas were combined. in general males and the vertex area did the best. all subjects had some increase in hair count. no self-reported survey of cosmetic appearance was done. one-third of the patients reported some slightly increased hair shedding during the first month of treatment, this was no longer was noted at the two-month visit. otherwise, there was no reported adverse effects from use of the extract. cannabis, a publication of the research society on marijuana 57 table 1. subject change in hair count over six months patient age sex area baseline 6 months after difference change(%) 1 47 m t 23 45 22 95.7 2 34 m t 33 51 18 54.5 3 28 m t 22 31 9 40.9 4 56 m t 6 11 5 83.3 5 35 m t 16 28 12 75 6 29 m t 38 56 18 47.4 7 34 m t 12 46 34 283.3 8 51 m t 18 27 9 50 9 63 m t 16 16 0 0 10 29 m t 15 23 8 53.3 11 36 m t 28 37 9 32.1 12 55 m v 8 22 14 175 13 37 m v 36 41 5 13.9 14 29 m v 22 61 39 177.3 15 34 m v 19 36 17 89.5 16 51 m v 18 27 9 50 17 48 m v 14 64 50 357.1 18 59 m v 12 23 11 91.7 19 29 m v 18 26 8 44.4 20 38 m v 22 28 6 27.3 21 56 m v 18 31 13 72.2 22 35 m v 22 39 17 77.3 23 46 m v 12 23 11 91.7 24 72 m v 12 33 21 175 25 42 m v 12 23 11 91.7 26 60 m v 12 27 15 125 27 42 m v 24 38 14 58.3 28 30 m v 4 17 13 325 29 56 f t 32 51 19 59.4 30 66 f t 19 27 8 42.1 31 71 f t 22 29 7 31.8 32 46 f t 8 15 7 87.5 33 64 f v 19 29 10 52.6 34 76 f v 18 36 18 100 35 49 f v 19 27 8 42.1 note. t = temporal; v = vertex. hair regrowth with cbd-rich hemp extract 58 discussion this case study supports significant hair regrowth benefits in both men and women with aga. in general men did slightly better than women, and the vertex area did better than the temporal areas. on average there was 93.5% increase in nonvellus hair after six months of once-daily use. all subjects had some regrowth. the exact mechanism of therapeutic effects is not entirely clear, and furthermore, definitive research is planned. cbd may be functioning as a cb1 receptor antagonist, via negative allosteric effects, excessive trpv1 agonism and potentially also via wnt messaging. the dosing of the cbd needs to be further evaluated as preclinical research suggests that much higher doses of cbd may cause agonistic effects at trpv4 receptors which can cause premature entry of the hair follicle into the catagen phase, thereby, inhibiting hair growth. (boudaka et al., 2020) the safety of topically applied cbd has been previously well-documented (bíró et al., 2009; expert committee on drug dependence, 2018). once again there is no reported significant adverse effects for six-month application of this cbd topical. since the cbd works through novel mechanisms entirely different from both finasteride and minoxidil it can be used in conjunction with these current drugs and would be expected to have synergistic effects. just as finasteride and minoxidil have been shown to have synergism (suchonwanit et al., 2018). further research is planned with a hemp extract that is high in cbd, thcv and cbdv. in addition, comparative, cross-over studies with minoxidil should be considered. references bíró, t., bodó, e., telek, a., géczy, t., tychsen, b., kovács, l., & paus, r. (2006). hair cycle control by vanilloid receptor-1 (trpv1): evidence from trpv1 knockout mice. the journal of investigative dermatology, 126(8), 1909-1912. bíró, t., tóth, b. i., haskó, g., paus, r., & pacher, p. (2009). the endocannabinoid system of the skin in health and disease: novel perspectives and therapeutic opportunities. trends in pharmacological sciences, 30(8), 411-420. blume-peytavi, u., hillmann, k., dietz, e., canfield, d., & bartels, n. g. (2011). a randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. journal of the american academy of dermatology, 65(6), 1126-1134. boudaka, a., al-yazeedi, m., & al-lawati, i. (2020). role of transient receptor potential vanilloid 4 channel in skin physiology and pathology. sultan qaboos university medical journal, 20(2), e138. chung, h., fierro, a., & pessoa-mahana, c. d. (2019). cannabidiol binding and negative allosteric modulation at the cannabinoid type 1 receptor in the presence of delta-9tetrahydrocannabinol: an in silico study. plos one, 14(7), e0220025. corroon, j., & phillips, j. a. (2018). a cross-sectional study of cannabidiol users. cannabis and cannabinoid research, 3(1), 152-161. expert committee on drug dependence. (2018). cannabidiol (cbd) critical review report. world health organization. https://www.who.int/medicines/access/controlle d-substances/cannabidiolcriticalreview.pdf gupta, a. k., & charrette, a. (2015). topical minoxidil: systematic review and metaanalysis of its efficacy in androgenetic alopecia. skinmed, 13(3), 185-189. laprairie, r. b., bagher, a. m., kelly, m. e. m., & denovan-wright, e. m. (2015). cannabidiol is a negative allosteric modulator of the cannabinoid cb1 receptor. british journal of pharmacology, 172(20), 4790-4805. levy, l. l., & emer, j. j. (2013). female pattern alopecia: current perspectives. international journal of women's health, 5, 541. muller, c., morales, p., & reggio, p. h. (2019). cannabinoid ligands targeting trp channels. frontiers in molecular neuroscience, 11, 487. cannabis, a publication of the research society on marijuana 59 olsen, e. a., & weiner, m. s. (1987). topical minoxidil in male pattern baldness: effects of discontinuation of treatment. journal of the american academy of dermatology, 17(1), 97101. roberts, j. l. (1987). androgenetic alopecia: treatment results with topical minoxidil. journal of the american academy of dermatology, 16(3), 705-710. salman, k. e., altunay, i. k., kucukunal, n. a., & cerman, a. a. (2017). frequency, severity and related factors of androgenetic alopecia in dermatology outpatient clinic: hospital-based cross-sectional study in turkey. anais vrasileiros de dermatologia, 92(1), 35-40. shankar, d. k., chakravarthi, m., & shilpakar, r. (2009). male androgenetic alopecia: population-based study in 1,005 subjects. international journal of trichology, 1(2), 131. shapiro, j., & kaufman, k. d. (2003, june). use of finasteride in the treatment of men with androgenetic alopecia (male pattern hair loss). in journal of investigative dermatology symposium proceedings (vol. 8, no. 1, pp. 2023). elsevier. suchonwanit, p., srisuwanwattana, p., chalermroj, n., & khunkhet, s. (2018). a randomized, double-blind controlled study of the efficacy and safety of topical solution of 0.25% finasteride admixed with 3% minoxidil vs. 3% minoxidil solution in the treatment of male androgenetic alopecia. journal of the european academy of dermatology and venereology, 32(12), 2257-2263. szabó, i. l., herczeg-lisztes, e., szollosi, a. g., szegedi, a., bíró, t., & oláh, a. (2017). 263 (-)cannabidiol differentially influences hair growth. journal of investigative dermatology, 137(10), s238. telek, a., bíró, t., bodó, e., tóth, b. i., borbíró, i., kunos, g., & paus, r. (2007). inhibition of human hair follicle growth by endo-and exocannabinoids. the faseb journal, 21(13), 3534-3541. tóth, k. f., ádám, d., bíró, t., & oláh, a. (2019). cannabinoid signaling in the skin: therapeutic potential of the “c (ut) annabinoid” system. molecules, 24(5), 918. vallée, a., lecarpentier, y., guillevin, r., & vallée, j. n. (2017). effects of cannabidiol interactions with wnt/β-catenin pathway and pparγ on oxidative stress and neuroinflammation in alzheimer's disease. acta biochimica et biophysica sinica, 49(10), 853-866. funding and acknowledgements: there were no sources of funding for this study which was conducted by the authors at our own practice. the authors adhered to the us “federal policy for the protection of human subjects” (“common rule”). the authors/investigators have no economic interest in, does not act as officer or a director of, any outside entity whose financial interests would reasonably appear to be effected by this research study or its findings. the authors/investigators have no personal, business, or volunteer affiliations that may give rise to a real or apparent conflict of interest. relevant federally and organizationally established regulations and guidelines in financial conflicts are abided by. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i1a4_authors_final_21apr research article 60 abstract objective. although cigarette use has declined among adolescents, marijuana use has increased in subgroups of this population. the association between medical marijuana laws (mmls) and cigarette initiation among adolescents, however, needs further examination. we investigated the association between mmls and age of cigarette initiation and stratified findings by gender, race/ethnicity, and state dispensary status. method. data were from n=939,725 adolescents in 9th-12th grade living in 46 states who participated in the youth risk behavior surveillance system between 1991-2015. participants were asked the age they first smoked a cigarette and other sociodemographic characteristics. states were categorized as mml states if they had legalized marijuana for medicinal purposes by 2015. we used a difference-in-difference methodology and logistic regressions to assess the relationship between mmls and cigarette initiation. results. our results indicate lower odds of initiating cigarettes, in every age group (8 years old or younger, 9-10, 11-12, 13-14, 15-16, 17 years old or older) in states with mmls when compared to non-mml states. after stratification, we find lower odds of cigarette initiation in certain age groups by gender, race/ethnicity, and state dispensary status. we report no difference in state mml implementation and age of cigarette initiation among hispanic adolescents in every age group, and black adolescents 8 years or younger and 17 years or older. conclusions. cigarette initiation has decreased among adolescents in mml states compared with those in non-mml states. further research should evaluate how mmls and recreational marijuana policies are associated with e-cigarette initiation and use. key words: = medical marijuana laws, cigarette initiation, adolescents, drug policy, marijuana the landscape of marijuana legalization has changed significantly over the past two decades in the united states (state medical marijuana laws, 2020). currently, medical marijuana laws (mmls) have passed in 36 states (state medical marijuana laws, 2020). policies legalizing marijuana may influence substance use, such as cigarettes, in the broader population. adolescents remain particularly vulnerable as tobacco use is commonly established during youth (office on smoking and health [osh], 2020a). following the enactment of mmls, marijuana and other substances—such as cigarettes—may have a complementary relationship wherein both marijuana and substance use increases (cerdá et al., 2018; guttmannova et al., 2019). this may occur if co-use produces a synergistic psychoactive effect or if marijuana remains a gateway for other substances (cerdá et al., 2018). alternatively, marijuana may substitute other substances if they have similar psychoactive properties or if marijuana becomes more accessible (cerdá et al., 2018; guttmannova et al., 2019). state medical marijuana laws and initiation of cigarettes among adolescents in the u.s., 1991-2015 cannabis 2021, volume 4 (1) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.01.004 abhery das1, julie k. johnson2, gregory a. hard3, abenaa a. jones4 1program in public health, university of california, irvine, 653 east peltason drive, irvine, ca 92617 2cannabis policy research center of excellence, research department, cannabis control commission, commonwealth of massachusetts, 2 washington square, 2nd floor, worcester, ma 01604 3mgh institute of health professions, 36 first avenue, boston ma 02129 4department of human development and family studies, the pennsylvania state university, 105 health and human development building, university park, pa 16802, usa corresponding author: abhery das, mhs, program in public health, university of california, irvine, 653 east peltason drive, irvine, ca 92617., e-mail: abheryd@uci.edu cannabis, a publication of the research society on marijuana 61 in 2019, 2.3% of adolescents reported using cigarettes in the past 30 days – a decrease from 4.3% in 2011 (osh, 2020a). disparities also exist among youth, with some racial/ethnic groups reporting ever use of tobacco products at higher rates than non-hispanic whites (odani, 2018). studies reported that adolescents more often use marijuana and cigarettes concurrently as opposed to either substance alone (lanza et al., 2015). a systematic review indicated that 90% of crosssectional studies find a positive relation between cigarette smoking and marijuana use in adolescents (ramo et al., 2012). adolescents who use marijuana were six to 12 times more likely to smoke cigarettes (ramo et al., 2012). additionally, adolescents who use tobacco were 52 times more likely to use marijuana (ramo et al., 2012). previous research on mml and cigarette use among adolescents has found conflicting results by age. cerdá et al. (2018) reported that mmls were associated with a decrease in cigarette use among 8th graders, but an increase among 12th graders. wang et al. (2016) reported that statewide legalization of medical marijuana was associated with cigarette and marijuana co-use, with 12-17 year olds having three times the likelihood of nicotine dependence. wen et al. (2015) found a greater percentage of daily and non-daily smokers between 12-20 year olds in mml states as opposed to non-mml states. the relation between mmls and cigarette initiation rather than cigarette use among adolescents, however, remains unknown. youth cigarette initiation trends have changed over the past two decades. (cantrell et al., 2018). some studies have found that the majority of initiation occurs before 18 years old (osh, 2012). cantrell et al. (2018) reported that cigarette initiation decreased for those aged 12-14 and 1517 among all race/ethnicities and genders between 2002 and 2015. azagba et al. (2020) found that age of cigarette initiation increased, specifically among female and high school students. given the changing nature of cigarette use in the united states and the potential for a substitution effect between marijuana and tobacco following mmls, we examined whether mmls are associated with age of cigarette initiation by race/ethnicity, gender, and state marijuana dispensary status. methods study population we obtained data from the youth risk behavior surveillance system (yrbss) in 46 states from 1991 – 2015. this surveillance system monitors health risk behaviors among youth in the united states (center for disease control [cdc], 1995 – 2015). the yrbss is a crosssectional survey, of 9th to 12th-grade students conducted by the cdc and national, state, and local agencies. minnesota, oregon, and washington did not participate in the survey (cdc, 1995 – 2015). we were unable to obtain data on hawaii due to the data application process. yrbss draws state samples from a twostage cluster sampling design that first randomly selects schools to participate and then randomly selects classes within those schools. yrbss attains overall response rates of ≥ 60%. we weighted the data to obtain estimates representative of 9-12 grade students within each state. we therefore only included states that allowed for weighting (brener et al., 2013). measures for our outcome variable, we used the yrbss question, “how old were you when you first smoked a whole cigarette for the first time?” (cdc, 1995 – 2015). we created binary variables for the age of cigarette initiation, including 8 years old or younger, 9-10 years old, 11-12 years old, 13-14 years old, 15-16 years old, and 17 years old or older. these age groups may not coincide with the age of the survey participant as participants may have initiated cigarettes at earlier ages. as our exposure variable, we coded states that had enacted mmls as a binary variable (0 for before mml; 1 for after mml) (state medical marijuana laws, 2020). states that did not enact mmls were coded as ‘0’ for the entire study period. as control variables, we included the demographic characteristics of the survey participants including age, gender, and race/ethnicity (non-hispanic white, non-hispanic black, hispanic, and other) and state-year fixed effects. we also included variables indicating whether states allowed marijuana dispensaries to operate (0 for dispensaries not allowed; 1 for state medical marijuana laws and adolescents’ cigarette smoking 62 dispensaries allowed) and whether states had active dispensaries (0 for no active dispensaries; 1 for active dispensaries) for each year (state medical marijuana laws, 2020). statistical analysis we used pre-post, difference-in-difference (did) methodologies to examine both change in cigarette initiation in states before and after mml enactment with non-mml states, as well as states that never enacted mmls with states that enacted mmls in the study period. widely used in health policy research and in previous mml literature, did controls for secular trends that do not change over time. this quasi-experimental research design uses mml states as the ‘treatment group’ and both non-mml states and mml states prior to mml enactment as the ‘comparison group’. we used logistic regression analyses to examine the relations between mmls and the age of cigarette initiation overall and among race/ethnicity, gender, and state marijuana dispensary status. the did methodology assumes parallel trends in the outcome among the treatment and control groups prior to implementation of the ‘treatment’ or policy. this assumption was tested by creating line graphs to visualize outcomes over time and confirm parallel trends. we confirmed that mml and non-mml states had parallel trends in the outcome prior to the implementation of these policies. our state fixed effects specification accounted for differential characteristics among states. we also specified year fixed effects to control for year-specific factors that may correspond with the outcome of interest. we used stata 15 mp for all analyses. additionally, we used stata’s “svyset” command to account for yrbss sampling and weighting procedures. we used robust standard errors to adjust for heteroscedasticity in the residuals and any correlation of errors within the specified clusters (i.e., states). johns hopkins bloomberg school of public health institutional review board deemed this study exempt because it used publicly available, deidentified data. results sample characteristics the study sample comprised 939,725 adolescents. adolescent race/ethnicity included non-hispanic white (61.13%), non-hispanic black (14.53%), hispanic (14.13%), and other race/ethnicity (10.21%) (table 1). females and males comprised 50.88% and 49.12% of the study population, respectively. survey participants were aged 12 years old or younger (0.37%), 13 years old (0.36%), 14 years old (12.19%), 15 years old (26.16%), 16 years old (26.60%), 17 years old (22.71%), and 18 years old or older (11.62%) (table 1). table 2 details states that enacted mmls between 1991 – 2015, year of enactment, and the years of data before and after enactment. among the 46 states, 19 of them enacted mmls during the study period. initiation of cigarette use after adjusting by state, year, and individual demographics (age, gender, and race/ethnicity), the analyses indicate a lower odds of initiating cigarettes among all age categories in states with enacted mmls compared to states without mmls in the year of data collection (table 3). in table 3, we find a lower odds of cigarette initiation among all age strata for females and all age strata for males except for those aged 17 years old or older. initiation of cigarette use by race/ethnicity among the racial/ethnic categories, our results indicate a lower odds of cigarette initiation in mml states among all non-hispanic white age strata and all non-hispanic black age strata, except for 8 years old or younger and 17 years old or older (table 3). we did not find significant results for any age categories among hispanic adolescents. lastly, our results indicate a lower odds of cigarette initiation in mml states among other race/ethnicity except for 13–14-year-olds (table 3). cannabis, a publication of the research society on marijuana 63 table 1. sample characteristics (race/ethnicity, gender, and age) for participants in the yrbss from 46 u.s. states, 1991-2015 (n = 939,725). characteristics n (%) race/ethnicity whitea 574,454 (61.1%) blacka 136,543 (14.5%) hispanic 132,783 (14.1%) othera 95,945 (10.2%) gender female 478,132 (50.9%) male 461,593 (49.1%) age 12 years or younger 3,440 (0.4%) 13 years old 3,426 (0.4%) 14 years old 114,522 (12.2%) 15 years old 245,825 (26.2%) 16 years old 249,933 (26.6%) 17 years old 213,367 (22.7%) 18 years old or older 109,212 (11.6%) anon-hispanic table 2. states that enacted medical marijuana laws (mmls), enactment year, and years of preand postenactment data, 1991-2015. year mml enacted state years of data pre-mml enactment years of data post-mml enactment 1996 california (ca) 0 1 1998 alaska (ak) 1 5 1999 maine (me) 2 8 2000 colorado (co) 0 3 2000 nevada (nv) 4 7 2004 montana (mt) 6 6 2004 vermont (vt) 0 3 2006 rhode island (ri) 4 5 2007 new mexico (nm) 2 5 2008 michigan (mi) 6 4 2010 arizona (az) 4 3 2010 new jersey (nj) 3 2 2011 delaware (de) 5 2 2012 connecticut (ct) 5 2 2012 massachusetts (ma) 7 2 2013 illinois (il) 5 2 2013 new hampshire (nh) 7 2 2014 new york (ny) 8 1 2014 maryland (md) 5 1 state medical marijuana laws and adolescents’ cigarette initiation 64 table 3. logistic regression results predicting odds of cigarette initiation among adolescents, by age strata, in states with enacted mmls compared to states without mmls in the year of data collection, 1991-2015.a age of cigarette initiation adjusted or (95%ci) 8 years old or younger 0.86*** (0.790.94) 9-10 years old 0.72*** (0.650.78) 11-12 years old 0.77*** (0.710.83) 13-14 years old 0.79*** (0.740.84) 15-16 years old 0.85*** (0.800.90) 17 years old or older 0.87* (0.770.99) gender female 8 years old or younger 0.83** (0.730.95) 9-10 years old 0.69 (0.601.79) 11-12 years old 0.74*** (0.670.83) 13-14 years old 0.79*** (0.730.86) 15-16 years old 0.86*** (0.800.93) 17 years old or older 0.83 (0.711.99) male 8 years old or younger 0.88 (0.791.07) 9-10 years old 0.73*** (0.650.83) 11-12 years old 0.79*** (0.720.86) 13-14 years old 0.79*** (0.730.85) 15-16 years old 0.83*** (0.770.90) 17 years old or older 0.91 (0.761.07) race/ethnicity whiteb 8 years old or younger 0.80*** (0.710.90) 9-10 years old 0.67*** (0.590.77) 11-12 years old 0.78*** (0.710.84) 13-14 years old 0.79*** (0.740.85) 15-16 years old 0.85*** (0.790.91) 17 years old or older 0.83* (0.700.98) blackb 8 years old or younger 0.89 (0.691.14) 9-10 years old 0.72* (0.540.96) 11-12 years old 0.61*** (0.490.76) 13-14 years old 0.68*** (0.570.80) 15-16 years old 0.81* (0.670.97) 17 years old or older 1.06 (0.681.65) hispanic 8 years old or younger 1.05 (0.861.28) 9-10 years old 0.94 (0.781.13) 11-12 years old 0.89 (0.761.03) 13-14 years old 0.90 (0.801.01) 15-16 years old 0.89 (0.761.04) 17 years old or older 0.94 (0.771.16) other race/ethnicity 8 years old or younger 0.74 (0.591.93) 9-10 years old 0.76* (0.590.98) 11-12 years old 0.80* (0.660.95) 13-14 years old 0.87 (0.751.01) 15-16 years old 0.79 (0.661.93) 17 years old or older 0.54 (0.381.79) (table continues) cannabis, a publication of the research society on marijuana 65 state dispensary status dispensaries allowed 8 years old or younger 0.90 (0.801.01) 9-10 years old 0.71*** (0.630.80) 11-12 years old 0.74*** (0.680.81) 13-14 years old 0.75*** (0.690.82) 15-16 years old 0.77*** (0.720.84) 17 years old or older 0.82** (0.710.95) dispensaries active 8 years old or younger 0.93 (0.841.03) 9-10 years old 0.76*** (0.680.85) 11-12 years old 0.84*** (0.770.92) 13-14 years old 0.89** (0.830.96) 15-16 years old 0.98 (0.921.05) 17 years old or older 1.01 (0.881.16) *p<.05, **<.01, ***p<.001 astate and year variables included but not shown bnon-hispanic in table 3, we report lower odds of cigarette initiation in mml states with dispensaries allowed among all age strata, except for those aged 8 years old or younger. we also find lower odds of cigarette initiation in mml states with active dispensaries, among those aged 9-10, 11-12, and 13-14 years old. discussion our results indicate a lower odds of initiating cigarettes in mml states among all adolescent age groups. after stratifying by gender, race/ethnicity, and state dispensary status, we also find lower odds of cigarette initiation among certain age strata. as suggested by other scholars, the ‘substitution effect’ may play a role in the decrease in cigarette initiation after enactment of mmls. marijuana may provide the same psychoactive properties as cigarettes or become more accessible to adolescents in states with mmls (cerdá et al., 2018). however, previous studies have also found conflicting results as to marijuana use among adolescents following mml implementation (cerdá et al., 2018; johnson et al., 2017, 2021; ladegard et al., 2020). alternatively, adolescents may also substitute cigarettes with electronic cigarettes (“e-cigarettes” or “vaping”; osh, 2020b). e-cigarettes are popular among adolescents as more than 19% of high school students report using e-cigarettes in the past 30 days (wang, 2020). there also may be a ‘gateway effect’ of e-cigarette use leading to use of conventional cigarettes, especially among adolescents (morgenstern et al., 2018). one study conducted among 10th graders reported that ecigarette users more commonly experiment with conventional cigarettes (morgenstern et al., 2018). further investigation into whether mmls correspond with e-cigarette use or conventional cigarette initiation, by way of e-cigarettes, is warranted as research on this issue remains scarce. recent work reported, however, that adolescents have increased marijuana use with vaping devices following cannabis legalization (borodovsky, 2017; nicksic et al., 2020). additionally, increase in price, due to tobacco taxes, may deter adolescents from smoking cigarettes (hawkins et al., 2016). one study on whether cigarette price influences adolescent experimentation found no relation (emery et al., 2001). the study suggested that because adolescent experimenters consume few cigarettes, they are not affected by the price of cigarettes (emery et al., 2001). other studies indicated that higher tobacco tax rates were associated with reduced cigarette initiation and days smoked among adolescents (apollonio et al., 2021; forster et al., 2007). state-level differences in tobacco tax policies may influence adolescent age groups differently (forster et al., 2007). as with our findings, certain age strata may respond differently to state-level policies. further state medical marijuana laws and adolescents’ cigarette initiation 66 research would benefit from better understanding how tobacco tax laws may influence specific age groups. current media campaigns and communications aimed at reducing tobacco initiation among adolescents may also deter cigarette initiation (the community guide, 1999). several studies have found that an increase in mass-health communications – through television, radio, and print – show a reduction in tobacco use (the community guide, 1999). future research may also examine how media campaigns and communications about marijuana policy and e-cigarettes may correspond with adolescent substance use. marijuana policy in the u.s. continues to change as more states legalize medical and recreational use of marijuana and decriminalize marijuana possession. currently, 15 states have legalized recreational marijuana for adults. these policy changes may increase accessibility of cannabis to adolescents, therefore supporting the ‘substitution effect’ of marijuana use in place of conventional cigarettes (hartman, 2021). our findings further indicate the potential for substitution – rather than a complementary relationship – between cigarettes and marijuana. the increase in marijuana use among adolescent subgroups following cannabis legalization, however, remains concerning. previous studies have found that adolescent marijuana use precedes increases in substance use disorders, as well as adverse mental health and cognitive development in adulthood (ladegard et al., 2020). this warrants further research on the mental health and cognitive spillover effects of the implementation of such policies. limitations our study has limitations. we did not include additional policies, such as recreational marijuana legalization or tobacco laws, that may influence cigarette initiation in adolescents. the analysis attempted to address this potential confounding by using state and year fixed effects and a difference-in-difference study design (angrist & pischke, 2008). beginning in 2013, states began prohibiting tobacco product sales to persons less than 21 years old – also referred to as t21 laws – to reduce adolescent tobacco use (marynak, 2020). federal policy also raised the minimum legal sales age of tobacco products to 21 in 2019 (marynak, 2020). given the potential relation between t21 laws and mmls or adolescent tobacco use, further research would benefit from understanding this relationship. another limitation of the study includes the use of a general mml exposure variable with one provision category (allowed and active dispensaries). we did not include provision categories for mmls such as home cultivation, caregivers, possession, and patient registration as previous research has not found a relation between these provisions and adolescent substance use (johnson et al., 2017, 2021). nonetheless, further research should investigate how such provisions may affect adolescent cigarette initiation as mmls become enacted across the us. strengths despite any weaknesses, our study has significant strengths, including the use of the yrbss, a population-representative sample of students that is used extensively in literature (brener et al., 2013). its long history and consistent methodology allow for analysis of longterm trends in adolescent health behaviors (brener et al., 2013). in this study, we have included 25 years of data from 46 states with a large sample of over 900,000 adolescents. another strength of this study includes the use of the difference-in-difference methodology. this quasiexperimental design removes bias in the postintervention period comparisons resulting from permanent differences between the ‘treatment’ and ‘control’ groups (angrist & pischke, 2008). conclusion cigarette initiation has decreased among adolescents living in states that enacted mmls compared to those residing in non-mml states. this finding supports the possibility of a ‘substitution effect’ in that adolescents may substitute marijuana for cigarettes. given the significant increases in vaping among youth, research should examine whether mmls and recreational marijuana policies are associated with e-cigarette use. further research should also evaluate the possible mental health and cognitive effects associated with heightened marijuana use among adolescents following cannabis legalization. cannabis, a publication of the research society on marijuana 67 references angrist, j. d., & pischke, j.-s. 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(2015). the effect of medical marijuana laws on adolescent and adult use of marijuana, alcohol, and other substances. journal of health economics, 42, 64–80. funding and acknowledgements: this research was supported by the national institute on drug abuse (nida) grants: 5f31da036923-02 (pi: julie k. johnson), 4t32da007292-24 (julie k. johnson, abenaa a. jones, pi: renee m. johnson), r01da040488-04s1 (abenaa a. jones), k01da051715 (pi: abenaa a. jones), and commonwealth of massachusetts, massachusetts cannabis control commission. this content of this article is solely the responsibility of the authors and may not reflect the official views of nih, nida, or massachusetts cannabis control commission (julie k. johnson). authors would like to acknowledge renee m. johnson and jeremy kane for their mentorship during this study. disclosure of potential conflicts: dr. aa jones’ spouse works as an independent contractor for a 501c3 non-profit educational organization that educates citizens on the science of marijuana with an aim to decrease its use and related consequences. dr. jones’ spouse did not play a role in this study. no other disclosures are reported. author contributions: all authors have participated in study conception and design, analysis, interpretation of data, and drafting/revising of the manuscript. ad wrote the manuscript in consultation with aaj, gah, and jkj. jkj conducted the statistical analysis. all authors agree on the contents of the manuscript, take responsibility for the reported research, and approve the manuscript as submitted. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 1 abstract measures of medical cannabis (mc) use are lacking. this study details the development and psychometric evaluation of the medical cannabis expectancy questionnaire (mceq), a novel measure of positive and negative expectations associated with using combustible, vaporizable, and edible mc. 333 adult mc users completed a 30-minute online survey in spring 2017 (64.0% female, 82.3% white, mean age 32.77[±10.19] years). participants reported on demographics, product preference, mces, frequency of mc use, quality of life, and negative cannabis use consequences. psychometric analyses included evaluations of latent factor structure, measurement invariance, between-groups differences in mces, and test-criterion relationships with mc outcomes. the 27-item mceq evidenced a 2-factor structure (positive/negative). mces were scalar invariant by product type, sex, and reasons for mc use (medical only vs medical/recreational). participants held more positive mces for combustibles than for vaporizables or edibles and more negative mces for combustibles and edibles than for vaporizables. mces did not differ by sex. participants who also used cannabis recreationally reported stronger positive mces for all mc products. mces also differed by product preference. additionally, preference for and more positive mces associated with using a specific product were associated with more frequent use of that product. positive mces for all products also were associated with increased quality of life, but these relationships failed to reach statistical significance after accounting for covariates. finally, negative mces for combustibles and edibles were associated with more negative consequences. the mceq is the first psychometrically promising measure of mc expectancies, and it uniquely distinguishes among expectations associated with using combustible, vaporizable, and edible mc. as mc use continues to proliferate, having measures dedicated to mc (versus recreational cannabis) may better inform research and clinical efforts. further, differentiating between product types is important given established differences among them (e.g., duration of effect onset). key words: cannabis; marijuana; medical cannabis; medical marijuana; smoking; vaping rates of medical cannabis (mc) use are increasing, and mc currently is legal in 29 states and the district of columbia (procon.org, 2017). results of randomized clinical trials provide the strongest support for the efficacy of mc for treating symptoms of chronic pain, neuropathic pain, and muscle spasticity that occurs due to multiple sclerosis (e.g., hill, 2015). however, state cannabis 2019, volume 2 (1), 1-18 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.01.001 open access the medical cannabis expectancy questionnaire: adult medical marijuana users’ expectancies associated with combustible, vaporized, and edible cannabis use for medical purposes corresponding author: meghan e. morean, department of psychology, oberlin college, 120 w. lorain st., oberlin, oh 44074, email: meghan.morean@oberlin.edu meghan e. morean1, ellyn r. butler1 1 department of psychology, oberlin college, oberlin, oh, usa medical cannabis expectancy questionnaire 2 laws vary considerably with regard to the conditions that are approved for mc use, with some providing broad definitions and others listing specific medical conditions. for example, maryland permits the use of mc for treating the symptoms of “any condition that is severe, for which other medical treatments have been ineffective, and if the symptoms 'reasonably can be expected to be relieved' by the medical use of cannabis or if the patient has a chronic or debilitating disease or medical condition that causes severe loss of appetite, wasting, severe or chronic pain, severe nausea, seizures or severe or persistent muscle spasms, glaucoma, or post traumatic stress disorder (ptsd)” whereas california permits the use of mc for treating the symptoms of “aids, anorexia, arthritis, cachexia, cancer, chronic pain, glaucoma, migraine, persistent muscle spasms (including spasms associated with multiple sclerosis), seizures (including seizures associated with epilepsy), and severe nausea” (procon.org, 2017). of note, a recent study suggests that mc patients use mc for a variety of conditions, the most common of which were anxiety, pain, stress, insomnia, and depression (hellomd, 2016). importantly, three of these conditions (i.e., stress, insomnia, depression) are not listed specifically as qualifying conditions in any state, suggesting that a subset of mc users is using mc to treat symptoms of conditions for which there is limited or no scientific evidence of the efficacy of mc. despite the increasing popularity of mc, measures of mc-relevant constructs are lacking. further, many different mc products are available (e.g., combustible cannabis; vaporizable concentrates; edibles like baked goods containing cannabis; tinctures; salves/lotions; raw/juiced cannabis; schauer et al., 2016). notably, product potency can vary considerably. for example, relative to combustibles, concentrates can contain 4-20 times more tetrahydrocannabinol (thc), the cannabinoid that results in the characteristic cannabis “high” (loflin & earleywine, 2014; mehmedic et al., 2010). furthermore, the onset of drug effects differs by product type, with a delayed onset of effects characteristic of ingesting edibles (e.g., barrus et al., 2016). thus, in addition to developing psychometrically sound mc measures, it is important to differentiate between mc products used. the current study focuses on one of the most well-researched constructs in the substance use literature: outcome expectancies. broadly, expectancies, or the beliefs that individuals hold about the likely outcomes of using a substance, are powerful predictors of the initiation, maintenance, and cessation of a wide range of substances (e.g., aarons et al., 2001; brandon & baker, 1991; brown et al., 1987; connor et al., 2011; metrik, farris, aston, & kahler, 2017; & morean & l’insalata, 2017). using alcohol expectancies as an example (for which there is the largest body of research), research indicates that expectancies play a causal role in driving alcohol use. for example, expectancies develop during childhood before alcohol use onset occurs and predict the initiation of drinking (dunn & goldman, 1996; 1998; jester et al., 2015); predict alcohol use, alcohol-related problems, the development of alcohol use disorder, and treatment outcomes (jones, corbin, & fromme, 2001); mediate the relationship between other risk-factors and alcohol use including family history of alcoholism (sher, et al., 1991), impulsivity (barnow et al., 2004) and fun-seeking (wardell, read, colder, & merrill, 2012); and correspond to reductions in drinking in response to expectancy challenge (darkes & goldman, 1998; wiers, van de luitgaarden, van den wildenberg, & smulders, 2005). of note, there are numerous published expectancy measures (e.g., [alcohol] brown et al., 1987; morean, corbin, & treat 2012; [cigarettes] brandon & baker, 1991; [e-cigarettes] harrell et al., 2017; morean & l’insalata, 2017); [stimulants] aarons et al., 2001; jaffee & kilbey, 1994; schafer & brown, 1991; [cannabis] connor et al., 2011; schafer & brown, 1991; torrealday et al., 2008; [cannabis cessation] metrik, farris, aston, & kahler, 2017). although these measures have been invaluable to their respective fields, no measure has undergone sufficient psychometric validation to assess mces. further, prior research generally has not assessed expectancies associated with using different cannabis products; only one study of which we are aware has compared expectancies for different types of cannabis (synthetic/botanical; lauritsen & rosenberg, 2016). the current study focuses on the development and psychometric evaluation of the medical cannabis expectancy questionnaire (mceq), cannabis, a publication of the research society on marijuana 3 which assesses expectancies associated with three mc products: combustibles, vaporizables, and edibles. after reviewing the most commonly used recreational cannabis expectancy measures (meeq [schafer & brown, 1991]; ceq [connor et al., 2011]), we decided to develop a novel measure of mces rather than validate an existing measure for mc use. this decision was based on several factors. first, the meeq and ceq focus nearly exclusively on smoking cannabis and/or make broad statements about cannabis use that do not account for product type. second, each measure is lengthy (meeq [48-70 items]; ceq [45-60 items]) and items are phrased as sentences. third, although items should assess only one concept (furr & bacharach, 2014), both measures contain items assessing multiple concepts (e.g., ceq [i am more aware of what i say and do when i am smoking cannabis]; meeq [marijuana can cause me to become depressed and disappointed with myself]). finally, we wanted to ensure that the mceq included effects that correspond to the symptoms for which individuals most often use mc (e.g., “pain relief”  treating chronic pain). we largely based our item development on research about the subjective effects of cannabis (lyons et al., 1997; scherrer et al., 2009). these prior studies suggest that cannabis effects can be assessed using single-word items or short phrases without jeopardizing item integrity. for example, the meeq item “i get a sense of relaxation from smoking marijuana” could be shorted to “relaxed.” this approach simultaneously reduces participant burden and removes any reference to product type from the items. although many expectancy measures employ continuous response formats (e.g., the anticipated effects of alcohol scale [morean et al., 2013; the comprehensive effects of alcohol scale [fromme, stroot, & kaplan, 1993]; the marijuana effect expectancy questionnaire-brief [torrealday et al., 2008]), given that 30 expectancies were assessed for three products, we chose to employ a forced-choice response format (no/yes) that has been used in previous expectancy research (brown et al., 1980; schafer & brown, 1991). regarding psychometric evaluation, we evaluated the latent structure of the mceq using exploratory and confirmatory factor analysis; conducted measurement invariance analyses to determine whether mces could be compared meaningfully across product types, by sex, and by reasons for product use (medical only vs medical/recreational); examined differences in mces by product type (including examining the influence of product preference), sex, and reasons for use; and examined testcriterion relationships between mces for each product type and the frequency of using each product, quality of life since starting to use mc, and the experience of negative consequences of cannabis use. we expected that the mceq would evidence one of two possible latent factor structures. first, it seemed plausible that a two-factor structure reflecting positive and negative expectancies would emerge, similar to the ceq (connor et al., 2011). alternatively, the mceq items vary in terms of valence (negative/positive) and arousal (sedative/stimulant), so we also hypothesized that a four-factor latent structure may emerge, similar to the aeas (morean et al., 2013). we anticipated that the latent structure would be scalar invariant by product type, sex, and reasons for use, because, while mean-levels of endorsing expectancies may differ within these subgroups, the general latent structure was expected to remain stable. while we anticipated that mces may differ by product type, we did not outline specific hypotheses given the paucity of research on the topic. globally, we expected that holding more positive expectancies and fewer negative expectancies for a given product would be associated with more frequent use of that product and with increased quality of life since starting to use mc. we also anticipated that holding more negative expectancies would be associated with experiencing more negative cannabis consequences. of note, we expected that test-criterion relationships would be stronger for mc users’ self-reported preferred product. ultimately, to be considered a psychometrically promising measure, the mceq needed to demonstrate good psychometric properties across all domains assessed. method participants 354 adult mc users completed a 30-minute online survey in spring 2017, 333 of whom completed all central study questions (64.0% female, 82.3% white, mean age 32.77[±10.19] years). participants reported using mc primarily to treat pain conditions (55.9%), mental health medical cannabis expectancy questionnaire 4 conditions (35.1%), and insomnia/sleep problems (9.0%). procedure the institutional review board of blinded university approved the study. participants were recruited via qualtrics online sample, a secure, market research service. qualtrics sent emails to participants who computer algorithms deemed to be most likely to be eligible for our study based on their responses to previous surveys. an embedded email link directed participants to six screener questions. eligible individuals provided consent to participate. qualtrics compensated participants based on the terms of pre-established agreements with panel members (up to $10). measures screening questions. participants completed six screening questions; four were used to determine study eligibility and two were used to disguise the study aims (i.e., cigarette/alcohol use). to be eligible, participants had to report 1) living in a state in which mc was legal (response options: all fifty states and washington dc), 2) using cannabis in the past 30 days (no/yes), 3) using cannabis for medical reasons in the past 30 days (recreational, religious, medical), and 4) having “a valid ‘medical marijuana card’ that was authorized by a doctor and allows [them] to use medical marijuana legally” (no/yes). demographics. participants reported on their sex, age, race, duration of mc use (years/months), and reasons for mc use (medical only vs. medical/recreational). the medical cannabis expectancies questionnaire (mceq; see appendix). after reading the instructions, participants indicated whether they expected to experience 30 effects as a result of smoking, vaping, or eating mc edibles. twenty-five items were derived from extant subjective response measures (lyons et al., 1997; scherrer et al., 2009). the 9 positive effects obtained from previous measures were judged by our research team to map onto at least one common condition for which patients use mc. we developed 5 additional “positive” items that corresponded to reasons individuals commonly cite for mc use (i.e., “pain relief” [pain], “hungry” and “settled stomach” [appetite problems], “sleep better” [insomnia], “calm” [mental health conditions]). 16 items that were anticipated to be perceived as negative (e.g., paranoid, irritable) also were included. cannabis product use. participants indicated all of the following products they had ever tried (even once or twice in their life) and which one they preferred to use to treat their primary medical condition: smoked/combustible marijuana (e.g., joints, blunts, pipes, bongs), vaporizable marijuana concentrates (e.g., hash oil, wax), vaporizable marijuana flower (e.g., “bud”), and edible marijuana (e.g., edibles like brownies or candies containing marijuana). participants then reported how many days out of the past 30 days they used each product (0-30). in total, 90% of participants who endorsed vaping mc endorsed both vaping concentrates and vaporized flower. as such, vaping cannabis and vaping flower were combined into a single category (i.e., vaporizing cannabis). to further support combining these categories, we examined the mean positive and negative vaping expectancy scores for individuals who endorsed vaping flower and vaping concentrates, and the means and standard deviations were very similar [positive vaping expectancies for vaping flower (m = 5.21, sd = 4.40) and vaping concentrates (m = 5.24, sd = 4.32); negative vaping expectancies for vaping flower (m = 1.05, sd = 1.53) and vaping concentrates (m = 1.09, sd = 1.67)]. quality of life since starting to use mc. participants answered the following question: “since i started using medical marijuana, my quality of life has…” (dramatically decreased, decreased, stayed the same, increased, dramatically increased). negative consequences of cannabis use. participants completed the 21-item brief marijuana consequences questionnaire (bmacq; simons et al., 2012). sample items include “i have lost motivation to do things because of my marijuana use” and “i haven’t been as mentally sharp because of my marijuana use.” data analytic plan descriptive statistics. descriptive statistics were run on the central study variables. latent structure. given that mc users were most experienced with combustibles, we first ran an exploratory factor analysis (efa) on the cannabis, a publication of the research society on marijuana 5 mceq items for combustibles (n = 354). we considered factor solutions ranging from 1-10 latent factors based on the rationale that a latent factor should comprise ≥ 3 items to be estimated reliably (jöreskog and sörbom, 1989). we identified plausible latent structures based on a combination of eigenvalues (>1)/scree plots, model fit, item loadings (i.e., primary factor loadings ≥ .45 with cross-loadings < .30), the number of items per factor, and factor interpretability (e.g., tabachnick and fidell, 2013). plausible latent structure(s) identified via efa were fit to the data for vaporizables and edibles using confirmatory factor analysis (cfa). because the data were binary, we specified a robust weighted least squares approach (wlsmv). multiple fit indices were examined to evaluate acceptable model fit: bentler’s comparative fit index (cfi) ≥ .95 (hu and bentler, 1999), root mean square error of approximation (rmsea) ≤ .05 (ho, 20016), and weighted root mean square residual (wrmr)  1.00 (yu and muthén, 2002). measurement invariance. we used mplus 7.0 to run cfa models using a wlsmv estimator to determine whether mces could be compared meaningfully for men and women, by product type, and by reasons for mc use. in each case, we evaluated three levels of mi: configural (invariance of the number of latent factors and items per factor), metric (invariance of the item factor loadings), and scalar (invariance of the item factor loadings and thresholds). good fit was defined as cfi ≥ .95, rmsea ≤ .05, and 0 ≤ χ2 ≤ 2*df. configural invariance was established if the model fit the data. metric invariance was established if constraining the item factor loadings to equality did not result in significantly poorer model fit compared to the model testing configural invariance. scalar invariance was established if constraining both the item factor loadings and thresholds did not result in significantly poorer model fit compared to the model testing metric invariance. comparisons of the models evaluating configural, metric, and scalar mi were conducted using the wlsmv estimator and the difftest function in mplus, which produces χ2 difference tests between the models. comparisons of expectancies by product type, sex, and reasons for mc use. one-way, repeated measures anovas were run to compare mces for combustibles, vaporizables, and edibles within the total sample and to examine the effect of product preference on mces (product preference was entered as a between-subjects variable). independent-samples t-tests were run to examine differences in mces based on sex and reasons for mc use. test-criterion relationships. bivariate correlations were run to examine unadjusted relationships between mces, product use frequency, quality of life since starting to use mc, and negative cannabis use consequences within the total sample and by product preference. to account for family-wise error, p < .01 was used to determine statistical significance. finally, univariate general linear models were run to assess if mces explained significant variance in the frequency of using each product, quality of life since starting to use mc, and/or the experience of negative cannabis use consequences above and beyond participant demographics and product preference. when predicting quality of life and negative consequences, the frequencies of using each product also were included as covariates. again, p < .01 was used as the threshold for statistical significance. results demographics most participants had tried each mc product (combustibles [91.6%]; vaporizables [74.2%]; edibles [86.2%]), and the majority preferred combustibles (combustibles [58.3%;], see table 1 for information on all study variables). within the total sample, product use frequencies ranged from 4.8 days (edibles) to 15.52 days per month (combustibles). although several variables had non-normal distributions, using transformed data replicated the pattern of results observed using the non-transformed data. thus, to facilitate interpretability, we present results using the nontransformed data. latent structure the efa conducted on combustible mces indicated that a 2-factor solution was the only plausible latent structure; a single-factor solution did not fit the data, and models with > 2 factors had an insufficient number of items per subscale. however, the 2-factor model including all 30 items medical cannabis expectancy questionnaire 6 table 1. participant demographics % or m (sd) sex (% female) 64.0% race (% white) 82.3% age 32.77 (10.19) duration of medical cannabis use (yrs) 2.92 (3.32) use for medical & recreational reasons (% yes) 55.6% ever used product (% yes) combustible cannabis 91.6% vaporizable concentrates 67.9% vaporizable flower 61.0% any vaporizable cannabis (concentrates or flower) 74.2% edible cannabis 86.2% product preference (% yes) combustible cannabis 58.3% any vaporizable cannabis 19.5% edible cannabis 22.2% frequency of use (# of days/past 30 days) combustible cannabis 15.52 (12.07) any vaporizable cannabis 5.14 (9.59) edible cannabis 4.84 (8.34) positive expectancies combustible cannabis 7.39 (3.83) any vaporizable cannabis 4.31 (4.31) edible cannabis 4.33 (3.94) negative expectancies combustible cannabis 1.46 (2.14) any vaporizable cannabis 1.02 (1.64) edible cannabis 1.36 (1.90) quality of life since using medical cannabis 4.19 (0.65) negative consequences of cannabis use 4.00 (3.65) did not adequately fit the data, sot items were removed to improve fit. in order to be retained, items had to have primary factor loadings ≥ .45 and cross loadings < .30. using these cutoffs, 27 items were retained and the items lazy, drowsy, and keyed up were dropped. cfa indicated that this structure adequately fit the data for vaporizables and edibles (table 2). measurement invariance all unconstrained models fit the data (table 3), and imposing the constraints associated with the metric and scalar models did not produce significant decrements in model fit. as such, scalar invariance was established for sex, product type, and reasons for mc use. comparisons of expectancies by product type, sex, and reasons for use assumptions of sphericity were violated for all repeated measures anovas, so huynh-feldt corrections were applied. within the total sample, there were significant differences for positive mces (f[1.93, 641.04] = 118.83, ηp 2 = 0.26) and negative mces (f[1.84, 610.14] = 9.17, ηp 2 = 0.03, p-values < .001). pair-wise comparisons indicated that participants held more positive mces for combustibles (m[sd]: 7.39[3.83]) than for vaporizables (4.31[4.21]) or edibles (4.33[3.94]) and more negative mces for combustibles (1.46[2.14]) and edibles (1.36[1.90]) than for vaporizables (1.02[1.64], all p-values < .001; figure 1). when examining the impact of product preference on mces, significant interactions cannabis, a publication of the research society on marijuana 7 table 2. exploratory and confirmatory factor analysis of the medical cannabis expectancy questionnaire items exploratory factor analysis confirmatory factor analysis combustible vaporizable edible negative positive negative positive negative positive confused .71 -.13 .53 .57 unable to concentrate .70 .11 .80 .54 paranoid .78 .16 .69 .76 jumpy .66 .01 .61 .69 anxious .74 .01 .54 .72 depressed .89 -.18 .50 .58 out of control .73 -.27 .66 .73 lazy .47 .43 - - dizzy .74 .04 .63 .57 drowsy .40 .44 - - keyed-up .40 .19 - - nauseous .76 -.17 .72 .67 guilty .75 -.07 .68 .63 hear/see things that aren’t really there .74 .03 .76 .75 cry .71 .10 .73 .77 irritable .72 -.05 .73 .63 happy .33 .88 .86 .74 energetic .23 .49 .64 .61 creative .15 .70 .87 .76 euphoric .20 .76 .82 .73 mellow -.21 .88 .92 .87 sociable -.12 .84 .84 .75 confident -.09 .75 .80 .78 increased sex drive .08 .60 .74 .68 relaxed -.12 .95 .95 .89 pain relief -.08 .88 .92 .92 hungry .10 .83 .85 .75 settled stomach -.03 .75 .78 .92 calm -.02 .91 .94 .92 sleep better .29 .78 .82 .78 fit statistics rmsea .050 .028 .032 cfi .935 .991 .979 wrmr 1.097 1.002 1.007 note. bolded factor loadings indicate items that were retained based on the exploratory factor analysis. – denotes items that were not included in the confirmatory models. note that cross-loadings are not provided for cfa. emerged between product preference and positive mces (f[3.93, 647.72] = 25.35., p < .001, ηp 2 = 0.13) and negative mces (f[3.71, 612.66] = 2.48, p = .047, ηp 2 = 0.02). pair-wise comparisons indicated that, for combustibles, individuals who preferred smoking cannabis (7.91[3.43]) held more positive mces than individuals who preferred edibles (6.05[4.31], p < .001) and less negative mces (1.12[1.93]) than individuals who preferred vaporizables (1.72[2.09], p = .046) or edibles (2.14[2.52], p < .001). for vaporizables, individuals who preferred vaping reported more medical cannabis expectancy questionnaire 8 figure 1. positive and negative medical cannabis expectancies (by product type and product preference) a c b d note. panel a: positive expectancies in the total sample for each type of cannabis; panel b: negative expectancies in the total sample for each type of cannabis; panel c: positive expectancies for each type of cannabis by preferred product; panel d: negative expectancies for each type of cannabis by preferred product. cannabis, a publication of the research society on marijuana 9 table 3. medical cannabis expectancies are scalar measurement invariant by product type, sex, and reasons for use product type model df χ2 rmsea cfi χ2 difference test configural 753 1217.13 0.043 0.977 - metric 797 1241.70 0.041 0.978 χ2 (44) = 51.94, p = 0.19 scalar 793 1246.62 0.041 0.977 χ2 (40) = 52.61, p = 0.09 sex model df χ2 rmsea cfi χ2 difference test configural 502 1018.41 0.045 0.975 - metric 524 1021.29 0.044 0.976 χ2 (22) = 23.45, p = 0.38 scalar 522 1024.53 0.044 0.976 χ2 (20) = 24.02, p = 0.24 reasons for use (medical/recreational vs. medical only) model df χ2 rmsea cfi χ2 difference test configural 502 995.49 0.044 0.975 - metric 524 1012.16 0.043 0.976 χ2 (22) = 32.15, p = 0.08 scalar 522 1008.19 0.043 0.976 χ2 (20) = 25.55, p = 0.18 note. abbreviations are df (degrees of freedom); χ2 (chi-square statistic); rmsea (root mean square error of approximation); cfi (comparative fit index); χ2 difference test (chisquare values associated with comparing model fit to that of the configural model). positive mces (6.94[3.98]) than individuals who preferred either combustibles (4.17[3.49]) or edibles (4.14[4.07], p-values < .001). for edibles, individuals who preferred edibles reported more positive mces (5.84[3.76]) than individuals who preferred smoking cannabis (3.54[3.81], p < .001). for vaporizables and edibles, no significant differences in negative mces were observed. independent-samples t-tests indicated that there were no significant differences in mces based on sex (p-values > .50). however, individuals who used mc for medical and recreational reasons reported stronger positive mces for all products than individuals who used mc only for medical reasons (positive combustibles: med/rec 8.21 [3.56], med only 6.36 [3.93], t = 4.43, p < .001; positive vaporizables: med/rec 4.94 [4.44], med only 3.52 [4.01], t = 3.04, p = .003, positive edibles: med/rec 4.85 [4.05], med only 3.68 [3.71], t = 2.72, p = .007). no significant differences in negative mces were observed. test-criterion relationships correlations run within the total sample and by product preference indicated that positive mces for a given product were associated with more frequent use of that product (p-values < .01; table 4). among individuals who preferred vaping, fewer negative vaping mces also were associated with more frequent vaping (p-values < .01). within the total sample only, more positive mces for each product were associated with increased quality of life since starting to use mc (p-values < .01). among individuals who preferred vaping, positive vaping mces were associated with an increased quality of life (p = .001). however, for individuals who preferred combustibles and edibles, correlations failed to reach the adjusted level for statistical significance (p < .01). finally, within the total sample and among individuals who preferred combustibles, more negative mces for each product were associated with experiencing more negative cannabis use consequences (p-values < .001). initially, all glm models included two-way interactions between mces and product preference. however, none of the interactions were statistically significant, so the models were rerun including only main effects (table 5). the first glm accounted for 29.9% of the variance in the frequency of combustible mc use. more frequent combustible mc use was associated with medical cannabis expectancy questionnaire 10 table 4. medical cannabis expectancies are associated with the frequency of cannabis product use and the experience of negative consequences of cannabis use cannabis product use frequency (#days/past 30 days) expectancies combustible vaporizable edible improved quality of life negative consequences of cannabis use total sample smoking positive .37*** .12 -.04 .20*** .05 vaping positive .05 .39*** .11 .17** .12 edible positive .02 .12 .24*** .20*** .12 smoking negative -.14 .04 .13 -.04 .25*** vaping negative -.11 .03 .09 -.05 .24*** edible negative -.15** .10 .04 -.50 .32*** prefer smoke smoking positive .27*** .03 .03 .17* .02 vaping positive .12 .33*** .06 .12 .17 edible positive .15 .18 .13 .18* .10 smoking negative -.04 .10 .02 -.02 .32*** vaping negative -.08 .14 .08 -.01 .31*** edible negative -.19** .10 .03 -.01 .39*** prefer vape smoking positive .46*** .31 .05 .29* .12 vaping positive .14 .36** .20 .40*** .01 edible positive .15 .09 .15 .35** .29 smoking negative -.09 -.05 .07 -.09 .32** vaping negative -.04 -.31** .11 -.16 .20 edible negative -.04 -.01 -.13 -.14 .28 prefer edibles smoking positive .38*** .07 .10 .07 .10 vaping positive .26 .21 .18 .19 .04 edible positive .12 -.02 .24** .23* -.03 smoking negative -.08 -.05 .09 -.02 .06 vaping negative -.02 .03 .02 -.06 .08 edible negative .04 .02 .10 -.07 .18 note. * p < .05 ** p < .01 *** p < . 001 cannabis, a publication of the research society on marijuana 11 table 5. medical cannabis expectancies predict the frequency of cannabis product use and the experience of negative consequences of cannabis use above and beyond participant demographics and product preference cannabis product use frequency (#days/past 30 days) improved negative consequences combustible vaporizable edible quality of life of cannabis use f ηp 2 f ηp 2 f ηp 2 f ηp 2 f ηp 2 adj r2 = .30 adj r2 = .32 adj r2 = .22 adj r2 = .06 adj r2 = .14 sex 1.03 0.00 0.04 0.00 0.06 0.00 0.84 0.00 4.84 0.02 age 2.52 0.01 0.16 0.00 4.41 0.01 0.01 0.00 1.61 0.01 race 0.07 0.00 0.19 0.00 0.15 0.00 0.02 0.00 0.01 0.00 recreational use 0.83 0.00 1.76 0.01 0.26 0.00 0.50 0.00 0.64 0.00 duration of mc use 8.02 0.03** 2.07 0.01 0.85 0.01 0.23 0.00 0.65 0.00 product preference 24.53 0.13*** 35.12 0.18*** 28.41 0.15*** 1.26 0.01 0.06 0.00 positive expectancies smoking 25.70 0.08*** 0.09 0.00 0.24 0.10 0.71 0.00 1.10 0.00 vaping 0.02 0.00 32.47 0.09*** 0.26 0.00 0.12 0.00 0.87 0.00 edible 0.00 0.00 4.39 0.01 5.44 0.02** 5.53 0.02* 0.02 0.00 negative expectancies smoking 0.87 0.00 1.29 0.00 0.22 0.00 0.14 0.00 7.32 0.02** vaping 0.13 0.00 7.13 0.02** 0.35 0.00 0.30 0.00 0.02 0.00 edible 3.67 0.01 1.16 0.00 0.21 0.01 0.38 0.00 11.98 0.04** frequency of use smoking - - - 4.09 0.01 2.04 0.01 vaping - - - 0.01 0.00 0.50 0.00 edible - - - 0.37 0.00 0.03 0.00 note. sample size (n = 333) -variables not included in the model * p < .05 ** p < .01 *** p < .001 medical cannabis expectancy questionnaire 12 preferring to smoke cannabis (b[std. error] = 8.18[1.58], t = 5.19, p < .001) and holding more positive combustible mces (b[std. error] = 0.89[0.18], t = 5.07, p < .001). the second glm accounted for 32.4% of the variance in the frequency of vaporizable mc use. more frequent mc vaping was associated with preferring to vape cannabis (b[std. error] = 9.93[1.44], t = 6.89, p < .001), holding more positive vaping mces (b[std. error] = 0.81[0.14], t = 5.70, p < .001), and holding fewer negative vaping mces (b[std. error] = 0.95[0.35], t = -2.67, p = .008). the third glm accounted for 21.6% of the variance in the frequency of edible mc use. more frequent edible use was associated with preferring to consume edibles (b[std. error] = 7.70[1.35], t = 5.70, p < .001) and holding more positive edible mces (b[std. error] = 0.33[0.14], t = 2.33, p = .010). the fourth glm accounted for 5.7% of the variance in quality of life since starting to use mc. however, there were no statistically significant main effects at the adjusted p < .01 level. the final glm accounted for 13.6% of the variance in the experience of negative cannabis use consequences. experiencing more negative consequences was associated with holding more negative combustible (b[std. error] = 0.30[0.01], t = 2.71, p = .007) and edible mces (b[std. error] = 0.42[0.12], t = 3.46, p = .001). discussion the current study suggests that the mceq is a psychometrically promising measure for assessing expectancies associated with using combustible, vaporizable, and edible mc. exploratory and confirmatory factor analyses supported a 27-item, 2-factor structure reflecting positive and negative mces for each product type. although many of the expectancies included in the mceq also are included in recreational cannabis measures, the combination of mceq items is unique, and all five items that were developed to assess positive effects of using mc were retained. mces were scalar measurement invariant for product type, sex, and reasons for mc use. mc users generally held more positive mces for combustibles than for vaporizables or edibles and fewer negative mces for vaporizables compared to combustibles and edibles. the fact that mc users held different expectancies based on product type suggests that it is important to assess specific mc products rather than using inclusive terminology like “medical marijuana.” further, individuals who reported using mc for both medical and recreational reasons reported more positive mces for all products compared to individuals who used for medical purposes only, which is consistent with motivations for recreational use. no significant differences in mces were observed based on sex. when mces were examined by product preference, individuals who preferred combustible cannabis held more positive and fewer negative combustible mces compared to users who preferred other products. these findings were consistent with the hypothesis that individuals who prefer a given product should be more likely to hold more positive and fewer negative expectancies for that product. however, the hypothesis was only partially supported for individuals who preferred vaporizables or edibles. these individuals reported stronger mces associated with their preferred product but no differences in negative mces were observed. these findings likely are linked to the fact that mc users generally reported few negative mces across products, which resulted in limited variability. when considered in concert, the results of the unadjusted correlations and glms were partially consistent with our hypotheses. as predicted, preference for and more positive mces associated with using a given product were associated with more frequent use of that product compared to the other products. although we anticipated that holding fewer negative mces for a given product also would be associated with more frequent use of that product, this relationship was observed only for vaping. these results suggest that product preference and positive mces are more informative for predicting the frequency of mc use than are negative mces or demographics. with regard to quality of life, unadjusted correlations showed that positive mces for all products were associated with an increased quality of life since starting to use mc within the total sample. however, mces generally were not associated significantly with quality of life when examined by product preference or after accounting for demographic covariates and product use frequency. these findings may be linked to the fact that multiple conditions were combined together to form the categories used in cannabis, a publication of the research society on marijuana 13 the current study (e.g., mental health conditions; sleep problems) and that some participants were using mc for conditions for which there is limited or no scientific evidence to support the use of mc. for example, although evidence on the efficacy of mc for treating symptoms of depression is mixed (e.g., walsh et al., 2017), a recent study of psychiatric patients found that marijuana use exacerbated depression and anxiety symptoms and led to overall poorer physical health (bahorik et al., 2017). similarly, research findings on the utility of cannabinoids for treating insomnia have been inconsistent (e.g., gates et al., 2011; whiting et al., 2015). finally, the study findings generally were consistent with the hypothesis that holding more negative mces for each product would be associated with experiencing more negative cannabis consequences. however, only negative mces associated with combustibles and edibles were associated with experiencing more negative consequences above and beyond covariates. of note, product preference was not significantly related to negative consequences, suggesting that product preference may be a more relevant construct for understanding the frequency of mc use. the study findings should be considered in light of several limitations. importantly, qualitative research (e.g., focus groups with mc users) was not conducted as part of the development of the mceq. thus, the mceq may not assess the full range of positive and negative expectancies associated with using mc products, and some items may not be regarded as applicable to some mc users. further, the current study relied on self-report data which may be limited by participants’ willingness and ability to provide accurate responses. given the online nature of the study, we could not confirm that participants were mc users who held a valid “medical marijuana card.” also, our sample comprised american, adult qualtrics panel members, which may limit generalizability. however, relying on panel members also may be a strength because members are motivated to provide high quality data in order to remain panelists. to this end, there were very little missing data and no evidence that participants provided inaccurate responses. we also used a dichotomous scoring format for the mceq, which decreased participant burden but resulted in an inability to assess the strength of mces. future research should investigate the psychometric properties of the mceq when a rating scale is used. further, given that 90% of individuals who reported vaporizing mc had vaporized both concentrates and flower, we collapsed vaporizing concentrates and flower into a single category. related to this issue, the mceq did not differentiate between vaping concentrates and flower when assessing vaping mces. unfortunately, these limitations conflate mode of administration with product type, which may be problematic given that concentrates and flower can differ on a number of characteristics including thc content. as such, future research is needed to evaluate whether mces differ for vaporizing mc concentrates and flower. in addition, the restricted range of selfreported negative consequences, while consistent with prior research (e.g., hellomd, 2016), may have reduced statistical power to detect effects. further, the consequences measure we used did not differentiate between products. in addition, we did not assess positive subjective mc effects or positive consequences of mc use using a validated measure. thus, future research is needed to evaluate whether the current findings extend to product-specific negative and positive mc use consequences. finally, the study design did not permit an assessment of the full range of psychometric properties for the mceq. longitudinal research is needed to evaluate the predictive validity of the mceq, and a repeatedmeasures design is needed to evaluate test-retest reliability. despite its limitations, we found preliminary psychometric support for using the mceq to assess adult mc users’ expectancies associated with using combustible, vaporizable, and edible mc. in light of the continued growth of mc use in the united states and abroad, having measures that are dedicated specifically to assessing constructs related to mc use may have incremental utility for informing clinical and research efforts in this burgeoning area above and beyond measures of recreational cannabis use. further, given the documented differences between mc products (e.g., delayed onset of effects associated with consuming edibles), the ability to differentiate between products may provide a more comprehensive understanding of mc use. that said, future research is needed to evaluate whether the mceq has utility for medical cannabis expectancy questionnaire 14 assessing mces in other populations (e.g., adolescents; international mc users) and for other types of mc products (e.g., tinctures). additional research also is needed to evaluate whether the mceq items can be used to assess subjective effects of mc use. in the meantime, researchers who are interested in mc are encouraged to consider using the mceq. references aarons, g. a., brown, s. a., stice, e., & coe, m. t, (2001). psychometric evaluation of the marijuana and stimulant effect expectancy questionnaires for adolescents. addictive behaviors, 26(2), 219-236. bahorik, a. l., leibowitz, a., sterling, s. 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(2002). evaluation of model fit indices for latent variable models with categorical and continuous outcomes. paper presented at the annual meeting of the american educational research association; new orleans, la. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. cannabis, a publication of the research society on marijuana 17 appendix. the medical cannabis expectancy questionnaire smoking vaping edibles confused ☐ ☐ ☐ unable to concentrate ☐ ☐ ☐ paranoid ☐ ☐ ☐ jumpy ☐ ☐ ☐ anxious ☐ ☐ ☐ depressed ☐ ☐ ☐ out of control ☐ ☐ ☐ dizzy ☐ ☐ ☐ nauseous ☐ ☐ ☐ guilty ☐ ☐ ☐ hear/see things that aren't really there ☐ ☐ ☐ cry ☐ ☐ ☐ irritable ☐ ☐ ☐ happy ☐ ☐ ☐ energetic ☐ ☐ ☐ creative ☐ ☐ ☐ euphoric ☐ ☐ ☐ mellow ☐ ☐ ☐ sociable ☐ ☐ ☐ confident ☐ ☐ ☐ increased sex drive ☐ ☐ ☐ relaxed ☐ ☐ ☐ pain relief ☐ ☐ ☐ hungry ☐ ☐ ☐ settled stomach ☐ ☐ ☐ calm ☐ ☐ ☐ sleep better ☐ ☐ ☐ instructions. please indicate whether you expect to experience each effect when smoking marijuana, vaping marijuana, and/or eating edibles. for example, if you expect to feel confused when you smoke marijuana or eat edibles but you do not expect to feel confused when you vape marijuana, you would only check off the boxes for ‘smoking marijuana’ and ‘eating edibles.’ if you have never used one or more of these products (e.g., you have never vaped marijuana), please indicate how you think you would feel if you were to use it. medical cannabis expectancy questionnaire 18 copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 133 ved abstract cannabis retailer locations used to investigate geographic cannabis access are frequently ascertained from two sources: 1) webservices which provide locations of cannabis retailers (e.g., yelp) or 2) governmentmaintained registries. characterizing the operating status and location information accuracy of cannabis retailer data sources on a state-by-state level can inform research examining the health implications of cannabis legalization policies. this study ascertained cannabis retailer name and location from webservices and government-maintained registries for 26 states and the district of columbia legalizing cannabis sales in 2019. validation subsamples were created using state-level sequential sampling. phone surveys were conducted by trained researchers for webservice samples (n=790, november 2019 may 2020) and government-maintained registry (n=859, february june 2020) to ascertain information about operating status and location. accuracy was calculated as the percent agreement among subsample and phone survey data. for operating status and location, webservice derived data was 78% (614/790) and 79% (484/611) accurate, whereas government-maintained registry derived data was 76% (657/859) and 95% (622/655) accurate, respectively. fifty-nine percent (15/27) of states and the district of columbia had over 80% accuracy for operating status and 48% (13/27) states had over 80% accuracy for location information with both data sources. however, government-maintained registry derived information was more accurate in 33% (9/27) states for operating status and 41% (11/27) states for location information. both data sources had similar operating status accuracy. research using spatial analysis may prefer government-maintained registry derived data due to high location information accuracy, whereas studies looking at broad trends across states may prefer webservice derived. state level covid-19 restrictions had minimal impact on ascertainment of cannabis retailer operating status and location information via phone survey derived from webservices and government-maintained registries. key words: = cannabis; dispensaries; cannabis retailers; cannabis outlets; phone survey state legalization of the sale of cannabis for medical or adult use in the united states (us) is a rapidly evolving and highly variable landscape. by the end of 2019, 29 states and the district of columbia (dc) have legalized and implemented the sale and consumption of cannabis for medical use and 9 states and dc have legalized and implemented the sale and consumption cannabis michael williams1,2, matt mahlan1, connor holmes1, magdalena pankowska1, manjot kaur1, aderonke ilegbusi2, danielle f. haley1,3 1institute for health equity and social justice research and department of health sciences, northeastern university 2bouvé college of health sciences, northeastern university 3department of community health sciences, boston university school of public health cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000148 accuracy differences in cannabis retailer information ascertained from webservices and government-maintained corresponding author: michael williams, ph.d., institute for health equity and social justice research, department of health sciences; bouvé college of health sciences, northeastern university. email: mpw144@gmail.com state registries across us states legalizing the sale of cannabis in 2019 accuracy differences in cannabis retailer information 134 for adult use (legal science, 2017a, 2017b; norml foundation, 2022). by 2022, an additional 5 states have legalized and implemented the sale and consumption of medical cannabis and 8 additional states have legalized and implemented the sale and consumption of cannabis for adult use. state approaches to the legalization of cannabis are not static. states which have passed cannabis legalization in some form frequently update cannabis related policies and infrastructure over time (legal science, 2017a, 2017b). for example, new york legalized the sale and consumption of cannabis for medical use in 2014. this policy was updated in 2015 to include restrictions on how close medical cannabis retailers could be to specific buildings, such as churches (legal science, 2017a). furthermore, state approaches to cannabis legalization vary across states. for example, in new hampshire there are no policies set regarding cannabis retailer proximity to churches (legal science, 2017a). previous research has identified factors associated with cannabis retailer locations such as local supply and demand (morrison et al., 2014), housing prices (burkhardt & flyr, 2019; cheng cheng et al., 2018; conklin & diop, 2017; francesca ortegren, 2021), and local zoning ordinances (morrison et al., 2014). furthermore, policy within and across us states has been suggested as a factor relating to state-level heterogeneity in geographic access to cannabis retailers (chapman et al., 2016). beyond cannabis legalization and implementation policy, recent state policies emerging from the covid-19 pandemic may have influenced the operating status of cannabis retailers. on march 13th 2020, a national emergency was declared in response to the novel coronavirus (covid-19)(covid-19 disaster declarations | fema.gov, 2021; declaring a national emergency concerning the novel coronavirus disease (covid-19) outbreak, 2020). this declaration approved all 50 states and d.c. for major disaster declarations. shortly thereafter, many state governments also declared a state of emergency which in most cases included provisions for mandatory shutdowns of all businesses except those considered essential businesses. in many states, cannabis retailers were considered essential businesses while other states did not consider cannabis retailers essential businesses and therefore these businesses were temporarily shutdown (julia raifman et al., 2020). while the specific effects of covid-19 related shutdown policies have on cannabis retailer operating status is unclear, recent research has illuminated that cannabis sales (chong et al., 2022) and consumption (mackillop et al., 2021; schauer et al., 2021) increased during the pandemic in various parts of north america. these studies suggest specific aspects of covid-19 policies as potentially related factors to the increase in cannabis sales and consumption (e.g., shelter in place orders). altogether, this suggests that covid-19 may have had an impact on cannabis retailer operating status. numerous studies have leveraged cannabis retailer location information to explore how geographic access to cannabis influences cannabis use and other health outcomes (contreras, 2017; freisthler & gruenewald, 2014; lankenau et al., 2019; lipperman-kreda et al., 2014; mair et al., 2015, 2021; shi et al., 2016, 2018; shih et al., 2019; tabb et al., 2018). geographic access to cannabis retailers is frequently measured through the number of cannabis retailers per geographic unit (e.g., count of cannabis retailers in a census tract) or relative to a geographic point of interest (e.g., count of cannabis retailers within 3 miles of a school) (amiri et al., 2019; freisthler et al., 2017; freisthler & gruenewald, 2014; morrison et al., 2014; shi et al., 2016, 2018; tabb et al., 2018; thomas & freisthler, 2016). these measures are used to investigate how access to cannabis and cannabis retailers impact use and consumption of cannabis among key populations, (freisthler & gruenewald, 2014; shi et al., 2016). however, the relationship between geographic access to cannabis retailers and cannabis use is unclear. for example, two studies conducted in los angeles, california assessed frequency of cannabis use as a function of geographic access to medical cannabis retailers in young adults (lankenau et al., 2019; shih et al., 2019). one study conducted in 2016-2017 found that living near a medical cannabis retailer was positively associated with frequency of use (shih et al., 2019) while the other study conducted in 2014-2015 found that there was no association (lankenau et al., 2019). both studies used a different combination of techniques to generate lists of cannabis retailers. in addition to other confounding factors, it is possible that varying cannabis, a publication of the research society on marijuana 135 data sources used to create measures of geographic access to cannabis retailer may play a role in the divergent relationships between cannabis retailer access and frequency of use. the cannabis retailer data sources used in research leverage real-world data which are often not constructed with research purposes in mind. across the us, cannabis retailer locations are frequently ascertained from two primary sources: 1) webservices which provide the locations of cannabis retailers (e.g., yelp, leafly)(freisthler et al., 2017; freisthler & gruenewald, 2014; morrison et al., 2014; pedersen et al., 2018, 2020; shi et al., 2018; thomas & freisthler, 2016; unger et al., 2020) or 2) government-maintained registries (e.g., california bureau of cannabis control licensing directory) (amiri et al., 2019; freisthler et al., 2017; freisthler & gruenewald, 2014; shi et al., 2016; tabb et al., 2018; thomas & freisthler, 2016; unger et al., 2020). both data sources have different considerations for use in research. for example, data sourced from webservices can be unreliable due to listing incorrect or incomplete address information (e.g., only listing the town and state) (pedersen et al., 2018). additionally, cannabis licensing is handled by a variety of government bodies within and across states (e.g., departments of public health, departments of revenue), making both the licensing process and record keeping heterogenous across states. for example, some states provide separate registries for medical and adult use cannabis retailers, provide business contacts instead of the contact information for the storefront, or provide historical data for locations which have since closed (klieger et al., 2017). two studies conducted by pedersen and colleagues examining the accuracy of cannabis retailer data sources found that the accuracy of webservices with respect to operating status varied highly between webservice providers (pedersen et al., 2018, 2020). since both studies were conducted in los angeles, california, findings may not be generalizable to other states. furthermore, neither of these studies evaluated the accuracy of retailer address information. due to differences in cannabis legalization policy and cannabis infrastructure, cannabis retailer information such as location and operating status may vary across states and within states when derived from different sources (e.g., webservices or government-maintained registries). without characterizations of the accuracy of the primary data sources from which cannabis retailer information is derived, policy makers and researchers alike are potentially drawing incomplete or wrong conclusions surrounding the health implications of access to cannabis retailers. this study examines the accuracy of cannabis retailer operating status and location information across states and data sources by ascertaining cannabis retailer information obtained from webservices and government-maintained registries across 26 states and dc in 2019. we conducted a follow-up phone survey with a sample from each to confirm their operating status and location. there are two primary aims of this study. the first aim is to quantify the accuracy of observations from both webservices and government-maintained registries with respect to operating status and location across 26 states and dc in 2019. the second aim is to provide considerations for utilizing webservices and government-maintained registries for cannabis research. these aims stand to explicate the accuracy of cannabis retailer information ascertained from webservices and governmentmaintained registries which in turn will help policy makers and researchers alike contextualize research utilizing these data sources by providing considerations per data source and on a state-bystate basis. methods this study ascertained cannabis retailer information from webservices and governmentmaintained registries and used phone surveys to quantify the accuracy of operating status and location information in each. this study consisted of four stages: 1) primary data collection, 2) sequential sampling of retailer lists, 3) phone validation survey, 4) analysis (figure 1). this research was reviewed by the university of north carolina at chapel hill institutional review board and was determined to be non-human subjects research. primary data collection cannabis retailer information (name, location) was ascertained from two data sources: 1) webservices which advertise cannabis retailer information (i.e., yelp, weedmaps, leafly, canorml, accuracy differences in cannabis retailer information 136 figure 1. data collection and sampling of cannabis retailer information from webservices and government-maintained registries for use in phone survey to assess accuracy of operating status and location information in united states, 2019 kushguide) and 2) state government-maintained registries from all states and dc which had legalized and implemented cannabis for adult and/or medical use in 2019 (figure 1). webservices in june 2019, we obtained the name, location, and geocoordinates of all listed cannabis retailers from five different webservices (n=23,027). due to the large volume of observations, an algorithmic deduplication procedure was utilized to eliminate duplicate observations across webservices. two or more observations were considered duplicates if more than 50% of the characters in the name matched (position and alphabetical character) and the latitude and longitude were within 200 feet of each other. this procedure identified 3,399 observations with one or more duplicates across webservices, which once removed resulted in a dataset of 16,559 observations. after deduplication, 6,010 observations with no address information and 2,717 observations which corresponded to self-advertised non-cannabis retailers were removed from the dataset. we extracted flags used internally by each webservice to denote properties of the facilities advertised on their platform (e.g., doctor, delivery, online ordering). these flags were used to remove noncannabis retailers (e.g., doctor’s offices) from the final dataset. this resulted in a dataset where each observation was a unique potential cannabis retailer (n=7,832 cannabis retailers). this dataset was used for sampling as described below. cannabis, a publication of the research society on marijuana 137 government maintained registries throughout may to october 2019 the 29 states and dc which had legalized the sale of cannabis for adult or medical use as of october 2019 were contacted to solicit registries of cannabis retailers (figure 1). of the 29 states and dc contacted, 27 provided registries for cannabis retailers in their state. arizona and montana did not provide registries. the address associated with each observation in each registry was geocoded to obtain the latitude and longitude of each cannabis retailer. these registries were then cleaned by uniformly formatting column names and column data types across registries then removing noncannabis retailers (e.g., cannabis growers or testing labs). each registry was then merged into a dataset containing all states’ cannabis retailer information including name, location, and geocoordinates (latitude and longitude) (n=7,733). due to a data oversight, colorado registry information was not incorporated during this step. this dataset comprising 26 states and dc was used for sampling described below. sampling method a state-level sequential sampling method was used to enable a wide range of geographic regions within each state to be sampled and for each state to provide a critical mass of observations to the overall validation study. this sampling method also aligns with the goals of a parent grant-funded study which investigates geographic access to cannabis retailers (nida 5k01da046307). for each state in both the webservice dataset and the government-maintained registry dataset, the data were first sorted by census tract and then ~10% of the data were sequentially sampled. in states where the total number of observations was less than 10, all observations from that state were sampled. in states where different registries were provided for medical and adult use cannabis retailers, the sampling was done without replacement so that the same retailer could not be sampled twice from both registries. this resulted in a sample of 790 cannabis retailers from webservices and 859 cannabis retailers from government-maintained registries. colorado was dropped from the government-maintained registries sample due to a data oversight, and thus was excluded from the registry validation samples, leaving 29 states plus dc included in the webservice sample and 26 states plus dc in the registry sample. phone survey phone surveys were conducted by trained project staff for both webservice (november 2019 to may 2020) and government-maintained registry (february to june 2020) samples to ascertain accuracy of operating status and location. dedicated project staff were trained on how to conduct phone surveys using a detailed step-bystep protocol. this protocol walked project staff through the use of a tracking spreadsheet to track call attempts and meta information about calls (such as call time), the procedures for making the calls, and how to collect information during the phone surveys. google voice, a digital phone service, was used to standardize the phone number used for each call and maintain a centralized call log. qualtrics was used by project staff to capture data regarding operating status and location. survey scripts were standardized for different contingencies when calling potential cannabis retailers (attendant answered the phone, reaching a dial-based menu, and no answer). if there was no answer or the phone survey was incomplete (e.g., call dropped) then research staff were instructed via the protocol to call up to six times total. these repeat call attempts were spread across the project duration. measures and accuracy operating status was determined by phone surveyors. if the storefront they contacted sold cannabis products which contained thc for adultuse or medical consumption, this location was considered a cannabis retailer. storefronts which only sold cbd cannabis products (e.g., a naturopathic medical store) or sold no cannabis products (e.g., a grocery store) were considered non-cannabis retailers. when surveyors completed six or more call attempts which resulted in an inability to determine the operating status of a given observation, these observations were considered unconfirmed. location status was determined by phone surveyors by directly asking the attendant if the address on file is correct or using the information from a dial-based menu to compare against our accuracy differences in cannabis retailer information 138 data. the address was piped directly into the qualtrics survey from the respective data source and phone surveyors could respond to this question by confirming the address is correct, confirming the address is incorrect, or responding that they could not confirm the address information either way (unconfirmed). accuracy of both operating status and location information was operationalized as the percentage of agreement among observations between the primary data source and the phone validation survey for the same data source. with this operationalization, the percent agreement was conceived similarly to a measure of intercoder reliability (icr), where two coders label observations on the nominal scale (o’connor & joffe, 2020). icr is an analytic framework used across a variety of disciplines in qualitative research including public health and social psychology (o’connor & joffe, 2020). this framework was applied to our analysis, where the primary data source and follow-up phone survey were considered two different attempts to code the underlying population of cannabis retailers. in qualitative literature, a benchmark of 80% agreement is frequently used a minimum benchmark for acceptability of coding reliability (o’connor & joffe, 2020). for this analysis, the same 80% agreement benchmark is used to characterize acceptable accuracy for states and data sources. operating status accuracy was calculated using the entirety of each sample and location accuracy was calculated using a subset of each sample comprised of confirmed operating cannabis retailers. this was to avoid counting accurate locations of non-cannabis retailers in the accuracy percentage. to examine operating status and location accuracy across states, each state was categorized depending on whether both data sources had acceptable accuracy (greater than 80% agreement), one data source had acceptable accuracy while the other did not, or both data sources had lower than acceptable accuracy. further, among the cases where one data source had acceptable accuracy and the other did not, we categorized the degree of the difference between the two data sources as less than 10% or greater than 10%. due to a portion of phone surveys being conducted after covid-19 related restrictions were put into place in many states, we examined accuracy of operating status in both data sources preand postcovid-19 related lockdowns to assess the degree to which these lockdowns may have impacted our analysis. a national emergency was declared in the us on march 13th 2020 (declaring a national emergency concerning the novel coronavirus disease (covid-19) outbreak, 2020) regarding covid-19 and we used this date to determine preand postcovid-19 related lockdowns. states in which mandatory shutdowns of cannabis retailers were implemented were considered in this analysis (julia raifman et al., 2020). analysis was carried out using python with numpy and pandas libraries (numpy, 2022; pandas python data analysis library, 2022). results overall of the 790 potential cannabis retailers sampled from webservices (table 1), 614 (78%) were confirmed operating, 123 (16%) were confirmed to not be operating, and 53 (7%) were unconfirmed. three observations were confirmed operating via phone survey, but the call was dropped before surveyors could confirm location information and subsequent phone call attempts were unsuccessful. of these 611 remaining confirmed operating cannabis retailers derived from webservices, 484 (79%) were confirmed to be at the location listed in the web service data source, 108 (18%) confirmed location of retailer was incorrect, and 19 (3%) could not be confirmed either way (table 1). of the 859 potential cannabis retailers sampled from government-maintained registries (table 1), 657 (76%) were confirmed operating, 97 (11%) were confirmed to not be operating, and 105 (12%) were unconfirmed. two observations were confirmed operating but did not have location information as the call was dropped before surveyors could ascertain that information. subsequent call attempts were unsuccessful. of the 655 remaining confirmed operating cannabis retailers collected via government-maintained registries, 622 (95%) confirmed location, 24 (4%) confirmed the location of retailer was incorrect, and 9 (1%) could not be determined either way (table 1). cannabis, a publication of the research society on marijuana 139 table 1. operating status and location accuracy as determined through phone validation survey of cannabis retailer information solicited from web services and government-maintained registries web services (n=790) government-maintained registries (n=859) operating status n (%) n (%) confirmed operating, n (%) 614 (78%) 657 (76%) confirmed to not be operating, n (%) 123 (16%) 97 (11%) could not confirm either way, n (%) 53 (7%) 105 (12%) web services (n=611)2 government-maintained registries (n=655)3 location1 confirmed location, n (%) 484 (79%) 622 (95%) confirmed location is incorrect, n (%) 108 (18%) 24 (4%) could not confirm either way, n (%) 19 (3%) 9 (1%) 1location is calculated for observations which were confirmed to be operating cannabis retailers 2three observations in the phone survey were excluded due to the call being dropped before the location question was reached and further attempts were not able to reestablish a connection with either a person or a dial-based menu 3two observations in the phone survey were excluded due to the call being dropped before the location question was reached and further attempts were not able to reestablish a connection with either a person or a dial-based menu table 2. state level accuracy of cannabis retailer operating status information from webservices and government-maintained registries webservice (n=790) government-maintained registries (n=859) state total obs. n sampled obs. n operating n (%) not operating n (%) cannot determine n (%) total obs. n sampled obs. n operating n (%) not operating n (%) cannot determine n (%) ak 94 11 10 (91%) 0 (0%) 1 (9%) 102 10 9 (90%) 1 (10%) 0 (0%) az1 225 26 17 (65%) 9 (35%) 0 (0%) ----- ca 1525 154 98 (64%) 33 (21%) 23 (15%) 1336 133 105 (79%) 17 (13%) 11 (8%) co2 1072 104 93 (89%) 7 (7%) 4 (4%) ----- ct 24 10 9 (90%) 1 (10%) 0 (0%) 18 9 9 (100%) 0 (0%) 0 (0%) dc 7 7 6 (86%) 0 (0%) 1 (14%) 6 6 6 (100%) 0 (0%) 0 (0%) de 5 5 5 (100%) 0 (0%) 0 (0%) 4 4 4 (100%) 0 (0%) 0 (0%) fl 213 24 16 (67%) 8 (33%) 0 (0%) 122 9 9 (100%) 0 (0%) 0 (0%) hi 24 10 6 (60%) 4 (40%) 0 (0%) 7 7 7 (100%) 0 (0%) 0 (0%) il 89 9 7 (78%) 1 (11%) 1 (11%) 55 10 9 (90%) 1 (10%) 0 (0%) la 8 8 1 (12%) 7 (88%) 0 (0%) 9 9 8 (89%) 1 (11%) 0 (0%) ma 128 12 12 (100%) 0 (0%) 0 (0%) 21 5 4 (80%) 1 (20%) 0 (0%) md 99 11 11 (100%) 0 (0%) 0 (0%) 75 10 10 (100%) 0 (0%) 0 (0%) me 129 13 13 (100%) 0 (0%) 0 (0%) 8 8 8 (100%) 0 (0%) 0 (0%) mi 217 23 14 (61%) 8 (35%) 1 (4%) 70 10 8 (80%) 1 (10%) 1 (10%) mn 14 10 9 (90%) 1 (10%) 0 (0%) 8 8 8 (100%) 0 (0%) 0 (0%) mt1 115 12 8 (67%) 3 (25%) 1 (8%) ----- (table continues) accuracy differences in cannabis retailer information 140 nd 2 2 2 (100%) 0 (0%) 0 (0%) 7 7 7 (100%) 0 (0%) 0 (0%) nh 6 6 6 (100%) 0 (0%) 0 (0%) 5 5 5 (100%) 0 (0%) 0 (0%) nj 14 10 6 (60%) 4 (40%) 0 (0%) 6 6 6 (100%) 0 (0%) 0 (0%) nm 103 11 6 (55%) 2 (18%) 3 (27%) 98 9 9 (100%) 0 (0%) 0 (0%) nv 147 9 7 (78%) 1 (11%) 1 (11%) 240 21 17 (81%) 3 (14%) 1 (5%) ny 122 12 5 (42%) 5 (42%) 2 (17%) 114 10 8 (80%) 1 (10%) 1 (10%) oh 70 10 8 (80%) 1 (10%) 1 (10%) 18 10 10 (100%) 0 (0%) 0 (0%) ok 857 87 73 (84%) 8 (9%) 6 (7%) 1492 153 96 (63%) 15 (10%) 42 (27%) or 1076 107 91 (85%) 12 (11%) 4 (4%) 2060 205 135 (66%) 36 (18%) 34 (17%) pa 75 10 9 (90%) 1 (10%) 0 (0%) 45 10 10 (100%) 0 (0%) 0 (0%) ri 3 3 3 (100%) 0 (0%) 0 (0%) 3 3 3 (100%) 0 (0%) 0 (0%) vt 8 8 8 (100%) 0 (0%) 0 (0%) 5 5 5 (100%) 0 (0%) 0 (0%) wa 652 66 55 (83%) 7 (11%) 4 (6%) 1665 177 142 (80%) 20 (11%) 15 (8%) 1registry request was denied after multiple attempts including formal foia request. 2data oversight in government-maintained registry resulted in no data from co. table 3. state level accuracy of cannabis retailer location information from webservices and government-maintained registries1 webservice (n=611)2 government-maintained registries (655)3 state sampled obs. n correct location information n (%) incorrect location information n (%) cannot determine n (%) sampled obs. n correct location information n (%) incorrect location information n (%) cannot determine n (%) ak 10 10 (100%) 0 (0%) 0 (0%) 9 9 (100%) 0 (0%) 0 (0%) az4 17 14 (82%) 1 (6%) 2 (12%) ---- ca 97 79 (81%) 17 (18%) 1 (1%) 105 103 (98%) 1 (1%) 1 (1%) co5 93 78 (84%) 11 (12%) 4 (4%) ---- ct 9 7 (78%) 2 (22%) 0 (0%) 9 9 (100%) 0 (0%) 0 (0%) dc 6 3 (50%) 2 (33%) 1 (17%) 5 5 (100%) 0 (0%) 0 (0%) de 5 5 (100%) 0 (0%) 0 (0%) 4 4 (100%) 0 (0%) 0 (0%) fl 16 12 (75%) 3 (19%) 1 (6%) 9 9 (100%) 0 (0%) 0 (0%) hi 6 6 (100%) 0 (0%) 0 (0%) 7 7 (100%) 0 (0%) 0 (0%) il 7 5 (71%) 1 (14%) 1 (14%) 9 7 (78%) 0 (0%) 2 (22%) la 1 1 (100%) 0 (0%) 0 (0%) 8 8 (100%) 0 (0%) 0 (0%) ma 12 12 (100%) 0 (0%) 0 (0%) 4 4 (100%) 0 (0%) 0 (0%) md 11 7 (64%) 4 (36%) 0 (0%) 10 10 (100%) 0 (0%) 0 (0%) me 13 8 (62%) 5 (38%) 0 (0%) 8 7 (88%) 1 (12%) 0 (0%) mi 14 9 (64%) 4 (29%) 1 (7%) 8 8 (100%) 0 (0%) 0 (0%) mn 9 6 (67%) 1 (11%) 2 (22%) 8 8 (100%) 0 (0%) 0 (0%) mt4 8 4 (50%) 3 (38%) 1 (12%) ---- (table continues) cannabis, a publication of the research society on marijuana 141 nd 2 2 (100%) 0 (0%) 0 (0%) 7 7 (100%) 0 (0%) 0 (0%) nh 4 4 (100%) 0 (0%) 0 (0%) 5 3 (60%) 2 (40%) 0 (0%) nj 6 6 (100%) 0 (0%) 0 (0%) 6 5 (83%) 1 (17%) 0 (0%) nm 6 5 (83%) 1 (17%) 0 (0%) 9 9 (100%) 0 (0%) 0 (0%) nv 7 6 (86%) 1 (14%) 0 (0%) 17 17 (100%) 0 (0%) 0 (0%) ny 5 4 (80%) 1 (20%) 0 (0%) 8 7 (88%) 1 (12%) 0 (0%) oh 8 5 (62%) 3 (38%) 0 (0%) 10 9 (90%) 0 (0%) 1 (10%) ok 73 55 (75%) 18 (25%) 0 (0%) 96 89 (93%) 7 (7%) 0 (0%) or 91 78 (86%) 9 (10%) 4 (4%) 134 127 (95%) 6 (4%) 1 (1%) pa 9 5 (56%) 4 (44%) 0 (0%) 10 7 (70%) 0 (0%) 3 (30%) ri 3 2 (67%) 1 (33%) 0 (0%) 3 3 (100%) 0 (0%) 0 (0%) vt 8 3 (38%) 5 (62%) 0 (0%) 5 5 (100%) 0 (0%) 0 (0%) wa 55 43 (78%) 11 (20%) 1 (2%) 142 136 (96%) 5 (4%) 1 (1%) 1location is calculated for observations which were confirmed to be operating cannabis retailers 2three observations in the phone survey were excluded due to the call being dropped before the location question was reached and further attempts were not able to reestablish a connection with either a person or a dial-based menu 3two observations in the phone survey were excluded due to the call being dropped before the location question was reached and further attempts were not able to reestablish a connection with either a person or a dial-based menu 4registry request was denied after multiple attempts including formal foia request. 5data oversight in government-maintained registry resulted in no data from co. table 4. state-level accuracy acceptability categories for cannabis retailer operating status and location information from webservices and government-maintained registries1 state accuracy benchmark categories registry >= 80%, web service >= 80% registry >= 80%, web service < 80% registry < 80%, web service >= 80% registry < 80%, web service < 80% accuracy difference between data sources < 10% difference between data sources >= 10% difference between data sources < 10% difference between data sources >= 10% operating status alaska, connecticut, washington d.c., delaware, massachusetts, maryland, maine, minnesota, north dakota, new hampshire, ohio, pennsylvania, rhode island, vermont, washington nevada florida, hawaii, illinois, louisiana, michigan, new jersey, new mexico, new york oklahoma, oregon california (table continues) accuracy differences in cannabis retailer information 142 location information alaska, california, delaware, hawaii, louisiana, massachusetts, north dakota, new jersey, new mexico, nevada, new york, oregon, rhode island connecticut, washington d.c., florida, maryland, maine, michigan, minnesota, ohio, oklahoma, vermont, washington new hampshire illinois, pennsylvania 1colorado, arizona, montana, rhode island are not categorized due to only having webservice data for those states. table 5. operating status prior to and post covid-19 related shutdowns determined through phone validation survey of cannabis retailer information solicited from web services and government-maintained registries1 status prior to covid-19 related shutdowns status post covid-19 related shutdowns source obs. n operating n (%) not operating n (%) cannot determine n (%) obs. n operating n (%) not operating n (%) cannot determine n (%) webservices (n=64) 47 39 (83%) 7 (15%) 1 (2%) 17 13 (76%) 2 (12%) 2 (12%) dc 4 4 (100%) 0 (0%) 0 (0%) 3 2 (67%) 0 (0%) 1 (33%) ma 11 11 (100%) 0 (0%) 0 (0%) 1 1 (100%) 0 (0%) 0 (0%) me 10 10 (100%) 0 (0%) 0 (0%) 3 3 (100%) 0 (0%) 0 (0%) nd 1 1 (100%) 0 (0%) 0 (0%) 1 1 (100%) 0 (0%) 0 (0%) nj 8 5 (62%) 3 (38%) 0 (0%) 2 1 (50%) 1 (50%) 0 (0%) ny 7 2 (29%) 4 (57%) 1 (14%) 5 3 (60%) 1 (20%) 1 (20%) vt 6 6 (100%) 0 (0%) 0 (0%) 2 2 (100%) 0 (0%) 0 (0%) governmentmaintained registries (n=40) 23 23 (100%) 0 (0%) 0 (0%) 17 14 (82%) 2 (12%) 1 (6%) dc 4 4 (100%) --1 1 (100%) 0 (0%) 0 (0%) ma 0 ---5 4 (80%) 1 (20%) 0 (0%) me 8 8 (100%) --0 --- nd 0 ---1 1 (100%) 0 (0%) 0 (0%) nj 6 6 (100%) --0 --- ny 0 ---10 8 (80%) 1 (1%) 1 (1%) vt 5 5 (100%) --0 --- 1march 3rd, 2020 is used to designate preand postcovid-19 related lockdowns. cannabis, a publication of the research society on marijuana 143 by state the accuracy of operating status and location information within webservice and governmentmaintained cannabis retailer data was compared across states. tables 2 and 3 display each states operating status and location information accuracy, respectively, in both webservice and government-maintained registry samples. with respect to operating status, 15 states and dc (59%) observed acceptable accuracy with both data sources (table 4). in 9 (33%) states, acceptable accuracy was observed for government-maintained registries only and in 2 (7%) acceptable accuracy was observed for webservices only (table 4). california was the only state where both data sources simultaneously were considered unacceptable (table 4). in most states where one data source observed acceptable agreement and the other did not, the difference in accuracy exceeded 10% with a range of 10% to 77%. in nevada, where government-maintained registries achieved acceptable accuracy and webservices did not, this difference was less than 10% (table 4). of the 26 states and dc included in this study, 13 (48%) states demonstrated acceptable accuracy in both data sources for location. in 11 (41%) states, acceptable accuracy was observed from government-maintained registries only and new hampshire was the only state where acceptable accuracy was observed in web services only. in 2 (7%) states, both data sources observed below acceptable accuracy (table 4). for all 11 states where acceptable accuracy was achieved in government-maintained registries only, the accuracy disparity between webservice and government-maintained registry derived cannabis retailer information accuracy ranged from 10% to 62% (table 4). pre and post covid-19 related restrictions of the 26 states and dc represented in both webservice and government-maintained registry data sources, only 7 states had state mandated shutdowns (dc, massachusetts, maine, north dakota, new jersey, new york, vermont). table 5 represents operating status accuracy prior to and after covid-19 related business shutdowns for the 7 states in which cannabis retailers would have been affected. of the 64 observations in covid-19 shutdown affected states in the webservice sample, 47 (73%) observations were completed prior to covid-19 related shutdowns and 17 (27%) were completed post covid-19 related shutdowns. of the 47 observations completed prior to covid-19 related shutdowns, 39 (83%) were confirmed operating and of the 17 observations completed post covid-19 related shutdowns, 13 (76%) were confirmed operating. similarly, of the 40 observations in covid-19 shutdown affected states in the government-maintained registry sample, 23 (58%) observations were completed prior completed prior to covid-19 related shutdowns and 17 (42%) were completed post covid-19 related shutdowns. of the 23 observations completed prior to covid-19 related shutdowns, 23 (100%) were confirmed operating and of the 17 observations completed post covid19 related shutdowns, 14 (82%) were confirmed operating. discussion as the sale of cannabis for medical and adult use is legalized in more and more us states, there is a growing need to build a nuanced understanding of the cannabis retailer data sources used to generate knowledge about the impacts of access to cannabis on health. in this study we used a standardized phone survey to compare two cannabis retailer data sources (webservice and government-maintained registry) with respect to the accuracy of operating status and location information across 26 states and dc legalizing the sale of cannabis for medical or adult use in 2019. additionally, the potential impact of state level covid-19 related restrictions on ascertainment of phone survey data was evaluated on a state-by-state basis. our findings demonstrate that two main features of cannabis retailer data sources inform research practices and interpretation in this domain: data source and geographic location. furthermore, state level covid-19 restrictions were uncommon in states with cannabis legalization policies and in the states which had covid-19 restrictions in place during the study period, few showed any negative effects on the capability of phone surveys to ascertain operating status and location information in both data sources. overall, we found that both data sources observed similar accuracy with respect to the proportion of retailers confirmed as open and accuracy differences in cannabis retailer information 144 operating (78% in webservice, 76% in governmentmaintained registries). however, differences were observed between the data sources with respect to the proportion of confirmed non-cannabis retailers and the proportion of unconfirmable observations. roughly 4% more observations sampled from webservices were confirmed as non-cannabis retailers (e.g., a grocery store) as compared to the government-maintained registry data source. the webservice data cleaning procedures in this study determined that 16% of the observations were selfadvertised non-cannabis retailers and thus removed from the deduplicated webservice data prior to conducting the phone surveys. another 16% of the observations in the webservice sample were confirmed as non-cannabis retailers via phone survey. these findings align with research by pedersen et al. 2020 which suggest that webservice data retailer lists tend to overestimate the number of cannabis retailers.24 the results of our study support this claim. we found that webservice based data sources, such as weedmaps, often contained advertisements for retailers that did not sell cannabis, but advertise on the platform (e.g., dental offices). this suggests that webservice based approaches to generating cannabis retailer lists should invest resources into culling the relatively large number of identifiable noncannabis retailers present in these data sources. roughly half the observations sampled from webservices were unconfirmable compared to government-maintained registries. governmentmaintained registries often included establishment information associated with a corporate office, manager, or business owner. it is possible these individuals were less likely to answer a call from an unknown number than a retail store, leaving these observations unable to be confirmed as cannabis or non-cannabis retailers. this suggests, government-maintained registry information may not be suitably verifiable through phone-based methods alone due to the contact information not necessarily corresponding to the brick-and-mortar storefront of the retailer. among confirmed operating cannabis retailers, the accuracy of location information derived from government-maintained registries was very high (95%), while the accuracy of location information derived from web services is bordering on acceptable (79%). while prior work has characterized the accuracy of license and operating status information of cannabis retailer data sources, to our knowledge, this work is the first to quantify the accuracy of location information. due to the high accuracy of location information in government-maintained registries, these data sources may be more suitable for research in which specific location is a fundamental component (e.g., spatial analysis). in comparison, webservice based cannabis retailer lists may prove useful when conducting analyses across numerous states, as the data will be uniform across state lines. additionally, webservice based data sources may be acceptable when the outcome of interest is a lowresolution density measure, such as the number of cannabis retailers in a state or county. the accuracy of location and operating status information deviated on a state-by-state basis. in most states, both webservice and governmentmaintained registry-based data sources demonstrated acceptable accuracy or governmentmaintained registry performed better with respect to operating status. in california, where numerous research studies examining links between access to cannabis retailers and health outcomes have been conducted, (bachhuber et al., 2014; freisthler et al., 2013, 2016; freisthler & gruenewald, 2014; mair et al., 2015; morrison et al., 2014; shi et al., 2018a; thomas & freisthler, 2016; unger et al., 2020) neither webservice nor governmentmaintained registry based data sources were more than 80% accurate with respect to operating status. we were able confirm 64% of our webservice-based observations as open across california as a whole which aligns with previous work by pedersen et al. (2018) which found that 54% of cannabis retailers were confirmed operating using information derived from web-services in los angeles (pedersen et al., 2018). similarly, we confirmed 79% of observations sampled from government-maintained registries which aligns with cao et al. who found that 77% of observations taken from government-maintained registries in california were confirmed operating (cao et al., 2020). the observed low accuracy may be due to the high turnover of cannabis retailers in california, which has been suggested to be the result of proposition d, a regulatory measure which set zoning limitations and capped the number of cannabis retailers at 135 (thomas & freisthler, 2017). due to california being a focal point of access to cannabis research, these findings add to a body of literature suggesting that generalizability of findings derived from california cannabis, a publication of the research society on marijuana 145 may be limited. oklahoma and oregon were the only two states where webservices provided superior accuracy with respect to operating status and exceeded the 80% benchmark. the differences observed in these states may be due to a variety of reasons including registry and licensure procedures (e.g., in oklahoma, the online registry auto-populates as license information is filled out, (list of licensed businesses, 2022) which may be potentially prone to errors) or potential low regulation in rural areas of these states (fertig, 2022). these findings suggest that in these two states, webservice based approaches to generating cannabis retailer lists may be more suitable. our study used phone validation methods to verify the operating status and location of cannabis retailers. previous research seeking to validate cannabis retailer lists has utilized physical site visits, virtual site visits (via google street view), social media analysis, phone surveys, and government-maintained registry information (cao et al., 2020; pedersen et al., 2018, 2020). previous research suggests a mix of online and observational methods are best practices for ascertaining reliable cannabis retailer information (pedersen et al., 2018, 2020). this is due to an increase in accuracy of determining operating status provided by combining both methods. however, these studies were limited to california. additionally, pedersen et al. (2020) noted the infeasibility of using groundtruthing methods such as walkabouts to verify operating status of cannabis retailers, even on a smaller scale (pedersen et al., 2020). similar to cao et al., this study utilized phone survey methods to verify cannabis retailers. however, we verified roughly three quarters of the potential retailers as operating sampled across 26 states and dc between november 2019 and june 2020. this extends cao et al.’s work and suggests that phone validation may offer a feasible approach for verifying the accuracy of retailer lists, even on a large geographic scale. strengths & limitations this study is a first of its kind comparison of the two widely utilized cannabis retailer data sources across on a national scale, shedding light on the considerations of each data source in different geographic locations. however, this study includes some limitations. notably, our research identified variability in the acceptability of data sources within and across states. we are unable to make conclusions about the performance of registry data in arizona, colorado, and montana, as these data were not included in our sample. additionally, it is possible that covid-19 and the mandatory closure of cannabis retailers in some states may have impacted our ability to verify the operating status of retailers contacted after march 13th, 2020. however, the impact of covid-19 related shutdowns seems minimal. firstly, only 6 states and dc experienced any governmentmandated cannabis retailer related shutdowns out of the 26 states and dc represented in the study. secondly, these states only contributed 64 of the total 790 observations in the webservice sample (8%) and 40 of the total 859 observations in the government-maintained registry sample (5%). thirdly, in many states in both samples amongst the 6 states and dc, the operating status accuracy did not change after covid-19 related shutdowns. in the webservice sample, 3 states operating status changed after covid-19 related lockdowns. in one of those states (new york), the operating status accuracy improved from 29% to 60%. similarly, in the government-maintained registry sample, dc was the only geographic area to have phone surveys conducted before and after covid-19 related shutdowns and observed 100% accuracy before and after. the other 6 states represented in the government-maintained registry sample which experienced government-mandated covid-19 related shutdowns all observed acceptable accuracy. furthermore, the phone survey protocol instructs surveyors to re-call unconfirmed observations throughout the project duration which means that any observations which may have been potentially compromised due to covid19 related shutdowns would have the entire project duration to potentially be verified. finally, if covid-19 related shutdowns significantly impacted confirmation capabilities via the phone survey, one would expect to see a bias towards nonconfirmation. however, in the 6 states and dc which had mandatory shutdowns, operating status accuracy is grossly acceptable with many states at 100% accuracy in both data sources. this study also has numerous strengths. this study fulfills a critical literature gap – characterizing the accuracy of the two most widely used data sources for cannabis retailers lays the groundwork for future work in this area in addition to researchers and policy makers alike utilizing accuracy differences in cannabis retailer information 146 this work as a point of reference to interpret the results of other access to cannabis retailer studies. this study used phone surveys to verify over 1,500 cannabis retailers across 26 states and dc, as opposed to relying on government-maintained registries as the ground truth. this allowed us to not assume one of the data source’s veracity and instead study this empirically. conclusions data source and geographic location help to contextualize past research and inform future research using cannabis retailer lists. with respect to data source, research where specific cannabis retailer locations are a key element may prefer to use information extracted from governmentmaintained registries. however, research which aims to estimate the number of cannabis retailers in a broad geographic region (such as a large state or across multiple states) may prefer to use data extracted from webservices as this data will be uniform across geographic regions and be easier to filter down to only operating cannabis retailers at a large scale. furthermore, location may also further inform choices with respect to methodology and data source. using a carefully cleaned webservice-based data source may provide a more accurate depiction of cannabis retailers in oregon and oklahoma, whereas other states may be better suited utilizing data from government-maintained registries. while prior work has developed methods for assessing the accuracy of operating status within a webservice-derived cannabis 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(2020). locations of licensed and unlicensed cannabis retailers in california: a threat to health equity? preventive medicine reports, 19. https://doi.org/10.1016/j.pmedr.2020.101165 funding and acknowledgements: institute for health equity and social justice research health equity internship program. this research was funded by the national institutes on drug abuse 5k01da046307, pi: d. haley. the authors have no competing interests to declare. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 44 abstract cannabis is a commonly used substance among college students and is associated with a host of negative consequences. psychosocial variables (e.g., social norms, attitudes, and impulsivity) may explain individual differences regarding the increased cannabis use in recent years. attitudes, social norms, and broadband impulsivity have demonstrated consistent, independent relations with increased cannabis use; however, relations among approval and social norms, narrowband impulsivity, and cannabis use remain elusive. the current study (n = 718) examined approval (i.e., approval of peer cannabis use) and social norms as proximal predictors of impulsivity-cannabis use relations among college students across models of varying multivariate complexity. results from simpler multivariate models indicated that indirect effects of impulsivity-like facets, as assessed by the upps-p impulsive behavior scale, were statistically significant for all models via approval, descriptive norms, and injunctive norms. in general, individuals higher in impulsivity-like facets reported more positive attitudes or more perceived use or approval by friends, which, in turn, was associated with more cannabis use. differential relations emerged for the complex multivariate mediation model, such that approval exhibited the most consistent unique mediation effect. multi-group analyses by gender revealed an indirect effect of sensation seeking via descriptive norms stronger for males than females. consistent with the alcohol literature, this research highlights the importance of examining approval and social norms as proximal predictors of cannabis use, particularly as it is relevant for developing efficacious clinical interventions to reduce cannabis use by employing personalized normative feedback. key words: cannabis, marijuana, impulsivity, social norms, approval, mediation, multi-group analysis cannabis is a commonly used substance on college campuses, and a recent study suggests increasing prevalence rates of use among college students in the united states (i.e., 50.4% lifetime, 37.9% pastyear, 21.1% past-month, and 4.6% daily use; johnston, o’malley, bachman, schulenberg, & miech, 2016) compared to 2007 (i.e., 47.5% lifetime, 31.8% past-year, 16.8% past-month, and 3.5% daily use; johnston, o’malley, bachman, & schulenberg, 2008). indeed, past-year and pastmonth cannabis use are consistently higher among college students compared to non-collegeattending young adults (ages 19-28). thus, identifying individual differences which may contribute to cannabis use among college students is warranted. approval, social norms, and cannabis the extant substance use literature has demonstrated robust relations with social norms corresponding author: angela k. stevens, ms 2051 psychological sciences building, rm. 404, texas tech university, lubbock, texas, 79409-2051, usa. phone: 806-834-7295; fax: 806-742-0818; email: angela.stevens@ttu.edu cannabis 2018, volume 1 (1), 44-60 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.01.005 open access examining approval and social norms as proximal predictors of the impulsivity-cannabis use relation angela k. stevens1, brittany e. blanchard1, andrew k. littlefield1 1 texas tech university, lubbock, tx http://dx.doi.org/10.26828/cannabis.2018.01.005 cannabis, a publication of the research society on marijuana 45 and attitudes predicting substance use, and this notion is supported by sociocognitive theories (e.g., reciprocal determinism; bandura, 1986, 1999), including specific models, such as the theory of reasoned action/theory of planned behavior (ajzen, 1985; ajzen & fishbein, 1980) and problem behavior theory (jessor & jessor, 1977). however, research has focused on alcoholrelated outcomes (see borsari & carey, 2001). nevertheless, there is some evidence indicating beliefs about others’ cannabis use (i.e., descriptive norms) are predictive of cannabis use and cannabis-related problems (grossbard, hummer, labrie, pederson, & neighbors, 2009; kilmer et al., 2006; labrie, hummer, lac, & lee, 2010; napper, hummer, chithambo, & labrie, 2015; neighbors, geisner, & lee, 2008; martens et al., 2006; pearson et al., 2017; white et al., 2006; see buckner, 2013). further, others’ approval of cannabis use (i.e., injunctive norms) is also associated with more frequent cannabis use and cannabis-related problems (napper, kenney, hummer, fiorot, & labrie, 2016; neighbors et al., 2008; pearson et al., 2017), though strength of injunctive norms may vary as a function of the ‘other.’ for example, buckner (2013) found descriptive norms of friends (not students in general) and injunctive norms of friends were related to endorsement of more cannabis problems among college students. additionally, descriptive norms of friends accounted for the most unique variance in cannabis use frequency when examined in a multivariate context with injunctive norms (of friends and parents), positive and negative expectancies, and cannabis motives. this highlights the importance of the reference group when assessing cannabis social norms. although less research has examined actual approval (as opposed to perceived approval), approval of cannabis appears to provide consistent positive cross-sectional relations with cannabis use (e.g., labrie et al., 2010). labrie, hummer, and lac (2011) demonstrated approval of cannabis is associated with user status. in a longitudinal study, napper et al. (2016) evinced approval of cannabis was related to increased cannabis use with large effect sizes (i.e., r = .53.56) at baseline and 12-month follow-up. like the alcohol literature, the burgeoning field of cannabis research provides convincing evidence that approval and social norms are important in understanding cannabis-related outcomes within multiple theoretical frameworks. these theories also stress the importance of personality traits, such as impulsivity. impulsivity and cannabis another important construct to consider when understanding mechanisms of cannabis use among college students is impulsivity. within the alcohol literature, impulsivity is the most robust predictor of alcohol-related outcomes of all personality traits (see littlefield & sher, 2014), and emerging evidence suggests cannabis use is also associated with impulsivity. for example, broadband impulsivity was associated with cannabis use frequency and more cannabisrelated problems (day, metrik, spillane, & kahler, 2013). using `ecological momentary assessment, cannabis use was associated with increased impulsivity among young adults (ansell, laws, roche, & sinha, 2015). likewise, the prior day’s cannabis use predicted significant increases in next-day impulsivity, even without next-day cannabis use (ansell et al., 2015). researchers have begun examining mechanisms of impulsivity-cannabis use relations. using the acquired preparedness model, vangsness, bry, and labouvie (2005) found increased impulsivity was associated with fewer negative cannabis expectancies, which, in turn, was associated with increased cannabis use among college students. consistently, a later study examined positive and negative cannabis expectancies and cannabis refusal self-efficacy and found each fully mediated the relation between self-reported impulsivity and three cannabis-related outcomes (i.e., cannabis use frequency, problems, and dependence; hayaki et al., 2011). however, hakayi et al. (2011) used a 5-item broadband impulsivity measure, as opposed to a multifaceted measure, which could mask differential effects with cannabis-related outcomes. in the cannabis literature, few studies have used multifaceted measures of impulsigenic traits compared to the alcohol literature (e.g., the upps-p; see coskunpinar, dir, & cyders, 2013). reasonable evidence suggests impulsivity is a distal predictor of the impulsivity-cannabis relation, though improvements upon existing methodological limitations (i.e., use of broadband norms and impulsivity-cannabis relations 46 “impulsivity” measures) are necessary before making significant advancements in this area. previous work demonstrates “impulsivity” is not a unidimensional construct, but rather is comprised of separate, related constructs. importantly, these constructs exhibit differential relations with substance-related outcomes (see cyders, 2015). given recommendations for a disaggregated approach, the national institutes of health’s [nih] phenx toolkit (hamilton et al., 2011) has recommended the upps-p impulsive behavior scale (lynam, smith, cyders, fischer, & whiteside, 2007) as the self-report measure of impulsigenic traits. the upps-p is comprised of five facets: 1) positive urgency, the tendency to act rashly under extreme positive emotion, 2) negative urgency, the tendency to act rashly under extreme negative mood, 3) sensation seeking, the tendency to seek out new and thrilling experiences, 4) lack of planning, the tendency to act without thinking, and 5) lack of perseverance, the inability to remain focused on a difficult or boring task. following these recommendations, dvorak and day (2014) examined relations between higher-order factors of the upps-p, cannabis use, and cannabis-related problems. results suggested individuals lower in self-control (i.e., lack of planning, lack of perseverance) were more likely to use cannabis and to use it more intensely. likewise, sensation seeking was associated with increased likelihood to use cannabis, whereas urgency (i.e., positive and negative urgency) was associated with an increased likelihood to use cannabis, as well as more cannabis-related problems (dvorak & day, 2014). importantly, bravo et al. (2017b) were the first to examine impulsivity-like facets, as assessed by the uppsp, as distal predictors of cannabis outcomes mediated by more proximal predictors among college students. more specifically, protective behavioral strategies mediated relations between lack of planning and lack of perseverance and cannabis use frequency and related consequences (bravo et al., 2017b). however, no other proximal predictors have been examined as mediators of the facet-level impulsivity-cannabis use link. purpose of study taken together, previous research suggests that impulsivity-like facets, approval, and social norms are relevant constructs for understanding cannabis-related outcomes. simons, neal, and gaher (2006) examined both, social norms and impulsivity, as predictors of cannabis nonuser status and found only social norms were predictive of being a nonuser, whereas impulsivity was not. however, to our knowledge, no research has examined the relations among approval and social norms, upps-p impulsigenic traits, and cannabis use. therefore, the purpose of this study is to examine the extent to which social norms (i.e., descriptive and injunctive norms regarding friends) and approval of peer use mediate the relation between impulsivity-like facets and pastyear cannabis use across simple and complex multivariate mediation models. further, although the gender gap is narrowing with respect to substance use (e.g., steingrímsson, carlsen, sigfússon, & magnússon, 2012), current research shows gender differences with respect to cannabis use (e.g., bravo et al., 2017b). gender remains a relevant construct when examining norms and alcohol consumption (e.g., labrie, cail, hummer, lac, & neighbors, 2009; lewis & neighbors, 2004; neighbors et al., 2010), as well as impulsivityrelated constructs as assessed by the upps-p (see cyders, 2013). thus, this study will also determine whether the mediation effects differ by gender. in general, we expected positive, direct associations between impulsivity-like facets, cannabis approval, and social norms with cannabis use, and we hypothesized individuals higher in impulsivity-like facets would endorse more positive attitudes, perceived use, or perceived approval by friends, which would, in turn, be predictive of more cannabis use (i.e., significant indirect effects). although no specific hypotheses were proffered regarding differential relations or multi-group analyses by gender due to the exploratory nature of this work, we anticipated different associations to emerge across simple and complex multivariate models. cannabis, a publication of the research society on marijuana 47 method participants participants (n = 718) were enrolled in undergraduate introductory psychology courses at a large, hispanic-serving, southwestern university and completed a battery of self-report measures online. the plurality of participants (mage = 19.00, sd = 1.33) identified as white (66%) and female (66%), with a minority identifying as hispanic/latino (25%). three hundred ten participants (43%) endorsed pastyear cannabis consumption. all participants received course credit. the study protocol was approved by the institutional review board. measures demographics. participants completed a baseline measure of demographic questions including self-identified age, gender, race, and ethnicity. impulsigenic traits. the 59-item selfreport upps-p impulsive behavior scale (lynam et al., 2007), with a 4-point likert-type response scale ranging from (1) strongly disagree to (4) strongly disagree was used (negative urgency α = .88, positive urgency α = .94, lack of planning α = .83, lack of perseverance α = .83, and sensation seeking α = .86). cannabis approval and norms. cannabis approval, descriptive norms, and injunctive norms were assessed using select items from the american drug and alcohol survey – adolescent version (adas; rocky mountain behavioral science institute, 2003). descriptive norms were assessed using a summed score of the following two items using 4-point likert-type scales: “how often have your friends asked you to use marijuana?” with response options ranging from (1) not at all to (4) very often, and “how many of your friends use marijuana?” ranging from (1) none at all to (4) all of them. higher sum scores reflected higher (i.e., indicative of more perceived friend use) descriptive norms (α = .75). injunctive norms and approval were assessed using two items with response options ranging from (4) not at all to (1) a lot: “how much would your friends try to stop you from using marijuana?” and “how much would you try to stop your friends from using marijuana?” respectively. higher scores on these items reflected higher (i.e., indicative of more perceived peer approval) injunctive norms and more positive attitudes towards cannabis use, respectively. cannabis use. past-year cannabis use was assessed using the adas (rocky mountain behavioral science institute, 2003) using a single item (i.e., “how often in the last 12 months have you used marijuana?”). participants endorsed frequency of use on a 6-point scale (i.e., “none,” “12 times,” “3-9 times,” “10-19 times,” “20-49 times,” and “50 or more times”). analytic strategy exploratory data analyses were conducted to assess for normality (tukey, 1977). descriptive norms (a continuous outcome) and all impulsivitylike facets were approximately normally distributed (i.e., skewness and kurtosis between 1.00 and +1.00; fox, 2008). approval, injunctive norms, and past-year cannabis use were treated as categorical, given these outcomes are singleitem indicators using ordinal, likert-type response options. past-year cannabis use was rescaled such that low endorsement (i.e., less than 10% of the sample) categories were collapsed, which resulted in five response categories for this outcome (i.e., collapsing “20-49 times” and “50 or more times” into a single category). all data management, coding, and bivariate correlations were conducted using sas 9.4™ software (sas institute inc.). all mediation models were conducted in mplus 7.11 (see figure 1, muthén & muthén, 19982012). to test the extent to which approval, descriptive norms, and injunctive norms mediate the relations between the upps-p impulsivitylike facets and past-year cannabis use, model indirect was used to test the strength and significance of indirect effects of 15 simple mediation models (i.e., each impulsivity-like facet and mediator independently) and one complex mediation model (i.e., all impulsivity1 copyright © [2002-2014] sas institute inc. sas and all other sas institute inc. product or service names are registered trademarks or trademarks of sas institute inc., cary, nc, usa. norms and impulsivity-cannabis relations 48 figure 1. conceptual complex multivariate mediation model predicting past-year cannabis use note. depicts the conceptual complex multivariate mediation model for manifest impulsivity-like traits, cannabis approval and social norms, and past-year cannabis use. correlations among exogenous variables and correlations among mediators were also estimated, but not shown for simplicity. like facets and mediators simultaneously) using weighted-least-squares mean and variance estimation to model categorical variables. ninetyfive percent confidence intervals were computed for all direct and indirect effects with biascorrected bootstraps (i.e., using 5,000 bootstrapped samples), such that effects were determined to be significant if confidence intervals did not contain zero (preacher & hayes, 2004). to test whether these indirect effects differed by gender (i.e., conditional indirect effects), multi-group mediation analyses were conducted for each of the simple mediation models. model constraint was used to test whether the difference in indirect effects for males and females was significantly different from zero. proportion of the total effect that is mediated was calculated for all mediation models by dividing the indirect effect (ab) by the total effect (c; see kenny, 2016). results all impulsivity-like facets were significantly, positively correlated with social norms, approval, and past-year cannabis use with small-to-medium effect sizes (r’s = .10 to .30; cohen, 1988; see table 1). approval and social norms were significantly, positively associated with past-year cannabis use with medium-to-large effect sizes (r’s = .30 to .50). finally, males endorsed more past-year cannabis use when compared to females bivariately. simple multivariate mediation all total indirect effects for the 15 simple mediation models were statistically significant (see table 2). in general, individuals higher in impulsivity-like facets reported increased approval or social norms (i.e., injunctive or descriptive), which, in turn, was associated with increased past-year cannabis use. overall, lack of planning exhibited the largest indirect effect on cannabis, a publication of the research society on marijuana 49 table 1. correlations among impulsivity-like facets and cannabis approval, norms, and past-year use gender nu pu lplan lper ss approve desnorm injnorm pyuse gender nu -0.03 pu 0.12** 0.68** lplan 0.00 0.24** 0.29** lper -0.03 0.33** 0.31** 0.48** ss 0.33** 0.15** 0.23** 0.02 -0.21** approve 0.17** 0.20** 0.22** 0.25** 0.20** 0.15** desnorm 0.08 0.22** 0.15** 0.11** 0.09* 0.18** 0.45** injnorm 0.09* 0.19** 0.16** 0.24** 0.18** 0.10** 0.74** 0.47** pyuse 0.13** 0.24** 0.20** 0.28** 0.17** 0.20** 0.50** 0.59** 0.46** m/% 33.61% 27.66 27.31 21.50 19.28 34.41 2.38 4.39 2.66 43.18% sd 7.08 9.17 4.93 4.75 6.96 1.23 1.72 1.20 note. gender was coded ‘0’ = female, ‘1’ = male; nu = negative urgency; pu = positive urgency; lplan = lack of planning; lper = lack of perseverance; approve = cannabis approval; desnorm = cannabis descriptive norms; injnorm = cannabis injunctive norms; pyuse = past-year cannabis use. pearson product-moment correlations reported for bivariate correlations between continuous variables (i.e., impulsivity-like facets and cannabis descriptive norms). spearman’s rank-order correlations reported for ordinal-ordinal bivariate correlations (i.e., correlations among cannabis approval, injunctive norms, and past-year use), ordinal-continuous bivariate correlations (i.e., correlations among impulsivity-like facets and cannabis approval, injunctive norms, past-year use; correlations between descriptive norms and approval, injunctive norms, and past-year use), and ordinalbinary (i.e., correlations between gender and cannabis approval and injunctive norms). point-biserial correlations reported for correlations between gender and impulsivity-like facets (i.e., binary-continuous bivariate correlations). gender frequency reported for male; pyuse frequency indicates binary endorsement of past-year cannabis use. *p < .05, **p < .01. norms and impulsivity-cannabis relations 50 table 2. effects from simpler multivariate mediation models predicting past-year cannabis use model β/b [95% ci] % mediated positive urgency-approval totala .206/.023 [.015, .031] total indirect .141/.016 [.010, .021] 68.12% direct .066/.007 [.001, .014] negative urgency-approval totala .259/.038 [.027, .048] total indirect .129/.019 [.013, .025] 49.62% direct .131/.019 [.010, .029] lack of planning-approval totala .304/.065 [.050, .081] total indirect .168/.036 [.027, .045] 55.26% direct .136/.029 [.014, .044] lack of perseverance-approval totala .202/.043 [.028, .059] total indirect .143/.031 [.022, .039] 70.79% direct .059/.013 [-.002, .027] sensation seeking-approval totala .255/.038 [.027, .049] total indirect .100/.015 [.008, .022] 39.22% direct .155/.023 [.013, .033] positive urgency-injunctive norms total indirect .100/.011 [.006, .016] 48.54% direct .106/.012 [.005, .019] negative urgency-injunctive norms total indirect .113/.017 [.011, .023] 43.63% direct .146/.021 [.012, .031] lack of planning-injunctive norms total indirect .146/.031 [.023, .039] 47.87% direct .159/.034 [.018, .050] lack of perseverance-injunctive norms total indirect .111/.024 [.016, .033] 55.22% direct .090/.019 [.005, .034] sensation seeking-injunctive norms total indirect .066/.010 [.004, .016] 25.88% direct .189/.028 [.018, .038] positive urgency-descriptive norms total indirect .096/.011 [.006, .016] 46.60% direct .110/.012 [.006, .018] negative urgency-descriptive norms total indirect .142/.021 [.015, .027] 54.83% direct .117/.017 [.009, .026] lack of planning-descriptive norms total indirect .071/.015 [.006, .024] 23.36% direct .233/.050 [.038, .063] lack of perseverance-descriptive norms total indirect .057/.012 [.004, .021] 28.36% direct .144/.031 [.019, .044] sensation seeking-descriptive norms total indirect .118/.018 [.012, .024] 46.27% direct .137/.020 [.011, .030] cannabis, a publication of the research society on marijuana 51 note. significant effects are in bold typeface. significance was based on 95% bias-corrected unstandardized bootstrapped confidence intervals (based on 5,000 bootstrapped samples) that did not contain zero. a total effect (c) reflects the sum of the indirect effect and c’ (i.e., the direct effect when the potential mediators are not included in the model). total effects for each impulsivity-like facet are identical regardless of mediator, therefore these estimates are only presented once for simplicity. direct = c’. % mediated = the proportion of the effect that is mediated in each mediation model. past-year cannabis use through approval (standardized indirect effect [ie] = .168, accounting for 55.26% of the total effect), and injunctive norms (ie = .146, accounting for 47.87% of the total effect). lack of perseverance had the next highest indirect effect on past-year cannabis use through approval (ie = .14), accounting for 70.79% of the total effect (see table 2). complex multivariate mediation when examined simultaneously, the total indirect effects of all impulsivity-like facets except positive urgency remained significant, and differential relations emerged for the unique indirect effects (see table 3). the combination of approval, descriptive norms, and injunctive norms accounted for 69.19% of the total effect for negative urgency and past-year cannabis use, which explained the most variance of all impulsivity-cannabis use relations (see table 3). multi-group mediation by gender multi-group mediation analyses were conducted for each of the 15 simple mediation models. results suggested that the indirect effect of sensation seeking on past-year cannabis use via descriptive norms significantly differed by gender. more specifically, males exhibited a slightly larger indirect effect in this case (male: ie[β/b] = .178/.029; female: ie = .077/.011; unstandardized difference = .017, 95% unstandardized confidence interval [ci]: .004, .031), which suggests a stronger proximal effect of descriptive norms for high sensation-seeking males compared to females. the remaining multi-group mediation analyses were statistically nonsignificant. discussion the present study examined the direct effects of impulsivity-like facets, approval, and social norms on past-year cannabis use, as well as the indirect effects of impulsivity-like facets on pastyear cannabis use through approval and social norms regarding friends (as opposed to students in general) using multivariate approaches of varying complexity. further, the extent to which these indirect effects differed by gender were also tested for simpler multivariate models. notably, this was the first study, to our knowledge, to test the relations among impulsivity-like facets, as assessed by the upps-p impulsive behavior scale, approval, social norms regarding friends, and past-year cannabis use among college students. direct effects bivariate direct effects results from the present study suggested that negative urgency, positive urgency, lack of planning, lack of perseverance, and sensation seeking were significantly positively associated with past-year cannabis use. when examined simultaneously, all direct effects remained significant, except for positive urgency. although the extant cannabis research utilizing the upps-p is limited, these results differed from previous findings. for example, bravo et al. (2017a; 2017b) only found a bivariate relation between lack of perseverance and cannabis use frequency. however, consistent with the current findings, dvorak and day (2014) reported significant bivariate associations between urgency (i.e., positive and negative urgency), self-control (lack of perseverance and lack of planning), and sensation seeking, and past-6-month cannabis use intensity. discrepancies between the results from the present study and the results reported in bravo et al. (2017a; 2017b) likely are a result of norms and impulsivity-cannabis relations 52 table 3. effects from complex multivariate mediation model predicting past-year cannabis use predictor variable β/b [95% ci] % mediated positive urgency totala -.064/-.008 [-.018, .003] total indirectb -.018/-.002 [-.010, .006] 28.13% approval .015/.002 [-.001, .006] descriptive norms -.032/-.004 [-.009, .001] 50.00% injunctive norms -.001/.000 [-.002, .000] 1.56% direct -.046/-.006 [-.014. .003] negative urgency totala .172/.027 [.013, .041] total indirectb .119/.019 [.009, .028] 69.19% approval .019/.003 [-.001, .008] 11.05% descriptive norms .096/.015 [.009, .022] 55.81% injunctive norms .005/.001 [-.001, .004] 2.91% direct .054/.008 [-.003, .020] lack of planning totala .218/.049 [.032, .068] total indirectb .083/.019 [.007, .031] 38.07% approval .053/.012 [.006, .021] 24.31% descriptive norms .023/.005 [-.002, .013] 10.55% injunctive norms .007/.002 [-.004, .008] 3.21% direct .135/.030 [.017, .045] lack of perseverance totala .128/.030 [.010, .049] total indirectb .070/.016 [.004, .028] 54.26% approval .044/.010 [.004, .019] 34.38% descriptive norms .022/.005 [-.002, .013] 17.19% injunctive norms .003/.001 [-.001, .005] 2.34% direct .059/.014 [-.001, .029] sensation seeking totala .276/.044 [.032, .057] total indirectb .136/.022 [.014, .029] 49.10% approval .052/.008 [.004, .014] 18.84% descriptive norms .079/.013 [.008, .018] 28.62% injunctive norms .004/.001 [-.001, .004] 1.45% direct .141/.023 [.012, .033] note. significant effects are in bold typeface. significance was based on 95% bias-corrected unstandardized bootstrapped confidence intervals (based on 5,000 bootstrapped samples) that did not contain zero. atotal effect (c) reflects the sum of the indirect effect and c’ (i.e., the direct effect when the potential mediators are not included in the model). btotal indirect effects reflect the sum of indirect associations via approval, descriptive norms, and injunctive norms. direct = c’. % mediated = the proportion of the effect that is mediated in the complex multivariate mediation model. % mediated is not reported for the approval unique indirect effect of positive urgency, as calculations resulted in a negative value. % mediated should be interpreted with caution for variables with total effects less than .20 (see kenny, 2016). sampling and measurement differences. more specifically, bravo et al. (2017a; 2017b) used a large, restricted sample of college students who endorsed at least one day of past-month cannabis use, whereas the present study included cannabis abstainers. further, bravo et al. (2017a; 2017b) assessed cannabis use frequency during a “typical week” in the past month, whereas the present study used single-item indicator of past-year cannabis use frequency. overall, these findings cannabis, a publication of the research society on marijuana 53 suggest that differential relations among impulsivity-like facets and cannabis use may emerge depending on sampling characteristics (i.e., including abstainers vs. not), outcome of interest (i.e., past-month vs. past-year cannabis use), method of cannabis use assessment, and methodological approach. further, results from this study demonstrated significant positive bivariate associations between cannabis approval, injunctive norms, descriptive norms, and past-year cannabis use, which supports findings in the extant cannabis literature (e.g., napper et al., 2016; simons et al., 2006; pearson et al., 2017), as well as the broader substance use and social norm literature (see perkins, 2002, 2003 for reviews). indeed, these results are supportive of the theory of planned behavior (tpb; ajzen, 1985). intention is a function of several factors, including attitudes, subjective norms, and the perceived social pressure (ajzen, 1985). therefore, findings from the present study support the notion that cannabis approval (similar to tpb attitudes), descriptive norms, and injunctive norms are robust predictors of cannabis use. speculatively, this relation may be best explained by a “third variable,” or an individual’s intention to engage in cannabis use. notably, the present study was the first study to document the positive bivariate relations among facet-level impulsivity and cannabis approval and social norms regarding friends among college students. our results are congruent with previous work examining impulsivity and cannabis-related social norms. more specifically, simons et al. (2006) examined the bivariate correlation between social norms and impulsivity among college students, and reported a small-tomedium effect size for the association (r = .22). however, simons et al. (2006) did not distinguish between the distinct types of social norms (i.e., descriptive and injunctive) and used an overall measure of “impulsivity” (as assessed by the eysenck impulsivity scale measuring lack of control; eysenck & eysenck, 1978). although our results are consistent with previous findings which used the “lumping” approach to impulsivity and social norms, we maintain that examination of distinct impulsigenic traits is warranted. indeed, research has demonstrated the potential loss of vital information and that “lumping” (vs. “splitting”) can mask differential relations among constructs (e.g., blanchard, stevens, littlefield, talley, & brown, 2017). further, although the impulsivity-like facets did not necessarily demonstrate differential relations in the simpler models, using a “splitting” approach revealed differences in effect sizes (e.g., negative urgency-descriptive norms r = .22 vs. lack of perseverance-descriptive norms r = .09), which would have been masked if a “lumping” approach had been used. further, the differential gender effect reported from multi-group analyses would have been masked if a “lumping” approach had been employed in the present study. therefore, the present study illustrates the benefit of using more nuanced methods of assessment. mediational effects the primary interest of this study was to determine the extent to which relations between impulsivity-like facets and past-year cannabis use were mediated by approval and social norms. despite the potential for differential effects when adopting a “splitting” approach, results from 15 simple mediation models suggest that each of the five impulsivity-like facets exhibited significant indirect effects on past-year cannabis use via approval, descriptive norms, and injunctive norms. indeed, these consistent results across simple mediation models support etiological theories of substance use in the extant literature. problem behavior theory (e.g., jessor & jessor, 1977; jessor, 1987) postulates that “problem” or “deviant” behavior is a function of psychosocial forces, which are divided into two systems (i.e., the personality system and the perceived environment system; jessor, 1987). in this study impulsivity-like facets (a major component of the personality system) and social norms (i.e., perceived environmental system) are considered psychosocial variables, and results indicated significant overlap in individuals higher in facets of impulsivity, higher in approval and social norms, and more frequent cannabis use. these findings may suggest a more general pattern of deviance (e.g., associating with peers who are more approving of cannabis) and may be conceptualized as risk factors in the problem behavior framework. from the broader perspective of reciprocal determinism, it may also be that impulsigenic traits influence environment norms and impulsivity-cannabis relations 54 and choice of friends, which perpetuates certain norms, yielding increased cannabis use. differential relations emerged in the complex multivariate mediation model. more specifically, statistical redundancy and suppressor effects emerged when examined simultaneously. for example, in the simpler models, all total effects, direct effects, and total indirect effects for positive urgency were positive and statistically significant. in the complex model, the same effects became negative and statistically nonsignificant. given the strength of the bivariate correlation of positive and negative urgency (r = .68), this suppressor effect is not surprising (see conger, 1974). in fact, to address the statistical redundancy of positive and negative urgency, more recent research combines these two urgency facets (e.g., burris, riley, puleo, & smith, 2017; riley, rukavina, & smith, 2016), which smith and cyders (2016) recommend if “the two traits do not predict differently (which may be the case in the prediction of problem drinking or drug use)” (p. 57). likewise, in the complex model, injunctive norms no longer emerged as a significant mediator for any impulsivity-like facet, though it significantly mediated relations for all impulsivity-like facets in simpler models. again, this is likely a result of statistical redundancy, as injunctive norms and approval are highly correlated (r = .74 in the current study), which is suboptimal when examining multiple mediators simultaneously (see kenny, 2016). because of this, we caution readers from drawing firm conclusions regarding which mediator is superior in the complex model. further, it is recommended that the complex multivariate findings be considered in the context of the findings from the simpler models (see meehl, 1971), as it is likely individuals high in positive urgency may benefit from clinical implications of the present research despite that this facet did not demonstrate significant indirect effects in the complex model. interestingly, sensation seeking remained the most consistent in the complex model, as two of the three mediators remained significant. however, it is difficult to speculate about what sensation seeking represents in this complex model after removing variance shared with the other four upps-p impulsigenic traits (see lynam, hoyle, & newman, 2006 for the “perils” of partialling). further, although approval emerged as a robust mediator over and above descriptive and injunctive norms across most impulsivity-like facets in the complex multivariate model, only descriptive norms significantly mediated negative urgency while holding other variables constant. speculatively, given individuals high in negative urgency are driven by heightened emotional states (which may include anxiety/selfconsciousness/other negative social emotion), it is possible that descriptive norms are a more readily available heuristic compared to injunctive norms and approval. it is also plausible that descriptive norms as a construct are a proxy for cannabis availability, and cannabis use for individuals high in negative urgency may be best explained by substance availability. finally, multi-group mediation analyses by gender indicated that there were no statistically significant differences in indirect effects tested in the present study, except for the indirect effect of sensation seeking on cannabis use via descriptive norms. the lack of gender differences regarding mediational estimates found in the present study are not surprising, given the minimal gender differences in constructs of interests when examined bivariately. for example, of the five impulsivity-like facets, only positive urgency and sensation seeking were significantly related to gender (consistent with meta-analytic findings; see coskunpinar et al., 2013), with sensation seeking exhibiting the strongest effect size (r = .33; i.e., males reporting higher levels of sensation seeking). likewise, only approval and injunctive norms, but not descriptive norms, were significantly associated with gender, such that males endorsed more positive attitudes towards cannabis and perceived that their friends would be more approving of cannabis use. although significant differences in indirect effects were not observed in the present study, there is still considerable evidence to suggest that gender plays an integral role in social norms and related constructs. indeed, even though the present study made a specific reference to norms regarding friends, which is strength of the study, the present study utilized “gender-nonspecific cannabis norms,” or the social norms of cannabis use without specific reference to gender (see lewis & neighbors, 2004 for more details on genderspecific norms; see buckner, 2013 for more details regarding norms of friends vs. students in general). further, in the alcohol literature, there is evidence to suggest that gender-specific norms cannabis, a publication of the research society on marijuana 55 (i.e., same-sex norms or opposite-sex norms) are better predictors of alcohol consumption than gender-nonspecific norms; moreover, some research suggests that same-sex norms are stronger predictors of alcohol consumption for females compared to males (lewis & neighbors, 2004). notably, these nuances in assessment of social norms by gender may explain the nonsignificant gender differences in mediational estimates found in the present study, as we did not make a specific reference to gender when asking about social norms. therefore, this is an important line of inquiry moving forward in the cannabis literature, as little research has been conducted examining the impact of genderspecific social norms – especially as they relate to narrowband assessments of impulsivity. given the current findings, speculatively, personalized normative feedback (pnf) interventions may be effective in reducing consumption, (blevins, walker, stephens, banes, & roffman, 2018; copeland, rooke, rodriguez, norberg, & gibson, 2017). further, though this is speaking beyond the data, providing pnf interventions to individuals high in impulsivitylike facets, particularly those high in lack of planning and lack of perseverance might be most effective. if providing personality-informed, gender-specific normative feedback interventions, males high in sensation seeking may benefit most, as descriptive norms were more predictive of pastyear cannabis use for high-sensation-seeking males compared to females in the current study. further, to maximize reach and minimize cost, normative-based public service announcements (psas) are a potential alternative, especially those targeting high-sensation-seeking males, as previous research has demonstrated effectiveness for sensation-seeking-targeted psas in reducing cannabis use and positive cannabis attitudes (palmgreen, donohew, lorch, hoyle, & stephenson, 2001; palmgreen, lorch, stephenson, hoyle, & donohew, 2007). limitations results should be interpreted in light of study limitations. notably, participants were recruited from introductory psychology courses, and the plurality of participants were white females, so generalizability of our findings may be limited. further, a sizeable portion of our sample reported past-year cannabis use (43.18%); this rate is slightly higher compared to the reported national past-year cannabis use average (37.9%; johnston et al., 2016), which could also impact the generalizability of the current findings. further, it is recommended that future research replicate our findings using more sensitive measures of cannabis use frequency and cannabis social norms and approval. for example, future research in this area should prioritize the use of the modified daily drinking questionnaire (collins, parks, & marlatt, 1985) or the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017) as more comprehensive assessments of cannabis use, as opposed to a single-item indicator. to assess descriptive norms, we used two items, one of which assessed offers from peers to use cannabis, which may be more representative of direct peer influence, rather than descriptive norms. this should be taken into consideration when interpreting the current findings. further, the present study included a single cannabis outcome (i.e., cannabis use frequency), which has been shown in recent research to have weaker associations with upps-p impulsivity-like facets than cannabis use consequences (bravo et al., 2017b). extensions of the present study should prioritize the inclusion of cannabis use consequences (e.g., marijuana consequences questionnaire [macq]; simons, dvorak, merrill, & read, 2012) to address this limitation. given that the data was collected in a state without decriminalization or legalization of cannabis, our results may not generalize to states with more lenient cannabis policies. future studies should also examine the effects of state-level cannabis policies on cannabis-related norms, attitudes, and use. finally, given the cross-sectional nature of this study, conclusions regarding temporal precedence cannot be drawn from mediation models, and thus longitudinal research is needed. future directions norms and impulsivity-cannabis relations 56 expanding on the current study, it is important to consider the influence of different cannabis-related outcomes (e.g., cannabis-related problems, cannabis use frequency over various timespans), as impulsivity-like facets have exhibited differential relations with substance use outcomes (e.g., sensation seeking often relates to frequency, whereas negative urgency often relates to problematic use; see smith et al., 2007). further, researchers are encouraged to replicate the present findings using more specific assessments of social norms and approval. for example, it is necessary to determine the effect of gender-specific versus gender-nonspecific social norms on the relations examined in this study, as these potential differing effects have significant clinical implications with the use of social norms as a treatment target for decreasing cannabis consumption. finally, similar to the broader substance use literature (see borsari & carey, 2003), there is emerging evidence to support that cannabis users tend to misperceive (and overestimate) the cannabis use of the typical college student compared to their own use (e.g., pearson et al., 2017). therefore, future directions of the present study include considering how misperception of cannabis use relates to impulsivity-like facets. conclusions in conclusion, the current study provides evidence that, in general, approval of cannabis and social norms regarding friends are more proximal predictors of past-year cannabis use, whereas impulsivity-like facets serve as distal predictors in simpler multivariate models. moreover, differential relations emerge when examining these effects simultaneously. indeed, given this evidence, clinical interventions aimed at approval and social norms to reduce cannabis use among college students are important to explore, especially for individuals higher in impulsivity-like facets. more specifically, in the alcohol literature, personalized normative feedback has been efficacious in reducing alcohol consumption among college students (e.g., neighbors, larimer, & lewis, 2004), and it is important for future research to continue examining ways to improve these types of intervention strategies to reduce cannabis use. references ajzen, i. 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(2005). impulsivity, negative expectancies, and marijuana use: a test of the acquired preparedness model. addictive behaviors, 30(5), 1071-107 norms and impulsivity-cannabis relations 60 copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 39 abstract a growing body of work links posttraumatic stress disorder (ptsd) symptoms and substance use. unfortunately, much of the literature has examined associations in isolation (e.g., alcohol only). failure to account for simultaneous or concurrent substance use may limit conclusions that can be drawn from existing research, including the extent to which specific substances contribute differentially to ptsd symptom patterns. the current study examined differences in ptsd symptom profiles between individuals using one or both of the most commonly co-administered psychoactive substances – alcohol and marijuana. trauma-exposed participants (n = 533; mage = 21.15) comprised two mutually-exclusive groups: past-month alcohol-only use (n = 334) or past-month alcohol and marijuana use (n = 199). clusterlevel and symptom-level profile analyses evaluated mean differences and shape (parallelism) of ptsd symptom severity profiles between the groups. follow-up analyses examined symptom-specific difference in ptsd symptom endorsement and severity. overall, individuals using marijuana and alcohol evidenced greater ptsd negative cognition (30.8% greater) and hyperarousal (26.4% greater) symptom severity. alcohol and marijuana users were more likely to endorse, and report greater severity of, mood-related ptsd negative cognition symptoms (e.g., anhedonia, negative affect) and externalizing hyperarousal symptom (e.g., irritability/aggression, risky behaviors) than alcohol-only users. findings highlight important ptsd differences between individuals that are often lumped into homogenous categories of isolated substance users. findings provide preliminary support for an ‘additive’ self-medication model between ptsd and polysubstance use. lastly, findings indicate that mood-related negative cognition symptoms and externalizing hyperarousal symptoms may be important targets for ptsd-polysubstance use intervention. key words: substance use, alcohol, marijuana, ptsd, trauma an extensive and growing body of work has identified strong associations between posttraumatic stress disorder (ptsd) symptoms and problematic substance use (debell et al., 2014; jacobsen, southwick, & kosten, 2001). generally, research examining these relationships has supported a self-medication or mutual maintenance model of co-occurrence (ouimette & brown, 2003; stewart & conrod, 2008), whereby individuals use substances as a maladaptive means of coping with psychological or physiological distress associated with ptsd cannabis 2019, volume 2 (1), 39-52 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.01.004 open access alcohol and marijuana polysubstance use: comparison of ptsd symptom endorsement and severity patterns corresponding author: nathan kearns, department of psychology, university of north texas, 1155 union circle, denton, tx, 76203-5017, email: nathankearns@my.unt.edu nathan t. kearns1, renee m. cloutier1, caitlyn carey1, ateka a. contractor1, heidemarie blumenthal1 1 department of psychology, university of north texas, denton, tx, usa polysubstance use and ptsd profiles 40 symptoms. although much of the extant work has focused on the link between ptsd and subsequent alcohol use, similar associations have been demonstrated with other substances, including both stimulants (e.g., najavits et al., 2003; smith et al., 2010) and other anxiolytic intoxicants (e.g., marijuana; wilkinson, stefanovics, & rosenheck, 2015; betthauser, pilz, & vollmer, 2015). unfortunately, much of the existing ptsdsubstance use research has purposefully examined these associations in isolation (e.g., alcohol only) – in most cases not assessing for simultaneous or concurrent use of other substances (e.g., alcohol and marijuana). this methodological approach is problematic given the high prevalence of polysubstance use, particularly among individuals exposed to trauma and/or that are evidencing substance use-related harms. for example, results from the national alcohol survey indicate that, among all current alcohol users, approximately 11.4% also report simultaneous or concurrent use of marijuana in the past year (subbaraman & kerr, 2015). however, this prevalence rate triples to approximately 34.1-36.2% among individuals evidencing alcohol use-related negative consequences in the past year (e.g., deteriorating social relationships; subbaraman & kerr, 2015); such problematic behavioral outcomes have also been linked to increased ptsd symptom severity (e.g., debell et al., 2014). according to the global drug survey (n = 14,869 adults from us, australia, and uk), involvement in or exposure to violence also substantively increased risk of polysubstance use – in fact, it is among the strongest predictors of past-year use of six or more substances (morley et al., 2015). other work among trauma-exposed veterans indicates that 26.7% of individuals with one substance use disorder also met diagnostic criteria for at least one other substance use disorder – with alcohol and cannabis use disorder being the most common co-occurrence (bhalla, stefanovics, & rosenheck, 2017). given high prevalence of polysubstance use in both general and trauma-associated subpopulations, failure to account for other forms of simultaneous or concurrent substance use limits conclusions that can be drawn from the existing ptsd-substance use literature. in particular, our understanding of the extent to which specific substances – and combinations of substances – contribute or associate differentially to ptsd symptom patterns (e.g., endorsement, severity) may be limited, hindering both our theoretical modeling of ptsd-substance use interplay, as well as our ability to meaningfully integrate these findings into efficacious prevention and remedial efforts. some work has attempted to ameliorate this concern by evaluating associations between ptsd and various combinations of substances. although limited, this empirical work indicates that individuals who use other substances, in addition to alcohol, evidence greater ptsd severity and other forms of psychological distress in comparison to both alcohol-only and “other substance”-only users (mills, teesson, ross, & peters, 2006; ruglass, shevorykin, brezing, hu, & hien, 2017; salgado, quinlan, & zlotnick, 2007; ullman, townsend, starzynski, & long, 2006). for example, ullman and colleagues (2006) examined sexual assault survivors with ptsdonly, ptsd and illicit drug use (e.g., any cocaine, heroin, or psychedelics), ptsd and problematic drinking, and ptsd and polysubstance use (e.g., both drinking and any cocaine, heroin, or psychedelics). results of their study indicated that women with ptsd that were polysubstance users evidence more extensive trauma histories and greater ptsd symptom severity than sexual assault survivors in the other groups (ullman et al., 2006). however, generally, this research has either broadly examined ptsd (e.g., dichotomous ptsd diagnosis or overall ptsd severity; ruglass et al., 2017; salgado et al., 2007), categorized “other substances” with varying neurological effect (e.g., cocaine, heroin) into a generic polysubstance use variable (ullman et al., 2006), and/or did not account for other forms of concurrent or simultaneous substance use in their modeling (e.g., excluding participants currently using other substances). while general associations between (a) ptsd and (b) singlesubstance use and/or unspecified polysubstance use may be useful for laying an empirical foundation to build upon in future work, research examining specific ptsd symptoms (i.e., at the clusterand individuallevel) and differences between singular substance users and specified polysubstance users is a key “first step” to understanding the complexities of ptsd(poly)substance interplay needed to inform effective prevention and intervention efforts. cannabis, a publication of the research society on marijuana 41 current study the current study purports to extend the literature by examining differences in ptsd symptom profiles (i.e., intrusion, avoidance, negative cognitions, hyperarousal) between individuals using one or both of the most commonly used and co-administered psychoactive substances in the united states – alcohol and marijuana (grant et al, 2015; hasin et al., 2015). more specifically, the current study will examine ptsd symptom profiles between individuals that are currently only using alcohol and individuals that are currently only using alcohol and marijuana (i.e., excluding individuals that are currently abstaining or currently using other substances). given extant work examining ptsdalcohol use (jacobson et al., 2001; lehavot, stappenbeck, luterek, kaysen, & simpson, 2014; walton et al., 2018) and ptsd-marijuana use in isolation (turna, patterson, & ameringen, 2017; roitman, mechoulam, cooper-kazaz, & shalev, 2014) – both denoting strong associations between both ptsd negative cognitions and hyperarousal symptom and substance use – it was hypothesized that individuals who reported using both alcohol and marijuana in the past month would be more likely to (1) endorse ptsd negative cognition and hyperarousal symptoms at a clinical level and (2) report greater severity of ptsd negative cognition and hyperarousal symptoms than individuals who only reported using alcohol in the past month. conversely, given mixed – largely null – results in the literature (see debell et al., 2014; yarnell, 2015 for overviews), it was hypothesized that there would be no differences between the alcohol only and alcohol and marijuana groups on ptsd intrusion and avoidance symptoms. method participants and procedure the final sample comprised 533 undergraduate students (mage = 21.15, sd = 3.17, range = 18-58; 77.90% female) taken from a larger study (n = 1,658) on psychological well-being and substance use. data were collected from november 2016 through february 2018 at a large university in the state of texas, in which marijuana use is illegal for medical and recreational purposes (with the exception of lowtetrahydrocannabinol [thc] cannabidiol for patients with intractable epilepsy). participants were included in the final sample if they met the following eligibility criteria: (1) above the age of 18, (2) experienced at least one diagnostic and statistical manual of mental disorders – 5th edition (dsm-5) defined ptsd criterion a traumatic event (apa, 2013) as measured by the life events checklist for dsm-5 (lec-5; weathers et al., 2013a); (3) endorsed experiencing at least one ptsd symptom at any severity in the past month (i.e., not asymptomatic); (4) had consumed alcohol at least once in the past month; (5) had not consumed any other illicit substance(s) aside from marijuana in the past month; and (6) were able to provide informed consent for participation in the study. eligible participants completed a general assessment battery of psychological well-being and substance use through qualtrics – an online data management software that complies with hipaa regulations. all procedures were approved by the institutional review board at [omitted for blind review]. participants that met eligibility criteria were divided into two groups based on whether they reported (1) only using alcohol in the past month (n = 334) or (2) using both alcohol and marijuana in the past month (n = 199). comparative analyses indicated that the two groups did not differ in terms of biological sex or race/ethnicity. however, the alcohol and marijuana group (mage = 20.46) was statistically significantly younger than the alcohol-only group (mage = 21.56). see table 1 for full descriptives of the overall sample and substance use groups, as well as detailed results of the comparative analyses. measures trauma exposure. the life events checklist for dsm-5 (lec-5; weathers et al., 2013a) was administered to establish the presence of a dsm5 criteria a traumatic event (apa, 2013). the lec-5 demonstrates adequate to good psychometric properties in comparison to other established, self-report measures of trauma history (gray, litz, hsu, & lombardo, 2004). the lec-5 consists of 16 specified potentially traumatic events (e.g., life-threatening illness or injury, transportation accidents), as well as one unspecified traumatic event. response options include “happened to me,” “witnessed it,” polysubstance use and ptsd profiles 42 table 1. descriptives for overall sample and descriptive comparison between alcoholonly and alcohol/marijuana groups variables overall sample (n = 533) alcohol only (n = 334) alcohol and marijuana (n = 199) test statistics χ2 t age 21.15 ± 3.17 21.56 ± 3.42 20.46 ± 2.56 3.91** biological sex 0.05 female 415 (77.9%) 259 (77.5%) 156 (78.4%) male 118 (22.1%) 75 (22.5%) 43 (21.6%) racea 10.14 asian 34 (6.4%) 29 (8.7%) 5 (2.5%) african-american 73 (13.7%) 44 (13.2%) 29 (14.6%) white/caucasian 246 (46.2%) 156 (46.7%) 90 (45.2%) latino/hispanic 96 (18.0%) 53 (15.9%) 43 (21.6%) multiracial 70 (13.1%) 42 (12.6%) 28 (14.1%) other 14 (2.7%) 10 (3.0%) 4 (2.0%) note. agiven small sample size, “other” was excluded from comparative analysis; **p < .01 “learned about it,” “part of my job,” “not sure,” and “doesn’t apply.” only participants who endorsed “happened to me” for at least one of the 16 specified traumatic events were included in the current study. this conservative approach to defining traumatic event exposure has been used extensively in other trauma research (e.g., paulus et al., 2016; thornley et al., 2016). ptsd symptom endorsement and severity. the ptsd checklist for dsm-5 (pcl-5; weathers et al., 2013b) is a 20-item self-report measure that was used to assess ptsd symptom endorsement and severity. participants are asked to recall their most stressful event from the lec-5 and indicated how much they were bothered by specific symptoms in the past month. items 1-5 on the pcl-5 correspond with the intrusion symptom cluster (e.g., “repeated, disturbing dreams of the stressful experience?”); items 6-7 with the avoidance symptom cluster (e.g., “avoiding memories, thoughts, or feelings related to the stressful experience?”); items 8-14 with the negative cognition symptom cluster (e.g., “loss of interest in activities that you used to enjoy?”); and items 15-20 with the hyperarousal symptom cluster (e.g., “feeling jumpy or easily startled?”). responses range from 0 (“not at all”) to 4 (“extremely”). the pcl-5 is a psychometricallysound measure (blevins et al., 2015) and evidenced good reliability on each of the ptsd symptom cluster subscales (cronbach’s αs = .89 to .92). ptsd subscale scores were calculated by summing responses for each symptom cluster, with higher scores indicating more severe ptsd symptoms. ptsd symptom endorsement was defined as a participant reporting 2 (“moderately”) or greater severity on a given symptom (weathers et al., 2013b). in accordance with the dsm-5, to meet criteria for a particular symptom cluster, participants needed to endorse one symptom from the intrusion cluster (criteria b), one symptom from the avoidance cluster (criterion c), two symptoms from the negative cognition cluster (criterion d), and two symptoms from the hyperarousal cluster (criterion e), respectively (apa., 2013). substance use. past-month alcohol and marijuana use were assessed via single-item, facevalid questions. more specifically, for alcohol use, participants were asked, “in the past month, how many times have you used alcohol?”; for marijuana use, participants were asked, “in the past month, how many times have you used cannabis/marijuana?” responses on both questions ranged from “0 occasions” to “20 or more occasions”. participants reporting at least “1-2 occasions” of consuming alcohol met eligibility cannabis, a publication of the research society on marijuana 43 criteria for the overall sample. among eligible participants, those reporting at least “1-2 occasions” for marijuana use were included in the alcohol and marijuana group. data analytic plan independent-samples t-tests and chi-squared test, as appropriate, were used to evaluate differences between the alcohol-only group and alcohol and marijuana group on sociodemographic characteristics (i.e., age, biological sex, race/ethnicity). significant sociodemographic variables (p < .05 level) were included in the subsequent analyses as covariates. given the influence of time since trauma on posttraumatic symptom severity (jovanovic et al., 2013; weems & carrion, 2007), analyses also controlled for time since trauma. for the primary analyses, profile analysis (see kelly et al., 2009; tabachnick & fidell, 2007) was used to evaluate level effects (i.e., mean differences) and parallelism (i.e., the extent to which groups evidence the same pattern or “shape” of symptoms) between the groups on the four ptsd symptoms clusters. more specifically, the two groups were compared on the elevation and shape of their profile on the four ptsd symptom cluster severity scores (intrusion, avoidance, negative cognitions, hyperarousal) with a 2 (group) x 4 (cluster) multivariate analysis of variance (manova). symptom-level profile analyses then compared groups at the symptom level within each of the four ptsd symptom clusters using 2 (group) x 5 (intrusion); 2 (group) x 2 (avoidance); 2 (group) x 7 (negative cognition); and 2 (group) x 6 (hyperarousal) manovas. for secondary analyses, individual symptom level differences were examined using (1) univariate analyses of variance (anova) for symptom severity and (2) binary logistic regression for odds of ptsd symptom endorsement between the alcohol-only and alcohol and marijuana groups. for all analyses, p-values were interpreted for significance; eta-squared coefficients (η2) and adjusted odd ratios (or) were interpreted for effect size. missing data were minimal (i.e. < 2% on any given pcl-5 item) and were missing completely at random (mcar; χ2 = 416.74, p =.704), therefore missing data were accounted for via listwise deletion in the analyses. results cluster level analyses results of the cluster level profile analysis indicated a statistically significant main effect for group (f[1,527]= 6.29, p = .012) and a statistically significant departure from parallelism (f[3, 1581] = 12.84, p < .001). examination of group means indicated that individuals in the alcohol and marijuana group (m = 24.91) reported greater overall ptsd symptom severity than individuals in the alcohol-only group (m = 21.08). however, the test of parallelism indicated that the ptsd symptom cluster profile for the alcohol and marijuana group was not coincident with the symptom cluster profile of the alcohol-only group, necessitating further evaluation at the symptomlevel. symptom level analyses symptom level profile analysis for the ptsd intrusion symptoms indicated no main effect of substance use group (f[1,527] = 0.18, p = .672) and that parallelism between the groups was tenable (f[4,2108] = 0.48, p = .749). similarly, the symptom level profile analysis for ptsd avoidance indicated no main effect (f[1,527] = 0.80, p = .372) or departure from parallelism (f[1,527] = 0.13, p = .715). generally, these findings suggest that the ptsd intrusion and avoidance symptom profiles for the alcohol-only group and the alcohol and marijuana group were similarly shaped and did not differ, in terms of symptom severity. alternatively, symptom level profile analysis for ptsd negative cognitions symptoms indicated a significant main effect (f[1,527] = 11.49, p = .001) between groups and that parallelism was tenable (f[6,3162] = 1.73, p = .109). examination of group means showed that the alcohol and marijuana group (m = 8.87) reported greater ptsd negative cognitions severity than the alcohol-only group (m = 6.78). follow-up univariate analyses showed users of both alcohol and marijuana reported significantly greater severity of traumatic event amnesia (n1 in table 2), negative beliefs about oneself or the world (n2), negative trauma-related emotions (e.g., guilt; n4), post-trauma anhedonia (n5), feeling isolated (n6), and negative affect (n7) symptoms polysubstance use and ptsd profiles 44 table 2. symptom-level univariate analyses for ptsd symptoms by alcohol only vs. alcohol and marijuana groups ptsd symptom severity ptsd symptom endorsementa alcohol only alcohol and marijuana test statistics alcohol only alcohol and marijuana test statistics id ptsd symptoms m sd m sd p η2 % % or 95% ci i intrusion 5.79 4.81 5.92 4.90 .672 <.001 58.1 62.8 1.18 0.81 – 1.70 i1 unwanted memories 1.30 1.12 1.35 1.17 .559 .001 36.2 37.7 1.06 0.73 – 1.54 i2 disturbing dreams 0.81 1.14 0.88 1.16 .470 .001 22.5 24.6 1.08 0.71 – 1.62 i3 flashback 0.92 1.13 0.92 1.19 .903 <.001 25.7 27.1 1.05 0.70 – 1.57 i4 distress by reminder 1.68 1.29 1.65 1.26 .741 <.001 48.5 49.2 1.05 0.74 – 1.51 i5 physiological reactivity 1.08 1.25 1.12 1.27 .503 .001 31.4 33.7 1.13 0.77 – 1.65 a avoidance 3.13 2.64 3.31 2.63 .972 .002 50.9 56.3 1.24 0.87 – 1.78 a1 avoidance of thoughts 1.67 1.36 1.79 1.39 .331 .002 47.3 47.7 1.23 0.86 – 1.76 a2 avoidance of people/places 1.46 1.42 1.52 1.38 .466 .001 42.2 44.2 1.11 0.78 – 1.60 n negative cognitions 6.78 7.05 8.87 7.70 .001 .021 39.8 54.8 1.85** 1.29 – 2.66 n1 traumatic event amnesia 0.80 1.20 1.06 1.34 .025 .009 23.1 29.6 1.42 0.95 – 2.12 n2 negative beliefs 1.12 1.35 1.44 1.42 .016 .011 31.4 44.2 1.69** 1.17 – 2.45 n3 blame 1.21 1.37 1.38 1.43 .076 .006 34.7 39.7 1.27 0.88 – 1.84 n4 negative feelings 1.24 1.31 1.48 1.38 .044 .008 37.1 40.7 1.18 0.82 – 1.70 n5 loss of interest 0.70 1.16 0.96 1.29 .004 .016 19.5 27.1 1.63* 1.07 – 2.49 n6 feeling disconnected 0.91 1.24 1.40 1.42 <.001 .034 25.7 39.7 2.00** 1.36 – 2.94 n7 negative affect 0.79 1.19 1.14 1.36 .001 .022 22.5 33.2 1.78** 1.19 – 2.66 h hyperarousal 5.38 5.69 6.80 6.13 .003 .017 38.3 46.2 1.43 0.99 – 2.06 h1 irritable or aggressive 0.70 1.11 1.05 1.35 <.001 .024 19.8 31.2 2.02** 1.34 – 3.06 h2 risk taking 0.43 0.94 0.66 1.05 .008 .013 12.3 20.6 1.88* 1.16 – 3.04 h3 hypervigilant 1.20 1.35 1.41 1.39 .058 .007 36.2 40.7 1.25 0.86 – 1.80 h4 startle response 0.87 1.21 1.01 1.25 .203 .003 25.1 24.6 0.97 0.64 – 1.46 h5 concentration problems 1.02 1.27 1.25 1.37 .015 .011 30.2 36.2 1.36 0.93 – 1.99 h6 sleep problems 1.15 1.38 1.43 1.45 .015 .011 34.7 42.2 1.47* 1.02 – 2.13 t total 21.08 18.27 24.91 19.47 .012 .012 28.1 36.2 1.48* 1.01 – 2.17 note. all analyses are adjusted for time since trauma and age. odds ratios for intrusion, avoidance, negative cognition, hyperarousal, and total represent odds of meeting criteria for each symptom cluster and for the provisional diagnosis of ptsd. asymptom endorsement defined as participant reporting 2 (“moderately”) or greater symptom severity on a given symptom on the ptsd checklist for dsm-5 (pcl-5; weathers et al., 2013b). *p < .05 **p < .01 cannabis, a publication of the research society on marijuana 45 than alcohol-only users (all p <.05, η2: .01-.03). follow-up logistic regression analyses indicated that users of both alcohol and marijuana were at significantly greater odds of endorsing negative beliefs about oneself or the world, anhedonia, feeling isolated, and negative affect symptoms than alcohol-only users (all p <.05, or: 1.63-2.00). symptom level profile analysis for ptsd hyperarousal symptoms also indicated a significant main effect (f[1,527] = 9.21, p = .003) and parallelism (f[5,2635] = 1.18, p = .315) between groups. examination of group means showed that the alcohol and marijuana group (m = 6.80) reported more ptsd hyperarousal symptom severity than the alcohol-only group (m = 5.38). follow-up univariate analyses showed users of both alcohol and marijuana reported significantly greater severity of irritability/aggression (h1 in table 2), risky or destructive behaviors (h2), difficulty concentrating (h5), and difficulty sleeping (h6) symptoms than alcohol-only users (all p <.05, η2: .01-.02). follow-up logistic regression analyses indicated that users of both alcohol and marijuana were at significant greater odds of endorsing irritability/aggression, risky or destructive behaviors, and sleep difficulties symptoms than alcohol-only users (all p <.05, or: 1.47-2.02). full cluster-level and symptom-level descriptives for ptsd symptom endorsement and ptsd symptom severity, as well as detailed results for the comparative analyses between the two substance use groups, can be seen in table 2. symptom-level ptsd severity profiles for the two substance use groups can be seen in figure 1. differences in ptsd symptom endorsement and severity between the two substance use groups can be seen in figure 2. discussion despite an extensive body of work linking ptsd and substance use (debell et al, 2014; jacobson et al., 2001), the focus in the literature on (a) singular, isolated substance use – while not accounting for simultaneous or concurrent use of other substances – and/or (b) unspecified polysubstance use may not provide the specificity of information necessary to meaningfully advance our understanding of ptsd-(poly)substance use etiology and interplay. this concern may be particularly important given the high prevalence of polysubstance use among individuals exposed to trauma and those evidencing substance userelated problematic behaviors that are linked with ptsd (morley et al., 2015; subbaraman & kerr, 2015). the current study is the first, to the author’s knowledge, to examine differences in ptsd symptom profiles (at both the clusterand symptom-level) between current alcohol-only and current alcohol and marijuana users, while controlling for other forms of current illicit substance use. consistent with the first hypothesis, individuals currently using marijuana, in addition to alcohol, were at significantly greater odds of both endorsing ptsd negative cognition and hyperarousal symptoms and reported greater severity of ptsd negative cognition and hyperarousal symptoms. in fact, as can be seen in table 2 and figure 2, approximately 15.0% more participants in the alcohol and marijuana group met provisional diagnostic criteria for ptsd criterion d (negative cognitions; two or more symptoms in the cluster) and 7.9% more participants in the alcohol and marijuana group met provisional diagnostic criteria for ptsd criterion e (hyperarousal; two or more symptoms); further, participants in the alcohol and marijuana group evidenced 30.8% greater overall negative cognition symptom severity and 26.4% greater overall hyperarousal symptom severity compared to participants in the alcoholonly group. these results are generally consistent with extant work from separate literatures indicating strong associations between ptsd negative cognition and hyperarousal symptom and both alcohol (e.g., jacobson et al., 2001; lehavot et al., 2014; walton et al., 2018) and marijuana use (e.g., turna et al., 2017; roitman et al., 2014). consistent with the second hypothesis, results also indicated that use of marijuana, in addition to alcohol, did not increase odds of ptsd intrusion or avoidance symptom endorsement, nor were there significant differences between the substance use groups regarding ptsd intrusion or avoidance symptom severity. although some work has found these links within contextually-specific trauma subpopulations (e.g., vietnam veterans, plane crash survivors; mcfall et al., 1992; stewart, mitchell, wright, & loba, 2004), these findings support a broader literature that has not consistently demonstrated associations between polysubstance use and ptsd profiles 46 figure 1. ptsd symptom profiles on the ptsd checklist for dsm-5 (plc-5; weather et al., 2013b) by substance use group note. i: intrusion symptoms; a: avoidance symptoms; n: negative cognition symptoms; h: hyperarousal symptoms. 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 i1 i2 i3 i4 i5 a1 a2 n1 n2 n3 n4 n5 n6 n7 h1 h2 h3 h4 h5 h6 p t s d s y m p to m s e v e ri ty ptsd symptoms ptsd symptom profile by substance use group alcohol-only alcohol and marijuana cannabis, a publication of the research society on marijuana 47 figure 2. percentage difference in ptsd symptom severity and ptsd symptom endorsement note. i: intrusion symptoms; a: avoidance symptoms; n: negative cognition symptoms; h: hyperarousal symptoms; t: total ptsd symptoms. all differences represent increases in ptsd symptom severity and endorsement in the alcohol and marijuana group over alcohol-only group. for clarity, negative values were excluded; the alcohol-only group reported 1.8% greater symptom severity on distress caused by reminders of the traumatic event (r4) and 0.5% more of the alcohol-only group endorsed startle response symptoms (h4) than the alcohol and marijuana group. 0% 10% 20% 30% 40% 50% 60% i i1 i2 i3 i4 i5 a a1 a2 n n1 n2 n3 n4 n5 n6 n7 h h1 h2 h3 h4 h5 h6 t % d if fe re n ce in p ts d s ym p to m se ve ri ty ptsd symptom(s) percentage difference in ptsd symptom severity 0% 5% 10% 15% 20% i i1 i2 i3 i4 i5 a a1 a2 n n1 n2 n3 n4 n5 n6 n7 h h1 h2 h3 h4 h5 h6 t% d if fe re n ce in p ts d s ym p to m en d o rs em en t ptsd symptom(s) percentage difference in ptsd symptom endorsement polysubstance use and ptsd profiles 48 ptsd intrusion and avoidance symptoms and substance use outcomes in non-clinical, traumaexposed populations (see debell et al., 2014; yarnell, 2015 for overviews). although individual symptoms are broadly categorized into four clusters in the dsm-5, many of the symptoms within the negative cognition and hyperarousal symptoms clusters are notably distinct – as such, evaluation of at the symptomlevel is needed to better understand which specific symptom(s) are most strongly influencing observed differences between the substance use groups. results from the current study at the symptom-level suggest that mood-related negative cognition symptoms (e.g., loss of interest, negative affect) and externalizing hyperarousal symptoms (e.g., aggression, reckless or destructive behaviors) are the primary catalysts driving differences in ptsd symptom severity between the alcohol-only and alcohol and marijuana users. although no work has directly evaluated these specific ptsd-related symptoms and polysubstance use, these findings are generally consistent with broader research findings indicating positive associations between polysubstance use and both externalizing behavior (e.g., aggression and impulsivity; martinotti et al., 2009) and internalizing depressive symptoms (maslowsky, schulenberg, o'malley, & kloska, 2014; trudeau, spoth, randall, & azevedo, 2007). although replication and extension are needed, findings from the current study have at least three important implications for ptsdsubstance use modeling, prevention, and intervention. first and foremost, these results highlight important differences in ptsd symptom endorsement and ptsd symptom severity between individuals that are often lumped or grouped together into homogenous categories of isolated substance users (e.g., “past-month alcohol use” participants). this problem may be exacerbated in research attempting to isolate nonalcohol, singular substance use populations (e.g., marijuana users, cocaine users). for example, only 3.4% of trauma-exposed participants in our larger sample (n = 1,029) reported only using marijuana in the past month (i.e., no alcohol or other substance use), meaning that any evaluation of “past-month marijuana use” participants would actually be overwhelmingly comprised of alcohol-marijuana polysubstance users. given this confounding limitation, future work targeting ptsd-substance use comorbidity should, at a minimum, evaluate, acknowledge, and meaningfully control for other forms of current substance use. second, regarding theoretical implications, these collective findings provide preliminary support for an ‘additive’ self-medication model between ptsd and polysubstance use. more specifically, individuals may use multiple substances (i.e., alcohol and marijuana) with similar neurological effects (e.g., anxiolytics) to cope with more severe, specific types of ptsd symptoms. for example, an individual may use alcohol as a means of coping (e.g., dampening) with worsened irritability following their trauma; however, if that irritability is more severe and persists – despite minimal, temporary relief from alcohol use – they may incorporate simultaneous or concurrent use of another anxiolytic substance (e.g., marijuana) in a maladaptive attempt to fully ameliorate those feelings of irritability. as such, specific forms of polysubstance use among individuals exposed to trauma may serve as risk markers indicating greater severity of specific ptsd symptoms – an important, empiricallysupported consideration that may inform future prevention-oriented research and implementation efforts. last, findings from the current study may inform existing and developing interventions for individuals evidencing comorbid ptsd-substance use– important given that polysubstance use has been problematic for both substance use (dutra, et al., 2008) and comorbid ptsd-substance use treatment outcomes (donovan, padin-rivera, & kowaliw, 2001; mcfarlane, 2001). for example, symptom-level results from the current study indicate that mood-related negative cognition symptoms and externalizing hyperarousal symptoms may serve as important intervention targets for individuals reporting ptsd symptoms and alcohol/marijuana polysubstance use. although more research is needed to understand associations between ptsd symptomatology and other specified combinations of polysubstance use, these findings may also reinforce the importance of utilizing specialized, integrated treatments for comorbid ptsd-substance use – interventions that target transdiagnostic mechanisms underlying multiple types of (poly)substance use (e.g., developing adaptive coping skills in seeking cannabis, a publication of the research society on marijuana 49 safety; najavits, 2002; najavits, 2004), as opposed to concurrent or sequential treatments that target problematic use of a specific substance (e.g., disulfiram; alcoholics anonymous; humphreys, blodgett, & wagner, 2014.; jørgensen, pedersen, & tønnesen, 2011). limitations and future directions results should be interpreted while considering several limitations. first, the crosssectional nature of the data did not allow for evaluation of the directionality of the findings. indeed, our results could alternatively suggest that use of multiple substances with similar neurological effects exacerbate the severity of specific ptsd symptoms – more strongly implicating a mutual maintenance model of comorbid interplay. short-term, prospective (e.g., daily diary) and longitudinal designs are needed to evaluate the temporal sequencing of ptsd and alcohol-marijuana polysubstance use. second, findings in the current study may be limited by response bias (e.g., recall bias) inherent in selfreport of trauma exposure, ptsd symptom severity, and substance use. future work should consider use of established timeline follow-back procedures (tlfb; robinson, sobell, sobell, & leo, 2014; sobell & sobell, 1992) for more accurate evaluation of (poly)substance use history, structured clinical interviews for evaluation of trauma exposure and ptsd symptoms (e.g., caps; weathers et al., 2013c), and/or incorporating ecological momentary assessment (e.g., daily diary) designs. third, the sample in the current study was comprised entirely of undergraduate students. although this subpopulation may be ideal for preliminary evaluation of ptsd and substance use – given elevated rates of past-year trauma exposure (read, ouimette, white, colder, & farrow, 2011), prevalence of current ptsd (smyth, hockemeyer, heron, wonderlich, & pennebaker, 2008), and lifetime peaks for problematic substance use (johnston, o’malley, bachman, & schulenberg, 2011) – replication and extension are needed to evaluate if the current findings generalize to other developmentallyand contextually-distinct populations. further, although the current sample was relatively diverse, in terms of race/ethnicity, the majority of participants were female. given established gender and biological sex differences regarding ptsd (e.g., symptom severity, diagnosis rates; olff, langeland, draijer, & gersons, 2007), future work should also consider a stratified sampling approach to ensure relatively equal representation. last, the current study did not differentiate between concurrent and simultaneous alcohol-marijuana polysubstance use. given notable differences between these distinct forms of polysubstance use regarding alcohol-related problematic outcomes (e.g., drunk driving; subbaraman & kerr, 2015), incorporating more nuanced assessment of types of polysubstance use into future research is warranted. further, future work should consider evaluating potential differentiations in ptsd symptom profiles between other specified singular and polysubstance use groups (e.g., alcohol-only vs. alcohol and cocaine). despite these limitations, the current study meaningful extends the ptsd-(poly)substance use literature as the first study, to the authors knowledge, to examine differences in ptsd symptom profiles (i.e., severity and endorsement) at the individual symptom level between two specified substance use groups – current alcoholonly and current alcohol and marijuana users – while comprehensively controlling for other forms of current illicit substance use. although replication and extension with intensive prospective and/or longitudinal designs (e.g., daily diary) are needed in other contextuallyand developmentally-distinct populations, these findings (a) highlight the importance of evaluating and meaningfully controlling for other simultaneous and concurrent forms of substance use; 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(2015). the use of medicinal marijuana for posttraumatic stress disorder: a review of the current literature. the primary care companion for cns disorders, 17(3). funding: this research was not supported by any grant or funding body. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 19 abstract although marijuana use has been linked to negative consequences for intimate relationships, an emerging literature suggests that under some circumstances it may have positive consequences. couples who use substances together report better relationship functioning over time and may experience positive short-term outcomes. using a sample of 183 heterosexual, frequent marijuana-using couples from the community, reporting over 30 consecutive days, we examined whether marijuana use episodes were associated temporally with reports of couple intimacy experiences within the next two hours. we used multilevel modeling, within an actor partner interdependence model (apim) framework, modeling male and female outcomes simultaneously. consistent with hypotheses, simultaneous marijuana use (male and female partners reported use at the same hour) increased the likelihood of an intimate experience for both men and women. however, we also found positive effects for actor and partner solo marijuana use on male and female reports of intimacy events. when analyses were limited to marijuana use episodes in which the respondent reported on presence of partner, we found that positive effects on intimate experiences were limited to marijuana use episodes in which partner was present; use without partner did not influence likelihood of intimacy. the robust positive effects of using marijuana with one’s partner on intimacy events may serve to reinforce continued couple use and explain the positive effects of concordant substance use on relationship functioning over time. key words: cannabis, marijuana, relationship functioning, intimacy, daily diary although substance use within intimate couples has been linked to negative outcomes such as lower relationship satisfaction and elevated rates of aggression and divorce (cunradi, todd, & mair, 2015; marshal, 2003; yamaguchi & kandel, 1985), more recent perspectives consider that substance use may be a source of either pleasure or strain within relationships (rodriguez & derrick, 2017). an emerging literature suggests that concordant use of alcohol and other drugs has positive consequences for relationship functioning (homish & leonard, 2007; smith et al., 2014). for example, drinking together and similar amounts has been shown to increase short-term couple functioning (levitt & cooper, 2010) and long term satisfaction trajectories (homish & leonard, 2005). marijuana, the most commonly used illicit drug (pearson, liese, dvorak, & marijuana outcomes study team, 2017), may function similarly within couples. that is, shared or simultaneous use by intimate partners may contribute to positive couple interactions. however, very little is known about the immediate effects of marijuana use within couples. the present dyadic, daily report study considered the short term temporal effect of marijuana use episodes on subsequent experiences of partner intimacy over 30 days. cannabis 2019, volume 2 (1), 19-28 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.01.002 open access marijuana use episodes and partner intimacy experiences: a daily report study corresponding author: maria testa, research institute on addictions, state university of new york at buffalo, 1021 main street, buffalo, ny 14203, email: testa@ria.buffalo.edu, phone: (716) 887-2560 maria testa1, weijun wang1, jaye l. derrick2, kenneth e. leonard1 1 research institute on addictions, university at buffalo, buffalo, ny, usa 2 department of psychology, university of houston, houston, tx, usa marijuana and partner intimacy 20 compared to the large database of knowledge regarding the acute effects of alcohol intoxication, much less is known about the acute effects of marijuana or its consequences for behavior. marijuana users frequently report positive subjective consequences following use, including relaxation, happiness, and increased sexual pleasure (green, kavanagh, & young, 2003). studies involving controlled marijuana administration also suggest positive subjective effects, particularly among more experienced users (cooper & haney, 2014; hart et al., 2010; metrik, kahler, mcgeary, monti, & rohsenow, 2011; ramesh, haney, & cooper, 2013). it is plausible that these feelings of well-being contribute to subsequent positive experiences, which in turn, reinforce and perpetuate subsequent marijuana use (lee, derefinko, davis, milich, & lynam, 2017). although these effects have not been examined within couples, it is plausible that feelings of well-being after marijuana use lead the individual to experience – or perceive – intimacy with his or her partner. on the other hand, an emerging literature suggests that the impact of partner substance use within couples is more complicated. couple substance use may be a source of pleasure or strain within the relationship (rodriguez & derrick, 2017). an important determinant of its effects is whether the use is concordant or shared versus discrepant. for example, newlywed couples in which both partners used drugs (most commonly marijuana) reported higher relationship satisfaction at the time of marriage than couples in which only one partner used (homish, leonard, & cornelius, 2008). similarly, couples with smaller discrepancies in their alcohol and tobacco use experienced smaller declines in relationship satisfaction over time relative to couples with larger discrepancies (homish & leonard, 2007; homish, leonard, kozlowski, & cornelius, 2009). using longitudinal data from the present sample of marijuana using couples, we found a similar pattern using 4 time points, over 10 months. that is, at time points when the discrepancy in partner marijuana use frequency was greater than typical for the couple, relationship functioning was poorer (testa, wang, derrick, & leonard, 2018). corroborating these findings, crane, testa, schlauch, and leonard (2016) found that couples who were discrepant marijuana users (one partner used, the other did not) displayed more negative behavior in a conflict resolution paradigm than concordant users, even though they were not under the influence at the time. these studies suggest that concordant substance use helps to maintain relationship satisfaction, perhaps reflecting shared activities and values or shared positive experiences associated with substance use. the studies reviewed above considered global relationship functioning associated with concordant versus discrepant substance use over time, and not immediate couple consequences. there is some evidence that drinking together, as opposed to apart, has positive consequences for short-term couple outcomes. in a sample of college student couples, levitt and cooper (2010) found that drinking with the partner had positive effects on next-day relationship functioning (e.g., feelings of closeness with one’s partner) compared with drinking apart from one’s partner or not drinking. similar findings were observed in a sample of community couples: next day couple functioning was better following a day of drinking with partner compared with a day involving drinking apart from partner (levitt, derrick, & testa, 2014). it is plausible that using substances together leads to positive immediate consequences, such as shared emotional or sexual intimacy. in two daily report studies, sex was more likely to occur on days of marijuana use compared to days of no use (fortenberry et al., 2005; kerr, washburn, morris, lewis, & tiberio, 2015). however, these studies involved individuals, without consideration of partner marijuana use, thus it is unknown whether both partners used marijuana prior to sex. to date, no published studies have considered whether couple marijuana use, shared or independent, leads in the short-term to increased partner intimacy. the present study the present study was designed to consider whether episodes of marijuana use, reported independently by male and female intimate partners, increase the short term likelihood of reporting an experience of partner intimacy. the sample consisted of heterosexual couples in which at least one partner used marijuana at least twice weekly. to the best of our knowledge, no prior study has considered this research question, thus we took an exploratory approach. because several cannabis, a publication of the research society on marijuana 21 studies suggest that concordant or simultaneous substance use has different consequences than discrepant use or use without the partner, we considered the impact of these marijuana use events separately. drawing on prior literature (levitt & cooper, 2010), we hypothesized that simultaneous marijuana use by both partners would increase the likelihood that men and women would report experiencing intimacy in the next two hours compared with no marijuana use. the 2-hour window was chosen based on pharmacological studies suggesting that thc effects peak about 30 minutes after use and taper off after 2-3 hours (grotenhermen, 2003). similarly, we hypothesized that using marijuana in the presence, but not in the absence of one’s partner, would increase the likelihood of subsequent intimacy experiences. we separately considered whether episodes of marijuana use by only one partner (not both) influence intimacy experiences but offered no hypothesis. levitt and cooper (2010) found that relationship intimacy increased the day after a couple drank together but found no advantage or disadvantage for drinking apart from partner compared with not drinking. on the other hand, greater discrepancies in substance use between partners have been associated with poorer couple functioning over time (homish & leonard, 2007), suggesting that use by one partner and not the other may inhibit the occurrence of intimacy. it is also plausible that feelings of well-being following marijuana use contribute to increased experiences of intimacy with one’s partner regardless of whether the partner is using. use of the actor partner interdependence model (apim, kashy & snyder, 1995; kenny, kashy, & cook, 2006) allowed us to model the effects of one’s own marijuana use on one’s own reports of an intimate experience (actor effects) as well as the effects of partner’s use on one’s own report (partner effects). method sample and recruitment participants included 183 married or cohabiting heterosexual couples in which at least one partner used marijuana at least twice per week. this minimum frequency was chosen to provide sufficient episodes of marijuana use to permit consideration of its temporal effects, within person, over 30 days. men averaged 25.16 (sd = 3.07) and women 24.06 (sd = 3.09) years of age. most couples were cohabiting (84.2%) rather than married (15.8%), with average length of marriage or cohabitation of 2.50 years (range = 0.17-10.25, sd = 2.19). most had completed at least some college (70.5% of men, 79.3% of women, 24.0% currently enrolled) and were employed full or part-time (84.2% of men and 81.4% of women). most self-identified as european-american (78.1%), african-american (9.3%), or mixed race (6.6%). in the majority of couples (127/183, 69.4%) both partners reported using marijuana at least twice weekly. couples were recruited from a medium-sized metropolitan area in the northeast primarily via facebook ads (146/183, 79.8%) or print ads in local free arts newspapers (22/183, 12.0%) seeking couples who use marijuana; the rest were referred (15/183, 8.2%). all couples were screened for eligibility by telephone. to be eligible, both partners were required to be between 18 and 30 years old, married or cohabiting for at least 6 months, and at least one partner had to use marijuana at least twice weekly with no intention to quit or seek treatment. couples were excluded if either partner reported receiving psychiatric treatment, use of cocaine or stimulants, or pregnancy. couples were also excluded if either reported experiencing intimate partner violence that caused fear for one’s life or required medical care; they were provided referral information. procedures before beginning the 30-day reporting period, eligible couples completed a 90-minute in-person orientation. after study procedures were described to the couple, partners were escorted to private interview rooms to provide informed consent and complete computerized baseline questionnaires. couples were then reunited for instruction on how to make independent, confidential reports on a secure web-based portal via smartphone. most used phones provided for use during the study (277/366, 76.8%), the rest used their own phones. couples were instructed to initiate a marijuana report every time they were about to use marijuana and again when they finished. similarly, they were to initiate conflict reports whenever they perceived a conflict or felt angry, irritated, or annoyed by the partner even if marijuana and partner intimacy 22 no argument occurred; conflict was not examined in the present analysis. participants were instructed to make a daily report each morning and study compensation was based on completion of this report. text messages were sent at 7:00 am and 12:00 pm each day reminding them to complete their daily report by 3:00 pm when the portal closed for the day. whenever possible, staff contacted participants who failed to report by 3:00 pm to address any reporting problems and complete the daily report by telephone. participants were sent weekly texts thanking them for participation and reminding them of monetary bonuses they had earned ($1 per daily report, $10 weekly bonus for completing at least 6/7 morning reports, $30 for completing 4 weeks of reports, maximum of $100). all study procedures were approved by the university institutional review board. compliance with daily reports was excellent. of a possible 10,980 daily reports (30 days x 183 couples), men reported on 5,133/5,490 days (93.5%, m = 28.05 days, sd = 4.36) and women on 5,253/5,490 days (95.7%, m = 28.70 days, sd = 3.09). of these reports, 9,313/10,386 (89.7%) were made on time. measures marijuana. marijuana episodes were reported in two ways. first, participants were asked to make reports in real-time using a time-stamped, event-triggered report (up to 4 reports per day were permitted). however, to avoid missing any episodes of marijuana use, morning reports included assessment of whether at any time yesterday the respondent had used marijuana. if so, he or she was asked the time of use and whether that episode had already been reported. for marijuana episodes not already reported, an abbreviated set of follow-up questions was asked. all marijuana episode reports included the time of use and were included in temporal analyses, including 1,560 on-time reports and 6,075 next day reports. because we were interested in the effects of simultaneous use by both partners separate from the effects of use by one partner, we created three separate dichotomous marijuana variables to represent use in a given hour on a given day. when both partners independently reported a marijuana episode that occurred at the same hour, we considered that to represent an episode of simultaneous couple use. marijuana episodes reported by one partner only, with no corresponding report of use by the other partner at the same hour, were considered as actoror partner-only marijuana use episodes. at hours when no actor, partner, or simultaneous marijuana use was reported, use was coded as 0. intimacy events. intimacy experiences, the key dependent variable, were assessed on each morning report with the following question: “at any time yesterday, did you have an interaction or meaningful conversation with your partner that involved intimacy, love, caring, or support?” (0 = no; 1 = yes). for each reported intimate experience, participants indicated the time it occurred, allowing us to determine the temporal ordering of marijuana use episodes and intimate experiences reported on the previous day. analytic strategy we examined whether the likelihood of reporting an episode of intimacy is a function of marijuana use in the previous 2 hours. we used multivariate multilevel modeling with three levels and random intercepts using bayesian analysis within mplus version 7.4 (gelman, carlin, stern, & rubin, 2014; muthén & muthén, 2015; muthén, muthén, & asparouhov, 2016). our unique, dyadic sample allowed us to use the actor partner interdependence model (apim, kashy & snyder, 1995; kenny et al., 2006) to account for the effects of each person’s own marijuana use on his or her report of an intimate experience (actor paths) as well as the effects of each person’s use on the partner’s report of intimacy (partner paths). at level 1 (the hourly level), we entered as predictors: 1) simultaneous (actor and partner) marijuana use in the past 2 hours, 2) actor-only marijuana use, and 3) partner-only marijuana use. male and female reports of intimacy events were modeled simultaneously. level-1 marijuana use variables were binary and uncentered. at level 1 we also included time of day (1 = 5 pm-midnight, 0 = all other hours) to control for unmeasured temporal effects (uncentered). at level 2 (the daily level), we entered day of the study (1-30), grand mean centered, to account for the tendency for daily reports to decline over time (e.g., testa, wang, derrick, & leonard, 2018). at level 3 (the couple cannabis, a publication of the research society on marijuana 23 table 1. intimate events as a function of actor, partner, and simultaneous marijuana use in the previous 2 hours variable male report intimate event female report intimate event estimate (s.d.) 95% ci estimate (s.d.) 95% ci simultaneous marijuana use1 0.321 (0.058)*** [0.206, 0.434] 0.279 (0.057)*** [0.166, 0.388] actor only marijuana use 0.251 (0.032)*** [0.187, 0.312] 0.212 (0.034)*** [0.144, 0.278] partner only marijuana use 0.222 (0.036)*** [0.151, 0.291] 0.176 (0.032)*** [0.113, 0.239] evening vs. earlier time2 0.551 (0.018)*** [0.515, 0.587] 0.521 (0.017)*** [0.488, 0.554] day of the study3 -0.009 (0.001)*** [-0.011, -0.007] -0.008 (0.001)*** [-0.010, -0.006] actor total marijuana use episodes -0.001 (0.001) [-0.003, 0.001] -0.001 (0.001) [-0.002, 0.001] partner total marijuana use episodes 0.000 (0.001) [-0.002, 0.002] -0.001 (0.001) [-0.002, 0.001] total simultaneous marijuana use episodes -0.002 (0.002) [-0.006, 0.002] 0.000 (0.002) [-0.004, 0.004] actor total intimate events 0.034 (0.002)*** [0.032, 0.037] 0.031 (0.001)*** [0.029, 0.034] partner total intimate events -0.001 (0.001) [-0.003, 0.002] -0.002 (0.001) [-0.004, 0.001] note. *** p < .001, ** p < .01, * p < .05. male and female outcomes were modeled simultaneously. 1both partners reported marijuana use at the same hour. 2time (0 = hour 1 to hour 16; 1 = hour 17 to hour 24). level), we controlled for total number of simultaneous and solo marijuana episodes over 30 days, allowing us to distinguish within-person effects of marijuana use from between-person effects. we also included total number of intimate experiences, to account for between-person differences in the tendency to report intimacy. level-3 variables were grand mean centered (enders & tofighi, 2007). results event reports intimacy events were reported 4,887 times by the 366 participants over 30 days of reports, with nearly all couples (98.9%) reporting at least one such event. intimacy experiences were more likely to be reported after 5 pm than before 5 pm, χ²(1, n = 9,294) = 143.700, p < .001. women reported significantly more intimacy experiences (2,598, mean = 14.40, range = 0–30, sd = 7.80) than men (mean = 12.89, range = 0–29, sd = 8.25), χ²(1, n = 10,301) = 23.728, p < .001. on 1,618 (29.5%) days, both partners reported an intimacy event, on 1,784 (32.5%) days, neither did, and on 2,088 (38.0%) days, one partner but not the other reported an intimacy event. a total of 7,529 marijuana use episodes were reported on 6,324 days by the 366 participants. men reported more marijuana episodes and days of marijuana use (4,017 events, mean = 18.46 marijuana use days, range = 0–30, sd = 9.45) than women (3,512 events, mean = 16.10 marijuana use days, range = 0-30, sd = 10.20), t(10,978) = 12.232, p < .001. there were 1,640 episodes of simultaneous couple marijuana use, that is, both male and female partner reported use at the same hour. in addition, there were 3,196 episodes of male only use, and 2,693 episodes of female only marijuana use (i.e., no corresponding marijuana use by the partner at the same hour). most couples (140/183, 76.5%) reported both solo and simultaneous marijuana use events. temporal effects of simultaneous and solo marijuana use episodes on intimacy events table 1 displays the effects of simultaneous and solo marijuana use on the occurrence of male and female intimacy events in the next 2 hours. consistent with our hypothesis, simultaneous marijuana use (use by both partners at the same hour) significantly increased the likelihood of intimacy reports by both men and women compared with no marijuana use. however, we also observed significant positive effects of actor and partner solo marijuana use on men’s and women’s experiences of intimacy. men and women were more likely to report an intimacy experience within 2 hours of using marijuana in the absence marijuana and partner intimacy 24 table 2. intimate events as a function of marijuana use in presence of partner, previous 2 hours variable male report intimate event female report intimate event estimate (s.d.) 95% ci estimate (s.d.) 95% ci actor marijuana use, partner present 0.302 (0.041)*** [0.221, 0.381] 0.190 (0.042)*** [0.106, 0.271] partner marijuana use, partner present 0.122 (0.045)** [0.033, 0.208] 0.113 (0.044)* [0.026, 0.197] actor marijuana use, partner not present -0.002 (0.077) [-0.157, 0.149] -0.064 (0.104) [-0.281, 0.128] partner marijuana use, partner not present -0.158 (0.119) [-0.400, 0.062] 0.020 (0.073) [-0.128, 0.158] evening vs. earlier time1 0.565 (0.018)*** [0.529, 0.601] 0.531 (0.017)*** [0.498, 0.564] day of the study (1 – 30) -0.009 (0.001)*** [-0.011, -0.007] -0.008 (0.001)*** [-0.010,-0.007] actor total marijuana use episodes with partner present 0.000 (0.001) [-0.003, 0.002] -0.001 (0.001) [-0.003, 0.002] partner total marijuana use episodes with partner present 0.000 (0.001) [-0.003, 0.002] 0.000 (0.001) [-0.003, 0.003] actor total marijuana use episodes, partner not present -0.003 (0.002) [-0.006, 0.001] -0.002 (0.003) [-0.007, 0.003] partner total marijuana use episodes, partner not present 0.000 (0.003) [-0.005, 0.006] 0.000 (0.001) [-0.003, 0.002] actor total intimate events 0.034 (0.001)*** [0.032, 0.037] 0.031 (0.002)*** [0.028, 0.034] partner total intimate events -0.001 (0.001) [-0.004, 0.002] -0.002 (0.001) [-0.004, 0.001] note. *** p < .001, ** p < .01, * p < .05. male and female outcomes were modeled simultaneously. 1time (0 = hour 1 to hour 16; 1 = hour 17 to hour 24). based on 4,870 marijuana use reports with data on partner presence versus absence at time of use. of use by partner (actor effect) compared to no marijuana use. they were also more likely to report an intimacy experience within 2 hours of the partner using marijuana in the absence of their own use (partner effect) compared to no use. results were obtained after accounting for the effects of time of day, since as expected, intimate events were more likely to occur in the evening. results also accounted for the positive level 3 effects of number of intimate events reported; individuals who reported more intimate events over the 30 days were more likely to report an event in a given hour. total episodes of simultaneous and solo marijuana use were not associated with the likelihood of reporting an intimacy event in a given hour. our classification of simultaneous marijuana use required that both partners report use at the same hour. small errors in recall of the hour would result in classification of a simultaneous episode as two solo episodes, potentially inflating the positive impact of the latter. to address this potential weakness, we classified an episode as simultaneous use if partners reported using at the same hour or +/1 hour (e.g., 6 pm and 7 pm would be classified as simultaneous). results using this broader classification were identical to those depicted in table 1; that is, we still found positive effects of simultaneous and of solo actor and partner marijuana use. we also repeated the analysis replacing the 2 hour window with 1 hour and 3 hour windows and found identical results. simultaneous and solo marijuana use increased the likelihood of intimacy experiences for men and women within 1, 2, and 3 hours of use. temporal effects of using marijuana in presence of partner vs. without partner as an alternative way of considering the impact of simultaneous versus solo marijuana use, we conducted a second analysis using individual’s reports of whether the partner was present at the time of his or her marijuana use. for 4,870/7,529 (64.7%) marijuana reports, we had responses to a question regarding whether one’s partner was present at the time of marijuana use. the majority of marijuana cannabis, a publication of the research society on marijuana 25 episodes took place when the partner was present and using marijuana (3,019/4,870, 62.0%) or present but not using (564/4,870, 11.6%). in a smaller number of marijuana events, use took place when the partner was not present (1,287/4,870, 26.4%). we used these reports to create two dichotomous variables: marijuana use in a given hour with partner present and marijuana use in a given hour with partner not present. hours with no marijuana use were coded 0. within the apim framework, we considered the impact of actor marijuana use, with and without presence of the partner, and the impact of partner marijuana use, with and without presence of the partner. results of this analysis, displayed in table 2, show positive actor and partner effects associated with using marijuana in the presence of the partner for both men and women. for example, laura is more likely to report an intimacy event within 2 hours of using marijuana in mike’s presence (an actor effect) than when she doesn’t use marijuana. laura is also more likely to report an intimacy event within 2 hours of mike reporting marijuana use in laura’s presence (a partner effect). however, marijuana use when the partner was not present neither increased nor decreased the likelihood of experiencing intimacy relative to no marijuana use. discussion using data from an intensive daily report study of frequent marijuana-using couples, we found evidence that marijuana use is associated with increased experiences of intimacy, love, caring or support with one’s intimate partner in the next two hours. we had hypothesized, consistent with prior studies of drinking together versus drinking apart (levitt & cooper, 2010; levitt et al., 2014) that using marijuana with one’s partner would be particularly likely to increase intimacy. using two different methods of analysis, we found robust support for the positive effects of using marijuana at the same time as or in the presence of one’s partner on subsequent experiences of intimacy. findings were identical for both male and female intimate partners. results replicate and extend prior findings, which have shown positive effects of partners drinking together (versus drinking apart) on couple functioning the next day (levitt et al., 2014) and over time (homish & leonard, 2005). our study revealed that positive effects of marijuana on intimacy were observable within 1, 2, and 3 hours of use. these intimacy experiences may be the mechanism that contributes to better couple functioning the next day and over time. we also found some evidence that marijuana use by either partner in the absence of use by the other also increased reports of intimacy in the next few hours. this effect may reflect feelings of well-being and relaxation following marijuana use (green et al., 2003), which contribute to the experience of intimacy with one’s partner. however, this was not simply an actor effect but rather a partner effect as well: men and women were more likely to report an intimacy experience within 2 hours of their partner (only) using marijuana, possibly reflecting the effects of the partner’s positive affect. the partner effects are particularly striking given that these involve independent reports from two individuals, and partner effects are typically weaker than actor effects (orth, 2013). it will be important to replicate these unique findings since it is possible that positive effects of solo use are inflated by our method of classification. that is, correct classification as an episode of simultaneous use requires independent reporting from both partners. if one partner fails to record such an episode or records the wrong hour, the use of the other partner will be incorrectly classified as solo use. on the other hand, when we analyzed data using individual’s reports of partner presence at the time of marijuana use, we failed to find an effect of using marijuana when partner was not present on subsequent intimacy. rather, using marijuana without partner present had no effect, positive or negative, on subsequent reports of intimacy, a pattern consistent with levitt and cooper (2010). although substance use by only one partner is thought to represent a potential source of stress and conflict for the non-using partner (rodriguez, neighbors, & knee, 2014), we found no evidence that use without partner had detrimental effects on intimacy. however, this sample consisted primarily of couples in which both partners use marijuana frequently and often together; these couples may not be troubled by occasional independent episodes of use. marijuana and partner intimacy 26 limitations dyadic, daily report data provide a rich and unique view of daily relationship events, permitting examination of the effects of both partners’ marijuana use on couple outcomes. nonetheless, there are potential limitations associated with these data. although compliance with daily reports was excellent, compliance with event-triggered marijuana reports was not. many marijuana reports were made retrospectively, the next morning. as a result, individuals may fail to report every instance of marijuana use or may misreport the time of use. to mitigate against some of these concerns, we considered the effects of marijuana use with partner using different methods and found very similar results, increasing confidence that the positive effects of marijuana use with partner are robust. intimacy was defined broadly – which may be viewed as a strength or a weakness – and we have no specific information as to what type of intimacy was involved. it will be important for future research to gather more detailed information about these experiences and distinguish between different types (e.g., sexual versus emotional intimacy). importantly, results were obtained using a sample of couples who were recruited because of their frequent but not problematic marijuana use and it is not known how well our findings would generalize to other samples. couples in which one partner but not the other is a heavy or problematic user may not experience the same positive effects of marijuana use and may experience negative effects associated with unreciprocated use. in addition, the sample was young, and primarily white, employed, and recruited through facebook; findings may not generalize to other samples of marijuana-using couples. conclusions and implications the two methods of analyses reveal robust positive effects of marijuana use with partner on subsequent intimacy experiences, with some evidence for positive effects of solo use as well. in earlier analyses using these data, we also found temporal effects of marijuana use on partner conflict within the next two hours, although these effects were modest (testa, wang, derrick, & leonard, 2018). although at first glance these results appear inconsistent, it is certainly plausible that couple marijuana use episodes may increase the odds of either positive or negative outcomes occurring depending on daily, situational factors. it is also possible that some couples are more likely to experience positive versus negative outcomes. because the positive effects of marijuana are particularly strong, they are probably more apparent to users than the more modest effects on partner conflict, reinforcing positive marijuana expectancies and encouraging use within the couple. these shortterm effects of concordant marijuana use on couple intimacy may help to explain the longerterm positive effects of concordant substance use on couple functioning that have been observed (homish & leonard, 2005; 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(1985). on the resolution of role incompatibility: a life event history analysis of family roles and marijuana use. american journal of sociology, 90(6), 1284-1325. doi:10.1086/228211 funding: this research was supported by grant r01da033994 from the national institute on drug abuse to maria testa. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i1a6_authors_v2 research article 59 ved abstract background. concurrent use of alcohol and marijuana (i.e., cam use) is the most common poly-drug use pattern among adolescents and young adults and is associated with negative outcomes. research indicates that prototype willingness model (pwm) drinking cognitions are associated with alcohol use. this secondary analysis was conducted to explore cross-sectional associations between pwm drinking cognitions, alcohol, marijuana, and cam use. methods. adolescents and young adults between 15-25 years (n = 124, mage = 18.7) completed a baseline assessment as part of a larger study, including questions on alcohol and marijuana use, and pwm drinking cognitions. results. in the social reaction pathway, descriptive norms, perceived vulnerability, and prototype favorability, but not willingness were associated with greater alcohol use, whereas in the reasoned pathway attitudes and intentions were associated with frequency of drinking whereas injunctive norms were not. both willingness and intention to drink were related to marijuana and cam use when controlling for alcohol use frequency. greater willingness to drink was the only significant predictor of marijuana use, and only descriptive norms predicted cam use. however, of the cognitions within the reasoned pathway, greater attitudes toward drinking and drinking intention were related to greater marijuana and cam use. results also indicated that cam users displayed higher levels of certain risk cognitions than non-users or single substance users. conclusions. findings support and extend the utility of the pwm by indicating that specific alcohol cognitions are associated with alcohol, marijuana, and cam use in adolescents and young adults. key words: = alcohol; marijuana; prototype willingness model, adolescents, young adults alcohol, marijuana and concurrent alcohol and marijuana use alcohol and marijuana are the most commonly used substances among adolescents (johnston et al., 2020) and young adults (schulenberg et al., 2020). while adolescent alcohol use has declined over the past decade (patrick et al., 2017), more than a third (35.9%) of 8th 12th graders still report ever drinking alcohol (johnston et al., 2020). ricarda k. pritschmann1,2,3, nioud mulugeta gebru1,2,3,4, dana m. litt5, zhengyang zhou6, & melissa a. lewis5 1university of florida, department of health education & behavior, gainesville fl 2university of florida center for addiction research and education, gainesville fl 3university of florida center for behavioral economic health research, gainesville fl 4university of florida clinical and translational science institute, gainesville fl 5university of north texas health science center, department of health behavior and health systems, school of public health, fort worth, tx 6university of north texas health science center, department of biostatistics and epidemiology, school of public health, fort worth, tx cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.006 are drinking cognitions associated with marijuana and concurrent alcohol and marijuana use among adolescents and young adults? corresponding author: ricarda k. pritschmann, university of florida, p.o. box 118210, gainesville, fl, 326118210. email: rpritschmann@ufl.edu alcohol cognitions and substance use 60 unlike alcohol use, marijuana use has increased in the past decade among adolescents (ages 15 – 18 years) and young adults (ages 18 – 29 years; johnston et al., 2020, schulenberg et al., 2020). indeed, in 2019, one if four (25.2%) of high school students reported using marijuana in the past year (schulenberg et al., 2020). the past decade has also seen decriminalization and legalization of medicinal and recreational marijuana use across the u.s. (hall & lynskey, 2016; yu et al., 2020), which have been associated increased risk of cannabis use disorder among adolescents, but not in young adults (cerdá et al., 2017). alcohol and marijuana use by adolescents and young adults are associated with several shortand long-term consequences including compromised short-term memory and motor coordination, increased likelihood of future dependence, poor educational outcomes, and low life satisfaction (arria et al., 2013; suerken et al., 2016; volkow et al., 2014). adolescents and young adults may use only alcohol, only marijuana, or use alcohol and marijuana concurrently. concurrent use of alcohol and marijuana (i.e., cam) refers to using marijuana and alcohol within the same period of time (e.g., past month, past year) with nonoverlapping effects (patrick et al., 2018). data from national surveys indicate that 1.7% and 7.7% of adolescents and young adults, respectively, report cam use (patrick et al., 2018; subbaraman & kerr, 2015). cam use is associated with exacerbated negative consequences and health risks compared to alcohol and marijuana use alone. for example, cam users report more problems, higher alcohol dependency and consequences, and higher sexual risk taking compared to alcohol only users (cummings, et al., 2019; saha et al., 2018; shillington & clapp, 2001; 2002). in addition, cam use is related to greater social problems (e.g., fights, and work or relationship problems) than alcohol-only use (subbaraman & kerr, 2015). lastly, substance use outcomes are worse for young adults who are diagnosed with both alcohol and marijuana use disorder (i.e., dual use disorder), and those with dual diagnoses also report greater drinking intensity (i.e., number of drinks consumed per binge episode) than those with a single use disorder (hayaki et al., 2016). thus, identifying risk factors for cam use among adolescents and young adults is of critical importance to improve interventions targeting cam (yurasek et al., 2017). the literature indicates that alcohol and drug use trajectories across adolescence and young adulthood are related (pape et al., 2009; schulenberg & maggs, 2002; wiesner & windle, 2004) such that individuals who use alcohol frequently are also more likely to also use other substances at high rates (barrett et al., 2006; derefinko et al., 2016). research suggests that adolescents and young adults are more likely to report being an exclusive user of alcohol or cam user compared to being an exclusive marijuana user (cohn et al., 2016; patrick et al., 2018). research further indicates that marijuana use likely has a substitutionary and complimentary relation with alcohol use (o’hara et al., 2016), but it is more likely that marijuana is used as a complement to alcohol among 14-20 year-olds (pape et al., 2009). thus, risk factors for alcohol use may be closely linked to risk factors of marijuana and cam use. given the high rates of marijuana and cam use in adolescents and young adults, it is important to identify risk factors, which can be then used in targeted interventions. the prototype willingness model one particularly suitable theoretical framework to identify risk factors for substance use among adolescents and young adults is the prototype willingness model (pwm; gerrard et. al, 2008). the pwm is a dual-process model that hypothesizes two pathways that can lead to substance use among adolescents and young adults: the reasoned pathway and the social reaction pathway. the reasoned pathway characterizes constructs that impact behavior that is planned or intended, whereas the social reaction pathway models situational influences on a behavior, for example processes during a riskconducive situation (e.g., at a party). cognitions in the reasoned pathway include perceived approval by others (i.e., injunctive norms), approval of behavior (i.e., attitudes) and intention or plans. cognitions in the social reaction pathway include perceived likelihood of negative consequences from engaging in a behavior (i.e., perceived vulnerability), perceived peer’s frequency of engaging in behaviors (i.e., descriptive norms), images of peers who engage in a behavior (i.e., prototype favorability), and willingness or openness to engage in a behavior should the opportunity be presented (i.e., behavioral cannabis, a publication of the research society on marijuana 61 willingness). of note, both pathways may operate simultaneously and although intentions and willingness are often highly correlated, they serve as independent predictors of health risk behavior (gerrard et al., 2008; litt et al., 2014; todd et al., 2014). in addition, research indicates that pwm risk cognitions are often established prior to an individual engaging in a behavior (ajzen 1985; fishbein & ajzen 1975; gerrard et al., 2008), thus, cognitions related to a specific behavior may indicate a predisposition to engage in that behavior. as such, there is utility in examining pwm cognitions among substance users and nonsubstance users alike. the pwm and substance use historically, the pwm has been most commonly applied to examining alcohol use and research indicates that endorsing riskier alcoholrelated cognitions has consistently been found to be significantly associated with greater alcohol use (andrews et al., 2008; gerrard et al., 2002; litt & lewis, 2016; pomery et al., 2009; rivis et al., 2006). while there is less literature examining pwm cognitions in relation to marijuana use, research indicates that willingness to use marijuana is prospectively related to higher frequency of use and more marijuana-related problems (lewis et al., 2018). greater marijuana injunctive norms (i.e., approval by friends and parents) are also prospectively related to higher frequency of marijuana use (napper et al., 2016). of note, one study (linden-carmichael et al., 2019) found that young adult sam users reported significantly higher descriptive alcohol norms compared to alcohol-only users, which supports the importance of examining the role alcohol-related factors in relation to other substance use. coupled with research that indicates that alcohol is often the first substance initiated among adolescents and young adults (king & chassin, 2007) and largely precedes marijuana and cam use (patrick et al., 2019), it is possible that alcoholrelated pwm cognitions are associated with engagement in both marijuana and cam use. although there are several efficacious and evidence based prevention and early intervention efforts for alcohol use (e.g., dimeff et al., 1999) that incorporate many constructs within the pwm, alcohol interventions to date have not been efficacious in also reducing marijuana use (white et al., 2015). however, it is possible that there are specific pwm risk cognitions related to alcohol use, that if targeted, may also reduce marijuana and cam use. thus, identifying key individual alcohol cognitions that could be targeted in alcohol prevention efforts that may also reduce marijuana use and cam use is an important next step. purpose this secondary analysis of baseline data from a sample of adolescents and young adults taking part in a larger study (lewis et al., 2020) was conducted to examine associations between alcohol, marijuana, and cam use with 1) drinking willingness and intention, 2) cognitions in the social reaction pathway (i.e. descriptive norms, perceived vulnerability, prototype favorability and willingness), and 3) cognitions in the reasoned pathway from the pwm (i.e. injunctive norms, attitudes and intention to drink). we hypothesized that pwm alcohol cognitions in both pathways would be associated with alcohol, marijuana, and cam use. all associations were expected to be positive with the exception of perceived vulnerability, which was expected to have a negative association to the outcomes. methods participants participants included adolescents and young adults aged 15-25 years old (n = 124) who were part of a larger study examining within-person variation of drinking cognitions and alcohol use. see lewis et al. (2020) for more information about full study design. participants completed an online screening assessment, a verification phone call, and in-person baseline assessment and ecological momentary assessment (ema) training session. participants were then assessed using an ema burst design. data for the present analyses are from baseline assessments. the sample was majority female (57.3%) with a mean age of 18.77 years (sd = 2.86). ethnic and racial representation of the sample was 59.7% white, 15.3% asian, 13.7% more than one race, 7.3% black, 7.3% hispanic/latino, and 4.0% other/mixed. the majority of participants were high school or college students and 13.7% were not a current student. those who were not a current alcohol cognitions and substance use 62 student were 20 years or older. of those who were current students (86.3%), 40.3% were in high school, 33.9% attended a 4-year college, 4.8% attended a 2-year college, 4.8% were attending pre-college courses in high school, 1.6% attended graduate or professional school, and 0.8% attended an alternative high school. procedures all study procedures were approved by the university’s institutional review board, and no adverse events were reported. recruitment for this study was conducted in the greater seattle metropolitan area through online recruitment, print advertisements, participant referrals, and flyers. interested individuals were asked to complete a brief, online screening survey to determine eligibility for the study. participants were eligible if they were aged between 15 and 25, and reported drinking alcohol at least once a month in the past six months if 18 or older. see lewis et al., 2020 for full eligibility criteria details). eligible participants were then stratified based on demographic characteristics (i.e., biological sex, age, and typical number of drinks per month) to ensure a diverse sample. within each age category (e.g., 15, 16, 17, etc.), individuals were stratified by biological sex and typical number of drinks per month (0 drinks per month, 1-5 drinks per month, 6+ drinks per month). after stratification, eligible participants completed a phone screen to verify certain information and to exclude individuals who may have provided false answers or were professional survey takers. those with continuing eligibility following the phone screen were invited to complete an in-person training session and baseline assessment (n = 142). of the 142 participants that were invited, 124 participants provided consent and completed the baseline survey and are included in the analyses. participants earned $50 for completing the inperson training session and baseline assessment from which current data are drawn. measures demographics. participants reported demographics, including age, biological sex (coded 0 = female and 1 = male), and student status (0 = not current student, 1 = current student). frequency of alcohol use. participants responded to one item (“on average, during the past 3 months, how often have you consumed alcohol?”) on a scale from 0 (never) to 11 (every day; collins et al., 1985). frequency of marijuana use. participants responded to an open-ended item that asked, “during the past 3 months, on how many days did you use any kind of marijuana or hashish?” participants entered a numerical response from 090 into an open-ended text-box. concurrent alcohol and marijuana use (i.e., cam use). participants were asked to describe their alcohol and marijuana consumption using the following scale: 0 (i have never tried alcohol/marijuana), 1 (i have tried alcohol/marijuana, but currently do not drink/use), 2 (i am a light drinker/user), 3 (i am a moderate drinker/user), 4 (i am a heavy drinker/user). using these variables, cam use was categorized into 2 (i.e., current cam use), 1 (i.e., single use of alcohol or marijuana), and 0 (i.e., no current use of either alcohol or marijuana). the no current use group included those who tried either substance in the past, but do not currently use or never tried either substance. the single use group included those who had tried either but are currently only using either alcohol or marijuana. perceived descriptive drinking norms. the drinking norms rating form (baer et al., 1991) was used to assess perceived peer drinking with the question, “consider a typical week during the last three months. how much alcohol, on average (measured in number of drinks), does a typical male/female your age drink on each day of a typical week?” gender used in the question was same as that of the respondent. total weekly drinks were summed for the final score. perceived vulnerability. perceived vulnerability was assessed with four items (adapted from gerrard et al., 2008) used to rate perceived risk based on levels of alcohol use to the following stem: “how much do you think drinking alcohol at the varying levels (having 1 or 2 drinks nearly every day, having 1 or 2 drinks nearly every weekend, having 3 or 4 drinks each weekend, having 5 or 6 drinks each weekend) might cause you risk?” responses were on a scale from 0 (no risk) to 3 (great risk) and the composite score was calculated (cronbach’s alpha = 0.83). prototype favorability. prototype favorability was assessed by asking the degree to which six words [i.e., smart, popular (“cool”), mature, cannabis, a publication of the research society on marijuana 63 careless, attractive (good-looking), risky] describe the participant’s image of a typical heavy episodic drinker, using a scale from 0 (not at all) to 6 (extremely; gerrard et al., 2008; litt & lewis, 2016). scores for “careless” and “risky” were reverse scored, and a mean score of the six items was calculated such that higher scores reflected greater favorability (cronbach’s alpha = 0.76). drinking willingness. participants were presented with a scenario that involved drinking at a party and rated their willingness to engage in five actions (adapted from gerrard et al., 2008; litt & lewis, 2016). sample items include “choose a nonalcoholic drink” and “stay and have one more drink” (cronbach’s alpha = 0.85). response options ranged from 0 (not at all willing) to 4 (completely willing), and mean scores were calculated for analyses. perceived injunctive drinking norms. participants responded to a series of 5 statements (lewis et al., 2010) that assessed their perceptions of the typical male/female their ages (gender in question was based on same-sex of respondent) approval of drinking at various levels (e.g., trying one or two drinks, having 3 or 4 drinks each weekend). responses were on a scale from strongly disapprove (1) to strongly approve (6). a mean of all items was computed with higher numbers indicating more peer approval of drinking (cronbach’s alpha = 0.87). attitudes. participants responded to a series of six statements that assessed their approval (lewis et al., 2010) of drinking at various levels (e.g., never drinking, trying one or two drinks, having 3 or 4 drinks each weekend). responses were on a scale from strongly disapprove (1) to strongly approve (6). a mean of all items was computed with higher numbers indicating more approval of drinking (cronbach’s alpha = 0.79). intentions. participants responded to a series of 5 statements that assessed how often they expect to drink alcohol in the next month, how many drinks they will have in one occasion and how often they expect to consume 4 or more drinks in a single occasion, and if they intend to reduce their drinking. one item was reverse scored, and the mean was calculated (cronbach’s alpha = 0.69). data analysis three models were examined for each outcome of interest (frequency of alcohol use, frequency of marijuana use, and cam use vs. single substance use/no substance use), resulting in a total of nine models. for each of the three outcomes, the following constructs were examined in the three models: 1) willingness and intention to drink, 2) descriptive alcohol norms, perceived vulnerability, prototype favorability and willingness to drink (i.e., social reaction pathway), and 3) drinking attitudes, injunctive norms and intention to drink (i.e., reasoned pathway), respectively. age, and sex were included as covariates in all nine models, in addition to alcohol use when examining marijuana use. frequency of alcohol use was treated as a continuous variable, and multiple linear regression models were used to examine the associations between alcohol use and pwm cognitions. two participants reported missing marijuana use, and were excluded in the analysis. preliminary analysis showed frequency of marijuana use was positively skewed (s = 2.35, k = 4.13) and over-dispersed (variance = 643.63, mean = 11.92). we observed the frequency of marijuana use had a relatively large number of zero values (39.3%), however, due to a small sample size of 122, fitting zero-inflated models (e.g., zero-inflated negative binomial model) would lead to estimation error with convergence issues. therefore, negative binomial regression models were used to examine the effects of the pwm variables on marijuana use. in order to identify correlates of current cam (n = 40) compared to single use (n = 46) and no current use (n = 35), multinomial logistic regression models were used. cam was used as the reference group to aid in interpretation. because there were only 3 marijuana-only users in the single-users group, these were excluded from the cam use analysis. the vif was below 2.03 and tolerance above 0.49 for all models and variables, indicating acceptable levels of multicollinearity (hair et al., 2010). the ranges of values for vif and tolerance were reported for each model in the results section. results overall, participants reported drinking an average of 3.88 ± 2.84 on a scale from 0 (never) to 11 (every day), which corresponds to two to three times per month, and using marijuana on average 12.03 ± 25.66 days during the past three months. analyses of variance comparing age, and alcohol cognitions and substance use 64 frequency of alcohol and marijuana use across groups showed that cam users (m =19.58 ± 2.68) and single users (m = 20.20 ± 2.48) were older than non-users (m = 15.97 ± 0.92, p < 0.001; f(2,120) = 39.62, adjusted r2 = 0.39). cam users did not drink more often during the past three months compared to single users (m= 4.89 ± 2.00, p = 0.05; f(2,120) = 84.86, adjusted r2 = 0.58). cam users also used marijuana on more days in the past month (m = 34.4 ± 3.20) compared to single users (m = 0.98 ± 3.02). means, standard deviations and 95% confidence intervals are shown in table 1. pearson correlations between all model variables are shown in table 2. frequency of alcohol use all models examining frequency of alcohol use were significant (model 1a: f(4,123) = 73.99, adj. r2 = 0.70; model 2a: f(6,123) = 54.29, adj. r2 = 0.72; model 3a: f(5,123) = 65.03, adj. r2 = 0.72; all p’s < 0.001). parameter estimates are shown in table 3. willingness and intention. drinking intention was positively associated with frequency of alcohol use (β = 0.48) and age (β = 0.48, p’s < 0.001). willingness and sex were not statistically significant (p’s > 0.24). vif and tolerance values ranged from 1.07 to 1.66, and 0.60 to 0.93, respectively. social reaction pathway. older age (β = 0.42, p < 0.001) was associated with greater alcohol use. additionally, higher descriptive norms (β = 0.31, p < 0.001), lower perceived vulnerability (β = -0.25, p < 0.001), and higher prototype favorability (β = 0.13, p = 0.03) were associated with greater alcohol use. willingness to drink and sex were not significant (p’s > 0.07). vif and tolerance values ranged from 1.19 to 1.53, and 0.64 to 0.84, respectively. table 1. age, frequency of alcohol and marijuana use among non-users (n = 35), single users (n = 46) and cam users (n = 40) age years 95% confidence interval mean std. deviation lower upper non-users 15.97 0.92 15.65 16.29 single users 20.20 2.48 19.46 20.93 cam users 19.58 2.68 18.72 20.43 alcohol use use in past 3 months on a scale from 0 (never) to 11 (every day) 95% confidence interval mean std. deviation lower upper non-users 0.51 0.74 0.26 0.77 single users 4.89 2.00 4.30 5.49 cam users 5.68 2.26 4.95 6.40 marijuana use days in past 3 months 95% confidence interval mean std. deviation lower upper non-users 0.35 0.98 0.01 0.70 single users 0.98 1.22 0.61 1.34 cam users 34.40 34.89 23.24 45.56 note. the alcohol use scale values were labeled as follows: 0 – never, 1 less than once per month, 2 once a month, 3 two times a month. 4 three times a month, 5 once a week, 6 twice a week, 7 three times a week, 8 four times a week, 9 five times a week, 10 six times a week, 11 every day. cannabis, a publication of the research society on marijuana 65 table 2. pearson correlations between prototype willingness model drinking cognitions variable intentions willingness perceived vulnerability descriptive norms injunctive norms attitudes prototype favorability intentions 0.59** -0.56** 0.47** 0.31** 0.63** 0.40** willingness -0.48** 0.32** 0.14 0.51** 0.43** perceived vulnerability -0.40** -0.31** -0.59** -0.31** descriptive norms 0.50** 0.45** 0.04 injunctive norms 0.48** 0.18* attitudes 0.34** prototype favorability note. *p<.05; **p<.01. alcohol cognitions and substance use 66 table 3. parameter estimates from linear regression models on frequency of alcohol use model 1a – willingness and intention frequency of alcohol use 95% confidence interval parameter b std. error standardized β lower upper (constant) -8.13 0.94 -9.99 -6.27 sex = male -0.07 0.29 -0.01 -0.65 0.50 age (years) 0.48 0.06 0.48*** 0.36 0.60 willingness 0.15 0.13 0.07 -0.11 0.41 intentions 0.90 0.12 0.48*** 0.66 1.14 model 2a – social reaction pathway frequency of alcohol use 95% confidence interval parameter b std. error standardized β lower upper (constant) -5.70 1.25 -8.18 -3.23 sex = male -0.00 0.30 0.00 -0.59 0.59 age (years) 0.42 0.06 0.42*** 0.30 0.54 descriptive norms 0.10 0.02 0.31** 0.06 0.14 perceived vulnerability -0.99 0.23 -0.25*** -1.45 -0.53 prototype favorability 0.48 0.22 0.13* 0.04 0.92 willingness 0.22 0.12 0.11 -0.02 0.46 model 3a – reasoned pathway frequency of alcohol use 95% confidence interval parameter b std. error standardized β lower lower (intercept) -8.56 0.93 -10.40 -6.72 sex = male -0.19 0.05 -0.03 -0.29 -0.09 age (years) 0.46 0.29 0.46*** -0.11 1.03 injunctive norms -0.01 0.14 -0.00 -0.29 0.27 attitudes 0.59 0.19 0.20** 0.21 0.97 intentions 0.79 0.12 0.41*** 0.55 1.03 note. *p<.05;**p<.01;***p<.001. cannabis, a publication of the research society on marijuana 67 table 4. parameter estimates from negative binomial regression on frequency of marijuana use model 1b – willingness and intention frequency of marijuana use 95% confidence interval for exp(b)/irr parameter exp(b)/irr lower upper (intercept) 0.57 0.08 4.21 sex = male 1.15 0.73 1.81 age (years) 0.96 0.85 1.08 drinking days (past 3 months) 1.37*** 1.20 1.57 willingness 1.19* 1.01 1.41 intentions 1.47*** 1.18 1.18 model 2b – social reaction pathway frequency of marijuana use 95% confidence interval for exp(b)/irr parameter exp(b)/irr lower upper (intercept) 0.61 0.05 5.64 sex = male 1.23 0.73 2.06 age (years) 0.90 0.80 1.00 drinking days (past 3 months) 1.50*** 1.31 1.71 descriptive norms 1.08*** 1.04 1.11 perceived vulnerability 1.44 0.98 2.13 prototype favorability 1.21 0.82 1.79 willingness 1.25** 1.06 1.48 model 3b – reasoned pathway frequency of marijuana use 95% confidence interval for exp(b)/irr parameter exp(b)/irr lower upper (intercept) 0.35 0.05 2.66 sex = male 1.20 0.75 1.92 age (years) 0.97 0.87 1.09 drinking days (past 3 months) 1.37*** 1.20 1.57 injunctive norms 0.85 0.68 1.07 attitudes 1.69** 1.19 2.42 intentions 1.34* 1.06 1.70 note. *p<.05;**p<.01;***p<.001. alcohol cognitions and substance use 68 table 5. parameter estimates from multinomial logistic regression on cam use compared to single use and no use model 1c – willingness and intention cam use compared to single use and no use 95% confidence interval for exp(b) reference group: cam users (2) parameter exp(b) lower upper non-user (0) intercept sex = male 0.21 0.02 2.86 age 0.31** 0.14 0.70 willingness 0.27 0.07 1.01 intentions 0.05** 0.01 0.34 single user (1) intercept sex = male 0.78 0.30 1.97 age 1.09 0.91 1.30 willingness 0.88 0.57 1.35 intentions 0.55** 0.35 0.86 model 2c – social reaction pathway cam use compared to single use and no use 95% confidence interval for exp(b) reference group: cam users (2) parameter exp(b) lower upper non-user (0) intercept sex = male 1.02 0.12 8.38 age 0.31** 0.15 0.66 descriptive norms 0.93 0.76 1.14 perceived vulnerability 1.92 0.43 8.58 prototype favorability 0.41 0.10 1.74 willingness 0.24** 0.10 0.59 single user (1) intercept sex = male 0.61 0.21 1.82 age 1.21 0.99 1.47 descriptive norms 0.91* 0.85 0.98 perceived vulnerability 1.67 0.79 3.53 prototype favorability 0.70 0.31 1.57 willingness 0.86 0.56 1.33 model 3c – reasoned pathway cam use compared to single use and no use 95% confidence interval for exp(b) reference group: cam users (2) parameter exp(b) lower upper non-user (0) intercept (table continues) cannabis, a publication of the research society on marijuana 69 sex = male 0.57 0.05 6.92 age 0.37** 0.18 0.75 injunctive norms 2.60 0.92 7.40 attitudes 0.15* 0.03 0.82 intentions 0.05*** 0.01 0.24 single use (1) intercept sex = male 0.82 0.29 2.31 age 1.23 1.00 1.53 injunctive norms 1.44 0.79 2.63 attitudes 0.21** 0.08 0.55 intentions 0.70 0.43 1.13 note. the reference group was cam users, coded as 2. *p<.05; **p<.01;***p<.001. reasoned pathway. older age (β = 0.46, p < 0.001), positive attitude towards drinking (β = 0.20, p < 0.01) and intention to drink (β = 0.41, p < 0.001) were positively related to alcohol use. injunctive norms and sex were not significantly associated with the outcome. vif and tolerance values ranged from 1.10 to 1.88, and 0.53 to 0.91, respectively. frequency of marijuana use all models examining associations with frequency of marijuana use were significant (model 1b: χ2 (5) = 171.03, model 2b: χ2 (7) = 184.20, model 3b: χ2 (6) = 175.66, all p’s < 0.001). parameter estimates for the three models are shown in table 4. willingness and intention. the first model showed that frequency of drinking (incidence rate ratio irr = 1.37, p < 0.001), willingness to drink (irr = 1.19, p < 0.05), and drinking intention (irr = 1.47, p < 0.001) were positively associated with frequency of marijuana use. age and sex were not significantly associated with the outcome. vif and tolerance values ranged from 1.08 to 1.67, and 0.60 to 0.93, respectively. social reaction pathway. when including all constructs in the social reaction pathway (i.e., descriptive norms, prototype favorability, perceived vulnerability and willingness to drink), alcohol use (irr = 1.50 , p < 0.001), descriptive norms (irr = 1.08, p < 0.001), and willingness to drink (irr = 1.25, p < 0.01) were positively associated with frequency of marijuana use. perceived vulnerability, prototype favorability, age and sex did not show significant associations with the outcome. vif and tolerance values ranged from 1.19 to 1.57, and 0.64 to 0.84, respectively. reasoned pathway. when examining the constructs in the reasoned pathway, intention to drink (irr= 1.34, p < 0.05) and approval of drinking (i.e., attitudes; irr = 1.69, p < 0.01), in addition to alcohol use (irr = 1.37, p < 0.001) were positively associated with frequency of marijuana use. associations with injunctive norms, age and sex were not statistically significant. vif and tolerance values ranged from 1.11 to 1.88, and 0.53 to 0.90, respectively. cam use, single use, and no substance use all models were significant (model 1c: χ2 (8) = 130.78, model 2c: χ2 (12) = 117.00, model 3c: χ2 (10) = 141.84, all p’s < 0.001) and explained 7078% of total variance (model 1c: nagelkerke r2 = 0.74, model 2c: nagelkerke r2 = 0.70, model 3c: nagelkerke r2 = 0.78). the parameter estimates for the three models are shown in table 5. willingness and intention. the parameter estimates showed that younger participants (odds ratio; or = 0.31, p < 0.01) with lower intention to drink (or = 0.005, p < 0.01) were more likely to be non-users compared to cam users. willingness and sex were not statistically significant (p’s > 0.05). single users had lower intentions to drink (or = 0.55, p < 0.01) compared to cam users. age, sex, and willingness were not statistically significant. vif and tolerance values ranged from 1.09 to 1.68, and 0.60 to 0.92, respectively. alcohol cognitions and substance use 70 social reaction pathway. non-users were more likely to be younger (or = 0.31, p < 0.01) and have lower willingness to drink (or = 0.24, p < 0.01) compared to cam users. sex, descriptive norms, perceived vulnerability and prototype favorability were not statistically significant. single users had lower descriptive norms (or = 0.91, p < 0.05) than cam users. age, sex, willingness, perceived vulnerability and prototype favorability were not statistically significant. vif and tolerance values ranged from 1.21 to 1.56, and 0.64 to 0.83, respectively. reasoned pathway. non-users were younger (or = 0.37, p < 0.01), reported lower approval of drinking (or = 0.15, p < 0.05), and lower intentions to drink (or = 0.05, p < 0.001) compared to cam users. sex and injunctive norms were not statistically significant. single users had lower approval of drinking (or = 0.21, p < 0.01) compared to cam users. sex, age, injunctive norms and intentions to drink were not statistically significant. vif and tolerance values ranged from 1.11 to 2.03, and 0.49 to 0.90, respectively. discussion it is critical to identify risk factors for alcohol use, marijuana use, and cam use among adolescents and young adults in order to address the risks associated with these behaviors (arria et al., 2013; hayaki et al., 2016; suerken det al., 2016). previous research indicates that drinking cognitions from the pwm strongly predict alcohol use outcomes (gerrard et al., 2002; litt & lewis, 2016; pomery et al., 2009; rivis, sheeran & armitage, 2006). in this study, we found that several alcohol-related pwm cognitions on both social reaction and reasoned pathways were related to alcohol, marijuana, and cam use vs. single substance use/no substance use. intentions, descriptive norms and attitudes had significant effects on all the three outcomes, while perceived vulnerability and drinking prototype favorability were only significant for alcohol use. for all outcomes however, injunctive norms was not significantly related to frequency of use. overall, current findings indicate that some drinking cognitions from the reasoned and social reaction pathways of pwm (i.e., attitudes towards drinking, intention and willingness to drink, and descriptive norms) may be more consistently related to marijuana and cam use, suggesting potential common underlying cognitions regarding substance use in general. willingness and intention to drink were related to marijuana and cam use, but when comparing cam users to single users, only intention to drink was a risk factor for cam use. this finding is consistent with previous literature summarized in a meta-analysis suggesting that intention is a stronger predictor of behavior than willingness (todd et al., 2016). the first model in the current study indicated that drinking cognitions from both pathways are related to marijuana and cam use. models examining constructs from the reasoned pathway (i.e., injunctive norms, attitudes and intention) also showed that intention to drink were related to greater marijuana use frequency and that cam users compared to single users had greater intention to drink. taken together, results suggest adolescent and young adult substance use may be influenced by both individuals’ plan to use substance as well as situational factors such as willingness to drink and descriptive norms. findings from this investigation also highlight that cam users may be a unique population, with unique risk factors compared to single substance users of alcohol and marijuana, which is consistent with previous findings (lindencarmichael et al., 2019). current interventions for alcohol use and marijuana use largely focusing on addressing descriptive and injunctive norms by providing personalized normative feedback (e.g., leeman et al., 2016; walukevich-dienst et al., 2019) may benefit from including feedback on intention to drink, as results indicate it may play an important role in marijuana and cam use. results of the present study also provide preliminary evidence that targeting specific alcohol-related risk cognitions may lead to reductions in marijuana and cam use, a notion that should be further explored in future research. adolescents and young adults with more positive attitudes towards alcohol use reported greater frequency of marijuana use and were more likely to report cam. however, perceived peer approval of drinking (i.e., injunctive norms) was not related to either frequency of marijuana use or cam. previous cross-sectional and longitudinal research has primarily examined the social reaction pathway (lewis et al., 2018; litt & lewis, cannabis, a publication of the research society on marijuana 71 2016) with regards to substance use, but the current investigation adds to the literature as it indicates, that at least cross-sectionally, the reasoned pathway of the pwm can also be applied to adolescent and young adult substance use. further, results from cross-sectional (litt & lewis, 2016) and ecological momentary assessment studies (lewis et al. , 2016) using the pwm highlight the importance of situational factors in adolescent and young adults substance use, and suggest that interventions may benefit from educating youth regarding strategies to resist substance use. specifically, training on how to resist peer pressure in risk-conducive situations (e.g., parties), to reduce their overall and substance-specific willingness to use substances, and education on how to develop less risky substance use intentions in different situations may be beneficial according to the present findings. our findings also show that prototypes of alcohol users were not significantly related to frequency of marijuana use or cam. this suggests that prototypes of drinkers, marijuana users, and cam users may be different and need to be addressed differently. some interventions targeting prototypes aim to create a healthier prototype image (gerrard et al., 2008). the current study suggests that the kind of substance use should be considered when promoting healthier images. similarly, other cognitions of the pwm, including perceived vulnerability, were only found to be associated with alcohol use but not marijuana or cam use, suggesting that certain cognitions may be substance specific, whereas others may be relevant across substances. despite the contributions this study makes to the literature, this investigation is not without limitations. due to the small sample size, a full simultaneous pwm model was not assessed, which is an important step for future research. longitudinal tests of these associations would also be warranted given the mediational pathways proposed within the pwm (gerrard et al., 2008). in addition, cognitions towards marijuana use and cam were not assessed. thus, we are unable to assess whether alcohol cognitions predict above and beyond other substance-specific cognitions. because alcohol use, marijuana use, and cam use had different measurement scales, we cannot make direct comparisons related to effect size. however, as noted, a primary aim of the current investigation was to assess whether cognitions towards one substance (in this case, alcohol) would also generalize towards other substances (in this case, marijuana and cam) and so this particular concern is somewhat ameliorated. furthermore, findings are based on a cross-sectional sample, and thus do not provide information on causality. in addition, the internal consistency of the intentions measure was low (cronbach’s alpha = 0.69), which may lessen the reliability of results using that specific item. in summary, findings from the current investigation provide further evidence that constructs from the pwm are useful in better understanding substance use in adolescents and young adults. results highlight that specific drinking cognitions from the pwm may have utility in understanding marijuana and cam use but that it is possible that adolescents and young adults have substance-specific cognitions. overall, results suggest that interventions aimed at reducing adolescent and young adult substance use may be enhanced by also targeting substancespecific and cross-substance cognitions. references ajzen, i. 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184–193. funding and acknowledgements: data collection was supported by a grant from the university of washington alcohol and drug abuse institute awarded to m. a. lewis. manuscript preparation was supported by niaaa grant r01aa025611 awarded to m. a. lewis and by the national center for advancing translational sciences under university of florida clinical and translational science awards tl1tr001428 and ul1tr001427 to n. m. gebru. the content of this manuscript is solely the responsibility of the author(s) and does not necessarily represent the official views of the alcohol and drug abuse institute, national institute on alcohol abuse and alcoholism, or the national institutes of health. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i1a1_authors_final research article 27 ved abstract objective. prior studies documenting more frequent and problematic use among young adults who have acquired medical marijuana (mm) cards have broadly compared those who use medically to those who use recreationally. gaining a better picture of how health symptoms and problematic use vary both within those who have a mm card for specific condition domains and between those who do not have a mm card can provide key information for medical practitioners and states interested in adopting or updating mm policies. method. the current study categorizes young adults authorized to use mm into three mutually exclusive groups based on endorsements of qualifying conditions: (1) physical health only (e.g., aids, arthritis, cancer; n = 34); (2) behavioral health only (e.g., anxiety, depression, sleep problems; n = 75); and (3) multiple conditions (a physical and behavioral health condition; n = 71). multiple and logistic regression models examined differences across marijuana use, problems, mental health, physical health, and sleep quality for mm condition categories and for those that only use marijuana recreationally (n = 1,015). results. after adjusting for socio-demographic factors (age, sex, sexual orientation, educational status, employment status, race/ethnicity, mother’s education, prior intervention involvement in youth), mm card holders, particularly those with physical health or multiple health conditions, reported heavier, more frequent, and more problematic and risky marijuana use compared to those using recreationally. despite this pattern, those in different mm condition categories were generally not found to be more symptomatic in domains of mental or physical health relevant to their respective conditions, compared to different category groups or to those using recreationally. conclusions. findings emphasize the importance of providers conducting a careful assessment of reasons for needing a card, along with use, to reduce potential harms while adding credibility to a medical movement with genuine promise of relief for many medical conditions. key words: = medical marijuana, cannabis, legalization, physical health, mental health, sleep the marijuana policy landscape continues to evolve in the direction of legalization, as more states grant access to marijuana for medical purposes (procon.org, 2020). as of may 2020, 33 states and the district of columbia have legalized marijuana for medical purposes, and 11 states and d.c. have legalized it for recreational purposes. in this changing climate, marijuana use among young adults is of heightened scientific, clinical, and societal concern, particularly as more than half (54%) of young people in the u.s. initiate marijuana use by age 21 (chen et al., 2017), and among those reporting past 30-day marijuana use, about one in five young adults (21–22%) meets diagnostic criteria for cannabis use disorder (cud; richter et al., 2016). cannabis 2021, volume 4 (1) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.01.001 why young adults obtain a medical marijuana card: associations with health symptoms and heaviness of use corresponding author: justin f. hummer, phd., rand corporation, 1776 main street, po box 2138, santa monica, ca 90407-2138. email: jhummer@rand.org. phone: (310) 393-0411. justin f. hummer1, rachana seelam1, eric r. pedersen1,2, joan s. tucker1, david j. klein1, elizabeth j. d’amico1 1rand corporation, 1776 main street, po box 2138, santa monica, ca 90407 2university of southern california, keck school of medicine, department of psychiatry and behavioral sciences, 2250 alcazar street, suite 2200, los angeles, ca 90033 medical marijuana card 28 given that most states have medical marijuana (mm) laws which allow purchase and use of marijuana, the number of people receiving a mm recommendation from their provider and enrolling in their state’s mm program has risen dramatically in the u.s. (boehnke et al., 2019). moreover, an increasing amount of research has been conducted into the medical effects of marijuana. in a comprehensive review, the national academies of sciences, engineering and medicine (nasem) found conclusive or substantial evidence supporting that chronic pain, nausea and vomiting due to chemotherapy, multiple sclerosis spasticity symptoms, and short-term sleep outcomes among those with obstructive sleep apnea syndrome were improved as a result of marijuana treatment (nasem, 2017). however, there was limited, insufficient, or no evidence of therapeutic value for many other conditions allowed under many state laws, including cancer, epilepsy, and irritable bowel syndrome. research evidence on mm’s effects on mental health conditions, such as depression or anxiety, is also quite limited, and most of the broader indications for mm are supported by anecdote rather than controlled clinical trials (wilkinson & d’souza, 2014). moreover, the limited data on clinical effectiveness should be weighed against the substantial evidence for marijuana-related harms, such as worsening respiratory symptoms, increased risk of motor vehicle accidents, lower birth rates, and increased risk for developing psychotic disorders (nasem, 2017). more generally, marijuana’s long-term therapeutic benefits versus costs (including tolerance, addiction, and withdrawal) are not yet known (brigden & england, 2018; rhyne et al., 2016; wilkinson et al., 2016). despite potential for medical benefits, there is growing evidence that young people enrolled in their state’s mm program (oftentimes designated by having a “mm card”) who report using marijuana for medical purposes are more likely to report heavy and problematic use than those who use marijuana recreationally (choi et al., 2017; tucker et al., 2019). greater use may be expected among those who use marijuana medically because they presumably use on a regular schedule or have a medical regimen for use. it becomes more concerning when use becomes problematic. for example, cross-sectional data from the national epidemiologic survey on alcohol and related conditions found higher rates of cud among young adults reporting marijuana use for medical purposes compared to those who used it for nonmedical purposes (choi et al., 2017). crosssectional data from high school seniors in monitoring the future showed that those who obtained marijuana through their state’s mm programs also reported more frequent use and were more likely to report daily use and “being hooked” on marijuana compared with those obtaining marijuana from a nonmedical source (boyd et al., 2015). tucker and colleagues (2019) conducted a longitudinal study and found that young adults with a mm card were more likely to report heavier and more problematic use one year later, as well as a history of heavier use throughout adolescence compared to those without a mm card. it is presumed that one obtains a mm card because of physical or mental health conditions. however, young people may obtain mm cards for access to marijuana, perhaps because they live in states that do not offer recreational marijuana or they are under 21 and could not purchase recreational marijuana even if it was available, or they can purchase marijuana more cheaply due to state taxes being lower for mm than recreational marijuana. these factors may motivate those who use more heavily to obtain a mm card. indeed, one longitudinal study found that obtaining a mm card in young adulthood was primarily driven by frequency of use, rather than physical or mental health symptoms ostensibly associated with card acquisition (pedersen et al., 2019). given these findings, research is needed to better understand young adults’ reasons for getting a mm card, the extent to which reasons coincide with reported mental and physical health symptoms, and whether young adults with a mm card report more mental and physical health symptoms than those who use marijuana without a mm card. despite not being explicitly included in states’ list of qualifying conditions for mm, mental health conditions such as anxiety and depression are common reasons for using mm (kosiba et al., 2019; lankenau et al., 2018; walsh et al., 2013, 2017), and multiple states allow mm use for these conditions through an additional “other symptoms” category that states consider as debilitating or having capacity to cause serious harm to an individual if not alleviated. in a study of young adults in canada, self-reported mental health problems were higher among those who used mm, and mm card holders were more likely to report cannabis, a publication of the research society on marijuana 29 using marijuana to manage or improve mental health than those who did not use for medical reasons (wadsworth et al., 2020). an interviewbased study in california reported similar findings in a heavier using sample of young adults; those with a mm card were more likely to report a lifetime history of mental and physical health problems and to report using marijuana to relieve symptoms compared to those without a mm card (lankenau et al., 2018). in contrast, a screening of general adult primary care patients who reported using marijuana found few distinct differences in medical, psychiatric, and non-marijuana substance use characteristics between those who used for medical compared to recreational purposes (roybyrne et al., 2015). although many people utilize mm to treat physical and mental health conditions, there is relatively little research evidence to date on the effects of marijuana on anxiety, depression and ptsd, and findings are much less robust than for physical conditions, notably chronic pain, epilepsy, and ms symptoms (hill, 2015; nasem, 2017; stockings et al., 2018; whiting et al., 2015). given that the evidence of marijuana’s therapeutic benefit for mental health is not yet well-understood nor well-established, and that many young adults report using mm to manage mental health symptoms (wadsworth et al., 2020), research is needed to understand 1) how mental health symptoms manifest for young people who use marijuana for different medical conditions, and 2) how this compares to those who use for nonmedical reasons. the present study prior studies are limited by broadly comparing those who use marijuana medically to those who use recreationally (e.g., boyd et al., 2015; choi et al., 2017; lankenau et al., 2018; roy-byrne et al., 2015; tucker et al., 2019), lack of random sampling (lankenau et al., 2018), and lack of validated measures to assess symptom functioning (lankenau et al., 2018; wadsworth et al., 2020). gaining a better picture of how health symptoms and problematic use vary both within those who have a medical card for specific condition domains and between those who do not have a mm card, using validated measures of functioning, can provide key information for medical practitioners and states interested in adopting or updating mm policies. the current study adds to this literature by categorizing young adults in california authorized to use mm into three mutually exclusive groups based on endorsements of (1) physical health conditions only (e.g., aids, arthritis, cancer), (2) behavioral health conditions only (e.g., anxiety, depression, sleep problems) or (3) multiple conditions (e.g., both a physical health and a behavioral health condition). we examined how these mm groups compared to each other, and how they compared to a large and racially/ethnically diverse sample of young adults who reported recreational marijuana use on their frequency and quantity of marijuana use, marijuana-related problems and risk, and several domains of functioning corresponding to conditions for which mm card holders acquired their cards (i.e., mental health, sleep quality, and physical health). the premise that medical symptoms drive acquisition of a mm card should be reflected in endorsements of symptoms pertaining to card holders’ respective conditions, relative not only to those who use recreationally, but also relative to card holders with different conditions. therefore, compared to other medical condition groups and to non-card holders, we expected that the physical health only group would report greater symptoms of poor physical health, whereas the behavioral health only group would endorse more mental health symptoms and worse sleep quality. in addition, those reporting multiple conditions for mm card acquisition were expected to be the most symptomatic in all health domains and to demonstrate the highest rates of use and problems. overall, mm card holders across all health condition groups were expected to use marijuana more frequently, display more problematic and risky use, and be more symptomatic than non-card holders across all domains of functioning. methods participants and procedures participants are from a multiwave study of substance use. after being initially recruited in 6th/7th grade for a substance use prevention program (choice) conducted in 16 middle schools in southern california in 2008 (d’amico et al., 2012), participants completed up to eleven annual surveys, with the first five middle school surveys conducted during physical education class and the medical marijuana card 30 rest of the surveys completed online. further details of recruitment and retention rates across waves are described in detail elsewhere (dunbar et al., 2018; d’amico et al., 2016; d’amico, rodriguez et al., 2018). briefly, at wave 6, when most participants transitioned out of middle school to over 200 high schools across the region, 61% of the sample was retained, and wave-to-wave retention rates from waves 7-11 ranged from 80-92%. attrition from wave to wave was not associated with substance use. all study procedures were approved by the rand institutional review board. data for this study come from the online survey completed at wave 11 during 2018-2019 when participants were approximately 22 years old. sale and possession of recreational marijuana became legal in california on november 8, 2016 and recreational marijuana outlets began opening on january 1, 2018. all data collection for the current study occurred after these legal milestones. prior published studies utilizing data from this same cohort have examined associations between participant health characteristics, marijuana use, and mm card status (e.g., pedersen et al., 2019). however, the interrelationships between these domains have not previously been evaluated using cohort data from the wave of the study presented herein. measures socio-demographics. participants self-reported age, sex at birth, sexual orientation (heterosexual/straight vs. gay/lesbian/bisexual/ asexual/questioning), and race/ethnicity (“which race/group best describes you? (mark all that apply)”; mutually exclusive categories for nonhispanic white, non-hispanic black, hispanic, non-hispanic asian, and non-hispanic other/multi-racial). we assessed mother’s education level (“how far did your mother go in school?”; didn’t finish high school, graduated from high school, some college, college degree or above) as a proxy for family socioeconomic status (korupp et al., 2002). participants reported current college enrollment (“describe your current education setting”; currently in graduate school or college or technical/trade school vs. all other responses) and employment status (“are you currently working at a paid job (including self-employment)?”; employed part-time or employed full-time vs. unemployed and looking for a job right now or unemployed and not looking for a job). mm card status and conditions. participants who reported use of marijuana on at least one day in the past year were asked whether they currently had a mm card (yes/no). if they selected yes, they were then asked: “for what condition(s) have you been provided with a medical marijuana card?” response options included all qualifying conditions to become a medical marijuana patient in california according to proposition 215, with revised senate bill (sb) 420. conditions include: aids, anorexia, arthritis, cachexia, cancer, chronic pain, glaucoma, migraine, persistent muscle spasms, seizures, severe nausea. in addition, sb 420 includes a provision for “any other chronic or persistent medical symptom that either substantially limits a person’s ability to conduct one or more of major life activities as defined in the americans with disabilities act of 1990, or if not alleviated, may cause serious harm to the person’s safety, physical, or mental health.” given high rates of endorsement for mental health and sleep in the research literature, three additional items were included to capture the behavioral health domain: depression, anxiety, and sleep problems. lastly, to account for the provision of the senate bill around any other chronic or persistent symptoms, participants could write in a condition. card holders were asked to ‘select all that apply,’ and were categorized into mutually-exclusive groups based on endorsement of conditions: physical health (aids, anorexia, arthritis, cachexia, cancer, chronic pain, glaucoma, migraine, persistent muscle spasms, seizures, severe nausea); behavioral health (anxiety, depression, sleep problems). open-ended responses were included into categories as follows: physical health (e.g., back pain; fibromyalgia; period pains; sciatica) and behavioral health (e.g., panic attacks). those who endorsed conditions from both behavioral health and physical health were put into a multiple conditions category. young adults who reported past year use but did not currently have a mm card were categorized into the nonmedical group. two participants who reported being provided a mm card but did not endorse any of the health conditions were excluded from the analyses. in the resulting final sample of those reporting past year marijuana use (n = 1,195), 15.1% (n = 180) reported having a mm card. most of the sample belonged to cannabis, a publication of the research society on marijuana 31 the non-medical group (84.9%; n = 1,015). of those with a mm card, 41.7% (n = 75) endorsed only a behavioral health condition as the reason for which they were provided a mm card, 18.9% (n = 34) endorsed only physical health, and 39.4% (n = 71) endorsed both a physical health and a behavioral health condition as reasons for which they were provided a mm card. marijuana use. frequency of marijuana use was assessed with a single item on number of days used marijuana in the past month (0-30 days). participants also indicated how many times they use marijuana on the days they use it (bogart et al., 2005; ellickson et al., 2005). quantity of marijuana use focused on flower/bud, asking, “on the days you use marijuana, on a typical use day, how much marijuana flower/bud do you personally consume?” (kilmer et al., 2013). response options ranged from 1 = “less than 0.25g” to 10 = “more than 5g,” and were re-coded using the mid-point of each response option to represent quantities in grams (e.g., “between 1 and 1.5g” re-coded to 1.25g) with a final range from 0.25 to 5 grams. the majority (84.1%; %n = 1005) of the sample endorsed a quantity of flower/bud consumed on a typical use day; thus, we retained this information in our analyses. multiple episodes of use per day on days marijuana was used was assessed with the question “on the days you use marijuana, how many times do you use it?”. because the majority of responses were “once” per day, we dichotomized this item as once vs. more than once. marijuana-related problems. the cannabis use disorders short form (cudit-sf; bonnmiller et al., 2016) asks participants how often during the past 6 months they found they were not able to stop using marijuana/cannabis once they had started; devoted a great deal of their time to getting, using, or recovering from marijuana/cannabis; and had a problem with their memory or concentration after using marijuana/cannabis (rated 0 = never to 4 = daily or almost daily; α = 0.74). marijuana consequences were assessed with ten items asking frequency of negative outcomes in the past year due to their marijuana use, rated from 1 = never to 7 = 20 or more times. (e.g., “you had less motivation to do things because of using marijuana”) (bogart et al., 2005; ellickson et al., 2005; simons et al., 2012). items were summed to create a composite score (α = 0.90). separate items for marijuana-related problem behaviors asked how often in the past year participants had driven a car, motorcycle or other vehicle after using marijuana; had been a passenger in a car or other vehicle with a driver who had been drinking alcohol or using drugs; and sold marijuana or hashish (grass, pot, weed) (1 = not at all to 6 = 20 or more times). because they are rare events, these three items were dichotomized into indicators for any occurrence. behavioral health. the patient health questionnaire (phq-8; kroenke et al., 2009) assessed eight depression symptoms (e.g., “feeling, down, depressed or hopeless”) in the past two weeks (α = 0.91). the generalized anxiety disorder scale (gad-7; spitzer et al., 2006) assessed seven anxiety symptoms (e.g., “feeling nervous, anxious, or on edge”) experienced in the past two weeks (α = 0.94). items in both scales were rated from 0 = not at all to 3 = nearly every day, and composite scores were created by summing items. overall sleep quality in the past month was measured with a single item from the pittsburg sleep index (buysse et al., 1989) on a scale from 1 = very bad to 4 = very good. physical health. a composite score for physical health was generated from three items: the single item of the general health factor on the 12-item short-form health survey (ware et al., 1996) assessing “in general, would you say your health is…” with response options ranging from 1 = excellent to 5 = poor, and two items from the promis pediatric physical function scales (dewitt et al., 2011) (e.g., “in the past month…i have been physically able to do the activities i enjoy most”) with response options of 1 = with no trouble to 5 = not able to do. items were reverse scored with higher scores reflecting better physical health (α = 0.79). analytic plan several variables followed non-normal distributions in which more than half of responses contained the same value. these variables were more appropriate for logistic regression and dichotomized prior to analysis. the remaining outcomes approximated normal distributions and were deemed suitable for the robust nature of linear regression. multivariable linear or logistic regressions with follow-up post-hoc tests with tukey adjustment for multiple comparisons were conducted to compare the four mutually exclusive groups (mm card for physical health condition medical marijuana card 32 only; mm card for behavioral health only; mm card for multiple conditions; and no mm card) on frequency and quantity of marijuana use, marijuana-related problems, physical health, mental health, and sleep measures. group comparisons controlled for socio-demographic covariates: age, sex (male vs. female), sexual orientation (straight vs. other), college status (in college vs. not), employment status (currently employed vs. not), race/ethnicity (non-hispanic white, non-hispanic black, non-hispanic asian, non-hispanic other race, hispanic), mother’s education (less than high school, high school, some college, college or above), and choice intervention status. table 1. sample descriptives for young adults reporting past year marijuana use age, mean (sd) 21.6 (0.8) male gender, n (%) 547 (45.7%) sexual orientation, n (%) heterosexual/straight 966 (80.8%) gay/lesbian/bisexual/asexual/questioning 229 (19.2%) in college, n (%) 730 (61.0%) employed, n (%) 872 (73.1%) race/ethnicity, n (%) non-hispanic white 321 (26.8%) non-hispanic black 31 (2.6%) hispanic 503 (42.0%) non-hispanic asian 191 (16.0%) non-hispanic other/multi-racial 151 (12.6%) mother’s education, n (%) did not finish high school 158 (13.2%) high school 177 (14.8%) some college 165 (13.8%) college 627 (52.4%) don’t know 70 (5.9%) choice intervention, n (%) 632 (52.8%) medical marijuana card, n (%) 180 (15.1%) conditions endorsed for being provided with a medical marijuana card, n (%) physical health condition only 34 (2.9%) behavioral health condition only 75 (6.3%) multiple health conditions (at least one physical health and one behavioral health condition) 71 (5.9%) outcomes frequency of marijuana use in past month, mean (sd) [range 0-30] 7.7 (10.5) number of times using marijuana on days used, mean (sd) [range 0-63] 2.5 (4.0) cannabis use disorders identification test short form score, mean (sd) [range 0-12] 1.7 (2.6) marijuana consequences in past year, mean (sd) [range 2-70] 16.0 (9.4) number of times in past year having driven a car, motorcycle, or other vehicle after using marijuana, mean (sd) [range 0-20] 2.2 (5.3) number of times in past year having been a passenger in a car or other vehicle with a driver who has been drinking alcohol or using drugs, mean (sd) [range 0-20] 2.3 (4.6) generalized anxiety disorders scale-7, mean (sd) [range 0-21] 5.6 (5.4) patient health questionnaire-8, mean (sd) [range 0-24] 6.2 (5.6) physical health composite, mean (sd) [range 0-12] 9.1 (2.3) sleep quality, mean (sd) [range 1-4] 2.8 (0.8) cannabis, a publication of the research society on marijuana 33 results the analytic sample for this study (table 1) was comprised of young adults who reported past year marijuana use (n = 1,195). they were 21.6 years old on average (sd = 0.8), 46% male (n = 547); 80.8% reported being heterosexual (n = 966), 61.0% reported being in college at the time of survey administration (n = 730), 73.1% reported being employed (n = 872), and 52.4% of participants reported that their mothers had completed college (n = 627). the sample was racially and ethnically diverse; 42% reported being hispanic (n = 503), 26.8% non-hispanic white (n = 321), 2.6% non-hispanic black (n = 31), 16.0% non-hispanic asian (n = 191), and 12.6% reported being some other race or multi-racial (n = 151). marijuana use. a full description of regression and post-hoc tests for group differences can be found in table 2, with statistically significant findings summarized here. those with no mm card reported significantly less frequent marijuana use in the past month relative to those in the behavioral health only group (6.2 days vs 15.3 days, tukey-adjusted p < 0.001), the physical health only group (6.2 days vs. 12.0 days, p = .005), and the multiple conditions group (6.2 days vs. 18.4 days, p < .001). furthermore, those in the multiple conditions group reported more frequent use compared to the physical health only group (18.4 days vs. 12.0 days, p = .01). for using multiple times on days used, we found similar patterns: those with no mm card were less likely to use marijuana multiple times per day than those in the behavioral health only group (39% vs 77%, p = <.001), the physical health only group (39% vs. 64%, p = .04), and the multiple conditions group (39% vs. 79%, p < .001). a similar pattern was also seen for quantity of marijuana flower/bud consumed on a typical use day, with those in the no mm card group reporting consuming less flower/bud than the physical health only group (0.7g vs. 1.3g, p < .001), the behavioral health only group (0.7g vs. 1.1g, p < .001), and the multiple conditions group (0.7g vs. 1.3g, p < .001). marijuana-related problems. we also found differences between the no mm card group and the other condition groups for past year marijuana consequences and the cudit-sf score. those with no mm card reported fewer marijuana-related consequences in the past year than those in the physical health only group (15.5 vs. 21.7, p < .001) and those with multiple conditions (15.5 vs. 18.5, p = .03). those with no mm card also reported lower cudit-sf scores than those in the behavioral health only group (1.5 vs. 2.5, p = .006) and the multiple conditions group (1.5 vs. 2.7, p = .01). for marijuana-related problem behavior outcomes, we found some differences. those with no mm card reported fewer instances of ever driving under the influence of marijuana than those in the physical health only group (24% vs. 53%, p = .004) and the multiple conditions group (24% vs. 49%, p <.001). the behavioral health only group was also less likely to report any driving under the influence of marijuana (25%) than the physical health only (p = .04) or multiple conditions group (p = .02). the same pattern was found for selling any marijuana in the past year: those with no mm card reported fewer instances of selling marijuana than those in the physical health only group (7% vs. 32%, p < .001) and the multiple conditions group (7% vs. 29%, p < .001). additionally, the behavioral health only group was also less likely to report selling any marijuana in the past year (10%) than physical health only (p = .03) or multiple conditions (p = .02). finally, we found that those with no mm card were more likely to report ever having been a passenger in a car or other vehicle with a driver who had been drinking alcohol or using drugs than the behavioral health only group (43% vs. 27%, p = .03); the behavioral health only group also reported fewer such incidents than physical health only (27% vs. 54%, p = .04). mental and physical health and sleep. only one significant group difference was found for mental health: those with no mm card reported lower scores on the phq-8 than those in the multiple conditions group (6.1 vs. 7.8, p = .048). there were no significant differences between groups on physical health. finally, those in the physical health only group reported significantly better overall sleep quality relative to those in the no mm card group (3.2 vs. 2.8, p = .05) as well as multiple conditions group (3.2 vs. 2.7, p = .01). medical marijuana card 34 table 2. between group differences on study outcomes linear regression mean lcl ucl mean lcl ucl mean lcl ucl mean lcl ucl past month mj use 12.0 8.7 15.4 15.3 13.0 17.5 18.4 16.1 20.6 6.2 5.6 6.8 51.76*** nc < ph, bh, mc bh < mc quantity of mj flower/bud 1.3 1.0 1.6 1.1 0.9 1.3 1.3 1.1 1.5 0.7 0.6 0.7 21.47*** nc < ph, bh, mc mj consequences 21.7 18.5 24.8 17.0 15.0 19.1 18.5 16.4 20.7 15.5 14.9 16.0 7.28*** nc < mc, ph cudit-sf 2.4 1.6 3.3 2.5 1.9 3.1 2.4 1.8 3.0 1.5 1.3 1.7 7.03*** nc < bh, mc phq-8 severity 6.9 5.0 8.8 6.9 5.6 8.1 7.8 6.5 9.1 6.1 5.7 6.4 2.75* nc < mc gad-7 severity 4.7 2.9 6.5 5.9 4.7 7.1 6.9 5.7 8.1 5.5 5.1 5.8 2.01 physical health composite 8.8 8.0 9.6 8.7 8.2 9.3 8.7 8.2 9.3 9.1 9.0 9.3 1.37 sleep quality 3.2 2.9 3.4 2.8 2.7 3.0 2.7 2.5 2.8 2.8 2.8 2.8 3.14* nc, mc < ph logistic regression % lcl ucl % lcl ucl % lcl ucl % lcl ucl χ2 test (3df) use mj multiple times/day 64% 46% 79% 77% 66% 85% 79% 68% 87% 39% 36% 42% 67.29*** nc < ph, bh, mc riding with impaired driver 54% 36% 70% 27% 18% 38% 43% 32% 54% 43% 40% 46% 9.12* bh < ph, nc drove after using mj 53% 35% 70% 25% 17% 36% 49% 37% 60% 24% 21% 27% 28.40*** nc, bh < mc, ph sold mj/hashish 32% 18% 50% 10% 5% 18% 29% 20% 41% 7% 6% 9% 48.09*** nc, bh < mc, ph *p < 0.05, **p < 0.01, ***p < 0.001 note. these tests to compare group differences are adjusted for by: age, sex, sexual orientation, college status, employment status, race/ethnicity, mother's education, and choice intervention status. lcl = lower control limit; ucl = upper control limit; mj = marijuana; cudit-sf = cannabis use disorders identification test short form; phq = patient health questionnaire; gad = generalized anxiety disorders. f test (3df) significant differences between groups physical health (ph) behavioral health (bh) multiple conditions (mc) non card-holders (nc) health condition categories cannabis, a publication of the research society on marijuana 35 discussion the current study provides an in-depth look at differences across marijuana use, problems, mental and physical health, and sleep for mm card holders who have a card for different conditions, and for those who only use marijuana recreationally. as expected, young adult mm card holders reported heavier and more frequent marijuana use, including days of use, multiple episodes of usage on days used, and quantity on use days, than those who did not have a mm card. mm card holders reported using marijuana on at least twice as many days in the past month and used approximately twice the amount of marijuana flower/bud compared to non-card holders. drilling down by condition type, those who used marijuana to manage multiple behavioral and physical health conditions reported the most days of use in the past month; however, the three condition groups did not differ in the likelihood of using multiple times per day. young adult mm card holders, particularly those with physical health only or multiple conditions, also reported more problematic and risky use of marijuana compared to those using recreationally. those in the physical health condition group and those with multiple conditions reported greater marijuana-related consequences compared to those without a mm card, and a greater likelihood of driving after using marijuana compared to the behavioral health condition group. further, the physical health condition group and those with multiple conditions also reported selling marijuana more frequently than those in the non-card or behavioral health groups, replicating prior research (tucker et al., 2019). results of the cudit-sf revealed that the behavioral health condition group, the physical health condition group, and the multiple conditions group all had mean scores above 2.0, which has been found to reliably identify 78% of individuals who meet criteria for cud according to dsm-5 (bonn-miller et al., 2015). when comparing group differences, only those with behavioral health or multiple conditions had a significantly higher severity score than those with no mm card. thus, it appears that the most problematic use occurs among young adults who report physical health or multiple health conditions. overall, findings highlight the importance for providers to probe why young adults may want to obtain a card given that card holders were generally more likely to meet the threshold of cud. thus, screening for both reasons for providing the card and current marijuana use may provide an opportunity for brief intervention if needed. this is particularly important as recent studies find that teens age 1418 who report numerous marijuana consequences and/or who have a diagnosis of cud responded positively to a 15-minute brief motivational intervention, reporting less cannabis use and consequences one year later (d'amico, parast, et al., 2018; d’amico et al., 2019). interestingly, although mm card holders reported heavier and more problematic marijuana use than non-card holders, they were generally not found to be more symptomatic in the mental and physical health domains that were assessed. specifically, compared to all other groups, the behavioral health group did not report greater symptoms of depression, anxiety, or sleep quality, and the physical health condition group did not report worse physical health. those reporting multiple conditions did, however, report greater depressive symptoms than those without a card, and they also reported worse sleep quality than those with physical health conditions. although there are physical health conditions that can benefit from marijuana use (nasem, 2017), several studies show that in states with medical laws, many people who use medicinally also use marijuana recreationally (lankenau et al., 2018; pacula et al., 2016; walsh et al., 2013). moreover, a study of primary care patients who reported using marijuana found few distinct differences in medical, psychiatric, care utilization, and nonmarijuana substance use characteristics between those who used medically compared to those who did not (roy-byrne et al., 2015), and in a study of young adult mm patients, 15% admitted that their physician recommendations for the card were based on a fabricated health problem (lankenau et al., 2018). thus, some clinicians, media, and policymakers question whether people using marijuana for medical purposes are really different from those using marijuana for recreational purposes, which contributes to suspicion by some healthcare providers that mm is a way to increase the likelihood for legalizing recreational use (pedersen & sandberg, 2013) or, for individuals who use, a path to obtain marijuana more cheaply and in higher quantities. medical marijuana card 36 the concerns noted above must be weighed with attendant consideration to research design. for example, the overall pattern of our findings supports prior research showing greater frequency of use among young people with access to mm (boyd et al., 2015; tucker et al., 2019), and adds to these findings by categorizing individuals according to their condition clusters and evaluating several domains of functioning. however, findings do not represent definitive evidence of a lack of heightened symptoms pertaining to the condition for which individuals acquire a mm card given that our selected measures captured broad aspects of symptoms across these domains. further research is needed to understand how the condition for which an individual receives a mm card maps onto specific symptomatology. in addition, due to the crosssectional design, it is not possible to determine the extent to which marijuana is adequately treating the symptoms associated with card acquisition. even in the absence of a mm card, “selfmedicating” with marijuana—using marijuana to ease physical or psychological symptoms without direction or authorization from a licensed physician—is common among young people (bottorff et al, 2009). we did not assess motives for use among those without a card and many of those individuals may also be using marijuana for specific symptom relief; yet it is not without risks. perhaps most notable is the evidence concerning psychosis. a recent review found that of 13 prospective longitudinal studies, 10 showed that those who use cannabis had a significantly increased risk of psychosis compared with those who do not, while 2 of the remaining 3 showed a trend in the same direction (sideli et al., 2020). marijuana use may also exacerbate other mental health symptoms. a meta-analysis on longitudinal studies of marijuana and depression found that heavy marijuana use may be associated with increased risk of depression (levran et al., 2014). furthermore, individuals who use marijuana may experience acute adverse effects, such as anxiety (hall & weier, 2015), which could be contrary to what they aim to achieve through use (schofield et al., 2006; walsh et al., 2013). thus, for those not already doing so, providers who write prescriptions for mm should consider screening for common mental health problems, weighing the potential benefits with potential contraindications of recommending marijuana as a treatment, and make appropriate alternative referrals to mental health specialists as warranted. it’s important to note our study limitations. first, although we measured several domains, our constructs of physical and mental health were not exhaustive. it is possible that individuals within condition groups may vary on other measures, such as pain interference or other dimensions of mental and physical health. we also acknowledge that the two-week time period of mental health symptom assessment is brief, despite this being the standardized time frame for these measures. given this, we may not have had enough sensitivity within the time window to detect longer-term fluctuations of mental health symptoms. third, sample sizes within condition groups were somewhat small and varied; however, proportions were expected given smaller numbers of those who use marijuana medically (6.2%) in the u.s. relative to those who use recreationally (90.2%) or those who use both medically and recreationally (3.6%) (compton et al., 2017). fourth, the cross-sectional nature of this study prohibits definitive conclusions regarding cause and effect, and longitudinal research is needed to assess whether symptoms reported by mm card holders may be improving with use. finally, the study relied on subjective rather than objective reporting of symptoms and reasons for acquiring a mm card. more precise conclusions can be drawn through combined use of self-reported information along with medical documentation from treating physicians and/or medical records (see nunberg et al., 2011). despite limitations, findings add to our understanding of young adults’ reasons for getting a mm card and highlight the ways in which those with varying conditions compare on frequency and quantity of use, problematic and risky use, and on mental and physical health symptoms. perhaps most notably, we found that mm card holders did not report greater severity of mental and physical health symptoms than those without a card. many individuals struggle with legitimate medical and psychological concerns that can benefit from mm (nasem, 2017). if marijuana is to be used for such purposes, it should be subjected to the same evidence-based review and regulatory policies as those used for other pharmaceutical agents prescribed by physicians. our current findings emphasize the importance of providers conducting cannabis, a publication of the research society on marijuana 37 a careful assessment of the reasons for needing a card, along with use, given that those with a card tend to use more frequently and heavily and report more problems. this could help reduce potential harms due to heavy use and contraindications (such as use at a young age among those at risk for schizophrenia and other forms of mental illness), while also adding credibility to a medical movement with genuine promise of relief for many medical conditions. references boehnke, k. f., gangopadhyay, s., clauw, d. j., & haffajee, r. l. 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(2016). a systematic review of the evidence for medical marijuana in psychiatric indications. the journal of clinical psychiatry, 77(8), 1050-1064. funding and acknowledgements: this research was supported by grants r01aa016577, r01aa020883, and r01aa025848 from the national institute on alcohol abuse and alcoholism (pi: d’amico). the authors report no conflicts of interest. the authors wish to thank kirsten becker and jennifer parker for overseeing the data collection. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. microsoft word v1i2a4_doi.docx research article 36 abstract although depression is common among cannabis users, there is a paucity of targeted interventions addressing depression and cannabis use disorders concurrently. in the present pilot study, we examine the feasibility, acceptability, and preliminary outcomes of a computer-assisted intervention combining cognitive behavioral therapy (cbt) and motivational enhancement therapy (met) techniques for adults with comorbid major depressive disorder (mdd) and cannabis use disorder (cud) presenting for care in a psychiatric setting. adults with mdd and cud (n=26) recruited from mental health care settings were enrolled in a 10-week, computer-assisted psychosocial intervention: self-help for alcohol and other drug use and depression (shade). feasibility, acceptability, perceived helpfulness, treatment retention, completion, and clinical outcomes including cannabis use and depression were assessed. participants found the shade intervention to be acceptable and helpful in facilitating action towards their therapeutic goals concerning depression and cannabis use. treatment completion, achieved by the majority (85%) of participants, was excellent. on average, participants reduced their past 30 day cannabis use from baseline (mean percentage of days using = 69%) to follow-up (m=44%) (t(22)= 2.3, p<0.05; effect size= 0.79). concurrently, they evidenced reductions in depressive symptom severity, from the moderately severe range at baseline to the mild range at follow-up (t(24)=7.3, p<0.001; effect size=1.52). addressing comorbid cud and mdd using a computer-assisted, evidence-based treatment strategy is feasible in a psychiatric care setting, and may produce improvements in both depressive symptoms and cannabis use. key words: cannabis, treatment, comorbidity, outcome, depression cannabis use disorders (cud) are associated with four times the risk of developing a subsequent depression (bovasso, 2001; patton et al., 2002); likewise, high rates of cannabis use have been consistently demonstrated among individuals with mood disorders (degenhardt, cannabis 2018, volume 1 (2), 36-47 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.004 open access preliminary outcomes of a computerized cbt/met intervention for depressed cannabis users in psychiatry care corresponding author: suzette glasner, integrated substance abuse programs, david geffen school of medicine, semel institute for neuroscience and human behavior, ucla, 11075 santa monica blvd, suite 200, los angeles, ca 90025 u.s.a., phone: 310-267-5206, email: sglasner@ucla.edu suzette glasner1,2, frances kay-lambkin3, alan j. budney4, michael gitlin1, bruce kagan1, helene chokron-garneau1, alfonso ang1, alexandra venegas1 1 department of psychiatry and biobehavioral sciences, university of california, los angeles, los angeles, ca, usa 2 school of nursing, university of california, los angeles, los angeles, ca, usa 3 the university of newcastle 4 geisel school of medicine, dartmouth university cannabis, a publication of the research society on marijuana 37 hall, & lynskey, 2001; farrell et al., 2003; merikangas et al., 1998). australian data suggest that depression is the most commonly cited condition for which cannabis is used medicinally (56%), with two-thirds reporting the use of cannabis to assist in coping with emotional difficulties (swift, gates, & dillon, 2005). regardless of the precise etiology, it remains important to consider depression when managing cannabis use, particularly given that depression is the leading cause of disability in the world. published reviews indicate robust effects of psychosocial treatments for cud (davis et al., 2015; budney, roffman, stephens, & walker, 2007; mcrae, budney, & brady, 2003; nordstrom & levin, 2007). the great majority of controlled studies have evaluated motivational enhancement therapy (met), cognitivebehavioral therapy (cbt), and contingency management (cm) interventions, both as standalone and combined treatment approaches. met combined with cbt outperformed met alone in a large multi-site study (copeland, swift, roffman, & stephens, 2001; babor, 2004), and this approach is considered to be the current state-ofthe art psychosocial approach for cud (budney et al., 2007). enhancing dissemination and implementation of cbt and met using technology is of great importance because, although cbt and met are highly efficacious, (a) availability is low, as few treatment programs provide cbt and met, (b) resources needed to train staff and achieve fidelity of treatment delivery are not widely available, and (c) high caseloads and turnover rates increase the difficulty of maintaining quality (mclellan, carise, & kleber, 2003; glasner-edwards & rawson, 2010). likewise, evidence-based psychotherapies for depression have limited accessibility for similar reasons (andrews, cuijpers, craske, mcevoy, & titov, 2010; kiluk et al., 2011). there is an expanding literature on the use of technology-assisted interventions for the treatment of cud. systematic reviews and metaanalyses report effect sizes in the range of 0.11 0.19, indicating small but significant effects of technology-assisted treatments on cannabis use outcomes (tait, spijkerman, & riper, 2013; hoch et al., 2016; olmos, tirado-munoz, farré, & torrens, 2017). likewise, there is a burgeoning literature supporting the use of internet-based interventions in the treatment of mental health conditions such as depression, with therapistassisted cognitive behavioral therapy (cbt) producing the largest effect sizes, ranging from 0.6-1.9, followed by moderate effect sizes resulting from stand-alone cbt (0.3-0.7) (see saddichha et al., 2014). computer-assisted interventions for substance use disorders have largely been tested in primary addiction treatment settings (carroll et al., 2008), however, these approaches may have the greatest utility in settings where substance use disorders are underdiagnosed, such as in primary mental health or primary care service delivery systems. providing services to address substance use in such settings is feasible (madras et al., 2009; ernst, miller, & rollnick, 2007), can reach many more individuals who need treatment, promises better outcomes (babor et al., 2007; brousselle, lamothe, sylvain, forro, & perreault, 2010), and can reduce health care utilization costs (parthasarathy, mertens, moore, & weisner, 2003; parthasarathy, weisner, hu, & moore, 2001). in the present study, we pilot tested a computer-assisted cbt/met intervention targeting both cud and major depressive disorder (mdd), self-help for alcohol and other drug use and depression (shade), in a primary psychiatric care setting. the efficacy of shade in community based samples of adults with comorbid alcohol use disorders or cud and mdd has been established in two rcts (kay-lambkin, baker, lewin, & carr, 2009; kay-lambkin, baker, kelly, & lewin, 2011). in the first trial, cannabis users with mdd (n=43) reported twice the reduction in cannabis use in response to shade, relative to those who received therapist-delivered cbt/met, and approximately five times the reduction as compared to those who received a single brief intervention session (bi). likewise, shade was associated with a greater reduction in depression relative to bi, and equivalent reductions relative to therapist-delivered cbt/met. these findings were replicated in a larger rct (n=109 primary cannabis users), with those in shade reporting twice the reduction in cannabis use during treatment relative to therapist-delivered cbt/met (kay-lambkin et al., 2011), and those in the control condition slightly increasing cannabis use. of note, in the trials conducted by kaylambkin and colleagues, participants were depressed cannabis users 38 recruited from the community, and thus were treatment-seeking for their cannabis use and mdd. nevertheless, computer-assisted approaches to treating substance use disorders may have the greatest utility in clinical settings where: (1) substance use may be under-recognized and/or undertreated, and (2) evidence-based addiction treatment is not readily available. replicating and extending the prior work of kaylambkin and colleagues, our pilot study was designed to establish the feasibility, perceived helpfulness, and preliminary efficacy of the shade intervention in a primary psychiatric care setting, in a population comprising adults presenting for treatment of mdd. in this setting, we anticipated variability in participants’ recognition of their problematic cannabis use, and correspondingly, in their motivation to change their use of cannabis. we hypothesized that individuals with mdd and comorbid cud presenting for psychiatric care would find the shade intervention to be user friendly, helpful in achieving their goals concerning cannabis use and depression management, and participation in the intervention would be associated with reductions in cannabis use and depressive symptom severity. method participants participants were 26 adults with cud and mdd. the study was approved by the ucla institutional review board. participants were recruited from outpatient psychiatric clinics at the ucla medical center and campus counseling and psychological services center through flyers, clinician referrals, and word of mouth. flyers indicated that the study intervention addressed both depression and cannabis use. a trained research assistant screened all potential participants for eligibility by phone using a brief script. to be eligible for the study, participants were required to: (1) be > 18 years old; (2) have a dsm-5 diagnosis of cud and lifetime mdd (assessed using the psychiatric research interview for substance and mental disorders [prism]; hasin et al., 1996); (3) be able to read and understand english at or above the 6th grade level; (4) report cannabis use on at least 40 of the past 90 days (assessed using the timeline followback); (5) score 9 or higher on the current patient health questionnaire-9 (phq-9), indicating clinically relevant depressive symptom severity; and (6) be on a current antidepressant medication regimen. additionally, given that participants varied in terms of level of insight concerning problematic cannabis use or cud, the research assistant explained that while quitting or cutting back cannabis use was not required, participation requires a willingness to examine how depression and cannabis use patterns may relate to one another, and consider changing cannabis use. individuals were excluded if they: (1) exhibited medical impairment that compromised their safety as a participant; (2) were dependent on alcohol or any other substance from which medical detoxification was required or; (3) had a diagnosis of schizophrenia or schizoaffective disorder. to optimize generalizability, individuals with a diagnosis of bipolar disorder were not excluded. after complete description of the study to participants, informed consent was obtained. participants agreed to: (1) weekly computerized shade intervention sessions to be completed at the clinical research center, followed by a brief check-in with a study clinician for 10 weeks; and (2) in-person assessments weekly and at 1-month follow-up, with $20 compensation for each weekly assessment and $40 for the follow-up. over the 1-year study period, 71 individuals were screened, of whom 49 consented to participate. of those, 30 individuals were inducted and 26 individuals completed the shade intervention program. figure 1 depicts the study participant flow. sample characteristics. of the 49 consented participants, 10 failed the additional screen, and 9 were terminated from the study prior to initiating treatment. these 9 participants were terminated for the following reasons: 5 withdrew consent for reasons such as not enough compensation, transportation issues, or no longer being interested in participating, 3 did not return to complete baseline assessments after screening, and one participant was withdrawn by the investigator for acute and severe mental health symptoms that interfered with study participation. there were no statistically significant differences in baseline demographic characteristics, cannabis use frequency, and depressive symptoms between those who were consented and initiated shade treatment (n=30) cannabis, a publication of the research society on marijuana 39 figure 1. participant flow throughout the study. +inducted, received at least 1 shade session, **completed week 10 of the intervention, ***completed week 14 follow up assessed for eligibility (n=71) inducted+ (n=30) consented (n=49) completed follow-up*** (n=26) completed intervention** (n=26) failed additional screen (n=10) withdrew consent (n=5) withdrawn by investigator (n=1) missed 2+ weeks (n=3) dropouts (n=4) depressed cannabis users 40 and those who were enrolled but did not initiate (n=9). for those who initiated shade treatment, an active protocol to optimize retention included weekly outreach in the form of reminders, and follow-up calls for missed visits via phone, text messaging, and email to optimize treatment completion. four participants dropped out after initiation of shade and were lost to follow up. the participants were on average, 29 years of age (sd=10.9), with a mean of 12.5 years of education (sd=1.8) (see table 1). the sample was predominantly female (54%), never married (80%), and caucasian (73%). on average, participants reported cannabis use on 20 of the past 30 days (sd=11.2) at baseline. alcohol use in the past 30 days was reported by 61% (n=16) of the sample, with an average of 4.5 days using alcohol (sd=6.5) and 3.8 drinks per drinking day (sd=3.3). tobacco use in the past 30 days was reported by 31% (n=8) of the sample, with an average of 5.7 days of self-reported use (sd=10.7). in terms of ancillary treatment, all participants were in psychiatric care for mdd and none had received cud or other substance use disorder treatment in the past 30 days. in the past 90 days, 19% (n=5) reported having attended one or more 12-step self-help meetings, and the majority (80%; n=21) reported having received individual psychotherapy. procedure design. eligible participants completed a baseline assessment with a research associate to confirm eligibility and begin study procedures. once eligibility was confirmed, participants were scheduled for weekly visits over the course of 10 weeks. at each visit, participants completed the weekly computerized shade treatment session (kay-lambkin, baker, & bucci, 2002b; kaylambkin et al., 2009), followed by a brief 10-15minute check-in with a licensed therapist. participants also completed a battery of assessments, at each weekly visit, administered by a research associate. early termination from the study could be a result of missing two consecutive data collection visits or missing two consecutive shade sessions. intervention. self help for alcohol and other drug use and depression (shade). shade comprises a 10week, 10-session, computer-assisted cbt/met intervention for cud and major depressive disorder (kay-lambkin et al., 2011). shade begins with a face-to-face brief, tailored motivational intervention session, in which goals around changing cannabis use are explored and established, and the relationship of cannabis use to depression is examined, and individualized feedback is provided. the computerized shade modules are subsequently initiated in weeks 2 through 10. the text in shade computer modules is at the 6th grade reading level, and has audio accompaniment. at each visit, a research clinician met with the participant for a 10-15minute ‘check-in’ session, which included: review of homework exercises; development of plans for completing homework; brief suicide risk and mood assessment; and confirmation of the next appointment. a motivational interviewing style is employed in all clinician portions of the intervention, including the brief intervention session and the weekly check-ins. shade content. the shade program uses a client-centered approach in that participants choose their therapy goals (e.g., to reduce versus abstain from cannabis use). it also applies cbt strategies, as the program encourages participants to explore the possible relationships between depressive symptoms and cannabis use problems. motivational interviewing techniques are also a key feature of the intervention; later sessions incorporate discussions regarding making and sustaining changes regarding cannabis use. session 1 is a brief intervention emphasizing feedback concerning cannabis use, brief advice, and psychoeducation concerning both depression and cannabis use. the remaining 9 computerized sessions include modules on understanding cannabis use patterns, coping with cravings, mood monitoring, managing thoughts about using drugs, problem solving, drug refusal skills, coping with lapses, managing negative moods, assertiveness skills, and coping with life problems. explicit links between mdd and cud are made throughout. the programming employs three technological styles. first, computerassisted instruction presents information, requires active responses to queries designed to cannabis, a publication of the research society on marijuana 41 assess knowledge acquisition, and evaluates and provides immediate feedback. second, actors model coping behavior via video-based simulation (e.g., drug refusal skills). third, interactive exercises and worksheets are utilized to enhance learning and personalize content. participants use a unique password to access their program via the internet in a designated clinic office. prior computer experience is not necessary as the first module provides training. the master’s level study therapist, who was formally trained prior to this study in cbt and met, received standardized training on explication, demonstration, and role-playing of the shade intervention components, from dr. kay-lambkin, who developed the program. dr. kay-lambkin provided weekly supervision to the study therapist throughout the course of the trial. procedures and instruments trained interviewers conducted assessments at baseline, weekly during treatment, and at discharge and 1-month followup. cannabis use disorder was diagnosed at baseline using the prism (hasin, 1996). cannabis use. cannabis use was assessed using urine drug screens and the timeline follow back (tlfb), a calendar assisted structured interview (sobell & sobell, 1992) with demonstrated validity in substance treatment samples (fals-stewart, o’farrell, freitas, mcfarlin, & rutigliano, 2000). the tlfb was used to assess the number of days and daily use frequency in the preceding 30-day period at baseline, weekly during the intervention phase, and 30 days prior to follow-up. daily use frequency was assessed over each one-hour interval of the day (see hughes et al., 2014). for instance, if a participant smoked cannabis three times between 10-11, this was recorded as one episode of use. if a participant smoked cannabis at 10 and then at 11, this was recorded as two episodes of use. abstinence was examined as an exploratory outcome, given the variability in participants’ motivation to reduce versus abstain from cannabis use. to this end, urine specimens were collected at baseline, weeks 1 through 10 and at follow-up and tested using temperature controlled, fda-approved one-step, test cups (cliawaived inc). creatinine level (<30 ng/ml) was used to assess validity of the specimen, and an invalid specimen prompted requests to provide another specimen within 4–24h. based on prior studies (derogatis & melisaratos, 1983), the primary abstinence outcomes were the number of cannabinoid-negative urine specimens provided during the trial (ranging from 0 to 10) and the longest duration (i.e., weeks) of continuous abstinence. cannabis outcome goals were assessed using the marijuana outcome goals questionnaire (lozano et al., 2006). participants were asked about their goals with respect to changing their use of cannabis. answer choices were to “not use marijuana at all” or “use marijuana only in certain ways.” participants were also asked to rate, on a scale of 0 to 100, how important it is to them to achieve their goal. depression. the prism (hasin et al., 1996), a semi-structured interview with demonstrated reliability (hasin et al., 1996) and validity for differentiating substance-induced psychiatric symptoms from psychiatric disorders that are temporally independent from substance use, was administered by a trained research assistant at baseline to assess for lifetime major depressive disorder and to rule out schizophrenia and schizoaffective disorder. the interviewer was trained to criterion on the prism using standardized procedures including didactic instruction, practice interviews, and direct observation. the patient health questionnaire (phq-9), a reliable and valid measure of depressive symptom severity (spitzer, kroenke, williams, & patient health questionnaire primary care study group 1999; kroenke, spitzer, & williams, 2001) is a self-administered, 9-item questionnaire with scores ranging from 0 to 27. the phq-9 was administered at baseline and all subsequent visits during and after treatment. self-efficacy. the marijuana self-efficacy scale measured efficacy for avoiding use in situations involving negative affect, social discomfort, and presence of others using cannabis (litt et al., 2005). coping skills. the coping strategies scale assesses use of cbt based coping skills. ratings of frequency of use for various coping strategies provides a total coping score (litt et al., 2005). health related quality of life. the eq-5d is a self-report, standardized instrument to measure health outcomes of five broad areas or domains: depressed cannabis users 42 mobility, self-care, usual activities, pain/discomfort and anxiety/depression (euroqol group, 1990). participants were asked to rate whether they have no problems, moderate problems or extreme problems as it pertains to each domain. eq-5d descriptive scores were then converted to single summary index (euroqol, 1990). statistical analysis cannabis use was indicated by: (1) number of cannabis-negative urine drug screens; (2) percentage of days using in the past 30 days; (2) number of times cannabis was used per day. chisquare and paired t-tests were used to analyze baseline to post-treatment differences on key outcome variables. subsequently, using preto post-treatment change scores, correlational analyses were employed to examine the association between changes in cannabis use and functional outcomes (e.g., depressive symptom severity, health-related quality of life). results treatment acceptability, defined as attending 2 or more urine testing appointments (greater than 1 week of study participation) was excellent (95%). on average, participants submitted 8.8 of 10 urine specimens over the course of treatment and attended 9.6 of the 10 shade treatment sessions, consistent with prior trials conducted in non-psychiatric settings. treatment completion, defined as providing a urine specimen during week 10, was achieved by the majority of participants (85%). the percentage of days in the past 30 in which participants reported using cannabis declined from baseline (m=69%, sd=29%) to treatmentend (m=52%, sd=34%), an effect that approached significance, t(25)=1.9, p=0.05, d = 0.54. nevertheless, the percentage of days of use was significantly lower than baseline at 1-month follow-up (m= 44%, sd=41%), t(22)= 2.3, p<0.05, d = 0.79. the number of times cannabis was used per day on use days also declined significantly from m=2.7 times per day (sd=1.6) at baseline to m=1.7 times at discharge (sd=0.9), t(22)=2.8, p<0.05, d = 0.77). at follow-up, the number of times cannabis was used per day remained lower than that observed before treatment initiation (m=2.1, sd=1.4); however, this difference was not statistically significant. mean percentage of cannabis-negative toxicologies was 27% over the course of treatment, and 33% at 1-month followup. a little over a third of the sample (35%) achieved 2 or more consecutive weeks of abstinence from cannabis use over the 10-week intervention period. in terms of cannabis treatment goals, 15% of participants reported that their objective was “to not use at all” and the remaining endorsed the following goal: “to use marijuana only in certain ways,” the average baseline rating for changing cannabis use as a goal was 53.5 (sd=26.3) out of 100, indicating that it was of moderate importance. depressive symptom severity was reduced from the moderately severe range at baseline (m=13.3, sd=4.7) to the mild range at week 10 (m=8.0, sd=5.3), t(23)=5.3, p<0.001, d = 0.89. at 1-month follow-up, severity was further reduced from baseline (m=6.0, sd=4.9), t(24)=7.3, p<0.001, d = 1.52. reductions in cannabis use were significantly correlated with changes in functional outcomes, including reductions in depressive symptoms at both treatment-end (r=0.41, p<0.05) and 1 month fu (r=0.51, p<0.05), and health-related quality of life, measured by the eq-5d at treatment-end, albeit at the trend level (r=-0.35, p=0.12) and 1 month fu (r=-0,48, p<0.05). self-efficacy increased from baseline (m=65.5, sd=22.4) to treatment end (m=80.5, sd=31.2), t(21)=-3.03, p<0.01). likewise, coping skills improved significantly from initiation to completion of treatment, t(22)=-3.2, p<0.01. perceived helpfulness of shade was assessed using a consumer feedback questionnaire. the majority of participants agreed or strongly agreed that: they liked the shade content overall (100%); the therapist check-in component of the intervention was helpful (90%); they learned new information about relapse, triggers, and cravings (70%); and the shade program helped them work towards their goals (90%). qualitative participant feedback concerning shade corresponded with quantitative responses, and included the following: “shade gave me the tools. before this i felt a lot more helpless about the situation, and this was something i would live with for the rest of my life, and when it happened [depressive cannabis, a publication of the research society on marijuana 43 episodes, cannabis use], i had no control. now, i feel like… i have a lot more control over it.” shade homework “helped me focus throughout the week”, and the mindfulness activities “provided a conceptual framework for seeing the world from a more neutral perspective.” to begin to examine costs associated with shade delivery, we measured the amount of therapist time spent on the clinician delivered component of the intervention at each session. on average, time spent face-to-face with a clinician was 13 minutes (sd=6) per session, with an overall total of 105 minutes (sd=31) over the course of the intervention. discussion this is the first study to implement shade, a computer-assisted, integrated cud and mdd intervention in a primary psychiatric care setting. initial findings from this pilot investigation are promising, suggesting that introducing an integrated intervention in this setting is feasible and acceptable. a substantial proportion of screened participants who were receiving psychiatric care for mdd demonstrated interest in receiving an intervention targeting mdd and cud concurrently, and among those who enrolled, the majority perceived the intervention as helpful. likewise, most of the participants were retained in the computerized intervention, engagement and completion rates were excellent, reductions in depression were highly significant with corresponding large effect sizes, and changes in cannabis use were observed. cannabis abstinence rates over the course of treatment, while somewhat lower than that observed in other psychosocial clinical trials that involved computerized or face-to-face cbt/met (budney et al., 2011), were nevertheless noteworthy given the variability in participants’ motivation to change their use of cannabis. given the primary mental health care setting from which participants were recruited, it is not surprising that abstinence from cannabis use was infrequently endorsed as a treatment goal (i.e., only 15% reported an abstinence goal, with the remainder focused on reducing their use). thus, although abstinence rates were somewhat lower in this study relative to prior trials among depressed cannabis users (kay-lambkin et al., 2009; 2011), the observed capacity of the shade intervention to facilitate reductions in cannabis use among individuals who were predominantly open to changing, but not abstaining from cannabis use, is encouraging. likewise, despite the fact that cannabis use frequency at baseline was on average, somewhat lower than that reported in other clinical samples, changes in cannabis use, albeit moderate in terms of effect size, were observed from preto post-treatment. the potential to use a computer to deliver evidence-based therapies targeting substance use among individuals with major depression has important implications for clinical practice. first, easily deployable strategies for treating substance use disorders outside of specialty addiction treatment settings are needed, particularly among those with multiple chronic conditions. given the observation in this study that individuals in primary psychiatric care are receptive to an intervention addressing substance use, this model has the potential to be extended to other primary care settings, where substance use disorders are under recognized and undertreated, largely owing to the lack of availability of evidence-based treatments. moreover, although the shade intervention includes clinician involvement to assess for safety and reinforce therapeutic skills training and practice, therapist involvement in the delivery of this intervention is quite minimal from a cost perspective, with an average of 10 minutes spent with each participant per session (total of 90 minutes over the course of the intervention). although we did not conduct a cost analysis in the present study, prior work employing similar computerized cbt/met intervention protocols among cannabis users has shown substantial cost savings associated with reduced therapist time (i.e., approximately 10 fold less time), when the computerized condition was compared to a face-to-face intervention of equivalent frequency (see budney et al., 2011; 2015). moreover, using computerized cbt as an adjunct to usual care is cost effective and of good value from both clinician and patient perspectives (olmstead et al., 2010). though computer purchase costs are incurred with computerized interventions, these costs are relatively minimal when compared to the personnel and space costs associated with face-to-face behavioral treatment delivery. another advantage of using computer-assisted interventions such as shade in the treatment of depressed cannabis users 44 psychiatrically comorbid substance users is the potential reallocation of therapist time and effort for the most severe cases of multiple chronic conditions. additionally, given that comorbid populations are often difficult to reach, schedule for treatment, retain, and follow, technology assisted approaches may be of great value and have not been extensively tested in complex populations with more than one axis i disorder. finally, the standardization of treatment content and delivery achieved through this medium enhances replicability as well as our ability to study and understand the components of treatment that are effective in improving target outcomes. despite the promise of our preliminary outcomes and the clinical practice implications of this novel approach to the treatment of cooccurring cud and mood disorders, several limitations of the present investigation warrant comment. this study included a small sample size, did not employ control group for comparison with the shade intervention, and did not include post-treatment follow-up assessments beyond one month. moreover, continuous abstinence rates may have been underestimated given the long half-life of cannabis and the corresponding latency for some individuals to produce a cannabis-negative urine sample. the lack of a control group raises perhaps the most critical issue. in the absence of a control condition, one cannot directly determine if the shade intervention produced positive outcomes or had no effect at all. however, two prior rcts demonstrating the efficacy of the shade intervention among depressed cannabis users in reducing depressive symptoms and cannabis use (kay-lambkin et al., 2009; kay-lambkin et al., 2011), would suggest the former. whether changes in cannabis use and depression in response to shade in a psychiatric treatmentseeking population are comparable to those achieved when cbt/met are delivered face-toface remains to be tested and is an important future direction for research into this approach. a planned randomized trial will address many of the limitations of the current pilot trial. 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(2013). internet and computer-based interventions for cannabis use: a meta-analysis. drug and alcohol dependence, 133, 295-304. funding: the research presented in this paper was supported by nida grant 1r56da0367118 awarded to s. glasner and a p30 “center of excellence” grant from nida, da029926 (pi: lisa marsch, ph.d.). acknowledgments: we thank anne bellows lee and kathryn chavez for their assistance with data collection. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. brief report 22 ved abstract cannabis is increasingly accessible and use is increasing rapidly among older adults as laws change and cannabis becomes more frequently prescribed in healthcare settings. past research identified cognitive effects of cannabis use among adolescents and young adults that can persist for several weeks after intoxication, though little is known about how these effects generalize to older adults. participants (n = 1348) were drawn from the health and retirement study (hrs) and were categorized as current occasional users (up to once/week in the past year, n = 36), current frequent users (once per week or more in the past year, n = 92), past users (n = 334), and non-users (n = 886). participant ages ranged from 50 to 98 (m = 67.25, sd = 10.68). uncontrolled, one-way anovas and controlled ancovas were used to examine between-group differences on immediate and delayed wordlist memory and working memory (serial sevens). when controlling for age, gender, education, and minority status, current frequent users demonstrated significantly worse immediate memory performance compared to past and non-users. however, this difference could have been the result of acute, residual effects of past-month cannabis use among current users. in controlled analyses, there were no differences between groups on delayed or working memory. findings indicate that greater than weekly cannabis use may result in attentional and short-term memory deficits. further, these effects may be mitigated by sustained abstinence. limitations including sample size and measures of cannabis use warrant future studies to replicate and build upon these findings. key words: = marijuana; cognition; aging the cannabis plant has been used for thousands of years, yet still incites controversy today. the prevalence of cannabis use among older adults is increasing for several reasons, including cohort and period effects (han et al., 2017; kerr et al., 2018), and applicability in healthcare. cannabis is being used for a variety of ailments including management of pain associated with musculoskeletal problems and other sources of chronic pain, reducing spasticity in multiple sclerosis, and promoting sleep efficiency and appetite for varying patient populations (national academies of sciences engineering and medicine, 2017). older adults (individuals aged 65 and above) experience agerelated cognitive decline (cabeza et al., 2018) and multimorbidity (king et al., 2018) with corresponding polypharmacy (wastesson et al., 2018). while cognitive and physiological effects of cannabis use in adolescents and young adults have been frequently investigated, little is known about the potential acute and chronic cognitive side-effects of cannabis use among older adults. in the interests of informing both public health and the eventual creation of moderate use guidelines, the current study contrasts cognitive performance madison maynard1, daniel paulson1, michael dunn1, robert d. dvorak1 1 department of psychology, university of central florida cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000153 relationship between cannabis use and immediate, delayed, and working memory performance among older adults corresponding author: madison maynard, 4111 pictor ln, orlando, fl, 32816. email: madisonmaynard@knights.ucf.edu. cannabis, a publication of the research society on marijuana 23 between groups with varying patterns of cannabis use. taken together, previous findings that cannabis acutely impairs cognition in younger populations coupled with the inconclusive evidence of persisting cannabinoid effects after cessation of use, and very limited evidence of similar effects among older adults, suggests a gap in the literature which needs to be addressed. some literature (auer et al., 2016; broyd et al., 2016; ganzer et al., 2016; lovell et al., 2020; thames et al., 2014) suggests a linear relationship between extent of cannabis use and cognition. this relationship may be exaggerated by frequency of use (broyd et al., 2016), duration of use (stypulkowski & thayer, 2022), and agerelated cognitive decline. however, another line of research indicates there may be null effects of cannabis use on cognition in later-life, contrary to its deleterious effects on learning and processing speed in younger populations (mueller et al., 2021; weinstein & sznitman, 2020). thus, the examined hypothesis was that cannabis nonusers, past users, current occasional (less than weekly) users, and current frequent (at least weekly) users would differ in performance on working memory, immediate memory, and delayed memory. methods participants participants were drawn from the longitudinal health and retirement study (hrs) conducted by the university of michigan and supported by the national institute on aging (grant number nia u01ag009740). the university of central florida’s irb therefore determined the current study exempt from review, indicating no involvement of human subjects. the hrs includes seven birth cohorts (spanning six years each) of adult respondents age 50 years and older living in the united states and assesses factors related to health, retirement, and aging via telephone and inperson interviews. data collection in the hrs is biannual, beginning in 1992 and continuing today (health and retirement study, 2018). respondents are offered financial incentive for completing different survey components. additionally, to ensure adequacy in capturing the experiences of all older americans, minority groups (specifically, black/african american and hispanic individuals) and residents of florida are oversampled (hrs staff, 2008a, 2008b). in this study, data from the 2018 wave of participants, collected between april 2018 and june 2019, was used. a subsample of respondents was randomly selected for inclusion in a separate module assessing for cannabis use habits and attitudes. respondents to the question “have you ever used marijuana or hashish?”, found in the module 4 questionnaire, were included for data analysis. measures demographic data was obtained from the hrs cross-wave tracker file. this data accounted for respondent age, masked race (white/caucasian, black/african american, other), ethnicity (not hispanic, hispanic), gender (male, female), and years of cumulative education. race was dichotomized by minority status (white and nonwhite) to elicit more meaning from group comparisons than the original small, heterogeneous race group divisions would permit. cannabis use was defined by respondent answers to the module 4 questionnaire. prior to grouping, participants under the age of 50 (born after 1968) were filtered out of the dataset. respondents were then divided into groups based on recency and frequency of cannabis use. a control group of non-users (n = 885) indicated that they had never “used marijuana or hashish”, while users (n = 462) indicated that they had. users who subsequently responded “no” to the question, “have you used marijuana or hashish within the past year?” were considered past users (n = 334), while those who responded “yes” were current users (n = 148). current users were dichotomized based on the question “when you used marijuana or hashish most frequently, about how often did you use it?” participants then were asked to provide a number and select a unit of time to capture their heaviest period of use, as follows: “[number] times per [day, week, month, or year]”. to create equivalent units for every participant, each answer was converted to an estimated number of use times per year, whereby ‘1 time per day’ was equated to ‘365 times per year.’ current occasional users (n = 36) indicated that at the time of their heaviest marijuana use, they used less than 52 times per year. current frequent users (n = 92) indicated use 52 times per year or more. cannabis and older adults’ memory performance 24 cognition data was obtained from section d of the 2018 hrs core file. working memory was assessed using the serial 7’s task, in which participants must count backwards from 100 in increments of 7 and are given one point for each correct subtraction (even if a prior subtraction was incorrect) out of 5 answers in total (folstein et al., 2001). immediate free-recall and delayed freerecall (ofstedal et al., 2005) were assessed using a 10-item wordlist task, where participants were read a list of 10 nouns and asked to recall from memory those words immediately, and again after a delay of 5 minutes. final scores reflect the number of correct responses. measures of cognition in the hrs are described in detail in prior publications (ofstedal et al., 2005). although reliability and validity are not indicated for individual memory subtests, the cognitive items were adapted from the telephone interview for cognitive status (brandt et al., 1988), and despite minor methodological flaws, are generally considered to have sufficient construct validity (herzog & rodgers, 1999). within this sample, test-retest reliability for serial 7s scores, obtained in 2016 and 2018, was adequate (r = .65, p < .001). statistical analyses primary hypotheses were tested first using uncontrolled, one-way analyses of variance (anova) and subsequently, analysis of covariance (ancova) including age, gender, education, and race (tabachnick & fidell, 2013). the effect of cannabis use group status on immediate, delayed, and working memory were evaluated using this procedure. because groups were variable in size, the sidak post-hoc comparison procedure was employed. results the sample included 1,348 participants (59% female; n = 797). demographic data is provided in table 1. the sample was predominantly white (67%), and age ranged from 50-98 years (mean age = 67.25 years, sd = 10.68), and mean education was 13.05 years (sd = 3.05). participants were categorized as cannabis non-users (n = 886), past users (n = 334), current occasional users (used less than 52 times per year; n = 36), or current frequent users (used 52 times or more per year; n = 92). within the current occasional use group, 50% of respondents used cannabis 1-3 times per year (n = 18), 27.8% used 6-12 times per year (n = 10), and 22.2% used 2-4 times per month (n = 8). within the current frequent use group, 42.4% of respondents used 1-3 times per week (n = 39), 35.9% used 4-7 times per week (n = 33), and 21.7% used 2 or more times per day (n = 20). table 1. descriptive statistics by cannabis use group variables mean (sd) or % full sample (n=1348) current frequent (n=92) current occasional (n=36) past users (n=334) non-users (n=886) age 67.25 (10.68) 60.58 (6.22) 61.89 (9.31) 62.47 (7.80) 69.96 (11.03) gender (% female) 59.1% 41.3% 58.3% 47.0% 65.6% race (masked) white/caucasian 66.8% 64.1% 77.8% 64.1% 67.6% black/african american 22.0% 27.2% 13.9% 25.1% 20.5% other 11.1% 8.7% 8.3% 10.5% 11.7% hispanic ethnicity 13.9% 5.4% 8.3% 5.4% 18.3% cumulative years of education 13.05 (3.05) 13.51 (2.46) 13.94 (2.16) 13.56 (2.53) 12.78 (3.27) immediate recall 5.53 (1.63) 5.34 (1.80) 6.19 (1.58) 5.80 (1.56) 5.43 (1.62) delayed recall 4.58 (1.97) 4.57 (2.20) 5.32 (1.87) 4.80 (1.90) 4.46 (1.96) serial 7s 3.51 (1.69) 4.04 (1.50) 3.69 (1.74) 3.72 (1.60) 3.36 (1.72) cannabis, a publication of the research society on marijuana 25 regarding assumptions of anova-based statistical procedures, immediate and delayed memory scores were essentially normal upon visual inspection. serial 7’s task scores were negatively skewed, and a perfect score of 5 was the modal score. given the shape of the distribution, data transformations did not improve compliance with parametric assumptions. we examined the analysis using logarithmic, cube-root, and squared transformations (all appropriate for left skew). analyses were conducted on all of these outcomes. while this did tend to result in more normally distributed residuals, there was no difference in the interpretation of the model parameters. thus, for ease of interpretation, we present the nontransformed analyses, however, where possible, non-parametric analyses were employed. uncontrolled, one-way anovas and controlled ancovas were used to examine the effects of cannabis use on immediate memory, delayed memory, and working memory. uncontrolled analyses found that cannabis use group was associated with immediate memory, f(3,1246) = 6.09, p < .001, ηp 2 = .014. past users (m = 5.80, se = 0.09) were found to have slightly better immediate memory performance than those who had never used (m = 5.43, se = 0.06). by contrast, multivariate analyses found that when controlling for gender, f(1,1234) = 11.84, p < .001, ηp 2 = .010; education, f(1,1234) = 87.02, p < .001, ηp 2 = .066; age, f(1,1234) = 112.68, p < .001, ηp 2 = .084; and minority status, f(1,1234) = 17.27, p < .001, ηp 2 = .014, cannabis use was still associated with immediate memory, f(3,1234) = 3.68, p = .012, ηp 2 = .009 (see figure 1). controlling for demographic variables, post-hoc findings were that current frequent users’ (m = 4.94, se = 0.16) immediate memory was worse than that of both non-users (m = 5.48, se = 0.06) and past users (m = 5.49, se = 0.09; p < .05 for both). uncontrolled analyses suggested a significant main effect of cannabis use on delayed memory f(3,1245) = 3.71, p = .011, ηp 2 = .009. post hoc findings revealed a non-significant trend whereby non-users (m = 4.47, se = 0.07) had slightly worse delayed memory scores than past users (m = 4.80, se = 0.11, p = .063) and current occasional users (m = 5.32, se = 0.35, p = .097). multivariate analyses controlling for gender, f(1,1233) = 7.21, p = .007, ηp 2 = .006; education, f(1,1233) = 85.89, p < .001, ηp 2 = .065; age, f(1,1233) = 112.87, p < .001, ηp 2 = .084; and minority status f(1,1233) = 50.56, p < .001, ηp 2 = .039, found that cannabis use group was no longer associated with delayed memory, f(3,1233) = 1.63, p = .182, ηp 2 = .004. figure 1. summary of covariate adjusted means and standard errors of cognitive task scores for each cannabis use group cannabis and older adults’ memory performance 26 uncontrolled analyses suggested a significant main effect of cannabis use on working memory based on the serial sevens task f(3,1344) = 6.76, p < .001, ηp 2 = .015. post hoc findings showed that non-users’ (m = 3.36, se = 0.06) working memory was worse than both past users (m = 3.72, se = 0.09) and current frequent users (m = 4.00, se = 0.18; p < .01 for both). given that serial sevens data were heavily skewed, this analysis was repeated using a kruskal-wallis nonparametric test. interpretation of those results, h(3) = 24.76, p < .001, did not differ from interpretation of the anova. multivariate analyses controlled for gender, f(1,1332) = 14.54, p < .001, ηp 2 = .011; education, f(1,1332) = 160.16, p < .001, ηp 2 = .107; age f(1,1331) = 5.59, p = .018, ηp 2 = .004; and minority status f(1,1332) = 78.27, p < .001, ηp 2 = .055, found that cannabis use group was no longer associated with working memory f(3,1332) = 1.67, p = .171, ηp 2 = .004. discussion this study aimed to examine the relationship between cannabis use and immediate, delayed, and working memory in older adults. univariate findings were that past users’ immediate memory, delayed memory, and working memory were better than those of non-users. multivariate findings controlling for age, gender, education, and minority status were that current frequent users had worse immediate memory than did nonusers or past users, but no differences were found for delayed memory or working memory. occasional (less than weekly) and past users, however, performed comparably to non-users on all three measures of cognition, suggesting that past use does not adversely impact current functioning among older adults. the disparity between univariate and multivariate findings is not surprising in the substance use literature (delker et al., 2016), and underscores the critical importance of controlling for demographic characteristics in future research on cannabis use with older adults. frequent users’ relative deficits in immediate memory may be explained by residual effects of cannabinoids in the system. past research indicates that cognitive consequences of cannabis use can be attributed to residual cannabinoids or withdrawal and appear to resolve with approximately 25 days of abstinence (schreiner & dunn, 2012), a threshold not met by the frequent use group. the immediate free-recall task evaluates two primary cognitive components: attention and short-term episodic memory (gavett & horwitz, 2012). the findings that immediate memory was associated with recent frequent use, but delayed and working memory were not, suggest attentional deficits as a likely explanation. while cognitive impairments seen in cannabis users are somewhat inconsistent across literature, overall, findings support the idea that attentional impairments are present with acute cannabis use and persist mainly as a residual effect (broyd et al., 2016; ganzer et al., 2016; national academies of sciences engineering and medicine, 2017). deficits in immediate, delayed, and working memory are known to occur with acute use, and often resolve after periods of abstinence (broyd et al., 2016; national academies of sciences engineering and medicine, 2017). interestingly, aside from immediate memory, the current study contradicts past findings of delayed and working memory deficits. these findings may suggest that older adults are somehow less sensitive to adverse cognitive effects of cannabis use, that other dynamics of cognitive aging obscure these effects, or that limitations imposed via use of this large secondary dataset prevent measurement of these effects. in any case, future research should further examine cognitive, social, neuroanatomical, and later-life developmental impacts of cannabis use. given these results, older adults should be advised that frequent (at least weekly) cannabis use likely has negative effects on immediate memory. due to the unclear parameters of cannabis use available for this study, this finding could be interpreted in three ways. it is presently unclear if poorer immediate memory performance among frequent users is due to a cumulative effect of cannabis consumption over time, a pre-existing deficit in immediate memory performance among the self-selected population of individuals who subsequently initiate frequent cannabis use, or whether this effect reflects lingering sequalae of recent cannabis intoxication. these results suggest that, if no pre-existing difference exists between groups, cognitive effects of frequent use may be mitigated by sustained abstinence over time. older adults should consider that deficits in attention and short-term episodic memory may cannabis, a publication of the research society on marijuana 27 impede both social functioning (faraone et al., 2000) and performance of tasks associated with independence, including driving (barkley & cox, 2007). however, the prominence and practical application of such effects in older adult populations needs corroboration through future. current findings do not speak to perceived quality of life in older adults and its association with cannabis use (goldenberg et al., 2017). given the various medicinal and recreational purposes of cannabis consumption, such cognitive effects may be an acceptable tradeoff. older adults who are past cannabis users performed comparably to nonusers and therefore may not need to consider past cannabis use as a threat to present cognitive functioning. similarly, occasional (less than weekly) users do not differ from non-users, although this finding should be cautiously interpreted due to various limitations of the present study including variant sample size, measurement imprecision regarding cannabis use, and lack of control for certain confounding factors. the primary limitation to this study was its sample size – although cannabis use was assessed among many respondents, cannabis use groups were largely variant in size. this study was also limited by the measures of cannabis use collected from respondents. participants were asked if they had used cannabis within the past year, but nothing further denoting more recent cannabis use. assessment of use within recent hours, days, and/or weeks may better differentiate use patterns and residual effects among current users (schreiner & dunn, 2012). frequency of use was the only quantifiable dimension of cannabis use addressed in the module 4 hrs data. lack of standard “serving sizes” as in alcohol research is a known methodological challenge in cannabis research, especially prior to 2021 (national institutes of health, 2021) and future research should attempt to address dosage and/or cumulative lifetime use to further characterize cannabis use patterns. finally, although the present study controlled for age, gender, minority status, and education, other control variables not addressed by this study may influence cognitive performance between groups. depression (national academies of sciences engineering and medicine, 2017) and alcohol use (topiwala & ebmeier, 2018) are 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(2018). an update on the clinical consequences of polypharmacy in older adults: a narrative review. expert opinion on drug safety, 17(12), 1185-1196. https://doi.org/10.1080/14740338.2018.154684 1 weinstein, g., & sznitman, s. r. (2020). the implications of late-life cannabis use on brain health: a mapping review and implications for future research. ageing research reviews, 59, 101041. https://doi.org/10.1016/j.arr.2020.101041 funding and acknowledgements: the authors received no financial support for the research, authorship, and/or publication of this article. conflict of interest statement: the authors have no conflicts of interest to disclose. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 14 abstract young adult veterans are at risk for problematic marijuana use and associated consequences, which is partially due to their high rates of posttraumatic stress disorder (ptsd), depression, and problematic substance use. veterans tend to endorse more severe and chronic mental health symptoms compared to their civilian counterparts and they identify marijuana use as a method to cope with their symptoms. given the prevalence of marijuana use among veterans in the community and in clinical settings, it is important to explore the factors that may help minimize harm associated with use for those that choose to use the drug. the present study sought to examine the impact of protective behavioral strategies on the relationship between mental health symptoms and marijuana use and consequences in a sample of 180 young adult veteran marijuana users. participants were recruited via social media advertisements and completed measures of marijuana use and consequences, protective behavioral strategies, and ptsd and depression symptoms. findings indicated that more frequent use of protective behavioral strategies was associated with less marijuana use and consequences. participants who screened positive for ptsd or depression reported more marijuana consequences than did those not positive on these screeners. regression analyses revealed protective strategies moderated the relationship between ptsd and marijuana consequences such that young veterans who endorsed more ptsd symptoms and infrequent use of protective strategies reported the most marijuana consequences. no moderating effects were found for the relationship between depression and marijuana consequences. findings have clinical implications for working with young veterans. key words: cannabis, marijuana, veterans, young adult, protective behavioral strategies, posttraumatic stress disorder, depression, pbsm marijuana use among young adults in the united states approximately 10% of the american population reports past year marijuana use, with young adults between the ages of 18 and 29 reporting the highest annual prevalence rates (21%; hasin et al., 2015). about 7% of young adults ages 19 to 28 report daily use of marijuana (johnston, o'malley, bachman, schulenberg, & miech, 2016). the annual prevalence rates for marijuana use have increased over the past 10 years, as has the frequency of days used and the rates of daily use among marijuana users (compton, han, jones, blanco, & hughes, 2016; hasin et al., 2015). it is estimated that 8% of 1829 year olds and 3% of all 30-34 year olds meet corresponding author: eric r. pedersen, rand corporation, email: ericp@rand.org cannabis 2018, volume 1 (1), 14-27 © author(s) 2017 researchmj.org doi: 10.26828/cannabis.2018.01.002 open access use of protective behavioral strategies among young adult veteran marijuana users eric r. pedersen1, margo c. villarosa-hurlocker2, mark a. prince3 1 rand corporation, santa monica, ca 2 center on alcoholism, substance abuse, and addictions, university of new mexico, albuquerque, nm 3 department of psychology, colorado state university, ft. collins, co http://dx.doi.org/10.26828/cannabis.2018.01.002 cannabis, a publication of the research society on marijuana 15 criteria for a cannabis use disorder; among marijuana users these rates are 35% and 29% for 18-29 year olds and 30-34 year olds, respectively (hasin et al., 2015). the substance abuse and mental health services administration (samhsa, 2014) has identified marijuana as one of the most frequently abused substances in the united states and as a result, researchers have sought to identify those individuals at risk for developing a cannabis use disorder. veterans and marijuana use american veterans are one such at-risk group for marijuana use and cannabis use disorder due to their tendency to experience more severe medical problems and psychiatric difficulties compared to the general population (hoerster, lehavot, simpson, mcfall, reiber, & nelson, 2012; luncheon & zack, 2012). while reports of prevalence rates among veterans are limited, studies of veterans seeking services at the veterans health administration (va) suggest that approximately 12% of the veteran population reports past year marijuana use (goldman et al., 2010), with 1% of all va patients meeting criteria for a cannabis use disorder (bonn-miller, harris, & trafton, 2012b). though rates of cannabis use disorder among va patients are lower than what is seen in the general population, the rates of cannabis use disorder increased by approximately 59% between 2002 and 2009 among va patients, with the largest increases seen among younger veterans (bonn-miller et al., 2012b). a number of consequences have been observed among treatment seeking veterans in the va, such as respiratory, cardiovascular, and cognitive issues (goldman et al., 2010). importantly, researchers found that cannabis use disorders have been significantly underdiagnosed in the va, indicating that the prevalence rates of marijuana use and consequences among veterans may be higher than currently reported (bonn-miller, bucossi, & trafton, 2012a). it is necessary to also expand research efforts beyond studying those diagnosed with cannabis use disorder to examine prevalence rates of marijuana use and consequences among veterans outside va treatment settings. one attempt to better capture the marijuana prevalence rates of veterans in the community examined a sample of nearly 1,000 young adult veterans aged 19-34 recruited using social media and found that the sample was similar in demographics to the young veteran population (i.e., both va and non-va veterans), with the exception of race/ethnicity and former branch of service (pedersen, helmuth, marshall, schell, punkay, & kurz, 2015). using percentages weighted by the population estimates of race/ethnicity and former service branch, we found that 57% of veterans reported lifetime marijuana use, with 41% of lifetime users reporting past six-month marijuana use (24% of the full sample). using a screening measure for hazardous levels of marijuana use indicating a potential cannabis use disorder, we also found that 10% of the sample screened positive for hazardous marijuana use (pedersen, marshall, & kurz, 2016b). though this sample may not be generalizable to all veterans, these studies elucidate that marijuana use and resulting disorders are prevalent among veterans both presenting to the va for treatment and those nontreatment seeking veterans in the community, and that prevalence is particularly high among young adult veterans. use of marijuana to cope with mental health problems given that veterans also report high rates of mental health problems, most frequently depression and posttraumatic stress disorder (ptsd; schell & marshall, 2008; seal et al., 2011), it is possible that veterans may use marijuana to cope with mental health symptoms. first, there is much overlap between substance use disorders and depression and ptsd among veterans (seal et al., 2010). for example, since 2009, cannabis use disorder has been the most frequently diagnosed substance use disorder among veterans seeking care at the va for ptsd and substance use problems (bonn-miller & rousseau, 2017). marijuana use has been linked to increased mood, anxiety, ptsd symptoms, and psychotic disorders among va veterans (boden et al., 2013; bonnmiller et al., 2013; galang, babson, boden, & bonn-miller, 2015; goldman et al., 2010). gentes and colleagues (2016) found that among veterans seeking ptsd treatment, those who used marijuana in the past six months were more likely to experience more severe ptsd, depression, and suicidality than those who did not use. among va veteran marijuana protective strategies 16 patients with a cannabis use disorder in 2009, nearly three-quarters (71%) met criteria for cooccurring mental health diagnoses; more specifically, 23% also met criteria for depression and 29% also met criteria for ptsd (bonn-miller et al., 2012b). for comparison, we found that in our community sample, 6% of veterans screened positive for both ptsd and hazardous marijuana use and 5% screened positive for both depression and hazardous marijuana use (pedersen et al., 2016b). among those who screened positive for hazardous marijuana use, 60% also screened positive for ptsd and 50% also screened positive for depression. we also observed greater rates of lifetime and past month marijuana use among those screening positive for ptsd than among young adult veterans not screening for ptsd such that past month use was 2.3 times higher for those screening for ptsd than those not screening for ptsd (grant, pedersen, & neighbors, 2015). although rates of overlap between mental health problems and marijuana use indicate veterans may be using the drug to cope with negative affect (e.g., bonn-miller et al., 2012b), more direct research supports the idea. information gathered from veteran focus groups revealed most veterans believed marijuana helped reduce ptsd symptoms (elliot, golub, bennett, & guarino, 2015). in addition to reporting higher levels of marijuana use, cravings, and problems, those with cannabis use disorder and ptsd reported more use of marijuana to cope compared to those with cannabis use disorder without ptsd (boden et al., 2013). grant and colleagues (2015) found that young adult veterans’ beliefs about the relaxation and tension-reduction effects of marijuana (i.e., marijuana expectancies) moderated the association between ptsd and marijuana use, such that those who screened positive for a ptsd diagnosis and reported high relaxation and tension reduction marijuana expectancies were more likely to report past-month marijuana use. a veteran may believe that marijuana can lead to feeling calm and relaxed, thus reducing ptsd and depression symptoms such as hyperarousal (e.g., being on high alert), depressed mood, anger/irritability, or difficulties with sleep (e.g., trouble falling sleep, nightmares). it may be the short-term relief associated with marijuana use that then contributes to heavier use and the eventual experience of problems from such use. use of protective behavioral strategies to mitigate harms of marijuana use with high prevalence rates of marijuana use and mental health problems among veterans, it is important to better understand what factors may limit the harms associated with marijuana use among those veterans who choose to use the drug. one such factor is the use of protective behavioral strategies, which, generally, are practices used by substance users to protect against heavy and problematic use. marijuana protective behavioral strategies are behaviors used before, during, after, or instead of using marijuana, such as taking periodic breaks if one feels like they are using marijuana too frequently, limiting the amount of marijuana one uses in one sitting, and avoiding using marijuana before work or school (pedersen et al., 2017a; pedersen, hummer, rinker, traylor, & neighbors, 2016a). recent work has identified that use of these strategies by young adult college students are associated with fewer consequences and less frequent use (bravo, anthenien, prince, pearson, & the marijuana outcomes study team, 2017a; bravo, prince, pearson, & the marijuana outcomes study team, 2017b; pedersen et al., 2017a; 2016a) but no study to date has looked at use of marijuana protective strategies among veterans or among those with mental health symptoms. use of these strategies may be particularly important for marijuana users who report symptoms of ptsd and depression as use of strategies may help protect them from further distressing consequences in their life as well as from exacerbation of symptoms. thus, it is important to examine if use of protective strategies by veterans with mental health problems moderates the relationships between symptoms and marijuana use or consequences. to date, no study has addressed the moderating effect of protective behavioral strategies on the relationship between mental health symptoms and marijuana outcomes in any population, making an initial examination of veterans an important contribution to the emerging area of protective behavioral strategy use among marijuana users. the present study cannabis, a publication of the research society on marijuana 17 the present study was designed to examine how protective strategies practiced before, during, after, or instead of using marijuana moderated the effects of mental health symptoms on marijuana use and consequences among a sample of 180 young adult veteran marijuana users. the potential for marijuana problems among young veterans is particularly worthy of further study. studies have documented that rates of ptsd, depression, and problem substance use are higher in young veteran samples than they are in active duty and civilian samples (bray & hourani, 2007; kessler, chiu, demler, merikangas, & walters, 2005; ramchand et al., 2011; schell & marshall, 2008) and young adult veterans are more likely than young adult civilians to report mental health problems (grossbard et al., 2013). as such, this study focused on a young adult sample of veterans aged 19 to 34. three key questions guided the analyses for this study: (1) do veterans who use marijuana report more frequent use and/or more consequences based on depression/ptsd screening?, (2) do veterans who use marijuana report more frequent use of protective behavioral strategies based on depression/ptsd screening?, and (3) does frequency of use of protective behaviors moderate the relationship between depression/ptsd and marijuana use and consequences? method participants and procedures participants were part of a larger randomized controlled trial of a brief online alcohol intervention for young adult veteran drinkers (pedersen, marshall, & schell, 2016c; pedersen, parast, marshall, schell, & neighbors, 2017c). as such, all participants in this sample met screening criteria for the larger study: (1) between the ages of 18 and 34, (2) a united states veteran of the air force, army, marine corps, or navy, and (3) score on the 10-item alcohol use disorders identification test (audit; saunders et al., 1993) of 3 or greater for women and 4 or greater for men. the larger study enrolled 784 participants, of which 622 (79%) completed an online follow-up survey one month after the intervention. data from the present study were collected as part of the follow-up survey after main outcomes (past month drinking and drinking consequences) from the study were collected. recruitment of study participants was facilitated through facebook advertising and we have described the sample and the recruitment procedures in detail elsewhere (pedersen, naranjo, & marshall, 2017b). in the full sample of 622 young adult veterans, 180 reported using marijuana in the past six months (28.9%). these past six month users completed the follow-up measures including the items described below and were included in the analyses. measures demographics. participants reported their age, ethnicity (hispanic or not), race, prior branch of service, marital status, and years of active service in the military. marijuana use and consequences. participants were asked if they had ever used marijuana (in any form, including edibles and vaping) in the past six months, with response options of never, once or twice in the past six months, two to five times in the past six months, about once per month, about two to four times per month, about once per week, and a few times per week to daily. those who reported any response option besides never were asked follow-up questions about their past month use and experience of consequences in the past six months. past month use was assessed by asking participants to indicate how many days during the past month they used marijuana. they then completed the brief version of the marijuana consequences questionnaire (b-macq; simons et al., 2012), which features 21 items of consequences specific to marijuana, such as spending too much time using marijuana; feeling tired because of too much marijuana use; and losing motivation because of marijuana use. participants indicated whether they experienced each of the consequences (yes/no) in the past six months. reliability of the scale was adequate in the present sample (α = 0.84). responses on the scale were summed to reveal a composite score. protective behaviors for marijuana use scale (pbsm). the pbsm was developed and validated in our prior work (pedersen et al., 2016a; 2017a). we utilized the brief version of the scale (the pbsm-17), which contains 17 items from the larger 36 item bank that were determined with veteran marijuana protective strategies 18 item response theory analyses to be free from bias regarding gender (male/female), race (white/nonwhite), ethnicity (hispanic or latino(a)/nonhispanic or latino(a), and state legalization status (i.e., whether respondents lived in states that had laws regarding legal recreational marijuana or not) in a large young adult college sample. participants were asked to “please indicate the degree to which you engage in the following behaviors when using marijuana/cannabis” using response options of 1 = never, 2 = rarely, 3 = occasionally, 4 = sometimes, 5 = usually, and 6 = always. the scale displayed adequate internal reliability (α = 0.95). scores on the pbsm were computed as a continuous value by summing responses and converting raw scores to t-scores as advised by pedersen and colleagues (2017a). mental health symptoms. symptoms of depression were assessed with the patient health questionnaire 8-item (phq-8; kroenke et al., 2009; α = 0.92), which contains items corresponding to the symptoms of depression such as little interest or pleasure and feeling down or depressed. items are rated from 0 = not at all to 3 = nearly every day in the past two weeks. scores on the measure range from 0 to 24. scores of 10 or greater are indicative of a positive screen for depression, with 100% sensitivity and 95% specificity for major depressive disorder in the general population (kroenke et al., 2009). ptsd symptoms were assessed with the ptsd checklist for dsm-v (pcl-5; blevins et al., 2015; α = 0.97). the pcl-5 contains 20 items corresponding to how much participants had been bothered by the symptoms of ptsd in the past month, with response options ranging from 0 = not at all to 4 = extremely. scores on the measure range from 0 to 80. scores of 33 or greater are indicative of a positive screen for ptsd, with 88% sensitivity and 69% specificity for predicting a ptsd diagnosis among veterans (bovin et al., 2015). data analytic plan to describe the sample and to answer our first two key questions, we ran a series of descriptive analyses to document means and frequencies of marijuana use, consequences, and pbsm item endorsement. using independent samples t-tests, we then compared veterans who screened positive for depression using the phq-8 criterion score of 10 (kroenke et al., 2009) to those who did not screen positive for depression on marijuana use, marijuana use consequences, and protective strategies. next, we compared veterans who screened positive for ptsd using the pcl criterion score of 33 (bovin et al., 2015) to those who did not screen positive for ptsd on marijuana use, marijuana use consequences, and protective strategies. to evaluate our third key question, we ran two regression models predicting marijuana use and marijuana use consequences. both count outcomes were positively skewed (marijuana use skew = 0.83, marijuana consequences skew = 2.26) and greater than or equal to zero; thus, we ran a series of negative binomial regression analyses (hilbe, 2011). to determine which count distribution best fit our data, we compared analyses with poisson, zero inflated negative binomial, and normal distributions, finding that a negative binomial model fit the data best. covariates of age, gender (male versus female), and race/ethnicity (white versus other) were included. both depression and ptsd were included in the two models given the overlap between the two mental health problems in the veteran population. two interaction terms were included in the models to determine moderation: depression screening (phq-8 categorical score) x pbsm continuous score and ptsd screening (pcl-5 categorical score) x pbsm continuous score. results sample description among the 180 past six month users, 144 (80%) reported using marijuana in the past month (see table 1). the sample of past six month marijuana users reported using a mean of 9.95 (sd = 11.83) days per month, ranging from cannabis, a publication of the research society on marijuana 19 table 1. sample description past six-month marijuana users (n = 180) age 28.40 (3.34) male gender 83.3% ethnicity non-hispanic 86.7% hispanic 13.3% race white 85.0% black 4.4% other† 10.6% married 41.7% branch of service army 65.6% navy 9.4% air force 6.7% marine corps 18.3% years served in the armed forces 5.11 (2.43) positive depression screen 33.0% positive ptsd screen 37.1% marijuana use (days, past month) 9.92 (11.83) marijuana use consequences (sum, past 6 months) 1.89 (2.81) pbsm (sum converted to t-score) 47.70 (13.45) note. †category includes asian (n = 2), native hawaiian/pacific islander (n = 1), american indian/alaska native (n = 5), multiracial (n = 7), and other unspecified (n = 4). pbsm: protective behavioral strategies for marijuana scale (17 item version). one day (15% of the sample) to 30 days (17% of the sample). frequency of use ranged from once or twice in the past six months (27%) to a few times per week or daily (34%). participants reported a mean of 1.89 (sd = 2.81) consequences in the past six months, ranging from 0 to 16 consequences. marijuana use and consequences among those screening for ptsd and depression participants who screened positive for depression (33% of sample) reported marijuana use on 8.33 (sd = 10.97) days in the past month, while participants not screening for depression reported use on 10.82 (sd = 12.21) days; a nonsignificant difference (p = 0.174). participants who screened positive for depression reported significantly more marijuana use problems (m = 2.76, sd = 3.90) than participants not screening positive for depression (m = 1.48, sd = 1.97), t (177) = 2.37, p = 0.020. participants who screened positive for ptsd (37% of sample) reported marijuana use on 9.55 (sd = 11.30) days in the past month, while participants not screening for ptsd reported use on 10.22 (sd = 12.24) days; a non-significant difference (p = 0.709). participants who screened positive for ptsd reported significantly more marijuana use problems (m = 2.54, sd = 3.13) than participants not screening positive for ptsd (m = 1.54, sd = 2.56), t (176) = 2.20, p = 0.030. use of protective strategies among those screening for ptsd and depression veteran marijuana protective strategies 20 participants screening positive for depression (m = 47.27, sd = 14.18) did not significantly differ in the overall use of protective behavioral strategies from those not screening positive for depression (m = 47.91, sd = 13.13), p = 0.765. likewise, participants screening positive for ptsd (m = 48.29, sd = 12.64) did not significantly differ in the overall use of protective behavioral strategies from those not screening positive for ptsd (m = 47.44, sd = 13.98), p = 0.689. there were also no differences in frequency of each of the 17 specific strategies used between those screening positive for depression and those not screening positive for depression, as well as between those screening positive for ptsd and those not screening positive for ptsd. models for marijuana use and consequences parameter estimates for the count regression models for marijuana use and consequences can be found in table 2. for marijuana use in the past month, male gender (estimate = -0.75, incident rate ratio [irr] = 0.47, se = 0.23) and pbsm score (estimate = -0.05, irr = 0.95, se = 0.01) irr = 0.95, se = 0.01) predicted marijuana use, such that females reported 53% less marijuana use compared to males and for each additional unit of protective strategy use frequency participants reported 5% less use in the past 30 days. neither positive depression nor positive ptsd screens were associated with marijuana use, nor did either of the interactions between depression or ptsd screening and pbsm scores. table 2. negative binomial regression for marijuana use and marijuana use consequences outcomes marijuana use past 30 days paramete r estimate standar d error wald chi-square incident rate ratio p-value (intercept) 6.01 0.98 37.81 409.12 0.000 age -0.03 0.03 1.27 0.97 0.260 male gender1 -0.75 0.23 10.97 0.47 0.001 white 0.21 0.23 0.82 1.23 0.366 pbsm -0.05 0.01 20.90 0.95 0.000 phq-8 positive screen -1.35 0.97 1.92 0.26 0.166 pcl positive screen 0.59 0.97 0.37 1.80 0.545 pbsm x phq-8 interaction 0.02 0.02 1.10 1.02 0.294 pbsm x pcl interaction -0.01 0.02 0.32 0.99 0.570 marijuana consequences past 6 months (intercept) 2.91 1.14 6.44 18.27 0.011 age -0.06 0.03 3.13 0.95 0.077 male gender1 -0.06 0.27 0.05 0.94 0.816 white 0.28 0.28 1.02 1.33 0.313 pbsm -0.03 0.01 5.61 0.97 0.018 phq-8 positive screen -0.87 0.97 0.81 0.42 0.368 pcl positive screen 2.55 0.97 6.93 12.85 0.008 pbsm x phq-8 interaction 0.03 0.02 2.31 1.03 0.129 pbsm x pcl interaction -0.05 0.02 5.76 0.95 0.016 note: gender was coded 0 for males, 1 for females. white was coded 1 for white race, 0 for non-white race. phq-8: patient health questionnaire – 8 item. pcl: posttraumatic stress disorder checklist for dsm-5. pbsm: protective behavioral strategies for marijuana scale (17 item version). cannabis, a publication of the research society on marijuana 21 veteran marijuana protective strategies 22 figure 1. interaction findings for pcl x pbsm scores on marijuana consequences in the past 6 months note: b-macq: brief marijuana consequences questionnaire. pcl: posttraumatic stress disorder checklist for dsm-5. pbsm: protective behavioral strategies for marijuana scale (17 item version) for marijuana use consequences in the past six months, pbsm score (estimate = -0.03, irr = 0.97, se = 0.01) and ptsd screening (estimate = 2.55, irr = 12.85, se = 0.97) predicted marijuana use consequences, such that each unit increase in frequency of protective strategy use was associated with 3% less marijuana consequences in the past six months, and those screening positive for ptsd reported 12.8 times more marijuana consequences compared to those who did not screen positive for ptsd. the interaction effect between pbsm score and ptsd screening was significant (estimate = -0.05, se = 0.02), indicating that the relationship between ptsd and marijuana consequences was moderated by frequency of protective behavioral strategies. graphing this interaction showed that participants who screened positive for ptsd and who reported low frequency of protective behavioral strategies (1 standard deviation below the mean) were at higher risk for consequences (see figure 1). simple effects tests further confirmed that the relation between the pcl and marijuana use consequences was stronger at low levels of protective strategy use: -2 sd on the pbsm estimate = 0.58, irr = 1.79, se = 0.25, -1 sd on the pbsm estimate = 0.59, irr = 1.80, se = 0.25, +1 sd on the pbsm estimate = 0.60, irr = 1.82, se = 0.25, and +2 sd on the pbsm estimate = 0.61, irr = 1.84, se = 0.25. neither the positive depression screens nor the interaction between depression screening and pbsm scores associated with marijuana consequences. discussion the present study examined the use of protective behavioral strategies among a sample of 180 young adult veteran marijuana users. like college students (bravo et al., 2017a; 2017b; pedersen et al., 2017; 2016), we found that for young veteran marijuana users, use of protective behavioral strategies reduced risk for frequent marijuana use and negative marijuana-related consequences. male veterans reported more frequent marijuana use compared to female veterans, which fits with prior work that young adult males use marijuana more frequently than young females (haberstick et al., 2014; hasin et al., 2015; johnson et al., 2015). also, as in prior work with veterans specifically (bonn-miller et al., 2012; bonn-miller & rousseau, 2017, gentes et al., 2016), ptsd was associated with more problematic marijuana use. yet protective behavioral strategies moderated the relationship between ptsd and marijuana-related 0 1 2 3 4 5 pcl negative screen pcl positive screen b -m a c q t o ta l s c o re ( p a s t 6 m o n th s ) low pbsm score high pbsm score cannabis, a publication of the research society on marijuana 23 consequences, such that those young veterans who screened positive for ptsd and who reported low use of protective behavioral strategies were at the most risk for consequences in the past six months. in other words, the use of protective behavioral strategies somewhat safeguarded young veterans with ptsd from experiencing marijuana-related consequences. despite findings for ptsd and consequences in regression models, we did not observe any effects for depression when controlling for ptsd and other factors. as such, it appears that after controlling for depression (which overlaps much with ptsd in veteran samples; seal et al., 2010), ptsd was the specific problem driving the experience of marijuana consequences. this may be due to the cognitive and physiological effects that marijuana has on an individual, which may vary depending on mental health symptoms. for example, an individual with ptsd may use marijuana to cope with intrusive or hyperarousal symptoms, such as flashbacks and feeling on guard. supporting the anecdotal claims of veterans that marijuana helps to alleviate ptsd symptoms (elliot et al., 2015), there is evidence that the neurobiological effects of marijuana may make it easier for individuals to feel less anxious, fall asleep, or be less reactive to flashbacks and traumatic memories (passie et al., 2012). yet, the short-term reductions in ptsd symptoms experienced after using marijuana are not well understood in the context of the ptsd diagnosis as a whole (national academies of sciences, engineering, and medicine, 2017), such as whether a marijuana user with ptsd is maintaining symptoms through avoidance and is not treating the core components of ptsd that could be addressed in more intensive pharmacological or psychological treatment (foa, keane, friedman, & cohen, 2009; steenkamp, litz, hoge, & marmar, 2015). for some of these psychological treatments, emotional processing of the traumatic event is an essential component of therapeutic success, and marijuana use may inhibit intrusive and arousal symptoms; thereby preventing recovery from ptsd and perhaps leading to further exacerbation of marijuanarelated consequences. to date, there is no evidence from clinical trials that marijuana can be used as an effective pharmacological treatment for either ptsd or depression (national academies of sciences, engineering, and medicine, 2017). use of protective strategies among veterans was particularly important for those veterans screening positive for ptsd. as such, helping veterans to practice protective strategies before, during, after, and instead of using marijuana may be helpful in clinical settings. protective behavioral strategies are consistent with a harm reduction philosophy of drug use, such that any level of reduced use or avoidance of consequences is seen as a step in the right direction to reducing harm. however, clinicians and users themselves may believe that abstinence is the best way to reduce harm and it is unclear if such strategies are helpful to achieving an abstinence goal. additionally, marijuana is still illegal for medical and recreational use at the federal level, which means that the federal institution where most veterans receive ptsd and substance use care (i.e., the va) does not support the use of marijuana in any form. that is, va clinicians are not permitted to offer recommendations for medical marijuana use. moreover, if veterans are in treatment for ptsd, exacerbation of ptsd symptoms that often accompany initial sessions of ptsd treatment could trigger cravings for marijuana use, which in turn could hinder the efficacy of ptsd treatment or lead to relapse (back et al., 2014; boden et al., 2013; bonn-miller et al., 2007, 2011). for example, veterans with cannabis use disorder have a poorer prognosis for mental health treatment (bonn-miller, boden, vujanovic, & drescher, 2013). despite large numbers of young veterans screening for hazardous marijuana use and cooccurring mental health problems, few seek treatment. for example, we found that only 34% of those screening for hazardous marijuana use reported attending at least one appointment for substance use care in the past year at the va or elsewhere (pedersen et al., 2016b). in the same study, we found that only 32% of those screening positive for hazardous marijuana use received a minimally adequate course of treatment for any substance use or mental health condition. this suggests that despite the potential for marijuana use to exacerbate mental health symptoms and confound treatment progression, most veterans who use marijuana do not seek treatment. thus, for these veterans, use of protective strategies may help to prevent heavy or frequent use and the veteran marijuana protective strategies 24 experience of negative consequences. nevertheless, the use of protective strategies in preventing marijuana problems, such as medical and psychological problems (volkow, baler, compton, & weiss, 2014) among long-term users is unknown. a recent report by the u.s. department of justice (2014) highlighted that regular marijuana users are likely to experience cognitive impairment (e.g., memory, processing speed), increased mental health problems (e.g., psychosis or other substance use disorders), and poor psychosocial functioning (e.g., academic performance). an even more recent report from the national academies of sciences, engineering, and medicine (2017) similarly concluded that marijuana use has long term effects such as worsening respiratory symptoms (e.g., chronic cough, bronchitis), dependence on the drug, cognitive impairments (learning, memory, attention), increased risk of motor vehicle accidents when driving under the influence, and increased risk for developing social anxiety and schizophrenia. thus, it will be important in future work to determine if protective strategies can help to prevent these consequences among long-term users. limitations this study is not without limitations and several should be considered when interpreting the findings. first, as in most studies of substance use behaviors, marijuana use and consequences were assessed by self-report, and outcomes may have been reported differently by collaterals (e.g., friends, spouses) or through biomedical testing. however, there was no indication that participants underreported their use and they were assured confidentiality through a confidentiality certificate we obtained for the study. second, the sample comprised young veterans recruited for an alcohol intervention study. as such, all participants met a screening criteria for drinking, albeit a low threshold on the audit. findings may not generalize to nondrinkers as they were excluded from the study. it should be noted that the sample was recruited from facebook through advertisements that were meant to attract veterans not seeking alcohol treatment, which helps to assuage concerns that this was a treatment-seeking sample. we have written extensively about the recruitment method, including generalizability of the sample to the larger young veteran population and methods used to reduce participant misrepresentation, in our other work (pedersen et al., 2017b). lastly, we did not assess expectancies of marijuana use (e.g., does one believe marijuana relieves tension) or marijuana motives (e.g., does one use specifically to cope with negative affect) so more detailed information about why protective strategies moderated the relationship between ptsd and consequences is not well understood. though some work indicates that those with ptsd symptoms may use marijuana to cope with, control, or momentarily alleviate symptoms; (bonn-miller et al., 2011; tomlinson et al., 2006), further research that includes marijuana use motives can tease apart why veterans with varying levels of depression and ptsd symptoms use the drug (e.g., to cope with negative affect, to enhance sociability). conclusion the aforementioned findings expand the college student marijuana studies using the pbsm and indicated that greater frequency of protective strategies associated with less frequent marijuana use and fewer consequences among young veterans. in addition, this study adds to the literature on mental health problems and substance use among veterans by documenting a moderating effect of protective strategy use on negative marijuana outcomes. further, although there is evidence for the utility of protective behavioral strategies in the relationship between mental health symptoms and alcohol-related outcomes (labrie, kenney, & lac, 2010; labrie, kenney, lac, garcia, & ferraiolo, 2009; martens et al., 2008; villarosa, messer, madson, & zeiglerhill, 2018; villarosa, moorer, madson, zeiglerhill, & noble, 2014), this is the first study to examine the moderating effect of marijuana protective behavioral strategies on the relationship between mental health symptoms and marijuana related outcomes. findings suggest that use of protective strategies may be important for young veterans who choose to use marijuana, in particular for those that may use marijuana to cope with symptoms of ptsd. references cannabis, a publication of the research society on marijuana 25 back, s. e., killeen, t. k., teer, a. p., hartwell, e. e., federline, a., 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(2018). depressive symptoms and drinking outcomes: the mediating role of drinking motives and protective behavioral strategies among college students. substance use & misuse, 53, 143-153. villarosa, m. c., moorer, k. d., madson, m. b., zeigler-hill, v., & noble, j. j. (2014). social anxiety and alcohol-related negative consequences among college drinkers: do protective behavioral strategies mediate the association?. psychology of addictive behaviors, 28(3), 887-892. volkow, n. d., baler, r. d., compton, w. m., & weiss, s. r. (2014). adverse health effects of marijuana use. new england journal of medicine, 370, 2219-2227. funding: the study was funded by a grant from the national institute on alcohol abuse and alcoholism (niaaa, r34aa022400, brief online intervention to reduce heavy alcohol use among young adult veterans) awarded to eric r. pedersen. dr. villarosa-hurlocker is supported by a training grant (t32aa018108) from the niaaa. copyright: © 2017 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 22 abstract knowing the names, locations, and signage of medical marijuana dispensaries is critical for assessing how marijuana availability affects neighborhood quality and marijuana use, yet no detailed methods for locating and coding dispensaries are published. limitations regarding accuracy of official records, unregulated businesses, and the size of areas where dispensaries are located make it difficult to accurately capture all open dispensaries in any area. in this study, we test a practical and feasible method to collect a point-in-time portrayal of medical marijuana dispensaries in a large urban area lacking an official record of these businesses. using publicly-available internet sources alone, we collected the name, address, phone number, signage, and open/closed status of medical marijuana dispensaries in los angeles county between october 2016 and february 2017. data were verified by calling a subset of dispensaries and comparing data against a list of licensed dispensaries. our methods yielded 872 unique dispensaries in los angeles county, of which 470 were open. most open stores were discernable by a green cross sign; however, few had names that clearly indicated the store sold marijuana. data verification procedures showed that internet sources were able to locate nearly all dispensaries in the county that were then verified with non-internet methods, such as calling the businesses to confirm information. this study is significant as it provides methodology that can be replicated in other metropolitan areas, facilitating comparisons across databases in different locations and regulatory environments. however, caution should be taken when solely using internet sources. accurate information on dispensary names, locations, and signage can advance research and provide important information for policy decisions. methods for enhancing the online methods described in this study are discussed. key words: marijuana, medicinal cannabis, dispensaries, neighborhood in the 22 years since marijuana for medical purposes was legalized in california, medical marijuana dispensaries have proliferated throughout the state. though the actual size of the medical marijuana market in california is not known, some industry sources estimate that it is a billion dollar industry. in november 2016, california voters passed proposition 64, the adult use of marijuana act, making it legal for individuals aged 21 years or older to grow and sell marijuana for recreational use. the market will no doubt continue to flourish, as licenses for cannabis 2018, volume 1 (2), 22-35 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.003 open access online methods for locating medical marijuana dispensaries: practical considerations for future research corresponding author: eric r. pedersen, rand, 1776 main street, p.o. box 2138, santa monica, ca 9040 u.s.a., email: ericp@rand.org eric r. pedersen1, megan zander-cotugno1, regina a. shih2, joan s. tucker1, michael s. dunbar3, elizabeth j. d’amico1 1 rand corporation, santa monica, ca, usa 2 rand corporation, arlington, va, usa 3 rand corporation, pittsburgh, pa, usa http://dx.doi.org/10.26828/cannabis.2018.02.003 cannabis, a publication of the research society on marijuana 23 recreational stores became available in january 2018, expanding access to marijuana to all california residents aged 21 and older regardless of medical conditions. one primary argument in opposition to marijuana legalization was the unknown effects of how availability of the drug would affect youth and adult use and normative behaviors. several studies in the united states on alcohol retail stores have shown that access to alcohol outlets, measured by either density or proximity to retail stores, is associated with drinking behaviors (gmel, holmes, & studer, 2016; shih et al., 2015). to date, however, there are very few studies addressing how proximity to and density of marijuana dispensaries may affect adolescent and adult marijuana use (freisthler & gruenewald, 2014; shi, meseck, & jankowska, 2016); how dispensary locations are related to other demographic, economic, and social environmental factors, such as crimes and physical violence, within surrounding neighborhood(s) (freisthler, gruenewald, & wolf, 2015; freisthler, ponicki, gaidus, & gruenewald, 2016); and whether dispensaries are disproportionately located in areas that target low-income or minority populations (thomas & freisthler, 2016). these and future studies can help to answer research questions that are essential to informing policies as states, counties, and cities develop guidelines regarding locations of dispensaries. the first step to advance this important research is to locate medical marijuana dispensaries to document visibility of dispensaries and develop metrics of their density and proximity in neighborhoods. though researchers have attempted to locate medical marijuana dispensaries in california, colorado, and washington (freisthler & gruenewald, 2014; freisthler et al., 2016; hunt, pacula, & jacobson, 2014; kepple & freisthler, 2012; kilmer et al., 2013; nunberg, kilmer, pacula, & burgdorf, 2011; pacula, chriqui, reichman, & terry-mcelrath, 2002; saloga, boustead, jacobson, pacula, & anderson, 2013; shi, 2016; thomas & freisthler, 2016), there are no detailed methods published. it is crucial to develop standardized, comprehensive, and practical methods to locate medical marijuana dispensaries to better understand the effects of marijuana availability on neighborhood quality and marijuana use. this can pave the way for future methodological work on locating and coding outlets that sell marijuana for recreational purposes. the difficulty with locating dispensaries in los angeles county los angeles county represents an area where it is particularly difficult to locate and count marijuana dispensaries given that it is a very large area and there are no city level records as of the time of this writing. thus, the current study focuses on whether online methods can be used to collect location and other information about dispensaries in the los angeles area. this is an important undertaking given that many other large metropolitan areas across the united states may soon face similar challenges. due to fluctuations in store closings and new store openings, differing medical marijuana dispensary regulations across cities and neighborhoods within los angeles county, and operation of stores without business licenses, it is not possible to utilize official records documenting the open dispensaries in the county, as no such comprehensive list exists (freisthler, kepple, sims, & martin, 2013). the california department of public health’s office of medical cannabis safety is currently tasked with developing statewide standards and regulations for medical marijuana dispensaries, and the office began issuing new business licenses to dispensaries for both medical and recreational use in january 2018. the broader los angeles county expands over 4,750 square miles and contains 88 incorporated cities such as long beach, glendale, santa clarita, torrance, pasadena, and inglewood. some estimates on the internet report there are over 1,700 open marijuana dispensaries in the city of los angeles alone, which represents the largest city in los angeles county. however, official records at the city level are non-existent at the time of this writing. for example, business tax records do not fully capture the extent of dispensaries. in 2016, the los angeles city controller found that 756 dispensaries in the city of los angeles held business tax registration certificates (btrc), but just 139 dispensaries obtained btrcs in 2017 that were determined to be in compliance with the city’s tax regulations (los angeles controller, 2017). due to stores not being legally compliant, there is constant locating marijuana dispensaries 24 fluctuation in stores’ open and closed status across the city. the los angeles city controller states that the los angeles city attorney’s office has filed criminal charges against 563 dispensaries and the city attorney’s website claims to have “shut down more than 800 of the unlawful dispensaries throughout the city” since 2013 (los angeles city attorney, 2017). as stores close or are shut down by the city, more stores emerge in their place and the closed stores may simply relocate or change names. the issue of fluctuation in dispensaries and lack of official records is likely to plague other cities as they develop regulations around medical marijuana dispensaries, and for some, recreational marijuana dispensaries. similarly, any study that uses lists of licensed dispensaries alone will no doubt miss many dispensaries that are unlicensed and unregulated. for example, shi and colleagues (shi et al., 2016) used the directories of licensed marijuana stores from the enforcement division of colorado department of revenue to locate marijuana dispensaries in colorado, but given the lenient laws around cultivation in the state, individuals and cooperatives have found ways to grow and sell the drug in an unregulated “grey market” (colorado office of the governor, 2016). outside of marijuana dispensaries, official lists of licensed stores have not adequately captured all the retail shops selling electronic nicotine delivery systems (ends), which are e-cigarettes and related products (typically sold in combination with nicotine “e-liquids”) that deliver nicotine to an individual in aerosolized form. such specialty “vape shops” and other outlets selling ends (e.g., convenience stores) have proliferated in recent years, coinciding with the dramatic rise in popularity of these products (united states department of health and human services, 2016). for example, researchers in florida reported that only 32.5% of the stores they verified as selling ends were actually in the list of licensed tobacco retailers from the florida department of business and professional regulation (kim et al., 2016). the limitations of prior research on locating medical marijuana dispensaries recent studies that have focused on how to locate medical marijuana dispensaries have limitations that need to be addressed. first, descriptions of methods for locating dispensaries are typically limited to a few sentences, making it difficult to replicate methods. for example, researchers describe using websites designed to search a particular area for medical marijuana dispensaries (e.g., weedmaps, www.weedmaps.com) and internet search engines (e.g., yelp; www.yelp.com) to locate marijuana dispensaries, followed by in some cases, very extensive efforts such as calling, driving by, or visiting stores to ensure they are open (freisthler & gruenewald, 2014; freisthler et al., 2015; freisthler et al., 2016; lipperman-kreda, juliet, morrison, & bridget, 2014). however, there is not enough detail in these brief methods sections to replicate findings for one’s own research purposes. in addition, the methods that have been used have not been examined in the context of the other limitations we describe below and further efforts to verify that these methods are adequate are necessary. second, prior work does not make mention that any data collection period represents a pointin-time snapshot, nor is there mention that a plan is needed for updates to any dispensary database. as with any type of business, fluctuations in store closings and new store openings make continual updating of any medical marijuana dispensary database necessary, as data collected at any one time point would be an accurate reflection of the number and density of stores for only a brief period of time. for example, researchers collected location information for marijuana dispensaries in long beach, california beginning in january 2012 (freisthler et al., 2016). at the start of the study, they identified 37 open dispensaries, but two years later in december 2013, only five of these dispensaries were identified as open. given the turnover, it is necessary for researchers to develop methods that can feasibly be replicated for continuous updating of location data, particularly if researchers are attempting to determine if proximity to and density of marijuana dispensaries is associated with marijuana use among the public. for example, if the goal is to examine how dispensary proximity and density are contemporaneously associated with neighborhood characteristics (e.g., poverty levels in a neighborhood, use of marijuana among neighborhood residents), using outdated dispensary data will result in erroneous cannabis, a publication of the research society on marijuana 25 conclusions. thus, methods will need to be practical and efficient in order to be continuously updated in an effort to be as accurate as possible. third, some of the more extensive data collection efforts, such as driving and/or calling every dispensary were feasible in previous work because the search was constrained to a smaller area; such as in long beach, california (where only 37 open dispensaries were located) (freisthler et al., 2016) and sacramento, california (where only 16 open dispensaries were found) (lipperman-kreda et al., 2014). in areas that are much larger, such as los angeles county, it is not feasible due to budget constraints and the constant fluctuation of these businesses to verify the location data of medical marijuana dispensaries through these more extensive means. it is more practical to use publicly available online information; however, research is needed to better understand how online websites can be used to adequately capture dispensary locations. detailed methods for how to replicate these methods are also needed, so that researchers can find ways to improve upon the methods and use them for their own purposes. finally, no study to date has described signage or store names, presumably because this information has not been collected. signage, such as a green cross or a marijuana leaf on exterior doors or windows, is especially important with respect to public awareness and perceived accessibility. for example, stemming from work examining storefront advertising of cigarettes, alcohol, and fast food (celebucki & diskin, 2002; hillier et al., 2009), it likely makes a difference whether an individual lives near a dispensary designated by a marijuana leaf on the door versus a dispensary with no sign to indicate that the store sells marijuana. lack of signage may still influence exposure to marijuana and normative beliefs, but without data on signage, the pathways through which outlets may influence adolescent and adult marijuana use are unclear. similarly, if a store has a name that is clearly related to marijuana (e.g., doctor 420’s pot shop), someone may easily ascertain that marijuana is sold inside, versus a store with a more ambiguous name (e.g., beach city patient collective). information on signage and store names could help policymakers make decisions about effects of signage and store names on increased marijuana use or degradation in neighborhood quality. note that names of stores throughout this paper were fabricated for illustrative purposes and do not intend to represent actual businesses. this paper addresses many of the limitations of previous work by detailing a specific plan for locating dispensaries in large metropolitan areas using online methods and specific lower cost verification procedures. we utilized this plan within los angeles county, an area that has a large population (over 10 million in 2017) living in a large area, but with a dense distribution of medical marijuana dispensaries located within clearly identified boundaries. we describe detailed methods to create a comprehensive database that can be updated regularly. this database can be an invaluable resource to researchers looking to explore changes in medical marijuana and/or recreational outlet number and density over time. this latter point is especially relevant due to recent legalization of recreational marijuana sales in california and other states. because we utilize online website sources alone, it is anticipated that methods developed in this study for los angeles could be easily replicated in other metropolitan areas (e.g., san francisco, seattle), facilitating comparisons across databases in different locations and regulatory environments. method databases and search methods data were collected from october 2016 through february 2017. we searched for and located medical marijuana dispensaries in los angeles county based on all 526 county zip codes. to ensure the feasibility of continually updating this database, our methods were based solely on publicly available online information collected by a single data extractor. data verification procedures were conducted by an additional two coders. given that no publicly available official database existed, we collected dispensary data from five websites: stickyguide (www.stickyguide.com), weedmaps (www.weedmaps.com), yelp (www.yelp.com), leafly (www.leafly.com), and where’s weed (www.wheresweed.com). similar to other public websites with business information (e.g., google, yellow pages), these websites offer searchable locating marijuana dispensaries 26 databases of dispensaries by name and address, as well as customer reviews of the stores, phone numbers, and store hours. researchers have used websites such as these to help locate address data for medical marijuana dispensaries across a number of cities in california, including long beach and sacramento (freisthler & gruenewald, 2014; freisthler et al., 2016; kepple & freisthler, 2012; thomas & freisthler, 2016). in the current study, for the marijuana websites, we located stores by entering each of the los angeles county zip codes into the website’s search bar. for yelp, which contains businesses beyond marijuana dispensaries unlike the other websites, we entered multiple search terms (e.g., “marijuana dispensaries,” “cannabis clinics”) into the “find” search bar and each of the zip codes into the “near” search bar. we first collected location information regarding medical marijuana outlet business sources from the two online marijuana databases (stickyguide and weedmaps) that appeared most often in the prior literature, and were recommended by researchers who had used these websites to locate medical marijuana outlets in prior work. yelp was also initially identified from the prior research and from consultation with researchers as a resource that should be used in coordination with the marijuana websites. to assess whether any dispensaries in los angeles county that had an online presence were not identified by these three websites, we then searched two more marijuana websites (leafly and where’s weed) for all zip codes within three large neighborhoods chosen at random that covered 28 zip codes (venice beach, west hollywood, and long beach). this allowed us to see if either of these two websites located additional dispensaries beyond those that were found using stickyguide, weedmaps, and yelp. with these preliminary searchers, we began seeing that leafly and where’s weed identified dispensaries not found in the original three sources; thus, we then searched these two additional online sources for dispensaries in all 526 zip codes to ensure that we obtained every possible dispensary via these online methods. we originally planned to extract data from medical marijuana locators (www.medicalmarijuanalocators.com); however one month into data collection, we reached a “404 error” page when attempting to visit this website, indicating that this website was no longer available. thus, we selected “where’s weed” as the fifth source. we excluded dispensaries outside of los angeles county as well as dispensaries that did not have a physical location (i.e., those that were indicated as delivery only). as such, we did not collect data from dispensaries that were clearly labeled as delivery-only dispensaries (i.e., no brick-and-mortar store front). the findings for the delivery-only stores presented below represent dispensaries that were determined to offer delivery after we had completed initial data collection that led us to believe the dispensary had a physical location where customers could purchase marijuana. of note, many of the dispensaries with store fronts and physical addresses offered delivery, but we did not collect and document this information. data extraction we extracted the following data from each website: name of store, address (street, city, zip code), phone number, date store was opened, and current open or closed status. we documented the website(s) on which each dispensary was listed and made note of inconsistent or duplicate information. open/closed status was determined through a variety of methods such as by viewing the latest update to the dispensary menu or the date of the most recent comment on the websites, posted hours or “closed” indicator on yelp and google, searching for the store name in google and noting if the store was closed as indicated in news articles after large-scale police closures of stores, and in some cases, reviewing the social media pages for the stores and noting the most recent activity. when open/closed status could not clearly be resolved, the dispensary was indicated as having “unknown” status. we also coded whether the store name clearly indicated that the store sold marijuana using three codes: (1) clear indication (e.g., the pot joint), (2) no indication (e.g., heavenly remedies collective), and (3) possible indication (e.g., it’s easy bein’ green). for all dispensaries, we located signage by reviewing userand store owner-posted pictures of the store front and using google maps to view the store front, with particular attention paid to (1) a green cross, (2) a marijuana leaf or paraphernalia picture, and (3) the word “marijuana” or a clear variant of it (e.g., cannabis, a publication of the research society on marijuana 27 “weed” or “pot”). for this latter signage indicator, the word(s) could have been part of the store’s name as long as there was a sign outside with the word(s) on it. in addition, we noted (4) if stores indicated if they were “prop d compliant” or “preinterim control ordinance (ico).” although this type of signage was not a requirement, the label ostensibly indicates the store had been open since before a city moratorium on new dispensaries went into effect in 2007 (see below for description). we coded signs if they appeared on exterior doors, windows, walls, or anything visible from the street as one was walking by or driving by. though most dispensaries have tinted or covered windows, we did not include any devices (e.g., bongs, vaporizers) or signs inside a store that could be visible from the street. database verification in the absence of any official records, we used several verification methods to help determine if our online methods yielded accurate and up-todate information. first, after we finished collecting data solely from the internet sources, we called a random subset of dispensaries (approximately 10%) to verify information collected from the websites. as a second verification check, we compared dispensary information we collected from websites to the only known official available list of medical marijuana dispensaries in los angeles. as noted, currently most stores in los angeles county are unregulated and do not have business licenses. yet in 2007, the city of los angeles passed an ico that prohibited new medical marijuana dispensaries from opening but it allowed exemptions for stores that were already operating prior to the passing of the ico and that were registered with the los angeles city clerk (“preico”). in 2013, ballot measure proposition d allowed these 134 pre-ico stores to remain open, provided they fell outside designated proximity to schools, churches, and certain neighborhoods. later in 2013, the los angeles city attorney’s office made the list of these dispensaries publicly available. as this represents the only official document of established open dispensaries, we used this list as the second verification to confirm that our online methods had located all 134 dispensaries, with the caveat that the list was created in 2013. third, we were unable to determine the open/closed status of 100 dispensaries from online methods alone. although the lack of online information to clearly indicate whether a store was open was a good indicator that the store was closed, as a third validation check post-data collection, we called these dispensaries to verify whether they had indeed closed. lastly, we searched the five websites in august 2017, six months after initial data collection was completed, to determine how many of the confirmed open dispensaries were still open, had the same name, and had the same contact information (i.e., address, phone). this information was collected to demonstrate whether point-in-time snapshots of dispensaries are necessary given turnover, relocation, and closing of dispensaries. only internet methods were used for this recheck; that is, we used the five websites along with google maps to determine if the stores were open or closed using the same methods described for the initial data collection (e.g., viewing the latest update to the dispensary menu, observing “closed” as indicated on google maps or yelp). results our methods identified 942 medical marijuana dispensaries in los angeles county. we retained 872 unique dispensaries after removal of duplicate and triplicate records. most duplicate and triplicate dispensaries differed in name, but had the exact same address, across the website databases. three dispensaries had the same name, but different addresses, across websites due to name changes that were reflected on the website with the most current information. using website sources only, we determined that 470 dispensaries were open, 289 were closed, 13 were delivery only, and 100 were of unknown open/closed status. characteristics of the unique dispensaries by open, closed, and unknown open/closed status are found in table 1. characteristics of the 470 unique open dispensaries identified through the online methods are further summarized below. among the 470 unique open dispensaries, most (47%) were within the city of los angeles (including south, east, and west), followed by the cities of hollywood (6%, including east, north, and west hollywood), van nuys (4%), pasadena locating marijuana dispensaries 28 (3%), and compton (3%). weedmaps was most effective at locating open dispensaries, finding table 1. characteristics of the 872 unique dispensaries located from the website methods open (n = 470) closed (n = 289) unknown open/closed status (n = 100) website source number of dispensaries located per source weedmaps 446 (95%) 70 (24%) 17 (17%) where’s weed 321 (68%) 204 (71%) 60 (60%) leafly 320 (68%) 86 (30%) 43 (43%) yelp 191 (41%) 124 (43%) 30 (30%) stickyguide 169 (36%) 187 (65%) 45 (45%) city location of dispensary number of dispensaries located per city los angeles 221 (47%) 144 (50%) 59 (59%) hollywood 30 (6%) 15 (5%) 5 (5%) van nuys 19 (4%) 24 (8%) 5 (5%) pasadena 14 (3%) 0 (0%) 1 (1%) compton 13 (3%) 6 (2%) 6 (6%) sylmar 10 (2%) 3 (1%) 0 (0%) wilmington 9 (2%) 7 (2%) 2 (2%) torrance 9 (2%) 4 (1%) 0 (0%) rosamond 8 (2%) 0 (0%) 0 (0%) sherman oaks 7 (1%) 0 (0%) 2 (2%) studio city 7 (1%) 5 (2%) 0 (0%) canoga park 7 (1%) 4 (1%) 2 (2%) sun valley 7 (1%) 2 (1%) 0 (0%) san pedro 6 (1%) 9 (3%) 5 (5%) long beach 1 (<1%) 10 (3%) 0 (0%) other 102 (22%) 56 (19%) 13 (13%) signage number of dispensaries with type of signage green cross 201 (43%) 7 (2%) 35 (35%) prop d compliant 34 (7%) 1 (<1%) 1 (1%) pre-ico 32 (7%) 1 (<1%) 1 (1%) picture(s) of marijuana leaf 26 (6%) 0 (0%) 2 (2%) “cannabis” or “420” 3 (1%) 0 (0%) 2 (2%) other 16 (3%) 1 (<1%) 1 (1%) no signage 192 (41%) 10 (3%) 41 (41%) unable to be determined 26 (6%) 269 (93%) 21 (21%) name of store indicates sale of marijuana number of dispensaries with name type clearly indicative 18 (4%) 10 (3%) 2 (2%) probably indicative 32 (7%) 16 (6%) 7 (7%) not indicative 420 (89%) 263 (91%) 91 (91%) note. 13 dispensaries not included in the table above due to delivery only. numbers within columns represent dispensary information prior to verification checks (e.g., the three unknown dispensaries that were determined to be open after a verification check are included in the unknown column). cannabis, a publication of the research society on marijuana 29 95% of open dispensaries. where’s weed and leafly both located 68% of open dispensaries, yelp located 41%, and stickyguide located 36%. forty of the open dispensaries were located on one website source only (most often weedmaps), 115 on two websites, 152 on three websites, 91 on four websites, and 72 on all five websites. weedmaps also featured the least number of closed or unknown status dispensaries, whereas where’s weed was most likely to have closed or unknown status dispensaries listed (see table 1). a green cross was the most popular signage icon, with 43% of open dispensaries featuring this image, followed by signs indicating “pre-ico” (7%), “prop-d compliant” (7%), and picture(s) of a marijuana leaf (5%). two dispensaries featured the word “cannabis” on a sign, one featured the outline of a green bong, and one sign contained the phrase “420” (i.e., as part of the store name). other signs featured images and wording that did not clearly specify the site as a marijuana dispensary: two had pictures of leaves that were not in the shape of a marijuana leaf, four featured a non-green cross (e.g., yellow, red), four featured a palm tree, and five featured other pictures or wording that were not indicative of marijuana (i.e., a crown, the word “delivery,” three diagonal lines, stars, and a green clover). forty-one percent featured no sign. we were unable to determine if there was a sign present for 5% of stores because the google maps image of the location was time stamped as prior to the dispensary’s open date (indicating lack of reliability), the image was unclear or illegible, the dispensary was located in a suite inside a larger building, or the store front was not visible from the street view available. we were able to determine the open date for 59% of dispensaries (n= 275), which ranged from 2000 to 2016. we obtained month and year of opening for 128 dispensaries, year alone for 95, and a range of “2007 or prior” for the remaining 52. this latter category was determined due to a posting on the website(s) sources that indicated it had been featured on the site since 2007 or if the store featured a “pre-ico” sign. regarding names of the open stores, the majority (89%) had names that were not indicative that the store sold marijuana, 4% had names that clearly indicated the store sold marijuana, and 7% had names that probably indicated the store sold marijuana. the most commonly used terms in the dispensary names were “collective” (n=190); “green” (n=103); “care,” “caregiving,” or “caregiver(s)” (n=100), “wellness” (n=44), “herbal” (n=27); and “organic” (n=25). twenty-four dispensary names featured the word “cap,” (e.g., “buddy’s 25 cap”) which indicates the maximum price a dispensary has set for oneeighth ounce of their “top shelf” (high-grade) product. data verification we called 116 stores picked randomly in the full database to confirm information obtained from the online sources. we confirmed that 83 of the 83 closed dispensaries were closed (e.g., no answer at address during regular business hours, phone not in service, different business answered at location), eight of the eight delivery-only services were delivery only (i.e., no store front), and 24 of the 25 open dispensaries were open, with signage also confirmed. we were not able to confirm information for one open dispensary; after three attempts at calling there was no answer. for all closed dispensaries where the line rang with no answer after three attempts, we further confirmed the store was closed by using a google maps image search to ensure the store was not currently located at the specified address. using the list of 134 licensed dispensaries from the los angeles city clerk in 2013, we found that our methods located 111 of these dispensaries (83%). of these 111, 38 had the same name and address on the official list as we found through our methods, 54 had the same name but a different address listed between the website sources and the city list, and 19 were confirmed to have changed their name since the 2013 list. twentytwo of these 111 dispensaries were confirmed as closed. of the missing 23 dispensaries that were on the city list but not found via our methods, 15 were determined to have closed through a google search; five were unable to be confirmed as closed or open through our website sources, google search, or by calling phone numbers located from a google search; one we could find no record of through a google search of either the name or address; one was not found because it was not included in any of our website sources (but we found it through a google search as open); and one was not found through our search, but this dispensary was listed on weedmaps as open. for this latter one, however, the dispensary was locating marijuana dispensaries 30 added to weedmaps during the month after we had completed the website’s extraction and conducted the verification check. to verify the status of the 100 unknown open/closed status dispensaries, we called all 97 that had listed phone numbers and determined that these were closed if there was no answer after three attempts during business hours (n=41), the number was not in service (n=39), or there was a different business at the number (n=14). for three of these stores, someone answered and verified the store was open. for one of these three open stores, the clerk revealed that the store had a different name from the one that was listed on the marijuana websites. we also searched on the five websites for the open dispensaries six months after the initial data collection period ended. of the 470 dispensaries that were confirmed as open during the initial data collection period, 53 (11%) were verified as being closed at the time of the recheck. an additional four (about 1%) dispensaries could not be located on any of the websites, nor through a google search of the store’s name, address, or phone number. seventy-five of the 470 dispensaries (16%) were located but could not be verified as open or closed using the five websites and google maps alone. the majority of the 470 dispensaries were verified as open (72%); however, 24% of these verified open dispensaries had information that was inconsistent from the first data collection period: 4% of the 338 open dispensaries had different addresses posted on the websites, 11% had different names, and 15% had different phone numbers. several stores had more than one piece of information different from the first data collection period to the recheck six months later (e.g., both different address and different phone number). figure 1 shows more details about these recheck findings. figure 1. use of internet methods to recheck information for the 470 open dispensaries cannabis, a publication of the research society on marijuana 31 discussion this is the first study to provide extensive detail on how to create a comprehensive and replicable database of medical marijuana dispensaries using data from online sources. given that there is currently no official record of these marijuana outlets in los angeles county, we conducted a point-in-time data collection of dispensaries available on four medical marijuana dispensary search websites and one general business search website. we located 872 unique dispensaries, of which 470 were currently open. we verified our information by calling stores and reviewing our database against a 2013 official city list. although our results and data verification outcomes speak to the thoroughness of our methods, it is clear that web-based observable methods alone may miss some dispensaries. for example, using the internet alone we were not able to verify whether 100 stores were open or closed; thus, we needed to call these stores and inquire about their status. interestingly, 97 of these 100 stores were verified as closed; thus, it may be reasonable to assume that if a store does not have an updated web presence, they may no longer be in business. in addition, there is much fluctuation in these dispensaries. one of our data verification procedures was to verify if contact information for the 470 open dispensaries changed six months after the initial round of data collection. we found that 11% had closed since our first data collection period and an additional 1% could no longer be located through any internet search. even though we found that 72% of the dispensaries that were open during the first data collection period were still able to be verified as open using the internet methods alone, nearly a quarter of these had inconsistent information across the time periods, such as different names, addresses, or phone numbers. in all, only 55% (257 of 470) of the dispensaries at the recheck were verified as open and had all the same information from when we did the first collection. as these businesses fluctuate, the online dispensary search website sources also fluctuate. for example, two of the six website sources used by prior researchers to locate dispensaries in major cities in california have since shut down (freisthler & gruenewald, 2014) and one of our original website targets was taken down during the first month of data collection. this makes it clear that multiple website sources are needed in case a website goes offline or is not maintained. in the absence of any official list from the county, these website sources appear to be the best source for updated and accurate information about dispensaries. yet even with an official list, albeit four years old at the time of our data collection, dispensary location and name data did not always match what we found on the websites. for example, despite being able to determine that 83% of 134 dispensaries from an official los angeles city list had information on the websites, only 34% of these dispensaries had matching information (i.e., name, address) between the websites and the city list. others had different names, addresses, or had been closed. thus, extracting information from internet sources may represent the most feasible and practical method for documenting the location of medical marijuana dispensaries in los angeles county at one point in time. the weedmaps website generated the most accurate and up-to-date information, locating 95% of open dispensaries in our database and featuring the fewest closed dispensaries on its site. this is likely because of the four marijuana websites we searched, weedmaps is currently the largest and most used website. although updated financial records are not available, the website was estimated to generate about $30 million in revenue in 2014 (carreon, 2016). weedmaps also has a free app that can be downloaded by customers, they are well advertised on billboards and social media (bierut, krauss, sowles, & cavazos-rehg, 2017), and they are a major partner with the national organization for the reform of marijuana laws (norml), which gives them a national presence. weedmaps data have been used to answer important research questions, such as how dispensaries use weedmaps to make claims about the health benefits of marijuana online, and whether underage youth are able to access information about marijuana when clicking from the website to dispensaries’ independent websites without needing to verify their age (bierut et al., 2017). we found that using weedmaps in conjunction with other website sources was helpful, as using google maps helped identify store front signage and determine open/closed status. however, it should be noted that advertising an unregulated/illegal business online comes with risks, and it is likely locating marijuana dispensaries 32 that some business owners opted not to include their information on weedmaps, yelp, or other websites. business owners likely have to weigh the drawbacks of not appearing on the sites (e.g., losing out to more well-advertised competition, closing down because of no customers) against the risk of publicly advertising an unregulated business. as noted earlier, our methods may have missed dispensaries not appearing on any of these sites, but we cannot verify this in the absence of any official or accurate source for the location of these dispensaries. we found that of the open stores, most did not have names that clearly discerned them as selling marijuana, and very few had signs besides green crosses that were clear indicators of marijuana. of note, a limitation to using google maps to determine signage was that some signs were illegible and google maps only showed the street view of the store front, which could miss signage on the sides or back of businesses. moreover, signage or store name alone are not the sole indicators of whether an individual is aware of a store’s presence in a neighborhood. for example, friends or relatives may alert someone to the presence of a store that is otherwise lacking a sign, customers may be loitering outside stores with paraphernalia or clothing referencing marijuana, and there may be a smell of the drug on the street outside the store from customers who have used the products before or upon exiting from the store. though prior studies have not collected signage information, which no doubt has some effect on awareness of the dispensary’s existence in the neighborhood, studies that look at neighborhood density and proximity to these stores may need to also ask study participants if they are aware of dispensaries in their neighborhood regardless of whether they have or lack any clear signage or discernable store name. driving by locations is a method that may help to verify dispensary address and signage data. after first locating stores and addresses online, other researchers have driven to the posted addresses of medical marijuana dispensaries in long beach, california and sacramento, california (freisthler et al., 2016; lippermankreda et al., 2014). researchers have also located “vape stores” that sold ends in two north carolina counties by first locating them through online search engines and then driving on primary and secondary roads in the counties to confirm locations and look for stores selling ends that they may have missed (lee, d’angelo, kuteh, & martin, 2016). such methods are possible in these smaller areas: long beach has a square mileage of 52 and sacramento has a square mileage of 100. the two counties in north carolina covered about 950 miles, but researchers only searched in populated (non-rural) areas. such methods are not feasible in los angeles county as it covers over 4,750 square miles, with no largely unpopulated areas (e.g., average population per square mile is approximately 8,300 across los angeles county’s 272 neighborhood; see http://maps.latimes.com/neighborhoods/populatio n/density/neighborhood/list/). in addition, because dispensaries fluctuate often and any database would need to be updated regularly, using online methods alone is more practical; although it likely misses some of the dispensaries that one may locate by driving every street in the county. yet even these methods may miss dispensaries that choose not to have a street-side presence. if driving to locations is not feasible, calling stores to verify information is another option for data collection. researchers have also used online search engines such as yelp, google, and yellow pages supplemented by crowdsourcing to identify vape stores in the state of florida that sold ends (kim et al., 2016). though the internet search methods alone were mostly accurate in the study (e.g., yelp identified 78% of stores selling ends) and represented a better system than using an outdated florida state tobacco licensure list, the method was enhanced by using a crowdsourcing platform (amazon mechanical turk [mturk]) to call each store located from the online searches and confirm the store sold ends. mturk workers took eight hours to call 1,459 stores and confirm information, and researchers replicated the eight hour task two more times to verify accuracy across mturk workers. though costs of the tasks were not reported, this crowdsourcing methodology is no doubt more cost effective than driving to each location or having grantor university-funded research assistants call each location and confirm information. although we did not employ this methodology in the present study as we only called 10% of stores, it could be cost effective and practical for mturk users to call the 872 dispensaries located in website searches and confirm open/closed status, verify addresses, and cannabis, a publication of the research society on marijuana 33 inquire about signage. future studies may consider this approach. to demonstrate feasibility of using the websites to document a point-in-time portrayal of the medical marijuana dispensaries in the area, we utilized a single coder for data extraction. this was meant to represent the typical extraction effort that may be completed on a small budget, perhaps by a research assistant or a graduate student collecting their own data for a thesis. although the data verification procedures were conducted by two additional researchers, using an additional coder to extract data and documenting inter-rater reliability would have been a more rigorous (albeit time intensive) method of data verification at the extraction stage. it may also be possible to automate searches such that these websites are swept for current addresses, phone numbers, and store names, though signage information and current open status may be difficult to collect from automated methods. researchers interested in using these methods should consider the effort needed to collect data from the other four websites beyond weedmaps alone, as only 5% of the outlets we found on at least one website were not found on weedmaps. if weedmaps and yelp were used alone, we would have located 464 of the 470 open outlets (99%). to locate the missing six outlets (1%), we would have needed to use leafly and stickyguide or leafly and where’s weed. there were no outlets that were solely located on where’s weed or stickyguide alone; thus, there was no unique benefit of using both of those sites after already using weedmaps, yelp, and leafly. more research is also needed to determine how comprehensive the websites can be in locating recreational marijuana outlets, as recreational sales are now legal in several states. each of the marijuana websites we used can differentiate between medical and recreational outlets. our methods focused on los angeles county alone to determine the feasibility of this approach in a large urban area covering over 4,750 square miles. future studies can help determine if these methods are appropriate for locating marijuana outlets in other large cities or in more rural areas. the five websites used in this study cover many areas in the united states; for example, weedmaps and yelp cover all the states across the nation where medical (and now recreational) marijuana is available for legal purchases from dispensaries. stickyguide currently allows searches for marijuana outlets in california (bay area, la, sacramento/stockton), colorado (denver, boulder, colorado springs), maryland, washington state (seattle/tacoma), and washington, dc. leafly is searchable for 27 states and washington, dc, and where’s weed is searchable for 25 states and washington, dc. as these websites widen their searchable areas, researchers across the united states can replicate our methods to help determine the feasibility and utility of this approach in their local areas. conclusions we acknowledge the prior work that has paved the way for our online methods of identifying medical marijuana dispensaries (freisthler & gruenewald, 2014; freisthler et al., 2016; hunt et al., 2014; kepple & freisthler, 2012; kilmer et al., 2013; nunberg et al., 2011; pacula et al., 2002; saloga et al., 2013; thomas & freisthler, 2016; shi, 2016). our work is innovative and moves the field forward in several ways. first, we have described our methods in detail, which makes replicability and generalizability possible. methods could be used to develop databases of dispensaries in other large cities. second, we included information about signage and name of store to describe if the dispensaries were clearly recognizable as medical marijuana outlets. this information is essential for researchers interested in determining mechanisms by which youth and adults may be influenced by proximity to dispensaries. third, our methods indicated that it is important to maintain and update this database regularly given fluctuation of these businesses. the methods presented here provide a structured guide to researchers to help them better identify dispensaries, which is crucial as availability of legal recreational marijuana continues to increase. important caveats about the accuracy of data collected from online sources alone should be considered. using online methods alone may be feasible and practical; however, use of other data sources and methods can improve the accuracy of these methods. these may include calling all located dispensaries to determine open status, driving by posted addresses to confirm address data, driving down populated streets to locate dispensaries not posted online and to verify locating marijuana dispensaries 34 signage information not available online, and comparing dispensaries located online to any available city, county, or state lists of licensed and unlicensed dispensaries. however, online methods may represent a best, practical effort for researchers seeking to locate dispensaries in a cost-effective way. utilizing these methods, researchers can be better equipped to investigate how dispensary density changes over time, how these dispensaries associate with neighborhood factors such as crime and disorganization, and how proximity to and density of dispensaries may affect adolescent and adult marijuana use. accurate information on dispensary names, locations, and signage can also provide important information on how marijuana availability may affect neighborhood quality, which can, in turn, inform policy decisions. references bierut, t., krauss, m. j., sowles, s.. j., & cavazos-rehg, p. a. 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(2016). e-cigarette use among youth and young adults. a report of the surgeon general. atlanta, ga: united states department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health. funding: work on this paper was supported by two grants from the national institute on alcohol abuse and alcoholism (r01aa016577; r01aa020883) to elizabeth d'amico. acknowledgments: the authors wish to thank the rand survey research group for coding of the marijuana outlets for this study. we also wish to thank rand colleagues priscillia hunt, ervant maksabedian, rosalie pacula, clinton saloga, and michael woodward for their assistance in developing the methodology and beau kilmer for an initial review of this manuscript. the database of open dispensaries is available by sending a request to the first author. data requesters will be asked to sign a data use agreement and agree that they are using the database of medical marijuana dispensaries for research purposes (i.e., not personal or commercial purposes). copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 14 abstract social norms play a critical role in motivation for marijuana use, particularly for emerging adults. the current report evaluated the differential impact of perceived friends’ approval of use (injunctive norms) and perceived friends’ and classmates’ use (descriptive norms) on marijuana use in 187 college students. while injunctive norms were significantly associated with participants’ marijuana use, most reported their friends would be indifferent to abstinence or infrequent use. our model using a traditional measure of injunctive norms indicated that perceptions of friends’ approval of marijuana use is not uniquely associated with use when considered in combination with descriptive norms. given the lack of variability in perceptions of friends’ approval of all but regular use, we compared our original model with an exploratory one evaluating the differential impact of injunctive norms for regular use in addition to descriptive norms. results indicated that perceptions of friends’ approval of regular use influenced participants’ use above and beyond perceptions of friends’ actual use. such findings may be indicative of the current social climate, in which occasional use of marijuana is accepted, and may parallel similar findings in the binge drinking literature. key words: cannabis, undergraduates, social norms, injunctive norms, emerging adults marijuana use is a significant public health concern that has been linked to shortand longterm consequences, including changes in mood, impaired movement and memory, and decreases in executive functioning, especially among early onset and heavy users (buckner, ecker, & cohen, 2010; gruber, sagar, dahlgren, racine, & lukas, 2012; curran et al, 2016). recent work indicates that there is a softening of the perceived risk associated with marijuana use among adolescents, with the majority of high school seniors reporting that they do not consider regular marijuana use to be harmful (johnston et al., 2015). these lowered perceptions of risk are troublesome given previous research illustrating an inverse relationship between perception of harm and frequency of use (bachman, johnson, & o'malley, 1998). this change in risk perception merits further consideration within college-aged youth, as marijuana is the leading illicit drug used by 18-25 year olds (samhsa, 2014). social norms theory has provided a useful framework for understanding problematic alcohol use in this age group, and may provide similar insight for marijuana use. social norms theory posits that behaviors are influenced by one’s perceptions of the behaviors and opinions of peers (berkowitz, 2004; labrie, hummer, lac, & lee, 2010). indeed, peer influence is key to understanding a number of cannabis 2018, volume 1 (2), 14-21 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.002 open access frequency of use matters: the role of peer norms and approval on college students’ marijuana use corresponding author: victoria ameral, department of psychology, clark university, 950 main st, worcester, ma 01610, u.s.a., phone: 508-793-7274, fax: 508-793-7265, email: vameral@clarku.edu victoria ameral1, meghan e. reilly2, kathleen m. palm reed,1 denise a. hines1 1 department of psychology, clark university, worcester, ma, usa 2 division of alcohol and drug abuse, mclean hospital, belmont, ma, usa http://dx.doi.org/10.26828/cannabis.2018.02.002 cannabis, a publication of the research society on marijuana 15 health behaviors in college students, including risky sexual behaviors (scholly, katz, gascoigne, & holck, 2005) and unhealthy weight-control behaviors (eisenberg, neumark-sztainer, story, & perry, 2005), in addition to substance use (borsari & carey, 2003; buckner, 2013; labrie et al., 2010; neighbors, geisner, & lee, 2008). injunctive norms, or the perceived peer approval for engaging in a certain behavior, are considered separately from descriptive norms, or the perception of how frequently peers engage in the same behavior. both descriptive and injunctive norms have been linked to alcohol use among college students, who tend to overestimate peers’ drinking behaviors and approval of drinking, which is, in turn, positively associated with their own use (borsari & carey, 2001; borsari & carey, 2003; labrie, hummer, neighbors, & larimer, 2010; labrie, hummer, & lac, 2011; larimer et al., 2011; neighbors, larimer, & lewis, 2004). more recently, researchers have applied social norms theory to marijuana use among college students (buckner, 2013; labrie et al., 2010; labrie et al., 2011; neighbors et al., 2008). similar to alcohol use, college students believe that a much higher percentage of their peers have tried marijuana (83.6% of their peers; acha, 2014) than actually have (18.3%; acha, 2014). this divergence between perceived and actual use underscores the potential importance of correcting norms for this population. both descriptive and injunctive norms are associated with marijuana use above and beyond other cognitive factors, including expectancies and coping motives (neighbors et al., 2008; buckner, 2013). perceived approval and use of closer reference groups, like close friends, show the strongest association with use behavior, highlighting the importance of reference group for the role of norms in the decision to use marijuana (labrie et al., 2011). among high school seniors, injunctive norms influence marijuana use above and beyond descriptive norms of such proximal reference groups (neighbors et al., 2008; buckner, 2013). however, these studies have been limited by age group (e.g., recently graduated highs school seniors only, neighbors et al., 2008), or by narrowly defining injunctive norms as approval of risky marijuana use only (i.e., regular use in combination with risky behaviors while intoxicated; buckner, 2013). while high school seniors are not chronologically distant from college students, there is a meaningful shift during this developmental period, punctuated by newfound autonomy, instability, identity-seeking (merrill & carey, 2005), and the highest rates of substance use and substance use disorders compared to other age groups (center for behavioral health statistics and quality, 2016). furthermore, there is not currently sufficient evidence to suggest that perceived approval of risky marijuana use alone would impact frequency of use, though lowered perceptions of risk (johnston et al., 2015) highlight the importance of considering the continuum of marijuana use patterns in norms research. taken together with recent concern regarding replication work in psychology (open science collaboration, 2015), as well as the key role of norms research in informing prevention and intervention efforts, further investigation into the influence of norms on marijuana use in college students beyond their first academic year is merited. thus, the current study aimed to replicate and extend previous work by examining whether injunctive norms (i.e., perception of peer approval) significantly impacts frequency of marijuana use above and beyond descriptive norms (i.e., perceived frequency of peers’ marijuana use) in a college student sample of marijuana users. we hypothesized that those who perceived their friends as more approving of marijuana use would use marijuana more frequently, and that these injunctive norms would influence use above and beyond perception of friends’ and classmates’ actual use. method participants responses were gathered from a larger campus survey of undergraduate and graduate students on well-being, substance use, and interpersonal violence that was conducted in november, 2011. all students were invited to participate in an online, anonymous survey, which was programmed to prevent multiple responses from a single ip address. raffle incentives including one $100 and ten $20 gift cards to the university bookstore were offered. study methods were approved by the institution’s board of ethics. frequency of use matters 16 inclusion criteria for the current analysis included age between 18 and 24 at the time of the survey in order to limit the sample to the typical college student age range. further, we included only those participants who reported at least one instance of marijuana use in the two months preceding the survey. this criterion allowed us to evaluate the influence of norms on a continuum of current use patterns. of the 612 students who participated in this larger study, 187 (30.5%) met these inclusion criteria. participants’ average age was 20.07 (sd = 1.43) years old, and the majority of participants (73.3%) were female. the majority of the sample was white (90.9%), followed by multiracial (4.3%), asian (1.1%), black (1.1%), and latino/a (1.1%); 1.6% did not provide racial/ethnic information. class years were wellrepresented, with 18.7% first year, 25.7% sophomore, 23.0% juniors, 24.1% seniors, and 8.6% graduate students. distribution by class year for the larger sample did not differ as a function of marijuana use in the past two months [χ2(4, n=534) = 5.45, p = .245]. measures frequency of use. frequency of marijuana use was assessed by asking participants to answer the question “how often do you use marijuana?” responses were coded as 0 = never, .5 = less than once per week, 1 = once per week, 2 = twice per week, 3.5 = 3-4 times per week, and 5 = 5+ times per week. descriptive norms. descriptive norms were assessed by asking participants to indicate “how often do you think most students at your school use marijuana?” and “how often do you think your friends use marijuana?” responses were coded following the same scheme as frequency of use (above). injunctive norms. similar to previous studies (neighbors et al., 2008), injunctive norms were assessed by asking participants to indicate their friends’ approval if they (a) abstained from marijuana use, (b) if they tried marijuana once or twice, (c) if they used marijuana occasionally, and (d) if they used marijuana regularly. friends’ approval was used due to the importance of proximity of reference group for injunctive norms (labrie et al., 2011). for each item, responses were coded as -1 = they would disapprove, 0 = they wouldn’t care, and 1 = they would approve. all four items were collapsed into a single continuous variable according to the method used by neighbors and colleagues (2008), resulting in a 6point scale in which 6 = approval of regular use; 5 = approval of moderate but not regular use; 4 = approval of using once or twice but not more; 3 = disapproval of abstinence but not caring about or not approving of use; 2 = not caring about abstinence or use; and 1 = disapproval of regular use. results all data was examined to ensure assumptions for normality were met. missingness was less than 5% for all variables. mean value replacement was used for all variables, with the exception of the injunctive norms questions. given the nature of the injunctive norms questions, missing responses for these items were not mean-replaced for the 4 participants who did not provide responses, resulting in a sample size of n = 183 for all analyses that included the injunctive norms variable. while mean value replacement is limited by its simplicity (meyers, gamst, & guarino, 2013), this method was retained due to follow-up analyses indicating that the pattern of results did not differ when cases with missing data were excluded. descriptive statistics and inter-correlations for frequency of use and injunctive norms are presented in table 1. over half of participants (53.5%) reported using marijuana less than once per week, with about a quarter (23.0%) reporting use between 1-3 times per week and the remainder (21.4%) reporting use three or more times per week. participants perceived greater marijuana use frequency among friends (2-4 times per week; m = 2.46; sd = 1.72; t(186) = -7.65, p < .001) and students more generally (2 times per week; m = 1.94, sd = 1.30; t(186) = -2.66, p = .009), compared to their own reported use (1-2 times per week; m = 1.57, sd = 1.61). as shown in table 1, participants’ reported frequency of marijuana use was significantly associated with perceptions of friends’ and classmates’ use, as well as friends’ approval of use. cannabis, a publication of the research society on marijuana 17 table 1. means and intercorrelations of variables of interest m sd 1 2 3 1. frequency of use – self ◊ 1.57 1.61 2. frequency of use – friends 2.46 1.72 .54*** 3. frequency of use – classmates 1.94 1.30 .18* .29*** 4. approval of use – friends ‡ 2.70 1.79 .20** .34*** .12 note. * p < .05, ** p < .01, *** p < .001. ◊frequency of use was measured on a 6-point scale as follows: 0 = never, .5 = less than once per week, 1 = once per week, 2 = twice per week, 3.5 = 3-4 times per week, and 5 = 5+ times per week. ‡approval of use, or injunctive norms, were measured on a 6-point scale (see method section). to examine the relative influence of descriptive and injunctive norms on participants’ frequency of use, we conducted a multiple regression analysis (table 2). the overall model was significant, f(3, 179) = 25.46, p < .001, and accounted for approximately 30% of the variance in marijuana use. however, only descriptive norms for friends’ use showed a significant independent influence on use (β = 0.53, p < .001, sr2 = .23), with descriptive norms for classmates (β = 0.03, p = .622) and the six-point injunctive norms score (β = 0.01, p = .905) failing to show a significant influence on use above and beyond descriptive norms for friends. examination of response patterns to the four individual injunctive norms questions indicated lack of variability in some items along the continuum of abstinence through occasional use. the vast majority (76.4%) of respondents indicated that their friends would not care if they abstained from smoking marijuana, zero respondents indicated that their friends would disapprove of them trying marijuana once or twice, and only 2% of participants indicated that their friends would disapprove of occasional use. friends’ approval of regular use was the only question with substantial variability in responses, with 36% of respondents indicating that friends would disapprove, 48.8% indicating that their friends would not care, and 12.8% indicating that friends would approve of regular use. regular marijuana use patterns are most consistently associated with a broad range of adverse mental and physical health outcomes (hall, 2014). taken together with the lack of variability in approval of other use patterns, this item pertaining to friends’ approval of regular marijuana use appeared worthy of further investigation. table 2. results of multiple regression analyses predicting marijuana use frequency b se b β p f p r2 aic initial model 25.46 <.001 .30 119.98 descriptive norms-f .49 .06 .53 <.001 descriptive norms-p .04 .08 .03 .622 injunctive norms .01 .06 .01 .905 regular use model 28.12 <.001 .32 114.36 descriptive norms-f .43 .06 .47 <.001 descriptive norms-p .02 .08 .02 injunctive norms-r .40 .17 .16 .019 note. descriptive norms-f = perceived frequency of friends’ use; descriptive norms-p = perceived frequency of classmates’ use; injunctive norms = perceived friends’ approval of marijuana use; injunctive norms-r = perceived friends’ approval of regular use only. frequency of use matters 18 thus, we conducted an exploratory regression analysis to examine whether peers’ approval of only regular marijuana use influenced participants’ marijuana use, using the injunctive norms for the regular use (injunctive norms-r) item in a model together with descriptive norms (table 2). this overall model was significant, f (3, 179) = 28.12, p < .001, and accounted for approximately 31% of the variance in marijuana use. both descriptive norms for friends (β = 0.47, p < .001, sr2 = .17) and injunctive norms-r (β = 0.16, p = .019, sr2 = .02) showed significant independent influences on participants’ use in this model, though descriptive norms for classmates did not (β = 0.02, p < .001). descriptive norms for friends accounted for a greater percentage of unique variance in the model than injunctive norms, as indicated by the squared semi-partial correlation (sr2). approximately 12% of the variance in participants’ use of marijuana was due to shared variance between descriptive norms and injunctive norms for regular use. discussion the current study aimed to examine whether injunctive norms impact marijuana use above and beyond descriptive norms in a college sample of undergraduate and graduate students. the current study partially replicates neighbors and colleagues’ (2008) findings of a significant independent contribution for injunctive norms above and beyond descriptive norms on marijuana use. for our sample, only injunctive norms for regular marijuana use (injunctive norms-r) was uniquely associated with marijuana use, whereas overall injunctive norms were not. our finding that descriptive norms accounted for more of the unique variance in marijuana use relative to injunctive norms also aligns with the extant literature (neighbors et al., 2008; buckner, 2013). in addition to highlighting the importance of perceptions of friends’ approval of regular marijuana use, the current study extends previous findings of these relationships in entering college student marijuana users to a college age sample that spans across class years and into graduate school. these findings could be indicative of the current social climate, which may normalize and even promote experimental or occasional use of marijuana, but recognize the potential health/academic consequences associated with regular use. further, our results align with previous work evaluating injunctive norms related to risky use among college students (buckner, 2013). of note, 23.6% of the sample indicated that friends would care to some extent if the participant abstained from marijuana use. thus, college students may find themselves trying to navigate a fine line between occasional use and regular marijuana use, seeking approval from friends, and succeeding at school. this observed phenomenon is reminiscent of perceived friends’ approval of binge drinking in undergraduate populations – that friends are more likely to approve of occasional alcohol consumption, but acknowledge the potentially damaging impact of more frequent or heavy drinking. for example, strano and colleagues (2004) measured predictors of binge drinking in an undergraduate sample, and discovered that perceived friends’ approval was a significant predictor of binge drinking behavior (i.e., students engaged in less binge drinking if they perceived friends’ disapproval). limitations there were a number of limitations in this study. first, our sample is not reflective of university students in general, though similar results may be found in liberal arts colleges of similar size, of which there are over 500 in the us. second, more recent evaluations of injunctive norms have adapted the neighbor’s et al. (2008) approach using a 7-point, rather than a 3-point, approval scale, which may better capture variability in approval of marijuana use. despite assurance of anonymity, the use of self-report and sensitivity of substance use as a topic may have resulted in more conservative estimates of marijuana use. a number of additional limitations are due to the use of a larger dataset in which participant burden was an important consideration. first, we included only participants who reported any marijuana use in the past two months, which allowed for evaluation of the influence of norms along the continuum of current use. however, additional analyses considering the influence of norms on any lifetime history of marijuana use (an item not included in our database), could provide additional information with respect to the cannabis, a publication of the research society on marijuana 19 continuum from limited experimentation to regular use. second, a more traditional measure of marijuana use that does not impose restrictions to the upper limit of use (i.e., 5+ times per week) could provide a more accurate measure of the frequency and severity of marijuana use. the question in the current study was designed to match a series of similar questions in the climate survey, and is thus a less sensitive measure than those used in studies focused specifically on substance use issues. nonetheless, our upper limit of five or more times per week aligns with the epidemiological definition of “regular” or “heavy” use that is most often associated with negative health outcomes (hall, 2014). similarly, future research into the relationship between social norms and marijuana use should consider measuring frequency and consequences of use (buckner, 2013) concurrently, as each has been considered in isolation. reference groups, like friends, may report more disapproval when someone uses and engages in risky behaviors (i.e., driving under the influence), and this may or may not align closely with frequency of use. conclusion the current results suggest that perceptions of others’ use impacts frequency of marijuana use throughout students’ college careers. notably, our findings provide preliminary evidence for the role of marijuana use frequency in social norms research and applications, a consideration that should be explored further in future work. emerging findings suggests that social norms related to marijuana use can be modified with brief interventions (elliot & carey, 2012) and that marijuana use decreases in the short term in response to such interventions (e.g., over the semester; lee et al., 2013). however, future research on efficacious prevention and intervention programs with lasting, long-term effects for marijuana users is greatly needed. in addition to considerations of use frequency, the influence of other close reference groups, including parents (napper, hummer, chithambo, & labrie, 2015), will be important to monitor amidst ongoing societal shifts in perception of marijuana use. references american college health association (2014). american college health association – national college health assessment ii: undergraduate students reference group executive summary spring 2014. hanover, md: american college health association. bachman, j. g., johnson, l. d., & o'malley, p. m. 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(sma) 14-4863. rockville, md: substance abuse and mental health services administration. cannabis, a publication of the research society on marijuana 21 funding: this work was supported by the u.s. department of justice under grant no. 2009-waax-0012; and the u.s. department of education under grant no. q184h090012. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 66 special section editor bradley t. conner, ph.d. keynote address how cannabis research and cannabis policy can inform each other susan r. b. weiss national institute on drug abuse cannabis policies in the united states (and globally) are changing rapidly, far outpacing the knowledge needed to determine and minimize the public health impacts of these changes. cannabis is already the most commonly used federally illicit substance; and use has been increasing in young and older adult populations for the last 10 years; with at least 4 million individuals in the u.s. meeting diagnostic criteria for cannabis use disorder each year. cannabis now refers to a diversity of products, with varying potencies (i.e., tetrahydrocannabinol (thc) concentrations), including some with little or no thc and in turn, minimal abuse liability (e.g., cannabidiol or cbd products). federal and state laws don’t align, which creates multiple obstacles for researchers, patients, public health officials, and even those in the cannabis industry—who may be forced into unwieldy (e.g., cash only) business practices. this presentation highlights what we know and what we need to know about the adverse and potential therapeutic effects of cannabis, with the goal of identifying research needs and opportunities. while more evidence is needed on the long-term impact of cannabis, particularly in relation to causality and permanence, populations such as adolescents, pregnant women (and their offspring), and individuals with mental illness are likely to be the most at risk for adverse outcomes. the potential therapeutic uses of cannabis and its constituent cannabinoids are vastly understudied, despite their widespread use. there are many reasons for this, including long-standing barriers to research, some of which are starting to be addressed. as the evidence is being generated, it is crucial that we remain unbiased in our assessment of it, and forthright in our dissemination of information. only then can we advance the science and better inform policy and public health. contact: susan weiss sweiss@nida.nih.gov keynote address the complex, bi-directional & nuanced associations between cannabis and posttraumatic stress disorder marcel o. bonn-miller university of pennsylvania perelman school of medicine contact: marcel bonn-miller mbonn@pennmedicine.upenn.edu cannabis 2018, 2 (1), 66-111 © author(s) 2018 researchmj.org open access abstracts from the 2018 scientific meeting of the research society on marijuana july 28th-30th, 2018 fort collins, colorado conference abstracts 67 poster presentations all poster presentations and symposia were peerreviewed by the 2018 conference program committee of the research society on marijuana (rsmj) (chair: bradley t. conner, colorado state university). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. association between coping strategies and marijuana use among pre-clinical traumaexposed students angeles astorga, nathan kearns, rachel armour, renee cloutier, & heidemarie blumenthal university of north texas background: marijuana is the most commonly used illicit substance in the united states (nida, 2014) and has been linked to both short-term and long-term negative developmental, physical, and physiological outcomes (e.g., altered brain development, diminished life satisfaction; volkow et al., 2014). although epidemiological work has primarily emphasized sociodemographic characteristics (e.g., sex) associated with marijuana use (pacek et al., 2015), a burgeoning literature also has focused on the impact of trauma exposure and posttraumatic stress. indeed, extant work indicates that individuals exposed to trauma and/or that are evidencing posttraumatic stress disorder (ptsd) symptomatology are at increased risk for marijuana use and related problems (boden et al., 2013; cougle et al., 2011). expanding on this literature, recent work has focused on underlying mechanisms that may influence associations between trauma exposure and marijuana use, including specific coping motives and strategies that individuals use to manage posttraumatic stress (e.g., avoiding coping; bonn-miller et al., 2007). however, much of this work has been conducted in clinical populations with ptsd and/or cannabis use disorder, providing little insight or guidance for prevention efforts in preclinical populations following trauma. the current study begins to address this gap in the literature by evaluating 14 adaptive and maladaptive coping strategies that may be associated with increased or decreased likelihood of marijuana use in a heterogeneous sample of pre-clinical trauma survivors. methods: the sample included 1,152 participants (m = 20.72, sd = 3.26; 73.7% female) drawn from a large university in a southwestern state where marijuana use is not legal for medical or recreational purposes – that met the following eligibility criteria: (1) exposure to at least one dsm-5 criteria a traumatic event (apa, 2013) according to the list of events checklist for dsm5 (lec-5; weather et al., 2013) and (2) their indexed trauma occurred more than 30 days prior to assessment. participants completed the brief cope (carver, 1997) to assess 14 coping strategies related to dealing with stress and a single-item, face-valid question to assess pastmonth marijuana use. responses were dichotomized to 0 (“no”) or 1 (“yes”) based on any endorsement of past-month marijuana use. forward stepwise binary logistic regression (wald statistics) was conducted to isolate which coping strategies (or collection of variables) were most strongly associated with increased odds of marijuana use in the past-month. results. overall, five iterative steps identified the final model, which accounted for approximately 15% of the variance in past-month marijuana use. expectedly, substance use coping has identified as the coping strategy most strongly associated with past-month marijuana use (or = 1.65). further, increased frequency of self-distraction (or = 0.92), denial (or = 0.87), and religion (or = 0.89) coping strategies were associated with decreased likelihood of using marijuana; conversely, frequency of active coping was positively associated with increased likelihood of using marijuana (or = 1.13). conclusion: the results of this study indicate that certain coping strategies are more strongly associated with marijuana use after trauma exposure, and may inform future prevention-oriented work. coping strategyspecific implications, study limitations, and future research will be discussed. contact: heidemarie blumenthal heidemarie.blumenthal@unt.edu supplemental materials here conference abstracts 68 does the form of marijuana use impact the relation between marijuana use motives and daily frequency? chelsea l. banks, lillian j. canfield, alexa j. pellegrino, maryia m. schneider, megan h. smith, anastasia robirds, erica b. peteja, kerry d. duck, michael m. phillips, & kristina t. phillips university of northern colorado background: past research has illustrated a relationship between a range of marijuana use motives (e.g., coping, social) and marijuana use frequency. with a growing market of new marijuana forms (e.g., concentrates, edibles), strains (hybrid, indica, sativa), and methods of ingestion (e.g., vaping, dabbing), it is important to gain a better understanding of how variations in marijuana might influence these established associations. therefore, the goal of the current study is to examine whether marijuana form (flower vs. concentrates) moderates the relation between marijuana use motives and marijuana use frequency. methods: active college-student marijuana users (n = 79) were recruited and completed a baseline assessment that lasted approximately 90 minutes. participants were trained on a signal-contingent ecological momentary assessment (ema) protocol and responded to three random prompts each day for two weeks through a smartphone app. a baseline question examined the primary form of marijuana used (e.g., flower, concentrate, edibles). five subscales from the marijuana motives measure were used to assess specific reasons for using marijuana, including coping, social anxiety, enjoyment, boredom, and altered perceptions. marijuana use frequency was assessed using an ema question assessing the average number of times marijuana was used each day over the twoweek period. results: participants were 60% female, 61% caucasian, and averaged 20.35 (sd = 3.65) years of age. at baseline, participants reported an average of 22.77 (sd = 7.3; 4 30) days of marijuana use in the last month and an average of 5.23 (sd = 1.81) days of use per week. ema data showed that participants used, on average, once per day (m = 1.17; sd = .59). over the two-week ema period, participants reported using a mean of 16.32 (sd = 8.29) times over the two-week period. most participants were using flower (n = 60) or concentrates (n = 15) as their primary form of marijuana. four participants reported primarily using edibles or other forms; these participants were excluded from further analyses. we found that form of marijuana was related to the ema daily average of marijuana use. when examining the interactions between form and motives in five separate models, we found a moderated effect of form on daily ema average only for enjoyment motives (p = .04). more specifically, as enjoyment motives increased, concentrate users reported greater marijuana use daily instances via ema. in the relationship between altered perceptions and marijuana use frequency, marijuana form approached significance as a moderator (p = .08). conclusions: our findings suggest that the relationship between enjoyment motives and marijuana use frequency was particularly relevant for marijuana concentrate users. as more forms of marijuana become available, a more nuanced approach to understanding the relation between motives and frequency is needed. contact: kristina phillips kristina.phillips@unco.edu cannabis and schizotypy: revisiting an old problem brittany e. blanchard, angela k. stevens, & andrew k. littlefield texas tech university the link between cannabis and schizotypy (i.e., patterns of behavior which typify a genetic predisposition schizophrenia-spectrum pathology) is well documented, with some research indicating individuals with schizotypy are two-to-four more likely to report cannabis use (e.g., cohen et al., 2010). however, as previous work has indicated (e.g., earleywine, 2006), several markers of schizotypy assessed on self-report measures (e.g., speech-related problems, such as forgetting what one is saying) may also represent common effects of cannabis use (e.g., working memory deficits). given this, it is imperative to determine whether these items intended to assess schizotypal personality traits function the same across users and nonusers of cannabis. if these items exhibit differential item functioning, cannabis users may be erroneously classified as exhibiting schizotypy, conference abstracts 69 which can yield deleterious consequences in clinical work and impede research progress. the current study aimed to determine whether speech-related items on the schizotypy personality questionnaire-brief revised (spqbr) exhibit measurement invariance as a function of cannabis use status. participants consisted of college students from a southwestern university (n = 602, 63% female, 66% white, 27% latinx) who completed a battery of self-report measures, including the spq-br and a modified daily drinking questionnaire to assess cannabis use. to ensure adequate power, lifetime use (n = 353) versus non-use (n = 249) was used for the current analyses. to assess differential item functioning, measurement invariance was tested using structural equation models in mplus version 7.4 with spq-br items modeled as ordinal indicators using a wlsmv estimator. the difftest was used to assess statistically significant changes in model fit. preliminary results indicated the four-item odd speech subscale was not invariant across cannabis use status when comparing the configural (i.e., freely estimated) to scalar model (i.e., factor loadings and thresholds constrained across groups; difftest χ(15) = 36.96, p = .001). next, partial scalar invariance was tested by freeing one item at a time. partial measurement invariance could not be achieved when freeing any one item, suggesting all four items of the odd speech subscale of the spq-br function differently across cannabis users versus nonusers (difftest χ(14) = 25.6144.48, p < .05). although it is difficult to interpret differential item functioning, speculatively, it may be that cannabis users are reporting on cannabis-induced outcomes on items of the odd speech subscale (e.g., “i sometimes forget what i am trying to say”; “do you tend to wander off the topic when having a conversation?”), rather than endorsing indications of schizotypy. although directions on the spq-br specifically ask individuals not to consider substance-induced experiences when answering, this may not be sufficient. cognitive interviewing with cannabis users while taking the spq-br may be beneficial in understanding why these items function differently across users and nonusers. given these preliminary findings, establishing measurement invariance across cannabis use status for measures assessing schizotypy and similar constructs will be necessary going forward before any relation, causal or correlational, between cannabis use and schizophrenia-spectrum pathology can be elucidated. contact: brittany blanchard brittany.blanchard@ttu.edu the intersectionality of race, biological sex, and past 30-day marijuana use among trauma exposed emerging adults caitlyn n. carey, nathan t. kearns, quadreon k. miller, alisa c. payne, melissa n. whitted, & heidemarie blumenthal university of north texas background: marijuana is the most widely used illicit drug in the united states (samhsa, 2013), and is linked to various health, emotional, social, and legal consequences (degenhardt & hall, 2006). an extensive literature has consistently identified trauma exposure as a risk factor for problematic marijuana use (vlahov et al.,2002; kilpatrick et al., 2000; bremner et al., 1996). in an attempt to better understand substance use after trauma exposure, related research (e.g., alcohol) has identified both biological sex and race/ethnicity as risk markers (danielson et al., 2009). however, limited work has focused on these factors in relation to marijuana use in traumaexposed populations, and no work has evaluated the intersection of these sociodemographic markers (e.g., black males, white females). the current project begins to address this gap by assessing marijuana use frequency and the intersectionality of race/ethnicity and biological sex among trauma-exposed college students. method: a sample of 805 trauma-exposed undergraduates (mage= 20.68; 70.7% female) were recruited through an online participant pool. participants were included in the study if they reported (a) a diagnostic and statistical manual for mental disorders–fifth edition (dsm-5) criteria a traumatic event (apa 2013), and (b) some level of ptsd symptom severity in the past 30 days (i.e., not asymptomatic). due to limited sample sizes in other reported racial/ethnic categories (e.g., asian, pacific islander), only those primarily identifying as black/african american, white/caucasian, or hispanic/latinx were examined in the current analyses. a singleconference abstracts 70 item, face-valid question was used to assess past 30-day marijuana use, with response options ranging from 1 (no use) to 7 (20 or more times). a 3 x 2 factorial anova was conducted to examine the differences in marijuana use frequency between groups based on race/ethnicity and biological sex (i.e., male and female). results: results indicated no main effect for race/ethnicity [f(2, 799) = 0.59, p = .592, η2= .00], but a significant main effect was found for biological sex [f(1, 799) = 11.46, p < .001, η2= .01], indicating that individuals identifying as biologically male endorsed greater past 30-day marijuana use frequency (m = 2.03, sd = 2.58) than female peers (m = 1.52, sd = 2.18). further, the interaction was significant [f(2, 799) = 3.05, p = .048, ηp 2= .01]. specifically, men who identified as black/african american endorsed the most frequent marijuana use (m = 2.63, sd = 3.03), and females who identified as black/african american endorsed the least frequent marijuana use (m = 1.09, sd = 1.85). discussion: these results indicate that, across all race/ethnicity groups, trauma-exposed males endorsed greater frequency of past-month marijuana use than females. however, for individuals who identified as black/african american, that disparity appears to be more extreme, with black/african american males endorsing the highest frequency of marijuana use and black/african american females endorsing the lowest frequency of marijuana use. this finding highlights the importance of evaluating and meaningfully addressing the intersectionality of sociodemographic variables. further, these findings emphasize the need for prevention intervention methods that are tailored towards identifying the at-risk intersecting identities of minority groups. contact: heidemarie blumenthal heidemarie.blumenthal@unt.edu a meta-analytic investigation of the associations between cannabis use and negative consequences gabriel j. carrion-gonzalez, sarah l. simons, & matthew r. pearson university of new mexico in the current climate on policy change regarding cannabis (i.e., decriminalization, medicalization, and legalization), various stakeholders have strong interest in determining the associations between cannabis use and important outcomes, ranging from positive outcomes (e.g., medicinal benefits like decreased pain) to negative outcomes (e.g., psychosis). the present study sought to quantify the association between indicators of cannabis use and the experience of negative cannabis-related consequences. we are conducting an exhaustive search of the cannabis literature to identify studies that examine the use-consequence association, and are using metaanalytic methods to quantify this association and examine possible moderators of this association (e.g., percentage of females, measure of consequences, indicator of cannabis use, population). to date, we have coded 19 articles and present these findings here. given our expectation that we would find significant heterogeneity in effect sizes across studies, we conducted a random-effects meta-analysis. we found that cannabis use had a medium-sized effect on consequences, rw = .293, indicating that about 8.6% of the variance in consequences was attributed to the frequency or amount of cannabis use. in addition, we found significant heterogeneity of this effect, q = 217.832, p < .001, i2 = 93.114. in fact, over 90% of various across studies was due to true heterogeneity rather than chance/sampling error. when we have coded all articles, we will examine moderators of this association to further probe this heterogeneity. this study is important in that it describes the average effect size of cannabis use on a broad measure of negative consequences. given that 91.4% of the variance in negative cannabisrelated consequences was not explained by any single indicator of cannabis use, pointing to the fact that additional factors need to be examined to explain the experience of negative consequences conference abstracts 71 from cannabis use and that additional indicators of cannabis use may be needed. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here prevalence rates of marijuana, alcohol, and simultaneous use and associations with alcoholrelated consequences in at-risk youth daniel j. delaney, sara g. balestrieri, shayna s. bassett, & l.a.r stein university of rhode island objective: studies suggest that concurrent and simultaneous use of alcohol and marijuana (cam and sam, respectively) are associated with experiencing more alcohol-related consequences and higher rates of binge drinking, than alcohol use alone. however, rates of cam and sam, and possible associations with alcohol-related consequences have been little studied in samples of youth (e.g., ages 9-18) and at-risk samples. this study aimed to assess prevalence rates of marijuana and alcohol use (including cam and sam use) and associations with alcohol-related consequences in a sample of at-risk youth. methods: youth ages 9-18 (n=505, m=14.36, sd=2.57) were recruited from community mental health agencies and a juvenile correctional facility in the northeast united states (53% male; 25% hispanic; 67% white, 18% black, 6% american indian/alaskan native; 4.7% pacific islander; 2.2% asian). past 30-day prevalence rates of alcohol and marijuana use were measured using timeline follow-back (tlfb). five distinct use groups were identified: youth with (1) no substance use, (2) alcohol use only, (3) marijuana use only, (4) simultaneous use (operationalized as reporting same day use of alcohol and marijuana), and (5) concurrent use (reported using both substances but not same-day use). number of binge drinking occasions as defined by niaaa for youth was also measured using tlfb. alcoholrelated consequences were measured by the risks and consequences questionnaire. negative binomial regression and zero-inflated negative binomial regression (zinb) analyses were conducted to compare alcohol-only versus sam users on rates of binge drinking and alcoholrelated consequences. results: overall, 64% of youth reported no substance use in the past 30 days, 12.5% reported marijuana use only, 5.5% reported alcohol use only, 15% reported sam, and 3% reported cam. past 30-day prevalence across age was also calculated, and all youth ages 9-11 reported no substance use. as expected, prevalence of substance use increased from ages 12-18 (e.g., 0% of 12 year olds versus 51% of 18 year olds reported sam use). an equal proportion of males and females reported no substance use (50% vs. 50%), but a larger percentage of males as compared to females endorsed sam use (22% vs. 8%). negative binomial regression and zinb analyses indicated that youth reporting sam use had significantly higher rates of binge drinking compared to those who endorsed alcohol use only (irr = 2.74, p < .001), and significantly higher rates of drinking and driving (irr = 10.94, p < .001). no other consequences (e.g., alcohol related injuries, unprotected sex) were found to be significant. conclusions: among the substance using youth, sam and marijuana use only were most prevalent, especially among the older youth. these findings are alarming given the strong associations found with sam use and drinking and driving and higher rates of binge drinking. more research is needed to determine causal relationships between sam use and harmful drinking consequences. contact: daniel j. delaney dannyjdelaney@uri.edu impulsivity-like traits, use of protective behavioral strategies, and marijuana-related outcomes chloe j. espinosa, adrian j. bravo, matthew r. pearson, & marijuana outcomes study team university of new mexico the upps-p model of impulsivity (cyders et al., 2007) posits that there are five unique impulsivity-like traits that result in impulsive behaviors: negative urgency, premeditation (lack of), perseverance (lack of), sensation seeking, positive urgency. similar to findings in the alcohol field (coskunpinar et al., 2013), negative urgency has been found to be robustly associated with marijuana-related consequences (bravo et al., 2017). although a 5-factor model of impulsivity-like traits has much empirical conference abstracts 72 support, alternative factor structures have been examined, including a 3-factor model with positive and negative urgency loading onto a higher-order urgency factor, and perseverance and premeditation loading onto a higher-order deliberation factor. the present study examined whether use of marijuana protective behavioral strategies (pbs) mediates the effects of impulsivity on marijuana-related outcomes. further, we examine whether the mediating role of pbs use is best understood in the context of 1-, 3-, and 5-factor models of impulsivity-like traits. using a sample of 6,584 students recruited from one of eight universities across the u.s., we compared a 5-factor, a higher-order 3-factor model, and a 1-factor model. the 5-factor structure of impulsivity-like traits fit best and unique effects support examining these facets independently in the prediction of marijuanarelated outcomes. consistent with previous research with alcohol (coskunpinar et al., 2013) and marijuana (bravo et al., 2017), negative urgency was directly related to negative marijuana-related consequences. however, the effect of negative urgency on both typical marijuana quantity and negative marijuana consequences was partially accounted for by lower use of marijuana pbs. personality-targeted interventions have demonstrated promise among adolescents in particular (conrod, 2016), but perhaps pbs use could be one promising intervention target for these interventions individuals with elevated levels of negative urgency and/or sensation seeking. the fact that negative urgency demonstrated a direct effect even after controlling for pbs use suggests that additional factors need to be examined to explain why individuals with higher negative urgency experience more harms from their marijuana use. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here individual difference factors influencing cannabis non-use motives reagan e. fitzke, samuel r. davis, mark a. prince, randall c. swaim, & linda stanley colorado state university introduction: research on cannabis use motives is well established. however, there is limited research exploring cannabis non-use motives (i.e., motivations to not use cannabis). previous research on non-drinking motives shows evidence that greater non-use motives predict lower lifetime rates of alcohol use. additionally, research on american indian (ai) populations specifically shows factors such as ethnic identity can protect against substance use. ai populations have a higher prevalence of substance use compared to non-ai populations. these studies suggest that exploring non-use motives in relation to cannabis can assist in understanding cannabis use decisions. methods: this study investigates cannabis non-use motives in a national sample of individuals that report no lifetime cannabis use and live on or near reservations in the united states (n = 1867). approximately 22% of the present sample identified as white and 73% identified as ai. additionally, the relation between non-use motives and ethnic identity, ethnic pride, perceived discrimination due to ethnicity, parental awareness, and parental care/concern was explored. twelve non-use motives were included in the analysis. all analyses were conducted in mplus version 8 and were specified as complex to account for clustering by school. first, an exploratory factor analysis (efa) was run to assess the factor structure of the non-use motives scale. second, structural equation modeling (sem) was used to assess the relation between cannabis non-use motives and several demographic and other factors. results: results of the efa indicated that a one-factor solution best fit the data, with all goodness-of-fit indices falling within acceptable ranges. structural equation modeling results showed ai ethnic identity, ethnic pride, parental awareness, and parental care/concern were positively related to non-use motives. in contrast, perceived discrimination and white ethnic identity were not related to non-use motives. conclusion: ai ethnic identity was positively associated with non-use motives, but white ethnic identity had no conference abstracts 73 association with non-use motives. ai populations have previously been regarded to be particularly at-risk for substance use and misuse. the positive relation between ai ethnic identity and non-use motives suggests that ai cultural identity may be protective against marijuana use. parental care, awareness of cannabis use, and concern about cannabis use were also associated with a greater number of reported non-use motives. these findings indicate potential protective factors that all contribute to an individual’s choice to ultimately not engage in cannabis use. furthermore, these analyses suggest non-use motives are strongly related to protective factors in predicting use patterns. incorporation of nonuse motives has the potential to direct future prevention strategies, primarily for at-risk and underrepresented populations. contact: reagan fitzke refitzke@rams.colostate.edu the influence of mentor relationship quality on marijuana use during the campus connections mentoring program gereon fredrickson, shelley haddock, & kimberly henry colorado state university background: adolescent substance abuse is a serious public health concern. adolescents who abuse substances, particularly those who begin during early adolescence, are more likely to engage in risky sexual behavior, commit crimes, drop out of school, and develop a substance use disorder. additionally, adolescent marijuana use is associated with adverse consequences in later adulthood, including short-term memory impairments, altered brain development, and addiction. identification of programs, practices, and policies that have the capacity to prevent adolescent substance abuse are needed. mentoring has been recommended as one such initiative; however, not all mentoring programs are successful. nearly 50% of all mentoring relationships end prematurely and many do not produce improvements in the adolescent’s developmental trajectory. we propose that positive outcomes of mentoring will be heightened when the adolescent and mentor develop a highquality relationship. methods: the data for this study comes from a mentoring program called campus connections (cc). we hypothesized that adolescents who develop a high-quality relationship with their mentor during the cc program will be less likely to engage in marijuana use compared to youth who develop a low-quality relationship with their mentor. mentees selfreported their perception of the mentor relationship quality (mrq) using the cavell et al. (2009) mentor alliance scale (α = 0.86) at the end of the mentoring program. mentees also selfreported marijuana use at baseline and at the end of the program. marijuana use appeared to be over-dispersed and was specified as a count variable. a negative binomial regression model was used to estimate the association between mrq and marijuana use at the end of the cc program, controlling for baseline use and a set of confounders (gender, age, ethnicity, socioeconomic status, and baseline marijuana use prior to cc program start). results: a negative binomial regression model was used to calculate the results. adjusting for baseline marijuana use and relevant confounders, the expected days of marijuana use is 67% lower for each one unit increase in mrq. conclusions: consistent with prior research, we find that mentoring relationship quality is associated with better outcomes for adolescents. although having a mentor may be beneficial, having a strong alliance and relationship quality with a mentor appears to be more favorable. methods to enhance relationship quality are needed, and effective strategies may substantially enhance the effectiveness of mentoring interventions, including reductions in substance use for participating adolescents. contact: gereon fredrickson gereon.fredrickson@colostate.edu meaning in life and sensation seeking on marijuana use cara l. fresquez, alex tyskiewicz, theodore j. fetterling, & mark a. prince colorado state university presence of meaning in life has been identified as a protective factor decreasing the likelihood of marijuana use. meaning in life is defined as the sense and significance regarding the nature of conference abstracts 74 one’s being and existence. meaning in life is composed of two constructs, search for meaning and presence of meaning in life. sensation seeking is defined as the desire for novel experiences and the willingness to take risks for these experiences. past studies identify experience seeking as a predictor of initial drug use, but not of drug maintenance. however, risk seeking has been shown to predict drug maintenance and not initiation. previous research on meaning in life, sensation seeking, and substance use have demonstrated that religious meaning in life is a protective factor for marijuana use regardless of an individual’s level of risk seeking. the relations among existential (meaning in life not associated with religion) and personality factors (sensation seeking) and marijuana use has not yet been explored. the current study examined the relation among meaning in life, sensation seeking, marijuana use, using the meaning of life, sensation seeking personality type, and risky behavior inventory scales. we hypothesized meaning of life would moderate the relation between sensation seeking and past 30-day marijuana use. further, we hypothesized that individuals who had low search for meaning in life and high experience seeking, would use marijuana more frequently than individuals with high search for meaning in life and low experience seeking. the current study is a secondary data analysis of data that was collected in fall 2016 as a part of a larger study on health risk behaviors. study hypotheses were tested using negative binomial regression due to past 30-day use being a highly skewed count variable. marijuana use was determined by an individual’s reported frequency of use over the previous 30 days. we found a significant interaction between search for meaning in life and experience seeking on past 30day marijuana use. at low levels of the moderator, experience seeking negatively predicted past 30day marijuana use, whereas high levels of the moderator were associated with experience seeking predicting increased use. these results suggest that search for meaning in life moderates the relation between experience seeking and marijuana use. contrary to previous studies, which have identified experience seeking being a protective factor against drug use, the present study implicates it as a risk factor when moderated by search for meaning in life. thus, if a client present high in experience seeking and is searching for meaning in life, then he or she may be at risk for marijuana use. contact: cara l. fresquez cara.fresquez@colostate.edu supplemental materials here repetitive transcranial magnetic stimulation of the medial prefrontal cortex for reduction of polysubstance use craving: a pilot study jordan a. gette, gavin k. ueland, andrew k. littlefield, & yi-yuan tang texas tech university polysubstance use has been associated with myriad deleterious consequences in college students including increased risk for substance use disorders, poor academic performance, and risky sex behaviors. recent studies among college students suggest that over 50% of past-month substance users have engaged in use of two or more of the following substance: alcohol, tobacco, and cannabis (atc). repetitive transcranial magnetic stimulation (rtms) has been implemented as an alternative treatment to psychotherapy and has shown promise as a brief, noninvasive intervention for substance craving. the medial prefrontal cortex (mpfc) has been implicated in cognitive processes such as impulsivity and drug related cue responses making the mpfc a brain region of interest for the application of rtms. thus, the aim of the current study was to determine whether rtms on the mpfc could be utilized to reduce polysubstance craving over a brief four day intervention. participants (n = 14, 5 females, mage = 21.5, 50% white) completed demographics, the penn alcohol craving scale (pacs), the pacs adjusted for cannabis, and the pacs adjusted for tobacco. participants completed tms stimulation sessions of either two or three cycles on four consecutive days. in following with previous literature, rtms was set to 50hz with 1800 pulses per cycle at 110% of the individual’s resting motor threshold. dependent means t-tests were conducted to assess for decreases in atc craving from preto post-rtms sessions. results indicate a significant decrease in cannabis craving (p < .01) amongst cannabis users (n = 12). decreases in alcohol craving amongst users (n = 12) approached significance (p < .10). removal of an conference abstracts 75 outlier resulted in nominally significant decreases in alcohol craving (p = .01). results did not indicate significant decreases in tobacco craving (p = .43) amongst tobacco users (n = 8). although replication is necessary, these results show promise in using rtms as a means of reducing alcohol and cannabis craving. lack of significant decreases in tobacco craving may suggest that tobacco craving evidences differential patterns of cognitive control and impulsivity as compared to alcohol or cannabis. future studies should compare findings to a control group of atc users. additionally, comparison of decreases in atc craving between those receiving active rtms and those in a sham rtms condition would assist in dismantling if it is rtms or other factors (e.g. expectancy effects) driving the decreases in craving. future studies would also benefit from assessing how long decreases in craving are maintained and how decreases in craving relate to decrease in atc use. contact: jordan a. gette jordan.gette@ttu.edu supplemental materials here problems associated with adolescents’ and young adults’ marijuana and alcohol co-use joel w. grube & sharon lipperman-kreda prevention research center, pacific institute for research and evaluation although the adverse effects of marijuana use are debated, its use during adolescence and young adulthood has been associated with a variety of negative consequences, including increased risk of accidental injury, fatal motor vehicle crashes, respiratory illness, psychotic disorders, impairment of cognitive functioning and brain development, low educational attainment, drug dependence, and involvement in crime. these adverse outcomes may be exacerbated by the couse or simultaneous use of marijuana and other substances, including alcohol. we investigated the associations of co-use of marijuana and alcohol with experiences of negative outcomes using survey data obtained from 706 adolescents and young adults aged 16-21 years (mean age 18.3 years; 49% female) who lived in 24 midsized california cities. based on past year self-reported alcohol and marijuana use, we identified three groups: (a) non-users, (b) alcohol only users, and (c) co-users of alcohol and marijuana. interestingly, there were few marijuana only users in the sample (3%). marijuana only users were thus excluded from the analyses. of the study sample, 30% reported alcohol use only and 40% reported past year marijuana and alcohol couse. multi-level mixed effects logistic regression analyses were used to predict whether participants who reported alcohol only use or couse of alcohol and marijuana had experienced each of eight problems in the past year (got into argument/fight; got hurt/injured; had unprotected sex, had sex with a stranger; had an unwanted sexual experience, rode with an intoxicated driver, and drove while intoxicated). we controlled for individual-level demographics (age, sex, race/ethnicity) and city-level variables (% minors, % white, % hispanic, median household income). compared with non-users, young people who used alcohol only were significantly more likely to report unprotected sex (or = 1.85; 95% ci = 1.14, 3.02). they did not differ significantly from non-users in the likelihood of reporting any of the other problems. in contrast, those who reported alcohol and marijuana co-use were more likely than non-users to report getting into a fight (or = 1.53; 95% ci = 1.04, 2.26), unprotected sex (or = 4.98; 95% ci = 3.16, 7.85), sex with a stranger (or = 8.25; 95% ci = 3.83, 17.73), unwanted sex (or = 3.05; 95% ci =1.23, 7.52), riding with a drinking driver (or = 3.57; 95% ci = 2.04, 6.28), and driving after drinking (or = 10.44; 95% ci = 3.68, 29.62). overall, the findings suggest that young people who use both alcohol and marijuana are at greater risk for problem outcomes than are those who use alcohol only. it is unclear whether the associations are causal (i.e., co-use leads to greater problems) or the result of other common factors (i.e., impulsivity) that predispose young people to engage in risky behaviors more generally. nonetheless, prevention efforts should target the co-use of marijuana and alcohol. contact: joel w. grube grube@prev.org supplemental materials here conference abstracts 76 are we asking the right questions: results of a pilot study on marijuana use patterns and terminology? kerri hayes, helene r. white, sheila vandal, & kristina m. jackson brown university & rutgers university with the quickly changing landscape of marijuana products, it is difficult to accurately capture marijuana use. frequency can be relatively easily ascertained, but quantity is much more challenging; a standard in the field is yet to be widely accepted. without a common terminology and standard of measurement between user and researcher, either scant data is collected or tremendous detail is gathered that is difficult to distill into usable measures. in an effort to balance participant burden and reporting accuracy, it is important to better understand common terminology and patterns of use. an online screening survey was sent to a nationwide qualtrics panel. inclusion criteria for the full survey were age 18-24, weekly alcohol and marijuana use in the past-month. 811 individuals completed the screening survey, 207 met inclusion criteria with an average age of 21.9 years. 123 completed an anonymous online survey. the sample used marijuana an average of 20 days of the last 30 (range 2-30). to understand if patterns of marijuana use exist “when you use marijuana… how often would you say that your use follows a pattern or routine” was asked; 97.6% reported that their use at least sometimes follows a pattern; 30.1% reported their use was always patterned. participants were queried on several factors that contribute to patterns of use; they reported always using with the same people (39%), using the same mode of delivery (35.8%), in the same place (33.3%) and the same time of day (25.2%). participants also described their pattern in their own words. a content analysis of responses revealed mention of the following factors in descending order of prevalence: time of day, method, who with, quantity, associated activities, and motivations. participants were also asked to report in detail on their use in three different formats: hourly, block of day (day/evening/night), and with an open-ended item. in terms of reported quantity here (measured in grams), the hourly report generated the highest daily quantity with an average of 3.2 grams (range 0.1g-32g). the block format produced a daily average of 2.0g (range 0.1-12). when comparing the daily report to the block report 24.3% reported an equal quantity (defined by less than 0.1g disparity) with the 2 methods, while 45.5% reported greater quantity with the hourly, and 30.0% reported greater quantity with the block. those that had an equal report across the two methods reported using lower quantities (range 0.1-4, mean=0.9g) compared to those that had disparities between methods (mean range 1.6-5.4). the open-ended responses were examined for content–terms bowls and joints were most frequently used, followed by grams, hits and blunts. findings indicated that the terminology used around an important factor of use such as quantity needs to be thoroughly considered. additionally, the measurement terminology researchers utilize may not be how users conceive of their use, and different timeframes appear to elicit different responses, especially for heavier users. in this frequently-using sample, patterned use is common. with this in mind, future research may be able to reduce participant burden by continuing to understand these nuances. contact: kerri hayes kerri_hayes@brown.edu development of an mhealth diary that examines the effects of cannabis use on chronic neuropathic pain in individuals living with hiv brook l. henry, sarah henry, elizabeth quintana, & david j. moore university of california, san diego background: hiv sensory neuropathy (hiv-sn), typically characterized by sensory deficits and pain in the feet or hands, affects more than 50% of people living with hiv (plwh). hiv-related neuropathic pain (np) is often described as a chronic “stabbing”, “burning” or “aching” sensation that is a frequent source of disability in this population. traditional analgesic treatments are ineffective for many plwh with np, but recent data indicate that administration of smoked or vaporized cannabis can provide pain relief. however, previous clinical trials are limited by several factors, including short duration (typically 1-2 weeks), a focus on low doses of deltaconference abstracts 77 9-tetrahydrocannabinol (thc), but not cannabidiol (cbd), and a lack of data about various methods of cannabis administration, such as edible products or dabbing. there is thus a significant need to close the gap between existing clinical data and assessing the effects of “real-life” cannabis use on np. this abstract describes qualitative data from focus groups designed to obtain feedback about the effects of selfadministered cannabis on pain and the utility of mhealth methods (collection of health data via cell phones or other mobile devices) to track this information for subsequent intervention studies. methods: we recruited outpatients (n = 20) experiencing chronic pain (neuropathy, arthritis, or back pain) and self-reported cannabis use during the prior three months, including both plwh and hiv-uninfected participants, to obtain diverse feedback about cannabis use in the context of chronic pain. two focus groups, with 8 and 12 individuals, respectively, were conducted at the hiv neurobehavioral research program in san diego to discuss how to report the effects of cannabis exposure on daily pain using a mobile interface on their phones. results: two investigators independently coded focus group transcripts using the maxqda software. the kappa value for interrater reliability was 0.85, indicating a high degree of rater agreement. data analysis revealed three primary themes: 1) effective methods for reporting pain; 2) effective methods for reporting cannabis use; 3) the impact of cannabis on pain. participants expressed preferences for both qualitative (impact on everyday functioning) and quantitative (0-10 pain scale with anchors at 0 and 5) measures of pain, endorsed the feasibility of reporting cannabis content (thc and cbd), dose, and route of administration via a once-a-day text-message link to an online survey, reported that cannabis use allowed them to reduce their exposure to narcotic analgesics (opioids), and indicated that cannabisreduced pain was associated with improvement in affect and everyday function. conclusions: focus group feedback enabled the development of a mobile smartphone platform designed to record daily pain and cannabis effects on pain, including technical design (text links to survey), pain question content (inclusive of affect/everyday functioning), and a detailed assessment of cannabis use. these data were used to support an ongoing study that evaluates the consequences of thc and cbd on hiv-related np, including a 6month observational electronic diary (individual monitoring of pain and cannabis taken or impact). contact: brooks l. henry blhenry@mail.ucsd.edu marijuana policy research tool mike hilton national institute on alcohol abuse and alcoholism the purpose of the poster is to spread the word about a research tool that can be used to study the effects of marijuana legalization policy. niaaa's alcohol policy information system (apis) now contains an authoritative and systematic coding of policies to legalize the recreational use of cannabis. the original apis coverage is being expanded to cover about double the number of policy features covered by its earlier coverage. members of the research society on marijuana are positioned to take the lead in studying the effects of legalized cannabis, and hence need to know about the availability of this tool. also depicted in the poster is an example of the fact that policy has been changing quite rapidly in the recreational cannabis field compared to policies affecting alcohol use. finally, calls for grant applications are highlighted. these nih funding opportunity announcements are sponsored by both niaaa and nida. contact: mike hilton mhilton@willco.niaaa.nih.gov incidental effects of naltrexone maintenance on cannabis use in the combine study jon m. houck university of new mexico reciprocal functional interactions between the endogenous cannabinoid and opioid systems are well known. thc can reduce pain perception (vivian et al., 1998), and rhesus monkeys administered thc reduced their selfadministration of heroin (li et al., 2015). consistent with this, recent work in humans found that joint administration of cannabis and conference abstracts 78 low doses of oxycodone produce analgesia similar to that of larger doses of oxycodone alone (cooper et al., 2018). naltrexone is an opioid antagonist that also acts on cannabinoid receptors. in nonhuman primates, acute naltrexone reduces thc self-administration (justinova et al., 2004). in humans, the effects of naltrexone on cannabis use appear to vary with the experience of the individual. in non-cannabis-smokers, acute naltrexone potentiates the effects of low cannabis doses (haney, 2007), while in daily cannabis smokers, maintenance doses of naltrexone are associated with decreased cannabis selfadministration (haney et al., 2015). the combine study was a large multi-site medication (naltrexone, acamprosate) clinical trial for alcohol use disorder that did not exclude participants on the basis of cannabis dependence (anton et al., 2006). combine participants who used cannabis generally had higher alcohol use at the end of treatment did than those who did not use cannabis (subbaraman et al., 2016). however, cannabis users randomized to receive naltrexone and the combined behavioral intervention (cbi) reported end-of-treatment drinking equivalent to those randomized to receive naltrexone who did not use cannabis. the goal of the present study was to text the incidental effects of naltrexone maintenance for alcohol use disorder on selfreported cannabis use in the combine study. data on cannabis use days were obtained from the structured clinical interview for dsm-iv (scidi). naltrexone dose estimates in combine were generated by inspection of used blister packs. 206 participants (19.9% female) reported cannabis use during the 16-week treatment period. cannabis use was significantly lower in the naltrexonetaking groups than in other groups (x2(1)=3.865, p=.049). in a follow-up analysis comparing 85 participants assigned to receive either naltrexone or placebo, negative binomial regression controlling for baseline use indicated that participants randomized to receive naltrexone had significantly fewer cannabis use days during treatment than did those assigned to receive placebo (b=-1.969, p=.043). there was not a significant effect of cbi (b=-.563, p=.078). at the 12-month follow-up, there were no significant effects on cannabis use days. results of the present analysis suggest that in the combine study, naltrexone had incidental effects on participant cannabis use. that is, although combine was not designed to influence cannabis use, participants who used cannabis and took naltrexone had fewer cannabis use days during the treatment period than did those who did not take naltrexone, and participants who took the prescribed dose of naltrexone had fewer cannabis use days than those who did not. after participants stopped taking naltrexone, cannabis use did not differ between groups. although limited data on cannabis use reduce confidence in the study findings, these results suggest that naltrexone should be examined further as a treatment for cannabis use disorder, particularly in populations that also use alcohol. contact: jon m. houck jhouck@unm.edu greater past month and lifetime marijuana use are associated with poorer cognitive flexibility in young adult college students sarah lahanas & anita cservenka oregon state university objective: marijuana (mj) is the most commonly used illicit substance in the united states. the use of mj is particularly common among college and university students with 4.9% of them reporting daily or near-daily mj use. substantial evidence suggests frequent mj users exhibit deficits in memory and attention, beyond the acutely intoxicated state. however, less is known about how recent and lifetime mj use affect components of executive functioning, such as cognitive flexibility, which is critical to setshifting and overcoming habitual actions. due to the continued maturation of the prefrontal cortex during young adulthood, and the importance of this region for executive functioning, it is necessary to examine frequent mj users in this age range for aberrations in cognitive flexibility related to mj use. this is particularly important to investigate in young adult college students, as mj use has been associated with adverse academic outcomes. the current study examined the association between quantity of mj use and cognitive flexibility in frequent mj users, ages 1822, who were recruited as part of a larger study on mj use and executive functioning. method: seventeen heavy mj users (mean age: 20.12 ± .27; 9 male, 8 female) reporting 5 or more episodes of conference abstracts 79 mj use per week over the past year were included in the current study. participants were instructed to remain abstinent from mj use for 12 hours prior to their study visit to insure they were not acutely intoxicated during testing. the 30-day timeline followback (tlfb) was used to assess recent mj use and participants were asked to estimate lifetime mj use occasions. participants completed the modified wisconsin card sorting test (m-wcst), a measure of cognitive flexibility. results: greater past 30-day mj use was associated with poorer performance on the mwcst. past 30-day use was negatively correlated with t-scores for the following variables: categories correct (r = -.59, p = .01), perseverative errors (r = -.67, p = .003), percent perseverative errors (r = -.62, p = .008), and executive function composite (r = -.67, p = .003). greater lifetime use was negatively correlated with perseverative errors (r = -.59, p = .01), percent perseverative errors (r = -.65, p = .005), and executive function composite (r = -.49, p = 0.046) t-scores. when controlling for recent use, lifetime use significantly predicted percent perseverative errors (f(2,14) = 8.60, p = .004, ∆r2 = .17, β = -.46, t = -2.31, p = .04), above and beyond recent use. conclusion: these findings suggest a dosedependent relationship between mj use and cognitive flexibility in young adult college students who are frequent users of mj. cognitive inflexibility may result in the maintenance of craving and preoccupation with mj use due to an impaired ability to consider alternatives to and consequences of mj use. further research is needed to understand whether these deficits are the result of neurotoxic effects of mj or preexisting impairments in cognitive flexibility prior to initiation of use, and whether these deficits persist after longer periods of abstinence. contact: anita cservenka anita.cservenka@oregonstate.edu supplemental materials here mental health symptoms and marijuana consequences: protective behavioral strategies as a mediator jenae b. lynch, andrew p. weinstein, matthew r. pearson, & marijuana outcomes study team university of new mexico individuals that have elevated mental health symptoms are more likely to suffer from consequences of marijuana use than individuals without such mental health symptoms. several mechanisms could be responsible for this relationship, including the individuals’ motives for use, their expectancies, or their use of protective behavioral strategies (pbs). pbs are behavioral strategies that can be used to reduce the negative consequences from substance abuse, such as only using during a certain time or limiting the amount used. pbs use was examined as a possible mediator for the effect of mental health symptoms on marijuana consequences. from a larger sample of 6,584 college students recruited from 8 universities in the u.s., we examined a subsample of marijuana users who completed the dsm-5 level 1 cross-cutting symptom measure (ns range from 909 – 922 across models), which assesses 13 psychiatric domains. in separate models (i.e., each mental health symptom), pbs use significantly mediated the association between each mental health domain and marijuana consequences (14.29% 43.90% of the total effect) except for anger. in a combined model with all 13 mental health symptoms, there were significant indirect effects through pbs use for memory, dissociation, and anger, though the effect through anger was opposite of its total effect. lastly, we found pbs use partially mediated the effect of a latent factor of all 13 mental health symptoms on marijuana consequences. pbs use was found to be a partial mediator for the amount of marijuana consequences experienced by individuals that have elevated mental health symptoms, suggesting that pbs use may be a promising intervention target for these individuals. research is needed to determine why these individuals use fewer pbs (e.g., lower perceived harm of marijuana use, lower capability of planning their use, etc.) in order to determine optimal intervention strategies. importantly, pbs use only accounted for some of the effects of conference abstracts 80 mental health symptoms on consequences, indicating that other possible mediators should be examined contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here trauma cues elicit greater conditioned craving responses than do cannabis cues in cannabis users with trauma histories ioan t. mahu, pablo romero-sanchiz, tristan park, jennifer swansburg, joshua salmon, mohammed al-hamdani, daniel rasic, sean barrett, & sherry h. stewart dalhousie university conditioned craving is said to develop in drug users in response to drug cue exposure. through repeated pairing of drug cues with desired outcomes of drug use, strong associations are formed in memory, such that presentation of the drug cue alone is sufficient to elicit a conditioned craving response. through a similar learning process, exposure to trauma cues is theorized to elicit conditioned drug craving in individuals with trauma histories, following the repeated use of the drug for the relief of trauma-related symptoms. little is known regarding whether this type of trauma cue-induced conditioned craving occurs in traumatized cannabis users. we examined the link between trauma cue exposure and cannabis cravings using a cue-reactivity paradigm in cannabis users with trauma histories. participants are exposed to three types of personalized audio and visual scripts (trauma, cannabis, neutral) in random order. following exposure to each cue, participants rate their cannabis cravings (marijuana craving questionnaire – short form (mcq-sf); heishman et al., 2009) and mood (positive and negative affect schedule (panas); watson, clark, & tellegen, 1988; mood-vas scale; lundahl & greenwald, 2016). although data collection is ongoing, we present preliminary results on our first eight participants (mean age = 42.63, 87.5% male, 50% military, 37.5% met criteria for ptsd). we conducted one-way (cue type) repeated measures anovas (with greenhouse-geisser adjustment) separately for each mood and cannabis craving scale, followed by lsd post-hoc tests. on the panas, the trauma cue induced significantly more negative mood than both cannabis and neutral cues, f(1.684, 11.787 ) = 7.963, p = .008, although there was no difference between cue types for positive mood, f(1.106, 7.744) = .457, p = .538. participants also reported feeling significantly more “anxious” (f(1.382, 9.674) = 11.580, p = .005) and “down” (f(1.905, 13.334) = 10.848, p = .002) on the moodvas scale after trauma vs. both cannabis and neutral cue exposure, supporting the validity of the trauma cue exposure in inducing negative mood. on the mcq-sf subscales, trauma cues were significantly more likely to elicit cannabis cravings for relief (i.e. “emotionality”; f(1.878, 13.145) = 6.522, p = .012), induce an inability to control cannabis use (i.e. “compulsivity”; f(1.538, 10.768) = 7.808, p = .011), create an anticipation of positive outcomes from using cannabis (i.e. “expectancy”; f(1.448, 10.135) = 6.752, p = .019), and induce cravings reflecting an intention and planning of using cannabis (i.e. “purposefulness”; f(1.431, 10.017) = 17.516, p = .001), when compared to both cannabis and neutral cues. cannabis cues in turn elicited more craving in the purposefulness domain than neutral cues. overall, these preliminary results indicate that trauma cues elicit more craving, as well as more negative affect (anxiety, sadness), than both cannabis and neutral cues in this cannabis-using population with significant trauma histories. this suggests that exposure to trauma cues (i.e., external trauma reminders and/or internal trauma memories) may be a strong predictor and motivator for cannabis use in this population. thus, exposure to trauma cues may promote cannabis use for regulating negative affect via conditioned craving processes. contact: ioan t. mahu ioan.tiberiu.mahu@dal.ca campus climate matters: the impact of racial microaggressions on marijuana use among undergraduate students of color miesha marzell, woojae han, elora orazio, tess k. drazdowski, & ada robinson-perez binghamton university background: microaggressions are verbal, behavioral, or environmental indignities, conference abstracts 81 intentional or not, that communicate hostile, derogatory, or other negative racial assertions to people of color. recent research focused on racial microaggressions indicates that experiencing them is associated with a higher risk for stress, low self-esteem, and anxiety among college students of color. also, students of color who perceive an unwelcoming campus climate can experience academic difficulties and increased risky substance use. at the same time, marijuana use by all college students has seen a steady increase over the last decade. in 2016, more than 20% reported use in the past 30 days, up 5% from 2006. many students use marijuana to cope with stress and social anxiety, with related negative health and academic outcomes. we sought to identify associations between perceived microaggressions, marijuana use, and motivations for use among undergraduate students of color, hypothesizing that the more a student experienced racial microaggressions, the more likelihood of marijuana use. methods: a sample of 251 undergraduate students of color from a medium-size university in the northeastern us responded to a racial microaggressions and substance use survey. original data were collected using the racial microaggressions scale (rmas), which is factored into six subscales: invisibility, criminality, lowachieving/undesirable culture, sexualization, foreigner/not belonging, and environmental. we explored relationships among racial microaggressions, motives for marijuana use, and marijuana use, conducting a path analysis to test the significance of hypothesized connections between variables. results: the majority of students were aged 18-20 (62.5%) and female (69.9%). approximately 42% of the sample reported using marijuana during the past 30 days, 22% reported use 1-3 times per month, and 17% multiple times per week. path analysis indicated that motives for marijuana use mediated the relationship between racial microaggressions and actual marijuana use. discussion: and implications. although our analyses showed no direct relationship between perception of racial microaggressions and marijuana use, taking into account motives for use revealed that racial microaggressions do indirectly influence marijuana use. specifically, our study suggests that when undergraduates of color perceive negative characteristics of their environment related to race (e.g., absence of people from one’s racial background in school or being in contexts where an individual is the “only person of color”), their motives to use marijuana, especially those involving social reasons (e.g., to fit in with peers), increase the likelihood of their using marijuana. our study demonstrates that students of color may have unique reasons for marijuana use and reinforces the importance of college administrators’ efforts to make the campus climate more inclusive and welcoming for all students. implications for practitioners include tailoring substance use prevention programs and counseling services to better address the health and well-being of students of color. contact: miesha marzell mmarzell@binghamton.edu who volunteers for cannabis research? examining potential participation in cannabis research among emerging adults maha n. mian, brianna altman, & mitch earleywine university at albany, suny while many contemporary empirical studies draw inferences from the undergraduate student population, little is known about the patterns of research participation in this group. the sensitive nature of substance use may play an influential role in studies investigating illicit use, particularly in the emerging adult population. the present study examined cannabis use and willingness to participate in cannabis-related research in emerging adults. undergraduate students enrolled in a psychology course (n=262) reported frequency of cannabis use and if they would be willing to participate in hypothetical research studies on cannabis, varying in study type and compensation. chi-square tests for independence revealed significant relations between gender and cannabis use per week, as well as use per year and lifetime use. notable significant associations also appeared between willingness to ingest marijuana for pay and lifetime use (cramer’s v=.433, p<.0001), as well as willingness to ingest marijuana for scientific contribution with both yearly and lifetime use (cramer’s v=.434, p<.001; cramer’s v=.580, p<.001). additionally, significant relations with conference abstracts 82 gender suggested that males were less willing to complete a survey for a prize, but more willing to come to a lab study for scientific contribution, and to ingest cannabis for scientific contribution; odds ratios (respectively) were, or=.372 [95% ci, .171.811], or=2.336 [95% ci, 1.318-4.138] and or=2.182 [95% ci, 1.154-4.123]. these results demonstrate important trends exist in potential participation for cannabis-related research in the emerging adult population, specifically around gender, and suggest cautious interpretation for the generalizability of studies on cannabis in undergraduate students. contact: maha n. mian mmian@albany.edu marijuana expectancies as a predictor of substance use initiation among high school students kevin s. montes, katie witkiewitz, matthew r. pearson, & adam m. leventhal university of new mexico & university of southern california adolescence is a high-risk period for substance use onset. expectancies have been identified as proximal predictors of adolescent onset of substance use. however, little is known about whether change in marijuana expectancies is a risk factor for marijuana use onset. the present study was conducted to examine trajectories of marijuana expectancies and to investigate whether change in marijuana expectancies was predictive of marijuana use onset. data from 3,396 ethnically diverse high school students were collected across eight waves of assessment (followup assessments were 6-months apart with baseline assessment commencing when participants were in 9th grade and concluding when participants were in 12th grade) and analyzed within a latent growth modeling framework. parallel process latent growth models with robust weighted least squares estimation were conducted to derive the slopes and intercepts from the first four waves of positive and negative marijuana expectancy data to examine whether these parameters were predictive of marijuana use onset that occurred during the last four waves of assessment. the results from the study indicate that the slopes of positive marijuana use expectancies were prospectively predictive of marijuana use onset. specifically, the slope of positive marijuana expectancies was positively associated with the likelihood of initiating marijuana use for the first time after controlling for gender, age, and baseline level of positive marijuana expectancies (b=1.26, p<.001; β=.32). moreover, the slope of positive marijuana expectancies accounted for unique variance that was not accounted for by baseline levels of positive marijuana expectancies. that is, regardless of the level of positive marijuana expectancies endorsed by participants at baseline, change in positive marijuana expectancies was still predictive of marijuana use onset. baseline level of positive (b=.63, p<.001; β=.54) and negative (b=-.19, p=.03, β=-.15) marijuana expectancies were also found to be prospective predictors of marijuana use onset. results from the present study indicate that change in marijuana expectancies – as well as level of positive and negative marijuana expectancy endorsement at 9th grade – may be markers of risk propensity for prospective marijuana use onset that occurs in high school. contact: kevin s. montes kmontes@csudh.edu retail availability of cannabis in oregon counties, perceived availability, and cannabis use among adolescents mallie j. paschall, joel w. grube, & anthony biglan prevention research center & oregon research institute research on local cannabis policies, retail cannabis availability and cannabis use among adolescents is limited. this study examines relationships between cannabis sales policy in oregon counties, retail availability of cannabis, perceived availability of cannabis, normative beliefs, and cannabis use among adolescents. we hypothesized that a higher density of cannabis retail outlets would be present in counties that allowed cannabis sales for medical or recreational use, and that greater retail availability would be positively associated with perceived cannabis availability, normative beliefs favorable to cannabis use, and cannabis use among adolescents. we also hypothesized that perceived conference abstracts 83 availability of cannabis and normative beliefs more favorable to cannabis use would act as mediators of the association between retail cannabis availability and cannabis use among youth. data on oregon county cannabis sales policy and licensed retail outlets were obtained from the oregon liquor control commission, indicating which cities and counties prohibited sales of cannabis for medical and recreational use, and the locations of licensed retail outlets, respectively. we computed licensed retail outlet density per 10,000 county population. we obtained county-level prevalence rates for past30-day cannabis use among 11th graders from the 2015-16 student wellness survey (n=57,742) conducted by the oregon health authority. the sws also included questions about perceived availability of cannabis and perceived disapproval of cannabis use by parents and friends. bivariate correlations for 32 oregon counties indicated significant positive associations between the prevalence of past-30-day cannabis use among 11th graders and counties allowing sales of cannabis for medical or recreational use (r = .58, p<.01), density of licensed outlets (r = .48, p<.01), and the perception that cannabis would be very easy to get (r = .70, p<.01). parents’ disapproval of cannabis use was inversely related to the prevalence of past-30-day cannabis use among 11th graders (r = -.51, p<.01), as was friends’ disapproval (r = -.48, p<.01). perceived availability of cannabis was positively associated with counties allowing cannabis sales (r = .55, p<.01) and a higher density of licensed cannabis outlets (r = .40, p<.05). parents’ and friends’ disapproval of cannabis use were inversely related to counties allowing cannabis sales and density of licensed cannabis outlets. linear regression analyses indicated possible indirect effects of county cannabis sales policies and cannabis outlet density on past-30-day cannabis use among 11th graders, as the beta coefficients for these predictors were no longer significant in models with perceived cannabis availability. however, the normative beliefs variables did not appear to act as mediators. these results suggest that legalization of cannabis for medical and recreational use is associated with greater retail availability of cannabis and greater perceived availability of cannabis among adolescents, which may increase their risk for cannabis use. further research is needed to better understand effects of local cannabis policies and availability on cannabis use and related problems among youth. contact: mallie j. paschall paschall@prev.org ptsd symptom severity and cannabis use: the moderating role of race/ethnicity alisa payne, nathan kearns, renee cloutier, quadreon miller, anabel potts, & heidemarie blumenthal university of north texas elevated posttraumatic stress disorder (ptsd) symptoms appears to be a significant risk marker for problematic cannabis use. however, unlike the ptsd-alcohol literature, few studies have evaluated sociodemographic characteristics that may moderate the association between ptsd and cannabis use. epidemiological work has identified differences in cannabis use patterns as a function of race/ethnicity, but the nature of the relation differs when trauma history and psychological characteristics (e.g., diagnostic status) are also considered. for example, in the recent national surveys on drug use and health, individuals identifying as black or native american reported the highest rates of cannabis use and related problems; however, in a large sample of traumaexposed individuals, kevorkian and colleagues (2015) found the highest rates among those identifying as white. to date, no work has addressed race/ethnicity as a potential moderator of the association between ptsd and cannabis among those exposed to trauma expressing clinical and preclinical symptoms. the present study tested whether race/ethnicity moderated the association between ptsd symptom severity (ptsdss) and past-year cannabis use. based on prior studies, we hypothesized that whites and hispanics who present ptss would have higher rates of cannabis use, followed by african americans and asians who would report the lowest rates. the final sample consists of 1,067 college participants (m = 20. 71 years; 72.9% female) who completed a demographics questionnaire which assessed the participants’ race/ethnicity; a single, face valid question measured past-year cannabis use; and the ptsd checklist which measured ptsdss. first, anova and multiple regression analyses were conference abstracts 84 conducted to preliminarily examine the influence of racial/ethnic identity on past-year cannabis use. for primary analyses, separate moderation analyses were conducted using process in spss to examine specific race/ethnicity identification groups as moderators in the relationship between ptsdss and cannabis use. consistent with past literature, results of the anova found that individuals identifying as white (m = 4.20) and african american (m = 4.25) used significantly more frequently than those identifying as asian (m = 3.30) or hispanic/latino (m = 3.59); further, results of the regression analyses indicated that identification as asian (β = -.01; p = .021) or hispanic/latino (β = -.12; p = .007) was significantly associated with less pastyear cannabis use. however, results of the primary analyses indicated that race/ethnic identity was not a significant moderator in the association between ptsdss and cannabis use. results indicated that race/ethnicity did not play an important role in the association between ptss and cannabis use among trauma-exposed college students. future research addressing race/ethnicity, as a function of diagnostic status (e.g., with or without ptsd, cannabis use disorder), and across other contextuallyand developmentally-distinct periods, is needed. for example, work-addressing periods characterized by relevant vulnerability (e.g., puberty) could be a key to understanding the nature and boundaries of these relations. contact: alisa payne alisapayne2014@gmail.com does marijuana use impact academic performance in the college setting? erica b. peteja, kerry d. duck, anastasia robirds, megan h. smith, alexa j. pellegrino, lillian j. canfield, maryia m. schneider, chelsea l. banks, kristina t. phillips, & michael m. phillips university of northern colorado background: past research has examined the impact of marijuana use on college student academic performance. marijuana use has been associated with gpa and failure to obtain a university degree. a recent longitudinal study found that as marijuana use escalated, college students were more likely to skip classes and performed more poorly academically, as measured by gpa. few studies have assessed other academic components that might influence completion of one’s college degree among marijuana users, such as academic motivation and self-efficacy. the goal of the current study was to assess whether frequency of marijuana use, problem use, academic motivation, academic self-efficacy, and academic self-regulation impact university retention and performance. methods: active college-student marijuana users (n = 52) were recruited and completed a baseline assessment. although all participants completed two-week ecological momentary assessment, the current presentation focuses on baseline data. marijuana use frequency was assessed through days of marijuana use over the last month. problem marijuana use was assessed through the rutgers marijuana problem index (rmpi). academic self-efficacy and self-regulation were assessed using subscales of the motivated strategies for learning questionnaire (mslq). academic motivation was assessed using a subscale from the learning and study strategies inventory (lassi). results: the sample was 57.7% female, 59.6% caucasian, and averaged 20.04 (sd = 1.49) years of age. mean cumulative gpa was 2.80 (sd = 0.65; range from 1.07-3.93). participants were heavy marijuana users, reporting near daily use across the past 30 days (m = 23.56, sd = 6.85). we examined whether academic variables and marijuana use/problem use predicted current gpa via multiple regression. the overall model accounted for 32.9% of the variance. self-efficacy (b = .05, se= .02, p =.006) and academic motivation (b = .07, se = .03, p = .017) contributed to current gpa. after controlling for academic variables, neither the frequency of marijuana use, nor problem use, were associated with current gpa. logistic regression was used to assess whether academic variables and marijuana use/problem use contribute to student retention. in the current sample, 86.5% (n = 45) of participants remained at the university one semester after their baseline appointment. due to the large number of retained students, there were no significant predictors of academic retention. conclusions: frequency of marijuana use over the last 30 days did not contribute to gpa when controlling for academic factors (academic self-efficacy and motivation). conference abstracts 85 there were no significant predictors for retention, although this was due to a lack of power to detect differences. future studies with more participants should continue to evaluate the potential impact of marijuana use on college student success. research reported in this abstract was supported by nida of the national institutes of health under award number r15da041656 (pis: k. phillips, m. phillips). contact: erica b. peteja erica.peteja@colostate.edu reduction of benzodiazepine use in patients prescribed medical cannabis chad purcell, andrew davis, nico moolman, & s. mark taylor dalhousie university & acadia university background: benzodiazepines are a class of medication with sedative properties, commonly used for anxiety and other neurological conditions. these medications are associated with several well-known adverse effects. this observational study aims to investigate the reduction of benzodiazepine use in patients using prescribed medical cannabis. methods: a retrospective analysis was performed on a cohort of 146 medical cannabis patients (average age 47 years, 61% female, 54% reporting prior use of cannabis) who reported benzodiazepine use at initiation of cannabis therapy. these data are a part of a database gathered by a medical cannabis clinic (canabo medical). descriptive statistics were used to quantify associations between the proportion of benzodiazepine use with time on medical cannabis therapy. results: after completing an average two-month prescription course of medical cannabis, 30.1% of patients had discontinued benzodiazepines. at a follow-up after two prescriptions, 65 total patients (44.5%) had discontinued benzodiazepines. at the final follow-up period after three medical cannabis prescription courses, 66 total patients (45.2%) had discontinued benzodiazepine use, showing a stable cessation rate over a six-month period. conclusion: within a cohort of 146 patients initiated on medical cannabis therapy, 45.2% patients successfully discontinued their preexisting benzodiazepine therapy. this observation merits further investigation into the risks and benefits of the therapeutic use of medical cannabis and its role relating to benzodiazepine use. contact: chad purcell chad.purcell@dal.ca supplemental materials here examining protective behavioral strategies as a mediator in the relationship between social anxiety and cannabis-related consequences cody a. raeder, matthew r. pearson, adrian j. bravo, & protective strategies study team old dominion university & university of new mexico individuals high in social anxiety have been shown to experience a greater number of alcohol and cannabis-related consequences relative to those lower in social anxiety, despite insignificant differences in levels of substance use. therefore, an important goal for researchers in this field is to determine what factors may reduce the risk of experiencing both alcoholand cannabis-related consequences. protective behavioral strategies are strategies an individual can utilize when using both alcohol and cannabis to reduce the number of negative consequences experienced as result of use. previous research has shown that both alcohol and cannabis protective behavioral strategies are robustly negatively associated with use frequency and consequences for both substances. recent work in the study of social anxiety and alcohol protective behavioral strategies has found that serious harm reduction strategies mediates the relationship between social anxiety and alcohol-related consequences. given similarities in the social anxiety literature in regards to alcoholand cannabis-related consequences, the purpose of the current research was to examine if cannabis protective behavioral strategies similarly mediates the relationship between social anxiety and cannabis-related consequences. participants were 1022 students from multiple universities who completed measures assessing social anxiety, cannabis protective behavioral strategies, and cannabisrelated outcomes. cannabis protective behavioral strategies were found to mediate the relationship between social anxiety and cannabis-related consequences such that those higher in social anxiety used fewer protective behavioral conference abstracts 86 strategies, and in turn experienced more cannabis-related consequences when controlling for quantity and frequency of use. these results indicate that those with social anxiety who also use cannabis may benefit from interventions designed to increase the use of cannabis protective behavioral strategies. contact: cody a. raeder craed001@odu.edu supplemental materials here differences between college student medical and recreational cannabis users: more similarities or more differences? mariah d. sandoval, adrian j. bravo, matthew r. pearson, protective strategies study team, & marijuana outcomes study team university of new mexico currently, thirty states and the district of columbia have legalized medical use of cannabis, with several other states allowing the use of some constituent of cannabis for medical purposes (i.e., cannabidiol). common reasons for medical use include posttraumatic stress symptoms, anxiety, chronic pain, stress, insomnia and depression (bonn-miller et al., 2014). few studies explicitly examine differences between medical and recreational users of cannabis (lin et al., 2016), especially in the college student population. in some ways, one may expect some difficulties with separating medical from non-medical use. for example, many “recreational” users report using marijuana to cope (e.g., with negative affect), thus the degree to which a distinction between medical and non-medical use can be made is unclear. using two large college student samples, the purpose of this study was to determine the extent to which college student medical users (i.e., individuals reporting having a medical card) differ systematically from recreational users. using two large samples of college students (study 1: 7307 college students, 4081 lifetime users, 2226 past month marijuana users, 46 medical users; study 2: 6584 college students, 3744 lifetime users, 1969 past month marijuana users, 70 medical users). although we found reliable differences between medical and recreational users in use patterns, cannabis use disorder symptoms, and use of protective behavioral strategies, we failed to find reliable differences on negative consequences, mental health symptoms, and most marijuana use motives. although one may expect medical users to report higher coping motives or expect coping motives to be their strongest motive for use, they actually reported higher use of expansion motives and (like recreational users) reported enhancement motives as their strongest motive for use. although not replicated due to not being assessed in both studies, the largest differences found were medical users reporting higher craving, higher marijuana identity, and lower perceived negative consequences of marijuana use taken together, we found some striking similarities as well as some reliable differences between college student medical and recreational users. future research should examine the extent to which these risk/protective factors operate similarly across medical vs. recreational users. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here a person-centered approach to investigate relations among substance user profiles and impulsivity molin shi & andrew k. littlefield texas tech university alcohol use and other substance use remain highly prevalent for college students in the united states. the extant literature has supported the notion that impulsivity-like facets are significant correlates and predictors of consumption and problematic usage of alcohol and other substances. however, there is a scarcity in the literature on how polysubstance use relates to these facets. further, most studies in the literature have focused on variable-centered approaches to examine these relations. although person-centered approaches like latent class analysis (lca) have been utilized to profile drinking patterns, and more recently, subgroups of marijuana users, more work is needed to explore the relations between profiles, impulsivity facets, and alcohol use outcomes. provided these gaps in the literature, the present study aimed to use a person-centered approach to examine whether empirically-identified latent substance conference abstracts 87 use profiles relate to impulsivity-like facets (i.e., positive urgency, negative urgency, lack of perseverance, lack of planning, and sensation seeking) and problem drinking differently among college students. a sample of 702 students from a large, southwestern university was used (mage = 19.30, sd = 1.74; 71.79% female). a latent class analysis of various past-month indices of alcohol and other substance use (e.g., marijuana use, binge drinking, e-cigarette use) was conducted in mplus. after examining the aic, bic, adjusted bic, vuong-lo-mendell-rubin likelihood ratio, and entropy model-fit statistics from oneto seven-class solutions, a three-class solution was identified as the most parsimonious and bestfitting solution. the classes consisted of (1) a predominantly drinking class (n = 288), (2) a nonusers class (n = 209), and (3) a poly-substance users class (n = 205). a chi-square test of independence revealed that substance use profiles differed significantly on problem drinking as measured by audit χ2 (4, n = 700) = 360.26, p < .001. pairwise comparisons indicated that the poly-substance users reported the highest levels of severe and moderate problematic drinking, followed by predominantly drinkers, then nonusers. conversely, poly-substance users reported the lowest level of minimal problematic drinking, followed by non-users and predominantly drinkers. additionally, analysis of variance tests revealed significant effect of substance use profiles on each of the impulsivity-like facet as measured by the short upps-p, with varied pairwise differences between substance use profiles. for example, poly-substance users reported greater positive urgency than either predominantly drinkers (p < .001) and non-users (p < .001). in contrast, both poly-substance users and predominantly drinkers endorsed higher sensation seeking levels than non-users (p < .001, p = .003, respectively), but did not significantly differ between one another. these findings indicate that different groups of substance users exhibit varied levels of impulsivity-like facets and severity of problem drinking. future work could further delineate and explain differences in profiles, as distinct profiles could be targets of intervention to prevent or intervene on problem drinking. contact: molin shi molin.shi@ttu.edu supplemental materials here antecedents, contexts, and consequences of marijuana use: a comprehensive review of microlongitudinal studies sarah l. simons, gabriel j. carrion-gonzalez, & matthew r. pearson university of new mexico due to a lower level of research interest on marijuana over the past few decades relative to other drugs, there are substantial knowledge gaps regarding the antecedents, contexts, and sequelae of marijuana use. importantly, all study designs are not equal with regards to closing these knowledge gaps. when considering cost and feasibility, we argue that the microlongitudinal design can most rapidly close these knowledge gaps. the microlongitudinal design includes repeated measurement in relatively close proximity to one another and is facilitated by the use of ecological momentary assessment (ema; shiffman, 2009) methods, also known as experience sampling and ambulatory assessment, among other things. the simplest ema design is the daily diary design in which individuals complete a single assessment per day, but ema studies can include several assessments per day or even continuous assessment (e.g., transdermal alcohol monitoring, alessi, barnett, & petry, 2017; heart rate monitoring, wilhelm, pfaltz, & grossman, 2005). ema studies are able to examine the associations among variables at both the between-subject and within-subject levels. importantly, when examining the associations between a putative antecedent and outcome at the within-subject level, each individual is essentially serving as their own control. the present comprehensive review examines all ema studies that had been published on marijuana use (or related outcomes) at the time of the writing of this review. to date, we have 47 articles published through april 2016, but will be presenting all articles published up until june 2018. the purpose of this review is threefold: 1) summarize ema studies to better characterize the conference abstracts 88 antecedents, contexts, and consequences of marijuana use, 2) identify methodological limitations of these studies that can be overcome in future research, and 3) identify areas of research that have not yet taken advantage of ema methods that would help to close important knowledge gaps in the marijuana field. the most common form of ema collection was the use of a pda which emitted random signals throughout the day which participants would answer preprogrammed assessments. the assessments most commonly measured the frequency of marijuana use since previous signal as well as subjective effects (i.e., anxiety and depression levels), environment, and social situation the participant was in. the range of signals emitted per day was as little as one-time (daily diaries) to as much as twelve times. the range of the duration of ema data collection was as few as six days to as much as thirty days. one clear limitation across studies is that quantity of marijuana use is still not often measured in ema studies, diminishing our ability to detect dose-response associations. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here marijuana use patterns among college students: promise of probing user heterogeneity melissa sotelo, matthew r. pearson, & marijuana outcomes study team university of new mexico the majority of marijuana research to date has been a comparison of marijuana users versus nonusers, assuming that the marijuana user population is a homogenous group. using latent profile analysis (lpa), previous studies have shown that marijuana users are a heterogeneous group, exhibiting several subpopulations as opposed to a single use pattern. pearson et. al. (2017) have found four classes of college student marijuana users, with the largest group being low-quantity, infrequent users who reported the least number of consequences. the current study sought to distinguish subpopulations within college student marijuana users, measuring the quantity (in grams) of marijuana used, number of consequences reported, frequency of use within the past 30 days, and “typical frequency” of use during a “typical week”. a weekly grid was used to divide each day of the week into six 4-hour time blocks where the participant was asked to record the amount of marijuana in grams they used during a time block. a brief form of the marijuana consequences questionnaire (simons, dvorak, merrill, & read, 2012) was used to measure marijuana consequences. using lpa, we identified four classes of marijuana users. class 1 was low-quantity, infrequent users which contained 71.29% of users; class 2 was lowquantity, moderate users containing 17.16% of users; class 3 was moderate-quantity, frequent users containing 9.97% of users; and class 4 was frequent, high quantity users containing 1.59% of users. between classes, there were substantial differences in quantities, with class 1 reporting on average 2.352 grams on average per typical week, and class 4 reporting approximately 80 grams per typical week. these classes also differed on the reported number of consequences, with class 1 reporting the least, and class 4 reporting the most consequences. class 4 also reported the highest likelihood for cannabis use disorder symptoms, used less protective behavioral strategies, and identified the most strongly as a marijuana user. for future research, there needs to be a more immediate and accurate way of reporting use and quantity in order to corroborate results. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here endorsing beliefs for using cannabis around exercise: an exploratory study alicia stewart, renee e. magnan, & benjamin o. ladd washington state university vancouver & washington state university there is limited knowledge concerning the relationship between cannabis use and exercise. as accessibility to cannabis increases, there is growing need to study how cannabis influences health and daily activities. cannabis decreases motivation to exercise and can negatively affect motor control, while cannabis can also decrease inflammation and physical discomfort brought on by exercise (gillman et al., 2015). using a crosssectional survey, a community sample of at least conference abstracts 89 twice weekly cannabis users (n = 88) indicated if they ever use cannabis one hour before engaging in exercise and/or within four hours after exercising. participants then rated their beliefs about the positive influence of cannabis on exercise (e.g., cannabis enhances performance, cannabis makes it easier to recover) from 1 (strongly disagree) to 7 (strongly agree). participants also indicated the concentration of tetrahydrocannabinol (thc) and cannabidiol (cbd) in the cannabis they use most often. this was multiplied by average quantity (in grams) of use to create a dose score. participants reported an average thc dose of 0.06 g (sd = 0.10) and average cbd dose of 0.02 g (sd = .03) per use episode. the majority of individuals (87.5%) used cannabis one hour before and/or four hours after exercise. overall, participants who used cannabis around exercise reported higher agreement (m = 4.89, sd = 1.21) with the positive beliefs compared to participants who did not report using cannabis around exercise (m = 3.62, sd = 1.12), t(81) = 3.07, p < .01. similar results were observed for each of the five beliefs individually. regarding the specific beliefs, people were most likely to support the belief that cannabis makes it easier for them to recover from exercise (m = 5.44, sd = 1.64). this belief was also the only one significantly associated with thc dose (r = 0.27, p < .05) and demonstrated a trend with cbd dose (r = 0.20, p < .1). these results suggest that cannabis users who use cannabis around times of exercise may do so because of their positive beliefs about exerciserelated benefits of cannabis. alternatively, the act of using cannabis around exercise may serve to enhance the positive beliefs cannabis users hold around exercise-related benefits of cannabis. negative exercise-related beliefs of cannabis were not assessed in the current study, which also may be a contributing factor to the strength of the cannabis-exercise relationship. further research on cannabis beliefs around exercise performance and recovery and thc and/or cbd consumption, together with biological mechanisms, could inform efforts to understand the risks and benefits of cannabis on physical activity. contact: benjamin o. ladd benjamin.ladd@wsu.edu cognitive and behavioral risk correlates of marijuana use by older adults susan a. stoner university of washington marijuana use by older adults is on the rise. published data from the national survey of drug use and health (nsduh) suggested that rates of self-reported marijuana use increased significantly among adults aged 50 to 64 and substantially among adults aged 65 or older (seniors). notably, however, of 447,196 individuals in the combined 2006-2013 nsduh dataset, seniors represented only 4.0% of the sample (n=17,837), and only 154 seniors (0.8%) reported marijuana use in the past year. little is known about older marijuana users; most research has been conducted with young adults, in whom marijuana use is associated with cognitive impairment and risk-taking behavior. using data from the behavioral risk factor surveillance system (bfrss), we examined whether similar associations were evident in an older adult population. in 2016, 13 states (4 with legal nonmedical use, 3 with legal medical use, 4 with legal cbd use, and 2 with no legal use) optionally queried marijuana use in the prior 30 days as part of the brfss. of 129,782 individuals in the 13state dataset, seniors comprised 36.5% of the sample (n=47,422) and 892 seniors (1.9%) reported marijuana use in the past 30 days. percentages of persons aged 45-64 who selfreported marijuana use ranged from 2.1% to 12.8%, varying by state. percentages of seniors who did so ranged from 0.3% to 6.7%. any marijuana use in the prior 30 days was negatively correlated with healthy days/health-related quality of life in both age groups and positively correlated with having fallen in the last 12 months; ongoing difficulty concentrating, remembering, or making decisions; and cognitive decline over the last 12 months, particularly in the 45-64 age group. in the small subset of senior marijuana users who reported cognitive decline and completed optional follow-up questions administered by 3 states (n=50), there was a strong association between level of marijuana use and the extent to which cognitive decline had led respondents to give up household activities or chores (r=.425) or interfered with work or social activities (r=.420). any marijuana use in the prior conference abstracts 90 30 days was positively associated with likelihood of alcohol use, binge or heavy drinking, driving under the influence of alcohol, and hiv risktaking in both age groups. among marijuana users, level of marijuana use was negatively associated with likelihood of drinking alcohol and hiv risk-taking. findings suggest that older adults who use alcohol and take other risks are more likely to use marijuana than those who do not, which may reflect non-medical use, and those who use marijuana tend to be in poorer health than those who do not, which may reflect medical use. however, because the data are purely correlational and cannot demonstrate causality, the nature of these relationships is unclear. the effect of marijuana on cognition is concerning as older adults are vulnerable to harm from cognitive errors, such as errors in medication selfadministration. cognitive and behavioral effects of marijuana in older adults require further examination with controlled studies. contact: susan stoner sastoner@uw.edu supplemental materials here the role of risk seeking, negative urgency, and perseverance in marijuana use frequency and marijuana related consequences alexander j. tyskiewicz, jamie e. parnes, & bradley t. conner colorado state university the acceptance of marijuana as a medicine and a recreational drug has been increasing in the u.s. the number of marijuana users in the u.s. is increasing. the need for research that helps us understand variables that influence marijuana use, and the strategies that help people abstain from misuse/abuse and evade marijuana related consequences (mrc) is also increasing. sensation seeking has been shown to predict substance use. researchers have also found that impulsivity and emotion dysregulation have a close link to drug use and abuse. research concerning the influence of personality traits on mrc is becoming more abundant. research has supported the fact that impulsivity predicts mrc in frequent users. research also supports the notion that emotion dysregulation is a predictor of increased frequency of use. one group of researchers examined the influence of emotion dysregulation, impulsivity, and sensation seeking on marijuana use frequency, and mrc. negative binomial regressions indicated that negative urgency, a facet of impulsivity, and risk seeking a facet of sensation seeking, significantly predicted the experiencing of mrc. risk seeking was also found to predict past 30-day intoxication frequency and typical week marijuana use. perseverance, a facet of impulsivity, showed to be a protective factor that decreases mrc, past 30-day intoxication frequency, and typical week marijuana use frequency. further research concerning variables that either cause or interfere with these relations will help us understand how to predict marijuana outcomes. past research has supported the notion that protective behavioral strategies (pbs) mediates the relation between sensation seeking and mrc. therefore, pbs may also mediate the relation between other personality traits and mrc. since pbs serve to reduce mrc, continued research on this factor is warranted. in this study, we will test if there are significant effects of risk seeking, perseverance, and negative urgency on three marijuana outcomes; mrc, past 30-day intoxication frequency, and typical week marijuana use frequency. we will also test to see if the use of pbs mediates those interactions. based on previous literature, we hypothesize that the use of pbs will mediate the effect risk seeking has on mrc, past 30-day intoxication frequency, and typical week marijuana use frequency. further, we hypothesize that pbs use will mediate the interaction between perseverance and all three outcomes being analyzed. lastly, we hypothesize that pbs use will mediate the interaction between negative urgency and mrc. we expect results to uphold our hypothesis. the data that shows the relations between these traits and outcomes will increase our ability to predict marijuana outcomes. if the mediation of pbs is shown to be significant in these relations, useful clinical implications could be made. this study could support an emphasis on pbs in clinical and counseling settings. contact: alexander tyskiewicz alexander.tyskiewicz@colostate.edu supplemental materials here conference abstracts 91 examining predictors of initial marijuana engagement using recursive partitioning gemma t. wallace, bradley t. conner, & audrey m. shillington colorado state university while several constructs have been associated with initiating marijuana use, most studies have examined only a few risk factors at a time, often due to statistical constraints of a priori analyses. exploratory analyses that use machine learning allow for the joint analysis of hundreds of predictor variables without concern for statistical power. thus, exploratory analyses may identify risk factors for marijuana use that have not been examined in previous literature. we used recursive partitioning to identify sets of variables that are associated with lifetime presence of marijuana use. data are repeated cross-sectional survey responses to the american college health association’s national college health assessment (acha ncha) from 2011, 2013, and 2015. participants were students at a colorado university (n = 4052, 77% white, 61% female, mean age = 22.77). the acha ncha measures a wide range health-related constructs, including alcohol and substance use behaviors and norms, sexual behaviors, physical and mental health, negative and positive affect, academic difficulties, and stressful and/or traumatic experiences. thus, the acha ncha provides an opportunity for a broad assessment of factors that may be associated with marijuana use. given multicollinearity between marijuana and other substance use variables, non-alcohol substance use measures were not included in these analyses. we tested two recursive partitioning models to examine correlates of ever having used marijuana. our first model evaluated all constructs within the acha ncha dataset that had an endorsement frequency of ≥ 50 (193 variables). alcohol consumption amount and frequency were the strongest correlates, and this first tree explained 39% of the variability in user status (relative error = 0.61, cross-validation error = 0.62, se = 0.02). in our second model, we removed alcohol variables to identify constructs that were most correlated to user status in the absence of substance and alcohol measures (160 variables). in this second tree, sexual behavior variables were the strongest correlates, and this model accounted for 25% of the variability in this sample (relative error = 0.75, cross-validation error = 0.75, se = 0.02). both recursive partitioning models produced parsimonious decision trees that accounted for a substantial amount of variance in the lifetime presence of marijuana use. among a wide-ranging set of predictor variables, higher engagement in alcohol use and sexual behaviors seem to be the most salient correlates of ever having used marijuana. these exploratory analyses corroborate previous literature suggesting that individuals who engage in multiple types of health-risk behavior are more likely to initiate marijuana use. contact: gemma t. wallace gemma.wallace@colostate.edu perceived risk, perceived addictive potential, and protective behavioral strategies’ impact on marijuana outcomes andrew p. weinstein, matthew r. pearson, & marijuana outcomes study team university of new mexico perceptions about the risk associated with marijuana use behaviors have been changing over time. a recent study examining the perception of how risky marijuana use behaviors are found that the perceived risk of marijuana use behaviors (e.g. regularly using marijuana) has changed between 1991 and 2016 while a protective effect remained stable among most populations of us 12th grade students (terry-mcelrath et al., 2017). large national samples, like the national survey of drug use and health, typically use these questions to assess the perceived risk of marijuana use. another protective factor for marijuana outcomes are protective behavioral strategies (pbs), which are cognitive behavioral strategies used proximal to substance use, which limit consumption or mitigate negative consequences (pedersen et al., 2016). in the present study we sought to 1) examine perceived risk an alternative measure of perceived risk among college students and 2) assess the relationship between marijuana protective behavioral strategies and perceptions of risk with marijuana-related outcomes. we used the data from the marijuana outcomes study team, which is a large multisite study examining a myriad of conference abstracts 92 marijuana related topics at 8 us universities in 8 states. we found that a traditional measure of perceived risk and perceptions of addictive potential were constitutionally different factors and interacted with pbs to influence marijuana outcomes. contact: matthew r. pearson mateo.pearson@gmail.com supplemental materials here sleep difficulties, marijuana use and suicidal behaviors in adolescents maria m. wong, ph.d. idaho state university this study examined the relationship among sleep difficulties, marijuana use and suicidal behaviors (ideation and attempts) in adolescents. additionally, we also tested whether marijuana use mediated the relationship between sleep difficulties and suicidal behaviors. previous research reported that sleep difficulties and substance use predicted suicidal thoughts and attempts (roane & taylor, 2008; wong & brower, 2012). here we extended the literature by specifically testing whether marijuana use had any relationship with suicidal behavior, after controlling for other prominent risk factors of suicide such as depressive symptoms and alcohol related problems. study participants were 6504 adolescents from the national longitudinal study of adolescent health (add health) (harris et al., 2009). data were collected from interviews and questionnaires. the current study analyzed data from both times 1 and 2 (t1 and t2), which were one year apart. sleep difficulties were measured by the question, “please tell me how often you have had each of the following conditions in the past 12 months trouble falling asleep or staying asleep?” (0=never, 1=a few times, 2=once a week, 3=almost every day, 4=every day). lifetime marijuana use was examined by the question, “during your life, how many times have you used marijuana?” suicidal thoughts were measured by the question, “during the past 12 months, did you ever seriously think about committing suicide?” suicidal attempts were measured by one question, “during the past 12 months, how many times did you actually attempt suicide?” marijuana use and suicide variables were recoded as dichotomous variables (0=no; 1=yes). data were analyzed by logistic regression. all analyses controlled for demographic variables that are associated with suicidal behaviors (i.e., sex, age, school grade, poverty, and chronic health problems) as well as depressive symptoms and alcohol-related problems (e.g., driving under the influence of alcohol, getting into a fight with family due to drinking). in t1, controlling for demographic variables, depressive symptoms and alcoholrelated problems, both sleep difficulties (or = 1.26, p<.001) and marijuana use (or = 2.45, p<.001) were associated with suicide ideation. controlling for t1 suicide ideation and all other covariates, both sleep difficulties (or = 1.13, p<.05) and marijuana use (or = 1.33, p<.05) were significant predictors of t2 suicide ideation. marijuana use at t1 significantly mediated the relationship between t1 sleep difficulties and t2 suicide ideation (95% asymmetric confidence interval = .004 to .08, p<.05). both sleep difficulties (or = 1.35, p<.001) and marijuana use (or = 3.05, p<.001) were associated with suicide attempts at t1. controlling for t1 suicide attempt and all other covariates, sleep difficulties were not a significant predictor (or = 1.14, p=.09) while t1 marijuana use was a significant predictor (or = 1.81, p<.01) of t2 suicide attempt. both sleep difficulties and marijuana use were concurrently and longitudinally associated with suicide ideation. suicide prevention programs for adolescents could include information on management of insomnia symptoms, as well as the health effects of both acute and chronic marijuana use. contact: maria m. wong wongmari@isu.edu insomnia symptoms, protective behavioral strategies for marijuana and hazardous marijuana use among college students maria m. wong, bianca montoya, elizabeth craun, & protective strategies study team idaho state university previous research has reported that sleep problems longitudinally predicted both onset of substance use and substance-related problems (wong, brower, & zucker, 2009; wong, robertson, conference abstracts 93 & dyson, 2015). however, the mediators of this relationship remain unclear. the main goals of this study were to examine (i) the relationship between insomnia symptoms and cannabis use problems and (ii) whether protective behavioral strategies for marijuana mediated this relationship. study participants were 984 college students from ten different universities in the u.s. these students participated in an anonymous survey on substance use and related risk and protective factors. insomnia symptoms refer to problems falling asleep, problems staying asleep, and early morning awakening. these symptoms were measured by the insomnia severity index (isi) (morin, belleville, bélanger, & ivers, 2011). protective behavioral strategies for marijuana were measured by the protective behavioral strategies for marijuana scale (pbsm) (pedersen, huang, dvorak, prince, & hummer, 2017). cannabis use problems were measured by the cannabis use disorders identification test revised (cudit-r) (adamson et al., 2010). cut-off scores of 8 and 12 were used to indicate hazardous cannabis use and possible cannabis use disorder respectively. all analyses controlled for three demographic variables that have been shown to associate with substance use, i.e., gender, age and race. insomnia symptoms were associated with an increase in the odds of hazardous cannabis use (or=1.02, p<.05) and cannabis use disorder (or=1.04, p<.01). insomnia symptoms also had a significant relationship with pbsm (b=-.02(.01), =-.08, t=-2.51, p=.01). severity of insomnia symptoms negatively predicted the use of protective behavioral strategies for marijuana. controlling for insomnia symptoms and demographics variables, pbsm significantly predicted lower odds of hazardous cannabis use (or=.50, p<.001) and cannabis use disorder (or=.49, p<.001). pbsm significantly mediated the relationship between insomnia symptoms and hazardous cannabis use (95% aci=.002 to .018, p<.05), as well as the relationship between insomnia symptoms and possible cannabis use disorder (95% aci=.002 to .020, p<.05). we discussed the implications of these findings on the prevention of cannabis use problems among college students in the u.s. past research showed that insomnia symptoms were associated with alcohol and drug-related problems. however, in those studies, the use of cannabis was not examined separately from other drugs. this study extended past research by showing that insomnia symptoms were associated with both hazardous cannabis use and possible cannabis use disorder. additionally, protective behavior strategies significantly mediated the relationship between insomnia symptoms and cannabis use. higher insomnia symptoms were associated with lower scores of protective strategies, which in turn was associated with higher cannabis consumption. the use of protective strategies (e.g., limit use to weekends, avoid using marijuana to cope with emotions such as sadness or depression) requires planning and thinking in advance before marijuana use. problems falling or staying asleep may make it difficult for individuals to have the mental energy and self-control to engage in these strategies. prevention and intervention programs of marijuana use could consider the potential impact of insomnia symptoms on protective behavioral strategies. contact: maria m. wong wongmari@isu.edu conference abstracts 94 symposia symposium: co-use of marijuana with alcohol and tobacco among young adults: current research and future directions chair: adrian j. bravo university of new mexico concurrent polysubstance use can be defined as the use of two or more substances within a given time period (e.g., over the past month or year) and can lead to dramatic health consequences due to the additive or interactive effects of combining substances. within the present symposium, we feature five researchers who have examined diverse research questions on the concurrent use of marijuana with either alcohol or tobacco among young adults. first, dr. pedersen will present on findings examining the effects of differing co-use patterns (e.g., simultaneous use vs using both, but on separate occasions) of marijuana and tobacco and their effects on negative consequences. second, dr. prince will present on findings exploring the relations among a variety of alcohol and cannabis co-use patterns (i.e., use of alcohol and cannabis on the same day; alcohol first; cannabis first; alcohol last; cannabis last; simultaneous use) and alcohol and cannabis related consequences (both separately and combined). third, dr. jackson will present on the predictive utility of simultaneous alcohol/marijuana (sam) motives as compared to motives for drinking and marijuana use on substance use. fourth, dr. villarosa-hurlocker will present on findings testing motivational models of alcohol and marijuana use problems among college students who endorsed both pastmonth marijuana and alcohol use, and endorsed varying levels of social anxiety. fifth, dr. bravo will present on findings comparing etiological models of protective behavioral strategies for both alcohol and marijuana among college student cousers. finally, dr. white will discuss the clinical and research implications from these studies. contact: adrian j. bravo ajbravo@unm.edu co-use of marijuana with tobacco and nicotine products among young adults eric r. pedersen, joan s. tucker, rachana seelam, & elizabeth j. d’amico rand corporation as an increasing number of states within the united states legalize marijuana for recreational sale and possession, it is important to understand if certain methods of use are associated with increased risk for heavy use and consequences among young adults. one manner by which marijuana is used is through co-use with tobacco and/or nicotine products (e.g., using marijuana and combustible cigarettes right after one another, vaping marijuana together with nicotinecontaining e-liquid in electronic cigarettes). there is a significant public health concern that changes in recreational marijuana policy may have the unintended consequence of increasing use of tobacco/nicotine products and impeding smoking cessation efforts among young people who are cousing the products. however, to date, there is little information on methods of tobacco/nicotine and marijuana co-use, as well as how co-use may associate with negative outcomes among the young adult population. existing research on the correlates and consequences of tobacco and marijuana co-use has been limited in that most studies in this area (1) were conducted at a time when these substances were almost exclusively smoked and do not reflect the recent proliferation in product types (e.g., electronic cigarettes, marijuana edibles) and methods of use (e.g., ingesting, vaporizing, dabbing) and (2) did not have the ability to differentiate between tobacco and marijuana concurrent use, simultaneous use, and co-administration. in this study, we examined the marijuana and tobacco/nicotine co-use behavior of a sample of over 1,200 young adult (mean age of 21 years old) marijuana users living in california. participants completed an online survey about their use of marijuana and tobacco/nicotine products in the past year. the most prevalent co-use behaviors were using an ecigarette to vape marijuana, smoking a cigarette and then smoking a joint on the same occasion, and smoking a joint that contained both tobacco and marijuana. we compared marijuana users who reported no co-use of tobacco/nicotine products to marijuana users who reported co-use conference abstracts 95 of marijuana and tobacco/nicotine as (a) concurrent use (i.e., using both, but on separate occasions), (b) simultaneous use (i.e., using one right after the other, such as smoking a marijuana joint and then smoking a combustible cigarette), and (c) co-administration use (i.e., using both through the same delivery system, such as smoking tobacco and marijuana together in a blunt). compared to marijuana users who reported no co-use, marijuana users who reported concurrent use, simultaneous use, or coadministration use reported more frequent marijuana use, had higher rates of screening for cannabis use disorder, and reported greater frequency of marijuana consequences. coadministration use emerged as the riskiest of the three co-use behaviors. those who reported engaging in all three types of co-use were the most at-risk for frequent use and consequences. however, those who reported marijuana use without any co-use reported a higher quantity of marijuana use than those in the co-use groups. these findings help to illuminate both the prevalence and risks associated with co-use of marijuana and tobacco/nicotine products and can be used to inform policies for states considering regulation of marijuana and tobacco/nicotine products. alcohol and cannabis co-use and consequences: the role of timing mark a. prince, kristina t. phillips, michael m. phillips, & trent l. lalonde colorado state university & university of norther colorado approximately one-fourth of u.s. college students report use of cannabis in the last month, one-third report heavy drinking, and up to 90% report co-use of both substances. recent data shows that cannabis use among college students in u.s. states with legal recreational use is higher than in states without legal use. college students are an important sub-group to assess, as cannabis and alcohol use peak in young adulthood and can still have an impact on the developing brain. both substances are associated with lower academic achievement, cognitive impairment, addiction, driving impairment and injury, and mental health effects. past research has shown that simultaneous or concurrent use of cannabis and alcohol can lead to more negative consequences than use of either substance alone. method: the present study examined college students (n = 632) who reported both alcohol and cannabis co-use across 2semesters of cross-sectional data collection. we explored the relations among a variety of alcohol and cannabis co-use patterns (i.e., use of alcohol and cannabis on the same day; alcohol first; cannabis first; alcohol last; cannabis last; simultaneous use), and alcohol and cannabis related consequences both separately and combined (i.e., a sum of the two scales) using path analysis. results: alcohol and cannabis consequences were negative binomial distributed when examined separately, and the combined consequences outcome was poisson distributed. patterns of significance and the direction of the effects were the same when alcohol and cannabis consequences were modeled separately or together (both using a composite score or separate variables in the same model). using cannabis last was a robust positive predictor of alcohol, cannabis, and combined consequences. using alcohol and cannabis on the same day, but not necessarily simultaneously, was a significant and negative predictor of alcohol, cannabis, and combined consequences. surprisingly, simultaneous use was not associated with any of the three consequences outcomes. using cannabis first negatively predicted alcohol consequences and was not associated with either cannabis or combined consequences. similarly, using alcohol first was negatively associated with cannabis consequences but not associated with either alcohol or combined consequences. finally, using alcohol last had a trend towards a positive effect on alcohol consequences and was not related to either cannabis or combined consequences. discussion: the most salient clinical implication of the current study is that using cannabis after alcohol portends risk for both alcohol and cannabis related problems. while it is possible that there may be a manner of using both alcohol and cannabis on the same day that results in fewer consequences, future studies using person-centered and episodelevel approaches are needed to identify risky and safer patterns of co-use. understanding how the timing of alcohol and cannabis co-use relates to alcohol and cannabis consequences provides insights that can be used in prevention and intervention efforts aimed at college students. conference abstracts 96 using marijuana and alcohol together: specificity in substance use motives among college students kristina m. jackson, alexander w. sokolovsky, kerri l. hayes, & helene r. white brown university & rutgers university the majority of college students who use both alcohol and marijuana have used them simultaneously on at least one occasion, but the motivations underlying simultaneous alcoholmarijuana (sam) use have been understudied. although sam motives may overlap conceptually with alcohol and marijuana motives, the degree to which simultaneous use is uniquely driven by sam motives is unclear. the purpose of this study is to examine the predictive utility of sam motives as compared to motives for drinking and marijuana use. additionally, we explore the moderating role of negative affect and peer descriptive norms on the relationships between sam use and conceptually related coping motives and social motives, respectively. past-year alcohol and marijuana users age 18-24 (n=1,390; 62% female; 69% white; 12% hispanic) recruited from three college campuses in the u.s. completed a 3045-minute web survey assessing alcohol and marijuana use, motivations for use, affect, and peer descriptive norms at two time points separated by three months. past 30-day alcohol use was reported by 93% of the sample and 75% reported past 30-day marijuana use, with at least one occasion of sam use in the past 30 days reported by 71% of users of both alcohol and marijuana. the most frequently endorsed sam motives were coping motives, social motives, desire to attain greater positive effects with combined use, and boredom. in a series of regression models we predicted past 30-day use of each type of substance from coping and social motives pertaining to each substance or sam. coping and social motives were significant predictors of use with strongest associations observed in models where there was correspondence between type of motive and type of substance use behavior. further, accounting for sam-specific coping motives, using marijuana to cope was still predictive of sam, but using alcohol to cope was not; alcohol and marijuana social motives were not significant predictors of sam when sam-specific social motive were included the model. finally, in a set of models testing interactions with affect and norms, the interaction between coping motives and negative affect was significant for alcohol, marijuana, and sam use. somewhat unexpectedly, coping motives were greater for those low on negative affect. there was also a significant interaction between social motives and friend norms such that the effect for social motives was most pronounced for those who reported sam-using friends; the same effect (although less pronounced) was observed for marijuana use but was not significant for alcohol use. for the most part, use of alcohol and marijuana together appears to be driven by motives specific to simultaneous use. additionally, the strength of these motivational influences depends on salient individual and contextual characteristics. future work should examine the extent to which motives may indicate particular vulnerability for some young adults to established contextual antecedents of substance use. the relationship between social anxiety and alcohol and marijuana use outcomes: a motivational model of substance use margo villarosa-hurlocker, adrian j. bravo, matthew r. pearson, & protective strategies study team university of new mexico background: college students with social anxiety are particularly vulnerable to problematic alcohol and marijuana use given their susceptibility for elevated anxiety symptoms in social settings combined with the normative nature of substance use. existing research has supported copingmotivated substance use for these students when examining alcohol and marijuana use problems separately. the next step is to determine whether students with social anxiety who use both substances, do so for similar or different reasons. objectives: the current study tested motivational models of alcohol and marijuana use in a sample of college students from 10 universities across the u.s. who endorsed both past-month alcohol and marijuana use. method: among college student dual alcohol/marijuana users (n = 2,034), the majority of participants identified as being either white, non-hispanic (67.95%) or of hispanic/latino ethnicity (15.88%), female conference abstracts 97 (69.08%), and reported a mean age of 20.24 (sd = 3.16) years. results: path analyses revealed that negatively reinforcing drinking motives (coping with anxiety and conformity) significantly mediated the positive relationship between social anxiety symptoms and alcohol-related problems. further, coping and expansion marijuana use motives significantly mediated the positive association between social anxiety and marijuana-related problems. conclusions: taken together, students with social anxiety who are focused on anxiety management may use either alcohol or marijuana; however, these students may be more inclined to drink to fit in with peers and use marijuana to expand their perceptual experiences. the relationship between distal antecedents and alcohol and marijuana use outcomes among dual users: a comprehensive examination of protective behavioral strategies adrian j. bravo, andrew weinstein, matthew r. pearson, & protective strategies study team university of new mexico background: protective behavioral strategies (pbs) are behaviors that are used immediately prior to (e.g., setting a limit on consumption), during (e.g., using only in a safe context), and/or after substance use (e.g., using a designated driver) that reduce consumption, intoxication, and/or substance-related harm. among college samples, increasing evidence suggests that both alcohol and marijuana pbs use are robust protective factors and have been shown to mediate the effects of known risk factors (i.e., gender, age of drinking onset, college substance use beliefs, drinking motives, and impulsivity-like traits) on alcohol (bravo et al., 2015, 2016, 2017a) and marijuana outcomes (bravo et al., 2017b). however, it is unknown whether pbs use would operate similarly for both substances among dual users. objectives: in an extension of previous research, the present study examined which distal antecedents uniquely (i.e., controlling for other factors) relate to alcohol/marijuana outcomes via alcohol/marijuana pbs use and among a large group of college students who use both alcohol and marijuana. method: participants were college students that consumed both alcohol and marijuana at least one day in the previous month (n=2,034, 69.09% female). across two models (one for each substance), proposed distal antecedents (i.e., gender, age of first use, college substance use beliefs, impulsivity-like traits, and motives) were modeled as predictors of negative consequences via pbs use and substance use consumption. results: across both models and controlling for the effects of all other predictors, pbs use was significantly negatively associated with all substance use outcomes. across both substances, pbs use significantly mediated the associations between gender (women reported higher pbs use), age of first use (having an older age of first use was associated with more pbs use), and college substance use beliefs (higher beliefs was associated with lower pbs use) on all substance use outcomes. in the alcohol model only, alcohol pbs use significantly mediated the associations of both negative urgency and enhancement motives (both associated with lower pbs use) on each alcohol outcome. within the marijuana model only, marijuana pbs use significantly mediated the associations between coping (associated with lower pbs use) and conformity motives (associated with more pbs use) on all marijuana outcomes including the double-mediated paths. discussion: our results suggest that pbs use is a good candidate to be considered as a mechanism by which dual alcohol/marijuana users moderate their substance use and attenuate their risk of experiencing related consequences. based on the current sample, we can identify certain characteristics that might be particularly good targets for pbs based intervention efforts. for example, our results indicate that male college students and those with higher college substance use beliefs may benefit from increasing their pbs use for both substances. moreover, several differences were found across substances and targeting specific characteristics for a particular substance may improve the efficacy of pbs interventions. discussant: helene r. white rutgers university conference abstracts 98 symposium: dealing with the frequently comorbid condition of depression and cannabis use disorder in adolescents chair: albert j. arias yale university this symposium will deal with the frequently comorbid conditions of depression and cannabis use disorder (cud). dr. chris hammond will present on the literature linking depression and cud, including epidemiology, and including the possible pathophysiological basis for comorbidity. cud in adolescents is associated with clinically significant depression. reliable data estimating the prevalence of significant depressive symptoms and major depressive disorder (mdd) in this population are scarce, although one estimate based on literature review is about 20 to 30% of adolescents with cud are depressed. depression and co-occurring drug use disorder in adolescents are associated with higher rates of alcohol use and alcohol use disorders, as well as greater risk of suicidal behavior. multiple pathways to developing depression and cud are possible, and there is data suggesting that some adolescents develop cud after becoming depressed, and some develop depression after cud. another important clinical question is whether or not having depressive symptoms foils the treatment of substance use disorder. the second talk by dr. albert arias will review a secondary analysis of the cannabis youth treatment study of n=600 adolescents in treatment for cud which asks that question and examines the relationship between depression and cannabis use over time in that sample. lastly, dr. yifrah kaminer will discuss research on treatment of cud in adolescents, and will discuss how to deal with depression in this population, and with commentary on directions for further research. contact: yifrah kaminer kaminer@uchc.edu the link between affective disorders and cannabis use in adolescents christopher j. hammond johns hopkins university this talk will review the scientific evidence linking cannabis use and mood disorders in adolescents. the talk will include epidemiology, as well as a review of longitudinal studies examining the risk of developing mood disorders with cannabis use. pathways to developing dual diagnosis will be discussed. a clinical case presentation will be included. the impact of depressive symptoms on cannabis use treatment outcomes in adolescents albert j. arias yale university objectives: depressive symptoms are common in adolescents with cannabis use disorder (cud), and can complicate assessment and treatment. a question remains about whether depressive symptoms interfere with cannabis use treatment. this is a report of a retrospective analysis of a data set where we examine the response of depressive symptoms to treatment of only the cud. method: n= 600 adolescents (age 12-18) with cud received three months of active treatment for substance use with one of five types of psychotherapeutic psychosocial treatment. none of these treatments was aimed specifically at treating depressive symptoms. self-reported number of days having used cannabis in the past 90, as well as self-reported level of depression was assessed at baseline (bl) and again at 3-, 6-, 9-, and 12-months. a dual change latent change score (lcs) model was used to examine the trajectory of frequency of cannabis use and depressive symptoms. results: rates of major depressive disorder (mdd) and any depressive symptoms at bl were 18% and 70.2% respectively. depressive symptoms improved over the course of treatment, as did cannabis use (reduction). greater baseline depression was a significant associated with attenuated improvement in subsequent cannabis use (less improvement for those with greater depressive conference abstracts 99 symptoms). change in cannabis was not associated with subsequent change in depression, suggesting that the improvement in depressive symptoms was not specifically due to the improvement in cannabis use. conclusion: in this cohort of adolescents with cud, depressive symptom severity improved over time, however there was a measurable impact of depression on the treatment effect for cannabis use. research on the treatment of youth with cannabis use disorder and comorbid conditions yifrah kaminer university of connecticut healthcare center dr. kaminer will describe his work in developing treatments for adolescents with cud, as well as its common dual diagnoses of depression and anxiety disorders. also reviewed will be the common strategies for clinical treatment in this population. additionally, directions for future research will be reviewed. discussant: yifrah kaminer university of connecticut healthcare center symposium: rehashing approaches to marijuana-related consequences: a budding area of research chair: jamie e. parnes colorado state university understanding physical and mental health risks of marijuana use is critical to harm reduction interventions. as such, research has extensively focused on understanding factors associated with negative consequences of use. while many antecedents of harm have been identified, there remain unexamined factors that may account for significant variance in negative consequences. moreover, most literature to-date has measured consequences as a count of the number of negative consequences experienced. however, other consequence-related factors, such as the severity of reported consequences, or positive consequences, have yet to be examined. other unexamined influences on negative consequences, such as price of marijuana, may help inform interventions. four symposium talks will address unexamined factors and alternative ways of examining consequences of marijuana use. the first talk will focus on incorporating the marijuana purchasing task into understanding the relation between marijuana use motives (mums) and number of negative marijuanarelated consequences experienced. this study examined the influence of marijuana price breakpoint (i.e., price at which one no longer purchases marijuana) as a potential mediating variable. the second talk examined how use relates to negative consequence count, consequence severity, and individual differences. the third talk examined if classes based on mums were associated with marijuana-related negative consequences and severity. the final talk will discuss the relation between mums and positive consequences of use. the four talks will provide greater understanding of marijuana consequences from various perspectives. results may inform harm reduction interventions seeking to reduce negative consequence number and severity, as well as increase positive outcomes. contact: jamie parnes jamie.parnes@colostate.edu a behavioral economic approach to analyzing the relations between marijuana use motives and marijuana related consequences in young adults kirstyn n. smith-lecavalier, samuel r. davis, & mark a. prince colorado state university as the landscape of marijuana changes with greater social acceptance, prevalence of use, and more permissive legislation, the demand for a deeper understanding of the factors that relate to marijuana misuse and related negative consequences is increasing. previous studies have described the direct positive association between marijuana use motives (mums) (i.e., social, coping, enhancement, conformity, expansion), marijuana use, and marijuana-related consequences (mrc). moreover, mums account for unique variance in marijuana related consequences that is not fully explained by marijuana use alone. recently, purchase tasks have been used to establish economic demand for marijuana use. the marijuana purchase task (mpt) assesses estimated consumption of conference abstracts 100 marijuana at specific prices per “hit” of marijuana. from a behavioral economics view, mpt has been used to demonstrate a negative association between demand for marijuana and price. additionally, greater demand for marijuana and lower sensitivity to price fluctuations have been observed in persons who display marijuana dependence symptoms. however, little research has examined the mpt in relation to psychological constructs such as motives and negative consequences. this study focused on whether breakpoint (i.e., cost where individuals are no longer willing to purchase marijuana) mediated the relation between mums and mrcs. the present study is a secondary data analysis of the initial marijuana outcome study team (most) data collection. the analytic sample consisted of the young adults who reported using marijuana in the past 30 days (n = 2044). all study hypotheses were tested using path analysis. number of consequences was specified as a negative binomially distributed count variable. monte carlo confidence intervals will be used to assess the significance of the indirect effects in each model. results indicated that when controlling for other motives, enhancement, coping, and expansion motives positively predicted mpt breakpoint. furthermore, controlling for mums and breakpoint, all mums were associated with mrc. with regard to the direct effects of the individual models, social motives are negatively related to mrc. in addition, coping, enhancement, conformity, and expansion motives are positively associated with experiencing negative consequences. findings for the indirect effects suggest that breakpoint may partially mediate the relation between social, enhancement, expansion, and coping motives. results from the current study can contribute to the understanding of factors that are associated with marijuana demand characteristics and purchasing behaviors among college student marijuana users. negative consequence severity: what’s the worst that can happen? theodore j. fetterling, jamie e. parnes, samuel r. davis, mark a. prince, & bradley t. conner colorado state university marijuana use rates are highest among collegeaged individuals for both annual (41%) and past 30-day (25%) use compared to all other age groups. additionally, marijuana use has been linked to a variety of negative consequences (e.g., feeling sluggish, dependence). while the prevalence of negative consequences related to marijuana use has been widely studied, research has yet to examine the perceived severity of marijuana-related consequences. although heavier users report experiencing significantly more marijuana-related consequences, they are not more likely to anticipate future consequences than individuals with low use. thus, consideration of consequence severity is warranted. studies have shown perceived consequence severity can decrease likelihood of engagement in various health risk behaviors. further, sex differences have been noted for engagement in risky activities. the present study has two aims. the first is to test the relations between recent marijuana use, endorsement of negative consequences, and reported negative consequence severity. the second aim is to explore potential descriptive differences (e.g., sex, age) on consequence severity ratings. we hypothesized that past 30-day marijuana use would predict greater average consequence severity and highest severity consequence, and that number of consequences endorsed would mediate this relation. we also explored descriptive differences among severity ratings of consequences. college student marijuana users (n = 695) completed a survey containing items from the marijuana consequences questionnaire (macq) with an associated 5-point likert scale to rate consequence severity (“minimally negative” to “extremely negative”). hypotheses were tested using path analysis. number of consequences endorsed was a negative binomially distributed count variable and monte carlo confidence intervals were used to test the indirect effects. findings indicated that the direct effect of past 30day marijuana use significantly predicted increased average and highest consequence conference abstracts 101 severity ratings. when including number of endorsed consequences as a mediator, significant indirect effects were detected for both average, and highest consequence severity. exploratory analyses were used to test for differences in perceived consequence severity among descriptive variables. results suggest the effects of past 30day marijuana use on perceived consequence severity are transmitted through number of endorsed consequences. we expected the consequences rated as more negative to vary by sex as well as other demographic variables. the current study provides preliminary evidence that marijuana users who endorse greater negative consequences are likely to experience higher severity of negative consequences. the combined findings may inform interventions aimed at reducing specific marijuana-related consequences, informed by demographic differences, to attenuate the frequency and severity of experienced consequences. marijuana use motives relation to frequency and severity of negative consequences samuel r. davis, mark a. prince, & bradley t. conner colorado state university marijuana use motives (mums) are positively associated with marijuana use and marijuanarelated negative consequences. in particular, motives to enhance positive affect are associated with greater use and fewer consequences, while motives to cope are associated with greater frequency of negative consequences. however, no research has examined the relation between mums and severity of these negative consequences. this study examines mums and their relation to frequency and severity of marijuana-related negative consequences. this study is a secondary data analysis of college-aged marijuana users at a large public university (n = 668, mage = 20.40). a series of latent class analyses (lcas) were conducted to discern latent classes of mums. once latent classes were identified, differences among latent classes of frequency of negative consequences experienced in the last 30 days, frequency of consequences in a typical week of use, frequency of consequences in a heavy week of use, and severity of negative consequences experienced in the last 30 days were tested using the bch method in mplus version 8. a four-class solution provided the best overall model fit to the data. class 1, labeled as the enhancement class (enh), was characterized by higher enhancement motives and low conformity, coping, social, and expansion motives. class 2 was characterized by low mums and was labeled the low motives class (lm). class 3, labeled as the low conformity class (lcon), was characterized by high enhancement, coping, social, and expansion motives and low conformity motives. class 4 was characterized by moderate marijuana use motives and was labeled the moderate motives class (mm). the bch test was significant for past 30-day consequences, typical week consequences, heavy week consequences, and severity of consequences. comparisons revealed that the lcon and mm classes reported greater severity of negative consequences, and greater frequency of negative consequences compared to the enh and lm classes. the enh class reported significantly lower severity of negative consequences than the lm, lcon, and mm classes. results suggest that among college marijuana users, profiles for moderate-to-strong overall motivation to use marijuana are associated with greater negative consequences and severity of those consequences compared to low overall motive users. however, a profile of just high enhancement users is associated with less severity of the negative consequences compared to low, moderate, and high overall motive users. future interventions should target persons with greater coping, social, and expansion motives compared to persons with greater enhancement motives when working to attenuate severity and frequency of marijuanarelated negative consequences. motivated to feel good: marijuana motives predict positive consequences of use jamie e. parnes colorado state university past research has extensively examined negative consequences of marijuana use. however, despite experiencing negative consequences, many individuals continue using. therefore, it is important to understand the factors that maintain use. one of these factors is positive consequences of use, such as activity enhancement, euphoria, and stress reduction. conference abstracts 102 another influencing factor is marijuana use motives. motives for use, including social, coping, enhancement, conformity, and expansion motives, all uniquely relate to negative consequences of use. however, it is not known how these motives relate to positive consequences. each motive may uniquely relate to positive outcomes. motives associated with greater positive outcomes likely become more reinforced over time than other motives. the present study seeks to examine how motives predict positive consequences of marijuana use. given the lack of previous research, exploratory analysis was conducted to examine these relations. undergraduate marijuana-using students (n = 676) completed a survey measuring past 30-day marijuana use, marijuana use motives, and positive consequences of use. multiple linear regression was conducted with all five marijuana use motives predicting positive outcomes of use, controlling for past 30day use. given the multiple comparisons made in this study, alpha was set to .01 to reduce likelihood of type 1 errors. results indicate that coping motives, enhancement motives, expansion motives, and past-30 day use positively predict positive consequences of use. additionally, conformity motives negatively predict positive consequences. social motives were unrelated to positive consequences. overall, results support that positive outcomes experienced by users vary by use motive. those using to conform with peers experience fewer positive consequences, possibly as these users may feel extrinsic pressure to use rather than an intrinsic desire. alternatively, those using for their own desires, such as coping, enhancement, or expansion, experience greater positive outcomes as they may be using for internally motived reasons. moreover, positive experiences related to specific motives may reinforce continued use for certain motives rather than others. for example, positive consequences from use to cope with negative affect may reinforce using to cope. however, using to cope also predicts greater negative consequences of use that pose various health risks. harm reduction interventions seeking to maximize the benefits of use may target marijuana use motives. intervening on those using for conformity motives may help reduce use when it is likely to lead to fewer positive consequences. future research should continue to examine positive consequences as both an outcome and predictor of continued use. doing so may help increase understanding of how to help users maximize the benefits of use and reduce occasions associated with fewer positive consequences. discussant: jamie e. parnes colorado state university symposium: brain imaging in relation to both acute and chronic cannabis use chair: godfrey pearlson yale university consequent on widespread medical marijuana legalization and recreational marijuana decriminalization/legalization, there is a growing need to understand cannabis’ acute and longerterm effects on brain function and behavior, many facets of which are under-documented. this symposium will examine brain and behavioral consequences of acute cannabis use relevant to a variety of different contexts by describing emerging findings from our studies that employ task-based fmri, resting state fmri, and proton spectroscopy. to examine cognitive and brain consequences following acute use, we were interested in how single doses of vaporized cannabis impact behavioral performance on timeestimation and three separate measures of simulated driving behavior that represented different crucial aspects of motor vehicle operation. in particular, we wanted to document the time courses of these behavioral and brain changes, their relationship to administered dose and blood levels of thc and its metabolites and any differences attributable to baseline marijuana use frequency. because of concerns about the drug’s effect in younger individuals, particularly on memory function, we were especially interested in measuring brain metabolic effects using proton spectroscopy in relationship to robust functional mri assessment of memory encoding. overall, this symposium will attempt to showcase novel uses of mri-based neuroimaging in the context of human marijuana neuroscience. contact: godfrey pearlson godfrey.pearlson@yale.edu conference abstracts 103 alterations in resting state functional mri connectivity following acute doses of cannabis . shashwath meda olin research center, institute of living resting state functional mri (rs-fmri) examines how activation in numerous distal brain regions engage in synchrony over time in the absence of formal experimentally-driven performance demands. as such, rs-fmri characterizes frequently engaged-neural systems and can quantify many different types of network connectivity abnormalities in those circuits. rsfmri have not only been used to characterize physiological perturbations such as drowsiness and a large number of different neuropsychiatric illnesses such as schizophrenia and alzheimer’s disease, but fs-fmri has demonstrated its sensitivity to acute intoxication with a variety of medications. numerous studies suggest the sensitivity to thc, but the evidence comes indirectly from studies that examine samples with different types of regular thc use, dependence, or abstinence. there is an absence of cannabis challenge studies that directly characterize the acute effects of thc intoxication or its persistence over time. as part of a nida-funded study, we examined the differences in rs-fmri between placebo marijuana (mj) and two doses of active drug (0.5 g of ~6% and ~13% thc -containing floral mj) administered using a volcano vaporizer in n = 14 subjects. data were acquired from 6m 43s of resting fmri signal acquired on a 3-t mri scanner. data were preprocessed using the minimal preprocessing guidelines prescribed by the human connectome project (hcp) that include distortion correction, surface generation, cross-modal registration and spatial alignment. low frequency drift was then removed from the preprocessed data and analyzed using the group ica toolbox to derive temporally coherent intrinsic resting networks. within-network spatial differences in resting connectivity across different doses and over time within sessions were assessed using a repeated measure ancova design (adjusted for age, sex and motion) implemented in the palm package. we will present preliminary results from analyses that quantify functional connectivity within the nodes of brain systems that are highly reproducible across people and different task contexts (e.g., the frontoparietal executive network, cinguloopercular salience network, etc.), as well as icaidentified neural systems that integrate those brain regions that have a high density of cb receptors (e.g., striatal, cerebellum). results are pending and will be discussed at the time of the symposium. effects of chronic cannabis use on brain proton spectroscopy measures, and working memory fmri alecia dager yale university emerging adults show the highest rates of heavy marijuana use. marijuana use is associated with memory impairments and altered functional magnetic resonance imaging (fmri) response, but the neurochemical underpinnings remain unclear. to better understand the relationship between marijuana use and memory dysfunction, we collected information on hippocampal and frontal lobe neurochemistry, brain activation levels during an active memory encoding and recognition fmri task, and performance on neurocognitive measures of verbal list learning in current heavy marijuana users and controls, ages 18-22. the california verbal learning task (cvlt) assessed verbal learning. during fmri, participants performed an object-pair encoding and recognition task (ragland et al., 2012). magnetic resonance spectroscopy yielded nacetylaspartate (scaled to total creatine, naa/tcr), a marker of neuronal integrity, in left hippocampus and left prefrontal cortex. marijuana users performed worse than controls during cvlt immediate recall (t=2.28, p=0.049), and trended toward poorer cvlt delayed recall (p=0.051). groups did not differ on frontal or hippocampal fmri response during encoding or recognition. however, left hippocampal response during encoding correlated with better cvlt delayed recall (rho=0.991, p=0.001). although there were no group differences in naa/tcr, groups differed in their relationship between naa/cr and fmri response in hippocampus (t=2.5, p=.042). here, controls demonstrated a trend for a positive relationship (t=2.5, p=.069), whereas marijuana users demonstrated no relationship. this within-subject comparison of conference abstracts 104 fmri and magnetic resonance spectroscopy provides preliminary evidence of altered relationships between hippocampal neurochemistry, memory-related fmri response, and verbal learning. ongoing data collection will further characterize these relationships, providing critical insight into the neural impact of marijuana use in this vulnerable population. this work has important implications as marijuana use increases with legalization and medicalization. acute cannabis exposure alters behavior and brain activation on an fmri time estimation task michael stevens olin research center, institute of living time estimation is impaired by acute cannabis use. as part of an ongoing nida-funded study (r01da038807), fmri data were collected from n=10 regular mj users. on three separate days, participants used a vaporizer and paced inhalation method to smoke marijuana, randomly receiving 0.5gm of either nida herbal 13.4% thc, 5.9% thc, or placebo cannabis. on each visit, participants were administered drug using paced inhalation by 9:00 a.m., then underwent fmri 3 separate times post-dose (1½ h, 3½ h and 5½ h), in a randomized, double-blind, counterbalanced design across visits. after dosing, participants underwent fmri while performing a rapid, event-related time estimation task, where they were presented with a sequence of boxes and were instructed to decide which box was on the screen longest. the task presented short (500-900 msec) or long (1500-1900 msec) stimuli durations within either of these ranges to assess drug impact on both neural systems. both short and long intervals for all 9 fmri runs for each participant were included in analyses to determine the extent of regional activation regions during the task. as expected from prior studies, time estimation task performance engaged bilateral cerebellum and putamen, plus an extended set of bilateral cortical regions comprising anterior insula, inferior frontal gyri, middle frontal gyri (ba 9/46), and dorsal anterior cingulate and medial frontal gyrus. short interval time estimation elicited greater cerebellum activity, whereas lateral and medial prefrontal regions were more engaged during long interval estimation. an analysis of reaction time (rt) and accuracy found significant changes over time since thc use only for short interval rt for the moderate mj dose condition. here, rt decreased with continued recovery from drug use (t1 vs. t3 p = .029). as behavioral effects were greater for short interval trials, we focused fmri analyses on this condition. the predominant effect of recent thc use was to reduce brain activation. common to both drug doses, less activity was elicited in basal ganglia and frontoparietal network regions. cerebellum was relatively unaffected in by moderate, but was hypo-functional following low dose. there were different dose effects in sii somatosensory processing regions. a large effect size change was observed in dorsal anterior cingulate (dacc), where over time the amount of activation decreased for low dose days (xyz = 0, 32, 30, cohen’s d = 1.57). in addition, throughout low dose days, more bold signal change was noted in left putamen and left amygdala. by 5½ h postdrug, right putamen activation had not yet returned to normal in either the low or moderate dose conditions. interestingly, after 5 ½ h postmj use, activation in frontoparietal regions consistent with the dorsal attention network showed greater activation relative to the comparable placebo fmri for both drug doses. overall, mj use resulted in relative hypoactivation compared to placebo for striatal brain regions known to play an important role in mental timekeeping cognitive processes, as well as for several distributed neural systems engaged for higher-order cognition. disruption of brain circuits involved in a simulated driving fmri task following acute cannabis exposure godfrey pearlson yale university although numerous studies provide evidence that recent marijuana use can impair performance on tests of cognitive abilities thought to be important for optimal motor vehicle operation, there is little understanding of exactly how the drug affects the brain to cause such impairments. fmri data were collected from n=12 regular marijuana users. on three separate days in a randomized, doubleblind, counter-balanced design across visits, conference abstracts 105 participants used a vaporizer and paced inhalation method to smoke marijuana, randomly receiving 0.5gm of either nida herbal 13.4% thc, 5.9% thc, or placebo cannabis. although the overall protocol collected fmri data 3 separate times following marijuana use at 9:00 a.m., here we focused on fmri data collected 1½ hours postdose to observe dose effects related to virtual driving performance not only after peak thc intoxication. using real time, inc. realistic virtual driving simulation software, multiple instances of different driving demands were naturalistically embedded into three ~10-minute fmri driving tasks administered during each inscanner drive. event onsets were extracted, then modeled to create activation maps for each condition. we contrasted study doses in repeatedmeasures statistical comparisons to identify which brain regions had greater or lesser bold signal response for the events in that task relative to the implicit baseline formed by the remainder of the timeseries for each paradigm: gap acceptance is a strategic planning task where participants decide when to accelerate from a stop to overtake a parked car by merging into a lane of oncoming traffic. the task engaged diverse prefrontal cortex regions within both frontoparietal executive and ventral attention networks, disengaged motor planning regions, lateral orbitofrontal cortex, and regions within dorsal attention and default mode networks. carfollowing measures tactical decisions when participants respond to the acceleration/deceleration of a lead car that pseudo-randomly alters speed. the task elicited greater activation in motor planning/execution brain regions, motor anterior cingulate, posterior dorsal attention network and right putamen. the caudate disengaged to these events, as did bilateral sii somatosensory cortex. lane keeping assesses operational vehicle control where participants maintain car position despite unpredictable wind gusts that elicit vehicle correction. the task elicited greater left hemisphere lateral prefrontal cortex activation in superior frontal sulcus, mid-dlpfc, anterior vlpfc and bilateral cerebellum and relative decreases in activity in right caudate, dorsal cingulate and bilateral precentral gyri. marijuana use altered brain function in every driving context. across all driving tasks, bilateral putamen was less engaged by active study drug. all other effects were diverse and differed by thc dose. during gap acceptance, both doses showed extensive right hemisphere frontoparietal deficits and lower anterior cingulate cortex activation. for lane keeping, supplemental motor area and secondary visual cortex activity were reduced after both low and moderate mj doses, as were greater right dorsolateral, ventrolateral, and ventromedial prefrontal cortex activity. for car following, putamen deficits were dose specific, with higher doses linked to lower activation. other dose-specific effects included bilateral precentral gyri and left frontoparietal cortex deficits. after both doses, there was greater activity in visual association, motor, premotor, and supplementary motor cortices. discussant: godfrey pearlson yale university symposium: measuring marijuana: assessment challenges and our partial solutions chair: matthew r. pearson university of new mexico every known drug of abuse has dose-dependent effects. in the context of increased medicalization and legalization of marijuana (or cannabis) in the united states and throughout the world, there is a rising pressure to quantify the risks and benefits of marijuana use. however, the crude assessment of marijuana use is at best obscuring and at worst preventing our ability to detect the associations between marijuana use and important outcomes. a review of the marijuana literature reveals that there are two primary ways that marijuana (or cannabis) use is assessed: 1) user status (a comparison of marijuana users and non-users with various time windows: past month, past year, lifetime, etc.) and 2) marijuana use frequency (i.e., number of days used in the past 30 days). unfortunately, marijuana use quantity is not typically measured and there is no clear gold standard for assessing marijuana use quantity. the lack of a gold standard measure of marijuana is not befuddling. there are several challenges with assessing marijuana use. marijuana is available in many different preparations including flower, concentrate, and edible preparations. these products can have different routes of administration (e.g., smoking, vaping, conference abstracts 106 eating) and there is not a standard apparatus for most of these (e.g., bowl/bong sizes vary). even within each preparation, potency of marijuana varies significantly. in the present symposium, each presentation will measure marijuana use in a unique way to overcome some of the limitations mentioned above, and we will discuss how the field can improve upon the measurement of marijuana use. contact: matthew r. pearson mateo.pearson@gmail.com marijuana use grid: a brief, comprehensive measure of marijuana use matthew r. pearson university of new mexico the present study introduces a brief, yet comprehensive retrospective self-report measure of frequency and quantity of marijuana use: the marijuana use grid (mug). a large sample of college student marijuana users were recruited from 8 universities throughout the united states (total sample n = 6,584, past month marijuana users n = 1,969), including states that reflect each of the categories of legal marijuana: 1) no legal marijuana, 2) legal medical marijuana, and 3) legal medical and recreational marijuana. using a weekly grid, the mug asks participants to report the amount of marijuana that they use (in grams) during each of 6 4-hours blocks of time each day (12a-4a, 4a-8a, 8a-12p, 12p-4p, 4p-8p, 8p-12a) during a typical week of marijuana use (monday – sunday). from this measure, we can calculate a large number of variables including frequency (i.e., counting all non-zero values) and quantity (i.e., summing number of grams) of marijuana use for each day of the week, for each time of day, and for the entire week. we used spearman rank correlations to examine the associations between these marijuana use measures and marijuana consequences and symptoms of cannabis use disorder (cud). we found moderate associations between overall marijuana frequency and consequences/cud symptoms (strongest r = .546 for cudit-r, weakest r = .326 for cast). we also found moderate associations between overall marijuana quantity and consequences/cud symptoms (strongest r = .466 for cudit-r, weakest r = .274 for cast). to explore whether frequency and/or quantity of use on particular days or during particular time periods were most predictive of consequences, we conducted four stepwise regressions: 1) day of week frequency, 2) time of day frequency, 3) day of week quantity, and 4) time of day quantity. week-end use (i.e., friday/saturday) tended to be most predictive of consequences, but time of day analyses were inconsistent across frequency and quantity estimates. lastly, to test for incremental validity, we examined with mug frequency or quantity measures predicted consequences above and beyond the effect of a simple past month frequency measure. although marijuana use frequency assessed by the mug predicted consequences above and beyond the effect of a simple past month frequency measure, marijuana use quantity did not. this finding suggests either that quantity is less important than frequency in the determination of marijuana consequences, or that significant error in the assessment of quantity diminishes our ability to detect such relationships. although improvements on marijuana use measures need to continue, the mug has shown utility in its association with important outcomes and given its brief nature, the mug can easily be integrated in future marijuana studies. quantifying cannabis: a field study of marijuana quantity estimation mark a. prince, bradley t. conner, & matthew r. pearson colorado state university & university of new mexico the assessment of marijuana use quantity poses unique challenges. these challenges have limited research efforts on quantity assessments. the goal of the present study was to examine regular and heavy marijuana users’ ability to estimate quantity (e.g., weight in grams) of both flower and concentrated marijuana to narrow the gap between tightly controlled lab studies and surveybased observational studies. this study had four primary aims: 1) determine the typical dose (i.e., grams used) for two common types of marijuana products (i.e., flower and concentrates), 2) determine the relative accuracy of marijuana users’ estimations of quantities of marijuana, 3) identify salient predictors of quantity of conference abstracts 107 marijuana prepared for a single dose, and 4) identify salient predictors of estimation (in)accuracy. we recruited a sample of 128 regular-to-heavy marijuana users (48% female) for a field study wherein they prepared and estimated quantities of marijuana flower in a joint or a bowl as well as marijuana concentrate using a dab tool. for aim 1, we found that participants typically packed .25 grams of marijuana into a bowl, rolled about .58 grams into a joint, and loaded about .08 grams of concentrate using a dab tool. for aim 2, we found that the vast majority of participants overestimated the quantity of marijuana that they used in their preparations (71% 81% across preparations). effect sizes indicate these overestimations were medium-tolarge in size (.557 < ds <. 823). in terms of proportional difference, the estimates of concentrated marijuana were the most inaccurate (estimated quantity was 113.2% higher than actual quantity) followed by flower in bowls (estimated quantity was 68.3% higher than actual quantity) and flower in joints (estimated quantity was 37.2% higher than actual quantity). for aim 3, we used spearman’s rank correlations and found that males used significantly more marijuana flower in their preparations than females (ρ= .259), an effect driven by their tendency to prepare larger joints (ρ = .463). individuals who reported being a recreational user only (compared to individuals who endorsed being a medical user, both a recreational and marijuana user, or a cbd only user) used significantly more marijuana flower generally, significantly more flower in a joint, marginally more flower in a bowl, and significantly more concentrate (.348 < ρs < .587). compared to individuals not employed in the cannabis industry, individuals employed in the cannabis industry also used significantly more flower in a joint, in a bowl, and more concentrate (.267 < ρs < .412). for aim 4, we used spearman’s rank correlations and failed to find robust predictors of estimation accuracy. self-reported quantity estimates are inaccurate, which has implications for studying the link between quantity and marijuana use outcomes. introducing the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu) carrie cuttler, alexander spradlin, & protective strategies study team washington state university we created the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu) because the current lack of psychometrically sound inventories for measuring these dimensions of cannabis use has impeded research on the effects of cannabis in humans. in study 1, we recruited a sample of 2,062 cannabis users to assess the dfaq-cu’s factor structure and reliability. to assess validity, a subsample of 645 participants completed additional measures of cannabis dependence and problems. a six-factor structure was revealed, with factors measuring: daily sessions, frequency, age of onset, marijuana quantity, cannabis concentrate quantity, and edibles quantity. the factors were reliable, with cronbach’s alpha coefficients ranging from .69 (daily sessions) to .95 (frequency). results further provided evidence for the factors’ convergent (mshq, tlfb), predictive (cast, cudit-r, cupit), and discriminant validity (audit). in study 2, we recruited 1,976 cannabis users, of which 1,285 completed the dfaq-cu. to assess validity, we included other measures of marijuana use (marijuana use grid [mug]), cannabisrelated problems, symptoms of cannabis use disorder, marijuana use motives, marijuana refusal self-efficacy, and marijuana protective behavioral strategies. supporting its convergent validity, dfaq-cu’s frequency measure was strongly correlated with mug frequency (r = .74) and past month frequency (r = .86); dfaq-cu’s age of onset measure was strongly correlated with an alternative measure of age of first use (r = .82); dfaq-cu’s marijuana quantity measure was most strongly associated with mug quantity (r = .47). among the facets of the dfaq-cu, its frequency measure was most strongly positively associated with cannabis-related problems, symptoms of cannabis use disorder, and marijuana use motives, and most strongly negatively associated with refusal self-efficacy and use of protective behavioral strategies. supporting its discriminant validity, none of the dfaq-cu subscales were significantly correlated conference abstracts 108 with eating disorder behaviors. overall, the dfaq-cu is a psychometrically sound inventory that measures frequency, age of onset, and quantity of cannabis use. it contains pictures of marijuana to facilitate the measurement of quantity of marijuana used, as well as questions to assess the use of different forms of cannabis (e.g., concentrates, edibles), methods of administering cannabis (e.g., joints, hand pipes, vaporizers), and typical thc levels. as such, the dfaq-cu should help facilitate research on frequency, quantity, and age of onset of cannabis use. supplemental materials here examining the role of potency on marijuana use and problems utilizing retrospective self-report and ecological momentary assessment benjamin o. ladd & renee e. magnan washington state university, vancouver tetrahydrocannabinol (thc) potency has increased by as much as tenfold in the past 40 years and with the greater availability of concentrated marijuana products this trend is likely to continue. one perspective is that with increased potency, users may titrate their consumption; on the other hand, increased potency may lead to greater adverse consequences. due to a variety of ethical, legal, and practical reasons, assessment of marijuana use has largely overlooked variability in marijuana potency. the purpose of the current study was to examine relationships among selfreported marijuana use and preferred cannabinoid potency at the aggregate and event levels. recreational marijuana users (n = 94) aged 21 and older were recruited from the community in two bordering states with legal recreational markets. at baseline, participants completed a past-month quantity-frequency measure that included items on typical thc and cannabidiol (cbd) potency. participants then completed a 14day ecological momentary assessment (ema) protocol using their personal smartphone, during which they self-initiated a brief survey after each use episode. results from the baseline assessment suggest that higher thc was associated with greater frequency, r = .32, p < .01, but not quantity of use. cbd levels were not associated with either frequency or quantity. additionally, thc and cbd levels were not significantly correlated. a similar pattern was observed in the ema data. participants reported similar thc levels across the baseline and ema assessments, t(91) = -1.35, p = .18, m = 21.3%, sd = 5.1% and m = 20.6%, sd = 5.2%, respectively. significantly higher baseline cbd levels were reported compared to ema reports, t(91) = -4.41, p < .001, m = 9.1%, sd = 6.5% and m = 6.4%, sd = 3.7%, respectively. baseline thc was not associated with marijuana problem severity. baseline cbd was negatively associated with problem severity, b = -7.57, se = 3.77, p < .05, however this effect became a trend (p = .06) when quantity and frequency of use were also entered into the regression model. when considering the ema data, an opposite effect emerged such that thc was positively predictive of problem severity, b = 9.42, se = 4.36, p < .05, while cbd was not a significant predictor. however, again the effect of thc was reduced (p = .07) when quantity and frequency were included. results suggest that contrary to the titration hypothesis, users selecting higher thc marijuana also report more frequent use. additionally, relationships among consumption variables and marijuana problem severity differed based on the measurement modality. these findings further support the need for greater consideration and refinement of marijuana use measurement. as with other substances, researchers should carefully consider the goals and demands of a given research project when selecting a measurement approach. discussant: matthew r. pearson university of new mexico symposium: examining both sides of the coin: cannabis as treatment target and potential therapeutic agent chair: eric r. pedersen rand corporation cannabis occupies a peculiar space among drugs. by some metrics, it has a lower addictive potential/abuse liability than most other drugs of abuse; however, given higher prevalence rates, cannabis use disorder is more prevalent than any of other illicit drug use disorder. in the united states, use/sale/possession of cannabis is federally conference abstracts 109 illegal and it is listed as a schedule i drug, which indicates that it is without medical value; however, 30 of 50 states permit the use of cannabis for medical purposes. in this symposium, researchers explore the different sides of cannabis in the context of treatment. dr. ozechowski reports the effects of enhanced supervision of functioning family therapy, an evidence-based family-centered intervention, on marijuana-related outcomes among adolescents. in a sample of adolescents with alcohol use disorder (and majority with a cannabis use disorder), dr. kaminer examines how commitment to a harm reduction vs. abstinence goal affects cannabis outcomes. dr. houck observes incidental effects of treatment for alcohol use disorder on cannabis outcomes in patients from project match and combine. dr. sisley reviews the barriers and discusses the implications of such barriers to conducting research examining the therapeutic potential of cannabis. preventing adolescent marijuana use with a family-centered behavioral health intervention: a 12-month follow-up study holly b. waldron, michael s. robbins, timothy ozechowski, hyman hops, charles w. turner, & janet brody oregon research institute background: with an increasing number of us states legalizing adult recreational and/or medical marijuana use, with a concomitant increase in teen use, the need for effective prevention efforts is clear and imperative. most efforts to date have been school-based with mixed results. another potential avenue for marijuana use prevention is via community-based treatment for adolescent mental health problems. the primary aim of the current study was to examine implementation processes associated with functional family therapy (fft), an evidence-based familycentered intervention for youth disruptive behavior, and widely disseminated in community practice settings. a critical feature of efficacious interventions as shown in a number of studies is maintaining fidelity to the program. in research based interventions, fidelity is maintained via observation-based methods, whereas in most community based interventions, supervision is based on the therapists’ self-report, the latter a much less expensive approach. yet, evidence for the clear superiority of the different methods has not been established. we compared observationbased supervision (boost building outcomes with observation-based supervision: an fft effectiveness trial) using session audio recordings uploaded to the supervisor, with the fft dissemination program’s supervision as usual (sau; using self-reports) for youth referred for behavioral health treatment in community practice settings. none of the adolescents was referred specifically for drug-related problems, thus, the rates of drug use were relatively low with a number of non-users (approximately 65%). however, supervisors were knowledgeable in techniques specific to drug treatment. hence, in the context of this study, we examined the extent to which fft, implemented using boost versus sau, would have preventive effects on adolescent substance use over a 1-year period. sample: boost (26 therapists, 105 families) and sau (21 therapists, 59 families) supervision was implemented in eight community mental health settings with fft experienced therapists (77% female). method: participating youth (41% female) had been referred for treatment for diverse problem behaviors (e.g., delinquent and/or disruptive behaviors, depression, noncompliance). families included those with hispanic (62%), african american (19%), non-hispanic white (12%) or other (7%) ethnic/racial origins. therapy sessions were audio-recorded. clinical process variables included treatment fidelity, engagement, and retention. clinical outcomes, including adolescent behavior, family functioning, and substance use, were measured at baseline, 5 months, and 12 months after treatment initiation. results: the boost therapists did not differ significantly from sau therapists in engagement, retention rates, or rated adherence. however, boost adolescents with a prior history of use had significantly lower rates of marijuana use at the 5th and 12th month assessment. moreover, the rates for adolescents in the sau condition continued to increase through the 12-month assessment. in contrast, teens in the boost condition decreased from baseline to the 5-month assessment and maintained these levels through to 12 months. conclusion: the results suggest that enhanced and more expensive therapy supervision of family-based therapy can prevent conference abstracts 110 the normal escalation of marijuana use in highrisk adolescents. moreover, the results also suggest that family-based therapy needs to focus on drug-specific components in order to achieve success. adolescents in treatment for cannabis use: goal commitment predicts outcome yifrah kaminer, christine m. ohannessian, & rebecca h. burke university of connecticut school of medicine objective: commitment to change is an innovative potential mediator and mechanism of behavior change (mobc) that has not been examined in adolescents with cannabis use disorders (cud). the adolescent substance abuse goal commitment (asagc) questionnaire is a reliable and valid 2-scale measure developed to assess the adolescent’s commitment to either abstinence (i.e., recovery model) or harm reduction (hr) model, that in addition to decrease in negative consequences, includes consumption reduction as a stated treatment goal. the objective of this paper is to examine the asagc’s ability to predict treatment outcome of youth with cud. method: during sessions three and nine of a 10-week treatment program, therapists completed the asagc for 170 adolescents 13-18 years of age with alcohol use disorder (aud), the majority of whom (82%) were diagnosed with co-occurring cud. cannabis use during treatment and aftercare was confirmed by drug urinalysis and self-reports until 12-month from study onset. results: results from logistic regression analyses assessing goal commitment at session 3 indicated that both hr and recovery predicted marijuana use at session 3. however, only recovery assessed predicted later marijuana use (assessed at session 9 and during aftercare). when goal commitment at session 9 was examined, only recovery predicted marijuana use, concurrently and longitudinally. these results indicated that adolescents who had higher scores for recovery were less likely to be positive for marijuana use. hr was not a significant predictor for outcome. conclusions: study findings demonstrate that goal commitment consistently predicts cud treatment outcome. hr may not be an attainable goal for youth due to delayed neurodevelopmental processes of inhibitive behaviors. commitment to recovery specifically is a salient predictor for concurrent and future marijuana use. incidental effects of treatment for alcohol use disorder on cannabis use: results from project match and the combine study jon m. houck university of new mexico reciprocal functional interactions between the endogenous cannabinoid and opioid systems are well known. thc can reduce pain perception (vivian et al., 1998), and rhesus monkeys administered thc reduced their selfadministration of heroin (li et al., 2015). consistent with this, recent work in humans found that joint administration of cannabis and low doses of oxycodone produce analgesia similar to that of larger doses of oxycodone alone (cooper et al., 2018). naltrexone is an opioid antagonist that also acts on cannabinoid receptors. in nonhuman primates, acute naltrexone reduces thc self-administration (justinova et al., 2004). in humans, the effects of naltrexone on cannabis use appear to vary with the experience of the individual. in non-cannabis-smokers, acute naltrexone potentiates the effects of low cannabis doses (haney, 2007), while in daily cannabis smokers, maintenance doses of naltrexone are associated with decreased cannabis selfadministration (haney et al., 2015). the combine study was a large multi-site medication (naltrexone, acamprosate) clinical trial for alcohol use disorder that did not exclude participants on the basis of cannabis dependence (anton et al., 2006). combine participants who used cannabis generally had higher alcohol use at the end of treatment did than those who did not use cannabis (subbaraman et al., 2016). however, cannabis users randomized to receive naltrexone and the combined behavioral intervention (cbi) reported end-of-treatment drinking equivalent to those randomized to receive naltrexone who did not use cannabis. the goal of the present study was to text the incidental effects of naltrexone maintenance for alcohol use disorder on selfreported cannabis use in the combine study. data on cannabis use days were obtained from the structured clinical interview for dsm-iv (scidi). naltrexone dose estimates in combine were generated by inspection of used blister packs. 206 conference abstracts 111 participants (19.9% female) reported cannabis use during the 16-week treatment period. cannabis use was significantly lower in the naltrexonetaking groups than in other groups (x2(1)=3.865, p=.049). in a follow-up analysis comparing 85 participants assigned to receive either naltrexone or placebo, negative binomial regression controlling for baseline use indicated that participants randomized to receive naltrexone had significantly fewer cannabis use days during treatment than did those assigned to receive placebo (b=-1.969, p=.043). there was not a significant effect of cbi (b=-.563, p=.078). at the 12-month follow-up, there were no significant effects on cannabis use days. results of the present analysis suggest that in the combine study, naltrexone had incidental effects on participant cannabis use. that is, although combine was not designed to influence cannabis use, participants who used cannabis and took naltrexone had fewer cannabis use days during the treatment period than did those who did not take naltrexone, and participants who took the prescribed dose of naltrexone had fewer cannabis use days than those who did not. after participants stopped taking naltrexone, cannabis use did not differ between groups. although limited data on cannabis use reduce confidence in the study findings, these results suggest that naltrexone should be examined further as a treatment for cannabis use disorder, particularly in populations that also use alcohol. slaying dragons for science--navigating the inexplicable barriers to us marijuana efficacy research suzanne sisley scottsdale research institute this lecture, led by sue sisley, md, will discuss the barriers to cannabis efficacy research and myriad ways us government has systematically impeded this work. we will use our recent battle to implement the veterans research as prime example of this research blockade trying to use medical marijuana to treat patients with treatment-resistant post-traumatic stress disorder (ptsd). copyright: © 2019 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 61 keynote address health effects of cannabis: what we know and what we don’t know r. lorraine collins university at buffalo, state university of new york this keynote address consisted of an overview of current findings about the health effects of cannabis and cannabinoids. currently, 44% of adults self-report lifetime use of cannabis (past month = 8%). those between the ages of 18 and 25 years, report the highest prevalence (53% lifetime, 20% past month). the current patchwork of cannabis policies includes seven states (e.g., wa, co) and dc that allow recreational use of cannabis and 44 states (e.g., fl, ny) and dc that allow some form of medical cannabis. federal statutes state that the use and/or possession of cannabis are not legal. cannabis is a complex plant that contains more than 500 phytochemicals, about 104 of which are cannabinoids. the most commonly studied cannabinoids are δ9 tetrahydrocannabinol (thc, psychoactive) and cannabidiol (cbd). information about the health effects of cannabis was taken from the 2017 report from the national academies of sciences, engineering and medicine, entitled the health effects of cannabis and cannabinoids: current evidence and recommendations for research. i served as a member of the multidisciplinary committee that compiled the report. among its tasks, the committee rated the evidence for different cannabis-related health harms and benefits, based on recent systematic reviews and/or the primary literature. the research evidence was rated as either conclusive (i.e., supportive findings, no credible opposing findings); substantial (supportive findings, but credible opposing findings); moderate (supportive findings, but some limitations); limited (few supportive findings, studies are weak or biased). there was substantial evidence for health harms related to respiratory diseases (e.g., bronchitis), injury and death (e.g., motor vehicle crashes) and prenatal exposure leading to lower birth weight of babies. there was moderate evidence of cannabis being related to impairments in cognition, memory and attention. regarding mental health, there was substantial evidence for cannabis being related to the development of schizophrenia and psychosis. there was moderate evidence for increased risk of other mental health conditions including bipolar disorder, depression, and social anxiety. the report concluded that smoking cannabis was the least effective ways of delivering health benefits because it also delivers other harmful byproducts. there are a range of natural cannabis products (e.g., oral capsules, oils) that are being evaluated. synthetic cannabis/cannabinoid products have existed since 1985. there was substantial evidence for cannabis health benefits for addressing chronic pain, chemotherapy nausea, and spasticity. there was moderate evidence for improving sleep/sleep apnea, fibromyalgia, and multiple sclerosis. there was limited evidence that cannabis was effective for increasing appetite and decreasing weight loss related to hiv/aids and improving symptoms of ptsd. cannabis does not seem to be effective for mental health conditions such as dementia or depression. the committee’s recommendations for research prioritized; 1) clinical and observational studies (shortand long-term effects); 2) health policy and economics research; and 3) public health and public safety. barriers to research include the designation of cannabis as a schedule 1 drug for cannabis 2018, 1 (1), 61-106 © author(s) 2018 researchmj.org open access abstracts from the 2017 scientific meeting of the research society on marijuana july 28th-30th, 2017 fort collins, colorado conference abstracts 62 which researchers require licenses from the dea, fda and nida. rigorous research is needed to continue to build the evidence about cannabisrelated harms, health benefits, prevention and treatment. contact: lorraine collins lcollins@buffalo.edu poster presentations all poster presentations and symposia were peerreviewed by the 2017 conference program committee of the research society on marijuana (rsmj) (chair: bradley t. conner, colorado state university). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. perceived norms moderate the effects of individual differences in sensation-seeking on marijuana use amber m. anthenien, bradley t. conner, clayton neighbors, & marijuana outcomes study team university of houston & colorado state university sensation-seeking has been established as a consistent predictor of marijuana use among college students. two distinct types of sensationseeking include desires for novel, unique, or interesting experiences (experience-seeking) and desires to engage in risky or dangerous activities (risk-seeking). however, some facets of sensationseeking may be more socially motivated or inclined than others and needs for stimulation among those higher in riskand/or experienceseeking may only be expressed through marijuana use if students believe use is uncommon among their peers as higher perceived norms may reduce a given behavior’s novelty and thus its appeal. therefore, the current study aimed to examine perceived norms as moderators of the associations of specific sensation-seeking facets with marijuana use. specifically, we expected that some facets of sensation-seeking would be less strongly associated with use among those who viewed marijuana use as more common. students (n = 7,947) from 11 universities completed an online survey assessing marijuana use. the sensation-seeking personality type scale (sspt), urgency, perseverance, premeditation, and sensation-seeking (upps), and the substance use risk profile scale (surps) captured sensation-seeking. measures of perceived norms and marijuana use included the number of days marijuana was used during a typical week (i.e., frequency). the sample included a large proportion of abstainers; thus, analyses employed a negative binomial hurdle (nbh) model. exploratory factor analysis using a bifactor modeling framework was used to examine factor structure. confirmatory bifactor models were estimated. norms moderated two of the sensationseeking measures such that higher risk and experience-seekers were less likely to use if they thought use was more common. results indicated that among users, norms and risk-seeking were both positively and uniquely associated with rates of use across outcomes. in addition, interactions with both measures of sensation-seeking suggested positive associations of experienceseeking and risk-seeking with rates of use were attenuated when accompanied by perceptions of use as common. notably, interactions were indicated only for models of lifetime use and odds of 30 day use. thus, lower norms may increase marijuana use initiation, but not increases in frequency of use. overall, the pattern of results suggests that non-users perceive use as more common than users, perhaps due to having negative prototypes of users or false uniqueness (i.e., seeing themselves as superior to users). among users, norms were positively associated with rates of use. yet, sensation-seeking tended to be more weakly associated with use when use was perceived as common for specific facets. higher perceived norms for a behavior may reduce its perceived novelty among experience-seekers and perceptions of potential danger among riskseekers. collectively, our findings suggest that 1) sensation-seeking is a multi-faceted construct, and 2) targeting those higher in sensationseeking, globally, may be less fruitful than targeting the facets of sensation-seeking most strongly associated with use. contact: amber anthenien amanthen@central.uh.edu conference abstracts 63 post-traumatic stress and marijuana outcomes: the mediating role of marijuana protective behavioral strategies asia l. ashley, kray scully, mallorie c. carroll, adrian bravo, michael b. madson, & protective strategies team university of southern mississippi & university of new mexico college student marijuana use is on the rise and is currently at an all-time high, with 38% of students reporting annual use and 20% reporting monthly use. this is particularly concerning because increased marijuana use is related to an increase in negative marijuana-related consequences and escalates the risk for developing a cannabis use disorder. according to the american college health association, over 50% of college students report experiencing more than average or tremendous stress. specifically, posttraumatic stress disorder (ptsd) is one mental health problem that exacerbate one’s marijuana use. additionally, there are positive associations between trauma exposure and marijuana use, as well as ptsd symptom severity and cannabis use disorder. because of the harmful nature of these relationships, researchers have begun to examine other variables that may better explain the associations between ptsd and marijuana. protective behavioral strategies (pbs) are behaviors individuals can engage in that reduce substance use and decrease substance userelated negative consequences. recently, researchers found that increased use of marijuana pbs (pbsm) is negatively correlated with frequency of marijuana use and negative marijuana-related consequences. yet this research is in its infancy and further exploration of pbsm and marijuana use is warranted, especially within the context of ptsd. the purpose of the current study was to examine the relationships between ptsd symptoms and marijuana use frequency, marijuana use quantity, marijuana dependence, and negative marijuana-related consequences, and to examine the mediating role of pbsm among college students. college student who consumed marijuana at least one day in the previous month, reported their gender, and completed the posttraumatic stress disorder checklist for dsm5 (pcl-5) participated in this study (n=296). participants completed the protective behavioral strategies for marijuana, a modified daily drinking questionnaire applied to marijuana use, marijuana consequences questionnaire (macq), and the cannabis use disorder identification test-revised. mediation analyses controlling for gender (conducted using the process macro for spss) revealed that pbsm use significantly mediated the associations between ptsd and all four marijuana outcomes, such that ptsd was associated with lower pbsm use (β = -.14), which, in turn, was associated with higher marijuana outcomes (-.36<βs>-.16). these results suggest that students with ptsd symptoms are at greater risk for experiencing marijuana related outcomes when their pbsm use is lower. contact: asia ashley asia.ashley@usm.edu what's in a word? how do emerging adults refer to cannabis intoxication kyle m. bennett & douglas c. smith university of illinois urbana-champaign background: although researchers have investigated what words are commonly used to describe intoxication for alcohol, as well as subjective intoxication levels associated with such words we are unaware of any studies that have done so for marijuana. this study investigates emerging adults’ marijuana-related vocabulary by identifying the most current common terms for cannabis intoxication, perceptions of quantities of marijuana needed to reach such states, and whether individuals meeting diagnostic criteria substance use disorders (sud) possess expanded marijuana-related vocabularies. method: participants (n=468) were recruited for an online survey from amazon mturk after being screened for eligibility (i.e., ages 18-29) using qualification test questions. we eliminated survey responses that were completed in short times and those that missed validity check questions. a majority of the sample was male (58.1%), caucasian (72.7%), enrolled at a four-year college or university or not currently enrolled in any type of school (81.6%), and employed full time (54.1%). the average respondent was 25.4 years of age and earned just over $27,000 in the past year. participants responded to questions regarding what words they may use to describe their feelings after using conference abstracts 64 marijuana (e.g., high, stoned, baked, blazed, wrecked, and blitzed). they likeliness of using each word for describing cannabis intoxication (0 = completely unlikely, 5 = completely likely). similarly, participants rated each word for subjective level of intoxication (0 = not intoxicated, 5 = extremely intoxicated). results: the most common words used to describe cannabis intoxication were high (m=4.61, sd=.75), stoned (m=4.09, sd=1.26), and baked (m=3.11, sd=1.67). blazed (m=2.54, sd=1.76), wrecked (m=1.19, sd=1.49) and blitzed (m=1.03, sd=1.41) were the least common. stoned (m=4.27, sd=.80), baked (m=4.21, sd=.99), and wrecked (m=4.18, sd=1.47) were associated with the highest levels of marijuana use, while blazed (m=4.00, sd=1.27), high (m=3.79, sd=.87), and blitzed (m=3.43, 1.78) were associated with lower levels of use. we found no significant differences between individuals with past year dsm 5 suds (n=105) and those with no diagnoses (n=353) for either likeliness or subjective intoxication ratings. however, subjective intoxication was negatively associated with number of past your dsm 5 symptoms endorsed (r = -.134, p<.01), perhaps indicating that individuals with higher tolerances/more symptoms provide lower ratings. age related differences were found for likeliness ratings on two items (e.g. wrecked, blitzed), with older emerging adults more likely to use such descriptors of cannabis intoxication. conclusions: findings have practical value for designing intervention scripts for on-line marijuana treatment interventions as some words are were more likely to be used to describe the effects of smoking cannabis. contact: kyle m. bennett kmbennet@illinois.edu medical cannabis: the most effective treatment for a range of medical and psychological conditions? julia birenbaum & meghan morean oberlin college background: previous research has shown that medical cannabis (mc) is effective for treating the symptoms of a wide range of conditions including chronic pain, several psychological disorders, appetite/nausea conditions, and numerous neurological conditions (i.e., multiple sclerosis, epilepsy). the current study evaluated mc patients’ lifetime use of eight different treatments that commonly are used to manage the symptoms of a variety of medical and psychological conditions (i.e., mc, prescription medications, therapy/counseling, yoga/meditation, acupuncture, physical therapy, exercise, and change in diet). in addition to assessing which treatments patients had ever tried, we evaluated which treatment each patient found to be the most effective at treating the symptoms of his or her primary condition (i.e., pain, mental health, neurological, appetite/nausea, or sleep disorder). finally, we examined whether treatment preference differed based on primary condition. method: the study sample comprised 373 mc patients (65.1% female, 82.3% white, mean age = 33.0 [10.4] years, duration of mc use = 3.0 [3.4] years) who completed an online survey about mc use. to be eligible for the study, participants had to reside in a state where mc is legal, report current cannabis use, and report having a valid mc “card” that they use to obtain mc. participants reported on the primary condition for which they currently use mc. they subsequently reported whether they had ever tried any of the following eight treatments to manage the symptoms of their primary condition: mc, prescription medication, therapy/counseling, yoga/meditation, acupuncture, physical therapy, exercise, or a change in diet (participants could choose as many treatment options as were applicable). finally, patients indicated which treatment they experienced as most effective at treating the symptoms of their primary condition. in addition to examining descriptive statistics, we ran a χ2 analysis to determine if the treatments identified as most effective by mc patients varied by primary condition. results: patients reported conference abstracts 65 the following primary conditions: pain (53.4%), mental health (33.2%), neurological (3.8%), appetite/nausea (1.3%), and sleep problems (8.3%). on average, participants reported trying 4.43 (1.80) different treatments, and there was no difference in the total number of treatments tried based on primary condition. overall, 80.7% of mc patients reported that mc was the most effective treatment for their primary condition. the χ2 analysis indicated that mc was chosen as the most effective form of treatment irrespective of primary condition (pain: 81.4%; mental health: 78.2%; neurological: 71.4%; appetite: 100%; sleep: 87.1%). conclusions: over 80% of mc patients selected mc as the most effective treatment out of 8 common treatment options that included gold standards like prescription medication and therapy. importantly, mc was chosen as the most effective treatment irrespective of patients’ primary medical condition, indicating that patients find mc effective at treating a diverse range of symptoms. contact: meghan morean meghan.morean@oberlin.edu associations between cannabis use and upps-p impulsive traits by gender brittany e. blanchard, angela k. stevens, & andrew k. littlefield texas tech university substantial evidence suggests that impulsivity is associated with substance-related behaviors, including cannabis use. although impulsivity is a contentiously-debated term in the literature, many researchers agree that impulsive dispositions encompass traits like urgency and lack of premeditation. in light of evidence that impulsivity is a heterogeneous construct comprised of distinct facets, the upps-p impulsive behavior scale is often used to gain a more nuanced understanding of relations between impulsive-like traits and psychopathology, including substance use behaviors. however, less work has focused exclusively on cannabis use among college students when examining traits assessed by the upps-p. thus, the current work used hierarchical linear modeling to examine upps-p impulsivity profile differences between users and non-users of cannabis, and whether these profiles differed across gender. participants consisted of college students, ages 18-25, from a southwestern university (n = 718, 66% female, 69% white, 26% hispanic). past-month (endorsed by 29%) and past-year cannabis use (endorsed by 43%) were assessed using items from the american drug and alcohol survey. cannabis use was dichotomized for each analysis. each uppsp facet score was standardized for ease of interpretation (i.e., m = 0, sd = 1). significant main effects of cannabis use and gender emerged from both analyses, as did significant gender x impulsivity interactions. although no gender x cannabis use or cannabis use x gender x impulsivity interactions were statistically significant, we planned several a priori contrasts to examine upps-p disposition differences between users and non-users of cannabis as a function of gender. contrasts indicated that all five facets significantly distinguished between past-month female users and non-users of cannabis, such that users scored higher (βs = .27 .44, ps < .0001 .05). among males, positive urgency (β = .30, p < .05), lack-of-planning (β = .51, p < .001), and sensation seeking (β = .37, p < .001) were higher among past-month cannabis users versus non-users. all facets of upps-p were significantly higher among male and female pastyear cannabis users compared to non-users (βs = .29 .59, ps < .0001 .01). given that all five upps-p facets significantly distinguished between past-month and past-year female users and non-users of cannabis, the upps-p may have more utility in identifying college student females at risk for cannabis use. however, sensation seeking and lack-of-planning may be important predictors of cannabis use across gender, whereas urgency relations are stronger for negative urgency among females and positive urgency for males. clinically, this suggests that different emotion-regulating motives may be associated with cannabis use as a function of gender. contact: brittany blanchard brittany.blanchard@ttu.edu conference abstracts 66 medical cannabis patients’ preferences for different routes of cannabis administration emma blackman & meghan morean oberlin college background: medical cannabis (mc) effectively treats the symptoms of a wide range of medical and psychological conditions (chronic pain: whiting et al., 2015; ptsd: bonn-miller et al., 2014). currently, patients have many options for how they ingest mc, and recent research indicates that many non-combustible methods of administration (e.g., “edibles”; tinctures; vaping bud/concentrates) may be healthier alternatives to traditional, combustible methods of mc administration. further, research indicates that specific routes/methods of administration may be experienced as more effective for managing the symptoms of certain conditions (e.g., oral cannabis to treat pain stemming from multiple sclerosis; hill, 2015). however, few studies have examined patients’ preferences for using different mc administration methods. thus, we evaluated: 1) what administration methods mc users had ever tried (i.e., oral, tincture, smoked, vaporized concentrate, vaporized bud, raw/juiced cannabis, topical) and 2) what administration method patients experienced as most effective for managing the symptoms of their primary condition (i.e., pain, mental health, neurological, appetite/nausea, insomnia/sleep problems). method: in total, 373 adult mc users who reported residing in a state in which mc is legal and possessing a valid mc “card” completed an online survey. due to small cell sizes, individuals with primary neurological (n = 14) or appetite/nausea (n = 5) conditions were excluded from the analyses. in addition to descriptives, we ran a χ2 analysis to explore whether patients with different primary conditions preferred different routes of mc administration. finally, we assessed how often patients successfully obtained their preferred method of mc administration (5-point scale; never-always). results: the analytic sample comprised 354 mc patients (64.1% female, 82.5% white, 33.02 [10.46] years, duration of mc use 2.91 [3.26] years). on average, patients reported trying 4.14 (sd = 1.82) different mc administration methods, and there were no differences in the total number of methods tried across the primary conditions. patients reported trying and preferring: oral mc (ever tried: 86.2%; preferred: 20.9%), tinctures (37.0%; 3.1%), combustibles (89.8%; 54.8%), vaporized concentrates (67.8%; 11.6%), vaporized dried bud (61.0%; 6.8%), raw/juiced mc (30.8%; 1.7%), and topicals (41.2%; 1.1%). there were no significant differences in preferred administration method by primary condition. most patients (74.5%) reported that they were able to obtain their preferred mc administration method often or always. conclusions: irrespective of primary condition, the majority of mc users reported preferring combustible mc to other routes of administration. thus, individuals with chronic pain, psychopathology, or a sleep disorder were equally likely to prefer combustible mc. these findings run contrary to the notion that non-combustible (and possibly healthier) methods of mc administration are being adopted by individuals with particular medical conditions. with regard to mc access, most users reported being able to obtain mc products aligning with their desired route of mc administration. these findings suggest that patients’ subjective treatment needs (with regard to mc administration method) largely are being met. future research should explore why combustible mc continues to be the administration method of choice for treating a wide range of conditions despite the availability of potentially healthier routes of administration. contact: meghan morean meghan.morean@oberlin.edu regulatory focus and hazardous marijuana use mallorie c. carroll, kray scully, & michael b. madson university of southern mississippi marijuana use among college students is at an alltime high, with roughly 38% reporting annual use and 20% reporting monthly use. this trend is particularly concerning, given that increased cannabis use is associated with greater marijuana-related negative consequences. given the volume of use, the frequency of negative consequences, and the expectation that consumption will likely increase as more states legalize recreational use, it behooves researchers to improve our understanding regarding factors that impact, maintain, and influence the use of marijuana and the related negative consequences. conference abstracts 67 self-regulation is one factor that has recently been examined in the context of marijuana use. specifically, dvorak and day (2014) found that greater behavioral self-regulation characteristics (e.g., self-control, sensation-seeking) significantly predicted less marijuana consumption. additionally, authors found that emotional selfregulation characteristics (e.g., affect, distress tolerance) significantly predicted marijuanarelated consequences, but the directionality depended upon the type of emotional regulation. these results suggest that self-regulation may play an important role in one's marijuana use and experience of consequences. one relatively unexplored dimension of self-regulation that may also be related to marijuana use is regulatory focus. regulatory focus theory posits that individuals regulate behaviors through two types of motivational systems: promotion and prevention. while a promotion focus is concerned with more risk-taking to obtain pleasure and positive outcomes and seeing goals as opportunities or advancement, a prevention focus is associated with avoiding discomfort, preventing negative outcomes and seeing goals as meeting responsibilities and staying safe. although regulatory focus theory has never been examined with marijuana use, previous research has found promotion regulation focus to significantly moderate the relationship between parenting style and drinking behaviors. given the recently discovered link between promotion regulatory focus and other substance use behaviors, more exploration of the associations among marijuana and regulatory foci is warranted. the purpose of the current study was to examine the relationships of promotion and prevention selfregulation with marijuana use, particularly hazardous marijuana use. hazardous marijuana use is measured by the cannabis use disorder identification test (cudit), which accounts for both excessive cannabis use and marijuanarelated consequences. we expected that greater endorsement of promotion and prevention selfregulatory focus would predict less hazardous marijuana use. a sample of 100 college students (m=20.21; sd=1.49) that reported marijuana use at a mid-sized, southeastern university completed the regulatory focus questionnaire (rfq) and the cudit. multiple regression analysis indicated that a promotion-oriented regulatory focus significantly predicted cudit scores [β= .229; t (2, 83) = -2.17; p< .05], such that lower promotion self-regulation predicted more hazardous marijuana use. this suggests that individuals who report less regulation aimed obtaining positive outcomes are more likely engage in hazardous marijuana use. preventionoriented regulatory focus did not significantly predict cudit scores. implications, limitations, and future research directions will be discussed. contact: mallorie carroll mallorie.carroll@usm.edu examining the non-linear relationship between conformity motives and marijuana use renee m. cloutier, nathan kearns, brittney jackson, michelle fresnedo, alisa payne, & heidemarie blumenthal university of north texas marijuana is one of the most widely used substances in the us, particularly among emerging adult college students. understanding motives for marijuana use is an important step towards developing tailored interventions. although findings have varied considerably across studies as to whether a single motive is most strongly associated with problems (e.g., coping, social/enhancement), many have evidenced positive associations between frequency of use and marijuana-related problems. the exception is conformity motives, which are often unrelated, or negatively related, to both marijuana use frequency and related problems. it is possible that individuals who use marijuana regularly across several contexts simply endorse more motives overall. however, it is important to note that conformity motives were initially hypothesized to be salient in the earlier stages of marijuana use, before other motives have been internalized. the inconsistent findings between conformity motives and marijuana use frequency may be a consequence of their non-linear relationship. the present study compared nonlinear and linear regression models of marijuana motives and use frequency. coping, enhancement, and social motives were expected to have positive linear relationships with marijuana use history. in contrast, conformity motives were expected to evidence an inverted ‘v’ shape: individuals reporting moderate marijuana use would endorse the greatest mean level of conference abstracts 68 conformity motives compared to both experimental/light users (e.g., 1-2 uses) who use more out of curiosity, and heavy users who may have already internalized other motives (e.g., coping, enhancement). each motive was regressed on lifetime, past year, and 30-day marijuana use frequency using both linear and spline regression, then compared for model fit. the sample included 145 emerging adults (18-25 years) enrolled in a public university. all participants endorsed lifetime marijuana use on an online questionnaire (drawn from monitoring the future survey, 2016) and completed the fourfactor marijuana motives questionnaire, where scores on each motive ranged from 5-25. as expected, conformity motives were predicted best with non-linear spline regressions (r2 = 7.6% 17.8%) than linear regressions (r2 = 0.1% 2%). of note, the location of the ‘peak’ before the positive slope declined occurred at lower use frequency levels when participants were asked about more recent time frames. specifically, when asked about lifetime use, frequency of use positively predicted conformity motives until 2039 times (conformity m = 10.00) before declining at 40+ uses (conformity m= 6.89); for past year and 30-day frequency the positive slopes peaked at 10-19 uses (conformity m=9.41) and 3-5 uses (m=9.55), respectively. in contrast, use frequency best predicted coping (r2 = 22-27%), social (r2 = 20-26%), and enhancement (r2 = 16-31%) motives with positive linear regressions. findings support the idea that generally more frequent use leads to greater internalization of motives – a key exception is conformity motives which decline at higher use rates and are replaced by other motives. contact: renee cloutier reneecloutier@my.unt.edu marijuana use in the context of risk seeking, experience seeking, and fun seeking marielle l. darwin, joey k. smith, & bradley t. conner colorado state university the constituents of the behavioral approach system (bas) and sensation seeking are implicated in the pursuit of rewarding, novel or risky experiences. while both bas and sensation seeking are associated with marijuana use, the relation between the three elements has yet to be explored. the current study aimed to identify the facets of sensation seeking that are most related to marijuana use, as well as explore the mediating role of bas in this relation. mediation analyses indicate that the fun seeking component of bas plays a crucial role in both the initial decision to use marijuana and the age of first use in conjunction with high experience seeking behavior. conversely, fun seeking partially contributes to the initial decision to use marijuana but has no significant relation to age of first use in respect to risk seeking behavior. results indicate that separate aspects of sensation seeking offer a more comprehensive narrative than the construct as a whole in relation to marijuana use. contact: marielle darwin marielle.darwin@colostate.edu supplemental materials here spatial distribution of cannabinoids, terpenes and other significant molecules within agricultural cannabis products: basic analytical science and its practical implications joseph a. diverdi colorado state university, xtr systems, llc & xtr laboratories cannabis is grown in predominantly a single form commonly referred to as “leaf”, “flower”, “bud” and a number of other even more colloquial names while it is significantly modified into a wide ranging number of different forms for trade and for eventual consumption. the tracing and tracking of the several significant classes of molecules (analytic chemistry) through this product chain is an extremely important activity that provides key information to scientific https://publications.sciences.ucf.edu/cannabis/files/rsmj2017darwin.pdf conference abstracts 69 investigators, product formulators, customers and consumers without which informed decisions by any of these parties are impossible. one particular recurring problem is the apparent variation in multiple measurements by either the same or several different laboratories on what is purportedly the same analytic sample. a priori expectations that the raw agricultural materials are intrinsically inhomogeneous drive analysts to utilize larger and larger samples and mechanically homogenize them to draw from and examine. other problems reside in use of headspace methods in these analyses that are intended to reduce instrument maintenance and have the coincident tendency to increase the complexity of the physical system being studied and providing additional confounding results. this work will report results of the application of analytic methods to map the concentration of several molecule classes (cannabinoids, terpenes, waxes, etc.) in the raw agricultural flower or bud with an eye towards addressing significant recurring questions, including those identified above, that arise in the execution of legally and common sensibly required analysis and reporting. contact: joseph diverdi joseph.diverdi@colostate.edu “i use marijuana to sleep”: relations to frequency, problematic use, & sleep problems in young adults tess k. drazdowski university of california, los angeles marijuana is a popular substance used among young adults with one in five reporting current use nationally and across college campuses. anecdotally and in emerging research, people report using marijuana to help with sleep and certain strains are marketed as sleep aids (e.g., “tahoe og kush”). in the united states more than a third of the adult population report not getting enough sleep, with estimated economic costs of $411 billion annually. prescription drugs are avoided because they are less effective over time and have unwanted side effects. however, people looking to use marijuana as a sleep aid contradicts research that using marijuana results in more sleep disturbances and reducing marijuana use improves sleep. while some work has looked at how sleep disturbances affect individuals’ abilities to reduce their use, there is a dearth of research in this area. further, gender differences are important to consider. the present study addresses current research gaps by investigating sleep as a motivation for marijuana use in a diverse sub-sample of 354 young adult college students (68% female; 57% white, 18% black, 25% other) at a southeastern university who reported using marijuana in the past year (42% of the total sample). there were no recreational, medical, or decriminalization marijuana laws at the time of data collection. the 4-point likert item, “i use marijuana to sleep,” was added to the marijuana motives measure to capture this phenomenon. participants also selfreported through an online survey their frequency of use in the past year and 30 days, problematic use, and sleep problems. t-tests revealed that men reported more frequent marijuana use and problematic use in the past 30 days and past year (ts=4.24-4.30, ps<.001; ts=2.47-3.19, ps=.002-.014, respectively), and had less sleep disturbances (t=3.45, p=.001) as compared to women. however, there were no gender differences in using marijuana to sleep, total sleep problems, sleep latency, daytime dysfunction, sleep quality, needing medications to sleep, and sleep efficiency. almost half of the sample (44%) reported being motivated to use marijuana to sleep at least some of the time. using marijuana to sleep significantly predicted frequency of use and problematic use and accounted for 13-29% of the variance in the regression models. further, using marijuana to sleep predicted total sleep problems and most sleep problem subscales, though it accounted for less of the variance comparatively (1-6%). interestingly, total sleep problems did not predict frequency or problematic use. gender was only found to moderate the relations between using marijuana to sleep and problematic use in the past year (β=-.23, t=-2.10, p=.007) and past 30 days (β = -.16, t = -2.30, p = .022), with men reporting using marijuana to sleep more as use increased, compared to women. this study highlights the importance of investigating the perceptions and relations between marijuana and sleep in young adult populations. future work needs to investigate the generalizability of the findings, use objective measures of sleep problems, use longitudinal designs, and get more detailed information about the strains and conference abstracts 70 method of marijuana ingestion being used for sleep. contact: tess k. drazdowski tkdrazdowski@ucla.edu correlates and trajectories of cannabis withdrawal in adolescence jarrod m. ellingson, l. cinnamon bidwell, kent e. hutchison, & angela d. bryan university of colorado, boulder cannabis withdrawal is frequently reported for adolescents via clinical anecdote, but the validity of these reports and the vulnerability of adolescents to cannabis withdrawal is unclear. the present study investigated the correlates and trajectories of cannabis withdrawal in a high-risk sample of adolescence. 706 adolescents had participated in a treatment study of brief interventions for risky sexual behavior and substance use (ages 14-18, predominantly hispanic). substance use and withdrawal were assessed at baseline, prior to the intervention, and again 3, 6, 9, and 12 months following baseline. latent profile analyses were conducted to distinguish profiles of change on substance use and withdrawal. for cannabis withdrawal, four latent profiles were identified, corresponding to absent (n = 359), mild (n = 241), moderate (n = 76), and severe withdrawal (n = 30). unexpectedly, there was almost no change in cannabis withdrawal for each profile. that is, trajectories for the four groups were parallel during the study. in contrast, all four groups demonstrated markedly decreased frequency of cannabis use following baseline, suggesting weak associations between cannabis use and withdrawal. indeed, there was a moderate correlation at baseline (.32) and weak correlations at subsequent assessments (r's < .22). a similar pattern was found for alcohol withdrawal and alcohol use. unexpectedly, there were strong correlations between cannabis withdrawal and alcohol withdrawal at each assessment (r's = .40 .55). subsequently, regression models were conducted to assess other characteristics of cannabis withdrawal. cannabis withdrawal was associated with polysubstance use (number of other illicit substances used) and emotional lability (anger). in summary, findings suggest that cannabis withdrawal is only weakly associated with severity of cannabis use, with stronger associations with alcohol withdrawal, polysubstance use, and emotional lability. future research should investigate whether clinicaland self-reports of cannabis withdrawal are more indicative of emotional lability or a general propensity toward coping motives in adolescence. further, fine-grained data regarding use, such as dosage and mode of administration, may be important for understanding cannabis withdrawal in adolescence. contact: jarrod ellingson jarrod.ellingson@colorado.edu search for meaning in life and difficulty with impulse control on marijuana use cara fresquez & mark a. prince colorado state university with the recent change of legalization of medical and recreational marijuana in certain states, attitudes about marijuana have also begun to change. one of the gaps in the research on marijuana surrounds the interplay of existential (i.e., meaning in life) and personality constructs (e.g., impulsivity) and their influence on marijuana use. search for meaning is often emerges from an event that caused stress to the individual. however, search for meaning, extends beyond coping with meaninglessness. search for meaning is a psychological factor with individual differences that occurs in the absence of life events. moreover, difficulty with impulse control is a facet of emotion regulation, characterized by the absence of the ability to regulate one’s emotions. for the purposes of this study marijuana use was determined by an individual’s reported use over the previous 30 days. the current study set out to examine the relation among search for meaning in life, difficulty with impulse control, and marijuana use. we hypothesized that individuals who are searching for meaning, and lack impulse control, would use marijuana more frequently than individuals searching for meaning with strong impulse control. the current study is a secondary data analysis of data that was collected in fall 2016 as a part of a larger study on health risk behaviors. data were analyzed using a negative binomial hurdle model. hurdle models have two parts, a logistic regression examining likelihood of using marijuana in the past 30 days, and a count conference abstracts 71 regression assessing if they used, how much. an interaction between search for meaning and impulsivity and entered in the model as a predictor of marijuana use. there were no significant main effects or interactions in the count portion of the model. however, the prediction of any marijuana use produced two significant main effects. there was a positive relationship between likelihood of marijuana use and impulsivity for participants who were one standard deviation below the mean on search for meaning. in contrast, there was a negative relationship between likelihood of marijuana use and impulsivity for participants who were one standard deviation above the mean on search for meaning. these results suggest that meaning in life moderates the relation between impulsivity and marijuana use. specifically, the present study indicates that search for meaning in life, may act as a protective factor for impulsive individuals. the results of this have clinical utility in the role meaning in life plays in the relation between difficulty with impulse control and marijuana use. individuals high in difficulty with impulse control, may benefit from interventions promoting search for meaning in life, to regulate their marijuana use. contact: cara fresquez clfres17@rams.colostate.edu supplemental materials here biomarker discovery for marijuana use utilizing modified aptamer and metabolomic panels christian hopfer, kristen raymond, laura saba, jost klawitter, & uwe christian university of colorado, denver aims: peripheral biomarker discovery of marijuana use. method: eight discordant and four concordant marijuana using twin pairs were queried about their marijuana use. participants completed a blood draw, urine toxicology testing, as well as questions about past 30 day substance use. 1310 modified aptamers (somascan) and 258 metabolomic markers were examined for association with marijuana use. results: the 24 subjects were all non-hispanic whites. 66% were female. median age was 30. marijuana using subjects reported using marijuana 23.4 out of the past 30 days; mean urine thc level were 688ng/ml. subjects who did not endorse regular marijuana use reported 0.125 days of use in the past 30 days and had undetectable thc levels. for the somascan analysis, we used a linear mixed model that accounted for differences in relatedness between monozygotic and dizygotic twins to identify proteins with quantitative levels that differed between marijuana users and nonusers. the most significant protein, neurexin-1beta (nrx1b; p<0.001), was more abundant in marijuana users than non-users. neurexin 1 has been implicated in several neurological disorders including addiction. using functional enrichment, we identified several kegg pathways associated with marijuana use including pathways related to the proteasome, cell adhesion molecules, olfactory/taste transduction, and morphine addiction. metabolomic analyses utilized partial least squares-discriminant analysis (pls-da) showed a clear clustering of controls versus thc groups. the major contributing compounds were maleic acid and d-gluconate and other compounds. a correlation analysis revealed that, 4-aminobutyrate (gaba) and glutathione showed the highest correlation (pearson) with thc levels. conclusions this pilot study demonstrated the feasibility of utilizing joint proteomic and metabolomics analysis for marijuana biomarker discovery and identified biomarkers that distinguished marijuana users from non-users. grants: k24da032555; da035804, ag046938. contact: christian hopfer christian.hopfer@ucdenver.edu when clients tell you what they want to change, believe them: substance-specific effects of speech jon m. houck, brigitte r. stevens, & lauren n. rowell university of new mexico the technical hypothesis of motivational interviewing (mi) posits that within-session client change talk (i.e., client statements favoring healthier behavior) mediates the relationship between clinician language and intervention outcomes. while there is empirical support for this hypothesis, recent work has suggested that client sustain talk (i.e., statements favoring the status quo) is more important. however, these effects have been observed only among https://publications.sciences.ucf.edu/cannabis/files/rsmj2017fresquez.pdf conference abstracts 72 participants mandated to treatment, who may not express the ambivalence about substance use typical of treatment-seeking participants. it is challenging to directly compare the speech of treatment-seeking and non-treatment-seeking participants, as they differ in important ways. however, polysubstance use involving both alcohol and cannabis is common, making it possible to study participants who use multiple substances but are only seeking treatment for one of them. the goal of the present study, then, was to evaluate client speech about cannabis separately from client speech about alcohol in a sample of participants from project match, and to evaluate the relationships between speech and outcomes separately for alcohol and cannabis use. a sample of mi/met sessions from 85 participants (70.2% male, m age=33.1, sd=7.7 years) were rated using the misc 2.5 and the cacti coding application, with client speech about alcohol categorized separately from client speech about cannabis. of this sample, 76.2% reported prior cannabis use at baseline, with a mean of 8.68 cannabis use days during the 90-day baseline period. all were seeking treatment for alcohol use and reported recent alcohol use, with a mean of 61.7 (sd 60.5) drinks per week during the baseline period. relationships between speech counts and substance use at the 12-month followup were evaluated using negative binomial regression, covarying for baseline use. sustain talk about cannabis predicted cannabis use (b=0.908, p=.025), and change talk about alcohol predicted alcohol use (b=0.019, p=.035). no effects were found relating speech about one substance to use of another substance (all p>.50). in a sample of alcoholand cannabis-using participants seeking treatment for alcohol use but not for cannabis use, we found that client change talk about alcohol predicted reduced alcohol use, while client sustain talk about cannabis predicted ongoing or increased cannabis use. this supports the notion that neither change talk nor sustain talk has any special inherent predictive power; instead, the intervention focus and the client's ambivalence about it are the determining factors. cannabis use was not the focus of project match, and although cannabis use fell during treatment, it increased steadily over the subsequent year of follow-up, and was predicted by cannabis sustain talk. in contrast, alcohol use fell sharply and remained low, and was inversely associated with change talk. these data support the notion that neither aspect of ambivalence (i.e., change talk or sustain talk) is "special"; instead the effects of client speech are substance-specific, and the relationship between speech and substance use will vary depending upon the client's level of ambivalence about the specific substance. contact jon m. houck jhouck@unm.edu treatment outcome for cannabis use disorders in youth referrals from the justice system yifrah kaminer, christine ohannessian, & rebecca burke university of connecticut objective: youth with substance use disorders (sud) referred to treatment from the juvenile justice system (jjs) accounts for approximately half of the treatment admissions nationwide. the objective of this analysis of the results of treatment for cannabis use disorders (cud) study was to compare retention and outcomes of adolescents referred by the jjs to referrals from the general community. method: a total of 172 adolescents, 13-18 years of age, 83% males, 70% jjs referrals, diagnosed with dsm-iv cud, enrolled in this outpatient, randomized, continued care study. following a 7-session weekly motivational enhancement and cognitive behavioral therapy intervention (met/cbt-7) only poor responders (defined as failing to achieve abstinence at week seven for any reason) were randomized into a 10-week second phase of either an individualized enhanced cbt or an adolescent community reinforcement approach (acra) intervention. results: jjs referrals' retention rates were significantly higher than non-jjs referrals retention rate (χ2(1) = 11.21, p < .01) at the end of phase i (i.e., week 7). however, there was no difference in abstinence rates between the groups at the end of phase i, phase ii or any additional follow-up assessment points. conclusion: additional research examining how to capitalize on superior retention rates by activating mediators of change in order to improve abstinence among youth jjs referrals is conference abstracts 73 necessary. supported by grants from nida (1ro1 da 03054-02) & niaaa (1ro1aa 021735-02). contact: yifrah kaminer kaminer@uchc.edu risk seeking moderates the association between emotion dysregulation and marijuana-related consequences shane d. kentopp, nicholas johnson, cara fresquez, mark a. prince, bradley t. conner, & marijuana outcomes study team colorado state university background. understanding contributing factors of problematic consequences associated with marijuana use is critical for the reduction of harm. sensation seeking and emotion dysregulation have been identified as contributing factors, although findings have been mixed. objectives: the study seeks to clarify relations between sensation seeking, emotion dysregulation, and marijuana-related consequences. method: crosssectional data were gathered from 8,141 undergraduates in 11 states from 2015-2016 by the marijuana outcomes study team (most). marijuana users (n=2,128) were assessed for sensation seeking (sensation seeking personality type questionnaire), emotion dysregulation (difficulties in emotion regulation scale), and marijuana-related consequences (marijuana consequences questionnaire). data were analyzed using negative binomial regression within a structural equation model. results: results revealed a significant positive association between risk seeking (a facet of sensation seeking) and marijuana-related consequences, as well as between emotion dysregulation and marijuanarelated consequences. a significant negative association was observed between experience seeking (another facet of sensation seeking) and marijuana-related consequences. a significant interaction was found between emotion dysregulation and risk seeking, but not experience seeking. conclusions: whereas risk seeking appears to be a risk factor for marijuanarelated consequences, this was only true at lower levels of emotion dysregulation. at high levels, the effect of emotion regulation superseded that of risk seeking. these findings have implications for the prioritization of clinical concerns in individuals seeking treatment for problematic marijuana use. contact: shane kentopp shane.kentopp@colostate.edu identifying the scientific and clinical training practices of cannabis dispensaries dustin kieschnick, kayla jimenez, shelby scott, james sottile, robin brody, rebecca rothberg, kimberly babson, marcel o. bonn-miller, & nancy a. haug palo alto university, va palo alto healthcare system, university of pennsylvania, & stanford university school of medicine with the proliferation of medical and recreational cannabis dispensaries due to state legalization efforts, little is known about dispensary operating procedures and training practices for staff. in our previous work, we identified that dispensary workers have minimal medical and scientific background. the current study expands upon that research through a qualitative examination of scientific and clinical training for medical cannabis employees. semi-structured qualitative interviews were conducted with dispensary workers (n=8) from four states (az, ca, co, dc) to better understand the nature of their training and the factors involved in making recommendations to patients. interview transcriptions were coded in nvivo for mac (version 11) by two independent raters (d.k. and k.j.) and evaluated by a third rater (s.s.) using an iterative process. themes were identified from interview content using a grounded theory approach. participants described several training methods that varied widely across dispensaries: on-site, online/webinars, onboarding and ongoing (e.g., new products, delivery methods). notably, training may be informal, and include content such as reading materials from supervisor or other staff, state-mandated information, policy manuals and budtender certification programs. dispensary staff highlighted several barriers to consistent training, such as time, cost, high employee turnover, education, stigma, understaffing, changing regulations and administrative approval. a prominent theme emerged around the role and identity of dispensary staff workers. roles included being a “budtender” or customer service specialist on the conference abstracts 74 front line dispensing cannabis to patients, an expert on various aspects of cannabis (e.g., delivery methods, products, dosing), and a business-oriented function, which involves increasing sales and reducing inventory. consistent with a non-medical identity, staff typically reported they did not screen patients for history of psychiatric disorders or addiction; nor did they assess current medication regimens. in conclusion, there is significant variation in training protocols across dispensaries and major obstacles to implementation. dispensary practices are complicated by competing priorities of the cannabis industry. there is confusion among dispensary workers about what their role entails, particularly between providing product recommendations and medical advice. this research provides valuable information to inform the development of a standardized scientific and clinical training protocol for dispensaries to implement in the comprehensive education of cannabis dispensary workers. contact: nancy haug nhaug@paloaltou.edu effectiveness of brief interventions targeting marijuana outcomes among mandated college students tess kilwein, luci dumas, monica keele, michaela tratos, & greg sandman university of wyoming unlike alcohol use, little research has examined the effectiveness of prevention and intervention strategies focused on reducing marijuana (mj) use and related consequences among college students. as a result, substance use education programs on campuses that are tasked with providing education and brief interventions for mj to students are often required to develop their own intervention strategies. the current study aimed to examine the effectiveness of two brief mj interventions adapted from already effective alcohol interventions on various mj outcomes. participants were 165 predominantly male (80%) students from a western university ranging in age from 18 to 53 (m=20.10, sd=3.94). a majority of students were freshman (57%), with all students having been cited for a mj violation in the past 4 academic years. participants completed an intake session with a peer educator and baseline measures of past-month mj use, including: the number of times they used mj (frequency), the number of days they used mj (days), the amount of money spent on mj, consequences experienced from mj (consequences), readiness to change mj use, hours spent under the influence of mj (hours), and risk for a cannabis use disorder. next, participants were assigned to one of two interventions based on severity of their mj use: 1) marijuana education seminar (mes; a one-time group education session for students with less severe mj use history); or 2) a modified version of brief alcohol screening and intervention for college students (basics; 2-3 individual sessions of an alcohol intervention adapted for mj use for students with more severe mj use history). outcomes were again assessed 30-days and 60days post-intervention via online survey. multivariate tests revealed a significant main effect of time (f(2,192)=2.08, p=.037, η2=0.43), with significant changes in past-month frequency (f(2,102)=4.32, p=.033, η2=0.8), days (f(2,102)=8.52, p=.001, η2=0.14), and hours (f(2,102)=3.48, p=.048, η2=0.06) over time. specifically, participants reduced their frequency of mj use from baseline to 60-day follow-up (p=.020), reduced their days of mj use from baseline to 30(p=.013) and 60-day follow-up (p=.001), and reduced their hours spent under the influence of mj from baseline to 60-day follow-up (p=.002). in addition, there was a significant main effect of intervention (f(1,45)=2.23, p=.049, η2=0.26), with significant differences in pastmonth days (f(1,51)=5.16, p=.027, η2=.09), cudit (f(1,51)=5.95, p=.018, η2=.10), consequences (f(1,51)=4.61, p=.037, η2=.08), and hours (f(1,51)=11.16, p=.002, η2=.18) between groups. specifically, participants assigned to basics had significantly higher scores than participants assigned to mes on these outcome measures, which is expected given that participants were assigned based on severity of mj use. finally, there was no significant interaction between time and intervention type (f(1,192)=1.49, p=.162, η2=.36). findings from this study can be utilized to inform current substance use education programs on college campuses about the potential effectiveness and limitations of alcohol interventions adapted for mj use. in addition, this study highlights the need for further research in the area of developing conference abstracts 75 evidence-based interventions for mj use on campuses, as well as standardized measures of mj use similar to the “standard drink”. contact: tess kilwein tkilwein@uwyo.edu supplemental materials here relationships among marijuana frequency, quantity, and potency using based on retrospective self-report and ecological momentary assessment benjamin o. ladd & renee e. magnan washington state university, vancouver national trends suggest that perceived risk of marijuana is declining while the prevalence of use is increasing. additionally, the prevalence of cannabis use disorders among users has decreased, while the majority of users do not appear to experience significant problems. given unique considerations of marijuana as a psychoactive substance, greater precision of measurement of consumption is needed. in terms of its psychoactive effects, there is considerable variability in potency based on two main chemical agents, tetrahydrocannabinol (thc) and cannabidiol (cbd). the purpose of the current study was to examine relationships among frequency, quantity, and preferred potency of marijuana use. as part of an ongoing study, regular marijuana users over the age of 21 were recruited from the community (n = 102) in two states with legalized recreational marijuana. at baseline, participants completed a battery of selfreport measures, including a 30-day timeline followback interview. participants then completed a 14-day ecological momentary assessment (ema) protocol using their personal smartphone, providing real-time assessment of marijuana use events. for both assessments, four consumption measures were computed: frequency, quantity, thc potency, and cbd potency. during the baseline assessment, participants completed the marijuana dependence scale (mds) which yielded a score indicating level of marijuana-related risk. retrospective self-report frequency was positively associated with quantity, r = .30, p < .01, and thc potency, r = .27, p < .01. no significant associations between quantity and potency were observed. a significant association between frequency and thc potency also emerged using aggregated ema data, r = .26, p < .01. frequency and quantity of use were associated across the retrospective and ema measures, r = .34, p = .001 and r = .51, p < .001, respectively. thc and cbd potency also were associated across measures, r = .38, p < .001 and r = .44, p < .001, respectively. when the four retrospective consumption variables were entered simultaneously as predictors of mds score, the model was not significant. the regression model with the four ema consumption variables as predictors was significant, r2 = .11, f(4, 95) = 2.85, p < .05. the simple effects of quantity, β = .21, p < .05, and thc potency, β = .25, p < .05, were significant. thus, individuals using more marijuana per use event and those selecting marijuana with higher thc levels reported greater marijuana-related risk. the current research suggests that not all marijuana use measures are equivalent and researchers should make careful consideration of measurement strategies based on their research goals. further research examining important components of marijuana use may facilitate better understanding of risk levels based on preferred consumption and dosage patterns. contact: benjamin ladd benjamin.ladd@wsu.edu supplemental materials here daily use as a predictor of marijuana use outcomes in two legal recreational states clara r. lewis, renee e. magnan, & benjamin o. ladd washington state university, vancouver introduction: to laypeople and clinicians alike, use frequency is an important factor when considering substance use risk. daily use is relatively easy to determine and may be a potentially meaningful risk indicator; however, it is unknown whether daily marijuana (mj) use is associated with mj-related outcomes. the present investigation examined whether daily users differed from less frequent users in terms of various mj outcomes. we hypothesized that daily users would report greater dependency, use motives, craving, quantity, and potency. method: a community-recruited sample (n = 102; mage = 35.7 [sd = 11.1] years; 55.4% female; 83.3% white) of recreational and medical users from two https://publications.sciences.ucf.edu/cannabis/files/rsmj2017kilwein.pdf https://publications.sciences.ucf.edu/cannabis/files/rsmj2017ladd.pdf conference abstracts 76 states with legal recreational markets completed a battery of self-report measures. frequency and quantity measures were collected using a 30-day timeline followback interview. the marijuana dependence scale (mds) was used to establish dependence risk. mj motives and craving were assessed using the marijuana motives measure (mmm) and marijuana craving questionnaire (mcq), respectively. participants indicated mj potency via single items indicating percent tetrahydrocannabinol (thc) and cannabidiol (cbd) of their preferred marijuana strain. a dichotomous use frequency variable was created; participants reporting use for the past 30 consecutive days were categorized as daily users, and participants reporting abstaining on any of the past 30 days were categorized as non-daily users. for relevant variables, outliers were winsorized to address violations of normality. results: in the current sample of 102 participants, approximately half reported daily mj use (n = 52). daily users were significantly more likely to be male, χ2(1) = 7.49, p < .01. independent samples ttests revealed no significant differences between daily and non-daily users on mmm scales, mcq scales, mds score, or thc and cbd potency. of note, mcq-purpose, t(100) = -1.74, p = .09, and mcq-compulsivity, t(100) = -1.96, p = .05, demonstrated nonsignificant trends such that daily users reported greater cravings than nondaily users. significant group differences were found for average mj quantity, t(100) = -3.46, p < .001 and for total mj quantity, t(100) = -4.03, p < .001. conclusions: in this sample, daily users demonstrated significantly higher average quantity of use than non-daily users, suggesting that the difference in overall consumption may be even greater than frequency alone would suggest. however, no significant differences were found between daily and non-daily users on other measures of mj outcomes, suggesting that daily use alone may not be a useful indicator of mj risk level among current users. establishing relatively simple risk indicator variables is important for clinical and research screening purposes. while the current study did not find many differences between daily and non-daily mj users, continuous measures of frequency may yield different results. additionally, future research should examine whether different frequency cutoffs (e.g. weekly vs. non-weekly, daily vs. weekly vs. monthly) are associated with mj-related risk. contact: clara lewis clara.lewis@wsu.edu supplemental materials here medical cannabis patients’ perceptions of cannabisand alcohol-induced driving impairment noah lipshie & meghan morean oberlin college background. research indicates that both adult and adolescent recreational cannabis users perceive cannabis as less impairing than alcohol in terms of operating a motor vehicle. however, it is unclear whether medical cannabis (mc) patients share similar risk perceptions. in the current study, mc patients reported on how impairing they perceive mc to be on their own driving ability and on other’s driving ability. they also reported on perceptions of alcohol-induced driving impairment. finally, we examined whether patients’ perceptions of mc-related risk to their own driving was associated with the frequency of driving after mc use. method. participants included 373 mc patients from 19 mc states who completed an online survey (65.1% female; 82.3% white; mean age 33.0 [sd = 10.4] years). a series of paired-samples t-tests was run to compare the following risk perceptions: 1. mc [own driving] versus mc [others’ driving]; 2. alcohol [own driving] versus alcohol [others’ driving]; 3. mc [own driving] versus alcohol [own driving]; 4. mc [others’ driving] versus alcohol [others’ driving]. a univariate glm model subsequently was run to determine whether mc risk perceptions were associated with driving after mc use. model covariates included sex, race, age, and duration of mc use. results. mc patients believed that mc or alcohol use would produce less impairment in their own driving compared to others’ driving: mc (own driving: m = 2.54, sd = 1.32) vs. mc (others’ driving: m = 2.86, sd = 1.24, t(372) = -6.83, p=.001); alcohol (own driving: m = 4.36, sd = 0.99) vs. alcohol (others’ driving: m = 4.48, sd = 0.90, t(372) = -4.33, p < .001). however, mc patients reported that, compared to alcohol, mc use would produce less driving impairment irrespective of who was driving: mc (own driving: m = 2.54, sd = 1.32) vs. alcohol (own driving: m = https://publications.sciences.ucf.edu/cannabis/files/rsmj2017lewis.pdf conference abstracts 77 4.36, sd = 0.99, t(372) = -23.87, p < .001); mc (others’ driving: m = 2.86, sd = 1.24) vs. alcohol (others’ driving: m = 4.48, sd = 0.90, t(372) = 23.25, p < .001). the univariate glm model accounted for 8.5% of the variance in driving after using mc. neither sex, age, nor race were associated with driving after using mc. however, using mc for a longer duration (p 2 = 0.02, p = .02) and perceiving mc to confer lower driving-related risk (p 2 = 0.06, p < .001) were associated with more frequent driving after using mc. conclusions. the current study suggests that mc users perceive similar driving risk associated with cannabis use as do recreational cannabis users. consistent with prior research, mc users perceived mc to impair their own ability to drive less than others’ ability to drive. of note, mc patients universally perceived mc as less impairing than alcohol use. importantly, risk perceptions were linked to driving behavior such that mc patients who perceived mc to be less impairing to their own driving were more likely to report driving after using mc. contact: noah lipshie nlipshie@oberlin.edu one-year trajectory of marijuana use in a college student sample: sensation seeking and impulsivity as risk predicators sha liu, ryan rahm-knigge, mark a. prince, & bradley t. conner south china normal university & colorado state university introduction: though marijuana use among u.s. college students has received substantial attention in the past decades, research on patterns of marijuana use has tended to focus on average use in the population, which obscures individual heterogeneity in marijuana use over time. the current study sought to use personcentered approach to identify subpopulations of marijuana users in a large college students sample. furthermore, the current study aimed to detect the most salient factors of risky personalities such as sensation seeking and impulsivity that distinguished different subpopulations of marijuana users. method: a sample of 1401 college students was recruited (mean age=19.73, sd=2.12, 48% male), participants were asked to report their marijuana use in the past 12 months, 6 months and past month. with risky personalities were examined as predictors of the latent class of marijuana use, a three-step approach was used instead of the conventional way of combining the latent class and regression model into a joint model, which has several drawbacks. in this approach, latent class analysis is utilized in the first step to identify latent groups of marijuana users, based on the fit indices of bic, entropy and lmr-p value. the mostly likely class variable is obtained in the second step and is regressed on predictor variables in the third step with the misclassification taken into account. results: lpa yielded a three-class solution. class 1 comprised 55% of the sample, youth in this class had significantly lower levels of marijuana use in past year, past six months and last month compared to class 2 and class 3. class 2 comprised 35% of the sample, the level of marijuana use in past year, past six months and last month were intermediate to those of class 1 and class 3. class 3 comprised 10% of the sample, youth in which evidenced higher level of marijuana use in past year, past six months and last month compared to class 1 and class 2. youth in class 1 had significantly older onset age of marijuana use and lower level of risk seeking compared to those of class 2 and class 3; however, lack of premeditation was significantly higher in class 1 members than those in class 2 and class 3. furthermore, higher level of negative urgency and positive urgency were observed in youth in class 2 compared to those in class 1 and class 3. conclusions: our results suggested three subgroups of marijuana users, low-, mediumand high groups. additionally, earlier onset ages and higher level of risk seeking were observed in medium and high marijuana users. while urgency traits of impulsivity were mostly salient for medium level of marijuana use. the overall results help to increase the effectiveness of person-targeted intervention programs of marijuana use. contact: bradley t. conner brad.conner@colostate.edu conference abstracts 78 collegiate athletes' psychological health and marijuana use related to sports injuries miesha marzell, corrine peek-asa, nadine r. mastroleo, & anne e. ray binghamton university, university of iowa, & real prevention llc considerable progress has been made in the physical treatment of collegiate athletes' injuries; however, there is less understanding of postinjury psychological health repercussions. among athletes' post-injury behaviors related to psychological health may be marijuana use, an activity that can have deleterious effects not only on recovery from injury but on other factors such as school performance. following an injury, athletes can experience symptoms such as depression and anxiety, as well as pain associated with the injury. some athletes may use substances such as alcohol or marijuana to selfmedicate in response to these symptoms. we sought to identify associations between sportrelated injuries, psychological health problems and marijuana use among collegiate athletes. we compared injured and uninjured athletes to identify differences in the frequency of marijuana use and the prevalence and types of post-injury psychological symptoms. a sample of 333 collegiate athletes from a midwestern division iii institution responded to a sports injury and substance use survey. the survey participants were 54% (n=178) male, mostly in the 18-20 age group (n=239, 73%), and predominantly white (n=271, 81%). other race/ethnicity represented in the sample were asian (11%), black (6%), and hispanic (5%). respondents were participating in either cross country, soccer, swimming, track, tennis, football, or baseball, with at least 10% of respondents involved in each sport. a total of 86 (25.8%) of respondents reported using marijuana, with two-thirds (n = 54) reporting use 1 day/week, 17% reporting use 2-3 days/week, and 20% reporting use 4-7 days/week. we compared the prevalence of marijuana use in the past 30 days in those with and without a sports injury in the past 30 days and found a significantly greater proportion of those with a sports injury using marijuana (37.1% vs. 24.1%; pearson chi-square p=0.036). the odds ratio of marijuana use for those with sports injury was 1.86; (95% ci: 1.03, 3.35). since marijuana use may be associated with the presence of pain, we stratified our comparison of marijuana use by pain in the last 30 days. among athletes reporting pain, a higher proportion of those with an injury reported marijuana use than those without an injury (p=0.012), while no difference was found among athletes not reporting pain. also, we found no significant difference in psychological symptoms between those with and without sports injury (p=0.284). findings such as ours provide foundational knowledge for developing and testing comprehensive injury prevention programs that can address psychological health issues, including marijuana use, related to sport injuries. contact: miesha marzell mmarzell@binghamton.edu pain patients’ experiences using medical cannabis meghan morean oberlin college background: although research indicates that medical cannabis (mc) is an effective treatment for chronic/severe pain (whiting et al., 2015), opioids remain the most commonly prescribed pharmacological intervention. of note, few studies have examined the intersection of pain, mc, and opioids. extant research indicates that adding mc to opioid pain management decreases opioid-related side effects and increases analgesia, decreases the need for opioids, and improves quality of life. method: we examined a range of mc patient experiences including common co-occurring conditions for which pain patients also use mc; duration of mc use; satisfaction with medical dispensaries and physicians; use of and preferences for different mc products (e.g., tinctures, combustible) and alternative pain treatments (e.g., yoga, exercise); changes in opioid use since starting to use mc; and perceived effectiveness of mc versus opioids for pain management. participants included 199 pain patients (58.8% female; 35.30 (10.24) years old; 87.4% white) from 19 mc states who completed an online survey. results: patients reported using mc for an average of 3.03 (3.18) years to treat 1.84 (0.99) conditions (pain [100%], mental health [30.7%], neurological [10.1%], appetite [14.1%], sleep [30.2%]). the majority of conference abstracts 79 patients (55.8%) reported using mc on a regular basis to manage pain compared to using mc an as-needed basis. patients reported that their physicians and medical dispensary staff workers were “knowledgeable” to “very knowledgeable” about mc (physician: 4.12[0.94] out of 5; dispensary: 4.01[0.85]) and about their pain condition (4.16[0.93]; 3.31[1.07]). patient satisfaction was “high” to “very high” (4.50[0.80]; 4.52[0.70]). participants had tried 4.20(1.85) routes of cannabis administration, but most preferred smoking mc (oral [tried: 83.9%; preferred 19.1%], tinctures [40.7%; 3.5%], combustibles [91.0%; 55.8%], vaping concentrates [67.3%; 11.1%], vaping bud [61.3%; 7.5%], raw cannabis [30.7%; 1.0%], topical [45.7%, 2.0]). patients reported trying 5.33(2.13) pain treatments, with the majority indicating that mc was most effective: mc (tried: 100%; most effective: 81.4%), opioid pain management (85.4%; 10.6%), therapy/counseling (55.3%; 1.5%), yoga/meditation (55.3%; 2.0%), acupuncture (38.2%; 0.5%), physical therapy (64.3%; 1.5%), exercise (75.4%; 1.5%), and dieting (60.3%; 1.0%). patients reported trying numerous opioid pain medications, but hydrocodone (44.7%) and oxycodone (48.2%; [percocet 25.1%; oxycontin 23.1%]) were most common. since starting to use mc, 65.0% of patients reported that they had completely stopped taking opioids, 32.1% reported reduced opioid intake, and 2.9% reported no change in their opioid intake; no patients reported increased opioid intake. most patients reported that mc was more effective (43.6%) or dramatically more effective (33.6%) than opioids at managing their pain; only 6.4% reported that mc was less effective. patients reported corresponding increases (63.3%) or dramatic increases (26.6%) in quality of life since starting to use mc for pain management. conclusions: the current study provides further evidence that mc is an effective treatment for pain. in light of the current opioid epidemic, the fact that 77% of patients reported that mc was superior to opioids in managing their pain and that 65% stopped using opioids entirely is encouraging. contact: meghan morean meghan.morean@oberlin.edu examining the relationship of habit to cannabis use: the self-report habit index meghan morean, dawn foster, kelly demartini, julie patock-peckham, robert leeman & stephanie o’malley oberlin college, yale school of medicine, arizona state university & university of florida prior research indicates that substance use is driven by both intentional and habitual processes. habitual behaviors have a history of repetition and efficiency (automaticity), and they occur in response to stable environmental cues. given that habitual processes are an integral part of how individuals organize their everyday lives, habitual behaviors also may reflect an individual’s sense of identity. the self-report habit index (srhi) has been used to examine key features of habit in varying behavioral contexts, namely repetition, automaticity, and expressing identity. however, the concept of habitual cannabis use has not been well-studied. the current study was designed to validate the srhi for assessing habitual cannabis use (srhi-c). this measure initially was developed to assess habitual engagement in non-substance-related behaviors. since its inception, the scale has been adapted to assess habitual alcohol use, although the psychometric properties have not been evaluated formally. in the current study, we examined the psychometric properties of the srhi-c within 522 young adults who reported past-year cannabis use on a survey conducted in 2015 and 2016. a confirmatory factor analysis conducted within a randomly selected 50% of our data indicated that the original 1-factor, 12-item latent factor solution did not fit the data. ultimately, a 6-item, single-factor latent solution evidenced good fit within the remaining 50% of the data (cfi = .979, rmsea = .077, srmr = .021), and this model had excellent internal consistency (α=.90). furthermore, the srhi-c evidenced measurement invariance within multiple groups of interest (e.g., sex, race), permitting mean-level comparisons of habitual cannabis use within these groups to be conducted with a sufficient degree of statistical confidence. differences in habitual cannabis use were observed by sex, such that women endorsed significantly higher habitual use than did men. there were no significant differences in habitual conference abstracts 80 use by race. finally, providing evidence of testcriterion validity, the srhi-c evidenced a concurrent relationship with cannabis use frequency above and beyond sex, age, race, and college gpa (all of which were associated with cannabis use frequency). these results suggest that the srhi-c is a psychometrically sound assessment of habitual cannabis use for use with young adults who are enrolled in college; the srhi-c can detect between-groups differences in habitual use by sex and is associated strongly with cannabis use. beyond having utility in a research context, this brief scale could be administered as part of screening procedures in university clinics to identify cannabis users who may be at risk for negative consequences associated with their use. further research is needed to determine whether the srhi is appropriate for use with a more diverse group of cannabis users. funding source: nida k12 da000167; niaaa 1k01aa024160-01a1; burton family foundation contact: meghan morean meghan.morean@oberlin.edu medical marijuana legalization and marijuana use among youth in oregon mallie j. paschall, joel w. grube, anthony biglan prevention research center, pire & oregon research institute legalization of marijuana for medical and recreational use raises concerns about possible effects that resulting increases in availability may have on adolescents. we examined the associations between numbers of registered medical marijuana patients and licensed growers per 1,000 population and the prevalence of marijuana use among youth in 32 oregon counties using data from 2006 to 2015. data on registered medical marijuana patients and growers were obtained from the oregon medical marijuana program and data on youth marijuana use, perceived parent disapproval, and demographic characteristics were obtained from the oregon healthy teens survey. multilevel analyses indicated that the prevalence of marijuana use among adolescents was significantly higher in counties with more marijuana patients and growers, controlling for youth demographic characteristics. conversely, marijuana patient and grower rates were inversely associated with perceived parent disapproval of marijuana use, which attenuated their relations with youths' use. changes in patient and grower rates across time were not associated with changes in the prevalence of marijuana use. overall, these findings suggest that although greater numbers of registered marijuana patients and growers are associated with a higher prevalence of marijuana use among youths, these associations are likely attributable to broader norms favorable towards marijuana use. contact: joel w. grube grube@prev.org self-generated protective strategies have predictive value over and above a standard list of strategies. mark a. prince, adrian j. bravo, & matthew r. pearson colorado state university & university of new mexico protective behavioral strategies (pbs) are a putative mechanism of behavior change. pbs are strategies individuals can use before, during, or instead of using substances to aid in cessation efforts or efforts to moderate use. by definition, effective use of strategies will result in reduced substance use. much research has established a negative relationship between pbs use and alcohol outcomes, and research is growing to establish this relationship with marijuana outcomes. one limitation to the research on pbs is that pbs are measured using a predefined list of strategies. this is problematic because participants may choose to use a strategy that is not on the list, which would lead researchers to believe that the participant did not use strategies. the goal of the present study was to examine the added predicted value of allowing participants to write in strategies in addition to completing a validated measure of marijuana pbs. participants were college students recruited from psychology department participant pools at 6 participating universities in the united states. participants completed an online survey examining the correlates of marijuana use among college students. participants completed the conference abstracts 81 protective behavioral strategies for marijuana (pbsm) modified to allow for up to three write-in strategies, modified daily drinking questionnaire applied to marijuana use, and the marijuana consequences questionnaire (macq). for the present study, only data from students that consumed marijuana at least one day in the previous month and reported their gender (n=531) were included in the final analysis from a larger sample (n=1,942). among college student marijuana users, the majority of participants identified as being either white, non-hispanic (n=335; 63.09%), or of hispanic/latino ethnicity (n=111; 20.90%), were female (n=369; 69.5%), were freshman (n=262; 49.3%), and reported a mean age of 20.16 (sd=3.15) years. hierarchical regression analyses controlling for gender and typical marijuana use quantity (i.e., step 1 predictors) revealed that higher marijuana pbs use assessed with the pbsm (step 2 predictor) was uniquely significantly associated with lower reports of marijuana negative consequences (β = .23, p <.001). when examining the effects of the pbsm written items (step 3 predictors), greater frequency of using those written protective strategies was uniquely significantly associated with fewer marijuana negative consequences (β = -.15, p = .033) over and above marijuana use, gender, and pbsm strategies. this study provides initial evidence that allowing participants to write in their own self-generated strategies helps to overcome one of the measurement issues in the pbs literature. contact: mark prince mark.prince@colostate.edu craving and motives for using marijuana: associations with problem use in college students maryia m. schneider, kerry d. duck, katherine j.e. tepper, leah wilson, geoa busto, chelsea banks, jason rose, kristina t. phillips, michael m. phillips, and the motivation and addiction research group university of northern colorado background: marijuana use is common among college students, with over half reporting marijuana use in their lifetime and approximately one-fourth reporting use in the last month. past research has demonstrated that marijuana use and consequences are associated with coping and enjoyment motives, as well as using for social facilitation. additionally, craving for marijuana has been shown to predict greater marijuana use and may play a role in treatment outcomes. based on past work, we examined whether specific motives for marijuana use (coping, social anxiety, and enjoyment) were related to problem marijuana use among college students who tested positive for marijuana. method: participants. college-students (n=300) were recruited through a psychology participant pool at a mid-sized western university and received course credit. participants completed a range of measures. days of marijuana use over the last month was based on self-report and a marijuana urine screen assessed recent use. a subset of students (n = 79) who endorsed marijuana use over the last 30 days and had a positive urine screen were included in the current analyses. measures: the rutgers marijuana problem index was used to examine problem use over the last year (α = .91). the purposefulness subscale of the marijuana craving questionnaire-short form was used to measure desire or craving to use (α = .81). three subscales from the marijuana motives measure were used to assess specific reasons for using marijuana, including coping (α = .85), social anxiety (α = .77), and enjoyment (α = .81). results: we used hierarchical multiple regression analyses to address associations with problem use for those who had positive urine screens. we first controlled for frequency of marijuana use over the last 30-days. at the next two steps, we included craving (step 2) and the three motives subscales (coping, social anxiety, and enjoyment; final step). conference abstracts 82 the model was significant and explained 30% of the variance in problem use. step one, frequency of marijuana use, was not significant ( = .168, p = .140). at step two, craving was positively associated with problem use ( = .259, p = .048). at step three, enjoyment (=.433, p = .002) and coping ( = .292, p = .012) motives (but not social anxiety motives) were associated with problem marijuana use. conclusion: we were interested in determining whether specific marijuana use motives were related to problem marijuana use after considering craving or desire to use. results showed that two motives, enjoyment and coping, were most associated with problem marijuana use even after accounting for marijuana use frequency and craving to use. these findings have implications for treatment, as high craving, as well as using marijuana to cope versus using for enjoyment, could influence the type of treatment a high-risk marijuana user may need (e.g., treatment for co-morbid psychological disorders, mindfulness for urges, etc.). contact: maryia schneider schn8458@bears.unco.edu supplemental materials here apis expands coverage for recreational use of cannabis jonathan schuler, michael klitzner, & sue thomas the cdm group, inc. & pacific institute for research and evaluation, the first states to legalize recreational cannabis use were colorado and washington, which did so in 2012. they were followed by alaska, oregon, and washington, d.c. in 2016, maine, massachusetts, california, and nevada adopted ballot measures of their own, bringing the number of jurisdictions allowing recreational cannabis use to nine. with legalization comes the need for data to illuminate the effects of these laws. this poster presentation informs researchers of the recent expansion of the alcohol policy information system (apis) to include state-level policy data on the legalization of recreational cannabis use. in 2003, the national institute on alcohol abuse and alcoholism (niaaa) introduced apis as a resource providing scholars with user-searchable access to authoritative, detailed, and comparable information on alcohol-related policies in the united states, at both state and federal levels. in 2016, apis introduced the recreational use of cannabis policy topic. the apis coverage of cannabis currently includes historical background, definitions, charts and other graphics, and user-searchable data tables comparing ten key state recreational cannabis laws, including: legalization of the purchase, possession, or consumption of recreational cannabis use by adults, the regulatory agency with authority in the jurisdiction, the products permitted for use, cultivation restrictions, retail sales permitted, pricing controls imposed, taxation, underage restrictions, impaired driving prohibitions, and local authority to opt out or permit restrictions additional to state regulation. apis coverage also includes the cannabis policy taxonomy, an inventory and taxonomy of cannabis policies organized in policy areas under nine broad categories. apis policy coverage for recreational use of cannabis begins on january 1, 2012. this poster presentation displays the apis recreational use of cannabis data table as of january 1, 2016. it also displays an outline of ten new policy variables that are in the process of being developed for 2017. apis is found at this url: https://alcoholpolicy.niaaa.nih.gov/ . the project is funded with federal funds from the national institute on alcohol abuse and alcoholism, national institutes of health, department of health and human services, under contract no. hhsn275201300002c. contact: jonathan schuler jonathan.schuler@cdmgroup.com supplemental materials here marijuana attitudes and norms: the moderating role of impulsivity-like facets among college students angela k. stevens, brittany e. blanchard, & andrew k. littlefield texas tech university cannabis is the most commonly used illicit drug among college students in the united states, and there is evidence to suggest that peers play an influential role in their cannabis use. although emerging research has demonstrated significant associations between attitudes, descriptive norms (i.e., perceived peer cannabis use), and injunctive norms (i.e., perception of peer approval of https://publications.sciences.ucf.edu/cannabis/files/rsmj2017schneider.pdf https://publications.sciences.ucf.edu/cannabis/files/rsmj2017schuler.pdf conference abstracts 83 cannabis use) and cannabis use, research examining possible moderators of these relations is in its nascent stages. thus, the current study sought to examine the potential moderation of impulsivity-like facets (i.e., negative positive urgency, lack of planning, lack of perseverance, and sensation seeking) as assessed by the uppsp impulsive behavior scale to predict cannabis use. undergraduate participants (n = 718; 68% white; 66% female; 26% hispanic; m age = 19.00) completed a battery of self-report assessments, including the upps-p and the american drug and alcohol survey (adas) to assess attitudes, norms, and past-year cannabis use. ordinal logistic regression was used to examine both main effect and interactions models. all models were adjusted for age and gender. cannabis attitudes, descriptive norms, and injunctive norms, separately, were predictive of past-year cannabis use, such that more positive attitudes towards cannabis use (b = .90, p < .01), higher levels of descriptive norms (b = .93, p < .01), and higher levels of injunctive norms (b = .87, p < .01) were predictive of increased endorsement of cannabis use. further, positive urgency significantly moderated the relation between injunctive norms and cannabis use (b = -.21, p < .01), such that the relation between injunctive norms and cannabis use was amplified for individuals lower in positive urgency. in other words, individuals higher in positive urgency and lower in injunctive norms endorsed increased cannabis use compared to those lower in both positive urgency and injunctive norms. similar patterns of moderation were found for lack of planning and injunctive norms (b = -.23, p < .01), lack of perseverance and injunctive norms (b = -.23, p < .01), lack of perseverance and descriptive norms (b = -.11, p < .01), positive urgency and attitudes (b = -.17, p < .01), lack of perseverance and attitudes (b = -.19, p < .01), and lack of planning and attitudes (b = .21, p < .01). findings from the present study indicate that cannabis norms and attitudes seem to be the most predictive of cannabis use for individuals who are lower in some facets of impulsivity. interestingly, findings also revealed that individuals higher in attitudes and norms endorsed similar rates of past-year cannabis use, regardless of impulsigenic trait endorsement (i.e., reached equifinality). future directions include using more refined measures of attitudes, norms, and cannabis use (e.g., modified daily drinking questionnaire), as this is a limitation to the present study. although, to our knowledge, this is the first study to examine differential relations among attitudes and norms, impulsivity-like facets as assessed by the upps-p impulsive behavior scale, and cannabis use among college students. contact angela k. stevens angela.stevens@ttu.edu an investigation of reported daily activities in college marijuana users: findings from ema and content analysis david williams, kerry duck, lillian canfield, arianna weisen, james hinshaw, janelle miller, michael m. phillip, kristina t. phillips, and the motivation and addiction research group university of northern colorado background: marijuana is the most commonly used illicit drug in the u.s. among young adults, with high rates found in states with legal recreational use, such as colorado. we investigated different life events as reported by heavy marijuana users throughout the day via a smartphone app using ecological momentary assessment (ema). ema employs momentary data collection by prompting participants over a defined interval of time. one major advantage of ema over retrospective responses is a reduction in recall bias, which is particularly beneficial in self-report of addictive behaviors and ephemeral psychological states. we sought to examine life events captured during signal-contingent ema and were interested in how many instances of marijuana use we would capture throughout the day. method: participants and procedures. participants (n = 27, 48% female) were screened and underwent an initial baseline assessment involving cognitive testing, marijuana use, psychological problems, and academics. selfreported last 30-day marijuana use during baseline was consistent with heavy use (m=23.85, sd=7.08). following the baseline assessment, participants were trained on the ema protocol and randomly prompted three times daily (time 1=8:00am-12:00pm, time 2=12:30-4:30pm, and time 3=5:00-10:00pm) over the next 14 days using a smartphone app. though participants completed a series of ema questions, the current proposal focuses on the first open-ended question conference abstracts 84 in the protocol regarding the activity participants were currently engaged in when prompted. content analysis: research assistants coded responses to the open-ended activity question. in the first pass, interrater agreement (fleiss’ κ=.80) was determined, raters discussed the categories, and a final set of categories were established. the following activity codes were finalized and used for the analysis: using marijuana, school-related, work-related, drinking alcohol, exercising, eating, errands/chores/personal hygiene, leisure, in transit, sleeping, and indiscernible. four coders had sufficiently high agreement (fleiss’ κ=.94). during a consensus meeting, 100% agreement was achieved after evaluating disagreements. results: we captured 886 responses (78% response rate) to the current activity question across the 14-day timeframe and evaluated the categories across the three time blocks. overall, roughly a quarter of the participants’ time was related to school-related activities with slight variations based on time of day (range 18-26%). when looking descriptively at captured responses across all time points, instances of exercise were less than or equal to instances of marijuana use in our sample. overall, participants reported current marijuana use when prompted approximately 5% of the time. reports of marijuana use increased throughout the day (2% for time 1, 4% for time 2, and 8% for time 3). the most highly endorsed activity during the first time period was sleep (33%). leisure activity was also high (14, 26, and 36%, respectively) over the 3 time periods. conclusions: this study provides insight into the average day of a college-aged marijuana user. across a two-week period using signal-contingent ema, we captured participants currently using marijuana a small percentage of the time. thus, if researchers are interested in deeper understanding of a marijuana event in the exact moment, they should consider the use of eventrelated prompts. contact: david williams david.williams@unco.edu supplemental materials here sleep difficulties and duration predicted marijuana use and related problems in adolescents maria m. wong idaho state university previous research found that poor sleep prospectively predicted alcoholand other drugsrelated problems in adolescents. individuals with trouble sleeping and those with shorter sleep duration were more likely than others to report problems such as driving under the influence of substances, getting into an argument or a physical fight due to substance use. this study focused on examining the concurrent and prospective relationship between sleep difficulties/duration and marijuana use, especially marijuana use under high risk circumstances, i.e., consuming marijuana before engaging in sexual intercourse and getting into a physical fight while using drugs. study participants were 6504 adolescents from the national longitudinal study of adolescent health (add health). data were collected from interviews and questionnaires. the current study analyzed data from both times 1 and 2 (t1 and t2), which were one year apart. sleep difficulties were measured by the question, “please tell me how often you have had each of the following conditions in the past 12 months trouble falling asleep or staying asleep?” responses were given on a five-point scale 0=never, 1=a few times, 2=once a week, 3=almost every day, 4=every day. sleep duration was measured by one question, “how many hours of sleep do you usually get?” a higher score represents more sleep. lifetime marijuana use was examined by the question, “during your life, how many times have you used marijuana?” responses were recoded into dichotomous variables (0=no; 1=yes). data were analyzed by logistic regression. in all analyses, we used t1 sleep problems and duration to predict marijuana use in t1 and t2, while controlling for demographic variables that have been known to associate with substance use -sex, age, school grade, poverty, and chronic health problems. in t1, sleep difficulties (or = 1.23, p<.001) but not sleep duration (or = .967, p=.253) were associated with lifetime marijuana use. one unit increase in sleep difficulties were associated with 23% increase in the odds of marijuana use. https://publications.sciences.ucf.edu/cannabis/files/rsmj2017williams.pdf conference abstracts 85 controlling for t1 marijuana use and demographics variables, t1 sleep duration significantly predicted t2 marijuana use (or = .92, p<.01). an additional hour of sleep in t1 was associated with 8% decrease in the odds of marijuana use. t1 sleep difficulties had no relationship with t2 marijuana use. t1 sleep duration predicted the odds of using drugs during the most recent sexual activity at t2 (or = .86, p<.05). among those who used drugs during sexual activity, 93% used marijuana. t1 sleep duration was significantly associated with the odds of getting into fights when using drugs at t1 (or = .78, p<.01) but not t2 (or = .85, p=.11). among those who got into fights while using drugs, 88% used marijuana. both sleep difficulties and duration were concurrently and longitudinally associated with marijuana use and related problems. the impact of sleep on marijuana use in adolescence will be discussed. future studies need to identify the mediators and moderators of this relationship. contact: maria wong wongmari@isu.edu supplemental materials here https://publications.sciences.ucf.edu/cannabis/files/rsmj2017wong.pdf conference abstracts 86 symposia symposium: a controlled pilot study of the marijuana echeckup to go protocol chair: bradley t. conner colorado state university marijuana use is quite common among college students in the united states, with 34% percent of students reporting past-month use and daily use at its highest level in the last 30 years. with changing legislation, we have seen changing patterns in use, for instance, colorado, one of the first 2 states to legalize recreational marijuana use, now ranks first in cannabis use among young adults. a review of the cannabis prevention literature reveals few controlled trials for interventions that reduce problematic marijuana use among college student populations, with even fewer interventions considered "evidence-based." marijuana echeckup to go (e-toke), a fully customizable online program designed to reduce marijuana use among college students is modeled on the evidence-based alcohol echeckup to go and has recently been developed for licensing by colleges/ universities. there are currently 2 published studies by one research lab that support the efficacy and effectiveness of the e-toke intervention. this symposium will present data from a controlled trial of the e-toke program in a college sample in the state of colorado. the initial presentation will introduce the study and the e-toke program. the second presentation will present primary study findings on the intervention. our third talk will present results of mediational analyses. finally, we will present data on dose-effects associated with multiple administrations of the e-toke protocol. the implications of these findings and future directions of the research will be discussed. contact: bradley conner brad.conner@colostate.edu reducing college student marijuana use: testing a personalized normative feedback intervention audrey m. shillington & jamie e. parnes colorado state university previous research has indicated interventions aimed at correcting normative perceptions through personalized normative feedback (pnf) are effective at reducing alcohol use and related harms. limited research has been conducted examining pnf interventions on marijuana use, with findings yet to yield significant results. however, these studies were conducted in states where marijuana use was illegal. this may have impacted normative attitudes towards marijuana use. in colorado's fourth year of legalization, normative attitudes are hypothesized to have shifted toward decreased perceived risk of use and increased perceived approval of use. as these norms shift away from being protective factors, pnf interventions may prove more effective at correcting norms, resulting in misuse prevention. marijuana echeckup to go (e-toke) is a web-based pnf intervention currently implemented by several universities. the intervention targets correcting descriptive norms, as well as providing education on marijuana use. to date, one previous study has been conducted testing e-toke's efficacy. findings indicated etoke participants experienced reductions in descriptive norms compared to control subjects, however there were no changes in marijuana use frequency, consequences, or injunctive norms. despite no changes in use patterns, these findings show promise in e-toke's ability to alter normative attitudes. this effect may be stronger among participants with more tolerant/accepting attitudes towards legalization of marijuana use. the present study was a controlled pilot test of etoke program among college students in a state with legal adult recreational marijuana use. students who reported typical marijuana use, at least twice weekly, were recruited through oncampus housing, fraternity and sorority life, and social media (i.e., facebook, instagram). a total of 298 participants were recruited, with 143 assigned to the pnf condition. participants were 51.0% male, approximately 19.97 years of age (sd = 2.02), 85.6% white, and 13.8% hispanic or latino. at baseline, participants reported an conference abstracts 87 average of 34.89 use episodes in the past month (sd = 39.84). data was collected across three time points in 6-week intervals. at the first time point, pnf condition participants received pnf and marijuana education while control participants received general stress reduction techniques. at the second and third time points, all participants received pnf. participants were compensated with a $20 amazon gift card for the first survey, and a $10 gift card for each subsequent survey. participants were emailed personalized survey links and given a week to complete each survey, with reminders sent to those who did not complete the survey within five days. 76.2% of the baseline sample completed the second time point and 74.5% completed the final time point. the subsequent presentations in this symposium will present the study findings. a discussion of the etoke protocol and the pilot study will also occur. effects of a pnf intervention for reducing heavy cannabis use among college students nathanial r. riggs & jamie e. parnes colorado state university liberalization of cannabis use policies is hypothesized to decrease social norms discouraging use and perceptions of harm resulting from use, both of which are protective factors against cannabis misuse. consequently, social norms and perceived harm represent targets for college student cannabis misuse interventions. this pilot study tested direct and moderated (by gender) program effects of e-toke, a web-based cannabis misuse preventive intervention providing university-specific personalized normative feedback (pnf) and research-supported cannabis misuse consequences and protective behavioral strategies (pbs) to students attending a university in a state with legalized adult recreational marijuana. it was hypothesized that e-toke participants would report significantly more accurate descriptive and injunctive cannabis use norms and consequences of misuse, increased marijuana misuse pbs, and decreased own use, than participants assigned to a healthy stress management (hsm) comparison condition. participants were recruited based on self-reports of heavy use (approximately twice weekly) in the fall 2016 semester. half of the 300 recruited students were randomly assigned to the e-toke condition. intervention participants immediately received individual pnf based on responses to a survey asking about their cannabis use, typical university student use, perceived and actual descriptive and injunctive norms for and consequences of cannabis use, and cannabis misuse pbs. hsm participants received stress management techniques equivalent in length to pnf. two hundred and twenty-seven participants (76% of the baseline sample; male = 107, female = 120) completed the same survey at 6-weeks postintervention and represent the study sample. general linear models (glms) with intervention condition as the independent variable tested direct program effects on study outcomes. multigroup glms with gender as the class variable then tested the moderating effect of gender on etoke intervention effects. results demonstrated that e-toke participants reported fewer weeks of use per month (b = -.45, se = .12, p < .001), greater number of days since last use (b = 2.03, se = .99, p < .05), fewer time periods high per week (b = 1.17, se = .58, p < .05), decreased estimates of campus-specific others' past 30-day use (b = -9.05, se = 2.87, p < .01), increased estimates of campusspecific others' past 30-day non-use (b = 6.03, se = 2.62, p < .05), and greater pbs engagement (b = .17, se = .74, p < .05). gender moderated e-toke effects on number of days since last use, total number of time periods high per week, hours high per week, decreased estimates of campus-specific others' past 30-day use, increased estimates of campus-specific others' past 30-day non-use, frequency of pbs engagement, number of pbs endorsed, and average helpfulness of endorsed pbs, such that females benefitted from the intervention more than males. results demonstrate preliminary support for e-toke in reducing personal use and increasing protective factors against misuse, particularly in females. future research should test the sustainability of program effects over time and adapt e-toke to increase efficacy for males. conference abstracts 88 mechanisms of change following the e-toke pnf intervention among college student melissa w. george & mark a. prince colorado state university with the changing legal and social acceptance of marijuana nationwide there is a need to evaluate marijuana-specific interventions that are relatively inexpensive and easy to disseminate. etoke is a web-based marijuana specific intervention that uses personalized normative feedback to encourage individuals to reduce their marijuana use and risk for negative marijuanarelated consequences. in addition, strategies are offered that may be helpful in reducing marijuana use and consequences. the premise of the e-toke intervention is that if students' normative perceptions (i.e., descriptive and injunctive norms) are modified to better match reality and if they are equipped with effective strategies for moderating use, then they will choose to moderate their use. the current study sought to examine these mechanisms of change following participation in either e-toke or a control condition in a sample of weekly marijuana using college students, examining sex differences in mechanisms as well. data are from 272 students (76% of baseline sample; male = 107). participants were recruited and randomized to receive the etoke intervention or a stress reduction comparison intervention. participants completed a baseline survey that included demographics, marijuana use frequency, descriptive and injunctive norms, and protective behavioral strategy use. participants then received the etoke intervention and received personalized normative feedback or the control condition with stress reduction and healthy living feedback six weeks post intervention, they completed the same baseline survey to measure change at the followup. analysis plan. a multi-group path analysis was used to examine (a) the effect of the e-toke intervention on marijuana use frequency, (b) whether changes in marijuana use frequency were mediated by changes in normative perceptions and strategy use, and (c) whether the direct or indirect effects varied by sex. the product of coefficients method was used to calculate indirect effects and bias-corrected bootstrapped confidence intervals that did not include 0 were considered statistically significant. in the model building procedure, there was a direct effect from e-toke intervention condition to marijuana use frequency, such that those in the treatment condition reduced their marijuana use frequency more than those in the control group. this effect was substantially stronger for females. descriptive norms mediated the treatmentmarijuana use relationship for males, and injunctive norms mediated this relation for females. protective behavioral strategy use did not mediate this relation for either group. however, the indirect effects showed evidence of a strong suppression effect, likely because the direct effect of treatment on marijuana use was much stronger than the total indirect effect for both descriptive and injunctive norms. findings suggest e-toke is an effective brief intervention for college student marijuana users with descriptive and injunctive norms promising as potential mechanisms through which intervention feedback reduces use; however, replication studies with a longer follow-up period are needed to better assess mechanisms of change. similarly, effects of protective behavioral strategies might be limited by the short follow-up period. examination of dose effects of the e-toke personalized normative feedback intervention bradley t. conner colorado state university the last talk will present data on repeated administrations of the e-toke platform. as reported in previous talks, in addition to seeing an overall significant effect of the intervention on marijuana use and consequences, we see differences based on sex. implementation of the etoke protocol in this study relied on a pseudowaitlist control, whereby those in the control condition received general information about reducing stress and improving health rather than receiving personalized normative feedback (pnf). at time 2 those in the control condition received pnf as did those in the treatment condition. as part of the ongoing data analyses for the e-toke study we are currently processing wave 3 data. wave 3 data will be used to test hypotheses around dose effect and sex differences based on any dose effects. we expect that those in the experimental condition will continue to show significant reductions in marijuana use and conference abstracts 89 consequences and a better understanding of injunctive and descriptive norms. we expect that those in the control condition, having now received pnf, will show similar significant reductions in marijuana use and consequences and a better understanding of injunctive and descriptive norms compared to these variables at time 2. we expect that significant differences between the two groups seen at time 2may still be present at time 3 given that all participants have now received pnf but that the magnitude of those differences will be significantly reduced. finally, we expect to see significant differences on the dependent variables in both males and females for those in the experimental group but not for those in the control group. we make this last hypothesis based on the notion that the repeated dosing will eliminate significant differences between males and females. the implications of the dose effects will be discussed. additionally, optimal implementation of the e-toke protocol will be discussed. symposium: neuropsychological performance in chronic cannabis users: seeing through the smoke chair: rayna hirst palo alto university in the last decade, research addressing the cognitive effects of adult-onset chronic cannabis use has advanced greatly. however, the proliferation of cannabis-related literature has produced more questions than answers. in particular, due to equivocal research findings, the extent to which chronic cannabis use affects adult cognitive functioning remains unclear some studies show small effects, while others, including recent meta-analyses, show none. in this symposium, to clarify the literature, the authors will present several studies investigating compelling factors that may explain the conflicting research findings: effort/motivation to perform well on neuropsychological testing and experimenter expectancy effects. first, we will present a study in which chronic cannabis users received a motivation enhancing statement prior to testing (i.e., a reminder of the research's contribution to marijuana legislation), which resulted in significantly better performance on learning, memory, and effort tests. we will then explore effort as a mediator between cannabis-use variables and learning/memory performance, presenting findings that effort mediates the relationship between frequency of cannabis use and learning/memory performance. regarding expectancy effects, we first demonstrated that neuropsychologists can differentiate between users and non-users based on a photograph alone. further, we will present results showing that the examiners in our studies, despite being blind to user status, were able to guess participants' user status with up to 75% accuracy. importantly, those judged as users performed worse on cognitive testing, even after controlling for actual user status. the implications of these findings and future directions of the research will be discussed. contact: rayna hirst rhirst@paloaltou.edu supplemental materials here enhancing neuropsychological performance in chronic cannabis users: the role of motivation rayna hirst palo alto university objective: this study sought to determine whether cannabis users demonstrate differential effort during neuropsychological assessment compared to nonusers, and whether better performance can be induced in participants with a motivational statement prior to testing. method: participants included cannabis users (n = 62) and non-users (n = 48) from an undergraduate university. to qualify as a cannabis user, individuals must have used cannabis at least four days per week for the past year. non-users must have tried cannabis at least once, but no more than five times in their lives and not within the past 30 days. prior to neuropsychological testing, individuals were randomly administered either a motivational or a neutral statement. the motivational statement consisted of a reminder of the study’s importance to legislation on marijuana policy; the neutral statement simply informed the participant that they would now began the series of cognitive tasks. results: users who received the motivational statement performed nearly one standard deviation better on learning and memory tests than users who received the neutral statement (cvlt-ii sum of trials 1–5 [cohen’s d = 0.58]; short delay free recall [cohen’s d = https://publications.sciences.ucf.edu/cannabis/files/rsmj2017hirst.pdf conference abstracts 90 0.84], and long delay free recall [cohen’s d = 0.80]). thus, within the neutral statement condition, users performed nearly one standard deviation lower than the non-users on a test of verbal learning and memory (cvlt-ii long delay free recall [cohen’s d = 0.60]). however, within the motivational statement condition, users and non-users did not differ in their performance (p>.05). conclusions: results suggest that a statement designed to enhance motivation may improve the performance of cannabis users, eliminating user and non-user differences on a measure of learning and memory. these findings indicate that deliberate motivation may lead to better performance in cannabis users, compared to their non-motivated user counterparts. ultimately, the lower learning and memory performance sometimes seen in chronic cannabis users may be due to motivational factors rather than true physiological damage secondary to cannabis use. a motivational statement may provide a research tool to address deflated neuropsychological performance in cannabis users, allowing for a more valid and accurate measurement of their cognition. trying to remember: effort mediates relationship between frequency of cannabis use and memory alexis rosen palo alto university objective: while many studies suggest that regular cannabis use leads to deficits in cognitive functioning, particularly in memory, few have measured effort put forth during testing, and none have examined this factor as a potential mediator. both age of onset of regular cannabis use and frequency of use have been linked to increased risk of memory deficits in cannabis users. the present study sought to determine whether effort mediated the relationship between frequency or age of onset of cannabis use and learning and memory performance. method: 62 participants (74% male, mean age = 19.25 years) who met criteria for chronic cannabis use (four or more days per week for at least 12 months) completed a neuropsychological battery after 24 hours of abstinence. the battery included the california verbal learning test-ii (cvlt-ii) and the rey complex figure (rcf) as measures of learning and memory, and the word memory test (wmt) as a measure of effort put forth during neuropsychological assessment. results: participants who used cannabis more frequently exhibited poorer effort (as measured by wmt performance; p<.01). bootstrapping yielded 95% confidence intervals for indirect effects and revealed that effort significantly mediated the relationship between frequency of cannabis use and cvlt-ii learning (sum of trials 1–5), cvltii delayed recall, and rcf delayed recall, but not rcf immediate recall. age of onset of cannabis use was not significantly related to effort. conclusions: findings indicate that effort mediates the relationship between frequency of cannabis use and performance on learning and memory measures. these results raise the possibility that previous findings that greater frequency of cannabis use produces cognitive impairments may in fact be attributable to variability in effort put forth during testing. given that effort may account for cognitive differences between frequent cannabis users and nonusers, future research should measure and control for effort performance. the myth of the “jay-dar”: identifying cannabis user status from a photograph and memory stereotypes dylan vaughn palo alto university objective: with increasing legalization of marijuana, cannabis use has risen globally. while individuals may choose not to disclose their cannabis use, if others can accurately guess cannabis user status based upon appearance, these perceptions could influence educational, employment, and social interactions, given common negative stereotypes about cannabis effects. additionally, few studies examining cannabis’s cognitive effects utilize research designs where examiners are blind to user status. even so, researchers may be able to guess participants’ user status, leaving these studies vulnerable to the expectancy effect confound. this series of studies examined the ability of individuals in general, and neuropsychologists specifically, to determine cannabis user status from a photograph. we also explored the memory impairment stereotype in actual and perceived conference abstracts 91 cannabis users. method: study 1 examined individuals' ability to discriminate between cannabis users and non-users, based upon photographs. undergraduates (n = 244, 70% female, mean age = 21.0 years) rated 21 photographs (12 cannabis users, 9 non-users) on the likelihood that the photographed individuals use cannabis. study 2 examined the same ability in neuropsychologists, the very professionals who would conduct research on cognition in cannabis users. neuropsychologists (n = 84, 60% female, mean age = 41.4) rated 25 photographs of individuals (12 cannabis users, 13 non-users) on the likelihood that the photographed individuals use cannabis. study 3 examined whether actual or perceived cannabis user status related to ratings of perceived learning and memory performance, based upon photographs. undergraduates (n = 218, 64.7% female, mean age = 25.2) viewed the same photos and rated how well they thought each individual would perform on a test of learning and memory (perceived memory performance ratings), despite raters having no knowledge of cannabis user status. results: in study 1, photographs of users received higher ratings than non-users on the marijuana use likelihood index. similarly, neuropsychologists in study 2 rated cannabis users’ photographs higher than nonusers on the same index. across both studies, males received higher ratings than females, regardless of user status. cannabis use explained approximately 40% of the variance in cannabis use likelihood ratings. results for study 3 indicate actual user status was unrelated to perceived memory performance ratings (pmr), perceived user status was negatively related to pmr. results suggest a potential stereotype against individuals who “look like” cannabis users, as those who had been previously perceived as likely to be cannabis users were presently rated as less likely to perform well on a complex task of verbal learning and memory, independent of their actual user status. these findings suggest that, irrespective of actual cannabis use, individuals who ‘look like’ cannabis users may appear to others to be less likely to perform well on learning and memory tasks. conclusions: these findings have important implications, not only for social and achievement factors such as potential stigma, but also for research on chronic cannabis use effects. moreover, the results demonstrate the possible negative influence of stereotype perceptions regarding cannabis use on educational, employment, and social interactions, as well as empirical studies of cannabis effects utilizing a blind research design. examiner expectancy effects: judgments of cannabis use status predict neuropsychological performance rayna hirst palo alto university objective: previous research suggests examiner beliefs about the effects of acute caffeine administration impact examinee cognitive performance and physiological response. however, this phenomenon of the expectancy effect confound remains largely unexplored in neuropsychological research. hirst and colleagues found neuropsychologists can discriminate cannabis users from non-users based upon photograph appearance alone. therefore, this population may be especially vulnerable to the expectancy effect confound in neuropsychological research, if examiners can guess participants’ user status. the present study investigated whether examiner beliefs of cannabis user status predicted cognitive performance on a neuropsychological battery. method: participants included 41 users and 20 non-users (n = 61, 59.70 % male, mean age = 21.89). prior to testing, examiners who were blind to participant user status privately rated whether they believed the examinee was a cannabis user or non-user. examiners then administered a battery of neuropsychological tests assessing core cognitive domains. the neuropsychological tests administered included the rey complex figure, california verbal learning test-ii, subtests of the wechsler adult intelligence scale-iii, trail making test, word memory test, and test of memory malingering. a series of regressions compared neuropsychological performance between the two groups. results: examinees who were judged as cannabis users scored lower than those judged as non-users on four of eight tests in the battery, including california verbal learning test-ii, word memory test, wechsler adult intelligence scale-iii coding subtest, and trail making test (p < .05). while group differences were not significant on the remaining tests, the trend remained that those perceived as users conference abstracts 92 received lower scores than those perceived as nonusers. findings remained consistent after controlling for gender and actual user status. conclusions: results of this study suggest that test examiners’ beliefs of an individual’s cannabis user status may affect performance on neuropsychological tests, due to experimenter expectancy effects even when examiners are blinded to actual user status. these findings have important implications for valid and accurate measurement of neuropsychological performance in both research and clinical settings, as test scores may partially reflect the examiners’ beliefs regarding the effects of marijuana use rather than participants’ true cognitive abilities. discussant: staci gruber harvard medical school symposium: flower, vapor, and dabs (oh my): acute and short-term effects of cannabis in the real world chair: kent hutchison university of colorado boulder this symposium features four talks that address the acute and short term effects of different forms of cannabis across a range of important outcomes that are highly relevant to public health, including driving ability, motor control, cognition, and mental and physical health effects. given the increasing prevalence of marijuana recreational and medicinal and changing legal policies, understanding the acute effects of different forms of marijuana is an increasingly important topic. this symposium will examine the acute neurocognitive and public health effects of cannabis in recreational and medicinal users. dr. bidwell will present on the use of a mobile laboratory to collect data on the acute intoxicating and cognitive effects of forms of marijuana available on the legal market, such as high potency flower and dabs. dr. tracy will present on the use of a mobile laboratory to collect data on the acute effects after self-administration of high potency legally-marketed marijuana products on measures of motor control and balance that may impact marijuana-related driving-impairment. dr. pearlson will describe the impact of different potencies of vaporized cannabis on driving behavior and neurocognitive processing using an fmri-based simulated driving paradigm. dr. gruber will discuss how health and brain functioning are affected after medicinal users initiate medical marijuana use. dr. hutchison, the discussant and chair, will integrate the presentations, discuss the public health implications of these findings, and consider the path forward for conducting rigorous and meaningful contact: kent hutchison kent.hutchison@colorado.edu a novel observational method for assessing acute responses to cannabis: preliminary validation using legal market products l. cinnamon bidwell, sophie york williams, raeghan mueller, sarah hagerty, angela d. bryan, & kent e. hutchison university of colorado, boulder over the last several years, there have been enormous changes concerning the public acceptance of marijuana. thus, the scientific data that can inform marijuana public policy and consumer decisions are critically needed. our research program seeks to study the effects of commonly used marijuana strains and products, as they are used in everyday life, as opposed to relying solely on testing the effects of u.s. government grown, lower potency marijuana in controlled laboratory experiments, which may underestimate effects of tetrahydrocannabinol (thc) and may ignore the effects of other major cannabinoids, such as cannabidiol (cbd). in one study, we examined the effects of two common commercially available strains, one with the average potency of thc in colorado and one strain that had lower thc and higher cbd on measures commonly associated with the potential for harm and the potential health effects of marijuana. in a second study, we study the impact of high potency thc flower and concentrates on these same measures. in the first study, 23 regular marijuana users were asked to switch from their normal high thc (~18%) strain to a common strain with high thc similar to what they normally use (thc ~ 18%; cbd <= 1%) or to a strain with lower thc but high cbd (thc ~ 9%; cbd ~12%). with 15 minutes of marijuana self-administration, users in the two strain groups were given a blood draw for an objective measure conference abstracts 93 of thc and its primary metabolites, thc-cooh and thc-oh, followed by measures relevant to harm reduction and health following cannabis use. results revealed significant interactions between strain type and our harm reduction measures. at the average thc level, use of high cbd strain is associated with a lower desire to smoke (p<.05; ηp 2= .194), with a feeling less mentally stoned (p<.005; ηp 2 = .394), and, at trend level, with fewer verbal memory errors (ηp 2= .105), than use of the high thc strain. in addition, although the groups did not differ at baseline, the cbd strain group had significantly lower average circulating cytokine expression than the thc strain group (p = .017). in our second study, individuals who have experience with high potency thc products (flower and concentrates) will be assessed on these same measures immediately before and immediately after use. this study is ongoing (current n=2) and will provide the first data on the impact of legal market high potency thc products on important measures relevant to public health and marijuana harm-reduction. although these pilot studies are not adequately powered to provide a comprehensive test of the effect of different strains of marijuana, the data suggest strong effect sizes and provide preliminary evidence that strains with higher cbd may mitigate some of the harmful effects of marijuana. clearly, more research on commercially available strains is needed to inform the public policy makers about strains that may have less potential for harm. a smartphone-based mobile motor battery for acute cannabis intoxication: there's an app for that brian l. tracy colorado state university in studies of acute cannabis intoxication and motor function, it can be impractical to bring subjects into a university-based movement lab setting, or to bring bulky, expensive testing equipment into “real world” mobile settings. yet crude field measures lack precision and sophistication. modern smartphones are ubiquitous, easy to use, and contain triaxial accelerometers and gyroscopic rotation sensors of remarkable sensitivity. therefore, the smartphone, properly employed, can be a “mobile movement lab” for field settings. an app can be used to sample data from onboard sensors at up to 100 samples per second while the device is attached to a human subject during an experimental motor task. movement data is stored as a text file and easily wirelessly transmitted to the lab for storage and subsequent analysis. in a novel collaboration with drs. hutchison and bidwell at the cu change lab, we have developed an entirely smartphone-based quantitative battery of motor function that can be carried out in a mobile testing van. we are currently employing the motor battery in two studies, 1) acute intoxication effects of smoking cannabis flower, and 2) acute intoxication effects of “dabbing” cannabis. both studies are tracking subjects before, immediately after, and 60 min after exposure. the equipment is an ipod touch and a set of velcro straps. the 15-min battery, some of which relates to driving ability, consists of instrumented tests of 1) standing postural stability, 2) simple neuromotor speed (finger tapping), 3) ballistic leg withdrawal reaction time, and 4) ballistic arm extension reaction time. 1) standing balance is measured with eyes open, eyes closed, and eyes closed/head tilted back. the front-to-back and side-to-side fluctuations in acceleration is measured from the hip-mounted ipod. values from eyes closed and head tilt conditions can provide information about reliance on proprioception and vestibular inputs. an expectation is that acute intoxication will impair balance during all conditions but with greater impairment during eyes closed and head tilt. 2) finger tapping involves 20s of maximal speed simple index finger tapping with the forearm and ipod resting on a table. the corner of the ipod is tapped and the accelerometer will register each tap. the time of each tap is measured and the intertap interval quantified over the 20 s task. we hypothesize that with acute intoxication the mean tapping rate will be reduced and the tapping rate will decrease more rapidly over 20 s compared with the pre-dabbing test. 3) the ballistic leg test has the seated subject lift the foot from the ground as rapidly as possible when a sharp tap to the shin-mounted ipod/leg is sensed. the latency from tap to initiation of lift is measured, as well as the peak acceleration of the foot lift. we hypothesize that the reaction time will be impaired and the movement speed reduced with acute cannabis intoxication. 4) the ballistic arm test has the conference abstracts 94 seated subject perform a ballistic “punch” of the forearm when they sense a sharp tap to the ipod/distal forearm. the latency from tap to movement and the peak outward acceleration is measured. it is expected that intoxication will increase the reaction time and reduce the peak movement speed. the goal of the presentation will be to introduce the audience to the utility of mobile, smartphone-based measures of human movement in the acute intoxication paradigm. discussant: kent hutchison university of colorado boulder symposium: driving under the influence of cannabis: theoretical issues, impact, and methods of detection chair: godfrey pearlson yale university because of increasing legalization/ decriminalization of cannabis and widespread use of medical cannabis, the rate of cannabisintoxicated driving will rise significantly. although cannabis-impaired driving is recognized as a potential public health challenge, public policy on this issue is neither well-rooted scientifically, nor consistent. currently there are few guidelines to assess cannabis-related driving impairment reliably, and few facts to guide authorities or users. the symposium will provide an update on cannabis-impaired driving. topics will include a) approaches to assessment of cannabis-impaired driving using driving simulators, b) relationships between intoxicated simulated driving and functional mri-related acute drug challenges, and c) methods for detecting cognitive changes that might affect driving performance (laboratory-based measures, roadside field sobriety tests). topics addressed will include the duration of impairment following acute drug exposure, effects of dose and cannabis use experience on performance, the relationship of impairment to blood and saliva levels of thc and its metabolites, subjective awareness of impairment, willingness to drive when intoxicated, and the effects of alcohol/cannabis interactions. drs. pearlson and marcotte will focus on driving simulation (including during functional mri) and considerations in constructing field sobriety tests. dr. stevens will focus on thc-related cognitive impairment and its assessment. dr. ranganathan will speak about differential effects of thc and cbd on drivingrelated cognition and discuss pilot data on effects of thc and alcohol on simulated driving. dr. ward will cover cultural factors of decision making to drive after using cannabis, and what cognitions influence a person's decision to drive under the influence of cannabis. contact: godfrey pearlson godfrey.pearlson@yale.edu the challenge of assessing driving under the influence of cannabis thomas d. marcotte university of california, san diego driving under the influence of cannabis is of increasing public health concern, particularly given recent trends in legalizing medicinal and recreational cannabis. although experimental studies have often shown decrements in driving related abilities, epidemiologic findings have been mixed. this presentation will briefly review what is known about the impact that cannabis has on driving performance, as well as the limitations of research to date. topics to be addressed include 1) experimental and epidemiologic findings regarding the relationship between cannabis use, driving performance and real-world crashes (including the effects of concurrent alcohol use), 2) studies examining current field sobriety tests and drug recognition expert (dre) evaluations for the detection of cannabis-impaired driving, and 3) the use of bodily fluids (blood, saliva, breath) to determine impairment and cannabis use recency. lastly, an overview of two recently initiated projects to assess the effects of smoked cannabis and oral thc on driving abilities, as well as possible approaches to validating and enhancing field sobriety tests, will be presented. optimal design considerations for cannabis intoxicated driving research godfrey pearlson yale university a large number of practical considerations influence the design of successful cannabisintoxicated driving experiments. one initial key conference abstracts 95 choice is how best to maximize naturalistic aspects of such studies. some of these important initial decisions include whether to administer marijuana in smoked or vaporized form versus iv delivery, and the validity of virtual motor vehicle operation compared to actual on-road driving. in designing the latter, virginia tech's "smart road" and the national advanced driving simulator provide useful resources to validate "real world" aspects of driving simulations. the design of the individual simulated driving measures also involves assessing the extent to which strategic, tactical and operational levels of driving need to be quantified and incorporated in the research design. another important design aspect involves maximizing immersive (and minimizing videogame-like) subject responses to simulated driving. strategies to increase realism include provision of safe-driving bonuses, penalties for exceeding speed limits etc. as well as designing detailed instructions to subjects and non-intrusive reminders of rules. design of in-mri functional driving tasks involves additional practical constraints and training issues. some of these include the need for adequate out-of-scanner behavioral training to asymptote performance with subjects lying supine, in addition to seated desktop simulator rehearsal, redesigning driving manipulanda used in-scanner to be compatible in high-strength magnetic fields, limiting the number of behavioral events that can be feasibly presented during task scenarios in event-related designs, and designing multiple alternative task versions. we will present practical "how to" design lessons illustrated by examples to illustrate the above points. neurocognitive evidence that guides research of driving under the influence of cannabis michael c. stevens, olin neuropsychiatry research center iol there is a long history of experimental research that has tested the effects of cannabis use on how well people perform on laboratory tests of cognition and behavior. such tests are useful because by design they isolate specific abilities that are grounded in the function of particular neural systems of the brain. the most consistent, strongest evidence for cannabis-induced impairments come from tests that assess executive cognitive abilities (e.g., divided attention, set shifting and others), time estimation, and visuomotor tracking. for research studies of cannabis' effect on driving, these tests can be useful to validate the presence and extent of dose-related cognitive impairment. moreover, because these abilities are relevant to optimal driving performance, "real world" driving analogues of these abilities can be built into simulations to observe the effect of cannabis use on these specific cognitive processes during driving. this presentation will review and summarize the results of laboratory cannabis challenge neurocognitive studies, then describe how some of these tasks have been translated into formats that are compatible with using brain functional neuroimaging methods (fmri). neuroimaging methods provide valuable information to the question of driving-related impairment by characterizing how any cognitive or driving decrements that are detected are related to altered function of specific neural systems of the brain. the presentation will summarize available fmri studies of cannabis' effects on brain dysfunction, including emerging evidence from our studies of driving-relevant fmri task probes during cannabis challenge studies. interactive effects of thc with cbd and etoh on cognition and driving performance mohini ranganthan yale university given the high rates of cannabis use, the varying concentrations of the delta-9tetrahydrocannabinol (thc) and cannabidiol (cbd), the two main components in cannabis, and the increasingly common practice of using ethanol (etoh) and cannabis together, there is a need to systematically characterize the interactive effects of thc and cbd in cannabis and their effects in combination with etoh on cognitive processes relevant to driving as well as driving performance. we will present data from a series of studies in healthy humans examining 1) the interactive effects of thc and cbd, on driving related cognitive tasks and 2) the interactive effects of etoh and low dose thc using a simulated driving task. we find that thc reduced the amplitude of the event related potential, p300 on conference abstracts 96 a sustained attention task. cbd had no effects on p300 amplitude by itself, but attenuated the thc induced reduction in amplitude. further, our preliminary data suggest that while low dose etoh clamped at blood alcohol concentrations below the legal limit (0.04 bac) and low dose thc alone had minimal effects on driving performance measured as the standard deviation of lateral position (sdlp), the combination of the two produced significant alterations in driving outcomes (increased sdlp and speed). the cultural basis for deciding to drive under the influence of cannabis (duic) nicolas ward montana state university driving under the influence of cannabis (duic) is a choice. it does not happen by “accident”. and so, cannabis would not be debated as a crash factor if drivers never chose to drive after consuming it. although this appears to be an obvious and simplistic assertion, it does represent an important perspective on cannabis and traffic safety. even after we understand the effects of cannabis, we still need to understand the determinants of the decision to drive after using this drug. as inconsistent with safe driving as cannabis effects might be, they would be irrelevant to traffic safety if users shared a culture that prohibited driving while stoned. as social beings, our choices are influenced by our social environment. we are motivated to make decisions that that are consistent with the culture we perceive to represent the groups with which we identify. our motivation is to reinforce our membership in those groups and avoid rejection. in this context, “traffic safety culture” can be defined as the values and beliefs shared among groups of road users (and stakeholders) that influence their decisions to behave in ways that improve traffic safety. so what are the relevant factors of traffic safety culture amongst cannabis users that impact their intention and willingness to duic? this presentation will summarize the results of three separate studies that used survey methods based on a model of that operationalized traffic safety culture and predicted its influence on duic intention and willingness. across these studies, several cultural factors consistently influenced both duic intention and willingness including values, behavioral beliefs, attitudes, and norms. by identifying these predictive factors, it is then possible to develop strategies to transform culture and reduce the intention and willingness to duic. accordingly, this culturebased paradigm is an important component of a strategy plan to reduce duic behavior and cannabis-related traffic fatalities. supplemental materials here symposium: use of marijuana protective behavioral strategies by young adults chair: eric pedersen rand given recent state legalization of recreational marijuana use and majority popular opinion favoring these laws, it is important to identify strategies that may mitigate harms related to marijuana use among those young people who choose to use the drug. in this symposium, we feature four researchers who have examined the use of marijuana protective behavioral strategies – behaviors that one engages in before, during, after, or instead of using marijuana to reduce the harms of use – among young adult college students and veterans. using large and diverse samples of young adults, researchers examined how use of these strategies mitigates harms through several different pathways and among individuals with various mental health symptoms, motives for marijuana use, and personality traits, as well as how perceived effectiveness of these strategies and timing of strategy use impacts experience of negative marijuana outcomes. findings suggest that use of marijuana protective strategies may moderate the effects of mental health symptoms on negative consequences among young adult veterans and they may buffer the effects of risk factors and enhance the effects of protective factors on marijuana-related outcomes among college students. findings also demonstrate that college students are more likely to use marijuana protective behavioral strategies if they perceive them to be effective, that the protective effect of strategy use is strongest among students who perceive them to be effective, and students experience less harm from their marijuana use on days which they use a higher number of protective https://publications.sciences.ucf.edu/cannabis/files/rsmj2017ward.pdf conference abstracts 97 strategies. clinical and research implications will be discussed. contact: eric r. pedersen ericp@rand.org use of protective behavioral strategies among young adult veteran marijuana users eric r. pedersen, margo villarosa-hurlocker, mark a. prince rand, university of new mexico, & colorado state university veterans are a population that are at risk for heavy marijuana use and resulting cannabis use disorder. though actual prevalence rates are not well reported, it estimated that approximately one-fifth to one-quarter of veterans in the va and in the community report past year marijuana use. cannabis use disorder is somewhat prevalent in the population and has been found to be significantly underdiagnosed in the veterans health administration compared to other substance use disorders. veterans are particularly at risk given their tendency to experience more severe medical problems and psychiatric difficulties compared to the general population and marijuana use has been linked to risk for posttraumatic stress disorder (ptsd) in particular. many veterans believe marijuana helps reduce negative mental health symptoms and researchers have found an exacerbation of symptoms among veterans using marijuana to cope. the present study was designed to examine how protective strategies used before, during, after, or instead of using marijuana (e.g., take periodic breaks if it feels like you are using marijuana too frequently, limit the amount of marijuana you smoke in one sitting, avoid using marijuana before work or school) moderated the effects of mental health symptoms on marijuana use and consequences among a sample of 180 young adult veteran marijuana users. in addition to a 17-item brief version of the protective behavioral strategies scale for marijuana (pbsm-17), veterans aged 19-34 recruited through the internet completed online measures of demographics, mental health symptoms of ptsd, and marijuana use and consequences. more frequent use of marijuana protective strategies associated with less frequent marijuana use and fewer negative consequences. those screening positive for ptsd experienced more consequences from use but that effect was moderated by their use of protective strategies, such that those with a positive ptsd screen who used protective strategies more frequently experienced fewer consequences than those with a positive ptsd screen who used protective strategies less frequently. findings expand on the college student studies indicating greater frequency of protective strategies associates with less frequent marijuana use and fewer consequences by replicating these findings among veterans. in addition, this study adds to the literature on mental health and substance use among veterans by documenting a moderating effect of protective strategies use on negative marijuana outcomes. findings suggest that use of protective strategies may be important for young veterans who choose to use marijuana, in particular for those who may use marijuana to cope with symptoms of ptsd. marijuana protective behavioral strategies as a moderator and mediator of the effects of risk/protective factors on marijuana-related outcomes adrian j. bravo, mark a. prince, matthew r. pearson, & the marijuana outcomes study team university of new mexico & colorado state university given the high prevalence of marijuana use among college students, it is imperative to determine the factors that may reduce risk of problematic marijuana use and/or the development of cannabis use disorder. from a harm reduction perspective, the present studies examined whether the use of marijuana protective behavioral strategies (pbs) mediates or moderates the effects of several distinct risk and protective factors that have been shown to relate to marijuana-related outcomes (i.e., use frequency and consequences). specifically, we examined marijuana pbs use as a mediator and moderator of the effects of gender, age of first use, impulsivity-like traits, and marijuana use motives on marijuana use frequency and marijuana-related consequences in a large sample of college students (n = 2,093 past month marijuana users across 11 universities). in all conference abstracts 98 models, marijuana pbs was identified as a robust negative predictor of marijuana use frequency and marijuana-related consequences. further, marijuana pbs use fully or partially mediated the effects of gender, premeditation, perseverance, coping motives, enhancement motives, conformity motives, and expansion motives on marijuana outcomes. among interactions, we found: 1) unique significant interactions between specific impulsivity-like traits (i.e., premeditation, perseverance, and sensation seeking) and marijuana-pbs use on marijuana consequences, 2) unique significant interactions between each marijuana use motive and marijuana-pbs use on marijuana use frequency, and 3) that using marijuana-pbs appears to buffer the risk associated with male gender across both marijuana outcomes. taken together, our results suggest that marijuana-pbs use can buffer the effects of risk factors and enhance the effects of protective factors on marijuana-related outcomes among marijuana using college students. further, our results suggest that marijuana pbs use is a good candidate to be considered as a mechanism by which marijuana users moderate their marijuana use and attenuate their risk of experiencing marijuana-related consequences. overall, the current studies provide evidence that marijuana-pbs use is associated with less marijuana use frequency and marijuana related consequences among college students. thus, there is a need for a marijuana-pbs use focused intervention targeting college student marijuana users. future research is needed to understand context-specific factors and individual-level factors that may make marijuana-pbs use more effective. perceived effectiveness of marijuana protective behavioral strategies and marijuana-related outcomes mark a. prince, matthew r. pearson, adrian j. bravo, & the marijuana outcomes study team colorado state university& university of new mexico a large literature demonstrates that use of alcohol protective behavioral strategies (pbs) is related to less alcohol use and the experience of fewer alcohol-related problems. a small number of studies have begun to establish that marijuana pbs use is related to less marijuana use and negative marijuana-related consequences. in the alcohol field, two studies have examined the role of perceived effectiveness of pbs treating perceived effectiveness as an antecedent of pbs use (i.e., antecedent model). the assumption these researchers made was that individuals would choose strategies they believed to be effective. however, in some of our previous work we have found some support for an alternative model (i.e., mediation model) such that perceived effectiveness of pbs mediates the effects of pbs use on alcohol-related outcomes. another reasonable alternative model that has yet to be tested would presume that the effects of pbs use on outcomes may depend on the perceived effectiveness of pbs use (i.e., moderation model). to date, none of these models have been tested in the context of marijuana use. using data from a large, multi-site (k = 11) online ongoing study of marijuana use among college students (marijuana outcomes study team), we examined the evidence for three alternative models: 1) an antecedent model (perceived effectiveness of pbs usepbs use marijuana consequences), 2) a mediation model (pbs use perceived effectiveness of pbs usemarijuana consequences), and 3) a moderation model (pbs use x perceived effectiveness of pbs usemarijuana consequences). although this study is ongoing (projected total n ~ 10,000; ~ 2,600 users), we conducted preliminary analyses using 271 past month marijuana users from 3 sites (total current n = 937). based on our preliminary analyses, we have found support for the antecedent model (i.e., pbs use fully mediating the effect of perceived effectiveness of pbs use on marijuana consequences), no support for the mediation model (perceived effectiveness did not have a protective direct effect on marijuana consequences when controlling for pbs use), and support for the moderation model (interaction effect accounted for an additional 5.2% of the variance in marijuana consequences beyond the component main effects). our results suggest that individuals are more likely to use pbs if they perceived them to be effective, and that the protective effect of pbs use is strongest among individuals who perceived pbs to be highly effective. although preliminary, these results have important clinical implications. specifically, our results suggest that clinicians need to conference abstracts 99 carefully discuss specific pbs with clients to determine which strategies the client perceives will be most effective for them. to the extent that a client perceived pbs to be ineffective at reducing harm, pbs-based interventions would benefit from including an educational component to demonstrate that these strategies are effective for many individuals. reducing harms from marijuana: a daily diary examination of marijuana protective behavioral strategies among college students adam d. wilson, matthew r. pearson, adrian j. bravo, bradley t. conner, & jamie e. parnes university of new mexico & colorado state university marijuana protective behavioral strategies (pbs) are cognitive behavioral strategies used before, during, after, or instead of marijuana use to reduce marijuana use, intoxication, and/or consequences. we examined the interindividual (between-subjects) and intraindividual (withinsubjects) effects of using marijuana protective behavioral strategies on various marijuanarelated outcomes. forty-three college student marijuana users from three different, large u.s. universities located in virginia, new mexico, and colorado completed daily brief surveys (<10 minutes) over a 12-day (april 15thapril 26th, 2016) period assessing use of protective behavioral strategies and marijuana-related outcomes (i.e., number of unique marijuana use sessions, subjective high/intoxication while under the influence of marijuana, number of grams of marijuana consumed, and marijuana relatedconsequences). between 49% (pbs item 11: “limit the amount of marijuana you smoke in one sitting”) and 63% (pbs item 7: “only use when you know you have nothing important to do for the rest of the day/night”) of the variance in marijuana pbs use items was at the withinsubject level (average icc = 0.566). for the pbs total score, 34% of the variance was at the withinsubject level (icc = 0.655). between 40% (subjective high) and 59% of the variance in marijuana outcomes was at the within-subject level (number of sessions: icc = 0.41, grams consumed: icc = 0.52, subjective high: icc = 0.60, negative consequences: icc = 0.48). at the withinsubject level, marijuana pbs use (total score) was associated with lower subjective high (β = -.23) and less number of sessions (β = -.18). at the between-subject level, marijuana pbs use (total score) was associated with lower subjective high (β = -.40), less number of sessions (β = -.64), and lower negative consequences (β = -.40). we also examined specific pbs items as they related to these outcomes at both within-subject and between-subject analyses. we found evidence that not only does pbs use have protective effects on marijuana-related outcomes at the betweensubject level, but also at the within-subject level. exploratory analyses further revealed that college student marijuana users are less likely to use pbs (specifically “avoid using marijuana early in the day”, “avoid buying marijuana”, and “using enough to only achieve a slight buzz”) on 4/20 (an event-specific marijuana use day) compared to other days. these findings suggest that an individual may experience less harm from their marijuana use on days on which they used a higher number of pbs. several specific pbs items predicted specific marijuana-related outcomes, further validating the daily assessment of pbs use. we discuss how the within-subject analyses using ecological momentary assessment data can be used to inform clinical interventions. symposium: using ema and daily process methods to examine marijuana motives and craving among young adults chair: kristina t. phillips university of northern colorado retrospective reports of marijuana use and associated behaviors can be problematic due to issues with memory recall and patterns of bias in estimating behavior. to improve on such limitations, ecological momentary assessment (ema) and daily diary methods are being used increasingly to assess complex behaviors closer to the moment. this symposium will provide an introduction to these methodologies and will discuss findings from four studies focused on young adults, with a focus on implications for intervention. first, phillips will provide a brief introduction to intensive longitudinal methods and applications to marijuana research. she will discuss preliminary data from an ema study focused on the role of craving and mood on marijuana use among college students in-theconference abstracts 100 moment. second, bonar will report on daily diary data from a community sample that examines associations between motives and quantity of marijuana consumed. bravo will present on daily diary data with college students that examines day-to-day variability in marijuana use motives and their associations with marijuana-related outcomes. finally, prince will discuss ema data with young adults from a community sample and will examine episode-level motives and craving related to marijuana use during and after an intervention. collins will close as discussant with a summary and interpretation of the presented findings. all speakers will discuss the implications of these findings for interventions with young adults in future research, including those that focus on the real-world context. marijuana use, mood, and craving: a study using ema with college students kristina t. phillips, michael m. phillips, & trent l. lalonde university of northern colorado background: heavy marijuana use is associated with a number of negative consequences, including addictive behaviors and emotional difficulties. past research has demonstrated that heavy marijuana users are more likely to experience depression and anxiety and that craving for marijuana may lead to greater use. however, it is unclear how certain substance use dynamics and mood might impact marijuana use in-the-moment, thus providing important information for the design of new interventions. the current presentation will provide an introduction to ema and daily process research and discuss preliminary data from a new study examining the impact of a range of complex factors on marijuana use among young adults in the college environment. method: collegestudents (n = 53) who used marijuana at least weekly or greater were recruited from a mid-sized western university and completed a baseline assessment and training on a two-week ema protocol. participants were sent questions through a smartphone application, three times per day for two weeks. for the current analyses, marijuana craving and mood were assessed on 010 scales (low to high), while marijuana use was assessed two ways: 1) the number of marijuana use instances and 2) the time spent (in minutes) using marijuana since the last prompt. we used four time-lagged hierarchical (mixed-effects) models (controlling for day of the week) to examine whether craving and mood predicted subsequent marijuana use at the next time point. results: participants averaged 20.02 (sd = 1.49) years of age, were 57% female, and 76% caucasian/non-latino. average marijuana use over the last month from baseline self-report was 23.6 days, characterizing the sample as daily or near-daily users. two mixed-effects models were used to assess the impact of craving, adjusting for day of the week and time of the study. model 1 showed that craving significantly predicted the amount of time participants spent using at the next assessment point (β = 1.43, p < 0.001). similarly, model 2 showed that craving also positively predicted the number of times participants used at the next time assessment (β = .064, p < 0.001). two additional time-lagged models examined whether ema mood predicted marijuana use (minutes spent smoking and the number of times smoked). neither model was significant. conclusions: a temporal association between craving and marijuana use was found, where greater momentary craving positively predicted greater marijuana use assessed through time spent using and the number of use instances. mood was not associated with marijuana use among participants, though this will be further assessed with more participants and as a potential mediator in future analyses. these findings have implications for future work with college student marijuana users. interventions that consider these factors in real-time, such as ecological momentary interventions or just-intime adaptive interventions, may be useful in targeting behaviors that impact marijuana use in the real-world context. daily relationships between marijuana motives and marijuana consumption erin e. bonar, jason e. goldstick, james a. cranford, rebecca m. cunningham, & maureen a. walton university of michigan background: marijuana use among emerging adults (ages 18-25) is associated with varied conference abstracts 101 individual and public health consequences. there is a need for greater understanding of the determinants of marijuana use among emerging adults, given its prevalence and potential for adverse effects, particularly in the context of increasing access to legal recreational marijuana. daily and event-level data can provide finergrained detail on the proximal factors influencing marijuana use, which may prove useful in developing personalized, tailored, and/or just-intime adaptive interventions to reduce marijuana use and its related consequences. motives are an important individual-level influence on consumption and potentially an important intervention target because they have been shown to change as a result of interventions. method: patients aged 18-25 were recruited from an urban emergency department to participate in a 28-day prospective, text message-delivered assessment study of drug use and sexual risk behaviors. study inclusion criteria were: past 4-week drug use, past 4-week sexual intercourse without a condom, and having a cell phone with text messaging. participants were trained to use a standardized method for estimating daily quantity of marijuana use. daily text-based assessments included questions pertaining to marijuana use and motives, other substance use, and sexual behaviors. the present analyses focus on motivations for daily marijuana use as related to predicting daily quantity consumed on days when participants reported using any marijuana. using a mixed effects linear regression model, we examined the relationships between daily motives ratings (enhancement, social, conformity, coping, and expansion; rated from 1=not at all to 4=a great deal) and quantity of marijuana consumed (rated from 1=<0.5g/<1 joint to 6=2.5g+/5+ joints). results: n = 95 participants reported marijuana use on at least one daily text survey. demographically, they were 48.4% male and 45.3% african american with a mean age of 22.0 (sd = 2.2). participants reported using marijuana on a total of 1,086 daily surveys during the 28-day period and provided complete motives data on 1,049 days. examining a multi-level linear regression analysis (where day was clustered within individual) that controlled for gender, race, and public assistance, (model r2=.50) we found that daily use of marijuana for enhancement (to enjoy the feeling, β=.27, p<.001), coping (to feel less depressed/nervous, β=.15, p<.001), and/or social motives (to make a social gathering more fun; β=.34, p<.001) was related to higher selfreported quantities of daily marijuana use. relationships for expansion (to increase awareness; β=.08) and conformity motives (to fit in, β=-.03) and conformity were non-significant. conclusions: this present analysis demonstrates the occurrence of significant daily relationships between three motivations for marijuana use and daily quantity consumed. interventions tailored to help emerging adults address enhancement, social, and coping motives should be considered. future research should examine a broader range of motivations for marijuana use (e.g., boredom, habit, sleep) in relation to daily quantities of marijuana use to better inform interventions. **this abstract represents work that was subsequently published: drug & alcohol dependence, vol. 178, p136–142, published online: june 15, 2017 why i get high: a daily diary examination of marijuana use motives among college students adrian j. bravo, matthew r. pearson, bradley t. conner, & jamie e. parnes university of new mexico & colorado state university objective: given that marijuana use among college students is prevalent and chronic marijuana use is associated with various health problems, it is important to identify risk factors associated with heavy and problematic (i.e., associated with negative consequences) marijuana use. motivation models of marijuana use (for an overview, see cooper et al., 2016) posit that marijuana use motives are the most proximal antecedent to marijuana use involvement. based on multivariate analyses across several studies, internally motivated motives (i.e., enhancement, expansion, and coping) are mostly strongly related to marijuana use and negative consequences, social motives are generally only modestly related to marijuana use (not strongly related to negative consequences), and conformity motives are largely unrelated to marijuanarelated outcomes. although these relationships have been thoroughly examined concurrently (i.e., cross-sectionally), less research has examined the effects of marijuana use motives prospectively and little is known about day-to-day variability in conference abstracts 102 marijuana use motives and their associations with marijuana-related outcomes. method: fortythree college student marijuana users from three different, large u.s. universities located in virginia, new mexico, and colorado completed daily brief surveys (<10 minutes) over a 12-day period assessing prior-day marijuana use motives (i.e., coping, conformity, enhancement, social, and expansion), marijuana use (i.e., number of unique marijuana use sessions, subjective high/intoxication while under the influence of marijuana, and number of grams of marijuana consumed), and marijuana related-consequences. results: at the within-subject level, enhancement motives were significantly associated with more grams consumed (β=.15), higher subjective high (β=.23), and more negative consequences (β=.36). conformity motives were significantly associated with lower grams consumed (β=-.33) and expansion motives were associated with lower negative consequences (β=-.09). at the betweensubject level, enhancement motives were uniquely associated with higher subjective high (β=.46) and coping motives were strongly associated with negative consequences (β=.86). conformity motives were associated with lower negative consequences (β=-.59). exploratory analyses further revealed that college student marijuana users are less likely to use coping and expansion motives on 4/20 (an event-specific marijuana use day) compared to other days. conclusions: these preliminary findings suggest that we may be able to predict, prior to marijuana use, how individuals might use marijuana differently and what consequences they may experience simply by measuring their motives for using marijuana. further, we found that mood-regulatory motives (i.e., enhancement and coping) were the most robust predictors of outcomes, providing additional empirical support for affect regulation models of substance use. from a clinical perspective, these results suggest that it may be prudent for interventions to address the use of marijuana to regulate one’s mood, whether one is focused on diminishing negative affect or enhancing positive affect. additional work is needed to examine the contextual factors that may enhance or diminish the effects of these specific marijuana use motives on marijuanarelated outcomes. physical activity may buffer the relation between episode-level motives and marijuana use mark a. prince, r. lorraine collins, sandy d. wilson, & paula c. vincent colorado state university & university at buffalo, state university of new york background: there are positive associations between marijuana use motives (mum; i.e., reasons for use) and marijuana consumption. two of the most common mums involve enhancement (i.e., to enjoy experiences) and coping (i.e., to forget problems); each has been linked to increased marijuana use. craving also is a contributor to marijuana use, particularly among users seeking treatment. research typically examines cross-sectional relations among these variables. however, it is important to understand situational (i.e., episode level) variation in contributors to marijuana use, particularly in the context of intervening to reduce marijuana use. in the current study, we examined episode-level motives and craving as related to marijuana use during and after an intervention. method: we developed and tested two motivational interviewing-based marijuana-reduction conditions (mi) that involved learning cognitive and behavioral strategies. the key difference between the conditions was that one included promotion of physical activity (pa) as a positive alternative to using marijuana (mi+pa condition) and the other did not (mi only condition). all participants (n = 37; n mi+pa = 18, n mi = 19) were regular marijuana users (> 3 time/week), interested in reducing their use. they used a smart-phone app to provide episode-level ecological momentary assessment data on the variables of interest during the 4-week intervention and at 2-week periods during followups at 1-, 3-, and 6-months. we sought to examine the impact of treatment condition on the relationships among two mums (i.e., enhancement, coping), craving, and quantity of marijuana use, each reported at the episode level. because pa was promoted as a way to enhance experiences, we hypothesized that treatment condition would moderate these relationships such that those in the mi + pa condition would have a weaker relation among motives, craving, and marijuana use. we used the random conference abstracts 103 coefficient prediction (rcp) method to conduct a multilevel sem to test the hypothesis. the rcp method involves creating a random slope, which is predicted by the moderating variable. it is particularly useful for modeling cross-level interactions. random slopes were calculated for the relations among the mums (i.e., coping, enhancement), craving and marijuana use; treatment condition was entered as a predictor of the random slopes on the between level. results: results supported an overall positive relationship between enhancement motives and quantity consumed in a given episode. this relationship was moderated by treatment condition, such that those in the mi + pa condition had a weaker relation between the enhancement motive and marijuana use. episode-level relations among craving, coping motives, and quantity of marijuana use were not significant. conclusions: our findings suggest that including pa in efforts to reduce marijuana use buffer the relationship between episode-level enhancement motives and marijuana use. it is possible that engaging in pa lessened the desire to use marijuana to enjoy oneself. surprisingly, once we controlled for motives, there was not a direct relation between episode-level craving and marijuana use, following the intervention. discussant: r. lorraine collins, university at buffalo, state university of new york symposium: predictors, consequences, & protective behavioral strategies for marijuana use with college students chair: joey k. smith colorado state university there is growing research on the relations between marijuana and a range of individual characteristics, e.g., personality traits, mental health diagnoses, and simultaneous polysubstance use. with increased availability and use of marijuana, the number of individuals enduring marijuana-related consequences may also increase. one intervention that has been shown to alter marijuana use and consequences is protective behavioral strategies (pbs). pbs consists of behaviors that individuals engage in that can reduce substance use and consequences. this symposium will present research from investigators primarily interested in predictors and consequences among college students; as well as what strategies can be used to reduce marijuana use and consequences. the first presentation will present a latent profile analysis of social anxiety and personality traits to examine if personality variables moderate the relation between social anxiety and marijuana use. the second presentation will demonstrate how simultaneous use of marijuana and alcohol moderates the relation between marijuana use and marijuana consequences. the final two presentations examine the mediating role of pbs in the relation between personality and marijuana consequences, as well as the relation between marijuana use motives and marijuana consequences experienced. furthering our understanding of personality traits, mental health diagnoses, and simultaneous marijuana and alcohol use allows for appropriate planning and intervention for these individuals. additionally, bolstering the literature with the moderating effects of pbs allows greater insight into successful strategies to reduce marijuana use and consequences. contact: joey smith joey.smith@colostate.edu examining the relations between social interaction anxiety and marijuana use among college students ryan l. rahm-knigge, mark a. prince, & bradley t. conner colorado state university social anxiety disorder is a common psychological diagnosis with a lifetime prevalence rate of 12%. research has shown that nearly 30% of people with cannabis use disorder also meet diagnostic criteria for social anxiety disorder. additionally, previous research has shown that those diagnosed with social anxiety disorder may use marijuana as a means for avoiding social interactions. college students with social anxiety are vulnerable to marijuana-related problems. despite this, findings as to whether social anxiety relates to increased marijuana use are mixed. additionally, factors that may affect the relation between social anxiety and marijuana use, such as the roles of personality traits that relate to increased substance use, are not well known. to better conference abstracts 104 understand the relation between social anxiety and marijuana use, we assessed social interaction anxiety, a facet of social anxiety disorder pertaining to interpersonal interactions with others; sensation seeking; urgency, emotion dysregulation; behavioral inhibition, and behavioral approach. we also measured frequency of marijuana use in the average week, past 30 days, and past six months. participants were 1003 undergraduate students in a state in which recreational marijuana is legal for individuals over the age of 21. we used finite mixture modeling to identify profiles of social interaction anxiety and all included personality traits. we hypothesized we would discern distinct classes of social interaction anxiety and all included personality traits. we also hypothesized that the discerned classes would differentially predict marijuana use. a four-class solution best fit the data based on multiple fit indices. of interest to this study were two high social interaction anxiety classes most distinguished by levels of urgency, emotion dysregulation, and risk seeking, such that one class was high in these traits (labeled high social interaction anxiety, high urgency) and one class low in these traits (high social interaction anxiety, low urgency). the high social interaction anxiety, high urgency class was significantly more likely to report using marijuana more frequently at all time points. these results allow us to better understand the relation between social interaction anxiety and, more broadly, social anxiety, and marijuana use. further, because individuals who engage in substance use and other risky behaviors may be excluded from diagnosis, results can help clinicians more accurately diagnose individuals with symptoms of social anxiety who engage in these behaviors. accurately diagnosing individuals who present with symptoms of social anxiety can help clinicians and researchers design interventions tailored to individuals who are using marijuana as a coping mechanism. for example, the first step would be to have clinicians assess for co-occurring cannabis use disorder and social anxiety disorder. if both are present, the clinician could treat both simultaneously so that reduction in one do not lead to exacerbation of the other. relation of marijuana-related consequences with simultaneous alcohol and marijuana use joey k. smith, jamie e. parnes, & bradley t. conner colorado state university marijuana and alcohol are commonly used by many young adults. previous studies have suggested that past-year prevalence rates of marijuana have doubled over the past ten years, and the rates of alcohol-use disorder continued to grow during the same period. the increased prevalence is also found in the simultaneous use of alcohol and marijuana. simultaneous polysubstance use is the ingestion of two or more substances within the same period, such that they interact in an additive or synergistic manner. these simultaneous users may be at increased risk of experiencing negative consequences, but no studies have examined this relation. we examine how simultaneous use of marijuana and alcohol moderate the relation of marijuana and alcohol use frequency on consequences experienced. data collection is ongoing at a large western state university, and currently includes 252 students (50.0 % female, 81.5% white, m = 20.7 years). to better understand how simultaneous polysubstance use interacts with consequences, we assess frequency of past-week marijuana use on the average severity of consequences experienced. we also examined the effect of past-week marijuana use on the total number of consequences experienced. to assess how frequency of alcohol use may be related, we assess number of days per week alcohol is typically consumed on the average severity of consequences experienced. we also examined the relation of number of days per week alcohol is consumed on the total number of consequences experienced. we hypothesize that simultaneous use of marijuana and alcohol will significantly moderate the relation of marijuana and alcohol frequency with the number of marijuana-related consequences experienced. due to the count-nature of the severity of consequences outcome, negative binomial regression will be utilized. we also hypothesize that simultaneous use of marijuana and alcohol will significantly moderate the relation of marijuana and alcohol frequency with perceived severity of consequences. the average severity of consequences will be analyzed using conference abstracts 105 hierarchical linear regression. preliminary analyses indicate that the simultaneous use of marijuana and alcohol significantly moderates the relations of substance use frequency and consequences experienced. furthering the understanding of how substance use is related to consequences among simultaneous marijuana and alcohol users will provide insight into the development of substance-related issues. this could also lead to advances in new interventions and strategies to assist those who are experiencing distress from their marijuanarelated consequences. this would be especially helpful to those who are simultaneous polysubstance users who are experiencing negative outcomes. protective behavioral strategies mediate sensation seeking & marijuana-related consequences relation ryan t. neugebauer, mikdalia j. oh, mark a. prince, bradley t. conner & the marijuana outcomes study team colorado state university given the recent increase in legal and social acceptability of marijuana access in the us, there is a growing need to understand risk and protective factors related to marijuana-related consequences (mrc). recent research found 30.1% of marijuana users reported having 4 to 8 negative mrc in the past month. one consistent predictor of marijuana use is sensation seeking, with previous research demonstrating that greater sensation seeking leads to greater use; however, no research to date has examined the link between sensation seeking and mrc. further, protective behavioral strategies (pbs) are behaviors that individuals can engage in to reduce their consumption of a given substance and/or attenuate consequences. bravo et al. showed that pbs can be effective in lowering both the frequency of marijuana use and mrc. we hypothesize that (a) those higher in risk seeking are less likely to use pbs and more likely to experience mrc, (b) that those who are high in experience seeking are more likely to use pbs and less likely to experience mrc, and (c) that pbs will mediate both relations between sensation seeking indices and mrc. method. the current study is a secondary data analysis of the initial marijuana outcome study team data collection. analysis plan. a path analysis was conducted to assess for indirect effects from both risk and experience seeking to mrc via frequency of pbs use. mrc were modeled as a negative binomial count variable due to high positive skew. indirect effects were tested using the product of coefficients method and monte carlo confidence intervals. results. as predicted, we found negative relations between both experience seeking and pbs and mrc and a positive relation between risk seeking and mrc. further, pbs mediated the relations between both risk and experience seeking and mrc. one index of effect size is the ratio of the indirect effect to the total effect (i.e., pm). our analyses showed that pm for the risk-seeking-pbs-mrc path was .58, and for the experience-seeking-pbs-mrch path was .68. discussion. results from the present study suggest that pbs is a strong mediator of the sensation seeking-mrc relation, with the indirect effect explaining half to two-thirds of the direct effects. moreover, we suggest that clinicians promote use of pbs with clients who are high in risk seeking. this recommendation follows from our findings that risk seekers are less likely to use pbs and that pbs are effective in reducing mrc. in addition, clinicians should support pbs use among experience seekers. pbs will help experience seekers have the experiences they are seeking with less risk. item-level protective behavioral strategies mediates marijuana use motives and consequences relation kirstyn n. smith-lecavalier, elaina l. keegan, mark a. prince, & the marijuana outcomes study team colorado state university with the changing legal and social acceptance of marijuana use across the nation and resultant increases in prevalence of marijuana use, there is a need to add to the intervention tools available to clinicians. over the past two decades, marijuana researchers have shown a positive association between marijuana use motives (mum; i.e., individuals' reasons for using marijuana) and the amount of marijuana consumed as well as the number of marijuana-related consequences experienced. simons et al. identified 5 distinct conference abstracts 106 mum (i.e., social, coping, enhancement, expansion, conformity) which each uniquely predict marijuana use outcomes. more recently, pedersen et al. developed a measure for marijuana protective behavioral strategies (pbs), which was shown to be negatively related to marijuana use and related consequences. pbs, in this context, are behaviors that individuals can use to reduce their marijuana use or reduce their risk for consequences. pedersen and colleagues recently reduced the 50-item marijuana pbs scale down to 17 items. the current study examined the mediating role of each marijuana-pbs item in the mum-marijuana consequences relation. method. the current study is a secondary data analysis of the initial marijuana outcome study team data collection. analysis plan. a series of 17 path analyses were conducted to assess for indirect effects from each of the 5 mum to marijuanarelated consequences via each individual marijuana-pbs item from the revised pbsm. marijuana-related consequences were modeled as a negative binomial count variable due to high positive skew. indirect effects were tested using the product of coefficients method and monte carlo confidence intervals. results. three strategies mediated all five mum (i.e., avoiding marijuana use to cope with emotions such as sadness or depression, limiting use to weekends, and avoiding using marijuana habitually which is multiple times a week). in addition, some specific strategies only served as mediators of certain mum. for social motives, avoiding mixing marijuana with other drugs had the largest effect size. for coping motives, avoiding using marijuana to cope with emotions such as sadness or depression had the largest effect size. for enhancement motives, avoiding methods of marijuana use that can make an individual more intoxicated than they would like had the largest effect size. for conformity motives, only purchasing marijuana from a trusted source had the largest effect size. finally, for expansion motives, avoiding using marijuana habitually had the largest effect size. discussion. results from the current study can help clinicians identify specific strategies that will be most successful for clients who report using for each type of mum or for a combination of mum. in summary, screening clients for their mum can identify the primary mum for an individual, and then the clinician can suggest the client try the strategy with the biggest effect size for that specific mum. alternatively, clients are unable to identify their most common mum, then clinicians might recommend one of the three protective behavioral strategies that mediated all mum copyright: © 2018 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i2a4_authors_final research article 40 ved abstract legal sanctions are purported to play a role in cannabis use and related consequences. general models of deterrence suggest that increases in arrests should decrease consumption by heightening perceptions of the negative consequences of use as well as the likelihood and severity of penalties. the present study examined if arrests resulting from cannabis possession relate to cannabis consumption, perceptions of use, and likelihood and severity of related penalties. combining data from the national survey on drug use and health with the fbi uniform crime report (2002-2013) allowed for the estimation of a series of fixedeffects models that compare rates of arrests and perceived risks of aggregate rates of self-reported use at the state-level over time. forty-nine states reported data (n = 592 state-years). cannabis-related arrest rates (ratio of possession arrests for state/state population times 1,000) ranged from 0.04 5.63. increases in cannabis-related arrests were associated with heightened perceptions of risk from use (b = .80 [-.16, 1.8], p < .05); but this association was non-significant in the model omitting states that legalized recreational cannabis in 2012. arrests related to greater perceptions of the severity of potential penalties, including community service (b = .54 [.24, .85], p < .05), probation (b = .85 [.44, 1.3], p < .001), and prison sentences (b = .25 [.02, .5], p < .05). arrest rates were not associated with cannabis use (b = -.25 [-.52, .05], p > .05) or the proportion of new initiates (b = -.02 [-.08, .05], p > .05). we conclude that increased arrests are associated with perceptions of negative consequences and penalty but appear unrelated to actual use. this study highlights the need to re-examine the utility of punitive approaches to reduce the public health burden posed by substance use. key words: = cannabis, marijuana, deterrence, arrest illicit drug use remains a persistent public health concern in the united states. in the united states, more than one in ten individuals over the age of 12 reported illicit substance use in 2017 (center for behavioral health statistics and quality, 2017). the most recent data from 2007 estimates a nearly $193 billion annual cost stemming from illicit substance use, including expenses for crime, loss of work, and healthcare (birnbaum et al., 2011; national drug intelligence center, 2011). by far, cannabis is the most consumed prohibited drug. of the 53.2 million individuals who reported using illicit substances in the past year in 2018, 43.5 million specifically indicated using cannabis (substance abuse and mental health services administration, 2019). at the federal-level, cannabis remains a schedule i substance. states’ policies vary substantially, ranging from the legalization of recreational cannabis to medical exceptions to total prohibition. to date, 37 states and the district of columbia (d.c.) have legalized medical cannabis, while 18 states and d.c. legally allow recreational use. similarly, policies regarding penalty for cannabis use, possession, and sales also vary widely by state, and can include considerable fines and prison time (see caulkins et al., 2016; room et al., 2010). federal prohibition of cannabis is maha n. mian1, matt vogel1, brianna r. altman1, luna f. ueno1, mitch earleywine1 1university at albany, state university of new york, usa cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.004 policing pot: state-level cannabis arrests increase perceived risks and costs but not use corresponding author: maha n. mian, department of psychology, university at albany, state university of new york. 1400 washington ave, albany, ny 12222. email: mmian@albany.edu cannabis, a publication of the research society on marijuana 41 longstanding, yet rates of use continue to rise (fielding et al. 2008). punitive policies implicitly rely on deterrence to stay the financial, social, and healthcare costs associated with problematic cannabis use, yet the effects of such efforts are not well understood. the general logic underlying deterrence policies is that the threat of sanctions will discourage individuals from engaging in criminal behavior (elliott et al., 1982; jervis, 1979; loughran et al., 2016; maccoun, 1993; nagin, 2013). in regard to cannabis, deterrence models assume that individuals will weigh negative consequences heavier than the perceived rewards of using, and act accordingly. such consequences include threat of punishment, but also social sanctions and negative consequences for mental and physical health. the effectiveness of deterrence relies on exposure to threats of punishment, including the consistent application of judicial procedures and penalties and one’s perceived relative risk of experiencing sanctions. fundamentally, individuals must also be aware of and understand the legal ramifications of one’s behavior. to work, deterrence requires individuals to be aware of and responsive to the possibility of punishment. the empirical evidence on the effectiveness of punitive criminal legal sanctions for curbing cannabis use is mixed. some work indicates that deterrence shapes the behavior of individuals who use cannabis who seek to avoid detection and penalty (elliott et al., 2012; erickson et al., 2013). certainty of punishment appears inversely related with cannabis use (meier et al., 1984; tittle, 1977). this trend is complicated by the finding that both users and non-users consider detection and arrest related to cannabis use to be unlikely (lundman, 1986). other work demonstrates that deterrence is has no effect on use (reinarman et al., 2004), or prompts the opposite effect, where greater likelihood for experiencing sanctions increases cannabis use (meier & johnson, 1977). further, early research on cannabis deterrence found that penalties of varying severity had little impact on use (single, 1989). a closer examination of deterrence on use, including social and perceptual factors, suggested that certainty of punishment might not play as decisive a role as previously hypothesized (erickson, 1980; erickson, 1982; meier & johnson, 1977).. more recent work focuses on the perceptual factors that relate to deterrence, such as risk, normalization, availability of cannabis, and public knowledge and attitudes surrounding cannabis policies (apel, 2013; arazan et al., 2015; hall et al., 2019; maccoun et al., 2009; nguyen et al., 2015). for instance, while many individuals are cognizant of penalties associated with cannabis, perceptions of risk appear more accurate among those already involved in criminal conduct (apel, 2013). additionally, proximal factors, such as the presence of peers, alter situational perceptions of risk, suggesting that risk perceptions are partly influenced by contextual factors. individual factors are also involved in the decision to use cannabis (erickson et al., 2013; jacobs, 2010). perceptions play a pivotal role in how individuals evaluate the risks and rewards associated with cannabis use, which inherently incorporate beliefs about stigma, acceptability, and therapeutic benefit (brunt et al., 2014; caulkins & pacula, 2006; hathaway et al., 2011b; maccoun et al., 2009; pacula et al., 2010). in addition to the insights gained from the present literature, an updated examination of perceptual factors and cannabis penalty is needed. the federal government and many states still prohibit the use of recreational cannabis. cannabis use is increasingly recognized as a public health issue, leading to adverse health outcomes and placing some individuals at an increased risk of social, financial, and legal consequences. cannabis policy changes appear to have a bearing on both use and penalty. results on the prevalence of use following legalization are mixed, with some reports indicating an increase in use, and others demonstrating stabilized rates over time (cerdá et al., 2012; doran et al., 2021; williams & bretteville-jensen, 2014). recent work indicates that decriminalization was associated with fewer arrests for adults (grucza et al., 2018a; gunadi & shi, 2021), though reductions vary across demographics (plunk et al., 2019; tran et al., 2020). despite the general trend toward decriminalization and legalization and subsequent reduced arrests, states overwhelmingly rely on the criminal legal system, and the primary tool in their kit, deterrence, to waylay the negative consequences of cannabis use. this is consistent with the increasing interest in substance use as a public health concern. assuming that the actions of the criminal legal system are an effective deterrent, we would still expect increasing levels of cannabis arrests and use 42 punishment, such as arrests, to increase perceptions of risks of cannabis use, ultimately driving down prevalence rates of use. the present study aimed to examine whether state rates of cannabis-related arrests between 2002 and 2013 were related to changes in use, proportion of cannabis initiates, and perceptions of risk and penalty. we predicted that perceptions of risk and penalty would increase as arrests increased, while use and proportion of new users would diminish, as arrest rates provide cues to the certainty of punishment and thereby disincentivise use. methods data we combine state-level data from the federal bureau of investigation’s uniform crime report (ucr) with disaggregated state-level data from the national survey on drug use and health (nsduh) for the period spanning 2003 – 2013. nsduh’s sampling strategy changed in 2013; we therefore selected this observation period to maintain consistency in sampling and survey items overtime. as noted below, this observation period also buttresses the legalization of recreational cannabis use in washington state and colorado in december of 2012. the ucr provides aggregate data on crimes known to police and arrests compiled from local jurisdictions across the united states. the ucr utilizes a standardized classification system which divides offenses into part i and part ii offenses. part i offenses are considered the most serious, occur with regularity, and are most likely to be reported to police. part ii offenses are less serious forms of offending, including substance use offenses. nsduh is a nationally representative survey of the civilian, noninstitutionalized u.s. population aged 12 years and older. nsduh collects, among other indicators, self-reported information about illicit drug use and the perception of harms associated with substance use. we rely on disaggregated state-level estimates of prevalence of cannabis use and related indicators computed by azofeifa and colleagues (2016). after removing missing data, we arrive at a final sample of 592 state-years. our primary independent variable, cannabis arrest rate, is the state-by-year specific arrest rate for cannabis possession, measured as the ratio of possession arrests for state/state population multiplied by 1,000. the ucr employs a hierarchical classification system in which only the most serious offense is recorded in situations in which multiple offenses occur during a single incident. the hierarchy rule ensures that cannabis possession will only be recorded in the most minor of events (e.g., those in which a more serious crime did not occur). as such, while our measure does not capture the full range of cannabis arrests, it captures ebbs and flows in innocuous forms of possession – those not linked to more serious forms of criminality. the dependent variables in our models are a series of estimates regarding the prevalence and perceived harms of cannabis use at the state-level over time. annual usage is the percentage of respondents who reported using cannabis in the past 12 months. past year initiates captures the percentage of first-time cannabis users. no risk and great risk are defined as those who reported that smoking cannabis once a month and once or twice a week might cause harm [great risk] and might not cause harm [no risk]. several items were included to capture perceived punishment associated with simple cannabis possession. these range from ‘no punishment’ to ‘mandatory prison sentence.’ a full description of these items is provided in supplemental i. descriptive statistics are presented in table 1. all nsduh estimates were weighted in our analyses. analytic strategy we employ a series of fixed effect regression models to estimate the effect of cannabis arrest rates on the indicators of state-level cannabis prevalence. we first examined fixed effects estimates of cannabis use, perceived risk, and perceived penalty regressed on possession rate for all states from 2002-2013 (n = 592). given the legalization of recreational cannabis at the end of 2012, we re-estimate our model omitting data from colorado and washington in 2013 (n = 590). as vermont legalized at the end of 2013, we retained vermont’s data from 2013 in our analyses. the fixed-effects estimator incorporates demeaned values of the independent and dependent variables, holding constant time-stable factors which might otherwise confound the observed association between year over year fluctuations in arrest rates and corresponding cannabis, a publication of the research society on marijuana 43 fluctuations in the measures of prevalence, harm, and perceived punishment. this helps overcome some of the issues associated with the ucr’s hierarchy rule. state-level processes that affect reporting and/or policing of minor possession are unlikely to change in meaningful ways, suggesting that the measurement error in our arrest rates should be relatively consistent within-states over this 12-year period. from this vantage point, the hierarchy rule provides a robust indicator of exactly the type of cannabispolicing to which we would expect the general public to be responsive. table 1. descriptive statistics for cannabis arrests, annual cannabis use, perceptions of risk, and perceptions of penalty (n = 592) mean sxb sxw min max possession arrest rate* 2.17 0.96 0.40 0.00 5.63 cannabis use annual usage self-report 11.42 2.67 1.35 5.30 21.40 past year initiates 1.58 0.36 0.31 0.50 3.90 perception of risk % reporting ‘no risk’ 12.74 2.47 3.59 4.90 28.40 % reporting ‘great risk’ 34.06 5.63 4.57 14.00 53.00 perception of penalty % reporting no punishment 4.47 3.96 3.62 0.50 58.20 % reporting fine 32.26 7.95 4.91 15.50 66.80 % reporting mand. prison 5.66 1.33 1.11 0.70 11.70 % reporting community service 8.24 1.55 1.47 2.40 19.20 % reporting probation 17.17 3.50 1.98 5.80 28.40 note. risk (no risk, great risk) and penalty (no punishment, fine, mand. prison, community service, probation) indicate percentage of perceived maximum legal penalty for cannabis possession. nsduh variables reported as percentages. complete survey items from ucr and nsduh can be found in supplemental 1. sx – standard error; b – between states; w – within-state; * – per 1000 individuals. results table 1 presents the descriptive statistics for each of the measures. the average possession arrest rate was 2.17 per 1,000 individuals. approximately 11 percent of the sample reported using cannabis in the past 12 months, with 1.6 percent of the population, on average, reporting first time initiation. respondents were more likely to report a great risk associated with regular cannabis use than they were to report no risk. the modal perceived legal sanction for cannabis possession was a monetary fine, followed by probation, community service, mandatory prison sentence, and no punishment. risk perceptions and perceived penalties varied greatly both between states and within states during our observation period. the parameter estimates, 95% confidence intervals, and standard errors for each of the outcomes regressed on the cannabis possession rate are presented in table 2. the coefficients can be interpreted as the expected change in outcome variable associated with a one-unit increase in the possession rate (1 additional arrest per 1,000 population) at the state-level. as evidenced here, arrest rates had no discernible effect on annual prevalence of cannabis use nor the prevalence of first-time initiates. a one unit increase in the possession rate was associated with an approximately one-percent increase in the percentage of the population reporting that regular cannabis use was a great risk (b = 0.80 95% ci [-.16, 1.8], p <0.05) and a concurrent onepercent decrease in those reporting regular cannabis use engenders no risk (b = 0.85 [1.6, .09], p < 0.05). turning to perceived penalties – state level increases in possession arrest rates were associated with more severe perceived penalties for cannabis possession. for instance, a one-unit increase in the arrest rate was associated with a .25 percentage point increase in those perceiving a mandatory prison sentence (b = .25 [.02, .5], p < 0.05), a .54 percentage point increase in those reporting community service (b = .54 [.24, .85], p < 0.001), and a .85 percentage point cannabis arrests and use 44 table 2. fixed effects estimates of cannabis use, perceived risk, and perceived penalty regressed on possession rate (n = 592) b [95% ci] se self-reported use annual usage self-report -0.25 [-.52, .05] 0.14 past year initiates -0.02 [-.08, .05] 0.03 perceived risk % reporting ‘no risk’ -0.85 [-1.6, -.09] 0.38 * % reporting ‘great risk’ 0.80 [-.16, 1.8] 0.48 * perceived penalty for possession % reporting no punishment -2.94 [-3.8, -2.1] 0.44 *** % reporting fine -1.34 [-2.4, -.31] 0.51 *** % reporting mand. prison 0.25 [.02, .50] 0.11 * % reporting community service 0.54 [.24, .85] 0.15 *** % reporting probation 0.85 [.44, 1.3] 0.21 *** note. se – standard error; *p < .05; **p < 0.01; ***p < 0.001 table 3. fixed effects estimates of cannabis use, perceived risk, and perceived penalty regressed on possession rate, removing colorado and washington state post-2012 (n = 590) b [95% ci] se self-reported use annual usage self-report -0.09 [-.38, .20] 0.15 past year initiates -0.01 [-.07, .06] 0.03 perceived risk % reporting ‘no risk’ -0.6 [-1.4, .10] 0.39 % reporting ‘great risk’ 0.61 [-.40, 1.6] 0.50 perceived penalty for possession % reporting no punishment -1.34 [-1.9, -.79] 0.28 *** % reporting fine -1.8 [-2.8, -.72] 0.53 ** % reporting mand. prison 0.17 [-.07, .40] 0.12 % reporting community service 0.41 [.10, .72] 0.16 * % reporting probation 0.70 [.28, 1.1] 0.21 ** note. se – standard error; *p < .05; **p < 0.01; ***p < 0.001 increase in those reporting probation (b = 0.85 [.44, 1.3], p < 0.001). by contrast, increases in arrest rates reduced those reporting ‘no punishment’ by 2.79 percentage points (b = 2.79 [-3.8, -2.1], p < 0.001) and those reporting a monetary sanction by 1.34 percentage points (b = 1.34 [-2.4, -.31], p < 0.001). finally, we examined estimates for outcomes regressed on the cannabis possession rate omitting 2013 data from colorado and washington (n = 590; table 3). overall, these results were similar to our initial model for past year annual use and initiates as arrests were not associated with either outcome. one unit increases in arrests were again related to greater perception of penalty, specifically for community service (b = .41 [.10, .72], p < 0.05), and probation (b = 0.70 [.28, 1.1], p < 0.01). notably, the association between cannabis arrests and cannabis, a publication of the research society on marijuana 45 perceived risk of use was no longer significant with the removal of the colorado and washington state. discussion the present study examined whether cannabis arrests were associated with changes in use and perceptions of risk of use and penalty of possession at the state-level. between 2002 and 2013, increases in cannabis arrest rates covaried with riskier perceptions of use and increased perceived penalty for possessing cannabis. the removal of states with legal recreational cannabis indicated that perceptions of risk were no longer related to arrests. we found no evidence in either model that arrest rates influence the proportion of new users or rates of self-reported use. these results demonstrate that increasing levels of arrest influence related perceptions of punishment severity. our results comport with prior findings that suggests the threat of sanctions shape substance use disclosure and the management of the potential risk of penalty (hammersley et al., 2001; hathaway, 2004a, 2004b). for instance, new york city implemented aggressive policing of public cannabis to deter more severe crime in the 1990s (elliott et al., 2012; nadelmann, 2010). the threat of penalty moved users to private or marginal spaces to consume cannabis, but failed to accomplish larger goals to prevent escalating crime or reduce use (elliott et al., 2012). our study similarly found that increases in cannabis arrests placed upward pressure on risk perceptions. similar trends are found in cross-sectional work demonstrating weak relations between actual punishment and perceived threat from punishment among offenders (bridges & stone, 1986). beliefs about cannabis risk, or even more generally about cannabis, invite a broader conversation regarding the perceived acceptability of the substance. qualitative work corroborates these findings, suggesting that many users endorse mainstream perceptions of cannabis as risky or deviant, yet normalize their own use (hathaway et al., 2011). much literature in this area agrees that despite the threat of sanctions and perception of risk, individuals continue to consume cannabis, albeit with updates to manage their use more discreetly. thus, rather than curb cannabis use, increasing arrests might move individuals who use cannabis to more marginalized spaces. the complex relationship between risk and access might also relate to our finding that perceptions of risk were not associated with arrests once we omitted states that had legalized recreational cannabis in 2013. recreational cannabis appeared to drive the original effect. the novelty of public acceptability of cannabis use could potentially contribute to perceptions of risk. similarly, legalization might indicate greater access to cannabis products, increasing the likelihood of problems and public health burden. such responses are not as likely to be susceptible to deterrence policies, given the change in legalization status. ultimately, while deterrence efforts can lead to appreciable shifts in aggregate attitudes about penalty, changing arrests have little bearing on actual use. perhaps the most important implication of this study is the disconnect between perceptions of cannabis risk and actual cannabis use behaviors. our study indicates that increases in arrest rates fail to predict meaningful changes in cannabis use, and just as many new individuals start using cannabis each year. this finding not only corroborates similar trends regarding deterrence and cannabis outcomes, but also brings up additional considerations (erickson, 1989; erickson et al., 2013; foglia, 1997). individuals might not be responsive to the potential penalty of arrest associated with cannabis possession. although not captured here, deterrent effects could manifest in more nuanced shifts in behavior. for instance, individuals using cannabis may take efforts to use more discreetly or in private or carry smaller amounts of product. this behavior is also consistent for those who normalize their own use, while recognize use as inherently risky or deviant (hathaway et al., 2011). these strategies are most pronounced for those who identify as more frequent or heavy users and hold prior charges for possession. while punishment alone might not deter cannabis use, exposure to punishment and perceptions of severity might alter behavior in more subtle or indirect ways. the results of our study might suggest that penalties aiming to deter cannabis use are ineffective in reducing the prevalence of cannabis use and the number of new users. a review of cannabis criminalization suggests that deterrence not only fails to achieve this goal, but can actually cannabis arrests and use 46 cause more harm in the lives of those punished for minor drug offenses (lenton, 2000). significant resources are expended towards deterrence, particularly around policing and criminal justice processes. fundamental goals of deterrence policies are to not just reduce use, but also mitigate the costs and harms associated with cannabis use. prioritizing cannabis use as a public health issue and not a criminal issue might better achieve these goals. criminalization of cannabis use, specifically through arrest, not only fails to limit use or number of initiates, but also does little to reduce the health and social consequences stemming from problematic use. with movement towards widespread legalization, other forms of regulation appear more effective to address these concerns (rehm & fischer, 2015). lessons from us regulations of tobacco and alcohol provide further insight (barry & glantz, 2016). emphasizing demand reduction strategies in a legal marketplace for cannabis, such as educating the community, protecting at-risk populations, and limiting market availability, could better allay public health concerns than traditional enforcement. additionally, prevention efforts targeting target high risk groups and prioritizing mental health and substance use screenings can promote a public health agenda (fischer et al., 2009). our study was not without limitations. first, our analyses depended on state-level estimates spanning 2002 to 2013. the reason for this range of time was based on several factors, including the availability of data, the consistency in methodology and items among the yearly surveys, and significant policy changes taking place in 2012. to the latter point, 2012 marked the first year that cannabis achieved recreational legal status (washington and colorado). as our variables relating to risk and use were likely impacted by changes in legal status, we opted to include data until recreational use became legalized. our data also invites caution regarding the generalizability of state-level trends. given that many states grant individual municipalities the opportunity to reject aspects of cannabis businesses even when they are legal within the state, generalizing from these state data to smaller jurisdictions would be inappropriate. future work should continue to examine how trends regarding cannabis arrest and perceptions of risk and use may change, particularly as cannabis policy continues to evolve after 2013 and into the present year. a second limitation involves the arrest data sourced from the ucr. specifically, the ucr hierarchy limits reporting of cannabis possession to instances where possession was the most serious crime reported. essentially, if possession co-occurred with a more severe crime, this event would be reported as a statistic for the more severe crime. this methodology could indicate that the present arrest data is underreported. this limitation is also linked to a broader concern that most cannabis use incidents remain undetected by law enforcement. despite this limitation, the data do represent important changes in arrest patterns as measurement error within our fixed effects model is likely to be consistent within states. moreover, this data is particularly insightful for drawing conclusions around the general population of cannabis users, those concerned primarily with use and possession and not serious criminality. relatedly, the use of ucr data in conjunction with nsduh data presents a limitation in the overlap of the two samples. ucr includes a small number of cases representing youth under the age of 12. additionally, nsduh data would not include incarcerated individuals, who are at higher risk for arrest and use; however, this limitation is consistent across all states and the examination of ucr with public health data is aligned with methods in previously published work (friedman et al., 2006; grucza et al., 2018b). finally, our data did not examine differences in perceptions of risk and penalty or in cannabis use across demographics. stratified analyses could potentially uncover meaningful differences between youth and adults across our study outcomes. given how penalty and policy effects vary substantially on factors such as race and socioeconomic status, future analyses should incorporate how group differences play a role in such outcomes. such analyses will also be particularly relevant in the context of expanding legalization policies, where adults have legal access to cannabis and youth do not. nevertheless, our present analyses provide general associations among study variables. while cannabis is currently legal in many states, federally, it remains classified as schedule 1 substance and nearly two-thirds of americans must still reckon cannabis, a publication of the research society on marijuana 47 with risk and penalty if they intend to use cannabis recreationally. despite these limitations, the call for alternative strategies to penalty is clear. such strategies might better utilize community resources to accomplish goals related to reducing harms related to cannabis use. adopting a novel framework for addressing cannabis use might prove even more effective. a move from prohibition policies that emphasize deterrence to paradigms that incorporate harm reduction and critical criminological theory could be worthwhile (fischer et al., 2020; pratt et al., 2006). while further research is certainly needed to examine these theories in practice, they might offer an advantage by examining motivations for cannabis use 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(2014). does liberalizing cannabis laws increase cannabis use? journal of health economics, 36(1), 20–32. funding and acknowledgements: the authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 120 abstract menstrual cycle (mc) phase appears to influence changes in females’ addictive behaviours (e.g., drinking, cigarette smoking). few studies have examined cannabis use across the mc. we examined phase-specific changes in stress and cannabis use quantity across the mc in daily cannabis users. we hypothesized there would be an increase in self-reported stress and cannabis quantity premenstrually and menstrually versus other mc phases. data were obtained prospectively, using a 32-day daily diary, from 14 normallycycling, community-recruited, female cannabis users (age: m = 29.3 years old, sd = 4.9). participants completed measures pertaining to their daily stress levels (the general stress scale) and the quantity of cannabis used daily. a priori planned comparison t-tests and non-parametric wilcoxon rank tests revealed mc phase effects on stress levels and cannabis quantity, respectively. in partial support of stress-response dampening (srd) model and self-medication theory (smt) predictions, stress levels were higher in the premenstrual versus the ovulatory phase, and a higher quantity of cannabis was used premenstrually versus the follicular and ovulatory phases. findings suggest stress levels and cannabis use quantity are mc phase-sensitive. results are consistent with srd model and smt predictions, where females learn to increase the quantity of cannabis used premenstrually to dampen their heightened stress response and negative affect. female cannabis users of reproductive age could be trained to employ alternative strategies to cope with elevated stress premenstrually to prevent increased cannabis use. key words: cannabis use, menstrual cycle, stress, sex, females cannabis is the most commonly used illicit drug worldwide (united nations office on drugs and crime, 2016). cannabis use disorders are highly comorbid with mental health disorders, such as depression, anxiety, and psychosis (agrawal, neale, prescott, & kendler, 2004; casas, roncero, trasovares, qureshi, & bruguera, 2007; connor et al., 2013; hayley, stough, & downey, 2017; robbins, ehrman, childress, & o’brien, 1999). research that has examined cannabis misuse suggests there are important sex differences in many aspects of cannabis use. therefore, findings from substance use research among males may not generalize to cannabis 2019, volume 2 (2), 120-134 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2019.02.002 open access a pilot daily diary study of changes in stress and cannabis use quantity across the menstrual cycle corresponding author: sherry h. stewart, department of psychiatry, abbie j. lane memorial building, 8th floor, queen elizabeth ii health sciences centre, 5909 veterans memorial drive, halifax, ns, canada, bsh 2e2, email: sstewart@dal.ca nacera hanzal1,2, kayla m. joyce2, philip g. tibbo2, sherry h. stewart1,2,3 1 department of psychology and neuroscience, dalhousie university, halifax, nova scotia, canada 2 department of psychiatry, dalhousie university, halifax, nova scotia, canada 3 department of community health and epidemiology, dalhousie university, halifax, nova scotia, canada cannabis and the menstrual cycle 121 female cannabis users (green, 2006; tuchman, 2010). a female-specific factor that may be useful in understanding triggers for addictive behaviour is ovarian hormone variations across the menstrual cycle (mc; carpenter, upadhyaya, larowe, saladin, & brady, 2006; franklin et al., 2004; hudson & stamp, 2011; moran-santa maria, flanagan, & brady, 2014; pearson & schipper, 2013; terner & de wit, 2006). examining the effects of ovarian hormone fluctuations across mc phase on substance use may allow for the development of sex-specific substance use treatments (lynch, roth, & carroll, 2002). the mc can be subdivided into five phases: menstrual (days one-five), follicular (days six-12), ovulatory (days 13-16), luteal (day 17 to the premenstrual phase), and premenstrual (five days prior to menstrual bleeding; evans, haney, levin, foltin, & fischman, 1998; johannes et al., 1995; pastor & evans, 2003). mc phases are characterized by rhythmic fluctuations in ovarian hormone concentrations (feher, 2012; griffin & ojeda, 2004; groome et al., 1996; levy, koeppen, & stanton, 2000). the menstrual phase is characterized by low progesterone and estrogen concentrations (griffin & ojeda, 2004). estrogen concentrations begin increasing during the follicular phase (griffin & ojeda, 2004). during ovulation, increases in follicle-stimulating hormone and luteinizing hormone concentrations are evident, resulting in a surge in progesterone and decline in estrogen concentrations (feher, 2012; groome et al., 1996; levy et al., 2000). estrogen concentrations remain stable during the luteal phase; however, progesterone concentrations increase and peak mid-phase (griffin & ojeda, 2004). in the absence of fertilization, estrogen and progesterone concentrations start to decline in the late luteal phase and continue to decrease premenstrually (griffin & ojeda, 2004). these fluctuations in ovarian hormones across mc phases have been implicated in variations in the addictive behaviour of reproductive-aged females, although findings have been mixed (see joyce, good, tibbo, brown, & stewart, 2019; moran-santa maria et al., 2014 for reviews). to date, studies examining addictive behaviours across mc phase have predominantly examined changes in alcohol consumption or tobacco intake. mixed findings surrounding alcohol consumption across mc phase are evident: levels of alcohol consumption have been variously shown to increase, decrease, or remain constant menstrually and premenstrually relative to other phases (carroll, lustyk, & larimer, 2015). most studies, however, show an increase in alcohol consumption premenstrually and menstrually (carroll et al., 2015; epstein et al., 2006). joyce and colleagues (2018) further showed that increases in alcohol consumption menstrually are explained by increases in drinking to cope with negative mood. further research examining selfadministration of cocaine has shown an increase in cocaine craving in the late luteal phase, suggesting that women are at higher risk of drug craving and relapse when levels of estrogen and progesterone begin to decline during the late luteal phase and into the premenstrual phase (moran-santa maria et al., 2014; terner & de wit, 2006). additionally, research examining nicotine intake found that intake increases during the (pre-)menstrual phases (see review by joyce et al., 2019a). smoking relapse is often triggered by elevations in stress and/or associated negative affect (anxious/depressed affect), which further signifies the importance of examining associations between stress levels and addictive behaviours (cohen & lichtenstein, 1990). stress can be defined by how overwhelming, unpredictable, and uncontrollable one finds a challenging situation to be (cohen, kamarck, & mermelstein, 1983). the perception of stress is subjective; hence, stress responses differ substantially across individuals (lazarus & folkman, 1984). the stress-response dampening model (srd; levenson, sher, grossman, newman, & newlin, 1980) of substance misuse has two tenets: (1) substances dampen response to stress and (2) consequently, individuals learn to use substances in response to stress as a maladaptive coping strategy. similarly, selfmedication theory (smt; khantzian, 1997) explains how an individual, during periods of elevated negative affect, may use substances to cope with negative mood states (joyce et al., 2018). consistent these two theories, research shows positive associations between daily negative emotions and one's desire to drink alcohol, such that elevations in negative affect increase one’s desire to consume alcohol (backerfulghum, patock-peckham, king, roufa, & hagen, 2012). in fact, there is a concrete link cannabis, a publication of the research society on marijuana 122 between experiencing negative affect and drinking alcohol in which increases in negative affect lead to an increase in alcohol consumption (cooper, russell, & george, 1988; dermody, cheong, & manuck, 2013). similar to alcohol, cannabis may also be used to dampen one's stress response and reduce negative affect, with cannabis users reporting coping with stress as the most common motivation behind their use (hyman & sinha, 2009). in fact, consistent with srd model predictions, archival data examined in one study showed that self-reported stress levels were reduced by 58% following (vs. prior to) cannabis use (cuttler, spradlin, & mclaughlin, 2018). sex differences in several aspects of cannabis use have been reported (sherman, baker, & mcrae-clark, 2016). for example, males are more susceptible to: initiating cannabis use, using at greater intensity, and developing a lifetime cannabis use disorder (cud; sherman, baker, & mcrae-clark, 2016). however, females exhibit a more rapid progression from first cannabis use to a cud which may be explained by their greater sensitivity to cannabis dose (cooper & haney, 2014; crocker & tibbo, 2018). females who are dependent on cannabis also exhibit more severe withdrawal than males, suggesting females may be less likely to respond to cannabis use interventions (crocker & tibbo, 2018). sex differences in the neurobiological mechanisms of cannabis may contribute to sex differences in cannabis use behaviours and the substance’s subjective effects (calakos, bhatt, foster, & cosgrove, 2017). one possible explanation for these unique responses to cannabis in women pertain to the female mc and its effect on stress. fluctuations in progesterone and estrogen are associated with phase-specific changes in the impact of psychosocial stressors (albert, pruessner, & newhouse, 2015; lahmeyer, miller, & deleon-jones, 1982; richards, rubinow, daly, & schmidt, 2006). for example, elevated estrogen concentrations during ovulation are believed to be associated with an increase in positive affect (griffin & ojeda, 2004; richards et al., 2006). in contrast, elevations in stress and negative affect premenstually/menstrually are thought to be the result of low progesterone and estrogen concentrations (angst, sellaro, stolar, merikangas, & endicott, 2001; richards et al., 2006; roney & simmons, 2015). these elevations in stress and negative affect premenstrually/ menstrually suggest that females may increase their cannabis use at these phases, consistent with srd and smt predictions. to date, two studies have examined cannabis use across the mc and findings have been mixed (griffin, mendelson, mello, & lex, 1986; mello & mendelson, 1985). in mello and mendelson’s (1985) study, cannabis acquisition and use patterns were studied in twenty-one females during a 35-day in-laboratory conditioning task. findings were mixed across participants: cannabis use increased premenstrually in some, decreased premenstrually in others, and remained constant across mc phase in yet another group (mello & mendelson, 1985). consistent with the srd and smt predictions, females with increased negative affect and impaired social function (indicative of higher stress) premenstrually, simultaneously reported more cannabis use premenstrually (mello & mendelson, 1985). however, the mello and mendelson (1985) study was a laboratory-based experiment; thus, findings may not generalize to real-world settings, indicating the need for more externally valid studies examining cannabis use across mc phase. to address some of the limitations of the mello and mendelson (1985) study, griffin and colleagues (1986) examined cannabis use and mood [via the moos menstrual distress questionnaire (moos, 1968)] in a daily diary study with 30 females across three consecutive mcs. cannabis use did not vary across the mc and no association was found between cannabis use and negative affect across mc phase. however, there were several methodological issues with griffin and colleagues’ (1986) daily dairy study. first, females who were not normally-cycling, with mc lengths of up to 44 days, were included. in the present study, only normally-cycling females (i.e., mc lengths of 25-32 days) were included as per usual inclusion criteria in mc studies (e.g., joyce et al., 2018). second, no stress measure was included in griffin and colleagues' (1986) study. thus, a psychometrically-sound daily stress measure, the general stress scale (bolger, delongis, kessler, & schilling, 1989), was included in the present study. third, participants were asked about negative affect and cannabis use simultaneously, which prevented the examination of whether earlier negative mood was associated cannabis and the menstrual cycle 123 with subsequent cannabis use during different phases. in the current study, participants reported stress levels and cannabis use quantity at different time-points to examine whether effects of mc on stress earlier in the day showed similar patterns to effects of mc on cannabis use levels later in the day, consistent with srd and smt predictions (khantzian, 1997; levenson et al., 1980). the present pilot study aimed to examine fluctuations in stress and cannabis use quantity across mc phase in reproductive-aged female cannabis users. consistent with prior literature (albert et al., 2015; angst et al., 2001; brugger, milicevic, regard, & cook, 1993; hastrup & light, 1984; woods, 1985), we hypothesized that stress levels would increase in the menstrual and premenstrual phases versus other mc phases (i.e., follicular, ovulatory, luteal). based on srd (levenson et al., 1980) and smt (khantzian, 1997) predictions, we also hypothesized that cannabis use quantity (during the first consumption episode following the stress assessment) would similarly increase in the menstrual and premenstrual phases versus other mc phases. method participants participants were recruited through advertisements posted throughout the community and on social networking websites (e.g., kijiji). a sample of 14 normally-cycling female cannabis users (age: m = 29.3 years, sd = 4.9; 85.7% caucasian, 14.3% mix race) were recruited. sixtyfour percent of participants were college/university graduates, 21.4% had completed some college/university, and 14.3% had completed some high school. on average, participants indicated using cannabis 25.7 days (sd = 8.4; 71.4% were daily users) during the prior 30 days on the cannabis timeline followback (robinson, sobell, sobell, & leo, 2014). participants reported experiencing an average cannabis use problem severity score of 12.7 (sd = 4.5) on the cannabis use disorder identification test with 64.3% scoring above the cutpoint of 12 used to indicate the likely presence of a cud (adamson & sellman, 2003). to be included in the study, respondents were required to have used cannabis at least four times during the month prior to participation to increase the likelihood of participants using cannabis during the 32-day daily diary. all participants were required to meet a list of exclusion criteria. females who were prescribed medicinal cannabis were excluded as medicinal users have a prescribed dose of cannabis (maccallum & russo, 2018). participants could not be receiving treatment for a cud and/or abstaining from or trying to abstain from cannabis use. participants were required to be between the ages of 19 and 45 years-old, as 45 is the standard cut-off in mc research to exclude females undergoing menopause/perimenopause (nelson, 2008). additionally, respondents were excluded if they were diagnosed with a pain disorder to help ensure participants were not using cannabis to self-medicate chronic pain. females with interferences to their mc causing changes in ovarian hormone concentrations were also excluded (i.e., recent/current pregnancy, current use of hormonal contraceptives, hormonal contraceptive use within the last three months, currently breastfeeding, past hysterectomy, current amenorrhea, or menopausal/ postmenopausal). all surveys were administered in english; therefore, participants were required to read and write efficiently in english. finally, participants were required to own/have access to a smartphone (with a data and texting plan) to receive their daily diary surveys. procedure interested females responded to advertisements and completed a telephone screening to assess eligibility. eligible participants were scheduled for their first inlaboratory session. during this session, eligibility was reconfirmed. participants then provided consent to participate in the study and answered two standardized self-report questionnaires (i.e., cannabis timeline followback and cannabis use disorder identification test – revised). participants began the study at different periods of the mc (mc days one-seven or 18-24) to ensure that any fatigue or reactivity effects due to daily monitoring were distributed across mc phase. over the course of 32 days following the initial session, the higher end of an average mc, cannabis, a publication of the research society on marijuana 124 participants received text message surveys via smartphone daily at 10:30 am and 2:00 pm. the 10:30 am survey asked questions pertaining to stress levels and mc day, while the 2:00 pm survey asked participants about the quantity of cannabis used. during the 2:00 pm survey, participants were asked to begin the survey only when one or more of the following were true: they had already used cannabis that day; they were using cannabis in that moment; they were planning on using cannabis within the next hour (i.e., they would return to answer the survey when using cannabis); or they had not used cannabis that day and were now going to bed. a reminder to complete the 2:00 pm survey was sent to participants at 6:30 pm and participants were asked to complete the 2:00 pm survey regarding their first cannabis use occasion since the stress assessment at 10:30 am. participants were debriefed and received their compensation at a final in-laboratory session. compensation was based on the number of in-laboratory sessions attended and daily diary surveys completed, with a maximum compensation of $97.65 (can). measures initial in-laboratory session cannabis timeline followback (ctlfb). the ctlfb was a 30-day retrospective calendar, which examined past-month cannabis use (robinson et al., 2014). the ctlfb examined a number of cannabis use parameters (e.g., type of cannabis intake, amount of money spent on cannabis). the ctlfb was used in this study to confirm eligibility (past month cannabis use frequency) and for participant demographics. the ctlfb has high test-retest reliability over a 30day period, with test-retest reliabilities ranging from 0.75 to 0.96 (robinson et al., 2014). cannabis use disorder identification test – revised (cudit-r). the cudit-r was an eightitem measure used to screen for problematic cannabis use by assessing cannabis use levels, problems, and dependence (adamson & sellman, 2003). the cudit-r demonstrates good internal consistency (α = 0.91; adamson et al., 2010) and was used to describe the sample in terms of their problematic cannabis use levels. daily diary surveys menstrual cycle day. participants responded to a single question to determine their current mc day. this question was asked once daily during the 10:30 am survey. if participants were unsure of their mc day, they were provided with the option of responding “unknown” until menstruation began (at which time day one was indicated). reporting mc day, as opposed to whether menstruation is occurring (yes/no) accounts for variable mc lengths and reduces errors when determining day one of menstruation (joyce et al., 2018). general stress scale (gss). the gss (bolger et al., 1989) was a three-item measure used to assess daily stress levels. the first question asked participants to choose from a list of situational stressors that may be troublesome for them that day (e.g., family demands, argument with someone). the second question asked participants to select their most troublesome stressor that day from the list of situational stressors. the third question asked participants to rate the amount of stress currently experienced as a result of their most troublesome stressor using a visual analogue scale (vas) ranging from “not at all stressful” (scored as zero) to “extremely stressful” (scored as 100; bolger et al., 1989). participants were instructed to respond by placing a mark on a point between the anchors “not at all stressful” to “extremely stressful”, scored as zero to 100 respectively for data analysis purposes. cannabis use. the cannabis use measure in the daily diary was an adapted version of a question on the ctlfb used to assess daily cannabis use prospectively (rather than retrospectively; robinson et al., 2014). for this study, the quantity of cannabis used during the first consumption episode since the 10:30 am stress assessment (in standard joint equivalents) was assessed. participants were informed that a standard joint referred to 0.50 grams of cannabis, five bong or pipe hits, or ten puffs (zeisser et al., 2012). the first cannabis-using occasion was examined as this occasion was the most temporally proximal to the daily stress assessment. cannabis and the menstrual cycle 125 data analysis daily diary data was divided into the following five mc phase designations: menstrual (days onefive), follicular (days six-12), ovulatory (days 1316), luteal (days 17 to the premenstrual phase), and premenstrual (five days prior to menstrual bleeding; joyce et al., 2019a). phase designation was determined using mc data obtained from the daily question pertaining to mc day. in the case of an unknown menstrual cycle day, an alternative method (i.e., a count forwardbackward method from the first day of menstruation) was used to retrospectively determine mc day for each survey (see joyce et al., 2018). following phase designation, the average stress level per mc phase and average quantity of cannabis used per mc phase were determined. the average stress level per mc phase was calculated by summing the stress vas scores for each day of a specific mc phase and dividing the sum by the number of days within each mc phase (joyce et al., 2019b). the quantity of cannabis used per mc phase was calculated by dividing the total number of standard joints consumed across each mc day within a specific phase by the number of cannabis-using days in that mc phase. once average stress level and cannabis use quantity per mc phase was determined, multiple imputations were used to account for missing data at the phase-level (i.e., for participants failing to answer the cannabis use question or gss survey for an entire phase). multiple imputations used an expectation maximization algorithm in spss (version 24). the average stress level and cannabis used per mc phase was calculated for a total of 70 phases (i.e., 14 participants across 5 phases). of the 70 averages calculated, multiple imputations were used to account for a total of five missing phases on both variables (i.e. stress level and quantity of cannabis used). prior to running any data analyses, the skewness and kurtosis of each variable (stress levels and cannabis use quantity) were analyzed to determine whether parametric or nonparametric statistical methods should be used given the study’s small sample size. findings suggested that self-reported stress levels were normally distributed with a skewness of 0.417 (se = 0.132) and kurtosis of -1.00 (se = 0.264), suggesting that parametric tests could be used (hair, black, babin, & anderson, 2010). cannabis use quantity was not normally distributed, with the data showing positive skew (γ1 =1.19; se = 0.136) and significant kurtosis (γ2 = 1.76; se = 0.271; hair et al., 2010). since parametric data analytic methods rely on normal distributions and are influenced by outliers, such analyses could not be performed within the present pilot study for the cannabis use quantity data. therefore, parametric planned comparisons were used to analyse the stress level data across mc phase, whereas planned comparisons in the form of nonparametric wilcoxon rank tests were used to analyse cannabis use quantity data across mc phase. one-tailed t-tests were used to assess hypothesis one, as a directional hypothesis was made a priori based on predictions of the srd model and previous research suggesting stress levels are highest premenstrually/menstrually (albert et al., 2015; angst et al., 2001; levenson et al., 1980). one-tailed tests were also used for cannabis use quantity across the mc. stress levels and cannabis use quantity premenstrually were compared sequentially to levels/use during all other phases except menstrual. similarly, stress levels and cannabis use quantity menstrually were compared sequentially to levels/use during all other phases except premenstrual. results a set of within-subjects planned paired comparison t-tests were conducted, with mc phase as the independent variable (see table 1). partially consistent with hypothesis one, findings revealed that stress levels were significantly higher premenstrually (m = 39.16; sd = 26.04) than at the ovulatory phase (m = 28.99; sd = 22.71; p = 0.039); this effect was of medium magnitude (d = 0.520; figure 1; table 1). partially consistent with hypothesis two, the quantity of cannabis used differed by mc phase. results suggested that females used more cannabis premenstrually (mdn = 1.58; range = 3.17) relative to the follicular (mdn = 1.00; range = 2.61; p = 0.003) and ovulatory phases (mdn = 1.21; range = 2.11; p = 0.018; figure 2; table 2); these effects were both large (r = .730 and r = .560, respectively); r is a correlation coefficient or the standardized measure of effect size for non cannabis, a publication of the research society on marijuana 126 figure 1. mean levels of stress endorsed by menstrual cycle phase. the error bars represent standard errors. significant differences (one-tailed tests) between premenstrual phase and other phases are indicated with asterisks. *significant at the p < 0.05 level. parametric tests. when a non-parametric test is conducted, two menstrual cycle phases are being compared. each r value indicates the relationship between the two menstrual cycle phases analyzed (see rosenthal, 1994 for more information). effects were identical if parametric statistics were to be used: females used more cannabis premenstrually (m = 1.75; sd = 0.87) relative to the follicular (m = 1.21; sd = 0.91; t = 3.695; p = 0.002; d = 0.989) and ovulatory phases (m = 1.24; sd = 0.75; t = 2.468; p = 0.014; d = 0.667) table 1. planned comparisons for stress levels across mc phase pairs. mc phase pair m se 95% ci t d df p general stress premenstrualfollicular .100 3.08 [-6.56, 6.76] .032 .009 13 .488 premenstrualovulatory 10.176 5.29 [-1.25, 21.60] 1.924 0.520 13 .039* premenstrualluteal 7.168 4.65 [-2.88, 17.22] 1.541 .414 13 .074 follicularmenstrual 1.449 4.56 [-11.31, 8.41] .317 .087 13 .378 menstrualovulatory 8.628 4.90 [-1.97, 19.22] 1.760 .493 13 .051 menstrual-luteal 5.620 5.04 [-5.28, 16.52] 1.114 .305 13 .143 note. all significant results are represented in bold. directionality of each effect is shown in the 'mc phase pair' column, with the highest value presented first. an asterisk (*) indicates significant difference in stress levels between mc phase pairs at the p < 0.05 level (one-tailed tests). m = mean difference in stress levels between the mc phase pairs. * cannabis and the menstrual cycle 127 figure 2. median quantity of cannabis use (standard joints/cannabis-using day) by menstrual cycle phase. significant differences (one-tailed tests) between premenstrual phase and other phases are indicated with asterisks. *significant at the p < 0.05 level. discussion the results of this 32-day daily diary study expand upon previous literature examining changes in cannabis use across the mc (griffin et al., 1986; mello & mendelson, 1985). the current study is the first to simultaneously assess mc phase-related changes in stress levels and mc phase-related changes in subsequent cannabis use quantity. based on prior research examining stress across the mc (albert et al., 2015; angst et al., 2001; brugger et al., 1993; hastrup & light, 1984; woods, 1985), stress levels were predicted to be higher premenstrually/menstrually versus the other mc phases. findings provided partial support for hypothesis, in that stress levels were significantly higher premenstrually than in the ovulatory phase – a difference of moderate magnitude. findings from this study are thus partially consistent with prior research table 2. summary of wilcoxon rank tests of cannabis use quantity across menstrual cycle phase pairs variable mc phase pair z p r cannabis use menstrual-follicular 1.293 .196 .346 quantity menstrual-ovulatory 1.138 .255 .304 menstrual-luteal .315 .753 .084 premenstrual-follicular 2.732 .003* .730 premenstrual-ovulatory 2.097 .018* .560 premenstrual-luteal 1.381 .167 .369 note. all significant results are represented in bold. directionality of each effect is shown in the 'mc phase pair' column, with the highest value presented first. an asterisk (*) indicates significant differences between mc phase pair at the p<0.05 level. the column "r" refers to the effect size of each phase comparison conducted (small effect size = 0.1; medium effect size = 0.3; large effect size = 0.5). * * cannabis, a publication of the research society on marijuana 128 suggesting females are most reactive to psychosocial stressors premenstrually/ menstrually, when estrogen and progesterone concentrations are low versus other mc phases (albert et al., 2015; ossewaarde et al., 2010). based on srd and smt models of substance use (levenson et al., 1980), it was also predicted that cannabis use quantity would increase premensturally/menstrually versus other mc phases. findings again provided partial support for srd and smt predictions, in that cannabis use quantity was higher premenstrually relative to both the ovulatory and follicular phases; these effects were both large in magnitude, respectively. as was the case for changes in stress, increases in cannabis use quantity during the premenstrual phase may be attributable to fluctuations in ovarian hormone concentrations, specifically progesterone and estrogen. the premenstrual phase is characterized by a precipitous decline in progesterone and estrogen concentrations (griffin & ojeda, 2004). since our results exhibited an elevation in both stress and cannabis use quantity premenstrually, but not menstrually, it may be the precipitous decline in estrogen and progesterone premenstrually (rather than low estrogen and progesterone concentrations menstrually; griffin & ojeda, 2004) which explains the observed increases in stress levels and cannabis use premenstrually. moreover, the fact that the difference in stress and cannabis use levels reported premenstrually were both relative to the ovulatory phase (and to the follicular phase in the case of cannabis use), points specifically toward the involvement of estrogen since it is estrogen that: begins increasing during the follicular phase, is highest during ovulation, and declines sharply during the premenstrual phase (feher, 2012; groome et al., 1996; levy et al., 2000). additionally, a surge in estrogen concentration, occurring during ovulation, is associated with an increase in positive affect (richards et al., 2006). increases in positive affect during ovulation may be related to the reported decrease in cannabis use quantity during the ovulatory phase (relative to cannabis use quantities premenstrually), as females may be less likely to use cannabis to cope during the ovulatory phase relative to the premenstrual phase given their stress levels are relatively lower during the ovulatory phase. overall, this pattern of findings points more toward the likely involvement of estrogen than progesterone. the exhibited fluctuations in cannabis use quantity were quite similar across mc phase to those seen for stress levels across mc phase. specifically, stress levels and cannabis use quantity were both significantly higher premenstrually than during the ovulatory phase. moreover, our study involved a temporal lag between the assessment of stress and the quantity of cannabis used during a subsequent cannabis use occasion later that day. srd model and smt predictions have two tenets: (1) cannabis reduces an individual’s response to stress/stressors and/or negative affect, respectively; and (2) people learn to use cannabis when experiencing stress/stressors and/or negative affect. recent findings indicate that using cannabis substantially alleviates self-reported stress, consistent with predictions of the first tenet of the srd model (cuttler et al., 2018). the present findings are consistent with the second tenet of the srd model (levenson et al., 1980), in that increases in earlier day stress levels were seen premenstrually as were increases in subsequent daily cannabis use quantity during the first cannabis-using occasion following the stress assessment. results are consistent with the possibility that the increase in cannabis quantity premenstrually may be used functionally to dampen a heightened response to stress premenstrually. limitations results should be interpreted with four limitations in mind. first, participants’ selfreported mc day was not validated via biological means (e.g., progesterone assays). however, selfreports of menstrual cycle day have been validated in prior work using progesterone assays as a form of biological verification (andreano, arjomandi, & cahill, 2008; andreano & cahill, 2010). in fact, data using an identical protocol with normally-cycling female drinkers and gamblers indicated that self-report mc phase could be validated via progesterone assays (joyce et al., 2018; joyce et al., 2019b). second, the small sample size within this pilot study (n = 14) may have reduced power to detect smaller magnitude effects. as an example, we had predicted that stress levels would be higher in the menstrual cannabis and the menstrual cycle 129 phase relative to other mc phases. while we did not observe a significant difference, stress levels menstrually were marginally higher relative to the ovulatory phase (p = .051) – an effect which was small-to-moderate in magnitude. this effect might have proved statistically significant if the sample size had been larger and thus adequately powered to detect smaller effects. the small sample size of this pilot study did not allow us to run a multilevel model; therefore, we were not able to test relations between earlier stress levels and later cannabis use and whether these relations varied by menstrual cycle phase. a larger sample size would permit analyses of these kind which could be used to further test predictions of the srd and smt models. third, we took steps to maximize variability in cannabis use quantity by excluding medical cannabis users (who would be using cannabis daily and/or at consistent doses). despite these efforts, we nonetheless recruited a sample that was predominantly daily cannabis users. additionally, the cudit-r suggests that many of our participants (64.3%) likely had a cud. as a result, these findings may not be generalizable to non-problem cannabis users. however, the results may well benefit treatments for reproductive aged females with cuds. while daily users and those with cannabis problems would be the mostclinically relevant samples of participants to examine, future studies should examine whether there are more marked changes in cannabis use quantity across the mc in females with various patterns of cannabis use (e.g., those who do not use cannabis daily). perhaps in such cases, it may be that the frequency (rather than the quantity) of cannabis use varies significantly across mc phase. finally, information pertaining to the type of cannabis used was not obtained. for example, sativa is a type of cannabis used to produce a euphoric effect, whereas indica is used for its relaxing and calming effects (piomelli & russo, 2016). identified differences in the effect of cannabis type suggests the strain of cannabis used may vary across mc phase. this research may be easier to conduct in canada or in certain us states now that cannabis is legalized. as such, participants will have more information on the content of the cannabis they are using. thus, future daily diary studies should ask participants to specify the type of cannabis used on each occasion. future research and implications future research should employ more rigorous statistical analyses (e.g., multilevel modeling or time-varying effect models; snijders & bosker, 2012; tan, shiyko, li, li, & dierker, 2012) to determine whether earlier stress predicts later cannabis use quantity, particularly in the premenstrual phase. our findings provide preliminary evidence to suggest that both stress levels and cannabis use quantity increase in the premenstrual (versus ovulatory) phase, however, these more rigorous statistical analyses will allow us to determine if daily stress levels predict the quantity of cannabis used at a daily level across the mc. for instance, the implementation of time varying effects models would allow us to determine whether increases in stress levels premenstrually explain the subsequent increase in cannabis use quantity observed premenstrually in this study (see joyce et al., 2018 for an example). furthermore, such analyses along with appropriately timed cannabis use and stress assessments would allow for the additional examination of whether cannabis use subsequently reduces stress, as predicted by the srd and smt models (see battista et al., 2015 for a similar daily diary study in the alcohol area; n = 132). further, future research should examine whether changes in cannabis use across the mc are mediated by changes in motives for use, specifically: enhancement, conformity, expansion, coping, and/or social motives (simons, correia, carey, & borsari, 1998). findings by joyce and colleagues (2018) indicated that coping and social motives are associated with increases in alcohol consumption menstrually and mid-cycle, respectively. srd and smt predictions (levenson et al., 1980) would suggest coping motives explain increased cannabis use premenstrually and coping motives, in particular, should therefore be assessed in future studies on cannabis use across the menstrual cycle. future research should also examine whether mc phase-related links exist between negative affect (depressed and/or anxious affect) and cannabis use quantity. perhaps changes in depressed and/or anxious affect across the mc cannabis, a publication of the research society on marijuana 130 may better explain changes in cannabis use quantity across the mc than changes in daily stress levels examined here. alternatively, depressed and/or anxious affect may mediate the hypothesized relation of stress to cannabis use in the premenstrual phase. conclusions findings indicated phase-related increases in both stress and cannabis use across the mc, specifically premenstrually (relative to at least one other mc phase) which may be useful when developing cannabis interventions options for reproductive-aged females. for example, quit attempts may be more efficacious if a quit date is set during an mc phase associated with decreased stress and decreased cannabis use levels (e.g., during ovulation rather than premenstrually). similar methods have been employed in smoking cessation interventions across the mc (franklin et al., 2008). additionally, given that the premenstrual phase appears to be associated with both increased stress levels and increased cannabis use quantity, implementing strategies to better cope with stress premenstrually may reduce the likelihood of females engaging in excessive cannabis use, thereby reducing cannabis-related risk. references adamson, s. j., kay-lambkin, f. j., baker, a. l., adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2012). a “standard joint”? the role of quantity in predicting cannabis-related problems. addiction research and theory, 20(1), 82–92. https://doi.org/10.3109/16066359.2011.569101 acknowledgments: this research was supported by a grant to dr. sherry h. stewart from the dalhousie university department of psychiatry research fund. at the time this study was conducted, dr. stewart was funded through a canadian institutes of health research (cihr) tier 1 canada research chair in addictions and mental health, ms. hanzal was supported by a social sciences and humanities research council (sshrc) undergraduate summer research award at dalhousie university, ms. joyce's graduate studies in psychiatry research were supported by a nova scotia graduate scholarship, a scotia scholar award from the nova scotia health research foundation, and a joseph armand bombardier canada graduate scholarship from sshrc, and dr. tibbo was supported through the jannsen chair in psychotic disorders. we acknowledge the contributions in research assistance provided by pamela collins, sharelle ulrich, and lauren mccarley. this work has been presented as a poster at the research society of marijuana's scientific meeting in july 2018 in fort collins, colorado, united states of america. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i2a2_authors_final research article 16 ved abstract psychedelic-assisted psychotherapy has established antidepressant effects. cannabis users appear to expect high doses administered in a session much like psychedelic-assisted psychotherapy to create comparable subjective effects. the current studies explored expectations of antidepressant effects of such cannabis-assisted sessions to replicate and extend previous work. users not only expected a cannabis-assisted psychotherapy session to decrease depression, but also to alter some of the same mediators of psychedelic or psychological treatments. over 500 participants in study i envisioned a cannabis-assisted therapy session akin to those used in psychedelic therapies and reported the effects that they expected on depression as well as relevant subjective reactions. a second sample of over 500 participants responded to identical measures and an index of dysfunctional attitudes that appears to mediate antidepressant effects of psychotherapy. expectancies of cannabis-induced antidepressant effects covaried with expected psychedelic effects. participants also envisioned that cannabis-assisted therapy would alter dysfunctional attitudes, which served as a separate, unique path to expected antidepressant effects unrelated to the subjective effects of psychedelics. these results add support to arguments for relevant clinical trials of cannabis-assisted psychotherapy and suggest that cannabis users would expect it to work in ways similar to psychedelics as well as cognitive therapy. key words: = tetrahydrocannabinol; oceanic boundlessness; mystical experiences; psychedelicassisted psychotherapy; depression depression’s dramatic, negative impact remains concerning as over 300 million people worldwide appear to suffer from the disorder (who, 2017). combining standard antidepressant medications with psychotherapy helps approximately 65% of individuals, but leaves many others unimproved (see cuijpers et al., 2020; earleywine & de leo, 2020). the link mitch earleywine1, maha n. mian1, brianna r. altman1, joseph a. de leo2 1department of psychology, university at albany, state university of new york, usa 2centre for compassionate care, ontario, canada cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.02 expectancies for cannabisinduced emotional breakthrough, mystical experiences and changes in dysfunctional attitudes: perceptions of the potential for cannabis-assisted psychotherapy for depression corresponding author: mitch earleywine, phd, department of psychology, university at albany, state university of new york, usa. email: mearleywine@albany.edu cannabis, a publication of the research society on marijuana 17 between cannabis and depression remains controversial. cannabis might cause, cure, or have only spurious links to the disorder (feingold & weinstein, 2021). cannabis consumption and depression appear to vary depending upon forms of administration, the presence of confounding factors, and numerous individual difference variables (e.g. bricker et al., 2007; grinspoon & bakalar, 1997; lev-ran et al., 2014). for example, recent work reveals that many cannabis users report that their consumption of the plant addresses depressive symptoms (gorfinkel et al., 2020; kosiba et al., 2019), but adolescents who use cannabis seem to be at greater risk for subsequent depressive mood or suicidal ideation (gobbi et al., 2019). turning to the plant as an attempt at selfmedication might be common, but frequent, relatively low-dose use might be ill-advised. longitudinal data suggest that decreasing frequent use might improve depressive symptoms (hser et al., 2004). these varied responses leave clinicians and clients in a quandary. in contrast, recent work suggests that a high dose of psilocybin, when administered in a therapeutic setting with sufficient support, precedes improvements in depression and other forms of human suffering (see carhart-harris et al., 2017, 2018; schenberg, 2018). a comparable approach with cannabis seemed to have potential given parallels between reactions to high dose cannabis and psilocybin (earleywine et al., 2021; farmer et al., 2019). three of the most promising subjective changes include a facet of mystical experiences dubbed oceanic boundlessness (obn), a sense of connectedness with a lowered sense of self-importance known as ego dissolution (ed), and a categorical leap in affective experience called emotional breakthrough (eb). all three of these responses to a psychedelic predict subsequent improvements (e.g. carhart-harris et al., 2017; garcia-romeu et al., 2019; nour et al., 2016; roseman et al., 2018; roseman et al., 2019; uthaug et al., 2018). generally, as these experiences increase, suffering decreases. in contrast, other changes in subjective state do not correlate consistently with improvements. for example, acute ketamine-induced dissociation might appear novel, but it does not predict subsequent antidepressant effects (mathai et al., 2020). cannabis at an ideal dose and low frequency might facilitate the relevant subjective experiences and improve depression as well (earleywine et al., 2021). spiritual traditions in some sufi mystics, tibetan buddhists, zion coptics, rastafarians, and hindus emphasize that ideal dosages of cannabis consumed in appropriate settings precede mystical “peak experiences” (ferrara, 2016, 2020), the same effects that predict psilocybin’s antidepressant effects. although cannabis does not have the impact on the 5ht2a receptors common to psilocybin and other psychedelics (curran et al., 2018; russo & marcu, 2017), their subjective effects overlap (barrett et al., 2018; earleywine et al., 2021; farmer et al., 2019). one previous relevant study asked experienced cannabis users to envision a high-dose session that would parallel the comfortable environs, trained support from guides, and internal focus of psilocybin trials (earleywine et al., 2021). participants reported expecting such a cannabis-assisted session to generate obn and decrease depression. a replication that extended those results to other facets of mystical experience that covary with improvement in depression appeared in order. should a new sample report that cannabis might create the relevant subjective effects and that they expect antidepressant impact, the rationale for cannabis-facilitated psychotherapy might improve. study 1 methods participants a total of 560 lifetime cannabis users (274 (48.9%) self-identified as female) passed attention checks and provided data on amazon’s mturk. the local irb approved cannabis implications for psychotherapy 18 all procedures. ages ranged from 18 to 69 (mean = 35.44, sd = 10.931) and education ranged from some high school to a graduate degree (modal, median, and mean = bachelor’s degree (262; 46.8%)). the sample included caucasians (402; 71.8%), african descent (57; 10.2%), asian (41; 7.3%), latinx (34; 6.1%), native american (17; 3%), and multiracial (9; 1.6%) participants. measures cannabis consumption. participants reported days per month they used cannabis (range 0-31, mean = 13.35, sd = 10.3) and how high they would feel on average sessions (1 (not at all high) to 6 (very high), mean = 3.40, sd = 1.265). antidepressant effects of cannabisassisted psychotherapy. participants responded to: “new research suggests that depressed people can benefit from taking the hallucinogen psilocybin and sitting quietly in a safe laboratory setting while listening to music, wearing an eye mask, and focusing on the effects. do you think an ideal dose of cannabis might help depression if administered under comparable circumstances?” from 0 (not at all) to 100 (a great deal). scores ranged from 0 to 100 (mean = 65.40; sd = 26.384). we chose an ideal dose rather than specify a specific number of milligrams to allow for disparate rates of familiarity and tolerance. subjective effects. we used multiple indices (emotional breakthrough, oceanic boundlessness, and ego dissolution) as detailed below. participants read: “here are some feelings others have reported in response to peak experiences of many kinds. please think about your experiences while using an ideal dose of cannabis and state how much each one applies to you. please give your best guess on each one.” they then answered, “how much would an ideal dose of cannabis in the absence of other drugs make you…” and rated intensity. emotional breakthrough (eb). participants rated the 8 items of the emotional breakthrough scale (roseman et al., 2019) from 0 (not at all) to 100 (very much). dropping two reverse-scored items brought cronbach’s alpha to .931 from .643. the average score per item (mean = 48.0825; sd = 24.268) exceeded those in roseman et al’s (2019) study (mean = 43, sd = 31.5; t (937) = 2.787 p < .01; d = .181). oceanic boundlessness (obn). participants rated 27 items from the oceanic boundlessness subscale of the altered states of consciousness scale (dittrich, 1998) that showed the highest correlations with subsequent antidepressant effects (roseman et al., 2018) of psilocybin at 5-week follow-up. the current sample described their likely response using the options of the mystical experiences questionnaire (griffiths et al., 2006), which covaries with oceanic boundlessness above r = .9 (liechti et al., 2017). participants responded with: 0 – none; not at all, 1 – so slight cannot decide, 2 – slight, 3 – moderate, 4 – strong (equivalent in degree to any other strong experience), or 5 – extreme (more than any other time in my life and stronger than 4). cronbach’s alpha was .962. scores ranged from 0-131 (mean = 62.99, sd = 28.064). ego dissolution (ed). participants rated the 8 items (nour et al., 2016) from 0 (not at all) to 100 (very much), including “i lost all sense of ego” and “i experienced a decrease in my sense of self-importance.” ed predicted greater improvement in depression in previous work (e.g. carhart-harris et al., 2017; garcia-romeu et al., 2019; uthaug et al., 2018). cronbach’s alpha was .924; scores ranged from 0-800 (mean = 352.232, sd = 184.877). results only p’s < .01 were considered significant. p-p plots suggested normal distributions. cannabis, a publication of the research society on marijuana 19 table 1. correlations among expectancies for cannabis-induced mystical experiences, antidepressant effects, and use (n = 556) 1 2 3 4 5 6 eb ed .735** obn .583** .712** freq of cannabis .322** .230** .155** .226** avg high .484** .424** .381** .435** .476** antidepress .497** .446** .316** .441** .274** .297** ** p < .01. eb = emotional breakthrough; ed = ego dissolution; obn = oceanic boundlessness; freq = cannabis use days per month; avg high = average high per session; antidep = improvement in depression demographic correlates eb, ed, obn, and expected antidepressant effects were orthogonal to age (maximum r = 0.12). gender differences (based on self-selected gender identity) were non-significant (maximum cohen’s d = 0.22), as were ethnic differences, which did not exceed d = 0.17, all p’s > .01. correlations pearson’s correlations (table 1) reveal that subjective effects covaried and increased with cannabis involvement. antidepressant effects we regressed expected antidepressant effects of cannabis-assisted therapy on the expected subjective effects after removing 9 multivariate outliers to conform to assumptions. only eb remained significant (standardized beta ed = -0.163, t = 2.427, rsquared change = .008 p = .016; standardized beta obn = -0.045, t = -0.788, r-squared change = .001 p > .40; standardized beta eb = .410, t = 7.360, p < .01, r-squared change = .254, respectively). participants apparently expect obn and ed to improve depression via eb. discussion cannabis might create subjective experiences comparable to those that seem important in psilocybin-assisted treatment (earleywine et al., 2021). the current study attempted to replicate previous work showing that cannabis users believed that a cannabisassisted psychotherapy session could increase obn and improve depression while also extending the results to ed and eb. the expected antidepressant effects correlated significantly with subjective obn, ed, and eb effects. the link between expected subjective experiences and expected antidepressant effects was no longer significant when eb was present as a predictor. perhaps an emotional breakthrough is the key source of relevant changes in depression, at least according to what cannabis users expect. these results raise questions about other potential underlying mechanisms. standard treatments for depression rarely rely on mystical experiences or emotional breakthroughs (see cuijpers, 2017). in contrast, cognitive treatments for depression rest on dysfunctional attitudes (see cristea et al., 2015). meta-analytic work reveals that these maladaptive beliefs underlie negative cannabis implications for psychotherapy 20 mood, depressive symptoms, and treatmentinduced improvements. even pharmacological treatments alter dysfunctional attitudes (cristea et al., 2015). the import of this alternative mechanism in assisted therapy is unknown but connecting dysfunctional attitudes to assisted therapy might help explain how best to offer support and integration. the role of dysfunctional attitudes in other disorders also underscores their potential (see wang et al., 2017; yapan et al., 2020). given clarion calls for replication (e.g. amrhein et al., 2019), we sought to replicate these expected effects of a cannabisassisted session and extend them to dysfunctional attitudes. we hypothesized that cannabis users would again anticipate that a cannabis-assisted session would decrease depression via the impact on obn, ed, and eb. we also hypothesized that they would anticipate that the cannabis-assisted session would improve depression via dysfunctional attitudes. we were also eager to explore if dysfunctional attitudes mediated the link with depression independently of the session’s impact on obn, ed, and eb. study 2 methods participants a total of 568 cannabis users (319; 56.1% female) recruited from mturk passed attention checks and provided complete data. the local irb approved procedures. all ip addresses differed from those in study i. ages ranged from 18 to 68 (mean = 35.09, sd = 10.415). the skew for age exceeded acceptable levels (.860; see osborne, 2013), but decreased with a square-root transformation (.512). education ranged from some high school to a graduate degree (mode, median, and mean = bachelor’s degree (217; 38.3%) followed by some college (139; 24.5%)). the sample was primarily caucasian (417; 73.4%), with african descent (56; 9.9%), asian (40; 7.0%), latinx (33; 5.8%), native american (11; 1.9%), and multiracial (11; 1.9%) participants as well. current use averaged 14.81 days per month (sd = 11.63) with a subjective “high” averaging 3.45 (sd = 1.268). measures subjective effects. we used the same scales and instructions employed in study i. antidepressant effects ranged from 0 to 100 (mean = 74.00; sd = 24.994). emotional breakthrough (eb). the sixitem version (cronbach’s alpha = .931) ranged from 0-600 (mean = 291.356, sd = 160.183), with an average item (mean = 48.560, sd = 26.697) that exceeded scores reported previously (roseman et al., 2019); (mean = 43, sd = 31.5; t (945) = 2.919, p < .01; d = .190). oceanic boundlessness (obn). the 27item scale (cronbach’s alpha =.962) ranged from 0-132 (mean = 59.73, sd = 29.128). ego dissolution (ed). scores ranged from 0-800 (mean = 347.87, sd = 195.268). cronbach’s alpha was .918. dysfunctional attitudes. participants rated how much they thought they would agree with maladaptive statements (from -2 (fully disagree) to +2 (fully agree)) both before and after a session of cannabis-assisted therapy (beevers et al., 2007). typical items included: “i must be liked by everyone or it’s a disaster,” and “if i fail partially, i have failed completely.” the “before” and “after” ratings were side by side in adjacent columns. cronbach’s alpha (pre-treatment) was 0.890 (mean = -2.57, sd = 13.322) and 0.889 (posttreatment; mean = -8.29, sd = 12.783). a difference score ranged from -60 to 32 (mean = -5.71; sd = 12.719). negative skew (-0.986) required transformation by anchoring the lowest score at 1, subtracting total score from the maximum possible plus one and then computing the square root (skew = 0.062; osborne, 2013). higher scores were less dysfunctional. cannabis, a publication of the research society on marijuana 21 results only p’s < .01 were considered significant. p-p plots suggested normal distributions. dysfunctional attitudes participants anticipated improved attitudes if they participated in the described cannabis session with an ideal dose and psychological support (pre-treatment mean = -2.737, sd = 13.33; post-treatment mean = 8.443, sd = 12.71; paired t(557) = 10.591, p < .001, d = .449). demographics responses and attitude changes were not statistically linked to age (maximum pearson’s r = |.13|) or ethnicity (all d’s < .13). all p’s > .10. men reported expecting more ed th an women (368.45 (sd = 193.561) vs. 320.525 (sd = 191.090), d = .249; t(553) = 2.897, p < .004). although this difference did reach significance, it was not significantly higher than the sex difference present in sample 1 (d= .220; z = 0.16; p > .10.) table 2. correlations among expectancies for cannabis-induced mystical experiences, antidepressant effects, dysfunctional attitudes, and use (n = 568) 1 2 3 4 5 6 eb ed .679** obn .580** .702** dysatt .144** .133** .128** freq .351** .172** .119** -0.013 avg high .432** .348** .351** 0.048 .404** antidep .392** .245** .249** .194** .251** .249** **p < .01. eb = emotional breakthrough; ed = ego dissolution; obn = oceanic boundlessness; dysatt = dysfunctional attitudes; freq = cannabis use days per month; avg high = average high per session; antidep = improvement in depression correlations pearson’s correlations (table 2) showed that subjective effects covaried with each other, expected changes in dysfunctional attitudes, and anticipated impact on depression. they also increased with cannabis involvement. anticipated antidepressant effects tests of regression assumptions confirmed normal distributions after we dropped 16 multivariate outliers based on mahalonabis distances. only eb and dysfunctional attitudes predicted antidepressant effects when all variables were included: standardized beta eb = 0.388, t = 7.188, rsquared change = 0.149; standardized beta dysfunctional attitudes = .156, t = 3.973 rsquared change = .020, p < .001; standardized beta obn = 0.066, t = 1.172, r-squared change = .001 p > .10; standardized beta ed = -.087, r-squared change = 0.002, t = -1.399, p > .10). cannabis implications for psychotherapy 22 discussion links between cannabis consumption and depression remain varied. a high dose of cannabis can create subjective effects that parallel psilocybin’s subjective effects, which seem to precede improvements in depression in psilocybin-assisted therapy. two samples of cannabis users reported expecting that an ideal dose of cannabis administered in a therapeutic setting could create subjective effects like those linked to psilocybin-related improvements. these results confirm previous work on cannabis-induced oceanic boundlessness (obn; earleywine et al., 2021). these new data reveal that users expect that an ideal dose administered in ways that parallel current psilocybin-assisted therapy will alter psychedelic experiences of multiple types, including oceanic boundlessness and emotional breakthroughs. in addition, users report that an ideal dose might alter dysfunctional attitudes—a key contributor to depression in cognitive models of the disorder (cristea et al., 2015). expected antidepressant effects correlated with expected cannabis-induced mystical experiences, eb, and changes in dysfunctional attitudes. the impact of expected mystical experiences on expected antidepressant effects was mediated by eb. dysfunctional attitudes, however, remained significant with mystical experiences and eb in the equation. apparently, users believe that a session of cannabis-assisted psychotherapy would improve depression through two paths: emotional breakthrough and dysfunctional attitudes. these results have implications for cannabis-assisted psychotherapy. sessions akin to the psilocybin-assisted trials would require initial meetings to develop rapport with guides, ingesting cannabis in a therapeutic setting with a consistent focus on internal experience, and follow-ups for discussion of insights, altered cognitions, and new behaviors (see johnson et al., 2019; luoma et al., 2020). standard treatments rarely emphasize emotional breakthrough or mystical experiences as mechanisms, but cognitive approaches often focus on dysfunctional attitudes. in a first study of this kind, the current data suggest that cannabis users anticipate that cannabis-assisted psychotherapy could not only elicit mystical and emotional experiences, but also improve maladaptive beliefs like, “i must be liked by everyone or it’s a disaster,” and “if i fail partially, i have failed completely,” etc. users report that they believe that links between changes in dysfunctional attitudes and improvements in depression remain even when the effects of mystical experiences and emotional breakthroughs are considered. the case for a randomized clinical trial of cannabis-assisted psychotherapy seems stronger under these circumstances. these effects might be unique to cannabis and the psychedelics. opiates and stimulants, for example, do not appear to create the relevant changes in mystical experiences (griffiths et al., 2006; lamas et al., 1994), and seem less likely to alter eb, dysfunctional attitudes, or symptoms of depression. examinations of the discriminant validity of these subjective effects of other psychoactive substances could prove informative. cannabis-assisted psychotherapy might seem unnecessary given successes with psilocybin or ayahuasca (palhano-fontes et al., 2019), but rates of treatment failure and the chance to reveal novel information about neurotransmitter functioning underscore the need for cannabis trials. available treatments fall short because of low success rates and delayed onset of improvement (cuijpers et al., 2020; earleywine & de leo, 2020). cannabis treatment might have pharmacological advantages. a treatment that relies on the cannabinoid system rather than monoamines could provide insights into neurotransmitters and psychopathology (cowen & browning, 2015; harmer et al., 2017; nutt et al., 2007). of course, other important contributors cannabis, a publication of the research society on marijuana 23 (including the psychotherapy relationship and process) can improve outcomes as well (cuijpers et al., 2020). these data require cautious interpretation. given the range of cannabis consumption in this sample and the small number of studies that have examined psychedelic-like effects of the plant or its constituents, the accuracy of any single person’s prediction is unknown. we have asked participants to envision a cannabisassisted session that might be unlike any that they have experienced. we also asked about an ideal dosage, which might vary dramatically across participants without an initial reaction to a test dosage. generally, those who were more involved with cannabis reported that they anticipated greater psychedelic effects after use (see tables 1 and 2). few laboratory administration studies address links between any cannabis expectancies and actual responses, but work with alcohol suggests that experienced drinkers have expectancies and actual subjective changes align (morean et al., 2013, 2015). had participants reported that they doubted that cannabis could help create the relevant experiences, this line of research could end. but users envision a potential here that might be worthy of pursuit. perceptions of efficacy of this treatment would likely vary with previous experience with depressive symptoms and various interventions, suggesting that future work would benefit from a thorough assessment of psychopathology and therapy experience. extending this work to other problems responsive to psilocybin also seems reasonable. cannabis users might expect improved cancer-related distress, posttraumatic stress disorder, and drug problems for relevant sessions, for example (bogenschutz et al., 2015; 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(2020). rumination, automatic thoughts, dysfunctional attitudes, and thought suppression as transdiagnostic factors in depression and anxiety. current psychology, 1–17. funding and acknowledgements: the authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript. the authors received no specific funding for this study. special thanks to matthew butcher and jardim das flores for support during this work. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i1a4_authors_final research article 30 samantha m. doonan1,2, julie k. johnson1, caislin firth3,4, alyssa flores1, & spruha joshi5 1massachusetts cannabis control commission (ccc), 2 washington sq., worcester, ma, 01604, united states 2new york university school of medicine, 180 madison ave. new york, ny, 10016, united states 3faculty of health sciences, simon fraser university, 8888 university dr., burnaby, british columbia, v5a 1s6, canada 4alcohol & drug abuse institute, university of washington, 1107 ne 45th st., seattle, wa, 98105, united states 5new york university school of medicine and school of nursing, 180 madison ave. new york, ny, 10016, united states ved abstract background: cannabis criminalization disproportionately harms communities of color in the united states. in massachusetts’ legal recreational (“adult-use”) cannabis industry, state regulations intend to promote diverse participation. we assessed short-term racial/ethnic and gender diversity across the industry and in senior-level positions with greater opportunities to build wealth (i.e., board members, executives, directors). methods: we extracted race/ethnicity and gender from required registration forms submitted to state regulators for each person working in a licensed adult-use cannabis business from october 2018 to april 2020 (n=4,883). we conducted descriptive analysis and negative binomial regression to assess characteristics associated with senior positions. results: as of april 2020, racial/ethnic and gender diversity in the massachusetts adult-use cannabis market (n=4,883) was 75% white, 7% latino, 6% black/african american, similar to the state labor market, and 65% male. diversity was more limited in senior positions. agents in senior positions (n=403) were 84% white, 2% latino, 5% black/african american, and 82% male. senior-level participation was markedly low for women of color. conclusion: despite legislative and regulatory commitment, diversity lacks in senior positions in this emerging cannabis market. states considering adult-use cannabis markets, and those that have already done so, should monitor participation to identify inequities and adapt initiatives to ensure black/african american and latino communities socially and economically benefit from state legalization. key words: social equity; cannabis; cannabis policy; marijuana policy; diversity; cannabis market despite federal illegality, u.s. states are increasingly legalizing cannabis for adult use (people at least 21 years old) and establishing licensure of cannabis establishments. ensuring that black/african american, latino, and indigenous communities socially and economically benefit from the state’s legal industry is critical, as cannabis prohibition enforcement disproportionately harmed these communities (ahrens, 2020; bender, 2016; perlman, 2020). in 1971, the nixon administration declared a war on drugs, and punitive enforcement measures ramped up in the cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.004 racial equity in cannabis policy: diversity in the massachusetts adult-use industry at 18-months corresponding author: samantha m. doonan, ba. massachusetts cannabis control commission (ccc), 2 washington sq., worcester, ma, united states; new york university school of medicine, 180 madison ave. new york, ny 10016, united states. email: samantha.doonan@nyulangone.org cannabis, a publication of the research society on marijuana 31 late 1980s under the reagan administration (bender, 2013). racism was a driving force in these policies (provine, 2011). taken together, the war on drugs and associated punitive enforcement policies (including for cannabis) created structural changes to substance use enforcement and are implicated in the disproportionately high arrest and incarceration rates for people of color and particularly black men for drug-related offenses (bender, 2013). today, impacts persist with diffuse harms. consequences include disruption to key correlates of health (e.g., housing, employment), economic opportunities, the social cohesion of neighborhoods, the wellbeing of family units, and have generational implications (bayerl et al., 2017; berson, 2013; valleriani et al., 2018). in contrast, some legalization proponents envision cannabis legalization as a means toward restorative social and economic justice for communities most harmed by prohibition enforcement (adinoff & reiman, 2019). cannabis legalization alone does not eliminate the individual, family, and community-level impacts of prohibition, but it opens doors for advancing equity. for example, cannabis arrests decline following legalization, but racial disparities persist (firth et al., 2019, 2020). participation in state legal industries is one opportunity to advance economic justice. senior industry positions (i.e., board members, executives, directors) are particularly important roles to consider as pathways to build wealth. however, the gray literature indicates that senior positions in cannabis enterprises are disproportionately held by white men (analytic insight, 2020; lewis, 2016; marijuana business daily, 2017). in response and in recognition of historical and persistent disparities, states are implementing unique approaches aimed at increasing equity through cannabis policies. the evidence-basis for specific equity-related policies is still developing. people and communities most harmed by cannabis prohibition face disproportionate barriers to enter the cannabis industry (bender, 2016; danquah-brobby, 2017; hamilton et al., 2019; rahwanji, 2019). all aspiring entrepreneurs face major financial barriers (e.g., access to capital, real estate costs), which are compounded by a lack of access to traditional banking services in the cannabis industry. yet racial disparities in wealth and discrimination in access to capital make such barriers more prohibitive for disproportionately impacted communities of color (bender, 2016; danquah-brobby, 2017; swinburne & hoke, 2020). in addition, necessary approvals and various regulatory complexities across local and state governments require access to legal services, favoring the politically well-connected (adinoff & reiman, 2019). for all positions, prior criminal convictions (including for cannabis) may restrict employment opportunities. this barrier then disproportionately restricts participation by people of color because of inequitable enforcement practices and outcomes in the justice system (perlman, 2020; rahwanji, 2019). further, cannabis remains a federally illegal substance (drug enforcement agency, n.d.). harms from prohibition and greater scrutiny of people of color by law enforcement may result in greater reluctance to enter a high-profile market that is not federally legal (bender, 2016; danquahbrobby, 2017). critically, these cannabis-specific barriers occur in the context of larger social systems and factors, including structural inequity, racism, and discrimination (garcía & sharif, 2015). women also participate in state’s legal cannabis markets less than men, and little is known about participation by women of color (august, 2013; camors et al., 2020; kittel, 2018; vangst, 2019). researchers in other fields identified distinct barriers to entry, particularly in senior positions, for women of color (sanchezhucles & davis, 2010). these overlapping institutional and interpersonal barriers (e.g., discriminatory practices in access to capital, racism and sexism within the industry, disadvantage resulting from systemic inequity), may similarly restrict access and opportunity in the cannabis industry (bowleg, 2012). given these barriers and past harms, particularly among disproportionately impacted communities of color, policies that facilitate access to economic opportunities in the newly legal industry are critical. social equity provisions in adult-use cannabis legislation often intend to increase equitable industry participation (swinburne & hoke, 2020). laws and regulations with this goal appear increasingly frequent in recent states to legalize cannabis (e.g., illinois [2019], michigan [2018], massachusetts [2016]) (swinburne & hoke, 2020). see appendix table a for massachusetts’ provisions. simultaneously, city-led initiatives such as policies, procedural changes, grants, and/or programs are spreading in both earlyand laterdiversity in ma adult-use cannabis industry 32 adopting states (e.g., oakland, california; portland, oregon; cambridge, massachusetts) (adinoff & reiman, 2019). state and local variation necessitate careful attention to provision and implementation heterogeneity for larger outcomes assessment (e.g., a manual expungement process for past convictions may affect fewer people compared to an automatic expungement process) (perlman, 2020). once provisions are defined, conducting a baseline analysis and ongoing monitoring of industry participation by race/ethnicity is needed to inform program evaluation and adaptation of programs to ensure success. massachusetts is an ideal case to examine the participation of people of color and women in the cannabis industry, as it was the first state to explicitly include a participation-related equity directive in enabling adult-use cannabis legislation. to meet this statutory requirement, the regulatory commission created and continues to develop and modify regulations and programs aiming to produce equitable participation in the cannabis industry [see appendix table a]. it is important to note that these provisions do not exclusively target specific racial and ethnic groups, but more broadly focus on people and geographic communities harmed by cannabis prohibition and the war on drugs. additionally, massachusetts collects robust demographic data on participation in licensed enterprises, enabling assessment that, to date, no other state provides. as part of employment and ownership registration requirements, all cannabis businesses report employee race/ethnicity, gender, position title, and residency information. in 2020, the massachusetts cannabis control commission published a gray literature report using one year of participation data which found that 75% of agents were white and 67% were male (doonan et al., 2020). however, this report was limited to registration forms which contained multiple counts of individuals and did not examine diversity within senior positions. the present study extends this report by combining duplicate registration forms to examine unique agent-level participation in the adult-use cannabis industry during the first 18 months of retail operations across position seniority. we examined racial/ethnic and gender diversity across the industry and among senior positions (i.e., board members, executives, directors). we expected that disproportionate barriers would result in lower participation among black/african american and latino people (as compared to percent of the state’s workforce), particularly in senior positions, despite equity provisions aimed at promoting diversity within the cannabis industry. methods sample the sample consists of paid personnel working in a licensed massachusetts adult-use cannabis business (“agents”) (massachusetts cannabis control commission, 2021). we included all agents that submitted a registration form (required to legally work in the industry) from the first submitted form on october 15, 2018, through april 28, 2020. to fully capture short-term industry participation, we included all active and inactive agents. we extracted all agent registration forms (n=8,450), then merged forms for the same individual into a single unique agent entry for analysis through a unique identifier built into the registration system (n=4,918). to verify that individuals were correctly associated with only one unique identifier, we queried first name, last name, and residential state. if these identifiers were a direct match but more than one unique identifier was associated, we examined street address, residential city/town, and place of employment. if two or more of the latter were direct matches, then we assumed this was the same individual and merged data into a single entry (dropped n=24 duplicate agent records). persons working as unpaid volunteers only were also dropped (n=11). the final data set included 4,883 agents. variables race/ethnicity. on registration forms, individuals may select all races that apply, but we utilized a single race/ethnicity variable for analysis to create mutually exclusive groups. this variable pooled agents into one of the following: white, black/african american, latino ethnicity, asian, other race, two or more races, or race not provided [see appendix table b for inclusion criteria]. we included those with missing race/ethnicity (“race not provided”) in this baseline estimate because we were unsure if there was systematic bias in cannabis, a publication of the research society on marijuana 33 reporting race/ethnicity. to ensure anonymity, we used “other race” to categorize agents whose race/ethnicity had a small sample size. this included people who identified as: american indian or alaska native, native hawaiian, pacific islander, and middle eastern or north african. our analysis focused on participation among black/african american and latino people as these communities were disproportionately impacted by prohibition in massachusetts, had a sufficient sample size in our data, and were specifically identified in several state equity provisions (i.e., mentioned in qualification criteria for equity programs) [see appendix table a] (doonan et al., 2020). gender. we extracted gender for all agents. agents were coded as male or female. to protect anonymity due to low sample size, agents who identified as non-binary, or reported different gender identities across forms, were combined with agents missing gender. we examined participation by gender because, over the period of analysis, massachusetts identified women for inclusion in diversity plans. seniority status. we extracted agent job titles and classified agents as their most senior title (from most to least senior: board member, executive, director, manager, employee). agents were stratified as holding a senior position if they worked as a board member, executive, or director and less senior if they worked as a manager or employee. promoting participation in all levels of seniority is a goal of the massachusetts social equity program, and several qualifiers for economic empowerment priority applicants included specific ownership criteria [see appendix table a]. analysis first, we conducted descriptive statistics for the entire industry. we do not report population groups with five or fewer people to protect anonimity. in order to obtain risk ratios (rrs), which are more interpretable, we ran a negative binomial model to assess the relationship between demographic characteristics and holding a senior position (binary outcome) (davies et al., 1998). stata mp 15 was used for all analyses. results racial/ethnic diversity in the entire cannabis industry agent characteristics for the full industry (n=4,883) are reported in table 1. the majority of agents worked as employees. across the entire industry, agents were 75% white, 7% latino, 6% black/african american, and 1% asian. for comparison, 2019 american community survey (acs) estimates of the massachusetts labor force indicated that the labor force was approximately 78% white, 11% latino, 8% black/african american, and 7% asian (u.s. census bureau, 2019). while these populations are not analogous, the comparison indicates that the racial and ethnic diversity of the entire industry is similar to the massachusetts workforce, except among asian people who participated at lower levels compared to proportion of the labor force. gender diversity in the entire cannabis industry the industry skewed male (65%) [see table 1]. within all racial and ethnic groupings, women represented a smaller percentage of industry participation as compared to same-race men. racial/ethnic diversity in senior-positions characteristics of agents holding senior positions and results of the rr analyses are shown in table 2. agents in senior positions were 84% white, 2% latino, and 5% black/african american. senior positions had lower levels of racial/ethnic diversity compared to less-senior positions (i.e., employees, managers) (p<.001, chi-squared test not shown). latino agents were 79% less likely to have a senior role compared to white agents (rr=0.21, 95% confidence interval (ci):0.10-0.45). no difference in likelihood was identified between black/african american and white agents. sensitivity analyses further indicated that in-state residents and residents of geographic areas targeted for inclusion by regulators had a lower likelihood of holding senior positions compared to out-of-state residents and in-state residents outside of geographically targeted areas respectively (data not shown, available upon request). diversity in ma adult-use cannabis industry 34 table 1. descriptive statistics for entire industry characteristics as identified in agent registration forms total industry frequency (%) n=4,883 position board member 93 (1.90%) executive 210 (4.30%) director 100 (2.05%) manager 322 (6.59%) employee 4,158 (85.15%) gender male 3,162 (64.76%) female 1,683 (34.47%) non-binary, multiple gender identities, or missing gender 38 (0.78%) race/ethnicity white 3,679 (75.34%) black/african american 281 (5.75%) latino 357 (7.31%) asian 67 (1.37%) other race 74 (1.52%) 2 or more races 111 (2.27%) race not provided 314 (6.43%) race/ethnicity and gender1 white male 2,351 (48.52%) black/african american male 195 (4.02%) latino male 232 (4.79%) asian male 47 (0.97%) other race male 57 (1.18%) 2 or more races male 77 (1.59%) race not provided male 203 (4.19%) white female 1,303 (26.89%) black/african american female 86 (1.78%) latino female 123 (2.54%) asian female 20 (0.41%) other race female 17 (0.35%) 2 or more races female 30 (0.62%) race not provided female 104 (2.15%) note. 1persons with non-binary, multiple gender identities, or missing gender not shown (n=38). cannabis, a publication of the research society on marijuana 35 table 2. senior-level positions note. untabulated demotes small sample size untabulated to protect anonymity. rrs were not run for groups that had a sample size of < 5 in senior positions. 1persons with non-binary, multiple gender identities, or missing gender not shown. characteristics as identified in senior-level agent registration forms (n=403) unadjusted rr (95%ci) gender1 (frequency [percent]) female (73 [18%]) ref male (329 [82%]) 2.40 (1.87-3.07) race/ethnicity white (337 [84%]) ref black/african american (22 [5%]) 0.85 (0.57-1.29) latino (7 [2%]) 0.21 (0.10-0.45) asian (untabulated) untabulated other race (untabulated) untabulated 2 or more races (13 [3%]) 1.28 (0.76-2.15) race not provided (13 [3%]) 0.45 (0.26-0.78) race/ethnicity x gender1 white male [271 (67%)] ref black/african american male (untabulated) 0.80 (0.51-1.26) latino male (untabulated) 0.26 (0.13-0.55) asian male (untabulated) untabulated other race male (untabulated) untabulated 2 or more races male (untabulated) 1.24 (0.71-2.17) race not provided male (untabulated) 0.51 (0.29-0.90) white female [65 (16%)] 0.43 (0.33-0.56) black/african american female (untabulated) untabulated latina female (untabulated) untabulated asian female (untabulated) untabulated other race female (untabulated) untabulated 2 or more races female (untabulated) untabulated race not provided female (untabulated) untabulated diversity in ma adult-use cannabis industry 36 figure 1. industry participation note. persons with non-binary, multiple gender identities, or missing gender or missing race (n=314 in entire industry, n=13 in senior-level) are not shown. men of color includes persons identified in our data as male and black/african american, latino, asian, other race, and two or more races. women of color includes persons identified in our data as female and black/african american, latino, asian, other race, and two or more races. gender diversity in senior-positions males were 2.4 times more likely to have a senior position compared to female agents (rr=2.4, 95% ci: 1.87-3.07) [see table 2]. we were unable to calculate the rr for each intersectional race/ethnicity and gender cohort in this sample because the sample size for women of color in senior positions was too low to run. after excluding those with missing race/ethnicity or gender, summary statistics show that women of color had approximately 2% of senior positions, in contrast men of color had 12%, white women had 17%, and white men had 70% of positions [see figure 1]. among agents with intersectional identities that we were able to run analyses for, we found that compared to white men, latino men had a 74% lower likelihood of having a senior position (rr=0.26, 95% ci:0.13-0.55). there was not a statistically significant difference of having a senior position among black/african american men compared to white men. white women had a 57% lower likelihood of holding a senior position as compared to white men (rr=0.43, 95% ci:0.33-0.56) [table 2]. these findings suggest participation is disproportionally limited among women, particularily women of color. discussion at 18-months in operation, the racial and ethnic makeup of the adult-use industry is similar to the massachusetts labor market, except among asian people for whom cannabis industry participation is lower than state labor market participation. however, senior positions in the cannabis market, roles with the greatest opportunity to build wealth and create opportunity for others, suggest a concerning lack of diversity in the short-term, despite state equity provisions and programs. senior-level participation is particularly 52% 70% 29% 17%13% 12% 6% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% entire industry senior-level pe rc en t o f t ot al white men white women men of color women of color cannabis, a publication of the research society on marijuana 37 low among latino people and among black/african american and latina women. this suggests more work is needed to achieve participatory equity. importantly, study findings are preliminary and reflect the demographic characteristics of earliest adopters to work and start cannabis businesses in massachusetts. the state’s adult-use market started from an existing medical cannabis market that did not have requirements or incentives to recruit staff from disproportionally impacted communities. established medical facilities are also vertically integrated, inherently more expensive to build than separate establishments, and thus have greater economic barriers for ownership. since medical cannabis businesses received prioritized application review for adult-use licenses, these establishments were poised to enter the adult-use marketplace in massachusetts (with existing staff) more quickly than new businesses. the earliest adult-use industry adopters may also reflect expansion of cannabis businesses from other legalized states, thus, racial composition and disparities operating in other markets could be reflected in the massachusetts market. however, additional systemic barriers and discrimination toward black/african american and latino people and communities likely create compounding and substantial obstacles for equity provisions to be fully successful. our finding of lower levels of racial diversity in senior-level cannabis industry positions aligns with research in other industries. for example, a comprehensive analysis of equal opportunity employment commission (eeoc) data representing about 35% of the civilian labor force identified stark disparities between racial and gender diversity in middle management and senior positions (bloch et al., 2020). evidence of increasing senior-level diversity is also important to monitor as it could indicate a positive trend toward overall diversity; people of color in senior positions are more likely to hire employees of color (swinburne & hoke, 2020). the current study shows that baseline analyses of diversity in cannabis markets should specifically monitor senior-level positions to accurately characterize industry participation. in massachusetts, we also identified extremely low numbers of senior positions held by women of color; such small subgroup sample sizes precluded inclusion of these cohorts in the regression analysis. other state assessments should similarly stratify by intersectional race/ethnicity and gender identity as aggregate data could obscure critical differences. as we identified [see appendix table a], multiple current regulatory requirements could positively impact findings overtime. for example, state regulators scrutinize business positive impact plans and diversity plans prior to granting the establishment a final license and may place conditions upon businesses to improve these plans (hamilton et al., 2019). massachusetts also restricts the number of cannabis business licenses that any person or entity may own (i.e., three of each license type). this provision prevents a small number of companies from monopolizing the market. as these considerations illustrate, heterogeneity between states, cannabis provisions, and enforcement tools are critical to document as differences may, directly and indirectly, impact participation outcomes (johnson & doonan, 2019). recently implemented and planned equity initiatives in massachusetts may also positively impact future diversity through a focus on ownership opportunities. for example, in january 2021, the regulatory commission promulgated regulations that restrict social consumption establishment, marijuana courier, and marijuana delivery operator licenses to certified economic empowerment priority applicants, social equity program applicants, microbusinesses, and/or craft marijuana cooperatives, all of which have residency requirements, for a period of three years. commissioners will evaluate the impact of this provision in promoting diversity and small business participation to determine whether to extend the exclusivity period. this provision may particularly impact senior-level participation as it primarily targets ownership. the current study provides a baseline prior to the enactment of these provisions. regulatory complexity and differences across systems of government (i.e., local, state, federal) form interlocking and unique barriers to entry in the cannabis industry, yet equity-focused initiatives frequently address a single factor. breaking such barriers requires a commitment to equity across multiple levels of government and social systems, thus, limits the abilities of any single entity (e.g., state legislation, state regulation, local policy, activist and nonprofit organizations, cannabis establishments) to affect change alone. our findings suggest that state diversity in ma adult-use cannabis industry 38 policy and regulatory provisions (as of april 2020) have not resulted in equitable senior-level participation among black/african american and latino agents at 18-months of the adult-use market’s operation. the present analysis represents preliminary findings for massachusetts, a majority white state, and the first east coast state to implement an adult-use cannabis market. we are unable to disentangle the effects of specific provisions in this study [see appendix table a], and the provisions in massachusetts do not represent all variations of equity provisions that affect industry participation. for example, massachusetts does not provide grants to equity program participants; in contrast, illinois established a funding mechanism through the “restore, reinvest, and renew program” to directly provide capital to equity program participants (swinburne & hoke, 2020). policy and procedural changes also occurred during this study, for example, the massachusetts social equity program eligibility changed from 400% of the federal poverty line to 400% of area median income, and provisions continue to change. policy and provision evolution add additional complexity to understanding the impact of equity provisions. further, while certain massachusetts equity provisions specify inclusion of black/african american and latino people, provisions also intend to promote participation from specified geographic areas and other groups, including: veterans, farmers, and lgbtq+ people. assessment of participation across these cohorts is beyond the scope of this study, but our sensitivity analyses indicate that further study of state residency and residency in targeted geographic areas is warranted. future work could also consider company characteristics (e.g., number of employees in company, leadership characteristics). the present study does not analyze the impact of locallevel provisions, which remain an important and often overlooked barrier or facilitator for equity in the marketplace (dilley et al., 2017). finally, while this study is limited to participation, equity-related outcomes of legalization are complex and multifaceted (e.g., cannabis-related arrests, access to expungement, cannabis-related disciplinary actions in schools, tax revenue for harmed communities). nonetheless, equitable participation is an intention of multiple policies and regulations and an important outcome to assess. as the industry matures, researchers and regulators should develop and/or continue monitoring participation by race/ethnicity and gender to evaluate participatory-related provisions. limitations this study is subject to limitations. first, experiences in massachusetts may not compare to other states with legal cannabis markets, given demographic differences and the unique laws and regulations for each market. in addition, our comparison to census data is imperfect. cannabis businesses hire adults at least 21 years old, while the census estimates used for comparison includes employed persons who are at least 16 years old. latino ethnicity is also coded differently in the present study as compared to the census (i.e., coded as a “single-race/ethnicity” in the present study and coded as ethnicity in addition to race in the census). data accuracy and missing data are also a concern. registration forms may be completed by a supervisor, rather than self-reported by agents, thus the extent to which race/ethnicity was selfreported is unknown. race/ethnicity data were missing for 6% of the sample. for analysis purposes, we pooled individuals into a single race or ethnicity category, but this could obscure participation differences for agents identifying multiple races and ethnicity. in addition, due to low sample size for african american/black and latina women in senior-level positions, we did not run regression analyses to assess participation for these intersectional cohorts. to capture all participation in the short-term market, we included all active and inactive agents, but further work is necessary to understand the characteristics of agents that exit the industry. finally, industry participation can take many forms, including ancillary businesses (e.g., accounting, consulting, sanitation services). the massachusetts social equity program explicitly includes ancillary businesses as a pathway to positively impact industry diversity, yet this study only includes agents directly working under a cannabis license(s) in the state’s legal adult-use industry. future research should additionally assess diversity within ancillary enterprises. conclusion structural racism is evident in u.s. drug prohibition and punitive enforcement policies (e.g., cannabis, a publication of the research society on marijuana 39 war on drugs) (bailey et al., 2017; provine, 2011). cannabis criminalization resulted in negative individual, community-level, and generational impacts, which disproportionately impacts black/african american and latino people in massachusetts (doonan & johnson, 2019). state cannabis legalization provides opportunities to advance equity. this study is a baseline assessment for one pathway: employment and economic opportunities in a state’s legal cannabis industry with a focus on senior-level positions. our findings of shortcomings in senior-level diversity, despite codified equitable aims and actions in massachusetts, should promote concern and suggest additional scrutiny of structural barriers that equity provisions operate within (e.g., enforcement policies, economic inequity) is necessary. we also identify key metrics for states to monitor in their markets, including intersectional diversity (at a minimum race, ethnicity, and gender) across seniority levels. while this study is unable to account for the impact of unmeasured structural barriers to participation (e.g., racism, intersectional racism and sexism), these findings suggest current equity provisions alone have not produced the desired outcomes among 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(2019). vangst 2019 report: women in cannabis. https://vangst.com/blog/vangst2019-women-in-cannabis-report funding and acknowledgements: s.m. doonan, a. flores and j.k. johnson were supported by the massachusetts cannabis control commission. the content is solely the cannabis, a publication of the research society on marijuana 41 responsibility of the authors and does not necessarily represent the views of the massachusetts cannabis control commission. s. joshi was supported by the nih/nida funded t32 training grant 5t32da007233-36. s.m. doonan, s. joshi, and j.k. johnson designed the study. s.m. doonan drafted the article and led the data analysis. s. joshi and c. firth advised on data analysis. all authors interpreted results, provided critical revisions, reviewed, and provided feedback on drafts of the article. all authors approved the article. no conflicts declared. three authors work for the cannabis control commission, commonwealth of massachusetts, the regulatory agency for cannabis laws in the massachusetts commonwealth as staff (s.m. doonan, j.k. johnson, a. flores). we gratefully acknowledge shawn collins, massachusetts cannabis control commission, erika scibelli, massachusetts cannabis control commission, david mckenna, massachusetts cannabis control commission, kyle potvin, massachusetts cannabis control commission, olivia laramie, massachusetts cannabis control commission, alisa stack, massachusetts cannabis control commission, and shaleen title, massachusetts cannabis control commission. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources are not modified, and the source is not used for commercial purposes. research article 48 abstract among college students, interpersonal conflict with others is a common, yet stressful negative interpersonal experience. research suggests that drinking episodes may contribute to the occurrence of conflict. marijuana use, independently or in conjunction with alcohol, may also influence the likelihood of subsequent conflict. we considered the temporal effects of independent and simultaneous alcohol and marijuana use episodes on the occurrence of interpersonal conflict. use of multilevel modeling allowed us to distinguish the within-person effects of substance use from between-person differences in frequency of use. within a sample of 427 college freshman males over 56 days of daily reports, we examined the independent and interactive effects of episodes of alcohol and marijuana on the odds of conflict within the next 1-, 2-, 3-, and 4 hours. multilevel modeling analyses showed that drinking episodes increased the likelihood of conflict occurring within the next 1-, 2-, 3-, and 4 hours. marijuana had weaker positive effects, significant only within the 2-hour window. there were no alcohol by marijuana interaction effects in any analysis. both marijuana and alcohol independently increased the likelihood of interpersonal conflict; however, the marijuana effect appeared less robust. as marijuana use becomes more normative and accessible for college students, it is important to understand the extent to which marijuana use results in negative consequences and the contexts under which these effects unfold. key words: marijuana, alcohol, college students, daily diary, interpersonal conflict heavy alcohol use and marijuana use have been associated with increased social, psychological, and physiological negative consequences (e.g., graham et al. 2011; volkow, baler, compton, & weiss, 2014). among potential consequences of substance use, interpersonal conflict is a common, yet stressful negative interpersonal experience among college students (robertson, forbes, & thyne, 2017). interpersonal conflict consists of an interaction involving negative emotion and disagreement or interference with the attainment of one or both persons' goals (barki & hartwick, 2001, 2004; fink, 1968). it may include verbal or physical aggression (anderson & bushman, 2002). studies using laboratory (e.g., eckhardt & crane, 2008; duke, giancola, morris, holt, & gunn, 2011), field (e.g., graham, bernards, osgood, & wells, 2006), and daily process (e.g., miller, quigley, eliseo‐ arras, & ball, 2016) methods provide evidence that acute alcohol use increases the likelihood of interpersonal conflict and verbal aggression. cannabis 2018, volume 1 (2), 48-59 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2018.02.005 open access alcohol and marijuana use in undergraduate males: betweenand within-person associations with interpersonal conflict corresponding author: whitney c. brown, research institute on addictions, 1021 main street, buffalo, ny, 14203 u.s.a., phone: 716-882-2218, email: wbrown@ria.buffalo.edu whitney c. brown1, weijun wang1, maria testa1 1 research institute on addictions, university at buffalo, state university of new york, buffalo, ny, usa http://dx.doi.org/10.26828/cannabis.2018.02.005 cannabis, a publication of the research society on marijuana 49 alcohol use is thought to contribute to interpersonal conflict and aggression due to its pharmacological effects: impaired cognitive functioning (giancola, 2000), increased physiological arousal (conrod, peterson, & pihl, 2001), and heightened attention to salient, provoking cues (steele & josephs, 1990; taylor & leonard, 1983). marijuana may independently contribute to the occurrence of conflict or potentiate alcohol’s effect on aggression; however, evidence is limited. associations between marijuana and conflict may also reflect confounding individual difference variables associated with aggression or concurrent alcohol use rather than acute effects of marijuana. in the present study, we used daily process methods to disaggregate within-person or temporal effects of alcohol and marijuana use on interpersonal conflict from between-person effects. marijuana, aggression, and interpersonal conflict marijuana is used by approximately one-third of college students (miech, johnston, o’malley, bachman, & schulenberg, 2015; suerken et al., 2014), often in conjunction with alcohol (mallett et al., 2017; terry-mcelrath, o’malley, & johnston, 2013). although marijuana is typically considered benign and associated with relaxation (okaneku, vearrier, mckeever, lasala, & greenberg, 2015; pearson et al., 2017; schuermeyer et al., 2014), its acute effects also include increased anxiety, arousal, confusion, heart rate, and perceptual distortion, which may increase the likelihood of conflict following its use (e.g., hunault et al., 2014). for example, marijuana users reported greater perceived hostility in others on days of marijuana use compared to days of no use, controlling for both within-day alcohol use and average drinking days during the study period (ansell, laws, roche, & sinha, 2015). trull and colleagues found complex associations between marijuana use and hostility after accounting for alcohol use. marijuana use was associated with increased hostility at the momentary level. at the between-person level, more frequent marijuana users were more likely to report higher levels of hostility, and lagged marijuana use was associated with decreased hostility, suggesting that participants may have been using marijuana to decrease feelings of hostility (trull et al., 2016). marijuana use days (versus days of no use) were also associated with increased impulsivity (trull et al., 2016). these two investigations suggest that marijuana use is associated with hostile feelings and attributions toward others and is proximally associated with impulsive behavior. in addition, some (e.g., epstein-ngo et al., 2014; shorey, stuart, mcnulty, & moore, 2014) though not all daily report studies (e.g., moore et al., 2011; epstein-ngo et al., 2013) find positive temporal effects of marijuana on perpetration of aggression. in a recent ema study of marijuanausing couples, there was a positive temporal effect of marijuana episodes on self-reported episodes of conflict and verbal aggression toward one’s intimate partner after accounting for drinking episodes (testa et al., 2018). alcohol, aggression, and interpersonal conflict there is well-established evidence for a positive temporal effect of drinking on subsequent conflict and aggression (e.g., ito, miller, & pollock, 1996). in a 30-day daily report study of college students, neal and fromme (2007) found that aggressive behavior was more likely to occur on days in which a student reached a daily blood alcohol concentration (bac) higher than their 30day average. analyses were conducted to ensure that drinking took place prior to aggression, facilitating the interpretation that drinking contributed to later conflict. robertson et al. (2017) assessed whether college students differed in the likelihood of experiencing different types of aggressive behavior (anger, verbal, physical, and relational aggression) on drinking days as compared to non-drinking days. most types of aggression were more likely to occur on drinking days than on non-drinking days, and students who drank more heavily were likely to perpetrate more verbal and physical aggression when drinking. however, alcohol events did not increase the odds of all aggressive acts. for example, while women and men reported more verbal and physical aggression on drinking days, men did not report differences in anger following drinking days. simultaneous use of marijuana and alcohol alcohol use is thought to contribute to interpersonal conflict due to its impairment of interpersonal conflict 50 cognitive functioning, particularly in persons predisposed to aggression and/or in situations with strong aggressive cues (giancola et al., 2012; steele & josephs, 1990; taylor & leonard, 1983). cross-sectional survey research suggests that people who use alcohol and marijuana together experience more negative consequences compared to users of either drug alone, including increased quantity and frequency of alcohol use (midanik, tam, & weisner, 2007; subbaraman & kerr, 2015). the pharmacological effects of alcohol may be exacerbated when consumed simultaneously with marijuana (lee, cadigan, & patrick, 2017; terry-mcelrath, o’malley, & johnston, 2013). alcohol effects (i.e., “dizzy, clumsy, confused”) were higher during simultaneous use episodes than during episodes of only alcohol use; however, the effects of “high” and “feeling marijuana effects” were lower during simultaneous use episodes than during marijuana use only episodes. drinks and time spent high interacted to predict greater simultaneous use effects such that for those who spent less time high, drinks were associated with increased effects of simultaneous alcohol and marijuana use (lee, cadigan, & patrick, 2017). if alcohol effects are exacerbated during simultaneous use, then these greater alcohol effects have the potential to increase likelihood of negative social consequences such as fighting and relationship problems. adolescent male simultaneous use predicted the occurrence of nondating violence, but not dating violence (epsteinngo et al., 2014). college students who used alcohol in combination with other substances (including marijuana) were more likely to experience negative consequences (e.g., drinking more than they planned, doing something embarrassing, saying harsh/cruel things) than students who used alcohol only (mallett et al., 2017). rationale and current hypotheses in the present study, we used intensive longitudinal methods to examine the between and within-person effects of alcohol and marijuana use on interpersonal conflict. our primary hypothesis was that alcohol and marijuana use would each increase the odds of interpersonal conflict occurring within the next several hours. prior research on the temporal effects of alcohol consumption has considered its effects within 3-4 hour windows, which approximates the average length of time that pharmacological effects of alcohol are thought to last (testa & derrick, 2014; testa et al., 2015). marijuana effects are thought to peak around 30 minutes after use and decline after 2-3 hours (grotenhermen, 2003), suggesting peak effects within a somewhat shorter window of time. we conducted analyses using 1-, 2-, 3-, and 4-hour windows to consider the extent to which alcohol and marijuana effects on interpersonal conflict varied depending on time. in addition, we considered whether simultaneous alcohol and marijuana use, operationalized as the interaction of alcohol and marijuana use, had a unique, temporal effect on interpersonal conflict. we used multilevel modeling to distinguish these hypothesized within-person effects from any between-person effects. within-person effects of alcohol and marijuana on interpersonal conflict suggest an acute effect of the substance or the substance use environment on the likelihood of interpersonal conflict. in contrast, betweenperson effects suggest that individual differences in substance use or personality increase the likelihood of interpersonal conflict. because delinquency is likely to be associated with conflict and substance use (ferguson & meehan, 2011), we also included delinquency as a between-person predictor, hypothesizing that college males with higher than average levels of delinquent behavior would be more likely to report conflict on a given day. exploratory cross-level interactions between substance use and delinquency were also considered as predictors of interpersonal conflict, allowing us to consider whether the effects of alcohol or marijuana on conflict were stronger for men predisposed toward aggression. method participants and recruitment participants (n = 427) were selected from a larger sample of freshman males who entered a large public northeastern university in the fall of 2011 or 2012, were 18 or 19 years of age and participated in a survey study at the end of their first semester (n = 2,037). eligibility criteria for the daily report study were designed to yield a sample of men likely to report drinking and cannabis, a publication of the research society on marijuana 51 engaging in sexual activity during the 56-day reporting period (see testa et al., 2015 for recruitment details). fall survey responses were used to identify men who: 1) drank 5 or more drinks on one occasion at least twice per month or drank weekly and 2) had a “hookup” or sexual intercourse with a woman at least once in the first semester or 3) who reported perpetrating sexual aggression on either the sexual experiences survey (koss et al., 2007) or the sexual strategies survey (strang, peterson, hill, & heiman, 2013). men who completed the daily report study (n = 427) were compared to those who were invited but did not participate (n = 337) on history of delinquency and sexual aggression, frequency of heavy episodic drinking, frequency of any alcohol use, and frequency/quantity of marijuana use in their first semester of college. those who were eligible but did not participate reported a higher frequency of past-semester marijuana use (m = 8.91, sd = 10.69) than those who participated in the diary study (m = 7.21, sd = 9.54), t(679.459) = 2.287, p = .02. the groups did not differ on the rest of the aforementioned variables. characteristics of the sample are provided in table 1. table 1. sample characteristics (n = 427) variable n, % first semester heavy episodic drinking 397 (93.0) first semester marijuana use 252 (59.0) race european-american 324 (75.9) asian-american 45 (10.5) african-american 19 (4.4) native american 3 (.7) other/mixed race 28 (.9) hispanic 32 (7.5) sexual orientation heterosexual 413 (96.7) bisexual or questioning 6 (1.4) homosexual 8 (1.9) lived during school year dormitory 319 (74.7) with parents/relatives 102 (23.9) off campus apartment 6 (1.4) procedures participants provided online consent before completing the fall baseline survey and also before completing the first day’s report in the daily report study. for the next 55 days, participants received email reminders at 9 am containing a link to the daily report. if they missed one day of reporting, they were allowed to complete an abbreviated make-up report for that day after completing the current day’s report. omission of more than one day triggered a phone call by project staff to determine whether there were any difficulties and to encourage continued reporting. daily surveys took no more than 5 minutes to complete. participants were compensated with campus cash as follows: $10 for each complete week (6/7 reports) and a $40 bonus for completing all 8 weeks (maximum $120). all procedures were approved by the investigators’ university social and behavior sciences institutional review board. measures substance use. for each daily report, men were asked “at any time since yesterday have you consumed any alcohol?”, using a dichotomous response option (0 = no; 1 = yes). for each episode, participants reported the hour that drinking started, permitting temporal ordering of alcohol use and interpersonal conflict episodes. they were also asked how many drinks they consumed. the same questions were asked regarding marijuana use: “at any time since yesterday have you consumed any marijuana?” (0 = no; 1 = yes). as with alcohol, participants reported the hour that marijuana use started and how high they felt on a 7-point likert scale (1 = not at high; 7 = extremely high). interpersonal conflict. for each daily report, men were asked “at any time since yesterday did you have an argument, fight, or angry disagreement with someone?” using a dichotomous (0 = no; 1 = yes) response option. participants also indicated the hour that this interpersonal conflict occurred. delinquency. at baseline, delinquency was assessed with the antisocial behavior checklist, adolescent version (zucker, 2005). this measure included 18 items (e.g., skipped school, took part in gang fight) rated on a 4-point scale ranging interpersonal conflict 52 from 0 (never) to 3 (often, 10 or more times in life). responses were summed. this measure showed good reliability, α = .80. data analyses the following analyses were designed to determine whether alcohol and marijuana use reported daily, as well as their interaction, increased the likelihood of interpersonal conflict. we conducted these analyses over several time windows designed to reflect the time frame of alcohol and marijuana’s pharmacological effects. analyses were conducted using multilevel logistic regression modeling with two levels and random intercepts in mplus version 7.4 (muthén & muthén, 1998-2015) using maximum likelihood estimation with robust standard errors. at level 1, we entered alcohol and marijuana use. in order to compute the temporal version of the predictors, we divided each day into 24 one-hour segments. we then created lags for the predictor variables within, for example, the previous hour and collapsed across those lagged variables to create “moving windows” that included any instances of alcohol and marijuana use in the previous 1 hour. we repeated this using 2-, 3-, and 4hour windows. alcohol and marijuana use were uncentered binary variables. we created an interaction term (alcohol x marijuana) to consider the effect of alcohol and marijuana occurring within the same time window use on interpersonal conflict. we also included weekend (0 = weekday, monday thursday; 1 = weekend; uncentered), given that substance use and potentially interpersonal conflicts are more likely to occur on weekends (testa et al. 2015; wood, sher, & rutledge, 2007). we also modeled at level 1 the effect of study day (1-56), since reporting of events typically decreases over time in daily designs (testa et al. 2015). the day of study was grand mean centered. at level 2, we controlled for each participant’s total days of only alcohol, only marijuana, and use of both alcohol and marijuana use over the study period to distinguish withinperson from between-person effects. we also considered the effects of delinquent behavior at level 2, as well as its cross-level interaction with alcohol and marijuana. level 2 variables were grand mean centered. results descriptive data participants (n = 427) completed a total of 20,366 daily reports over 56 days (85.2% of all possible days). men reported 2,284 days of alcohol use (11% of total days), 1,735 days (8.5%) of marijuana use, and 502 days (2.5% of total days) on which both substances were used. characteristics of marijuana and alcohol use events are reported in table 2. interpersonal conflicts were reported on 979 days (4.8% of total days). of days on which conflicts were reported, table 2. characteristics of substance use events variable alcohol episodes (n = 2,284) marijuana episodes (n = 1,735) number of people present (m, sd) (m, sd) men 6.59 (9.36) 2.25 (2.17) women 4.78 (8.62) 0.68 (1.88) (n, %) (n, %) weekend 1,508 (66.0%) 561 (32.3%) occurred between 8pm-12am 1,789 (78.3) 973 (56.1% ) preceded a conflict episode 139 (6.1%) 90 (5.2%) within 4 hours 67 (2.9%) 27 (1.6%) within 3 hours 54 (2.4%) 21 (1.2%) within 2 hours 35 (1.5%) 15 (0.9%) within 1 hour 18 (0.8%) 8 (0.7%) note. alcohol and marijuana use episodes were examined separately; weekend = friday and saturday. cannabis, a publication of the research society on marijuana 53 214 (21%) also included alcohol and 156 (15%) also included marijuana. few conflicts were reported as occurring at the same time as marijuana (n = 12, 1.2%) or alcohol use (n = 13, 1.3%). because temporal ordering could not be determined in these instances, these events were treated as zeros and thus not included in the final analyses. substance use and subsequent interpersonal conflicts we examined whether alcohol and marijuana use increased the likelihood of conflict occurring within the next 1, 2, 3, and 4 hours. as table 3 shows, alcohol was positively and significantly associated with conflict at all four time windows (ors = 2.587 3.474, all p < .001). marijuana use was also positively associated with conflict (ors = 2.009 1.681, all p <.10), but the effect reached the statistical significant level only in the 2-hour time window (or = 2.024; p < .05). the interaction between alcohol and marijuana use did not contribute independently to prediction of conflict for any time window. not surprisingly, for all time windows, conflict was more likely to occur on the weekends (p < .05) and reports declined over 56 days (p < .001), consistent with other daily report studies showing a decline in reporting over time (testa et al. 2015). regarding between-person effects on interpersonal conflict, men who reported more alcohol use only days over 56 days were more likely to report conflict in a given hour (p < .05). neither the number of marijuana use days nor use of alcohol and marijuana days reported across the study period increased the odds of reporting interpersonal conflict. contrary to expectations, men reporting more delinquent behavior were not more likely to report conflict in a given hour. we also considered the cross-level interaction between delinquent behavior and marijuana, as well as delinquency by alcohol use. these interactions were non-significant in all models, and subsequently dropped from these analyses. we conducted two separate analyses replacing any alcohol use with number of drinks as a main effect. first, we added an interaction between number of drinks and marijuana use (see table 4). in the second we replaced the dichotomous variable marijuana use with report of subjective “high” (see table 5). we also added an interaction between number of drinks and marijuana use high. the models were highly similar to the original dichotomous models, except that the marijuana high effects were significant in the 2-, 3-, and 4-hour analyses. the drinks by marijuana interactions were not significant in either model. discussion previous research suggests that alcohol use has a proximal effect on subsequent interpersonal conflict and verbal aggression (e.g., epstein-ngo et al., 2014; neal & fromme, 2007).we replicated this effect, finding that the positive effects of alcohol use on conflict were robust, emerging regardless of whether we used a 1-, 2-, 3-, or 4hour time window. we found some evidence for positive effects of marijuana use episodes on conflict, as well as a robust effect of subjective marijuana high on later interpersonal conflict. in contrast to hypotheses, we found no evidence for an interaction between marijuana use and alcohol on interpersonal conflict, suggesting that simultaneous use of these substances does not increase the likelihood of interpersonal conflict beyond use of either substance independently. moreover, we failed to find a level 2 effect of alcohol and marijuana use on odds of conflict. these findings do not negate emerging literature suggesting that simultaneous users experience particularly deleterious consequences, but rather may indicate that interpersonal conflict is not sensitive to these effects. it is important for these analyses to undergo replication to understand the extent to which marijuana use results in negative consequences and the contexts under which these effects unfold, particularly as marijuana use becomes more normative and accessible for college students. several prior studies found no independent event-level associations between marijuana and conflict or aggression (moore et al., 2011; shorey et al., 2014; stoddard et al., 2015); however, our methods differed in several ways. first, some of these investigations relied on well-validated timeline follow back methods (e.g., stoddard et al., 2015). these methods, while using a calendar visual aid, are still retrospective rather than prospective or concurrent reports and rely heavily on the participant’s ability to accurately report the (co)occurrence of substance use and interpersonal conflict or aggressive behaviors. interpersonal conflict 54 table 3. association between substance use and subsequent likelihood of interpersonal conflict 1 through 4 hours later note. or = odds ratio; b = unstandardized beta; alc = alcohol, mj = marijuana; *** p < .001; ** p < .01; * p < .05; + p < .10; ^ parameter was fixed to avoid the singularity of the information matrix. table 4. association between drinks, marijuana use and subsequent likelihood of interpersonal conflict 1 through 4 hours later note. or = odds ratio; b = unstandardized beta; alc = alcohol, mj = marijuana; *** p < .001; ** p < .01; * p < .05; + p < .10; ^ parameter was fixed to avoid the singularity of the information matrix. table 5. association between drinks, marijuana “high”, and subsequent likelihood of interpersonal conflict 1 through 4 hours later note. or = odds ratio; b = unstandardized beta; alc = alcohol, mj = marijuana; *** p < .001; ** p < .01; * p < .05; + p < .10; ^ parameter was fixed to avoid the singularity of the information matrix. variable 1 hour later 2 hours later 3 hours later 4 hours later within-level or 95% ci or 95% ci or 95% ci or 95% ci alc use 2.587*** [1.301, 5.142] 3.328*** [2.047, 5.409] 3.331*** [2.148, 5.165] 3.474*** [2.358, 5.118] mj use 2.009+ [0.940, 4.296] 2.024* [1.149, 3.565] 1.699+ [0.987, 2.924] 1.681+ [0.983, 2.873] alc × mj 0.000^ [0.000, 0.000] 0.255 [0.029, 2.240] 0.494 [0.121, 2.019] 0.527 [0.163, 1.709] weekend 1.432* [1.091, 1.879] 1.381* [1.059, 1.799] 1.350* [1.035, 1.762] 1.322* [1.020, 1.714] study day 0.974*** [0.966, 0.983] 0.975*** [0.966, 0.983] 0.975*** [0.966, 0.983] 0.975*** [0.967, 0.983] between-level b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci delinquency 0.006 (0.015) [-0.024, 0.036] 0.006 (0.015) [-0.024, 0.036] 0.006 (0.015) [-0.024, 0.036] 0.005 (0.015) [-0.025, 0.035] alc days 0.069 (0.026)* [0.018, 0.120] 0.067 (0.026)* [0.015, 0.118] 0.065 (0.026)* [0.014, 0.116] 0.064 (0.026)* [0.013, 0.114] mj days 0.022 (0.016) [-0.008, 0.053] 0.022 (0.016) [-0.009, 0.052] 0.022 (0.016) [-0.009, 0.053] 0.021 (0.016) [-0.010, 0.053] alc+mj days -0.002 (0.038) [-0.078, 0.073] -0.006 (0.039) [-0.081, 0.070] -0.007 (0.039) [-0.083, 0.068] -0.009 (0.039) [-0.085, 0.067] variable 1 hour later 2 hours later 3 hours later 4 hours later within-level or 95% ci or 95% ci or 95% ci or 95% ci alc use amount 1.045+ [0.992, 1.102] 1.069*** [1.026, 1.113] 1.074*** [1.037, 1.111] 1.082*** [1.048, 1.117] mj use 1.986+ [0.930, 4.244] 1.902* [1.095, 3.304] 1.646* [1.001, 2.705] 1.658* [1.030, 2.667] alc × mj 0.000^ [0.000, 0.000] 0.963 [0.798, 1.162] 0.993 [0.897, 1.099] 0.985 [0.907, 1.071] weekend 1.450** [1.109, 1.897] 1.414* [1.088, 1.838] 1.386* [1.065, 1.804] 1.354* [1.048, 1.748] study day 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] between-level b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci delinquency 0.006 (0.015) [-0.024, 0.036] 0.005 (0.015) [-0.025, 0.035] 0.004 (0.015) [-0.026, 0.034] 0.003 (0.015) [-0.027, 0.033] alc days 0.069 (0.026)** [0.018, 0.121] 0.068 (0.026)* [0.016, 0.120] 0.066 (0.026)* [0.015, 0.118] 0.064 (0.026)* [0.013, 0.116] mj days 0.022 (0.016) [-0.009, 0.053] 0.022 (0.016) [-0.009, 0.052] 0.022 (0.016) [-0.009, 0.053] 0.022 (0.016) [-0.009, 0.053] alc+mj days -0.002 (0.038) [-0.077, 0.074] -0.003 (0.038) [-0.079, 0.072] -0.005 (0.038) [-0.081, 0.070] -0.007 (0.038) [-0.083, 0.068] variable 1 hour later 2 hours later 3 hours later 4 hours later within-level or 95% ci or 95% ci or 95% ci or 95% ci alc use amount 1.045+ [0.992, 1.102] 1.069*** [1.026, 1.113] 1.074*** [1.037, 1.111] 1.082*** [1.048, 1.117] mj use 1.986+ [0.930, 4.244] 1.902* [1.095, 3.304] 1.646* [1.001, 2.705] 1.658* [1.030, 2.667] alc × mj 0.000^ [0.000, 0.000] 0.963 [0.798, 1.162] 0.993 [0.897, 1.099] 0.985 [0.907, 1.071] weekend 1.450** [1.109, 1.897] 1.414* [1.088, 1.838] 1.386* [1.065, 1.804] 1.354* [1.048, 1.748] study day 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] 0.974*** [0.966, 0.983] between-level b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci b (s.e.) 95% ci delinquency 0.006 (0.015) [-0.024, 0.036] 0.005 (0.015) [-0.025, 0.035] 0.004 (0.015) [-0.026, 0.034] 0.003 (0.015) [-0.027, 0.033] alc days 0.069 (0.026)** [0.018, 0.121] 0.068 (0.026)* [0.016, 0.120] 0.066 (0.026)* [0.015, 0.118] 0.064 (0.026)* [0.013, 0.116] mj days 0.022 (0.016) [-0.009, 0.053] 0.022 (0.016) [-0.009, 0.052] 0.022 (0.016) [-0.009, 0.053] 0.022 (0.016) [-0.009, 0.053] alc+mj days -0.002 (0.038) [-0.077, 0.074] -0.003 (0.038) [-0.079, 0.072] -0.005 (0.038) [-0.081, 0.070] -0.007 (0.038) [-0.083, 0.068] cannabis, a publication of the research society on marijuana 55 these investigations also only reported dichotomous marijuana use, rather than marijuana use quantity or intensity of subjective marijuana effects. moreover, none of these investigations designate a specific time window during which marijuana may lead to conflict or aggression. instead, either same-day or substance use occurring later in the day are used to predict conflict. using a 2-hour window may reflect acute effects of marijuana, though replication of these findings are needed. theory is scant, though recent research suggests that simultaneous use of alcohol and marijuana result in increased consequences beyond use of either drug alone (e.g., hayaki, anderson, & stein, 2016), potentially due to its enhancement of alcohol effects. we did not find an increase in interpersonal conflict following simultaneous use. this may be due to unique features of this sample. other investigators have found that participants with lower educational attainment, non-white ethnicity, and who are non-partnered are more likely to simultaneously use alcohol and marijuana (midanik, tam, & weisner, 2007; subbaraman & kerr, 2015). approximately 33% of this sample was in a relationship at the beginning of the study period. a low percentage of this sample was nonwhite, as well. other investigators found greater perceived simultaneous use acute effects in women (lee et al., 2017). young men in college may use alcohol and marijuana in a way that does not increase their risk for negative social consequences. for example, there may be risks for non-college attending young adults not relevant to this sample, particularly increased use of marijuana on weekdays. in a broader sample selected specifically for their levels of alcohol and marijuana use, there may be a wider range of negative consequences uniquely associated with simultaneous alcohol-marijuana use. notably, though men who drank more frequently reported more conflicts, increased number of simultaneous use days (or marijuana use days) did not increase the likelihood of conflicts. contrary to hypotheses, delinquency was unassociated with reporting conflict following alcohol and marijuana use nor did it interact with substance use. daily interpersonal conflicts may not be particularly sensitive to tendencies toward delinquency among a sample of college men. also, because men were chosen for participation because of their higher than average levels of drinking, delinquency scores are higher than in an unselected sample, potentially inhibiting our ability to test theoretically-derived predictions due to a truncated range of scores (see testa et al., 2015). limitations strengths of this study include a large sample with excellent compliance with the daily protocol. recording of the timing of events allowed us to precisely model the temporal associations between substance use and conflict over 56 days. however, there are limitations. daily assessment still involves some retrospection. in this study, college men typically reported substance use and conflict the next day; this could have led to less precise reporting of the timing of substance use and interpersonal conflict or failure to recall less salient episodes. either would inhibit our ability to consider temporal relationships between substance use and conflict. conflict was assessed with a single item, which, although behaviorally specific, may have underestimated the number of conflicts experienced. relatively few conflicts were reported, potentially reducing power to detect effects. moreover, the single item did not allow us to distinguish the conflict target or types of aggression (e.g., verbal, physical). it is possible that relations between substance use and conflict differ by conflict type (robertson et al., 2017; laws et al., 2017). future work should assess content and severity of interpersonal conflict, as well as the temporal precedence between conflict and substance use. although findings are consistent with hypothesized pharmacological effects, we cannot separate these pharmacological effects from contextual effects. that is, students use substances, particularly alcohol, in social contexts in which the odds of conflict are increased merely by the presence of others (e.g., wells, graham, speechly, & koval, 2005). alcohol use tended to occur in contexts that involved larger numbers of people, which may have contributed to the stronger alcohol effects. interpersonal conflict 56 conclusions and future research these findings uniquely consider the temporal effects of alcohol, marijuana, and their simultaneous use. the strengths and limitations of this work suggest several directions for future research that utilize ecological momentary assessment (ema) protocols. future ema investigations of alcohol and marijuana should signal participants throughout a drinking or marijuana use episode. such event-based protocols would decrease the time interval between measurement of acute effects of substance use, allowing for more precise detection of associations between acute drug effects and their influence on the occurrence of interpersonal conflict or other negative consequences. in the specific case of simultaneous marijuana and alcohol use, this would allow for clear isolation of the intention to use both drugs at the same time. these event-based ema designs are also ideal in the assessment of contextual settings of substance use, which may differ considerably by drug (e.g., lipperman-kreda, paschall, saltz, & morrison, 2018; phillips, phillips, lalonde, & prince, 2018). given our findings that marijuana use high is positively associated with interpersonal conflict several hours later, future simultaneous use research should also consider that modes of marijuana administration with longer lasting and/or increased concentration of thc/cbd (e.g., edibles, dabs). these may show possibility of extended acute effects (hunault et al., 2014) that then may predict negative consequences at longer time intervals than were 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(2005). manual for the antisocial behavior checklist. university of michigan. funding: this research was supported by r01aa019478 to maria testa and t32aa007583 to kenneth leonard, both from the national institute on alcohol abuse and alcoholism. acknowledgments: we acknowledge drs. r. lorraine collins and paul stasiewicz who provided helpful comments on early versions of this work. copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 1 ved abstract background: alcohol and cannabis use rates are highest in college-aged young adults, and both alcohol and cannabis use are independently related to high-risk sexual behaviors (hrsbs). hrsbs (e.g., sex without protection against sexually transmitted infections) are a prevalent public health problem in college students, with little research examining simultaneous alcohol and cannabis use (i.e., using both alcohol and cannabis at the same time so the effects overlap) and hrsbs. method: we examined simultaneous alcohol and cannabis-related hrsb frequency, gender differences in simultaneous alcohol and cannabis-related hrsbs, and differences in hrsbs between simultaneous and non-simultaneous users. alcohol and cannabis using college students (n = 534; average age = 19; 66.9% reported identifying as female) were recruited through a psychology department’s human subjects research pool and completed a one-time, online, self-report survey. results: one-third of participants engaged in simultaneous alcohol and cannabis use prior to sexual intercourse in the past 3 months. additionally, over one-third of participants reported heavy drinking (4/5 or more drinks for women/men) simultaneously with cannabis use prior to sexual intercourse in the past 3 months. simultaneous alcohol and cannabis use was significantly and positively related to sexual intercourse after simultaneous use and after heavy drinking simultaneously with cannabis use. past year simultaneous alcohol and cannabis users, relative to non-simultaneous users, reported increased incidents of sex without protection against sexually transmitted infections. no gender differences in simultaneous alcohol and cannabis-related hrsbs were found. conclusions: future research should continue examining simultaneous alcohol and cannabis use and hrsbs. key words: = college students; high-risk sexual behaviors; simultaneous alcohol and cannabis use high-risk sexual behaviors (hrsbs) are often defined as behaviors that increase one’s chance for contracting a sexually transmitted infection (sti) or an unwanted pregnancy (deckman & dewall, 2011). these behaviors, which can include sex without protection against pregnancy or sexually transmitted infections (stis), sex with multiple partners, or sex after substance use, are prevalent public health problems associated with a myriad of negative outcomes in college students (metrik et al., 2016; simons et al., 2010). indeed, negative outcomes related to hrsbs include contraction of stis and unwanted pregnancies (cooper, 2002). the treatment of stis is costly, totaling approximately $15.6 billion in the united states per year (owusu-edusei et al., 2013). in a recent study of college students, nearly 9% reported having four or more sexual partners in the past 12 months, nearly half reported not using a contraceptive method the last time they had vaginal intercourse, and 70% reported using alcohol and/or drugs prior to or during sexual haley kolp1, sarah horvath2, emily munoz1, jane metrik3,4, and ryan c. shorey1 1 university of wisconsin-milwaukee 2 children’s hospital colorado, aurora, co 3 center for alcohol and addiction studies, brown university school of public health 4 providence va medical center, providence, ri cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000134 simultaneous alcohol and cannabis use and high-risk sexual behaviors corresponding author: haley kolp, university of wisconsin-milwaukee, 2441 e hartford ave. milwaukee, wi, 53211. email: hmkolp@uwm.edu cannabis, a publication of the research society on marijuana 2 activity (american college health association, 2017; scott-sheldon et al., 2010). further, rates of cannabis and alcohol use are high in college students. cannabis is a commonly used drug on college campuses, with 42% of students reporting past-year cannabis use (schulenberg et al., 2019). additionally, the majority of college students (78%) report alcohol use in the past year, with 33% engaging in a heavy drinking episode (5/4 or more drinks in a row for men/women) in the past two weeks (schulenberg et al., 2019). further, simultaneous alcohol and cannabis use (i.e., using both alcohol and cannabis at the same time so the effects overlap) is common in college students, with nearly 75% reporting at least one occasion of simultaneous alcohol and cannabis use in the past year (white et al., 2019). despite the high rates of hrsbs, alcohol use, and cannabis use in college students, there is a lack of research examining the relationship between simultaneous alcohol and cannabis use and hrsbs. the increasing legalization of cannabis combined with the prevalence of simultaneous alcohol and cannabis use and hrsbs in college students indicate a need to investigate this relationship to inform hrsb prevention and interventions. alcohol and cannabis use and hrsbs research has demonstrated a strong link between alcohol use and hrsbs. among college students, 50% engage in alcohol use prior to sexual activity with a new partner, and 32% report drinking alcohol prior to unprotected vaginal intercourse (brown & vanable, 2007). further, alcohol use is related to unprotected vaginal sex with a non-steady partner (e.g., a casual acquaintance) in college students (brown & vanable, 2007), and heavy alcohol use among college women is related to less condom use with steady partners (scott-sheldon et al., 2010). further, a meta-analysis in college students found that an increase in blood alcohol concentration (bac) of 0.1 mg/ml equated to an increased likelihood of 5% of having unprotected sex, indicating that increased alcohol consumption within a drinking period is related to increased intentions to have high-risk sex (rehm et al., 2012). the relationship between cannabis use and hrsbs is less clear. for example, cannabis use is associated with increased odds of having sexual intercourse, reduced condom use with casual partners, and a decreased likelihood of discussing sexual risk before sexual engagement in both young adults and adolescents (anderson & stein, 2011; kingree & betz, 2003; metrik et al., 2016). yet, other studies have found no relationship between cannabis use and hrsbs. for instance, a study using retrospective interview methods found that cannabis use was not associated with increased odds of unprotected sex with a casual partner (metrik et al., 2016). overall, the findings on the relationship between cannabis and hrsbs are mixed, with future research necessary to continue investigating this relationship. simultaneous alcohol and cannabis use and hrsbs individuals who use both alcohol and cannabis are two times more likely to use them simultaneously (i.e., at the same time, so the effects of each substance overlap) rather than concurrently (i.e., using both alcohol and cannabis, but not necessarily at the same time), with almost half of cannabis-using college students and young adults reporting using alcohol simultaneously (haas et al., 2015; subbaraman & kerr, 2015). additionally, simultaneous alcohol and cannabis use is associated with a myriad of negative outcomes (e.g., increased alcohol use, social consequences) and increases the risk for these outcomes beyond either alcohol or cannabis use alone (subbaraman & kerr, 2015; yurasek et al., 2017). yet, few studies have investigated the relationship between simultaneous alcohol and cannabis use and hrsbs, and those that have found mixed results. for instance, a crosssectional study determined that bac levels and frequency of cannabis use were independently related to increased risk of engaging in hrsbs, but did not interact to predict hrsbs (simons et al., 2010). further, a study using retrospective interviews in young adult women did not find a relationship between simultaneous alcohol and cannabis use and hrsbs (anderson & stein, 2011). a different retrospective interview study in young adults found that engaging in both heavy alcohol use and cannabis use increased the odds of engaging in unprotected sex with an established partner, but each substance did not simultaneous alcohol and cannabis use and hrsbs 3 independently increase odds for unprotected sex with an established partner (metrik et al., 2016). overall, there is a lack of research examining these constructs, and the existing research demonstrates an unclear relationship between simultaneous alcohol and cannabis use and hrsbs. thus, additional research is necessary to examine the relationship between simultaneous alcohol and cannabis use and hrsbs. additionally, previous research has demonstrated that people who identify as men are more likely to engage in hrsbs (macdonald et al., 2000; nolen-hoeksema, 2004) and have higher rates of simultaneous alcohol and cannabis (brière et al., 2011; patrick et al, 2019; subbaraman et al., 2015) compared to people who identify as women. indeed, one study found no instances of alcohol or cannabis use prior to engaging in sexual intercourse without protection against stis or pregnancy with a casual partner in people who identify as women (metrik et al., 2016). however, there are no studies examining gender differences within the prevalence of simultaneous alcohol and cannabis-related hrsbs, at times due to lack of prevalence of these behaviors in their samples (metrik et al., 2016). thus, it is important to investigate whether these gender differences persist with simultaneous alcohol and cannabis-related hrsbs, which will inform future studies in developing interventions aimed at reducing these hrsbs. existing theory has yet to be applied to explain the relationship between simultaneous alcohol and cannabis use and hrsbs. alcohol myopia theory (steele & josephs, 1990), the leading theory utilized to define the relationship between alcohol use and hrsbs, states that the disinhibiting effects of alcohol increase attention on salient cues (e.g., sexual arousal) while decreasing the salience of other cues (e.g., sti risks from not using a condom during sexual intercourse), thus increasing risky decision making. additionally, cannabis use may increase a person’s risk for hrsbs through impairing inhibition (skosnik et al., 2001), increasing risky decision making (lane et al., 2005; metrik et al., 2012), and reducing cognitive performance (e.g., attention; harvey et al., 2007). further, simultaneous administration of alcohol and cannabis has been shown to increase subjective intoxication effects and behavioral and cognitive impairment, resulting in increased disinhibition (chait & perry, 1994; lukas & orozco, 2001; ramaekers et al., 2011). the effects produced by simultaneous alcohol and cannabis use may therefore increase a person’s likelihood of making risky decisions and, thus, their risk of engaging in hrsbs beyond either substance alone. current study overall, there is a dearth of research on the relationship between simultaneous alcohol and cannabis use and hrsbs. the present study aims to help fill this gap by examining simultaneous alcohol and cannabis use and hrsbs in a large college student sample, investigating novel types of hrsbs (e.g., sexual intercourse after heavy drinking simultaneously with cannabis use), and exploring unique aspects of the simultaneous alcohol and cannabis use-hrsb relationship (e.g., gender differences within this relationship). thus, the present study aimed to (1) investigate the prevalence of simultaneous alcohol and cannabisrelated hrsbs in a college student sample, (2) investigate the associations between simultaneous alcohol and cannabis use and hrsbs (e.g., sex without a condom or another form of protection, sex with multiple partners, or sex after substance use), and (3) examine gender differences within the prevalence of simultaneous alcohol and cannabis-related hrsbs. methods participants a total of 696 college students at a large midwestern university were recruited for the present study. a total of 162 participants were removed due to not meeting inclusion criteria for the study. thus, a final sample of 534 participants was utilized. the majority of participants reported identified as a woman (66.9%), 31.6% identified as a man, and the remaining identified as transgender, genderqueer, gender nonconforming, or preferred not to answer. over half of participants reported their sex assigned at birth as female (67.6%). the majority (88.4%) of participants identified as white, 6.7% identified as black/african american, 3.2% identified as multiracial, 2.2% identified as asian, 1.5% identified as american indian or alaska native, 0.9% identified as other, 0.7% identified as cannabis, a publication of the research society on marijuana 4 middle eastern, and 0.4% identified as native hawaiian or other pacific islander.1 the majority of participants identified as not hispanic or latino (91.9%). participants’ average age was 19.04 (sd = 1.66, range 18 to 28 years old) and the majority were first year students (55.9%). most participants were currently in a relationship with a dating partner (60.8%). based on the kinsey scale (kinsey, pomeroy, & martin, 1948), 77.7% of participants identified as exclusively heterosexual. procedure participants were recruited utilizing the psychology department’s human subjects pool. prior to participating, participants were able to view a study advertisement on the human subjects pool website that provided a brief description of the study and eligibility criteria, the course credit they would receive, and the approximate study length. to be eligible for the study, participants had to be 18 years or older, used alcohol in the past 12 months, used cannabis in the past 12 months, and be involved in a dating relationship lasting at least one month in the past 12 months (due to this study being part of a larger project aimed at investigating the potential effects of substance use on dating relationships). the informed consent and surveys were completed via qualtrics.com. participants viewed a debriefing form describing the purpose of the study, contact information for the study investigators, and local mental health resources after completing the study. all study procedures took approximately one hour and participants received course credit for their psychology course as compensation. the institutional review board approved all procedures prior to data collection. measures demographics questionnaire. participants were asked to report their gender identity, age, year in college, race, ethnicity, sexual orientation, and current relationship status. a dating relationship was defined broadly (i.e., “intimate relationship”) in the present study, thus a relationship may not necessarily have been exclusive. alcohol use. the alcohol use disorders identification test (audit) was utilized to assess for alcohol use and problems (saunders et al., 1993). the audit is a 10-item self-report measure, with scores ranging from 0 to 40, with higher scores indicating increased alcohol use and problems. the audit is a reliable and valid measure for use in college students (e.g., lundin et al., 2015) and has good internal consistency (cronbach’s alpha in the .80’s; reinert & allen, 2002). the internal consistency in the current sample was good (a = .77). cannabis use. the cannabis use disorders identification test – revised (cudit-r) was used to examine cannabis use (adamson et al., 2010). the cudit-r is an 8-item self-report measure, with scores ranging from 0 to 32, with higher scores indicating increased cannabis use and related problems. the cudit-r’s internal consistency (a = .91) and discriminant validity in distinguishing cannabis use and cannabis dependence is excellent (adamson et al., 2010). the internal consistency in the current sample was good (a = .78). simultaneous alcohol and cannabis use. one item was utilized to measure past 12-month simultaneous alcohol and cannabis use: “how often did you use both alcohol and marijuana on the same occasion during the past 12 months, so that the effects of alcohol and marijuana overlapped?”, with response options including never (scored as 0), monthly or less, 2 to 4 times a month, 2 to 3 times a week, and 4 or more times a week (scored as 4). this item is similar to prior research examining simultaneous alcohol and cannabis use (patrick et al., 2018, subbaraman & kerr, 2015). hrsbs. participants were asked to identify the frequency with which they engaged in hrsbs over the past 3 months, including 1) the number of times they engaged in sexual intercourse without a condom or another form of protection and 2) the number of sexual partners they had, consistent with prior research (e.g., snipes & benotsch, 2013). additionally, participants were asked to identify the frequency of simultaneous alcohol and cannabis-related hrsbs, with the following two items: “how many times did you have sexual intercourse (oral, anal, or vaginal) after having drunk alcohol and used marijuana in the same occasion in the past 3 months?” and 1 percentages sum to over 100%, as participants could select multiple races. simultaneous alcohol and cannabis use and hrsbs 5 “how many times did you have sexual intercourse (oral, anal, or vaginal) after having 4 or more alcoholic drinks if you are a woman, or 5 or more alcoholic drinks if you are a man, while also having used marijuana on the same occasion in the past 3 months?” three months was chosen for these items due to previous research indicating participants can accurately recall sexual behavior over that timeframe (napper et al., 2010). data analytic plan to begin, we examined the prevalence of simultaneous alcohol and cannabis use and hrsbs (i.e., frequency of sexual intercourse after simultaneous alcohol and cannabis use in past 3 months, frequency of sexual intercourse after heavy drinking and cannabis use in past 3 months, frequency of vaginal or anal sex without a condom or another form of protection in past 3 months, and number of sexual partners in past 3 months) in ibm spss statistics (version 28.0). next, we examined bivariate correlations between all study variables. we also conducted partial correlations to examine the associations between simultaneous alcohol and cannabis use and hrsb after controlling for alcohol and cannabis use. after that, we utilized independent samples ttests to determine whether gender differences between people who identified as men and women existed between simultaneous alcohol and cannabis-related hrsbs variables (e.g., frequency of sexual intercourse after simultaneous alcohol and cannabis use in past 3 months). finally, we utilized independent samples t-tests to examine whether people who engaged in simultaneous alcohol and cannabis in the past year differed on sex without protection and number of sexual partners compared to people who did not engage in simultaneous alcohol and cannabis use. results the majority (82.2%; n = 439) of participants were past-year simultaneous alcohol and cannabis users, with over one quarter (26.4%; n = 141) reporting simultaneous alcohol and cannabis use two to four times a month. in terms of sexual behavior, participants reported an average number of 1.61 (sd = 1.95) sexual partners in the last 3 months. further, 57.6% (n = 308) reported having vaginal or anal sex without a condom or another form of protection at least once in the past 3 months. additionally, 36.5% (n = 195) reported engaging in simultaneous alcohol and cannabis use prior to sexual intercourse at least once in the past 3 months, and 34.1% endorsed heavy drinking simultaneously with cannabis use prior to sexual intercourse at least once in the past 3 months. bivariate correlations revealed small to medium effects between study variables (see table 1). past-year simultaneous alcohol and cannabis use was significantly related to simultaneous alcohol and cannabis use prior to sexual intercourse, heavy drinking simultaneously with cannabis use prior to sexual intercourse, sexual intercourse without a condom or another form of protection, and number of sexual partners. results also demonstrated that alcohol use and problems were significantly and positively related to both simultaneous alcohol and cannabis use prior to sexual intercourse, heavy drinking simultaneously with cannabis use prior to sexual intercourse, and number of sexual partners. cannabis use and problems were significantly and positively related to simultaneous alcohol and cannabis use prior to sexual intercourse, heavy drinking simultaneously with cannabis use prior to sexual intercourse, and sexual intercourse without a condom or another form of protection. partial correlations, while controlling for alcohol and cannabis use, revealed positive and significant associations between simultaneous alcohol and cannabis use and two hrsb variables: simultaneous alcohol and cannabis use prior to sexual intercourse (r(436) = .22, p < .001) and heavy drinking simultaneously with cannabis use prior to sexual intercourse (r(436) = .21, p < .001). independent samples t-test results revealed no gender differences between people who identified as men and women on simultaneous alcohol and cannabis-hrsbs (see table 1). people who did not identify as men and women (e.g., transgender, gender nonconforming) were not included in analyses due to small sample size (n = 6). independent samples t-tests did yield differences on hrsbs when comparing past year simultaneous alcohol and cannabis users to nonpast year simultaneous users. results indicated that past year simultaneous alcohol and cannabis users reported more instances of sexual cannabis, a publication of the research society on marijuana 6 intercourse without a condom or other forms of protection in the past 3 months (m = 9.31, sd = 16.02) than non-simultaneous users (m = 5.71, sd = 10.79; t(481) = 1.95, p = 0.05). finally, no differences were found between past year (m = 2.05, sd = 7.51) and non-past year simultaneous alcohol and cannabis users (m = 1.15, sd = 0.82) in number of sexual partners in the past 3 months t(501) = 1.08, p = 0.28. table 1. zero-order correlations for study variables 1 2 3 4 5 6 7 1. audit ----0.14** 0.35** 0.13** 0.17** 0.04 .09* 2. cudit-r ----0.47** 0.24** 0.22** 0.20** -.03 3. simultaneous alcohol and cannabis use ----0.37** 0.38** 0.14** .11* 4. frequency of sexual intercourse after simultaneous alcohol and cannabis use in past 3 months ----0.82** 0.33** -.02 5. frequency of sexual intercourse after heavy drinking and cannabis use in past 3 months ----0.36** -.01 6. frequency of vaginal or anal sex without a condom or another form of protection in past 3 months ----.05 7. number of sexual partners in the past 3 months ---- mean for women 10.03 7.83 1.12 1.33 1.10 8.02 2.04 sd for women 5.58 5.55 0.78 3.59 2.90 13.96 8.28 n 355 355 355 333 333 322 336 mean for men 9.73 10.48 1.47 2.21 1.82 10.27 1.58 sd for men 5.08 5.97 0.87 5.93 4.59 17.98 2.26 n 169 168 169 158 160 154 160 note. *p < .05, **p < .01; bolded text indicate significant differences between people who identified as men and women. discussion the present study found that over one-third (36.1%) of participants reported engaging in simultaneous alcohol and cannabis use prior to sexual intercourse in the past 3 months, and 34.1% endorsed heavy drinking (four or more drinks for women, five or more for men) simultaneously with cannabis use prior to sexual intercourse in the past 3 months. previous studies examining simultaneous alcohol and cannabis use simultaneous alcohol and cannabis use and hrsbs 7 and hrsbs have found similar prevalence rates. for instance, a retrospective study examining hrsbs and simultaneous alcohol and cannabis use over a 60-day period found that unprotected sex with a casual partner was reported on 29% of cannabis use days when participants also reported heavy drinking on the same day (metrik et al., 2016). these prevalence rates provide important descriptive information regarding simultaneous alcohol and cannabis use and sexual intercourse. these results indicate a need to continue investigating the impact of simultaneous alcohol and cannabis use and hrsbs in college students, given the prevalence of these behaviors and associated negative outcomes. additionally, results of partial correlations indicated that after controlling for alcohol and cannabis use, simultaneous alcohol and cannabis use was significantly related to sexual intercourse after engaging in simultaneous alcohol and cannabis use and sexual intercourse after heavy drinking simultaneously with cannabis use. simultaneous alcohol and cannabis use was not significantly related to sexual intercourse without a condom or another form of protection and number of sexual partners after controlling for alcohol and cannabis use. this suggests individual, in the bivariate correlations, alcohol and cannabis use may have been driving the significant relationship between simultaneous alcohol and cannabis use and these specific hrsbs. further replication of these results is needed, but they may indicate a need to specifically target individual alcohol and cannabis use within simultaneous alcohol and cannabis users to reduce sexual intercourse without protection against stis and pregnancy. further, the present study did not find any gender differences within simultaneous alcohol and cannabis-related hrsbs. however, people who identify as men are more likely to engage in risky sexual behavior (macdonald et al., 2000; nolen-hoeksema, 2004), and prevalence of simultaneous alcohol and cannabis use is substantially higher among people who identify as men than people who identify as women (brière et al., 2011; patrick et al, 2019; subbaraman et al., 2015). there is a paucity of existing research investigating gender differences within simultaneous alcohol and cannabis-related hrsbs and more research is necessary to elucidate whether simultaneous alcohol and cannabis use differentially impacts risk of engaging in hrsbs for women than men to better inform future interventions. additionally, the present study found differences within past year and non-past year simultaneous alcohol cannabis users, with past year simultaneous alcohol and cannabis users engaging in increased instances of sexual intercourse without a condom or other form of protection. no differences between users and nonusers were found within number of sexual partners over the past 3 months. these results indicate simultaneous alcohol and cannabis use may increase the prevalence of certain types of hrsbs. future studies are necessary to replicate this finding but may suggest targeting simultaneous alcohol and cannabis use to reduce specific types of hrsbs (e.g., sex without protection against stis). the present study had a few limitations. the majority of the sample identified as white, heterosexual, and as women, which decreases the generalizability of the findings to more diverse college populations. additionally, participants were required to be in a relationship in the past year, which also decreases generalizability of the present findings. for instance, participants may have primarily engaged in sexual behavior with established partners. previous research has indicated condom usage may vary depending on partner type, with decreased usage occurring with established partners (macaluso et al., 2000). further, the present study took place in a midwestern state in which recreational cannabis use was not legal, and thus the findings may not generalize to states with different laws regarding recreational use. future research should continue to investigate the prevalence of, and gender differences within, simultaneous alcohol and cannabis use and hrsbs in states in which recreational cannabis use is legal. additionally, the present study consisted of college students. while simultaneous alcohol and cannabis use and hrsbs are prevalent in this population, future research should examine these behaviors in community-based young adult samples. further, the present study was cross-sectional, and it is possible gender differences within the simultaneous alcohol and cannabis use and hrsb relationship may differ when these constructs are examined over time. the cross-sectional nature of the present study also does not provide causality. cannabis, a publication of the research society on marijuana 8 it is possible that simultaneous alcohol and cannabis use you do not increase risk for hrsbs, but instead an outside construct, such as impulsivity (e.g., sensation seeking), may be driving the relationship between these variables. additionally, the effect sizes between simultaneous alcohol and cannabis use and the hrsbs examined (e.g., sex without a condom or another form of protection) were mostly small and were not significant when controlling for alcohol and cannabis use. additional replication in other studies is needed to further confirm these findings. further, the kinsey scale was utilized to measure sexual orientation. this scale does not provide specific options for sexual orientation (e.g., bisexual, lesbian), thus we were unable to provide this demographic information. future studies investigating sexual orientation in people who use simultaneous alcohol and cannabis and engage in hrsbs is warranted. finally, the present study did not ask about context of hrsbs with simultaneous alcohol and cannabis use (e.g., did hrsbs occur with established or casual partners). given the prevalence of simultaneous alcohol and cannabis use prior to sexual intercourse in the current sample, it is important for future studies to determine whether this use leads to sex without protection against stis or pregnancy and other types of hrsbs. there are numerous directions for future research regarding simultaneous alcohol and cannabis-related hrsbs. for instance, future research could expand the types of simultaneous alcohol and cannabis-related hrsbs to examine (e.g., simultaneous alcohol and cannabis use prior to sexual behaviors other than sexual intercourse, such as touching a partner underneath their clothing). future research could additionally investigate the prevalence of and gender differences within simultaneous alcohol and cannabis-related hrsbs in non-college young adults to determine if results generalize to this population. additionally, future investigations could also utilize event-level data (e.g., daily diary assessments) to better investigate the proximal relationship between simultaneous alcohol and cannabis use and hrsbs or timeline follow back methodology to reduce recall bias. with prior research indicating simultaneous alcohol and cannabis use effects are additive (chait & perry, 1994; ramaekers et al., 2011), additional research is necessary to determine whether simultaneous alcohol and cannabis use may impart additional risk for hrsbs above either alcohol or cannabis use alone. overall, future research is necessary to replicate and extend the present study’s findings. references adamson, s. j., kay-lambkin, f., baker, a. 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(2019). simultaneous alcohol and marijuana use among college students: patterns, correlates, norms, and consequences. alcoholism: clinical and experimental research, 43(7), 1545-1555. https://doi.org/10.1111/acer.14072 yurasek, a. m., aston, e. r., & metrik, j. (2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184-193. https://doi.org/10.1007/s40429-017-0149-8 funding and acknowledgements: research reported in this publication was supported by the national institute on drug abuse of the national institutes of health under award number f31da051140. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors report no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i2a5_authors_final research article 50 ved abstract objective. greater discrepancies between parent and adolescent reports of parenting behaviors are associated with poorer adolescent functioning. the present research aims to build from the existing literature by examining unique parent and adolescent perceptions of parental monitoring and distinct sources of parental knowledge (i.e, parental solicitation, parental control, child disclosure) and their association with adolescent cannabis and alcohol use and disorder symptoms using cross-sectional data. method. parent-adolescent dyads (n = 132) were recruited from the community and the family court system. adolescents were ages 12 to 18 (40.2% female; 68.2% white, 18.2% hispanic). parents and adolescents completed a questionnaire assessing the four domains of parenting behaviors. adolescents’ substance-use behaviors and related disorder symptoms were assessed via adolescent selfreport and semi-structured interviews. results. parental ratings of distinct parenting behaviors were higher (more favorable) than their child’s reports, as shown in prior studies. parent-reported parenting behaviors were uniquely related to cannabis use, over and above adolescent reports and the adolescent’s age. with regard to report discrepancies, interactive effects of parent and adolescent perceptions of parental control were not statistically significant in our analysis after correcting for multiple tests. conclusions. while most research relating parental monitoring to adolescent cannabis use relies solely on adolescent perceptions, our study suggests a unique role of parent perceptions for cannabis use and disorder symptoms, respectively. findings support the importance of considering unique parent and adolescent perceptions of what parents know, as well as how they know it, to understand early cannabis use and problem development. key words: = parental monitoring, sources of knowledge, informant discrepancies, cannabis, adolescents adolescence is the developmental period most strongly associated with the initiation and escalation of cannabis use (johnston et al., 2020) and the development of cannabis use disorder (cud) (volkow et al., 2021). parental monitoring, or knowledge of the child’s activities, whereabouts, and relationships, is associated with delayed initiation and levels of cannabis use (lac & crano, 2009; neiderhiser et al., 2013) and substancerelated problems (branstetter & furman, 2013). indeed, interventions designed to delay or prevent adolescent substance-use problems often target monitoring as a key aspect of the parent-child relationship (dishion et al., 2003; kobak et al., 2017; kuntsche & kuntsche, 2016). further, the degree of parent-adolescent disagreement in perceptions of monitoring is an indicator of poor relationship quality that is linked to adolescent alcohol use (abar et al., 2015), cigarette smoking (sartor et al., 2020), composite measures of substance-use initiation (lippold et al., 2011), and composite measures of delinquent behaviors (hou brianna parlette1, hayley treloar padovano1, melissa pielech1, samuel n. meisel1,2, robert miranda jr.1,2 1center for alcohol and addiction studies, brown university 2e. p. bradley hospital, riverside, ri cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.005 parent and adolescent reports of parental monitoring and sources of parental knowledge are linked to cannabis use and symptom development in adolescents corresponding author: robert miranda jr., phd., center for alcohol and addiction studies, brown university. box s121-4, providence, ri 02912. e-mail: robert_miranda_jr@brown.edu cannabis, a publication of the research society on marijuana 51 et al., 2018; reynolds et al., 2011). the present analysis aims to build on prior work by testing unique relations of adolescent and parent perceptions of specific parental-monitoring constructs with the adolescent’s likelihood of having used cannabis and meeting one or more symptom for cud. parental monitoring reflects both parental knowledge of their adolescent’s actions and relationships, but also how parents learn about their adolescent’s behavior (dishion & mcmahon, 1998; kerr & stattin, 2000). sources of parental knowledge include parental control (i.e., setting rules to control adolescent behavior), parental solicitation (i.e., engaging with the adolescent or other parents to gain information), and child disclosure (i.e., adolescent’s sharing or concealing of information). parental control and solicitation are active, parent-initiated efforts to know the activities of their child, whereas child disclosure relies on the child to self-initiate sharing information. an expanding literature suggests that parental knowledge largely depends on adolescents’ spontaneous and willing disclosure of activities, friendships, and whereabouts, rather than on parents’ “monitoring” of them (hou et al., 2018; kapetanovic et al., 2019; kerr & stattin, 2000; racz & mcmahon, 2011; stattin & kerr, 2000). thus, the distinction of parent-driven, active efforts to secure knowledge (i.e., solicitation and control) from child-driven processes (i.e., voluntary disclosure) is important for understanding which aspects of “monitoring” are protective against adolescent cannabis use and problem development. meta-analytic reviews demonstrate the protective role of adolescent perceptions of specific aspects of parental monitoring in relation to adolescent cannabis use (lac & crano, 2009), and the role of monitoring, broadly defined as parental knowledge, in relation to adolescent alcohol-use frequency/quantity and alcohol-related problems (yap et al., 2017). adolescent perceptions of parental monitoring, also broadly defined as knowledge, are prospectively linked to cannabisuse initiation (bohnert et al., 2012; epstein et al., 2017), and a range of alcohol-use behaviors and related problems (yap et al., 2017). yet, effect sizes for both cannabis and alcohol-related risks are modest, and substantial heterogeneity across studies limits accurate understanding of the effects of specific parental monitoring constructs (lac & crano, 2009; yap et al., 2017). factors contributing to heterogeneity of prior studies include use of conceptually broad and nonspecific measures of parental monitoring, as well as substance-use outcomes that vary in severity. whereas studies evaluating monitoring effects on alcohol outcomes include frequency of intoxication, drunkenness, binge drinking, heavy drinking, level of use, escalation of use, alcohol-related problems, and severe and problematic use (yap et al., 2017), studies of cannabis outcomes are primarily limited to less severe outcomes, such as lifetime use or recent use frequency (bohnert et al., 2012; epstein et al., 2017; lac & crano, 2009). at least one exception, however, identified a protective effect of adolescent-reported parental monitoring for a combined outcome assessing past-month frequency of negative consequences related to alcohol and other drug use (branstetter & furman, 2013). another gap in existing work assessing perceived parental monitoring, particularly in studies examining cannabis use, is that parent reports of monitoring are not assessed (bohnert et al., 2012; epstein et al., 2017; keogh-clark et al., 2021; lac & crano, 2009). including both adolescents and parents as informants is important because: (1) obtaining parent and adolescent reports of parenting behaviors is standard practice in clinical settings, and (2) parent and adolescent reports of parenting behaviors often demonstrate small correlations that are thought to reflect clinically relevant information (de los reyes et al., 2019, 2022). greater disagreement between parent and adolescent reports of parenting behaviors is linked to a wide range of problematic behavioral, academic, and mental health outcomes (de los reyes, 2011; hou et al., 2018), including symptoms of depression, anxiety, and conduct disorder (maurizi et al., 2012). such discrepancies may reflect differences in perceptions, contexts (e.g., an adolescent does not observe all the times, locations, and strategies a parent uses to monitor their behavior), or underlying relationship and communication deficits (lee et al., 2019). in fact, recent work suggests that one mechanism through which prevention interventions may reduce adolescent substance use is by decreasing discrepancies between parent and adolescent reports of parenting behaviors (lee et al., 2019). understanding how parental monitoring relates to cannabis use and cud development is parent and adolescent reports 52 further complicated by the use of aggregated outcomes that combine cannabis with other substances (branstetter & furman, 2013; neiderhiser et al., 2013) and other “normbreaking” behaviors (e.g., theft, vandalism, bullying, physical fights) (kerr & stattin, 2000; stattin & kerr, 2000; voisin et al., 2012). separating cannabis from other outcomes is important, in part, because attitudes towards cannabis and laws regulating cannabis use differ from those for alcohol or other drugs. for example, if youth view cannabis use as less harmful and more socially acceptable than other substances, it may foster child disclosure. further, the frequency of use and the ease with which use is concealed is different for cannabis, alcohol, and other substances. for example, among adolescents who engage in substance use regularly, cannabis and nicotine use may occur daily or multiple times per day, whereas adolescent alcohol use tends to be sporadic, opportunistic, and contextually limited (e.g., on weekends, unsupervised, with peers) (jackson, 2019; johnston et al., 2020). differences between use patterns and perceived harms of use may suggest that some parenting behaviors will be more effective than others for certain substances. for example, parental control may be effective for restricting alcohol use by reducing access to certain peers or unsupervised time, whereas child disclosure may be particularly relevant for cannabis use. to our knowledge, few studies have explicitly examined the unique contribution of parent and adolescent perceptions of parental monitoring to risk for adolescent cannabis use (cottrell et al., 2003; rusby et al., 2018). two studies showed nonsignificant (cottrell et al., 2003) or modest (rusby et al., 2018) correlations between adolescent and parent reports of monitoring, defined broadly as parental knowledge, suggesting parent-adolescent disagreement in perceptions of parental knowledge. cottrell and colleagues (2003) showed that both parent and adolescent (ages 12 to 16) reports of lower monitoring related to adolescent alcohol use in the past six months. only adolescent reports related to cannabis use in the past six months, however, and only adolescentreported lower monitoring uniquely related to alcohol and cannabis use over parent-reported monitoring (cottrell et al., 2003). in a prospective study, rusby and colleagues (2018) also showed that both parent and adolescent (ages 13 to 14) reports of lower monitoring predicted onset of alcohol use, binge drinking, and cannabis use one year later. only adolescent-reported lower monitoring, however, uniquely predicted cannabis use onset over parent-reported monitoring, adolescent and parent reports of the parent-child relationship, and parent substance use (rusby et al., 2018). prior studies provide essential foundational work relating adolescent and parent perceptions of parental monitoring, broadly defined as knowledge, with adolescent cannabis use (cottrell et al., 2003; rusby et al., 2018), upon which the present work aims to build. extant studies have focused on younger adolescents and onset of cannabis use; whether these associations generalize to a broader age range of youth and to other cannabis-related outcomes remains unknown. this is an important question given that risk for cannabis use (johnston et al., 2020) and cud onset (han et al., 2019; volkow et al., 2021) markedly increases as adolescents age. in addition, most studies assess only self-reported, adolescent perceptions of monitoring without exploring parent perceptions (cutrín et al., 2021; lac & crano, 2009; marceau et al., 2020; neiderhiser et al., 2013; rusby et al., 2018), and most examine parental monitoring operationalized strictly as knowledge (what parents know), absent of sources of this knowledge (how they know it) (cottrell et al., 2003; cutrín et al., 2021; neiderhiser et al., 2013; rusby et al., 2018). this is a significant limitation given that parents’ active efforts to secure knowledge (e.g., solicitation and control) are modifiable parenting behaviors that increase knowledge directly and through promoting child disclosure to prevent adolescent substance-use problems (hernandez et al., 2015; jiménez-iglesias et al., 2012; soenens et al., 2006). moreover, prior work has demonstrated distinctive relations of specific monitoring and source-of-knowledge domains in preto early adolescence when evaluating parentadolescent report discrepancies and alcohol use (abar et al., 2015), as well as aggregated deliquency outcomes that include trying cannabis (kerr & stattin, 2000; stattin & kerr, 2000) and driving while high (bouffard & armstrong, 2021). it is possible that parent and adolescent contributions to monitoring and sources of knowledge differ as adolescents increase use frequency and develop problems, and parent and adolescent perceptions of these practices may have cannabis, a publication of the research society on marijuana 53 unique importance for understanding use and disorder development. the current study leveraged cross-sectional data from a larger investigation (miranda et al., 2010, 2013) to fill gaps in understanding how specific parentand adolescent-reported parental monitoring domains relate to whether an adolescent had ever used cannabis and whether they met criteria for one or more cud symptoms in the past year. our goal was to build on prior cannabis research by studying a broader age range of youth, ages 12 to 18 years, examining indices of lifetime use and problem development, and testing unique relations of parent and adolescent reports across four key domains: parental monitoring (knowledge), parental solicitation, parental control, and child disclosure. prior work has focused on these domains as related to likelihood of any cannabis use (cottrell et al., 2003; rusby et al., 2018), a range of alcohol-related outcomes (abar et al., 2015), and delinquency (kerr & stattin, 2000; stattin & kerr, 2000). this investigation is the first to explore unique parent and adolescent associations with an early indicator of risk of developing one or more cud symptoms. we hypothesized that parent reports of parenting would, on average, be higher (more favorable) than adolescent reports of the same parenting practices, as widely demonstrated by prior literature (maurizi et al., 2012; reidler & swenson, 2012; reynolds et al., 2011). we also expected the “pure” parental knowledge domain and child disclosure to relate more strongly to cannabis use and symptoms, as suggested by seminal papers (kerr & stattin, 2000; stattin & kerr, 2000) and metaanalyses of adolescent cannabis use (lac & crano, 2009) and alcohol-related behaviors and problems (yap et al., 2017). our analysis also included past-year consumption of two or more alcoholic drinks in one sitting and likelihood of meeting criteria for one or more aud symptoms in the past year. it was difficult to speculate whether parent or adolescent reports of monitoring domains would matter more when it came to adolescent-reported cannabis and alcohol outcomes. whereas studies of outcomes specific to cannabis use tend to favor adolescent reports (cottrell et al., 2003; rusby et al., 2018), a recent prospective study showed added value for parent reports of parental knowledge, but not parental control, when predicting a composite measure of property offending, which included driving while drunk or high (bouffard & armstrong, 2021). this study sampled older adolescents (ages 14 to 18) than previous work and utilized a more severe and broad delinquency outcome (bouffard & armstrong, 2021). a prospective study of younger adolescents found unique effects of parent-reported control when examining a more severe alcohol-related outcome, i.e., ever drunk, but generally found that adolescent, but not parent reports of monitoring predicted likelihood of ever having a drink of alcohol (abar et al., 2015). taken together, these studies may suggest unique effects of parentreported monitoring for older adolescents and more severe substance-related outcomes. given the limited body of work examining unique associations of adolescent and parent perceptions of distinct monitoring domains, however, no apriori hypotheses were forwarded with respect to differences in parental monitoring-substance use associations by substance type. our analysis includes alcohol outcomes to draw out any distinctions between alcohol and cannabis in the same adolescent sample and to extend the age range of prior work from preto early adolescence to later adolescence (ages 12 to 18). methods participants participants were 132 adolescent-parent dyads from a larger study (n = 253) that sought to examine how differences in decision making and reactions to emotional situations are associated with adolescent problem behaviors, including alcohol and other substance use (miranda et al., 2010, 2013) . adolescents were recruited from the community and the family court system. eligible youth (age 12-19 years) had no history of traumatic brain injury, hearing difficulties, or suicidal ideation or psychotic symptoms. a negative urine toxicology screen for alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, and opiates was also required on the day of assessment. parent data, most commonly provided by the youth’s mother (91.3% of cases), was collected for 49.2% of participants. the current study included all participants with complete adolescent-parent dyadic data. adolescents were ages 12 to 18 years (m = 14.5; 40.2% female; 68.2% white, 18.2% hispanic) and accompanied caregivers were parent and adolescent reports 54 primarily biological or adoptive mothers (mothers = 86.4%; 8.3% fathers; 2.3% both parents; 1.5% biological aunt; 0.8% grandmother). procedure data were collected in rhode island from april 2005 through august 2007. cannabis has been legal medically in rhode island since 2006 for various health conditions. state-licensed dispensaries were approved in 2009. a cannabis decriminalization law did not go into effect in rhode island until 2013. at the time of data collection, 1 in 4 rhode island high school students reported cannabis use in the past month, and that prevalence has not changed over time (rhode island department of health, 2016). interested youth called the lab to learn more about the primary study and to complete a brief telephone screening to determine initial eligibility. individuals who passed the initial screening and did not endorse exclusionary criteria received an invitation to complete an in-person screening and, if applicable, obtain written informed consent or assent. parents/legal guardians were required to provide permission for youth younger than age 18 years; assent was obtained from minors. youth who were eligible participated in the half-day assessment session, which included completion of self-report, paper-and-pencil measures and a semistructured clinical interview. one parent/legal guardian for each participant was invited to participate and complete semi-structured interviews and self-report assessments about their adolescent’s psychiatric functioning and developmental history, but caregiver involvement was not required. with this approach, youth whose parents/legal guardians were unavailable or unwilling could still participate in the study. the university institutional review board approved all study procedures. measures demographics. adolescent participants reported information regarding race (68.2% white; 22.7% african american; 9.1% other), ethnicity (81.8% non-hispanic), gender (59.8 male) and age (12.1% twelve years old; 15.2% thirteen years old; 23.5% fourteen years old; 24.2% fifteen years old; 14.4% sixteen years old; 7.6% seventeen years old; 3.0% eighteen years old). alcohol and cannabis use disorder symptoms. psychiatric diagnoses, including substance use disorders, were attained using the kiddie schedule for affective disorders for school-age children (ksads; kaufman et al., 1997), a clinician administered semi-structured interview based on diagnostic and statistical manual of mental disorders criteria (4th ed.; dsm-iv-tr; american psychiatric association, 2000). adolescents were interviewed separately from parents and diagnoses were based on adolescent reports. interviewers underwent systematic training and achieved a high level of inter-rater reliability (kappa > 0.90). symptoms were coded according to severity (0= not present, 1= subthreshold, 2= clinical threshold). for each criterion, adolescents that met threshold were coded as having that aud or cud symptom criteria met, and coding was verified through case consensus involving two licensed clinical psychologists. due to low base rates of meeting clinical dsm-iv-tr diagnoses of alcohol abuse or dependence, participants were classified as to whether they met at least one symptom of aud. we used the same approach for cud. alcohol use. alcohol use was measured as a single item from an introductory section to the ksads section on aud. the item asked, “have you drank 2 drinks in 1 sitting within the last year.” responses were coded as yes or no. cannabis use. cannabis use was measured from a prior drug use checklist from the k-sads. participants were asked, “have you used any of the drugs on this list before, even if you have only tried them once. which ones have you used?” cannabis use was coded either yes or no, thus identifying a broad range of youth who may be at risk for problematic cannabis use. parental monitoring. parents and adolescents separately completed the parental monitoring questionnaire (pmq; kerr & stattin, 2000), a 9item questionnaire assessing parental knowledge of child activities. parent and adolescent versions of the pmq shared identical content with minor changes in wording to reflect the parent/adolescent perspective. for example, adolescents responded to “do your parents…: know what you do during your free time? …know who you have as friends during your free time?”, whereas parents responded to “do you…: know what your child does during his or her free time? …know who your child has as friends during his or her free time?” responses were indicated with 5-point likert scales (1 = no, never; cannabis, a publication of the research society on marijuana 55 2 = some of the time; 3 = about half the time; 4 = more than half, but not always; 5 = yes, always). response averages were calculated separately for parent and adolescent reports. sources of parental knowledge. parents and adolescents also separately completed the sources of parental knowledge scales (kerr & stattin, 2000), which assessed parental solicitation (5 items), parental control (3 items), and child disclosure (4 items). similar to the parental monitoring scale, parent and adolescent versions were identical in content other than wording referring to whose perspective was being assessed. parental solicitation, parental control, and child disclosure were developed by (kerr & stattin, 2000). these variables add information about parents’ own efforts to find out what their children are doing as well as a child’s willingness to divulge this information spontaneously. example items from these scales in the adolescent versions are: “how often do you need to ask your parents before you can decide with your friends what you will do on a saturday evening?” (parental control), “during the past month, how often have your parents started a conversation with you about your free time?” (parental solicitation), and “if you are out at night, when you get home, how often do you tell your parents what you have done that evening?” (child disclosure). one child disclosure item, “how often do you hide from your parents about what you do during nights and weekends?” was reverse coded. parent and adolescent response averages were calculated separately for each scale. analytic plan first, dependent samples t tests evaluated differences in average raw scores of parent and adolescent reports of parental monitoring, parental solicitation, parental control and child disclosure. point-biserial correlations related raw scores of these variables and age with binary substance-use outcomes (i.e., drank two drinks in past year, ever used cannabis, 1+ symptoms of aud, 1+ symptoms of cud). other covariate relations for nominal variables with binary substance-use variables used the phi coefficient (i.e., gender, ethnicity) and cramer’s v (race). only covariates with significant relations to outcomes were retained in subsequent models. next, sets of logistic regression models tested whether parent and adolescent perceptions of parental monitoring and sources of knowledge (i.e., parental solicitation, parental control, and child disclosure) uniquely related to substance-use outcomes. parent and adolescent scale scores were standardized (z-scores) prior to model entry. domains of parental behaviors were analyzed in separate models (abar et al., 2015). all models include covariates in a first step. in model 1, a second step included parent and adolescent standardized scores. inclusion of both parent and adolescent reports in the same model allows the following interpretation: (1) parent score main effects indicate the influence of parents’ reports of parenting behaviors, accounting for or apart from (subtracting) the influence of adolescents’ reports, and (2) adolescent score main effects indicate the influence of adolescents’ reports of parenting behaviors, accounting for or apart from (subtracting) the influence of parents’ reports. of note, prior research (e.g., abar et al., 2015) also tested models including discrepancy (i.e., difference) scores and either parent or adolescent standardized scores. such models have statistical and conceptual limitations (cronbach & furby, 1970; edwards, 1994, 2001) and are mathematically equivalent to including standardized parent and adolescent scores simultaneously in the same model, and thus, difference scores were not tested (laird, 2020). following current recommendations (laird & de los reyes, 2013; laird, 2020), we also modeled discrepant parent-adolescent perceptions by examining interactive effects of parent and adolescent reports. model 2 included the interactive effects of parent and adolescent standardized scores. this moderation approach provides a statistical test of whether adding informant discrepancies to the model provides unique information above and beyond model 1 (laird & weems, 2011). for all models, we applied a bonferroni correction to account for testing effects for two substance-use outcomes, with the adjusted p-value threshold for significance = .025. results descriptive information and bivariate associations of the 132 adolescent participants, 22 (16.7%) consumed two drinks in one sitting within the last year. thirty-eight (28.8%) reported ever trying cannabis, of whom 22 (57.9%) used more than once parent and adolescent reports 56 a month. using dsm-iv-tr criteria, 12 (9.1%) met criteria for one or more cud symptom and 8 (6.1%) met criteria for one or more aud symptom. the average number of criteria endorsed among participants who met criteria for at least one symptom was as follows: cud m = 3.25 (sd = 1.71), aud m = 1.63 (sd = 1.06). consistent with hypotheses and prior research, parents reported significantly higher average (more favorable) parenting behaviors than adolescents (parental monitoring: mdiff = 0.17, sd = 0.84, t(131) = 2.28, p < .024; parental solicitation: mdiff = 0.61, sd = 1.01, t(131) = 6.92, p < .001; parental control: mdiff = 0.70, sd = 1.03, t(130) = 7.76, p <.001; child disclosure: mdiff = 0.26, sd = 0.91, t(127) = 3.24, p < .001). bivariate correlations of parent and adolescent reports of parenting behaviors are shown in table 1. parent reports were interrelated, rs from .26 to .71, ps < .004. adolescent reports were also interrelated, rs from .45 to .71, ps < .001. parent and adolescent reports of the same monitoring domain were modestly related for parental monitoring, r = .30, p = .001, parental solicitation, r = .24, p = .005, and child disclosure, r = .43, p < .001, suggesting some lack of agreement among reporters. parent and adolescent reports of parental control were not significantly related, r = .16, p = .061. of note, between-reporter correlations of the same domain generally demonstrated lower agreement than within-reporter correlations of unique domains. adolescent reports of solicitation were also not related to parent reports of monitoring, r = .11, p = .192, or control, r = − .14, p = .101. likewise, adolescent-reported child disclosure was not related to parent-reported control, r = − .01, p = .905. bivariate relations of cannabis and alcohol variables with covariates (i.e., gender, age, race of adolescent, ethnicity of adolescent) and parent and adolescent raw scores are shown in table 2. of the putative covariates, only the adolescent’s age significantly related to cannabis and alcohol use and problem development, rs from .23 to .46, ps < .010. the adolescent’s gender, racial identity, and ethnic identity were not significantly related to these outcomes (see table 2). with regard to parenting behaviors, adolescent-reported parental monitoring, parental control, and child disclosure, was negatively related to adolescent use of cannabis and alcohol use and one or more cud/aud symptom(s). adolescent reported solicitation was only negatively related to aud symptom development, r = − .18, p = .046, but not cannabisuse outcomes or past-year alcohol use, rs from − .08 to − .13 ps ≥ .158. with a slightly different pattern, parent-reported monitoring and child disclosure were generally negatively related to these substance-use outcomes (see table 2). for control, however, parent reports demonstrated negative relations to cannabis outcomes, but not alcohol outcomes (see table 2). parent-reported solicitation was only negatively related to lifetime cannabis use, r = − .37, p < .001, but not cannabis problem development or alcohol outcomes, rs from 0.02 to – 0.14, ps ≥ .112. unique parent and adolescent report relations to cannabis use and symptoms of putative covariates, only age was significantly related to substance-use outcomes in bivariate analyses, and thus, it was the only covariate retained in logistic regression models (see tables 3 and 4, step 1). alone, age explained from 11 to 22% of the variance in cannabis use and problem development (pseudo r2 values from .11 to .22). specifically, each one-year increase in age was associated with more than doubled odds of having ever used cannabis, or = 2.72, p < .001, or meeting one or more cud symptoms in the past year, or = 2.24, p = .014. step 2, models a and b are age-adjusted models testing individual effects of adolescent and parent-reported parenting variables separately for each of the four parenting domains. step 3 tested unique effects of parentand adolescent-reported parenting variables. models including both adolescent and parent reports of monitoring explained from 13 to 43% of the variance in cannabis outcomes, reflecting an increase in pseudo r2 values from .02 to .21 (i.e., 2 to 21%) over age-only models. parent-reported higher levels of monitoring, solicitation, and child disclosure all related to reduced odds of the adolescent having ever tried cannabis, ors = 0.33, 0.48, and 0.41, respectively, ps < .025, over and above adolescent-reported parenting behaviors and the adolescent’s age. these odds ratios suggest that each one-unit increase in parentreported positive parenting practices was associated with from a 52 to 67% reduction in the odds of adolescents’ engagement in cannabis use. cannabis, a publication of the research society on marijuana 57 table 1. means (standard deviations) and pearson correlations among parent and adolescent reports of parenting behaviors 1 2 3 4 5 6 7 8 1. parental monitoring (parent) 4.09(.68) 2. parental control (parent) .41*** 4.80(.47) 3. parent solicitation (parent) .57*** .31*** 3.81(.76) 4. child disclosure (parent) .71*** .26** .53*** 3.83(.82) 5. parental monitoring (adolescent) .30** .14 .24** .38*** 3.93(.74) 6. parental control (adolescent) .32*** .16 .30*** .33*** .51*** 4.10(1.00) 7. parental solicitation (adolescent) .11 − .14 .24** .24** .46*** .45*** 3.20(.88) 8. child disclosure (adolescent) .29** − .01 .24** .43*** .71*** .51*** .50*** 3.57(.87) note: p<.01**, p<.001*** table 2. bivariate relations of focal variables and covariates with alcohol and cannabis use and disorder symptoms lifetime cannabis use one or more cud symptoms past-year alcohol use one or more aud symptoms gendera − 0.01 0.06 0.09 0.05 ageb 0.40*** 0.23* 0.46*** 0.27** race of adolescentc 0.07 0.10 0.07 0.04 ethnicity of adolescenta − 0.08 − 0.08 − 0.16 − 0.04 parental monitoring (parent)b − 0.48*** − 0.17* − 0.24** − 0.16 parental solicitation (parent)b − 0.37*** − 0.14 − 0.09 0.02 parental control (parent)b − 0.29** − 0.20* − 0.10 − 0.16 child disclosure (parent)b − 0.42*** − 0.22* − 0.32*** − 0.33*** parental monitoring (adolescent)b − 0.23** − 0.26** − 0.25** − 0.21* parental solicitation (adolescent)b − 0.12 − 0.08 − 0.09 − 0.19* parental control (adolescent)b − 0.31*** − 0.23** − 0.22* − 0.19* child disclosure (adolescent)b − 0.32*** − 0.17* − 0.31*** − 0.29* note: cud = cannabis use disorder; aud = alcohol use disorder. p<.05*, p<.01**, p<.001***. aphi coefficient. bpointbiserial correlation. ccramer’s v, with race recoded as 0 = white, 1 = black or african american, 2 = other. parent and adolescent reports 58 table 3. odds ratios (95% confidence intervals) from a series of logistic regression analyses relating parental monitoring and sources of knowledge to lifetime cannabis use and past-year disorder symptoms parental monitoring parental solicitation parental control child disclosure lifetime cannabis use step 1: all models age 2.72*** (1.70, 4.34) 2.72*** (1.70, 4.34) 2.72*** (1.70, 4.34) 2.72*** (1.70, 4.34) step 2—model a adolescent report 0.68 (0.44, 1.03) 0.77 (0.50, 1.17) 0.63* (0.42, 0.94) 0.56* (0.35, 0.88) step 2—model b parent report 0.32*** (0.19, 0.54) 0.47** (0.30, 0.74) 0.63† (0.40, 0.98) 0.37*** (0.23, 0.62) step 3 adolescent report 0.79 (0.50, 1.26) 0.92 (0.58, 1.45) 0.64† (0.42, 0.98) 0.73 (0.44, 1.23) parent report 0.33*** (0.19, 0.56) 0.48** (0.30, 0.76) 0.64† (0.42,0.99) 0.41*** (0.24,0.70) one or more cannabis use disorder symptom step 1: all models age 2.24* (1.18, 4.26) 2.24* (1.18, 4.26) 2.24* (1.18, 4.26) 2.24* (1.18, 4.26) step 2—model a adolescent report 0.47* (0.25, 0.87) 0.76 (0.39, 1.46) 0.60 (0.35, 1.03) 0.65 (0.35, 1.21) step 2—model b parent report 0.65 (0.38, 1.14) 0.71 (0.39, 1.30) 0.72 (0.47, 1.11) 0.53† (0.28, 0.99) step 3 adolescent report 0.48† (0.26, 0.92) 0.83 (0.42, 1.65) 0.62 (0.36, 1.08) 0.83 (0.42,1.66) parent report 0.71 (0.34, 1.29) 0.75 (0.40, 1.41) 0.75 (0.48, 1.18) 0.57 (0.28, 1.13) note. all independent variables were standardized prior to model entry. a bonferroni correction for type i error for tests of two outcomes requires p < .025. †p < .05, *p < .025, **p < .01, ***p < .001. cannabis, a publication of the research society on marijuana 59 table 4. odds ratios (95% confidence intervals) from a series of logistic regression analyses relating parental monitoring and sources of knowledge to past-year alcohol use and disorder symptoms parental monitoring parental solicitation parental control child disclosure past-year alcohol use step 1: all models age 4.60*** (2.36, 8.97) 4.60*** (2.36, 8.97) 4.60*** (2.36, 8.97) 4.60*** (2.36, 8.97) step 2—model a adolescent report 0.55† (0.32, 0.94) 0.78 (0.44, 1.37) 0.77 (0.47, 1.24) 0.47* (0.26, 0.85) step 2—model b parent report 0.59† (0.35, 0.99) 1.03 (0.59, 1.77) 1.02 (0.65, 1.61) 0.41** (0.22, 0.75) step 3 adolescent report 0.56† (0.32, 0.99) 0.75 (0.41, 1.37) 0.76 (0.47, 1.24) 0.59 (0.32, 1.12) parent report 0.60 (0.34, 1.04) 1.11 (0.62, 1.97) 1.07 (0.66, 1.73) 0.50† (0.26, 0.95) one or more alcohol use disorder symptom step 1: all models age 3.44* (1.46, 8.09) 3.44* (1.46, 8.09) 3.44* (1.46, 8.09) 3.44* (1.46, 8.09) step 2—model a adolescent report 0.49 (0.23, 1.03) 0.34† (0.11, 0.98) 0.63 (0.32, 1.22) 0.31** (0.13, 0.74) step 2—model b parent report 0.63 (0.32, 1.24) 1.53 (0.63, 3.74) 0.78 (0.47, 1.29) 0.21** (0.08, 0.58) step 3 adolescent report 0.51 (0.23, 1.09) 0.23* (0.07, 0.78) 0.66 (0.33, 1.29) 0.46 (0.18, 1.19) parent report 0.67 (0.33, 1.39) 2.49 (0.86, 7.20) 0.82 (0.47, 1.41) 0.27* (0.09, 0.79) note. all independent variables were standardized prior to model entry. a bonferroni correction for type i error for tests of two outcomes requires p < .025. †p < .05, *p < .025, **p < .01, ***p < .001. parent and adolescent reports 60 parent-reported parental control was not significantly related to reduced odds of using cannabis after correcting for multiple outcome tests, p = .047. adolescent perceptions of the same parenting behaviors were not related to engagement in cannabis use, over and above parent reports and the adolescent’s age. neither parent nor adolescent reports of parenting domains uniquely related to odds of meeting one or more cud symptoms (see table 3, step 3). adolescent-reported parental monitoring, which reflects parental knowledge alone and not sources of knowledge, was related to cud symptoms in an age-adjusted model, or = 0.47, p = .017, but not significantly related to cud symptoms after accounting for parent reports and correcting for multiple tests, p = .026. in a final step, interactive effects of parent and adolescent reports were added to evaluate whether explicitly modeling the combination of patterns of informant discrepancies (e.g., high parent report, low adolescent report) provides additional information over models testing unique associations. no interactive effects of parent and adolescent perceptions of monitoring domains were significant after a stringent bonferroni correction for multiple tests, ps ≥ .027. unique parent and adolescent report relations to alcohol use outcomes of all outcomes, age was most influential for reports of past-year alcohol use, with the likelihood of an adolescent reporting having two drinks in one sitting more than quadrupling for each one-year increase in age, or = 4.60, p < .001. models including adolescent and parent reports of monitoring explained from 24 to 49% of the variance in alcohol outcomes, reflecting an increase in pseudo r2 values from .01 to .29 (i.e., 1 to 29%) over age alone (see table 4). adolescent-reported parental monitoring and parental solicitation outperformed parent perceptions of these same behaviors in relation to past-year alcohol use, or = .56, p = .045, and alcohol-related problem development, or = .23, p = .018, respectively. although not statistically significant, parent-reported solicitation was actually related to greater odds of meeting one or more aud symptoms when also considering adolescent perceptions and the adolescent’s age, or = 2.49, p = .092. parent-reported control was marginally related to lower odds of past-year alcohol use, or = .50, p = .034, and significantly related to lower odds of problem development, or = 0.27, p = .017. interactive effects of parent and adolescent reports were not significant. discussion parental knowledge of their child’s whereabouts, activities, or relationships, i.e., parental monitoring, is linked to lower risk for adolescent cannabis use (e.g.. bohnert et al., 2012; epstein et al., 2017; lac & crano, 2009), as well as alcohol use and early indices of alcohol problems (yap et al., 2017). although disagreement in parent and adolescent reports of parenting behaviors are the rule, rather than the exception (de los reyes, 2011; korelitz & garber, 2016), evaluations of the influence of monitoring on substance-use outcomes primarily focus on adolescent perceptions of parental knowledge. exceptions for cannabis are limited to studies of unique effects of parentand adolescent-reported parental knowledge on cannabis-use onset or frequency (branstetter & furman, 2013; cottrell et al., 2003; rusby et al., 2018), without attention to sources of that knowledge (i.e., active parent efforts of solicitation and control, or child disclosure), or cannabis-specific outcomes. prior work for other related risk domains also focuses on the preto early adolescent years (abar et al., 2015; kerr & stattin, 2000; lippold et al., 2011; stattin & kerr, 2000). the present crosssectional analysis builds from prior literature to understand how specific parentand adolescentreported parental monitoring domains uniquely relate to cannabis and alcohol use and the likelihood of meeting one or more disorder symptom in adolescents (ages 12 to 18). overall, a meaningful percentage of variance in cannabis and alcohol use outcomes was explained by accounting for parent and adolescent reports of parental monitoring and sources of knowledge parenting behaviors. a main contribution of this work was examining both “pure” parental monitoring knowledge, but also sources of that knowledge, for understanding adolescent cannabis use and an early index of problem development. sources of knowledge include active parenting strategies (i.e., solicitation and control) and aspects of “parental” monitoring (i.e., child disclosure) which rely on the child’s behavior rather than the parents’ (kerr & stattin, 2000; stattin & kerr, 2000). prior literature suggests that cannabis, a publication of the research society on marijuana 61 parental knowledge may actually stem from the child’s disclosure (or concealing) of their behavior (stattin & kerr, 2000) and that greater fluctuations in adolescent-reported child disclosure over time are predictive of cannabis use initiation (marceau et al., 2020). in our analysis, lower parent reports of parental knowledge and child disclosure were most consistently related to cannabis and alcohol use and problem development. this is fitting with prior meta-analyses indicating that parental monitoring is most predictive of cannabis (lac & crano, 2009) and alcohol (yap et al., 2017) outcomes when characterized as parental knowledge. findings from the present study suggest that parent reports of their child’s disclosure may be particularly relevant for adolescent cannabis use. if youth can conceal their cannabis use from parents through less conspicuous modalities of administration, such as edibles or vaping (miech et al., 2020), protective “monitoring” effects may be contingent on parents acquiring information from their adolescents (i.e., through disclosure). relatedly, in a longitudinal examination of these constructs, decreases in youth-reported child disclosure over time were predictive of cannabis initiation (marceau et al., 2020). these findings highlight the importance of obtaining both adolescent and parent reports of parental knowledge and sources of knowledge. replication of the potentially important role of parent-reported child disclosure on adolescent cannabis use is critical, as prior work has relied on adolescent selfreports and predominantly assessed parental monitoring but not sources of knowledge (bohnert et al., 2012; epstein et al., 2017; lac & crano, 2009). additionally, correlations with substance-use outcomes suggested that parental solicitation is a less useful strategy for curtailing adolescent substance use (and avoiding related problems) than the adolescent’s free, willing disclosure (or concealing) of their activities, as noted in a seminal paper (kerr & stattin, 2000). indeed, marceau and colleagues (2020) paradoxically found that higher consistency in child reports of parental solicitation efforts over time were related to cannabis initiation; the authors posited that associations between lability in parental solicitation and lower risk of cannabis initiation over time could be conceptualized clinically as a parent’s ability to skillfully modulate levels of parental solicitation as needed, rather than inconsistent parenting (marceau et al., 2020). disagreement in parent and adolescent perceptions of parenting behaviors is longrecognized as a meaningful construct for understanding adolescent functioning (achenbach et al., 1987; de reyes & kazdin, 2005; guion et al., 2009). as expected, parental ratings of the parents’ behaviors were higher (more favorable) as compared to adolescent reports. parent and adolescent perceptions of the same parental monitoring knowledge and source-of-knowledge domains were also only modestly correlated, suggesting disagreement between reporters. notably, parent and adolescent reports of parental control were not correlated, which is the same pattern observed by abar and colleagues’ study of preto early adolescence sipping, drinking, and drunkenness (abar et al., 2015). although prior literature suggests that greater disagreement in parent and adolescent perceptions relates to greater risk of adverse outcomes (de los reyes, 2011; lippold et al., 2011), interactive effects of parent and adolescent perceptions were not statistically significant in our analysis after correcting for multiple tests. with regard to unique effects of informant reports, where many were found for cannabis, few were observed for alcohol, and tended to favor both parent and adolescent reports, depending on the parental monitoring domain. for cannabis, parent reports tended to provide unique information for understanding lifetime cannabis use, but not problem development, over adolescent reports and the adolescent’s age. these findings are in contrast with extant studies of preto early adolescent cannabis use (cottrell et al., 2003; rusby et al., 2018) and alcohol use (abar et al., 2015). our lack of unique influences of parent and adolescent reports for alcohol may be due to relative low base rates of drinking and aud symptoms in our sample, and so these findings should be interpreted with caution. one possible explanation for the greater influence of parent-reported behaviors on lifetime cannabis use frequency, rather than cud symptoms, is that the predictive utility of parent and adolescent reports may differ depending on the specific cannabis use behavior assessed. parents’ knowledge of whether their adolescent has ever used cannabis may be more accurate than their knowledge of their degree of frequent or problem use (piehler et al., 2020). regardless of the specific explanation for the findings in the current study, the results highlight the need for further research to understand the parent and adolescent reports 62 predictive ability of discrepant parent and adolescent reports more fully. future research should consider more extensive testing of parentadolescent discrepancies in parenting in relation to a range of cannabis use behaviors, such as age of initiation, frequency of use, quantity of use, and cannabis-related problems. limitations additional limitations of this study should be acknowledged. perhaps most problematic is that these data were only collected at one time. while our disaggregation of distinct parenting domains and focus on cannabis-use outcomes do move the field forward, our cross-sectional design limits the ability for predictive assumptions to be made. additionally, while aspects of the sample, such as the broader age range, make it more generalizable, the limited number of adolescent-reported disorder symptoms may have restricted our ability to find effects, particularly for alcohol-related problem development. future work should study a larger sample size at multiple time points to make more substantial predictive conclusions. larger samples would also facilitate alternative approaches to modeling parent-adolescent discrepancies. recent work suggests using both variable-centered (e.g., interactions or polynomial regressions) and personcentered analytic techniques (e.g., latent profile analysis) to examine parent-adolescent discrepancies (de los reyes et al., 2019). future work with sufficiently large samples could employ both of these analytic strategies to obtain a more nuanced understanding of parent-adolescent discrepancies and their associations with adolescent cannabis use. finally, as with many studies of parenting behaviors, we had a much higher number of mother parental reporters compared to father reporters. future studies may consider balancing parent recruitment on the basis of the parent’s gender. information from fathers could provide an additional perspective on this topic. conclusions disaggregating the broad parental monitoring construct is one method of resolving inconsistencies in prior literature describing relations with adolescent substance-use outcomes (lac & crano, 2009; yap et al., 2017). future studies of parental monitoring should consider both what parents know, as well as how they know it, from the perspective of parents and youth, to better understand adolescent substance use and disorder development. our study provides a meaningful step toward isolating the components of parental monitoring and sources of knowledge that most strongly relate to adolescent cannabis use and the development of disorder symptoms. we built on prior cannabis research by studying a broader age range of youth (ages 12 to 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(2017). modifiable parenting factors associated with adolescent alcohol misuse: a systematic review and meta-analysis of longitudinal studies. addiction, 112(7), 1142–1162. funding and acknowledgements: this work was supported by grants from the national institute of drug abuse (r21da016904, pi: miranda; f32 da049440, pi: pielech) and the national institute of alcohol abuse and alcoholism (f32 aa028414, pi: meisel; k24 aa026326. pi: miranda; k23aa024808, pi: treloar padovano). treloar padovano was also funded in part by p20gm130414, an nih funded center of biomedical research excellence (cobre). copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 87 ved abstract objective: to examine the correlates between cannabis use, motives to use, related psychosocial outcomes and academic behaviours among a sample of canadian university students. methods: a random sample of 6,000 students who were enrolled in at least one class and were 18 years or over were asked to complete a cross-sectional online survey. of the 920 students that responded, 478 (ages 18-55; mean age = 25.02, sd = 5.95) identified as having used cannabis within the past six months and thus were included as participants in the current study. participants completed a battery of measures designed to examine cannabis use and associated constructs (i.e., substance use risk, personal well-being, non-specific psychological distress, academic behaviours, and motivations for use). results: among the participants, 31% (n = 148) were found to be frequent (i.e., hazardous) users. using cannabis for enhancement, coping, expansion, sleep difficulties, and conformity purposes, as well as impulsive personality traits were found to be predictors of cannabis use severity, with the enhancement motive identified as the strongest predictor for the total sample, males, and hazardous users. the coping motive was the strongest predictor for females, and impulsivity was the strongest predictor for non-hazardous users. conclusion: findings will help inform the development of campus guidelines for lower risk cannabis use. information gleaned from this study will also provide important information for those that use cannabis, policymakers, and health care providers in considering optimal personal use, prevention, and intervention plans. key words: = cannabis; psychosocial outcomes; motivations; substance use risk cannabis is one of the most used drugs in canada (government of canada, 2021). in 2018, the recreational use of cannabis for those 18 or 19 years and older was legalized (government of canada, 2021). due to the novel nature of these laws, there are several unknowns regarding the understanding of cannabis use among young adults. these new laws have increased the availability and use of cannabis, making it important to gain a better understanding of the implications of legalization on use patterns and outcomes associated (keith et al., 2015). among the university student population, it continues to be found that young adults and youth use cannabis more commonly than any other age group (canadian centre on substance use and addiction [cssa], 2022). high rates of cannabis use among young adults can be associated with poorer psychosocial outcomes (meier, 2021) such as increased reports of anxiety and depression (keith et al., 2015), a decrease in academic achievement (e.g., fewer graduates, skipping class, conduct problems, lower grade point averages; arria et al., 2013a; arria et al., 2013b; arria et al., 2013c; fergusson et al., 2003), an increase in psychotic disorders (volkow et al., 2016) and cognitive impairments (e.g., reduced intelligent quotient, memory impairment; meier et al., 2012; zalesky et al., 2012), along with higher risk of other illicit drug use (lynskey et al., 2003). but the relationship between cannabis and adverse outcomes is complex as causality is not always firmly established, with some of the associations stronger than others (meir, 2021). moreover, the vast majority of those who consume jessica llewelyn-williams1 & david mykota1 1department of educational psychology and special education, university of saskatchewan cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000160 predictors of cannabis use among canadian university students corresponding author: david mykota, ph.d., department of educational psychology and special education, university of saskatchewan, saskatoon, saskatchewan, canada, s7n 5a2. phone: (306) 966-5258. email: david.mykota@usask.ca cannabis, a publication of the research society on marijuana 88 cannabis and who could be characterized as occasional users do not experience cannabis use related problems (fischer et al., 2022). given this context, the perceptions of cannabis risk among young adults appear to be decreasing, as many believe that cannabis is not harmful (miech et al., 2017; okaneku et al., 2015; pacek et al., 2015). for example, within university student samples, it has been found that students’ perception of harm has decreased over time. according to johnston et al. (2015), 35.1% of students perceived regular cannabis use as harmful in 2015, compared to 57.2% a decade prior. it has also been found that legalization in some jurisdictions may have impacted an individual’s perceptions of cannabis, as policy change has been associated with increased perceptions of health benefits of cannabis use and decreased perceptions of harm (friese, 2017; gali et al., 2021; o’callaghan & joyce, 2006; park & levenson, 2002). with this decrease in harm perception, there has been an increase in daily use of cannabis among the university student population (johnston et al., 2015) where there continues to be a specific subgroup of high intensity frequent users of cannabis who are at greater risk. it has been found that within this subgroup, over half are more likely to experience cannabis use disorder (cud), and many of the use-related problems tend to be concentrated among young adult males (fischer et al., 2022). cud involves a problematic pattern of cannabis use which leads to clinically significant distress (american psychiatric association [apa], 2013). those who have a cud may use cannabis daily over a period of months or years in which they spend much of their time under the influence. others with cud may not use cannabis as frequently, but when they do use it causes recurring difficulties related to either their family, school, work, or other important aspects of life (e.g., repeated absences from work; apa, 2013). subsequently, the diagnostic criteria for cud have been revised to combine both dependence and abuse criteria into a single disorder (apa, 2013). according to the results of the united states national epidemiological survey conducted in 2012-13, nearly 30% of those who used cannabis had problematic usage patterns (hasin et al., 2015). it has also been reported that individuals who started using cannabis before the age of 18 are more likely to develop a cud (winters & lee, 2008). within a university student sample (ages 17-20), caldeira et al. (2008) found that nearly one fourth of past-year students met the criteria for a cud. additionally, a more recent cross-sectional study of canadian university students found that of the students who used cannabis for medicinal purposes, 13.6% met the criteria for cud (smith et al., 2019). however, not all consumers of cannabis are high intensity frequent users. as such the relationship between cannabis use and adverse psychosocial outcomes remains unclear, as research has demonstrated inconsistent results. some studies have found that cannabis use was associated with increased reports of anxiety and depression (feingold et al., 2015; keith et al., 2015) while others suggest the opposite (danielsson et al., 2016; moore et al., 2007), or that anxiety and depression are possible motivations for using cannabis (patten, 2021). mixed results are also reported for the relationship between cannabis use affecting academic outcomes (fergusson et al., 2003; keith et al., 2015) and the association between age of onset and cognitive deficits (kroon et al., 2020; meier et al., 2019; scott et al., 2018). as to why, meier (2021) postulates that a possible causal effect exists and that, over time, the cascading effects of shared risks (i.e. deviant peer groups, genetic predisposition, or adverse social conditions) reinforce the associations between psychosocial risk and the use of cannabis. in canada, the consumption of cannabis is legalized and the argument for legalization is based on the premise that better regulation practices will result in the removal of cannabis from the illicit market and thereby facilitate the ability to provide more targeted interventions allowing for a reduction in the social and health related costs associated with the potential harms of cannabis consumption (cssa 2022). thus, an understanding of an individual’s reasons for initiating and/or continuing cannabis consumption can help clarify various cannabis related behaviours and risks, which in turn can inform prevention and treatment efforts. for example, past research has found that using cannabis for experimentation was associated with less cannabis use and fewer cannabis related predictors of cannabis use 89 problems, whereas using cannabis for enjoyment, habit, activity enhancement, and altered perception purposes has been associated with increased use and problems (lee et al., 2007), while using cannabis routinely and as a means to cope was shown to be moderately correlated with severity of use (genrich et al., 2021). when comparing adults who use cannabis medicinally to those who use it recreationally, lin et al. (2016) found that medicinal users were more likely to have poorer health and more likely to use cannabis daily than those who used recreationally. in another more recent study that compared medicinal users to recreational users in a community sample, it was found that medicinal users were more likely to show more psychopathology (e.g., anxiety, depression, trauma), substance use, and problematic cannabis use, and that the majority of medicinal users also used cannabis recreationally (turna et al., 2020). it was also found that those who use cannabis for both medicinal and recreational purposes report more substance use, with turna et al. (2020) suggesting that these users may be at greater risk for adverse outcomes. the purpose of this study was to address the following research questions: 1a) how important are academic behaviors, psychosocial factors, risk profile, recreational motives, medicinal motives, age, and age onset of use when they are used together to predict cannabis use among university students? 1b) do the aforementioned predictor variables differ between males and females? 1c) do the aforementioned predictor variables differ between students who endorsed hazardous and non-hazardous cannabis use? methods recruitment the university of saskatchewan campus experiences with cannabis survey was administered online over a period of one month, july to august 2020, with four weekly reminders sent out. a simple random sample of 6,000 students (including undergraduate students, graduate students, and off campus students) were drawn by the office of the registrar and invited to participate through the student wellness centre and the teaching, learning, and student experience team. participants had to be at least 18 years of age or older and be enrolled in at least one course. ethical approval from the university of saskatchewan behavioural ethics board was received prior to commencing data collection for the survey (beh id #1717). regarding the larger study conducted by student wellness, 920 university of saskatchewan students participated, of which 52% (n = 478) of students endorsed having used cannabis over the past six months, and 48% (n = 442) of students reported that they did not use cannabis over the past six months. the current study examined a subset of the larger study including only those participants that had endorsed cannabis use in the past six months. the survey, which took approximately 30-45 minutes to complete, was distributed via a thirdparty website with a link to the online survey provided. a consent form was made available immediately as the participants opened the survey link, to which they agree to consent or not. the consent form explained the study in full in terms of the purpose and procedure, potential benefits, and risks. if participants had any questions or concerns, they were encouraged to contact the researchers, as their emails were provided. as an incentive, all participants who completed the survey were entered into a draw to win one of three $200 gift cards. regarding possible risks involved, participants were reminded in the consent form that if this occurs, they must remember that they have the right to not answer any questions they wish or to withdraw their consent at any time without penalty. if participants decided to withdraw their consent, they could also request for their data to be permanently deleted at the end of the survey. in case participants required further support, the information and phone numbers of support services were provided in the consent and debrief forms. data analysis this study relied on descriptive cross-sectional research. regarding analyses, descriptive statistics were computed for the demographic information and for students’ current motivations for using cannabis. bivariate correlations were computed to examine the association between the frequency of cannabis use and/or problematic cannabis use and psychosocial factors, cannabis, a publication of the research society on marijuana 90 recreational cannabis motives, medicinal cannabis motives, substance use risk, academic behaviors, current age, age onset of use, and gender. an anova was computed to determine if significant differences exist between hazardous and non-hazardous users on the various measures. a stepwise multiple linear regression was computed to determine which (if any) factors (i.e., and psychosocial factors, recreational cannabis motives, medicinal cannabis motives, substance use risk, academic behaviors, current age, age onset of use, and gender) are most predictive of cannabis use. separate stepwise multiple linear regressions, using the same predictor and outcome variables, were further computed when the sample was split between males and females and hazardous and nonhazardous users. the decision to refrain from using strict diagnostic criteria by labelling students with cud and to focus on hazardous and non-hazardous users was made in partnership with student wellness and the teaching, learning, and student experience team who facilitated the survey’s administration. data were analyzed with ibm spss statistics (version 28). instrumentation online survey past six-month cannabis use. problematic cannabis use was assessed using the cannabis use disorders identification test-revised (cudit-r; adamson et al., 2010). the cudit-r has 8 items with total scores ranging from 0-32. using the diagnostic and statistical manual of mental disorders (5th ed.; apa, 2013) criteria, the cudit-r identifies the pattern of cannabis use among past six-month users as non-hazardous (08) or hazardous (scores of 9 or greater; marshall, 2013). in terms of its total score, the cudit-r has demonstrated excellent internal consistency (a=.91; adamson et al., 2010). using a sample of college students, schultz et al. (2019) found that the cudit-r demonstrated good internal consistency (a=.83), displayed evidence of concurrent and discriminant validity, and achieved high levels of sensitivity (0.93) and specificity (0.70). the current study demonstrated an acceptable level of internal consistency for the cudit-r (α =.79). age onset of use. to determine the age onset for participants who have used cannabis, currently or in the past, participants were asked how old they were when they first started using cannabis. response options included: under 10, 10-15, 16-20, 21-25, 26-30, 31-35, and 35+ years of age. recreational cannabis motives. motives for using cannabis recreationally were evaluated using items from the 25-item marijuana motives measure (mmm; simons et al., 1998). the items are scored on a five-point scale. the mmm measures five motives, with each representing a different form of cannabis use behaviour, including: enhancement, conformity, expansion, coping, and social. the five highest loading items for the 5-factor solution reported were used (i.e., social [-.90], coping [-.86], enhancement [.94], conformity [.84], and expansion [-.95]; simons et al., 1998). the mmm has demonstrated good to excellent internal consistency for the subscales (a=.84 to a=.94). medicinal cannabis motives. to evaluate motives for using cannabis medicinally, participants were asked to rate how frequently their own cannabis use is motivated by relieving: 1) anxiety, ocd, ptsd; 2) sleep disorder/ insomnia; 3) depression; 4) all types of pain; 5) stress, general mood issues; 6) cns (migraine headache); and 7) or other psychiatric and/or health related ailments that could be specified via an open-ended item. the items are scored on a five-point scale that ranges from 1 (almost never/ never), 2 (some of the time), 3 (half of the time), 4 (most of the time), to 5 (almost always/ always). substance use risk. personality traits that heighten risk for substance misuse and psychopathology were measured using the substance use risk profile scale (surps; woicik et al., 2009). the surps has 23 items that are scored on a four-point scale. the surps is based on a model of personality risk for substance abuse along four distinct and independent personality dimensions, including: hopelessness, anxiety sensitivity, impulsivity, and sensation seeking. the surps subscales have demonstrated adequate to good internal consistency within a large undergraduate sample (a=.61 to a=.86; woicik et al., 2009). the current study demonstrated an acceptable level of internal consistency for the surps total score (α = .711) predictors of cannabis use 91 with internal consistencies for the surps subscales ranging from (a=.686-.906). psychosocial factors. non-specific psychological distress was measured using the kessler-6 (kessler et al., 2002). the kessler-6 has six items that are scored on a four-point likert scale. the possible range of the total score is 0 to 24, with higher scores indicating greater psychological distress. the kessler-6 includes measures of depressed mood, anxiety, motor agitation, fatigue, and worthless guilt. the kessler-6 has demonstrated excellent internal consistency in terms of its total score (a=.92). the current study demonstrated an excellent level of internal consistency (α = .863). academic behaviours. the ability to organize tasks and structure time to set goals, plan activities, and complete necessary academic activity was assessed using the organization and attention to study subscale of the college learning effectiveness inventory (oas; kim et al., 2010). the oas has seven items in which higher scores indicate a greater likelihood of being able to use effective organizational planning and time management skills to succeed academically, and lower scores indicate a greater likelihood that one will avoid planning strategies and struggle with providing self-direction. according to newton et al. (2008) construct validity for the oas was determined by assessing the strength of the relationship between subscales of the validation instrument, the learning and study strategies inventory (lassi; weinstein & palmer, 2002) and the oas. newton et al. (2008) reported strong to moderate correlations for the lassi concentration (r=.71) and self-testing (r=.46) subscales. in a cross-validation study, yeager (2009) reported that the oas correlated with the lassi time management (r=.754); concentration (r=.711) and self-testing (r=.431) subscales. the oas has demonstrated good internal consistency (a=.81; kim et al., 2010) with the present study demonstrating an excellent level of internal consistency (α = .839). results data cleaning assumptions for each of the statistical tests ran were checked prior to analyses. the distribution of scores for cannabis use (i.e., cudit-r) were moderately positively skewed. therefore, a log10 transformation (fox, 2016) was performed on this variable before analyses were conducted, causing it to become normally distributed. sample characteristics of the 478 students who had used cannabis in the past six months, the majority were female (60.3% female, n = 288; 25.7% male, n = 123; 2.5% gender variant/ non-binary, n = 12; 0.4% preferred not to disclose, n = 2; n = 53 did not respond). the average age was 25.02 (sd = 5.95; age range of 1855). among those who had used cannabis in the last six months, 69% (n = 330) were considered non-hazardous users, and 31% (n = 148) were considered hazardous users. see table 1 for descriptive statistics for the demographic information of the current study. table 1. descriptive statistics of demographic information demographic variable n (%) sex (n = 425) males 123 (25.7) females 288 (60.3) gender variant/ non-binary 12 (2.5) prefer not to disclose 2 (0.4) mean age (sd; n = 414) 25.02 (5.95) academic program (n = 420) four-year bachelor degree 263 (55) after degree program 14 (2.9) master’s degree 71 (14.9) doctoral degree 49 (10.3) cannabis, a publication of the research society on marijuana 92 open studies 1 (0.2) extension studies 1 (0.2) certificate 8 (1.7) other 13 (2.7) full-time student (n = 419) yes 389 (81.4) no type of user 30 (6.3) hazardous user 148 (31%) non-hazardous user 330 (69%) recreational user 268 (56.1%) medicinal user 15 (3.1%) recreational and medicinal user 149 (31.2%) importance of associated outcomes in predicting cannabis use/ problematic use to determine which (if any) of all the variables in this study are most predictive of cannabis use, stepwise multiple linear regressions were computed for the total sample, for males, for females, for hazardous users, and for nonhazardous users. in almost all instances, the cudit-r was significantly correlated with the various measures used with the exception of age and the anxiety/sensitivity subscale of the surps, see table 2. table 2. correlations between problematic cannabis use and associated constructs measure cudit-r oas total score -.12* kessler-6 total score .10* surps total score .19** surps hopelessness .16** surps anxiety sensitivity -.07 surps impulsivity .24** surps sensation seeking .11* age .06 age onset of use mmm social mmm coping mmm enhancement mmm conformity mmm expansion anxiety/ ocd/ ptsd motive sleep disorder motive depression motive pain motive stress motive cns (migraine/ headache) motive -.10* .09* .39** .39** -.02 .32** .28** .26** .34** .18** .33** .13* note. cudit-r = cannabis use disorder identification testrevised; surps = substance use risk profile scale; pwi= personal wellbeing index; oas = organization and attention to study scale; mmm = marijuana motives measure. *p < .05. **p < .01. predictors of cannabis use 93 when analyzing the total sample, 32.1% of the variance was accounted for in the final model, f(6, 379) = 29.908, p < .001, r2 = .321, with an adjusted r2 of 31.1%. the mmm enhancement motive, mmm coping motive, mmm expansion motive, surps impulsivity subscale, sleep disorder motive, and mmm conformity motive were identified as significant predictors of cannabis use (cudit-r; see table 3). high scores in cannabis use were associated with high scores in the mmm enhancement motive, mmm coping motive, mmm expansion motive, surps impulsivity subscale, and the sleep disorder motive, and low scores in the mmm conformity motive. no other variables were identified as significant predictors of cannabis use severity within the total sample, including the oas, kessler-6, surps total, surps hopelessness, anxiety sensitivity, and sensation seeking subscales, age, age onset of use, social, coping, conformity, and expansion mmm motives, anxiety/ocd/ptsd, sleep disorder, depression, pain, stress, and migraine/headache motives. table 3. multiple regression analysis for variables predicting cannabis use for total sample model predictor b se b β r2 adj. r2 1 mmm enhancement motive .07 .01 .39** .15** .148 2 mmm enhancement motive mmm coping motive .06 .06 .01 .01 .31** .30** .24** .232 3 mmm enhancement motive mmm coping motive mmm expansion motive .05 .05 .04 .01 .01 .01 .26** .28** .20** .27** .266 4 mmm enhancement motive mmm coping motive mmm expansion motive surps impulsivity subscale .05 .05 .04 .02 .01 .01 .01 .00 .25** .25** .20** .16** .30** .287 5 mmm enhancement motive mmm coping motive mmm expansion motive surps impulsivity subscale sleep disorder motive .05 .04 .04 .02 .02 .01 .01 .01 .00 .01 .25** .21** .19** .16** .12** .31** .299 6 mmm enhancement motive mmm coping motive mmm expansion motive surps impulsivity subscale sleep disorder motive mmm conformity motive .04 .04 .04 .02 .02 -.07 .01 .01 .01 .00 .01 .02 .25** .23** .20** .17** .13** -.12** .32** .311 note. surps = substance use risk profile scale; mmm = marijuana motives measure. *p < .05. **p < .01. cannabis, a publication of the research society on marijuana 94 after splitting the sample by gender, the regression revealed some interesting gender differences, see table 4. for males only, 36.6% of the variance was accounted for in the final model, f(4, 106) = 15.287, p < .001, r2 = .366 with an adjusted r2 of 34.2%. the mmm enhancement motive, mmm coping motive, mmm expansion motive, and mmm conformity motives were identified as significant predictors of cannabis use for males, with high scores in cannabis use being associated with high scores in mmm enhancement, coping, and expansion motives, and low scores in the mmm conformity motive. for females, 32.4% of the variance was accounted for in the final model, f(5, 248) = 23.784, p < .001, r2 = .324 with an adjusted r2 of 31%. the mmm coping motive, mmm enhancement motive, surps impulsivity subscale, depression motive, and mmm expansion motive were identified as significant predictors of cannabis use for females, with high scores in cannabis use being associated with high scores in all variables identified. no other variables were identified as significant predictors of cannabis use severity for males and females. table 4. multiple regression analysis for variables predicting cannabis use by gender model predictor b se b β r2 adj. r2 males 1 mmm enhancement motive .08 .02 .38** .14** .136 2 mmm enhancement motive mmm coping motive .08 .09 .02 .02 .40** .38** .29** .278 3 mmm enhancement motive mmm coping motive mmm expansion motive .07 .08 .04 .02 .02 .02 .35** .35** .23** .34** .322 4 mmm enhancement motive mmm coping motive mmm expansion motive mmm conformity motive .07 .08 .05 -.09 .02 .02 .02 .04 .35** .35** .25** -.16* .37** .342 females 1 mmm coping motive .07 .01 .42** .17** .169 2 mmm coping motive mmm enhancement motive .06 .04 .01 .01 .33** .26** .23** .225 3 mmm coping motive mmm enhancement motive surps impulsivity motive .05 .04 .02 .01 .01 .01 .28** .24** .23** .28** .270 4 mmm coping motive mmm enhancement motive surps impulsivity motive depression motive .03 .04 .02 .04 .01 .01 .01 .01 .15* .25** .22** .23** .31** .301 5 mmm coping motive mmm enhancement motive surps impulsivity motive depression motive mmm expansion motive .03 .04 .02 .03 .02 .01 .01 .01 .01 .01 .15* .22** .23** .20** .12* .32** .310 note. surps = substance use risk profile scale; mmm = marijuana motives measure. *p < .05. **p < .01. predictors of cannabis use 95 after splitting the sample by students who endorsed hazardous and non-hazardous cannabis use (i.e., non-hazardous users = cudit-r total scores of 0-8; hazardous users = cudit-r total scores of 9 or greater), the regression revealed some differences, see table 5. for hazardous users, 20.1% of the variance was accounted for in the final model, f(6, 267) = 11.202, p < .001, r2 = .201 with an adjusted r2 of 18.3%. the mmm enhancement motive, depression motive, sleep disorder motive, surps total score, kessler-6 total score, and mmm conformity motive were identified as significant predictors of cannabis use for hazardous users, with high scores in cannabis use being associated with high scores in the mmm enhancement motive, depression motive, sleep disorder motive, and the surps total, and low scores in the kessler-6 total and mmm conformity motive. for non-hazardous users, 19.4% of the variance was accounted for in the final model, f(4, 101) = 6.075, p < .001, r2 = .194 with an adjusted r2 of 16.2%. only the surps impulsivity subscale, mmm coping motive, kessler-6 total, and pain motive were identified as significant predictors of cannabis use for non-hazardous users, with high scores in cannabis use being associated with high scores in the surps impulsivity subscale and mmm coping motive, and low scores in the kessler-6 total and pain motive. no other variables were identified as significant predictors of cannabis use severity for hazardous and non-hazardous users. table 5. multiple regression for variables predicting use by hazardous or non-hazardous users model predictor b se b β r2 adj. r2 hazardous users 1 mmm enhancement motive .04 .01 .30** .09** .084 2 mmm enhancement motive depression motive .03 .03 .01 .01 .27** .25** .15** .141 3 mmm enhancement motive depression motive sleep disorder motive .03 .02 .02 .01 .01 .01 .27** .16* .14* .16** .152 4 mmm enhancement motive depression motive sleep disorder motive surps total .03 .02 .02 .00 .01 .01 .01 .00 .27** .14* .15* .11* .17** .162 5 mmm enhancement motive depression motive sleep disorder motive surps total kessler-6 total .03 .03 .02 .01 -.01 .01 .01 .01 .00 .00 .27** .20** .14* .18* -.15* .19** .172 6 mmm enhancement motive depression motive sleep disorder motive surps total kessler-6 total mmm conformity motive .03 .03 .02 .01 -.01 -.05 .01 .01 .01 .00 .00 .02 .27** .21** .16* .21** -.17* 0.12* .20** .183 cannabis, a publication of the research society on marijuana 96 non-hazardous users 1 surps impulsivity subscale .01 .04 .28** .08** .067 2 surps impulsivity subscale mmm coping motive .01 .02 .00 .01 .24* .22* .12** .104 3 surps impulsivity subscale mmm coping motive kessler-6 total .01 .03 -.01 .00 .01 .00 .32** .33** -.25* .16** .137 4 surps impulsivity subscale mmm coping motive kessler-6 total pain motive .02 .03 -.01 -.02 .00 .01 .00 .01 .36** .36** -.27* -.19* .19** .162 note. surps = substance use risk profile scale; mmm = marijuana motives measure. *p < .05. **p < .01. a one-way analysis of variance (anova) was conducted to determine if scores of the variables in the study were different between hazardous and non-hazardous cannabis use, see table 6. regarding recreational cannabis use motives, using cannabis to be social (mmm social motive score) was significantly different between hazardous and non-hazardous cannabis users, with hazardous users (m = 2.80, sd = 1.17) scoring higher than non-hazardous users (m = 2.5, sd = 1.28), f(1, 446) = 5.129, p = .024, h2 = .01. using cannabis to cope with negative emotions (mmm coping motive) was significantly different between hazardous and non-hazardous cannabis users, with hazardous users (m = 2.69, sd = 1.38) scoring higher than non-hazardous users (m = 1.80, sd = 1.12), welch’s f(1, 195.920) = 41.421, p < .001, h2 = .10. using cannabis to enhance experiences and improve mental state (mmm enhancement motive) was significantly different between hazardous and non-hazardous cannabis users, with hazardous users (m = 3.88, sd = 1.09) scoring higher than non-hazardous users (m = 2.98, sd = 1.36), welch’s f(1, 287.774) =52.565, p < .001, h2 = .09. lastly, using cannabis to expand awareness/ creativity (mmm expansion motive) was significantly different between hazardous and non-hazardous cannabis users, with hazardous users (m = 2.57, sd = 1.37) scoring higher than non-hazardous users (m = 1.78, sd = 1.15), welch’s f(1, 203.012) = 32.932, p < .001, h2 = .08. there was no significant difference in conformity cannabis use motives between hazardous and non-hazardous users. regarding medicinal cannabis use motives, using cannabis to relieve anxiety/ocd/ptsd was significantly different between hazardous and non-hazardous users, with hazardous users (m = 2.79, sd = 1.50) scoring higher than nonhazardous users (m = 2.16, sd = 1.43), f(1, 425) = 16.146, p < .001, h2 = .04. using cannabis to relieve sleep disorders was also significantly different between hazardous and non-hazardous users, with hazardous users (m = 2.60, sd = 1.42) scoring higher than non-hazardous users (m = 2.06, sd = 1.35), f(1, 424) = 13.485, p < .001, h2 = .03. further, using cannabis to relieve pain was significantly different between hazardous and non-hazardous users, with hazardous users (m = 2.19, sd = 1.32) scoring higher than nonhazardous users (m = 1.77, sd = 1.28), f(1, 415) = 8.972, p = .003, h2 = .02. additionally, using cannabis to relieve stress was significantly different between hazardous and non-hazardous users, with hazardous users (m = 3.00, sd = 1.31) scoring higher than non-hazardous users (m = 2.16, sd = 1.33), f(1, 420) = 34.379, p < .001, h2 = .08. lastly, using cannabis to relieve depression was significantly different between hazardous and non-hazardous users, with hazardous users (m = 2.59, sd = 1.50) scoring higher than nonhazardous users (m = 1.76, sd = 1.21), welch’s f(1, 184.267) = 29.100, p <.001, h2 = .08. there were no significant differences between hazardous and non-hazardous users for cns/ predictors of cannabis use 97 migraine headache motives. thus, hazardous users more often used cannabis for social, coping, enhancement, expansion, anxiety/ocd/ptsd, sleep disorder, depression, pain, and stress motives than non-hazardous users. significant differences between hazardous and nonhazardous users, were also found for the oas with hazardous users (m = 47.68, sd = 9.86) scoring lower than non-hazardous users (m =50.38, sd = 10.00), f(1, 413) = 6.06, p = .014, h2 = .015. higher scores on the oas indicate better a better ability to use effective organizational planning and time management skills to succeed academically. table 6. one-way anova for cannabis use motives between hazardous and non-hazardous users measure hazardous non-hazardous f p η2 m sd m sd recreational motives mmm social 2.80 1.17 2.50 1.28 5.13 .021* .01 mmm coping 2.69 1.38 1.80 1.12 41.421 <.001** .10 mmm enhancement 3.88 1.09 2.98 1.36 52.57 <.001** .09 mmm conformity 1.13 0.44 1.11 0.44 .079 .382 .00 mmm expansion 2.57 1.37 1.78 1.15 32.93 <.001** .08 medicinal motives anxiety/ ocd/ ptsd 2.79 1.50 2.16 1.43 16.146 <.001** .04 sleep disorder 2.60 1.42 2.06 1.35 13.49 <.001** .03 depression 2.59 1.50 1.76 1.21 29.10 <.001** .08 pain 2.19 1.32 1.77 1.28 8.97 .002** .02 stress 3.00 1.31 2.16 1.33 34.38 <.001** .08 cns (migraine) 1.65 1.12 1.46 .99 2.72 .06 .01 surps hopelessness 18.55 3.94 19.32 3.07 4.56 .033 .01 impulsivity 10.10 2.50 9.15 2.35 13.46 <.001** .031 sensation seeking 14.18 2.86 13.57 2.95 3.71 .055 .009 anxiety sensitivity 12.45 2.87 12.86 2.65 14.18 .166 .005 oas 47.68 9.86 50.38 10.00 6.06 .014* .015 kessler-6 13.99 4.74 13.04 4.60 3.36 .067 .008 note. mmm = marijuana motives measure; surps= substance use risk profile; oas= organization and attention to study. *p < .05. **p < .01. cannabis, a publication of the research society on marijuana 98 discussion of the 920 students that participated in the study, 52% reported using cannabis at least once in the last six months, of which 31% met the criteria for hazardous cannabis use. these findings may suggest that both cannabis use and cannabis use severity are common among university students within a legalized landscape. though the present study cannot infer any causation due to its correlational nature, it provides some insight into the changing cannabis use trends. of all the variables included in this study, using cannabis to enhance one’s experiences, cope with negative emotions, expand awareness, be liked, and relieve sleep difficulties, along with a predisposition for impulsive personality traits were identified as important predictors of cannabis use severity among all past six-month users. among these variables, using cannabis to enhance one’s experience because one likes the feeling was identified as the strongest predictor of cannabis use within the total sample and among students who endorsed hazardous cannabis use. these findings add to the literature by further suggesting that cannabis use motives are important factors to consider when understanding cannabis use severity, as many of the strongest predictors identified were motives for use. the enhancement motive was the strongest predictor of cannabis use among the total sample, hazardous users only, males only, and the second strongest among females only. this suggests that using cannabis to enhance one’s experiences may increase the risk for problematic use. similar findings have been reported in previous research, as it has been found that the enhancement motive was significantly positively associated with cannabis frequency, as well as predicted severe use, and predicted cannabis related impairment beyond gender and frequency of recent use (bresin & mekawi, 2019; gonzalez-ponce et al., 2022; mader et al., 2019). the coping motive was another common predictor, as the current study found that it was the strongest predictor of cannabis use severity for female users, and the second strongest predictor for the total sample, non-hazardous users, and males. the coping motive was not identified as a predictor among hazardous users, implying it may suggest less hazardous yet still increasing problematic use. previous research has also found links between the coping motive and frequency of use, use severity, cannabis dependency, and higher cannabis consequences in the past month (gonzalez-ponce et al., 2022; mader et al., 2019). the coping motive has been linked to more problem substance use because it is typically a form of avoidance, which has been found to be associated with harmful outcomes (chao, 2011). an interesting relationship was demonstrated for the conformity motive. this motive was identified as a predictor for cannabis use severity in the negative direction for the total sample, males only, and hazardous users. thus, increased cannabis use severity was associated with decreased use of cannabis for conformity purposes. the current findings add to the conflicting research for the conformity motive and cannabis use, as some demonstrate no association, some a negative association, some a positive association, and some a negative association with frequency but a positive association with severity (bresin & mekawi, 2019; mader et al., 2019; schultz et al., 2019). conformity may be influenced by the legality of a substance, which may explain why some pre-legalization research has found a positive association between conformity and problem cannabis use (schultz et al., 2019), while the current study identified a negative association. the last recreational motive identified as an important predictor was the expansion motive. this motive was identified as a predictor in the total sample and for both males and females, and not identified for both hazardous and non-hazardous users. previous research has found that the expansion motive was significantly positively associated with cannabis use severity (mader et al., 2019). other important predictors identified included risk profile variables. the impulsivity subscale of the surps was found as a predictor for the total sample, females only, and as the strongest predictor among non-hazardous users. this suggests that impulsivity may increase cannabis use but not to a hazardous degree. further, the surps total score was found as a predictor only among hazardous users, implicating the surps as an identifier of potential hazardous use. these findings coincide with previous research that predictors of cannabis use 99 found impulsivity was directly related to cannabis related problems as impulsivity has been associated with the inability to effectively use harm reduction strategies, which has been found to be associated with more substance use problems (gonzalez-ponce et al., 2022; simons et al., 2005). additionally, some medicinal motives were identified as predictors of cannabis use severity. using cannabis to alleviate sleep problems was identified as a predictor in the total sample as well as among hazardous users. past research has found that sleep related motives are common among medicinal users, and that using cannabis to sleep was associated with increased problematic use, as well as worse sleep (drazdowski et al., 2019). similar themes have been found for using cannabis to alleviate depression, which was a motive identified in the current study as a predictor of problem use among females and hazardous users. past research has found that patients with depression who used cannabis were more likely to have poor recovery compared to non-users (bahorik et al., 2017). however, the current study did not find many medicinal use motives as strong predictors of cannabis use severity, which may be because the majority of the sample used cannabis for recreational purposes only, and the majority of those that used medicinally also used recreationally. implications the findings of this study provide a more nuanced understanding of cannabis consumption among the university student population. although the consumption, smoking, and growing of cannabis is prohibited on campus, findings suggest that cannabis use and hazardous cannabis use are common among university students. given this finding, and as there is no safe level for cannabis consumption (fischer et al., 2022), it is recommended that, in jurisdictions in which legalization has occurred, a campus policy restricting cannabis consumption to off-campus locations be endorsed. to help address concerns regarding consumption, a harm reduction approach is encouraged. to facilitate harm reduction, lower risk cannabis use guidelines (lrug) are advocated. based on the consensus of experts, the lrcug have been adopted internationally and recently updated with twelve recommendations on how to reduce the adverse effects of cannabis consumption (fischer et al., 2022). campus-based prevention and harm reduction initiatives that embrace lrcug embedded within a harm reduction framework have been shown to be effective when they are used as an education and intervention tool through campus-wide marketing (centre for addiction and mental health [camh], 2019). harm reduction, using peer support, has been shown to especially applicable with youth and young adults (gillespie et al., 2018). as such, postsecondary student support services are well positioned to promote harm reduction through educational/peer support programming. since it was found that some students use cannabis to selfmedicate, safe guidelines and protective strategies for cannabis consumption both in the traditional form and as edibles are required. this indicates there is significant room for continued education about safe guidelines and protective strategies regarding cannabis and its effects. to facilitate this, student support services can coordinate workshops for staff, faculty, and peer student volunteers along with social norming messages on campus plasma tvs and social media postings on student services platforms. it is further advocated that the development of addiction resources and supports in the form of brief interventions and screening tools is desirable not only for those most at risk but also for those who wish to better understand and minimize the risks of cannabis use. assessing cannabis use motives can be used to screen students who may be at highest risk for severe use to provide early intervention and prevent further harm. it also may be essential that post-secondary student support service clinicians have increased knowledge about evidence-based medicinal use to educate those students on its potential harms. for example, knowing that there is little evidence to support the use of cannabis in treating depression or sleep issues, and that it may worsen those issues, is important for clinicians to know to guide clients (bahorik et al., 2017). limitations this study is not without limitations. because cannabis is now legalized, participants may have cannabis, a publication of the research society on marijuana 100 been more likely to report that they use cannabis than pre-legalization. it is also important to note the impact that the covid-19 pandemic may have had on these findings. university closures and restrictions may have impacted cannabis use frequency, mental health, and academia. research during the pandemic has found that a large proportion of existing individuals that use cannabis increased their use during the first wave of the pandemic (camh, 2021). however, another study that surveyed us adults before and during business closures due to the pandemic found that there was no significant difference in the total amount or frequency of cannabis used before and during covid-19. thus, findings may not have been severely impacted by this global event. future research is required to verify and further clarify these findings. further, this study used the cudit-r total scores as a dependent variable, which may be limiting as the ratio between total scores and severity is unknown (mader et al., 2019). however, because previous research has demonstrated that items on the cudit-r are highly correlated and measure one underlying construct, it is likely that higher scores on the cudit-r indicate more severe use (adamson et al., 2010). conclusion this study sought to describe trends in cannabis use and examine psychosocial outcomes, academic outcomes, risk profile, and motives to use among students at the university of saskatchewan. over half of the total sample reported using cannabis in the last six months, with 31% meeting the criteria for hazardous use. of all the variables in the study, the enhancement motive was identified as one of the strongest predictors of cannabis use severity among the total sample, hazardous users only, males only and females only. other important predictors included the coping motive, expansion motive, impulsivity, sleep disorder motive, and depression motives. these findings can better inform campusbased 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(2016). effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review. jama psychiatry, 73(3):292–297. https://doi.org/10.1001/jamapsychiatry.2015.3 278 weinstein, c.e. & palmer, d.r. (2002). user’s manual: learning and study strategies inventory 2nd edition, h&h publishing company, inc. winters, k. c., & lee, c. y. s. (2008). likelihood of developing an alcohol and cannabis use disorder during youth: association with recent use and age. drug and alcohol dependence, 92(1-3), 239-247. https://doi.org/10.1016/j.drugalcdep.2007.08.0 05 woicik, p. a., stewart, s. h., pihl, r. o., & conrod, p. j. (2009). the substance use risk profile scale: a scale measuring traits linked to reinforcement-specific substance use profiles. addictive behaviors, 34(12), 1042cannabis, a publication of the research society on marijuana 104 1055. https://doi.org/10.1016/j.addbeh.2009.07.001 yeager, m. e. b. (2009). a cross-validation study of the college learning effectiveness inventory (clei). proquest dissertations publishing. http://cyber.usask.ca/login?url=https://www.p roquest.com/dissertations-theses/crossvalidation-study-collegelearning/docview/304911359/se-2 zalesky, a., solowij, n., yücel, m., lubman, d. i., takagi, m., harding, i. h., lorenzetti, v., wang, r., searle, k., pantelis, c., & seal, m. (2012). effect of long-term cannabis use on axonal fibre connectivity. brain, 135(7), 22452255. https://doi.org/10.1093/brain/aws136 funding and acknowledgements: funding for this project was received from the university of saskatchewan’s social sciences and humanities research council of canada institutional grant: sshrc explore; the social sciences and humanities research council’s joseph-armand bombardier canada graduate scholarship; and the college of education at the university of saskatchewan. the authors have no conflicts of interest to disclose or declare. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 34 ved abstract abstract objective: simultaneous use of alcohol and cannabis is associated with more negative consequences than use of either substance alone. research suggests that emotion dysregulation is linked to alcohol, cannabis, and polysubstance use. however, no previous research has examined whether emotion dysregulation scores differ among individuals without past month substance use (abstainers), individuals who report past-month alcohol use only (no past month cannabis or simultaneous use; alcohol-only users), and individuals who engage in past-month simultaneous alcohol and cannabis use (simultaneous users). our aim was to examine differences in overall levels of emotion dysregulation and emotion dysregulation subscales between these groups. methods: the sample included 468 college students. participants completed an online survey assessing demographics, emotion dysregulation, average number of drinks per week, days of monthly cannabis use, and simultaneous use of alcohol and cannabis. results: a one-way anova showed significant differences in emotion dysregulation between alcohol-only users, abstainers, and simultaneous users. a bonferroni post hoc analysis revealed significant differences in emotion dysregulation for simultaneous users (p = .004) compared to alcohol-only users and abstainers. a series of anovas were run to examine emotion dysregulation subscale scores and significant differences were found for impulse control difficulties (p = .003) and limited access to emotion regulation strategies (p = .005) for simultaneous users compared to alcohol-only users and abstainers, and for non-acceptance of emotional responses (p = .018) for simultaneous users compared to and alcohol-only users. conclusion: these findings indicate that simultaneous users have higher levels of emotion dysregulation, higher levels of impulse control difficulties, greater non-acceptance of emotions, and greater lack of access to emotion regulation strategies compared to abstainers and alcohol-only users. key words: = alcohol; cannabis; emotion dysregulation; simultaneous use; impulsivity alcohol and cannabis are the most widely used substances on college campuses (arria et al., 2008; white et al., 2019). a recent report by the substance abuse and mental health services administration (samhsa) reported that 18.8 million college-aged individuals currently use alcohol, while 11.8 million currently report using cannabis (samhsa, 2019). notably, many college-aged alcohol and cannabis users report using both substances simultaneously (subbaraman & kerr, 2015). simultaneous use is defined as using both substances during the same occasion so that their effects overlap and has been shown to be associated with greater negative consequences than using either substance alone (yurasek et al., 2017), such as driving hazards katie r. moskal1, jenni b. teeters1, diamonde c. mccollum1 1department of psychological sciences, western kentucky university cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000166 examining differences in emotion dysregulation between emerging adult alcohol-only users, abstainers, and simultaneous users corresponding author: katie r. moskal, m.s., psychological sciences department, western kentucky university, 1028 kelly thompson hall, 1906 college heights blvd, bowling green, kentucky 42101. telephone: (973) 908-4667. e-mail: katie.moskal702@topper.wku.edu cannabis, a publication of the research society on marijuana 35 (terry-mcelrath et al., 2014), poor academic performance (arria et al., 2013), and accidental injuries (hingson et al., 2009; white et al., 2019). given the rise in rates of simultaneous use of alcohol and cannabis among this age group, there is a need to determine risk factors that contribute specifically to simultaneous use of alcohol and cannabis among college students. although difficulties in emotion regulation, or emotion dysregulation (weiss et al., 2022), have been theorized to be linked to simultaneous use of alcohol and cannabis, research investigating this connection is scarce. emotion regulation has been described as the awareness, identification, understanding, and acceptance of emotions, the ability to control impulsive behaviors and behave in accordance with desired goals when experiencing negative emotions, and the ability to use situationally appropriate emotion regulation strategies flexibly to modulate emotional responses (gratz & roemer, 2004). the difficulty or inability to perform one or more of these tasks has been described as emotion dysregulation (gratz & roemer, 2004). while prior research has demonstrated associations between emotion dysregulation and alcohol use (for a review see weiss et al., 2022) and cannabis use (dorard & bungener, 2008; paulus et al., 2018), no previous studies have examined whether overall emotion dysregulation and specific emotion dysregulation subcomponents differ among college students who choose not to use alcohol or cannabis in the past month (abstainers), college students who drink alcohol but did not use cannabis or engage in simultaneous use in the past month (alcohol-only users), or college students who have engaged in simultaneous use of alcohol and cannabis in the past month (simultaneous users). positive and negative emotions have been shown to motivate substance-seeking behaviors. previous research suggests that individuals who experience heightened negative affect may use alcohol and cannabis to alleviate strong negative or positive emotions (weiss et al., 2015). this is consistent with negative reinforcement models of substance use, in which individuals use substances to escape or avoid their negative mood state, or regulate their emotions (cooper et al., 1995). moreover, drinking to regulate emotions has been linked to increased negative alcoholrelated consequences (dvorak et al., 2014). a recent review of emotion regulation and substance use disorders posits that individuals who have substance use disorders have greater emotion regulation difficulties than individuals without substance use disorders (stellern et al., 2022). conversely, recent ecological momentary assessment (ema) research has shown that alcohol and cannabis use in this age group may be more closely linked with positive affect than negative affect (dora et al., 2022). although previous research has demonstrated positive mood increases shortly after drinking is initiated (russell et al., 2020; treloar et al., 2015), there is evidence showing that college students may use substances to dampen or downregulate positive emotions (feldman et al., 2007; weiss et al., 2019). other research has suggested both positive and negative emotion regulation contribute to substance use. a review by weiss et. al. (2022) showed that for negative emotion regulation abilities (i.e., regulating negative emotions), there were small-to-medium effect sizes for alcohol use (r = 0.23, p < 0.001) and for use of multiple substances (r = 0.25, p < 0.001). for positive emotion regulation abilities (i.e., regulating positive emotions), there were medium effect sizes for alcohol use (r = 0.24, p < 0.001) and drug use (r = 0.28, p < 0.001). whether using substances in response to experiences of positive or negative affect, emotion regulation skills are crucial in responding appropriately to an emotion and behaving in accordance with desired goals. while the majority of published studies on this topic have examined the connection between emotion dysregulation and alcohol use, there is limited research connecting cannabis use to emotion dysregulation. some evidence supports emotion dysregulation as a predictor of cannabis-related problems (brook, 2016; dvorak & day, 2014; manning et al., 2019), such that higher levels of cannabis-related problems (e.g., memory loss, procrastination, lower productivity at work or school) were associated with greater emotion dysregulation (orr et al., 2020). additionally, other research has shown emotion dysregulation being associated with the risk of more problematic cannabis use (dvorak & day, 2014). overall, there is limited research examining how cannabis use may be associated with emotion dysregulation. there is also a lack of research examining whether simultaneous use of alcohol and cannabis emotion dysregulation and substance use patterns 36 is associated with greater levels of emotion dysregulation than alcohol use alone, as the existing research has examined emotion dysregulation in relation to polysubstance use broadly rather than simultaneous alcohol and cannabis use specifically. notably, polysubstance use broadly refers to the use of multiple substances (cicero et al., 2020), either simultaneously or at different times within a defined time period, whereas simultaneous use refers to the use of multiple substances together so that their effects overlap. a recent metaanalysis by weiss et. al. (2022) highlights the importance of investigating the link between polysubstance use and emotion dysregulation. their results indicated that the largest effect sizes exist for emotion dysregulation and polysubstance use, rather than alcohol or drug use alone. this may suggest that individuals who use multiple substances may experience greater emotion regulation difficulties than individuals who use these substances alone. similarly, crane and colleagues (2021) examined the frequency of alcohol, cannabis, and nicotine polysubstance use and associated risk factors in a sample of adolescents and found that greater symptoms of depression and anxiety along with weaker mood regulation expectancies were associated with increased polysubstance use over time (crane et al., 2021). while this study showed that mood regulation expectancies were related to polysubstance use, it did not examine the simultaneous use of alcohol and cannabis or examine emotion dysregulation. only one previous study examined the connection between emotion dysregulation and concurrent use of alcohol and cannabis (i.e., use of substances in the same time frame (month, day, etc.) but not use of them together at the same time (bravo et al., 2021). lucke and colleagues (2021) investigated the relationship between emotion dysregulation with individuals who concurrently use alcohol and cannabis. the authors found that while emotion dysregulation was not significantly associated with increased substance consumption, it was associated with an increase in substance-related consequences. given the consequences associated with simultaneous use of alcohol and cannabis and the lack of research examining the connection between emotion dysregulation and simultaneous use of alcohol and cannabis, there is a need to examine simultaneous use of alcohol and cannabis in relation to emotion dysregulation. while overall emotion dysregulation has been shown to be linked with alcohol and cannabis use, it remains unknown whether specific emotion dysregulation subcomponents are connected to simultaneous use of alcohol and cannabis. the most commonly used measure of emotion regulation difficulties is the difficulties in emotion regulation scale (ders), which has six subscales based on four dimensions of emotion dysregulation. the six subscales measured by the ders are 1. nonacceptance of emotional responses, 2. difficulty engaging in goal-directed behavior, 3. impulse control difficulties, 4. lack of emotional awareness, 5. limited access to emotion regulation strategies, and 6. lack of emotional clarity. to understand the connection between substance use and emotion dysregulation more clearly, it is important to dissect the subcomponents of emotion dysregulation and examine how these six components contribute to simultaneous use of alcohol and cannabis. dvorak and colleagues (2014) included specific facets of emotion dysregulation in relation to alcohol use and found that difficulties with impulse control were associated with overall alcohol-use and alcohol-related consequences among college students. additionally, they found that difficulties with goal directed behavior during negative mood, lack of emotional clarity, and non-acceptance of emotional responses were positively associated with frequency of alcohol-related consequences (dvorak et al., 2014). in regard to cannabis, bonnmiller and colleagues (2008) found that nonacceptance of emotional responses was uniquely related to coping-oriented cannabis use. relatedly, in their meta-analysis on emotion regulation and substance use among adults, weiss et.al. (2022) found large effect sizes for impulse control difficulties and use of multiple substances (r = 0.38, p < 0.001), medium effect sizes for non-acceptance of emotional responses and use of multiple substances (r = 0.28, p < 0.001), and medium effect sizes for difficulties with goal-directed behavior and use of multiple substances (r = 0.25, p < 0.001). this suggests that specific facets of emotion dysregulation are linked to polysubstance use behaviors. however, no previous research has examined whether scores on facets of emotion dysregulation differ between cannabis, a publication of the research society on marijuana 37 past month alcohol-only users, past month abstainers from alcohol and cannabis, and individuals who simultaneously used alcohol and cannabis in the past month. in summary, previous research has established that individuals who use substances are at risk of experiencing difficulties in emotion regulation (kenneson et al., 2013), and difficulties in emotion regulation have been associated with substance use (weiss et al., 2022). however, little research has examined how the simultaneous use of alcohol and cannabis relate to emotion dysregulation, and whether emotion dysregulation scores or facets of emotion dysregulation differ between past month alcoholonly users, past month abstainers, and past month simultaneous users. given the prevalence of simultaneous of alcohol and cannabis within the college student population, and that simultaneous use of these substances has been shown to be associated with significantly more problems than using each substance alone, research is needed to examine differences in emotion dysregulation specific to simultaneous users. understanding the connection between simultaneous use of alcohol and cannabis and emotion dysregulation could aid in developing prevention and intervention techniques aimed at teaching emotion regulation skills and healthy coping mechanisms to college students in order to potentially reduce problems associated with simultaneous use of alcohol and cannabis. thus, the primary goal of the current study was to examine the differences in overall emotion dysregulation among these groups and to examine differences on specific subscales of emotion dysregulation to better understand which subcomponents may be implicated in simultaneous alcohol and cannabis use. based on previous research (lucke et al., 2021; weiss et al., 2022), it is hypothesized that simultaneous users would have higher emotion dysregulation scores than abstainers and alcohol-only users. subscale differences were also explored but no a priori hypotheses were made regarding subscale differences. methods participants participants were 468 undergraduate students (78.4% female, 21.2% male; 55.1% freshmen, 26.1% sophomore, 10.3% junior, 8.3% senior, .2% not currently enrolled) from a large public university in the southern united states. participants averaged 19.38 (sd = 3.07) years of age (range: 18-46). participants were 77.8% caucasian, 8.8% african american, 2.6% hispanic, 2.6% asian, .4% american indian or alaska native, and 7.9% other or selected multiple races. additionally, participants were 83.7% heterosexual (straight), 2.4% homosexual (gay), 8.5% bisexual, 3.2% other, and 1.5% preferred not to say. procedure prior to the start of the data collection, the protocol was reviewed and approved by the university’s institutional review board. all participants were provided informed consent materials which review the confidentiality of responses and their right to terminate participation at any time without penalty. participants were eligible to participate if they were at least 18 years old. individuals who consented to participate were asked to complete an online survey. participants were recruited through an academic survey pool and were provided course credit for completion of the study. measures emotion dysregulation. emotion dysregulation was assessed using the difficulties in emotion regulation scale (ders). the ders is a 36-item self-report questionnaire that is commonly used to assess emotion dysregulation (gratz & roemer, 2004). it contains six subscales: 1. nonacceptance of emotional responses (i.e., the tendency to have a negative secondary or nonaccepting reaction to one’s own distress; a sample item is “when i’m upset, i become angry with myself for feeling that way”, this is referenced as “non-acceptance” throughout the manuscript), 2. difficulty engaging in goal-directed behavior (i.e., the difficulty in concentrating and/or accomplishing tasks when experiencing negative emotions; a sample item is “when i’m upset, i have difficulty focusing on other things” this is referenced as “goals” throughout the manuscript), emotion dysregulation and substance use patterns 38 3. impulse control difficulties (i.e., the difficulty remaining in control of one’s behavior when experiencing negative emotions; a sample item is “i experience my emotions as overwhelming and out of control” this is referenced as “impulse” throughout the manuscript), 4. lack of emotional awareness (i.e., the lack of awareness or inattention to emotional responses; a sample item is “i pay attention to how i feel” this is referenced as “awareness” throughout the manuscript), 5. limited access to emotion regulation strategies (i.e., the belief that there is little one can do to regulate oneself once upset; a sample item is “when i’m upset, i believe that i will remain that way for a long time” this is referenced as “strategies” throughout the manuscript), and 6. lack of emotional clarity (i.e., the extent to which an individual knows and is clear about his or her emotions; a sample item is “i have no idea how i am feeling” this is referenced as “clarity” throughout the manuscript). for each question, participants rated their responses on a scale from 1 (“almost never”) to 5 (“almost always”) with questions 1, 2, 6, 7, 8,10, 17, 20, 22, 24, and 34 being reversed scored. a total score was computed by summing the 36 items. total scores for each of the 6 subscales (non-acceptance, goals, impulse, awareness, strategies, and clarity) were also computed. the total ders score and subscale scores are continuous variables where higher scores indicated more emotion dysregulation. this questionnaire has been shown to have a high internal consistency (a = 0.86) and acceptable reliability (r = 0.74; gratz & roemer, 2004). internal consistency for the current study was high (α = 0.95). additionally, internal consistencies for each subscale were high with cronbach alpha scores of (a = 0.86), (a = 0.89), (a = 0.87), (a = 0.86), (a = 0.90), (a = 0.80) for nonacceptance, goals, impulse, awareness, strategies, and clarity respectively. alcohol use. the alcohol-only group was created using the daily drinking questionnaire (ddq). the ddq assessed frequency of alcohol use in a typical week in the past month (collins et al., 1985). for each day of the week, participants responded with the number of drinks consumed on that given day. a sample question is, “on a typical friday, i have __ drinks.” there are seven items which correspond to each day of the week, and a total score is summed to calculate total drinks per week. previous research has demonstrated that the ddq is highly correlated with other self-report measures of alcohol consumption (kivlahan et al., 1990). similarly, the ddq has good test-retest validity (neighbors et al., 2006) and criterion validity (neighbors et al., 2004). if a participant had a total score of 1 or greater on the ddq, indicated no past month cannabis use, and did not indicate past month simultaneous use of alcohol and cannabis, they were coded into the “alcohol-only users” group. simultaneous use of alcohol and cannabis. simultaneous alcohol and cannabis use were assessed with a single binary item from the drug use questionnaire (duq). the duq is a selfreport questionnaire that assesses past month illicit drug use and prescription drug use (hien and first, 1991). the single item asked participants, “have you used any of the following drugs with alcohol in the past month? marijuana (i.e., weed, pot, not including synthetic or analog forms/plant additives etc.).” participants responded with either “yes” or “no”, and responses were dichotomized to 1 = any simultaneous use in the past month, 2 = no simultaneous use in the past month. previous research has assessed simultaneous use with a similar item (patrick et al., 2018). the duq was also used to assess days of monthly cannabis use with the question “how many days in the past month have you used the following drugs? marijuana (i.e., weed, pot, not including synthetic or analog forms/plant additives etc.). responses were 0-30 for days of monthly cannabis use. participants who responded “yes” to using alcohol with cannabis were coded into the “simultaneous users” group, regardless of their answer on the ddq or the duq for days of monthly cannabis use. no substance use. the abstainer group was classified by individuals who reported “0” on the ddq and those who reported no simultaneous use on the single measure of simultaneous use from the duq. participants who scored a 0 on the ddq, endorsed no past month cannabis use, and had a response of “no” for simultaneous use were coded into the “abstainers” group. data analysis plan cannabis, a publication of the research society on marijuana 39 analyses were conducted using spss version 26.0. all variables were checked for outliers, skewness, and kurtosis (tabachnick et al., 2019). no outliers were identified. ders and all of the ders subscales (except for goals) were positively skewed. thus, we performed a square-root transformation for the ders total score (skew = 1.45) and each skewed subscale; (non-acceptance (skew = 1.79), impulsivity (skew = 4.30), awareness (skew = 0.38), strategies (skew = 2.10), and clarity (skew = 1.79)) to correct for the skew. after this transformation, the impulse control difficulties subscale was still positively skewed, so a log transformation was then performed to correct the skew further on the impulse control difficulties subscale (skew = 0.61). the data presented in the results represents the backtransformed values to help with interpretation of scores. descriptive characteristics of the overall sample were conducted including demographic information as well as means and standard deviations of drinks per week for alcohol-only users. means and standard deviations for drinks per week and days of monthly cannabis use were calculated for simultaneous users. the primary study analysis examined whether there was a statistically significant difference between substance use groups on levels of emotion dysregulation. a one-way anova was conducted to examine differences in emotion dysregulation between abstainers, alcohol-only users, and simultaneous users. a bonferroni post hoc analysis was run due to the overall model being significant. additionally, an exploratory series of anovas with bonferroni post-hoc tests were run to examine the differences between substance use groups on the emotion dysregulation subscales: 1. nonacceptance of emotional responses, 2. difficulty engaging in goal-directed behavior, 3. impulse control difficulties, 4. lack of emotional awareness, 5. limited access to emotion regulation strategies, and 6. lack of emotional clarity. results descriptive statistics for simultaneous use of alcohol and cannabis, 16.45% of the sample (n = 77) reported using both substances simultaneously in the past month, while 22.22% of the sample (n = 104) reported using alcohol only in the past month, and 61.32% of the sample (n = 287) abstained from alcohol and cannabis use in the past month. alcohol-only users reported an average of 8.01 (sd = 7.74) drinks per week, while simultaneous users reported an average of 11.29 (sd = 13.93) drinks per week and an average of 11.01 (sd = 9.67) days of monthly cannabis use. these results have been displayed in table 1. analysis of variance a one-way anova indicated there was a statistically significant difference in overall emotion dysregulation between simultaneous users, alcohol-only users, and abstainers (f (2, 465) = 5.63, p = .004, ηp2 = .024). a bonferroni post hoc analysis indicated the mean score on overall emotion dysregulation was greater for simultaneous users (m = 98.27, sd = 26.07) compared to abstainers (m = 88.82, sd = 23.48, p = .006) and alcohol-only users (m = 87.42, sd = 22.75, p = .007). for the ders subscales, a series of anovas were conducted to examine if there were differences within the facets of emotion dysregulation among abstainers, alcohol-only users, and simultaneous users. results revealed that impulse control difficulties were significantly different for simultaneous users than alcohol-only users or abstainers (f (2, 465) = 5.95, p = .003, ηp2 = .025). bonferroni post hoc analyses indicated that the mean score on the impulse control difficulties subscale was significantly greater among simultaneous users (m = 14.34, sd = 5.67) compared to alcohol-only users (m = 11.87, sd = 4.44), and abstainers (m = 12.39, sd = 5.05). additionally, lack of emotion regulation strategies was significantly different for simultaneous users than alcohol-only users or abstainers (f (2, 465) = 5.46, p = .005, ηp2 = .023). bonferroni post hoc analyses indicated that the mean score on the limited access to emotion regulation strategies subscale were significantly greater among simultaneous users (m = 21.73, sd = 8.29) compared to alcohol-only users (m = 18.31, sd = 7.03), and abstainers (m = 18.82, sd = 7.44). further, non-acceptance of emotional responses was significantly different for simultaneous users and alcohol-only users (f (2, 465) = 4.39, p = .013, emotion dysregulation and substance use patterns 40 ηp2 = .019). bonferroni post hoc analyses indicated that the mean score on non-acceptance of emotional responses were significantly greater among simultaneous users (m = 16.56, sd = 6.41) than alcohol-only users (m = 13.99, sd = 5.05), but not abstainers (m = 14.92, sd = 5.87). effect sizes are displayed in table 1. there were no other significant differences between abstainers, table 1. descriptive statistics for demographics and outcome variables total sample (n = 468) abstainers (n = 287) alcohol-only users (n = 104) simultaneous users (n = 77) χ2 sig. gender χ2 (2) = 2.84 p = .24 male n = 99 (21.2%) n = 68 (23.8%) n = 18 (17.3%) n = 13 (17.1%) female n = 367 (78.4%) n = 218 (76.2%) n = 86 (82.7%) n = 63 (82.9%) ethnicity χ2 (2) = 7.80 p = .02 white n = 364 (77.8%) n = 213 (74.2%) n = 91 (87.5%) n = 60 (77.9%) non-white n = 104 (22.2%) n = 74 (25.8%) n = 13 (12.5%) n = 17 (22.1%) sexual orientation χ2 (2) = 5.27 p = .07 heterosexual n = 392 (83.7%) n = 243 (84.7%) n = 91 (87.5%) n = 58 (75.3%) nonheterosexual n = 76 (16.2%) n = 44 (15.0%) n = 13 (12.5%) n = 19 (24.7%) m (sd) m (sd) m (sd) m (sd) statistical test f sig. p ηp2 age 19.38 (3.07) 19.17 (2.63) 19.95 (4.18) 19.42 (2.75) total drinks per week 3.63 (8.16) 0.00 (0.00) 8.01 (7.74) 11.30 (13.93) daily cannabis use 1.82 (5.65) 0.00 (0.00) 0.00 (0.00) 11.01 (9.67) ders total 90.07 (24.00) 89.62 (23.81) 89.37 (22.13) 98.27 (26.07) 5.63 .004* .024 ders nonacceptance 14.98 (5.84) 14.92 (5.87) 13.99 (5.05) 16.56 (6.41) 4.39 .013* .019 ders goals 16.07 (4.91) 15.75 (4.87) 16.13 (4.73) 17.21 (5.17) 2.69 .069 .011 ders impulse 12.59 (5.09) 12.39 (5.05) 11.87 (4.44) 14.34 (5.67) 5.95 .003* .025 ders awareness 14.99 (4.98) 14.90 (4.77) 14.87 (4.94) 15.45 (5.75) .410 .664 .002 ders strategies 19.19 (7.57) 18.82 (7.44) 18.31 (7.03) 21.73 (8.29) 5.46 .005* .023 ders clarity 12.24 (3.75) 12.04 (3.78) 12.25 (3.36) 12.99 (4.07) 1.95 .143 .008 note. * p <.05 with bonferroni correction; ders = difficulties in emotion regulation scale; “non-acceptance” is the “non-acceptance of emotional responses” subscale for the difficulties in emotion regulation scale, “goals” is the “difficulty engaging in goal-directed behavior” subscale for the difficulties in emotion regulation scale, “impulse” is the “impulse control difficulties” subscale for the difficulties in emotion regulation scale, “awareness” is the “lack of emotional awareness” subscale for the difficulties in emotion regulation scale, “strategies” is the “limited access to emotion regulation strategies” subscale for the difficulties in emotion regulation scale, and “clarity” is the “lack of emotional clarity” subscale for the difficulties in emotion regulation scale. alcohol-only users, and simultaneous users on the other subscales of emotion dysregulation. discussion alcohol and cannabis are the most widely used substances among college students, and simultaneous use of these substances increases the risk for harmful consequences. the purpose of the present study was to examine differences in overall emotion dysregulation and facets of cannabis, a publication of the research society on marijuana 41 emotion dysregulation among individuals who only used alcohol in the past month (alcohol-only users), those who abstained from alcohol and cannabis in the past month (abstainers), and those who have used alcohol and cannabis simultaneously in the past month (simultaneous users). our results suggest that simultaneous users endorsed significantly greater overall emotion dysregulation than alcohol-only users and abstainers. in addition, simultaneous users reported significantly greater impulse control difficulties, non-acceptance of emotional responses, and limited access to emotion regulation strategies than alcohol-only users and abstainers. based on the findings from the weiss and colleagues’ (2022) meta-analysis showing polysubstance users may experience more emotion dysregulation, we hypothesized that simultaneous users would report more emotion dysregulation than alcohol-only users and abstainers. this hypothesis was supported and is consistent with previous research examining emotion dysregulation with concurrent use of alcohol and cannabis (lucke et al., 2021). however, further research is needed to better understand exactly why simultaneous use of alcohol and cannabis is associated with greater emotion dysregulation. though speculative, it has been theorized that individuals experiencing greater emotion regulation difficulties may use multiple substances to help regulate their emotional experiences. individuals who have difficulty regulating their emotions may experience heightened psychological or interpersonal distress and may use multiple substances in an attempt to manage this distress (weiss et al., 2022). additionally, it is also possible that the differences in emotion dysregulation scores found in the present sample were a result of a heavier drinking pattern among those in the simultaneous use group. as shown in table 1, participants in the alcohol-only group reported and average of 8.01 drinks per week (sd = 7.74) versus 11.30 drinks per week (sd = 13.93) in the simultaneous use group, suggesting this group displays a different pattern of alcohol consumption than the other two groups. though it is not possible to test this research question with the current data, it is possible that this group’s pattern of heavier drinking is contributing to the differences in emotion dysregulation rather than their simultaneous use of alcohol and cannabis. this is an important research question that should be tested in future work on emotion dysregulation and simultaneous use of alcohol and cannabis. given the prevalence of co-use of alcohol and cannabis within the college student population, future research should further examine the underlying mechanisms connecting emotion dysregulation with simultaneous use of alcohol and cannabis. understanding these mechanisms could aid in developing prevention and intervention techniques aimed at teaching emotion regulation skills and healthy coping mechanisms to college students who use multiple substances. interventions that specifically target emotion regulation difficulties have been shown to be beneficial in treatment of a variety of mental health disorders, including substance use disorders (gratz et al., 2015). a recent metaanalysis exploring interventions targeting emotion regulation among individuals with depression and anxiety showed that both a reduction in disengagement emotion regulation skills (avoidance, suppression, and rumination) and an increase in engagement emotion regulation skills (acceptance, cognitive reappraisal, and problem solving) reduced depression and anxiety (daros et al., 2021). it is possible that teaching emotion regulation skills to college-aged individuals who engage in simultaneous use of substances may improve emotion dysregulation and impact substance use outcomes. additionally, previous work has shown that teaching dialectical behavior therapy (dbt) skills can lead to improved alcohol use outcomes among individuals with substance use disorders (cavicchioli et al., 2019). research is needed to determine whether teaching dbt skills to college student substance users would result in improved substance use outcomes in this population. brief interventions incorporating emotion regulation skills may be especially useful for college students who are using alcohol and cannabis simultaneously. moreover, prevention efforts using psychoeducation with college students on the connection between emotion dysregulation and consequences of simultaneous use may be beneficial. emotion dysregulation and substance use patterns 42 in the current study, simultaneous users reported greater impulse control difficulties than alcohol-only users or abstainers. this finding is consistent with previous research demonstrating that co-use of alcohol and cannabis is linked with impulse control difficulties (daros et al., 2022; trull et al., 2016; waddell et al., 2021). using ecological momentary assessment to measure impulsivity, affect, and substance use over the course of a month, trull and colleagues (2016) found both alcohol and cannabis were independently associated with increased impulsivity scores when individuals used figure 1. bar graph of mean scores for the difficulties in emotion regulation scale note. * p < .05; error bars are standard deviations. both alcohol and cannabis on the same day. additionally, previous research has shown that individuals with higher levels of impulsivity may be drinking more on days when they co-use alcohol and cannabis, relative to those lower in impulsivity who drink less (waddell et al., 2021). furthermore, daros and colleagues (2022) explored the moderating role of several components of impulsivity on the associations of cannabis and alcohol use and found that negative negative urgency and delay discounting factors of impulsivity play a role in co-use of alcohol and cannabis. the authors suggest that for individuals scoring high on negative urgency, they may be combining large amounts of alcohol and cannabis to experience relief from negative emotional experiences. thus, it is evident that impulse control difficulties may contribute to simultaneous use of alcohol and cannabis and interventions targeting impulsivity and emotion regulation may be beneficial to college students engaging in simultaneous use of alcohol and cannabis. another facet of emotion dysregulation related to substance use may be the non-acceptance of emotional responses, meaning that simultaneous users may be having difficulty accepting their emotions compared to alcohol-only users. this finding is consistent with previous research demonstrating that non-acceptance of emotional responses was associated with alcohol-related consequences (dvorak et al., 2014) and copingoriented cannabis use (bonn-miller et al., 2008). further, weiss and colleagues (2022) demonstrated medium-effect sizes between nonacceptance of emotional responses to use of multiple substances. thus, this study extends weiss and colleagues (2022) to demonstrate how the emotional dysregulation subscales differ between past month simultaneous users, alcohol-only users, and abstainers. previous research has also found an association between impulse control difficulties and m = 88.82 m = 87.42 m = 98.27,*p < .05 0 20 40 60 80 100 120 140 m ea n sc or es o n th e d iff ic ul tie s i n em ot io n r eg ul at io n sc al e abstainers alcohol-users simultaneous users cannabis, a publication of the research society on marijuana 43 the non-acceptance of emotional responses predicting problematic alcohol use, suggesting that these two facets of emotion dysregulation may be interrelated (miller and racine, 2022). at least one previous intervention has been developed to target impulse control difficulties among substance users. hall and colleagues (2021) examined the efficacy of an intervention for emotion regulation and impulse control (eric) in a sample of seventy-nine young adults with substance use comorbidities. following the 12-week intervention, there were significant reductions in severe emotion dysregulation and figure 2. bar graph of mean scores of subscales for the difficulties in emotion regulation scale note. * p <.05 with bonferroni correction; error bars are standard deviations; “nonacceptance” is the “nonacceptance of emotional responses” subscale for the difficulties in emotion regulation scale, “goals” is the “difficulty engaging in goal-directed behavior” subscale for the difficulties in emotion regulation scale, “impulse” is the “impulse control difficulties” subscale for the difficulties in emotion regulation scale, “awareness” is the “lack of emotional awareness” subscale for the difficulties in emotion regulation scale, “strategies” is the “limited access to emotion regulation strategies” subscale for the difficulties in emotion regulation scale, and “clarity” is the “lack of emotional clarity” subscale for the difficulties in emotion regulation scale. psychological distress symptoms improved. future research is needed to determine if this intervention results in reductions in substance use. additionally, an intervention targeting impulsive personality traits in high school cannabis users showed success in delaying cannabis use onset among youth high in sensation seeking (mahu et al., 2015). however, no previous interventions have directly targeted impulse control difficulties and measured whether improvements in impulse control result in decreased simultaneous use among college students. development and testing of a brief intervention designed to improve impulse related difficulties, increase acceptance of emotions, and reduce substance use in this population would be worthwhile in future research. in addition to greater impulse control difficulties, the present study has shown that simultaneous users may be experiencing greater problems accessing effective emotion regulation skills compared to abstainers and alcohol-only users. although this finding has not been demonstrated in previous research focusing on simultaneous use of alcohol and cannabis, previous research has speculated that people who may have limited access to emotion regulation strategies may be using multiple substances to modulate emotional experiences (weiss et al., 2022). previous research has shown that among individuals with alcohol use disorder, limited access to emotion regulation strategies mediated the association of positive urgency and binge drinking (pepe et al., 2022). this suggests that m = 14.92 m = 12.39 m = 18.82 m = 13.99 m = 11.87 m = 18.32m = 16.56, *p <.05 m = 14.34, *p <.05 m = 21.73, *p < .05 0 5 10 15 20 25 30 35 non acc ep tan ce goa ls im pu lse aware ne ss stra teg ies clar itysu bs ca le s co re s on th e d iff ic ul tie s in em ot io n re gu la tio n sc al e abstainers alcohol-users simultaneous users emotion dysregulation and substance use patterns 44 among individuals with alcohol use disorder, both impulsive traits and lack of access to emotion regulation strategies may be risk factors for binge drinking. further, pepping and colleagues (2014) found a negative indirect effect of mindfulness and psychosocial distress through lack of access to emotion regulation strategies. the authors suggest that individuals low in mindfulness have trouble adaptively reacting to distressing emotions, which impacts their psychosocial functioning. although this study did not examine substance use, individuals who use alcohol and lack to effective regulation strategies may engage in substance use to help control their emotions. this is consistent with previous research that found that negative affect intensity had an indirect effect on drinking to cope through individuals having limited access to emotion regulation strategies (veilleux et al., 2014). this suggests that learning more emotion-regulation strategies may be beneficial for those who are prone to use substances in response to emotion dysregulation. future research could examine whether teaching mindfulness-based emotion regulation strategies to simultaneous substance users would lead to improvements in access to effective emotion regulation strategies and whether such improvements would lead to decreases in incidences of simultaneous use of alcohol and cannabis. limitations the results of the current study should be considered in light of its limitations. the limitations include that the sample was limited to college students (the majority of whom were white and female), which limits generalizability of these findings to the college student population as a whole. future research on this topic with a more diverse sample is warranted. additionally, all data were collected via self-report and may have been subject to individual biases. however, previous research within this population has shown that self-report drinking behaviors are reliable, due to the nature of the information remaining anonymous (del boca & darkes, 2003). moreover, because this was a crosssectional study, causal relations among variables cannot be observed. longitudinal research examining individual change in emotion regulation over time and substance use behaviors is necessary to determine whether emotion dysregulation and impulsivity leads to increased simultaneous use or whether increased substance use leads to increased emotion dysregulation and impulsivity. additionally, the present study used one-way anova analyses to address differences in emotion dysregulation across differing groups of substance users and provides a surface-level examination of this relationship. an unsupervised machine learning approach could be employed in future research to develop profiles of the ders and examine how these profiles relate to alcohol use and simultaneous use of alcohol and cannabis. furthermore, our simultaneous use variable focused generally on if the individual used alcohol and cannabis together in the past month. although past research has used a similar assessment of simultaneous use (patrick et al., 2018), using a binary outcome limits our ability to understand frequency and severity of simultaneous use or consequences associated with simultaneous use. future research should examine how emotion dysregulation relates to severity, frequency, and consequences associated with simultaneous use of alcohol and cannabis to fully understand how emotion dysregulation may be contributing to simultaneous use of alcohol and cannabis. ecological momentary assessment (ema) could also be used to examine daily or moment-to-moment relations between emotion dysregulation and frequency, quantity, and consequences of simultaneous use of alcohol and cannabis. finally, due to the relatively small number of students in our sample endorsing use of cannabis-only in the past month (without pastmonth use of alcohol or simultaneous use; n = 30), the current study could not examine differences in emotion dysregulation for those who used only cannabis in the past month. it would be interesting in future research to see if this group differs on overall emotion dysregulation and emotion dysregulation facets when compared to alcohol-only users, simultaneous users, and abstainers. strengths and implications despite these limitations, this study has significant public health relevance as it identifies emotion dysregulation and facets of emotion dysregulation as potential contributors to the simultaneous use of alcohol and cannabis in a large sample of college students. the current study has supported that difficulties regulating emotions, and cannabis, a publication of the research society on marijuana 45 more specifically, deficits in impulse control, acceptance of emotions, and emotion regulation strategies, were linked to simultaneous use of alcohol and cannabis. thus, it may be helpful to emphasize these constructs when choosing therapy, intervention, and educational approaches for college students experiencing problems stemming from simultaneous use of alcohol and cannabis. therapeutic, intervention, and educational efforts aimed at improving overall emotion dysregulation, impulse control, and acceptance of emotions, as well as teaching strategies for coping with strong emotions, may be especially helpful for this population. conclusions in conclusion, the present findings complement and extend previous research exploring the link between emotion dysregulation and simultaneous use of alcohol and cannabis. specifically, the present findings suggest that individuals who are simultaneously using alcohol and cannabis have more difficulties regulating their emotions. particularly, non-acceptance of emotional responses, impulse control difficulties, and limited access to emotion regulation skills may be especially relevant among college students who use alcohol and cannabis simultaneously. future work should directly examine whether increasing access to emotion 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184–193. https://doi.org/10.1007/s40429-017-0149-8 funding and acknowledgements: this research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. the authors declare no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i3a2_authors_finalrev research article 11 ved abstract objectives. cannabis policy evaluations commonly assume equal policy exposure across a state’s population using date of implementation as the key independent variable. this study aimed to explore policy knowledge as another measure of exposure and describe the sociodemographic, cognitive, and behavioral correlates of cannabis policy knowledge in young adults in vermont. methods. data are from the pace vermont study (spring 2019), an online cohort study of vermonters (12-25). bivariate and multivariable analyses estimated prevalence ratios (pr) for correlations between knowledge of vermont’s cannabis policy (allowed possession for adults 21 and older) and sociodemographics, cannabis use, and harm perceptions in 1,037 young adults (18-25). results. overall, 60.1% of participants correctly described the state’s cannabis policy. being younger, hispanic, non-white race, and less educated were inversely correlated with policy knowledge. ever (pr=1.37; 95% ci 1.16-1.63) and past-30-day cannabis use (pr=1.27; 95% ci 1.12-1.45) were positively correlated with policy knowledge. policy knowledge was more prevalent among young adults who perceived slight risk of harm from weekly cannabis use (vs. no risk; apr=1.28; 95% ci 1.11-1.48) or agreed that regular cannabis use early in life can negatively affect attention (vs. disagree; apr=1.55; 95% ci 1.22-1.97). conclusion. findings suggest that 40% of vermont young adults in the study were unaware of current state cannabis policy and that policy knowledge was lower in younger, less educated, hispanic, and non-white young adults. future research should explore using a measure of policy knowledge as an exposure or moderator variable to better quantify the effects of changes in cannabis legal status on perceptions and use in young people. key words: = marijuana; legalization; cannabis; marijuana policy; cannabis policy; policy exposure; young adults in 2018, vermont became the first state to legalize possession of cannabis for adults aged 21+ through the legislative process distinguishing vermont from prior states that legalized cannabis through ballot initiatives (zezima, 2018). as of july 1, 2018, individuals aged 21+ could legally possess up to an ounce of cannabis, as well as two mature and four immature plants per household, julia c. west1,2, catherine peasley-miklus1, elias m. klemperer1,2, jeffrey s. priest3, megan trutor4, chelsea carman4, maria roemhildt5, jeffrey trites5, andrea c. villanti1 1vermont center on behavior and health, department of psychiatry, university of vermont larner college of medicine 2department of psychological science, university of vermont 3biomedical statistics research core, university of vermont 4alcohol & drug abuse programs, vermont department of health 5 health surveillance, vermont department of health cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.002 young adults’ knowledge of state cannabis policy: implications for studying the effects of legalization in vermont corresponding author: julia c. west, ma, vermont center on behavior and health, department of psychiatry, university of vermont larner college of medicine; department of psychological science, university of vermont. 1 s. prospect st., uhc old hall 3, ms 482, burlington, vt, 05041. email: julia.west@uvm.edu young adults’ knowledge of state cannabis policy 12 and the state eliminated penalties for limited possession by those aged 21+ (general assembly of the state of vermont, 2018). vermont legalized medical cannabis and decriminalized possession prior to the 2018 policy changes (general assembly of the state of vermont, 2004, 2013). in 2020, vermont became the eleventh state to legalize a taxed and regulated retail cannabis market and the second through the legislature (national conference of state legislatures, 2021a)—the state plans to open the market in 2022 (general assembly of the state of vermont, 2021). as of december 2021, other states— connecticut, new york, virginia, and new mexico—have legalized a regulated retail cannabis market through state legislation (national conference of state legislatures, 2021a). vermont’s 2018 cannabis policy mirrors cannabis policies in washington, dc at the time, and resembles legislation in montana, maine, new mexico, new york, virginia, and connecticut during transitions to a regulated market (commonwealth of virginia; "connecticut general assembly," 2021; lahut & lee, 2021; lopez, 2020; maine state legislature, 2021; metropolitan police department, 2014; "montana marijuana regulation and taxation act," 2020; national conference of state legislatures, 2021a; victor, 2021). previous studies (brooks-russell et al., 2019; cerda et al., 2017; fleming et al., 2016; paschall & grube, 2020) have identified cannabis harm perceptions and use as key outcomes for evaluating the impact of changes to cannabis legal status on youth and young adults. data from national surveillance have shown vermont young adults report lower perceptions of harm from cannabis use and higher average annual cannabis initiation rates compared to the u.s. overall (samhsa, 2019). this is consistent with national cross-sectional data suggesting that higher cannabis harm perceptions protect against cannabis use (terry-mcelrath et al., 2017). young adults in particular may be impacted by cannabis policy changes given cannabis is increasingly the first substance tried in adolescence (keyes et al., 2019) and the high prevalence of alcohol and drug use among this age group (dawson et al., 2004; grant et al., 2004; pearson et al., 2012; rath et al., 2012). since substance use behaviors developed in young adulthood may persist throughout life (arnett, 2005), substance use prevention and early intervention are beneficial to public health. additionally, data from a national sample of young adults suggest that changes to cannabis policies may affect behavior change, with 9% of current non-users of cannabis reporting that they would use cannabis if legalized and 14% of current users reporting they would use cannabis more often after legalization (cohn et al., 2017). results from studies using national survey on drug use and health data showed that young adults (aged 18–25) from states with medical cannabis had lower cannabis risk perceptions compared to young adults in states without medical cannabis policies (schuermeyer et al., 2014; wen et al., 2019). while many aspects of cannabis legal status may impact individual beliefs and behavior (e.g., retail market, social norms; (carliner et al., 2017), these findings highlight that policy implementation may impact use behaviors and individual attitudes and beliefs about cannabis. cannabis policies vary by state. these variations may include how the policy is enacted (i.e., ballot initiative vs. state legislative process) and specific components of the law (e.g., legal to buy or sell, number of plants legal to own). a systematic review of the effect of cannabis legal status on individual beliefs highlights that these differences, including knowledge of the policy and its specific components, may impact individual beliefs about cannabis (carliner et al., 2017). given the relationship between cannabis policy knowledge and attitudes and beliefs about cannabis (carliner et al., 2017), state measures of policy awareness could inform state public health communication efforts. colorado’s responsibility grows here campaign, for example, focuses on responsible cannabis consumption and includes messages targeting understanding of the state’s cannabis policy (colorado department of public health and environment, 2021). outcome evaluations may also benefit from accounting for policy knowledge in their analyses. existing evaluations of changes in cannabis legal status assess policy implementation based on the year in which the policy was implemented (johnson & guttmannova, 2019), which assumes equal policy awareness and exposure across the population. however, policy awareness may differ based on sociodemographic characteristics or experience with cannabis, which would suggest the need for more nuanced evaluations of policy cannabis, a publication of the research society on marijuana 13 implementation that account for differences between population subgroups. the goal of this study was twofold: first, to explore policy knowledge as an alternate measure of policy exposure and second, to describe the prevalence and correlates of knowledge of vermont’s cannabis policy in young adults, the age group with the highest past-month cannabis use in the state (samhsa, 2019). methods the policy and communication evaluation (pace) vermont study is an ongoing online cohort study conducted in vermont youth and young adults aged 12-25 designed to understand the impact of state-level policies and communication campaigns on substance use beliefs and behaviors in young vermonters. eligible participants were vermont residents aged 12 to 25 years who were willing to complete three 10to 15-minute web-based surveys over a 6-month period. recruitment was conducted by hark, a vermont-based digital design and marketing firm (hark inc), over a 10-week period (march 26-june 4, 2019). participants were recruited via the following three main mechanisms: 1) web-based recruitment including both paid and unpaid advertising, 2) community recruitment through partner organizations, and 3) participant referrals via a personalized link. further details on study methods are available elsewhere (villanti et al., 2020). participants represented each of the 14 counties in the state, with the distribution by county generally reflecting 2018 population estimates for vermont youth and young adults and past 30-day substance use estimates in the pace vermont sample were similar to those estimated in the national survey on drug use and health (vermont department of health, 2019; villanti et al., 2020). the study was approved by the university of vermont and vermont department of health’s institutional review boards and received a certificate of confidentiality from the national institutes of health. data for the current analyses were limited to the 1,037 young adults aged 18-25 who completed wave 1 (march 26-june 4, 2019) of the pace vermont study. the current study focuses on young adults—the age group with the highest prevalence of past 30-day cannabis use in the vermont (samhsa, 2019). measures knowledge of state cannabis policy. the term "marijuana” was used throughout the survey rather than “cannabis” to reflect language used by large national and state-level surveys (e.g., vermont youth risk behavior survey, monitoring the future, national survey on drug use and health; jones et al., 2020; miech et al., 2020; samhsa, 2019; schulenberg et al., 2020). to assess knowledge of cannabis law, all participants were asked, “marijuana law recently changed in vermont. which of the following best describe vermont's new marijuana law?” with the following response options: 1) “legal for anyone to use,” 2) “legal for people 21+ to use,” 3) ”may use in public,” 4) “allowed for medical use,” 5) “may own up to two plants,” and 6) “legal to sell.” respondents were asked to select all applicable choices. all responses to this item were categorized as either “correct marijuana policy” or “incorrect marijuana policy knowledge.” participants were incorrect if they selected “legal to sell,” “may use in public,” or “legal for anyone to use” as these were incorrect statements about key components of the law. young adults who did not select any of the incorrect responses were considered to have correct knowledge if they 1) selected “legal for people 21+ to use” and “may own up to two plants,” or 2) selected “allowed for medical use,” “legal for people 21+ to use,” and “may own up to two plants.” correct responses were considered with or without inclusion of “allowed for medical use” as medical use has been legal in vermont since 2004 but was not included in the 2018 legal status change (national conference of state legislatures, 2021a, 2021b); therefore, some participants may not have selected “allowed for medical use” despite it being part of current cannabis law. cannabis beliefs. cannabis harm perceptions were assessed with the item “how much do you think people risk harming themselves (physically or in other ways) if they use marijuana weekly?” response choices were “great risk,” “moderate risk,” “slight risk,” and “no risk.” participants were also asked to identify the substance in cannabis that makes a person high, with response options “cbd,” “thc,” “neither,” “both,” or “don’t know.” responses were collapsed to three categories: 1) correctly identified thc only, 2) did not identify thc only (i.e., “cbd,” neither,” young adults’ knowledge of state cannabis policy 14 “both”), and 3) don’t know. beliefs about the effects of cannabis use were assessed by agreement (“strongly agree,” “agree,” “disagree,” “strongly disagree,” or “don’t know”) with the following statements developed from evidence presented in a government report by the vermont department of health (vermont department of health, 2016): a) “regular marijuana use during early years of life can negatively affect attention and memory in adulthood;” b) “teens who use marijuana weekly or more often have twice the risk of depression or anxiety;” c) “approximately 1 in 6 teens who start using marijuana before age 14 develop addiction;” and d) “teens who use marijuana have lower academic performance and worse job prospects—and those who continue using marijuana regularly show a decrease in iq 20 years later.” responses were collapsed into three categories: agree (“strongly agree” and “agree”), disagree (“strongly disagree” and “disagree”), and don’t know. cannabis use. respondents received the following statement before cannabis use survey items “the next questions are about marijuana use. marijuana also is called pot, weed, or cannabis. marijuana is usually smoked, either in cigarettes, called joints, or in a pipe. it is sometimes cooked in food or used in concentrates. hashish is a form of marijuana that is also called ‘hash.’ one form of hashish is hash oil. these questions do not relate to the use of cannabidiol (cbd) products.” ever use of cannabis was measured with “have you ever, even once, used marijuana or hashish?” respondents chose from the following response options “yes,” “no,” and “i don’t know” with ever use defined as binary with ever use=1 and never use and “don’t know”=0. ever users were asked “how long has it been since you last used marijuana or hashish?” with current use collapsed into a dichotomous variable 1=use in the past 30 days, and 0=no use in the past 30 days. covariates. sociodemographic measures included age (grouped as 18-20 years and 21-25 years), sex assigned at birth, race, ethnicity, and education completed. subjective financial status was included as a proxy for socioeconomic status in young adulthood (williams et al., 2017). respondents were asked “considering your own income and the income from any other people who help you, how would you describe your overall personal financial situation? would you say you:” with the following response options: 1) “live comfortably,” 2) “meet needs with a little left,” 3) “just meet basic expenses,” and 4) “don’t meet basic expenses.” data analysis survey weights were developed post-hoc from population estimates of females and males between the ages of 12 and 25 (year by year) residing in each of vermont’s 14 counties in 2017 (the most current data available at the time of analysis) to correct for higher response by females and those residing in the most populous county (chittenden county). all analyses were conducted using survey (svy) procedures in stata/se statistical software version 16 (statacorp lp) to account for survey weighting. missing data (range of item-level missingness: 0%-2.8%) were handled through listwise deletion. bivariate analyses examined differences in sociodemographics and ever and past-30-day cannabis use stratified by cannabis policy knowledge (correct vs. incorrect knowledge). given the high prevalence of cannabis policy knowledge, multivariable modified poisson regression models (zou, 2004) were used to estimate the association between cannabis policy knowledge and cannabis harm perceptions, and knowledge of the psychoactive substance in cannabis, adjusted for age, sex, race and ethnicity, subjective financial status, and past-30-day cannabis use. results the weighted sample of 1,037 young adults was primarily non-hispanic white (84.3%) and approximately half were female (52.1%) with a mean age of 21.2 (sd=2.2) years (table 1). when asked about their subjective financial status, most young adults in the sample met their needs with a little left or lived comfortably (69.9%). in addition, most had at least some college education (69.7%). most of the sample reported ever cannabis use (70.6%), with 41.3% reporting past 30-day cannabis use. sixty percent of respondents reported correct knowledge of all aspects of vermont’s cannabis policy (table 2). when asked, “marijuana law recently changed in vermont. which of the following best describe vermont's new marijuana cannabis, a publication of the research society on marijuana 15 law?” most young adults correctly indicated that cannabis was legal for people 21+ to use (91.5%) and for medical use (71.8%). most participants accurately indicated that cannabis was not legal for anyone to use (98.3%), not allowed for public use (93.9%), and not legal to sell (94.8%). most young adults correctly stated that the state’s cannabis policy allowed the ownership of up to two plants (71.6%). a small proportion of young adults with correct knowledge responded “no” to whether cannabis was allowed for medical use (12.4%). table 1. sociodemographic correlates of state cannabis policy knowledge among vermont young adults, pace vermont study, spring 2019 incorrect knowledge (n = 400; 39.9%) correct knowledge (n = 637; 60.1%) total (n = 1,037; 100%) weighted % (n) weighted % (n) weighted % (n) pr (95%ci) young adults age group 18-20 53.7 (191) 37.5 (234) 44.0 (425) 0.76 (0.66, 0.88) 21-25 46.3 (209) 62.5 (403) 56.0 (612) ref. sex assigned at birth female 47.2 (285) 55.3 (496) 52.1 (781) ref. male 52.8 (114) 44.7 (141) 47.9 (255) 0.88 (0.77, 1.01) race/ethnicity non-hispanic white 74.0 (312) 91.1 (580) 84.3 (892) ref. non-hispanic asian, black, other*/multiple 13.7 (46) 6.7 (44) 9.5 (90) 0.65 (0.47, 0.90) hispanic 12.3 (42) 2.3 (13) 6.3 (55) 0.34 (0.20, 0.58) education completed less than high school 9.8 (41) 6.2 (45) 7.6 (86) 0.79 (0.60, 1.05) high school/ged 31.0 (97) 17.1 (99) 22.7 (196) 0.74 (0.59, 0.92) some college/aa 44.5 (175) 46.8 (284) 45.9 (459) ref. (0.00, 0.00) ba or more 14.6 (87) 29.9 (209) 23.8 (296) 1.23 (1.09, 1.39) subjective financial status don't meet basic expenses 6.7 (22) 5.6 (29) 6.0 (51) 0.89 (0.64, 1.24) just meet basic expenses 22.8 (100) 24.9 (156) 24.1 (256) 0.99 (0.85, 1.16) meet basic expenses with a little left 35.1 (147) 38.9 (273) 37.4 (420) ref. live comfortably 35.4 (129) 30.6 (179) 32.5 (308) 0.90 (0.77, 1.06) ever marijuana use yes 61.3 (254) 76.7 (488) 70.6 (742) 1.37 (1.16, 1.63) no/don't know 39.9 (146) 23.3 (149) 29.4 (295) ref. past 30-day marijuana use yes 32.3 (127) 47.2 (285) 41.3 (412) 1.27 (1.12, 1.45) no 67.7 (271) 52.8 (349) 58.7 (620) ref. note. abbreviations: pr, prevalence ratio. all findings account for survey weights. number of observations missing data on the following variables: sex assigned at birth (n = 1); subjective financial status (n = 2); past 30-day marijuana use (n = 5). *“other” race categorized by respondents who selected one of the following races: american indian or alaska native, native hawaiian or other pacific islander. number of observations responding “don’t know” to ever marijuana use: n = 5. young adults’ knowledge of state cannabis policy 16 table 2. distribution of responses to a measure of state cannabis policy knowledge incorrect knowledge (n = 400; 39.9%) correct knowledge (n = 637; 60.1%) total (n = 1,037; 100.0%) weighted % (n) weighted % (n) weighted % (n) young adults legal for people 21+ to use no 21.2 (90) 0.0 (0) 8.5 (90) yes 78.8 (310) 100.0 (637) 91.5 (947) allowed for medical use no 52.0 (197) 12.4 (75) 28.2 (272) yes 48.0 (203) 87.7 (562) 71.8 (765) may own up to two plants no 71.1 (260) 0.0 (0) 28.4 (260) yes 28.9 (140) 100.0 (637) 71.6 (777) legal for anyone to use no 95.6 (382) 100.0 (637) 98.3 (1019) yes 4.4 (18) 0.0 (0) 1.7 (18) may use in public no 84.8 (330) 100.0 (637) 93.9 (967) yes 15.2 (70) 0.0 (0) 6.1 (70) legal to sell no 87.0 (337) 100.0 (637) 94.8 (974) yes 13.0 (63) 0.0 (0) 5.2 (63) note. items in bold indicate key components of vermont 2018 marijuana policy. in bivariate analyses, being aged 18-20 (vs. 2125; pr 0.76; 95% ci, 0.66-0.88), identifying as hispanic (vs. non-hispanic white; pr=0.34; 95% ci, 0.20-0.58), non-hispanic american indian or alaska native, asian, black or african american, native hawaiian or other pacific island, or more than one race (vs. non-hispanic white; pr=0.65; 95% ci, 0.47-0.90), and having high school/ged as highest level of education (vs. some college; pr=0.74; 95% ci, 0.59-0.92) were inversely correlated with knowledge of vermont’s cannabis policy at the time of the survey (table 1). having a bachelor’s degree or more (vs. some college; pr=1.23; 95% ci, 1.09-1.39), ever cannabis use (vs. never; pr=1.37; 95% ci, 1.16-1.63), and past30-day cannabis use (vs. no use; pr=1.27; 95% ci, 1.12-1.45) were positively correlated with correct knowledge of the cannabis law. in a series of multivariable analyses adjusting for age, sex, race and ethnicity, subjective financial status, and past-30-day cannabis use, young adults who reported slight risk of harm from weekly cannabis use had a higher prevalence of cannabis policy knowledge (apr=1.28; 95% ci, 1.11-1.48) than those who reported no risk (table 3). young adults who identified thc as the substance in cannabis that makes a person high had a greater prevalence of correct knowledge of cannabis policy (apr=1.91; 95% ci, 1.30-2.79) than those who incorrectly identified thc as the psychoactive substance in cannabis. participants who agreed that “regular marijuana use early in life can negatively affect attention” (apr=1.55; 95% ci, 1.22-1.97) and young adults who did not know if early cannabis use impacts attention (pr=1.44; 95% ci, 1.06-1.95) had higher prevalence of cannabis policy knowledge than those who disagreed with this statement. policy knowledge was more prevalent among young adults who responded that they did not know whether “one in six teens who start using marijuana before age 14 develop addiction” than those who disagreed with the statement (apr=1.20; 95% ci, 1.01-1.43). correct knowledge of the policy was not associated with responses to the following items: 1) “teens who use marijuana have lower academic performance and worse job prospects” and 2) “teens who use marijuana weekly or more often have twice the risk of depression.” cannabis, a publication of the research society on marijuana 17 table 3. marijuana belief and harm perception correlates of state cannabis policy knowledge incorrect knowledge (n = 400; 39.9%) correct knowledge (n = 637; 60.1%) total (n = 1,03; 100%7) weighted % (n) weighted % (n) weighted % (n) apr (95%ci) young adults harm risk from weekly marijuana use great risk 13.9 (52) 4.5 (31) 8.2 (83) 0.66 (0.43, 1.01) moderate risk 25.3 (101) 19.3 (128) 21.7 (229) 1.09 (0.90, 1.32) slight risk 32.2 (143) 48.8 (309) 42.2 (452) 1.28 (1.11, 1.48) no risk 28.5 (103) 27.4 (169) 27.8 (272) ref. regular marijuana use during early years of life can negatively affect attention agree 73.9 (303) 82.1 (508) 78.8 (811) 1.55 (1.22, 1.97) disagree 16.3 (53) 8.3 (67) 11.5 (120) ref. don't know 9.8 (43) 9.5 (62) 9.7 (105) 1.44 (1.06, 1.95) approximately 1 in 6 teens who start using marijuana before age 14 develop addiction agree 57.2 (230) 54.5 (337) 55.6 (567) 1.09 (0.93, 1.28) disagree 28.3 (104) 24.8 (165) 26.2 (269) ref. don't know 14.4 (65) 20.7 (134) 18.2 (199) 1.20 (1.01, 1.43) teens who use marijuana have lower academic performance and worse job prospects agree 46.5 (178) 43.3 (261) 44.6 (439) 1.07 (0.93, 1.23) disagree 37.8 (146) 38.6 (259) 38.3 (405) ref. don't know 15.6 (75) 18.1 (116) 17.1 (191) 1.10 (0.93, 1.29) teens who use marijuana weekly or more often have twice the risk of depression agree 60.6 (230) 58.8 (363) 59.5 (593) 1.05 (0.91, 1.22) disagree 21.9 (91) 23.2 (159) 22.7 (250) ref. don't know 17.5 (78) 18.0 (114) 17.8 (192) 1.02 (0.85, 1.23) what substance in marijuana makes a person high? incorrect 19.1 (59) 4.9 (32) 10.6 (91) ref. correct (thc) 74.3 (309) 93.6 (594) 85.9 (903) 1.91 (1.30, 2.79) i don't know 6.6 (32) 1.4 (11) 3.5 (43) 0.77 (0.38, 1.58) note. abbreviations: apr, adjusted prevalence ratio. all modified poisson models adjusted for age, sex, race/ethnicity, subjective financial status, and past 30-day marijuana use and account for survey weights. number of observations missing data on the following variables: perceived risk of harm from weekly marijuana use (n = 1); effect of marijuana on attention (n = 1); effect of early marijuana use on addiction (n = 2); effect of early marijuana use on academic performance (n = 2); effect of weekly marijuana use on depression risk (n = 2). discussion approximately 60% of vermont young adults in the study correctly identified the state’s cannabis policy in 2019 in the survey. this is a high proportion of vermont young adults respondents with correct policy knowledge given that the law was enacted by the state legislature and likely received less political advertising than a public ballot measure. correct knowledge of cannabis policy was associated with being older, non-hispanic white, and more educated, as well as with past-month and ever cannabis use. compared to those who believed weekly cannabis use poses no risk, policy knowledge was more prevalent among young adults who believed cannabis use poses a slight risk of harm. cannabis policy knowledge was associated with several cannabis beliefs, including identifying thc as the substance in cannabis that makes a person high, agreement that regular cannabis use early in life can negatively affect attention, and the impact of early cannabis use on addiction. cannabis policy knowledge among young adults was not associated with other beliefs that cannabis use leads to depression or low academic and work young adults’ knowledge of state cannabis policy 18 performance. differences in cannabis harm perceptions and knowledge among young adults may be explained by cannabis use status (berg et al., 2015; terry-mcelrath et al., 2017), with more experienced users having a higher awareness of the policy. on the other hand, 40% of young adult respondents did not demonstrate knowledge of state cannabis policy, highlighting variation in policy knowledge after implementation. given that existing evaluations of state-level changes in cannabis legal status in youth and young adults rely on the dates of policy implementation, our findings indicate it may be important to account for policy knowledge in these evaluations (brooksrussell et al., 2019; cerda et al., 2017; fleming et al., 2016; paschall & grube, 2020). associations between ever and current cannabis use and policy knowledge may indicate how policy awareness impacts population subgroups differently. policy knowledge, therefore, could be used in several ways in sensitivity analyses to gain a more unbiased estimate of the effect of cannabis legalization on young adult beliefs and behaviors – as an alternate measure of policy exposure, as a control variable, or as a potential moderator. for example, current estimates may underestimate the effect of cannabis policy on behavior by grouping those without knowledge unlikely to change their behavior with those who have knowledge of the policy and may have considered or changed their behavior as a result. using policy knowledge as an exposure variable in sensitivity analyses may identify an upper bound for the likely effect of cannabis policy change on key outcomes of interest; these estimates would be useful in modeling the expected long-term impacts of the policy. second, findings that cannabis policy knowledge may differ by cannabis harm perceptions and use behavior in young adults are particularly salient as more states legalize cannabis and seek to evaluate policy effects (national conference of state legislatures, 2021b). controlling for policy knowledge may reduce variability in findings across states and provide greater insight into the effects of changes in cannabis legal status on youth and young adult beliefs and behaviors. third, using policy knowledge as a potential moderator of the relationship between date of policy implementation and outcomes of interest may identify differential patterns in change relevant to public health education efforts – for example, there may be greater changes in certain beliefs about cannabis use among those with policy knowledge that could be targeted in health communication programs. assessment of policy knowledge may also identify subgroups of the population at risk for greater cannabis use following policy implementation and inform efforts to prevent cannabis uptake and use. strengths of the current study are a large online sample of young adults from across the state of vermont, relevance to changes in state cannabis policy across the u.s., and data collection within nine months of the policy implementation. while this timeframe allowed for vermonters to be affected by the policy, news about the change in legal status likely occurred months before our data collection. other limitations of this study include: a convenience sample, the use of cross-sectional data, no questions about medical cannabis use, and a lack of data prior to the policy implementation in 2018. the sample was limited to participants from a small, largely rural, and non-hispanic white state. vermont’s homogeneity was represented in the sample and prevented detailed analyses of cannabis policy knowledge by race and ethnicity. prior to the 2018 cannabis policy change, vermont young adults had a higher prevalence of past 30day cannabis use (samhsa, 2017) and reported lower perceptions of harm from cannabis use compared to the national prevalence (moss et al., 2018). a high prevalence of use and low harm perceptions may impact the representativeness of the current study results and may influence the associations between cannabis policy knowledge and beliefs. additionally, policy knowledge is only one of several mechanisms by which policy impacts beliefs and behaviors (e.g., access, availability of cannabis, retailer licensing; (pedersen et al., 2021) and there are other outcomes related to cannabis legalization relevant to population health (e.g., criminal justice; (firth et al., 2019). our analysis is limited to policy knowledge, though future policy evaluations will need to consider the various mechanisms by which changes in cannabis legal status impacts a range of health outcomes to adapt state-level programming – and potentially, the policies themselves – to protect public health. conclusion cannabis, a publication of the research society on marijuana 19 evidence from vermont young adult respondents suggests that knowledge of changes in cannabis legal status is greater in older young adults (aged 21-25 years) and of legal age to possess cannabis in vermont, females, nonhispanic white young adults, those with the highest education, and ever and current cannabis users. while sociodemographic factors are typically treated as covariates in existing policy studies, future evaluations of changes in state cannabis legal status that account for policy knowledge may improve estimation of the impact of policy change on harm perceptions and use of cannabis. the large proportion of young adults with correct policy knowledge, combined with a higher prevalence of policy knowledge among past 30-day cannabis users and young adults with low perceived risk of regular cannabis use, signals novel opportunities for state-level education on cannabis to ensure all young adults have accurate policy knowledge and are informed of the potential harms of cannabis use. most young adults correctly understood the policy and nearly all respondents correctly identified that cannabis was not “legal for anyone to use” and that was “legal for people 21+ to use. a notable portion (40%); however, did not accurately identify all aspects of the policy, underscoring the potential to misattribute behavior change to policy implementation. assessment of policy knowledge could be used in future evaluations to better estimate the effects of change to cannabis legal status on cannabis use behavior and beliefs and to inform public health efforts to prevent or reduce cannabis use in young people. references arnett, j. j. 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(2004). a modified poisson regression approach to prospective studies with binary data. american journal of epidemiology, 159(7), 702-706. funding and acknowledgements: research reported in this publication was supported by the national institute on drug abuse of the national institutes of health under award number r21da051943, the vermont department of health, the university of vermont cancer center, and the university of vermont larner college of medicine. acv was also supported in part supported by the national institute of general medical sciences of the national institutes of health under award number p20gm103644. jcw was supported by the national institute on drug abuse of the national institutes of health under award number u54da036114. although this work product was funded in whole or in part with monies provided by or through the state of vermont, the state does not necessarily endorse the researchers' findings and/or conclusions. the findings and/or conclusions may be inconsistent with the state's policies, programs, and objectives. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health or the health resources and services administration. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 18 ved abstract more than half of the united states has legalized medicinal and/or recreational cannabis. the purpose of the study is to understand cannabis use and perceptions among college students with cannabis experience – 21 years and older – in a legalized cannabis state. participants included 170 college students, the majority identified as female (72.9%, n = 124) and latinx/hispanic (55.9%, n = 95). the online survey included demographic questions and questionnaires measuring cannabis consumption, cannabis use disorder, and quality of life. participants answered open-ended questions about the negative, positive, and spiritual impact/s of cannabis on their life and health, and how the covid-19 pandemic impacted their cannabis use. a paired-sample t-test indicated participants significantly found more relief using cannabis compared to non-cannabis treatments or medications. there was no significant correlation between quality of life and cannabis use disorder symptoms. inductive content analysis of 112 written responses revealed perceived negative effects (e.g., anxiety/mental health issues) and positive effects (e.g., relaxation/stress reduction) from using cannabis. most participants reported no spiritual benefits; however, some participants discussed cannabis use improving connection to self and self-awareness. regarding the impact of the covid-19 pandemic on use, most participants (27.8%) reported increased cannabis use, while some reported decreased cannabis use. these findings reflect the importance of understanding the wide-range of benefits and risks perceived by college students who consume cannabis and how these results can inform the development of university prevention and wellness strategies within states that have legalized recreational and medical cannabis. key words: = cannabis use, spirituality, quality of life, college students, covid-19 pandemic cannabis is the third most commonly used drug in the united states (u.s.) after alcohol and nicotine (substance abuse and mental health services administration, 2019). through medicinal and recreational legalization, cannabis has become increasingly accepted and consumed by the public (hall & lynskey, 2016). college students are more likely to engage in exclusive use of cannabis (i.e., without smoking tobacco) compared to non-college young adults (odani et al., 2019), and those who reside in states with recreational cannabis legalization are more likely to engage in cannabis use (e.g., barker & moreno, 2021; jones et al., 2018; koval et al., 2019). the present study used quantitative and qualitative methodology to explore college student perceptions of negative, therapeutic, and spiritual impacts of cannabis use during covid-19. negative health risks associated with cannabis use several emotional and cognitive risks are associated with frequent cannabis use. keith et al. selina espinoza1, melissa-ann lagunas1, claudia rocha1, jennifer l. lovell1 1california state university, monterey bay cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000157 perceived risks and therapeutic benefits of cannabis among college students amidst the covid-19 pandemic corresponding author: selina espinoza, university of california, merced, 5200 lake rd, merced, ca 95343. email: sespinoza34@ucmerced.edu cannabis, a publication of the research society on marijuana 19 (2015) found that 8.5% of undergraduates used cannabis at least ten days within the past month, and frequent use was associated with increased negative outcomes (e.g., substance use, anxiety, and depression). de faria et al. (2021) determined early exposure, greater use, high potencies, preexisting issues, and genetic predispositions were associated with increased risk for developing mental illness and negative academic outcomes among college students. the most common diagnoses associated with cannabis use were psychosis, anxiety, depression, attention-deficit hyperactivity disorder, sleep disorder, and cannabis use disorder (cud). cud is defined as an excessive use of cannabis despite clinically relevant impairment (dsm-5; american psychiatric association, 2013). caldeira et al. (2008) conducted a study examining cud and cannabis-related problems in 1,253 college students and found almost one in four cannabis users met diagnostic criteria for cud. brezing et al. (2018) found abstinence and/or reduced frequency of cannabis use improved the quality of life of individuals seeking treatment for cud. quality of life reflects the ‘goodness’ of life across multiple domains (e.g., emotional health, life fulfillment, relationship satisfaction; felce & perry, 1995). since there is limited research on quality of life and cud among college students, we explored this in the present study. therapeutic and spiritual benefits of cannabis therapeutic refers to the beneficial or curative effects of a treatment (american psychological association [apa], n.d.). medicinal cannabis has demonstrated to be therapeutic for some, including undergraduate students with generalized social anxiety disorder (e.g., bergamaschi et al., 2011; webb & webb, 2014), canadian male military personnel with post-traumatic stress disorder (ptsd; e.g., jetly et al., 2015), and individuals who use cannabis to treat chronic pain (e.g., webb & webb, 2014). there are some studies indicating similar areas of therapeutic improvement reported by non-clinical, college student samples. macdougall and maston (2021) used interviews to explore cannabis perceptions among canadian college students and how they were impacted by recreational cannabis legalization. general thematic analysis of 112 respondents revealed perceived positive health effects (e.g., relief from physical ailments), negative health effects (e.g., lung health), academic outcomes (e.g., increased creativity), and social effects (e.g., facilitation of social engagement) from using cannabis. additionally, kilwein et al. (2022) facilitated focus group discussions and used thematic analysis to understand perceptions of cannabis among college students attending a border state university (i.e., a state that has not yet legalized but borders a state that has). one of the three main themes included ‘relative benefits and harms of cannabis,’ with cannabis being largely discussed in relatively positive terms (e.g., mental and physical health, relaxation and anxiety management, creativity and productivity). researchers have also shed light on the complexity and nuances surrounding the effects of cannabis. for example, abizaid et al. (2019) noted that despite potential short-term positive effects, there were also potential adverse effects of chronic cannabis use, including cognitive disturbances, damage to neuronal plasticity and development in the adolescent brain, long lasting changes in brain functioning, potential abuse, and exacerbation of the course of schizophrenia for highly vulnerable populations. a systematic review conducted by stanciu et al. (2021) yielded limited evidence and mixed results on the effectiveness of delta-9-tetrahydrocannabinol (thc) and cannabidiol (cbd) to treat affective disorders, anxiety disorders, and ptsd. likewise, the relationship between cannabis and anxiety has been documented to be contradictory. some participants find alleviation while others experience increased anxiety and panic (crippa et al., 2009). in addition to the therapeutic uses for mental and physical ailments, some people use cannabis for spiritual benefits. spirituality is a broad concept that can involve religious traditions but ultimately refers to an individual’s relationship with transcendence (reinert & koenig, 2013). heide et al. (2021) recruited 1,087 adults to assess the spiritual benefits of cannabis and found that 66.1% reported spiritual benefits of cannabis, with 13.4% of participants indicating that cannabis is very compatible with their spiritual values. using ethnographic methods in rural catalonia, kohek et al. (2021) found that rituals associated with ancient psychoactive plants, like cannabis, are perceived as spiritual or religious practices that serve as self-care and heighten community connectedness. currently, there is a gap cannabis risks and benefits 20 in the literature regarding how spiritual benefits are perceived by college students who consume cannabis. perceptions of cannabis among college students and covid-19 perception is the process of using one's senses to learn about the world and then organize and interpret this information to inform behavior (apa, n.d.). perceptions of cannabis use are impacted by contextual and historical factors, with a recent example being the sars-cov-2 (covid-19) pandemic. the covid-19 pandemic has been associated with reported increase in stressors among medicinal cannabis users nationwide. vidot et al. (2020) surveyed 1,202 u.s. medicinal cannabis users (18+ years) from march to april 2020 and results indicated that after covid-19 was declared a pandemic, over 40% of participants reported an increase in cannabis consumption. additionally, 47.5% of respondents reported having less access to their necessary doses of cannabis causing an increase in stress. furthermore, participants who consumed combustible cannabis products reported an increase in fear that if they were to contract the virus, they would experience more severe covid-19 symptoms. as such, it is critical to further investigate perceptions of cannabis use and how users are being impacted by the covid-19 pandemic (borgonhi et al., 2021). the present study with the rise of cannabis legalization and consumption among college students, it is essential to understand perceptions, quality of life, and use among this vulnerable subgroup during the covid19 pandemic. to address gaps in the literature, the present study utilized a self-report survey with openended and scaled questions about college students’ use and perceptions of cannabis in a state where recreational and medicinal cannabis is legalized. this study differs from other relevant qualitative work devoted to understanding the externalities of cannabis. for example, kilwein et al. (2022) investigated the recent shifts toward cannabis use among college students and related harms, while macdougall and maston (2021) explored the perceptions of post-secondary students’ cannabis use on health, academics, and social lives with the legalization of cannabis. in contrast, the present study seeks to understand student’s perceptions of the negative, therapeutic, and spiritual impacts of cannabis use, specifically during the covid-19 pandemic. research questions and hypotheses 1. what negative health consequences do students report from cannabis use? a. are symptoms of cannabis use disorder (cud) associated with negative quality of life? hypothesis : college students who report higher levels of cud will also experience lower levels of quality of life. b. exploratory qualitative open-ended question about negative health outcomes. 2. what therapeutic and spiritual benefits do students report from cannabis use? a. do college students experience symptom relief when using cannabis versus non-cannabis treatments or medications? hypothesis : college students will experience symptom relief from using cannabis compared to non-cannabis treatments or medications. b. exploratory qualitative open-ended questions about positive outcomes and spiritual benefits of cannabis use. 3. what was the impact of covid-19 on students’ cannabis use and quality of life? a. exploratory qualitative open-ended question about impact of the pandemic on cannabis use. methods participants a total of 203 college students from a university in central california began our online survey between may 1 and december 12, 2020. participants who did not consent (n = 4, 2.0%) and reported never consuming cannabis (n = 29, 14.3%) were directed to the end of the survey, thus did not complete the survey and were not included in the analyses. thus, the sample included 170 college students with cannabis experience. participants answered demographic questions including age, gender, religion, race/ethnicity, class standing, major, and cannabis, a publication of the research society on marijuana 21 identification as a first-generation student. the majority of participants identified as seniors (n = 99, 58.2%) or juniors (n = 63, 37.1%), female (n = 124, 72.9%), and latinx/hispanic (n = 95, 55.9%) or european/white (n = 45, 26.5%). when asked about their spiritual/religious identity, most identified as catholic (n = 55, 32.4% ) or agnostic/atheist (n = 38, 22.4% ). see table 1 for detailed sample characteristics. when asked about the importance of their spirituality/religion, 28.8% reported very important (n = 49), 38.8% reported somewhat important (n = 66), and 24.1% reported not too/not at all important (n = 41). procedure the project was approved by the university institutional review board. undergraduate students were offered the opportunity to participate in an anonymous online survey to earn extra credit in courses. students were considered eligible if they were at least 21 years old and had experience using cannabis. students who agreed to participate were directed to a qualtrics survey including informed consent, demographic questions, open-ended questions, measures of cannabis use, cud, and quality of life. measures cannabis use the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq) is a 39-item measure of cannabis dimensions such as frequency, age of onset, and quantity of cannabis use (cuttler & spradlin, 2017). the current study utilized 16 items from the dfaq inventory which included factors such as screening/characterization (5 items), frequency (4 items), edible quantity (1 item), and age of onset (1 item). the measure demonstrated adequate to good internal reliability for subscales (cuttler & spradlin, 2017); however, we chose to only use specific items to gather descriptive information (see table 2) rather than the full scale and therefore could not run reliability analyses. symptom relief with cannabis three questions assessed the percentage of symptom relief from cannabis treatments and/or medications compared to non-cannabis treatments and/or medications. the questions were based on the formatting of questions included in the modified brief pain inventory short form (bpi-sf; cleeland, 1989) from the national palliative care research center. the first question asked participants if they used cannabis to help relieve symptoms for mental or physical troubles (answer options: yes or no). the second question asked, “how much relief do cannabis treatments or medications provide you?” the third question asked, “how much relief do non-cannabis treatments or medications provide you?” the second and third questions were rated on a percentage scale from 0% (no relief) to 100% (complete relief). table 1. sample characteristics (n = 170) demographic variable n (%) class standing seniors 99 58.2 juniors 63 37.1 sophomores 1 0.6 graduate level 1 0.6 major arts, humanities, and social sciences 126 74.1 health sciences and human services 18 10.6 science 10 5.9 other 10 5.9 first-generation status yes 110 64.7 no 93 54.7 gender identity female 124 72.9 cannabis risks and benefits 22 male 39 22.9 gender fluid or nonconforming 2 1.2 race/ethnic identity latinx/o/a, hispanic, or chicanx/o/a 95 55.9 european, caucasian, or white 45 26.5 multiethnic or biracial 18 10.6 african, caribbean, or black 6 3.5 other 8 4.7 spiritual/religious identity catholic 55 32.4 agnostic/atheist 38 22.4 christian 32 18.8 spiritual but not religious 24 14.1 other (e.g., muslim, jewish, buddhist) 9 5.3 cannabis use disorder the cannabis use disorders identification test-revised (cudit-r; adamson et al., 2010) identifies individuals who have used cannabis in a harmful or problematic way in the past six months (saunders et al., 1993). the cudit-r includes eight items, the first seven items are measured on a five-point likert scale 0 (never) to 4 (daily or almost daily), and the last item includes three answer options (0 = never; 2 = yes, but not in the past six months; 3 = yes, during the past six months). an example question includes, “how often during the past 6 months did you fail to do what was normally expected from you because of using cannabis?” cudit-r responses are summed into a single score with possible scores ranging from 0 to 32. adamson et al. (2010) identified a cut-off score of 13 or above for current cannabis use disorder in a clinical sample, but schultz et al. (2019) recommended using a lower cut-off score of six or above to adequately identify college students at potential risk of cud (nonclinical sample). previous studies have found good internal consistency for the cudit-r among clinical (0.914; adamson et al., 2010) and nonclinical, college student samples (0.83; schultz et al., 2019). cronbach’s alpha for the current study was acceptable (α = .76). quality of life the multicultural quality of life index (mqli) is a 10-item self-report scale measuring cultural dimensions of an individual’s quality of health and life (mezzich et al., 2010). example dimensions include physical well-being, psychological emotional well-being, occupational functioning, and spiritual fulfillment. each dimension is defined and rated on a 10-point scale from poor (1) to excellent (10). the mqli final score is an average of the scores from all items. mezzich et al. (2010) found the internal consistency to be fairly high among the combined sample (α = 0.92), a professional sample (α = 0.91), and a patient sample (α = 0.90). the cronbach’s alpha in the current sample was .92, suggesting good internal consistency. qualitative questions participants were invited to answer the following open-ended questions: “how has cannabis positively impacted your life and health (ex., physically, socially, emotionally, academically, occupationally, financially, cognitively)?” “in what ways have you spiritually benefited from cannabis?” “how has cannabis negatively impacted your life and health (ex., physically, socially, emotionally, academically, occupationally, financially, cognitively)?” and “in what ways has the covid-19 pandemic impacted your use of cannabis?” qualitative data analysis and positionality our study utilized a modified version of consensual qualitative research (cqr-m; spangler et al., 2012) to analyze qualitative responses. cqr-m has been adapted to accommodate large samples, ranging from 62 to 132 qualitative responses (hill et al., 2007; spangler et al., 2014), and is based on an agreement or consensus, with coding categories to reduce researcher biases (spangler et al., 2012). in the present study, cqr-m was most fitting due cannabis, a publication of the research society on marijuana 23 to a large sample (n = 112, 65.9%) for each qualitative question. four researchers took the lead when creating categories based on the phases of cqr-m, and the fifth researcher served as an auditor. before beginning group analysis, researchers reflected on their experiences with cannabis and how their experience may impact interpretation. a group of five researchers worked on this project, and all identified as cisgender females. three of the researchers identified as latina/x and two identified as white. all researchers had experience trying/using cannabis at varying levels, most with predominantly positive experiences and one with a negative experience. qualitative analysis was completed while four of the five researchers were undergraduates, and all students continued onto graduate school in psychology. the fourth author mentored the first three authors in the research design, analysis, and manuscript writing. during the first phase of cqr-m, researchers analyzed responses several times to understand the depth of participant answers. four researchers engaged in open-coding independently to identify an initial list of potential themes. the four lead researchers then discussed discrepancies in the emergent themes and created a table of code names and definitions to use. following this process, two researchers coded each set of questions separately and then compared coding. when discrepancies were identified, the two researchers consulted with the other team members to discuss, share perspectives, and ask questions. theme definitions were revised, discarded, and merged as needed when sharing ideas on how to best interpret participant responses. the researchers’ mentor provided guidance and served as an additional coder when there were remaining discrepancies. researchers came to a consensus on the categories created and application of categories to the responses. results cannabis use based on responses to the dfaq (cuttler & spradlin, 2017), 170 participants reported having used cannabis. the two most common ages reported for first use of cannabis included 16 (14.8%, n = 30) and 18 (11.8%, n = 24). most participants reported not being high while taking the survey (75.9%, n = 154). see table 2 for additional information about cannabis use and frequency. negative health consequences our first research question, explored quantitatively and qualitatively, asked about the negative health consequences students experienced from cannabis use. participants who answered “yes” to using cannabis within the last six months (70.5%, n = 117) were given the cannabis use disorder screener (cudit-r). we calculated sum scores and used a cutoff of six to determine college students with potential problematic use (schultz et al., 2019). of the participants who completed the cudit-r, 62.1% (n = 72) reported potential problematic cannabis use. table 2. the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq; n = 203) item n (%) have you ever used cannabis? yes 170 83.7 no (these individuals did not complete further items) 29 14.3 which of the following captures when you last used cannabis? i am currently high 6 3.0 today 12 5.9 yesterday 22 10.8 the past three weeks 44 21.7 one to six months ago 27 13.3 seven to twelve months ago 21 10.3 over a year ago 37 18.2 cannabis risks and benefits 24 how high are you right now? i am moderately high 2 1.0 i am a little bit high 12 5.9 i am not at all high 154 75.9 which of the following best captures your pattern of cannabis use throughout the week? i use cannabis on the weekends and weekdays 65 32.0 i only use cannabis on weekdays 3 1.5 i only use cannabis on weekends 41 20.2 i do not use cannabis at all 59 29.1 how many hours after waking up do you typically first use cannabis? within one hour of waking up 8 3.9 within two to six hours after waking up 25 12.3 within seven to twelve hours after waking up 54 26.6 within thirteen to eighteen hours after waking up 24 11.8 i do not use cannabis at all 56 27.6 which of the following best captures the average frequency you currently use cannabis flower (ex. taken in the form of joints, blunts, spliffs, bong, pipe, etc.)? more than once a day 15 7.4 once a day 7 3.4 three to six times a week 15 7.3 once to twice a week 14 6.9 once to three times a month 19 9.4 once every two to six months 29 14.3 once a year 8 3.9 less than once a year 14 6.9 i do not use cannabis flower 47 23.2 how old were you when you first tried cannabis? 10-15 years old 38 18.7 16-20 years old 95 46.8 21-24 years old 29 14.3 we conducted a bivariate correlation to test our hypothesis that college students with greater symptoms of cud would experience lower levels of quality of life (as measured by the mqli). contrary to our hypothesis, there was no significant relationship between symptoms of cud and quality of life, r(110) = -0.02 p = 0.836. second, we explored negative health consequences qualitatively. of the 145 participants who wrote a response regarding the negative impact of cannabis on the respondents’ life and health, anxiety and mental health (n = 36, 24.8%) was the most prominent theme, showing an increase in psychological stressors when consuming cannabis. the second most frequent themes included expensive (n = 23, 15.7%) and physical health (n = 23, 15.9%). one respondent shared the following: “it has negatively affected me in the way that over the years my tolerance has increased which has caused me to spend more money and i also don’t know the overall long term health effects it will have on me. sometimes i feel it has made my anxiety overall worse rather than helping it the way it used to.” other themes included impaired cognition (n = 21, 14.5%) and laziness or grogginess (n = 18, 12.4%). one respondent’s quote incorporated multiple themes (mental health, physical health, impaired cognition, school work, laziness or grogginess): “i abused cannabis for many years to escape issues i didn't want to deal with, so it stunted me emotionally. it kept me from being physically active, because i usually wanted to sit and eat, or sleep after i got high. it kept me cannabis, a publication of the research society on marijuana 25 socially isolated, because i didn't want to get high with other people, i liked getting high by myself. i didn't want to go to school or do homework, because i wanted to get high, so i would skip school when i was in high school, then i dropped out of college because i was unmotivated. when i was high i couldn't do homework, because i couldn't focus on the material, so it impaired me cognitively.” therapeutic and spiritual benefits our second research question asked about the therapeutic and spiritual benefits of cannabis use, both quantitatively and qualitatively. among the total sample, 83 (49.4%) participants reported that they consume cannabis to relieve symptoms for mental or physical troubles, and 85 (50.6%) reported they do not consume cannabis to relieve symptoms. participants were then asked the percentage of relief they normally experience when using cannabis and non-cannabis treatments or medications. we hypothesized that college students would report greater symptom relief from consuming cannabis compared to non-cannabis treatments or medications. we conducted a pairedsample t-test to test this hypothesis. results indicated that college students significantly found greater relief using cannabis as a treatment or medication (m = 5.23, sd = 3.30) than non-cannabis treatments or medications (m = 3.53 , sd = 2.94), t(104) = 4.36, p = .001, d = .42. of the 152 participants who wrote a response regarding the positive impact of cannabis on their lives, 35.5% (n = 54) reported relaxation and stress reduction as the primary benefit. one participant stated, “it helps me to relax. it helps with stress and to unwind, especially on tough days.” another participant stated: “cognitively/emotionally helps my chronic stress by making me forget about my stressors for a bit.” additionally, improved social connections (28.2%, n = 43), showed to be a prominent theme and is illustrated with the following quote: “as i only use cannabis socially, i've found that it has helped me connect more with my partner and reconnect with my sister.” similarly, a respondent stated “socially, i am able to feel like i connect with my friends at a deeper level and have great conversations.” the third most prominent theme was anxiety (n = 41, 26.9%). one participant stated: “cannabis calms my anxiety and lessens the frequency of my anxiety attacks throughout the week.” further, the theme uplifts mood and self concept (n = 27, 17.8%) emerged from respondents who shared how cannabis improved happiness. some participants indicated gaining positive qualities (e.g., gratitude, vulnerability) and better self-esteem from using cannabis. when asked about students’ perceptions of spiritual benefits from cannabis, a total of 132 participants responded. a majority experienced no spiritual benefits (n = 83, 62.9%) while 14.4% (n = 19) endorsed connection to self, defined by the researchers as individuals experiencing a novel and profound connection to themselves, an increase in self acceptance and self love, and the ability to understand themselves. within this theme, respondents wrote about feeling “connected” and “more in tune” with their bodies and minds. for example: “spiritually, i feel at peace with the state of my body now.” also, “it has helped me come in touch with my body and mind...” a third theme, awareness (n = 16, 12.1%), captured the ways in which cannabis led to introspection, openmindedness, and the development of positive qualities (e.g., humbleness). since studies regarding the spiritual benefits of cannabis are limited, we included the full theme list, definitions, and additional quotes in table 3. in a follow-up analysis, we explored the association between a participant’s reported religious/spiritual identity and their qualitative response to the aforementioned open-ended question about “spiritual benefits” of cannabis. first, we dichotomized the qualitative responses into those who wrote about benefits (n = 44) and those who wrote that cannabis had no perceived spiritual benefits (n = 83), five respondents were not included in this comparison because they wrote responses that were unable to be categorized/coded. we ran a chi-square test for independence and found a significant association between perceived spiritual benefits and religious/spiritual identity, χ2(4, n = 123) = 11.6, p = .02, phi = .31. participants who identified as agnostic, atheist or non-religious were significantly less likely (18.5%, n = 5) to report perceived spiritual benefits of cannabis whereas participants who identified as “other” religious identities were significantly more likely (75.0%, n = 6) to write about spiritual benefits of cannabis. although not significant, there was an interesting trend toward cannabis risks and benefits 26 catholic respondents being less likely to identify spiritual benefits (29.0%, n = 11) compared to respondents who identified as christian (40.0%, n = 12) or spiritual but not religious (50.0%, n = 10). impact of covid-19 pandemic our third research question inquired about the influence of covid-19 on students’ cannabis use and quality of life. we evaluated this question qualitatively, and a total of 151 participants responded. approximately more than a quarter of the participants reported that covid-19 led to more cannabis use (n = 42, 27.8%), and this was the most frequent theme. participants wrote about using cannabis to relieve stressors associated with table 3. qualitative themes: spiritual benefits of cannabis (n =132) theme definition example quote frequency, n (%) not helpful/neutral participants state that cannabis does not help them spiritually. “i have not spiritually benefited from it.” 83 (62.87%) connection to self/self love & acceptance participants feel more connected and accepting of themselves. participants say they feel they can love themselves more fully and discover themselves and their purpose “...spiritually i am able to feel like i am whole. one thing i lacked before cannabis was the ability to love and connect with myself. i felt as if so many pieces in my life had gaping holes. i needed to find a solution or i was sure i would die. cannabis has allowed me to tap into a better version of myself and meditate. i am able to connect internally and listen to what my body is telling me.” 19 (14.39%) awareness cannabis facilitates introspection, opens the mind to see different perspectives, promotes the capacity to question more and see more, gives the ability to remember what has been forgotten, and cultivates mindfulness. this also includes development of positive qualities (e.g., humbleness). “cannabis has opened my mind to new things and offered different perspectives on things in the world.” 16 (12.12%) connection to earth participants go outdoors more, are appreciative of earth's natural resources, and feel connected to nature. “it has made me a bit more spiritual with the earth and the universe.” 7 (5.30%) increase religion/spirituality participants feel more religious (read the bible more often), have spiritual revelations, increase their spiritual understanding and spend time thinking of spirituality. “cannabis allowed me to come to the confirmation that there is an afterlife in heaven, and it has helped me to not fear death.” 6 (4.54%) creativity cannabis improves the ability to make something new or think of something in a novel way. “during use, i feel a little more creative and determined to do things.” 5 (3.78%) mood improvement cannabis promotes feelings of joy and peacefulness. “i have been a calmer person. dont think as negative.” 5 (3.78%) more care for others/better bonding cannabis gives feelings of empathy for others and facilitates social connections to others. “in the sense of finding bonding and unity with others over cannabis.” 4 (3.03%) relaxing participants feel that cannabis is relaxing and gives a sense of calmness. “just by being able to let loose and relax is very beneficial to me.” 3 (2.27%) cannabis, a publication of the research society on marijuana 27 discipline participants possess more control and discipline over their actions to reach their goals. “spiritually cannabis has made me disciplined and allowed me to stick to my fasting diet.” 3 (2.27%) sleep cannabis enhances sleep for a better night's rest. “i'm able to sleep and stay asleep through the night.” 1 (0.75%) the pandemic (e.g., finances, academics, personal stress). increased social isolation appeared to be an additional factor associated with heightened cannabis use. for example: “covid-19 has actually caused my use to increase recently since my stress levels have been higher than normal and i have been indoors all day.” the following response provides support for the association between increased stress and cannabis use: “... isolation, constant negative news, little distraction, a bungled govt response, and too much school work...i am happy and extremely grateful that i am able to have access to legal cannabis during such a stressful time. i am not a big drinker and would advocate against using alcohol to manage stress, but fear that this amount of stress without cannabis may have resulted in me relying on alcohol to manage it.” additionally, some participants reported that covid-19 led to less use of cannabis (n = 20, 13.25%). a few participants who reported a decrease in cannabis use shared it was because of increased difficulty in accessing cannabis. further, respondents who consumed cannabis by smoking expressed a decrease in usage due to concerns about being more at risk to the virus if contracted. example responses include: “because smoking/vaping of any kind can put you more at risk for complications i have stopped” and “i started to use [cannabis] less for fear of contracting covid-19.” additionally, a few participants indicated that they have lessened their cannabis consumption due to having to relocate from their college campus to their family’s homes in which some members did not approve of cannabis. for example: “considering i am living back at home with my parents, i have not been able to use cannabis for the reason that my parents are against it…” other themes included social impact (n = 4, 2.7%), in which participants described social barriers to using cannabis such as not being able to use it with friends and/or living with parents who do not approve of it. a response that exemplifies this category reads, “my parents are super religious so i never get high while i am living under their roof.” dispensary delivery services (n = 4, 2.7%), was defined as an increase in cannabis prices and more difficulty accessing cannabis (i.e., as scheduling appointments to pick it up), such as one participant expressed, “it is difficult to get access to. you now have to make an appointment just to be able to go to the dispensary to pick it up.” relaxation (n = 3, 2%) is the theme where participants expressed they used cannabis as a tool to help them relax, such as “ i use cannabis about once a week, typically sunday's. covid-19 has impacted my use though because i've been under a lot of stress financially and academically. using cannabis is kind of a ‘relaxing time’ for me.” discussion the current study used a self-report, online survey to understand cannabis-related perceptions and behaviors among college students in california during the covid-19 pandemic (may-december 2020). the triangulation of quantitative and qualitative survey data allowed for a deeper exploration of the research questions and participants’ experiences with cannabis. the present study provided further support for both adverse health consequences and therapeutic benefits from the use of cannabis. scores from the cudit-r scale showed that nearly half of respondents who used cannabis within the last six months were categorized as having potential risk for cud. results are consistent with schultz et al. (2019) who discovered most college students in their sample were distinguished as having harmful or problematic cannabis use. our qualitative findings revealed mental health themes (e.g., anxiety) associated with cannabis consumption among approximately 25% of our sample. again, these findings are similar to cannabis risks and benefits 28 previous research studies in which significant positive relationships between anxiety and substance use disorder have been reported (crippa et al., 2009; kedzior & laeber, 2014; lai et al., 2015). contrary to our hypothesis, there was no significant relationship between cud symptoms and quality of life in the current study. goldenberg and colleagues (2017) conducted a systematic review and found heavy cannabis use and cud were associated with reduced quality of life. however, they reported 6 of the 14 studies failed to find an association between cannabis use and quality of life. two possible explanations for our lack of a significant finding could be (a) a mild effect of cannabis use on quality of life within college students or (b) lack of research design sensitivity to uncover the effects. cannabis use and quality of life is likely mediated by characteristics of cannabis users, and more research is needed to delineate these characteristics. in contrast to the negative health consequences associated with the use of cannabis, the majority of respondents revealed an increase in symptom relief when using cannabis compared to non-cannabis treatments and medications. findings are similar to those of stith et al. (2019) who used a mobile app to observe cannabis impacts in real time and discovered that on average, patients experienced significant improvements among the 27 health symptom categories measured (e.g., anxiety, inflammation). our qualitative analysis revealed a third of participants experienced relaxation and stress reduction as a primary benefit of cannabis use. our results are supported by nelson et al. (2020) who found 24.7% of college students in british columbia used cannabis to treat anxiety, 18.8% for physical pain, 30% to enhance their social life, and 29.4% to treat sleeplessness. research has consistently shown that cannabis can provide temporary relief from various health symptoms. however, a growing body of evidence suggests that prolonged cannabis use may also worsen these symptoms (koenders et al., 2016). therefore, it is important to note that our study's findings regarding the relationship between cannabis use and anxiety are likely bidirectional. furthermore, it is important to recognize that the effects of cannabis on an individual's health may vary depending on factors such as their consumption habits, length of use, and the health symptoms they are attempting to alleviate. our study is the first to assess the spiritual benefits of cannabis among college students, an understudied area in cannabis research. our qualitative analysis indicated that most of the participants did not report spiritual benefits from using cannabis. thus, spiritual benefits do not seem to be a driving factor for consuming cannabis among college students. although most participants did not report direct spiritual benefits, 14% of the participants described a greater connection with themselves. additionally, it is noteworthy that respondents reported benefits of cannabis within other qualitative questions that could be related to spirituality, such as gratitude and community connectedness. the researchers left the term “spiritual” to be open and defined by the participant, but this may also have limited responses based on their personal connection with this term. nonetheless, our results are consistent with the demographics of our sample as nearly half of our participants indicated that spirituality was only somewhat important or not too/not at all important to them. our findings correspond with the limited research that exists on spiritual benefits of cannabis in which most students are not drawn to cannabis for spiritual benefits, but for some it is associated with a greater sense of connectedness to self (kohek et al., 2021). finally, our study contributes to the call for current literature regarding the impact of the covid-19 pandemic on college students’ cannabis use and quality of life. roughly a quarter of the total participants who answered the question (27.8%) reported an increase in cannabis consumption, and numerous participants credited this to staying at home, anxiety, and stress due to the pandemic. other studies have also found increases in cannabis use throughout the covid-19 pandemic (boehnke et al., 2021; cousijn et al., 2021; van hoojidonk et al., 2022). specifically, bartel et al. (2020) conducted a study indicating that people who chose to self-isolate during the pandemic used larger amounts of cannabis than those who did not. a proportion of students (13%, n = 20) cannabis, a publication of the research society on marijuana 29 reported decreased cannabis consumption and almost half of these (n = 8) credited this to moving back home where parents disapproved of cannabis use and not being at college where cannabis is accessible. previous research explaining decreased cannabis consumption is limited; however, van hooijdonk et al. (2022) also found a small portion of their participants who reported decreased cannabis use due to covid19. implications the findings from the current study contribute to essential implications for the development of university prevention and wellness strategies. the results of the present study indicate college students perceived a significant amount of symptom relief using cannabis compared to traditional noncannabis treatments or medications. however, there were also a substantial number of students who reported potential problematic cannabis use. educational institutions within states with and without legalized cannabis should provide supportive resources such as cannabis education workshops (e.g., cannabis consequences, local and national cannabis policies, safe and therapeutic use of cannabis). campus counseling services and/or health educators could provide focus groups for students to share experiences with their use of cannabis and evidence-based cannabis programs (montemayor et al., 2022). limitations and future directions limitations of this study include a relatively small sample size of college students (n = 170), the majority of participants identified as female, and a lack of a diverse religious/spiritual identities as the sample primarily identified as catholic, agnostic/atheist, and christian. furthermore, the sample is composed of psychology students which is not representative of the general population. since the current study utilized a selfreport survey, desirability bias could have been present. additionally, the project was crosssectional and did not measure perceptions or the impact of perceptions on observable behavior or symptoms longitudinally. lastly, important cannabis use variables were not controlled for (e.g., dosage used, method of administration, cannabis strain) in order to accurately compare results and quantify the impact (goldenberg et al., 2017). our study adds to the limited literature exploring perceived spiritual benefits of cannabis among college students. we left the term spiritual open for interpretation by participants, and it would be interesting to compare our findings to future research in which researchers either define spirituality or qualitatively explore how participants define spirituality as it relates to cannabis use. future research should continue studying cannabis use experiences among vulnerable subgroups (e.g., college students and other ethnic minority groups) in states where cannabis is recreationally and/or medicinally legalized due to their increased cannabis use during and after the covid-19 pandemic (riehm et al., 2022; lee et al., 2023; schepis et al., 2021). given that more than half of the current sample reported potential problematic cannabis use, it is essential to understand the reasons for consuming cannabis and the associated health-related outcomes. moreover, it is important to replicate research across diverse samples of adults longitudinally and control for important cannabis variables in order to accurately compare results and quantify impact. moving forward, it will be essential to continue studying cannabis-related behaviors during and after historical moments in time which can impact health such as the covid-19 pandemic among at-risk groups. conclusion the present study used an exploratory approach to understand the ways, both beneficial and detrimental, in which college students use and perceive cannabis. the quantitative and qualitative findings provide a basis of understanding in regards to the impact of recreational and medicinal legalization and the covid-19 pandemic on cannabis-related behaviors among college students. proceeding forward, it is important for future research to examine various aspects of cannabis use and perceptions among vulnerable subpopulations in order to acquire more information in which it influences one’s mental, physical, and spiritual health. this will result in updating cannabis cannabis risks and benefits 30 prevention and wellness strategies that are culturally relevant to the rapidly evolving legal cannabis landscape across the u.s.a., especially among university institutions. references abizaid, a., merali, z., & anisman, h. 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(2014). therapeutic benefits of cannabis: a patient survey. hawai'i journal of medicine & public health, 73(4), 109–111. funding and acknowledgements: this work was supported by the mcnair scholars program (award number p217a170213) and the koret foundation (gift 20-0068) through the csumb undergraduate research opportunity center. we have no conflicts of interest to disclose. we thank courtney crouse for her contributions to the research study by helping analyze the qualitative data. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://doi.org/10.1176%2fappi.ps.202000189 https://creativecommons.org/licenses/by/4.0/ v5i3a6_authors_v2 research article 61 ved abstract cannabis use frequency among adolescents is associated with negative outcomes. two variables associated with cannabis use frequency are method of acquisition and accessibility of cannabis. prior research on the relation between methods of acquisition and cannabis use frequency is sparse. differences in cannabis use in states in which the sale of recreational cannabis is legal (recreational states) compared to states in which it is not warrants research on how adolescents acquire cannabis in recreational states, and how easy it is for them to do so. the primary way in which adolescents acquire cannabis and the ease by which they can acquire cannabis may be associated with cannabis use frequency via specific interactions. we hypothesized that primarily acquiring cannabis from a store would be positively associated with cannabis use frequency when compared to other primary methods of acquisition, and that accessibility would meditate relations between primary method of acquisition and cannabis use frequency. this study used data from high school students who completed the 2019 healthy kids colorado survey (hkcs) who reported using cannabis in the past 30 days. results indicated that primary method of acquisition was significantly differentially associated with 30-day cannabis use frequency, with participants who reported buying cannabis at a store reporting significantly higher 30-day cannabis use frequency than any other method of acquisition. ease of accessibility was not significantly associated with 30-day cannabis use frequency and did not significantly mediate the relation between primary method of acquisition and 30-day cannabis use frequency. results of the current study indicate that the ways in which adolescents acquire cannabis are associated with how often they use it. further, the positive relation between primarily acquiring cannabis at stores and frequency of use provide evidence that access to stores may be a risk factor for cannabis use frequency among adolescents. key words: = cannabis stores; healthy kids survey; perceived harmfulness cannabis use frequency among adolescents is associated with impaired cognition (estoup et al., 2016), mental health problems (buckner et al., 2010), risky behaviors (caldeira et al., 2008), negative physical health outcomes (aldington et al., 2008), and other negative outcomes (simons et al., 2012). while research has identified certain factors associated with cannabis use, two understudied variables are method of acquisition (king et al., 2016) and ease of accessibility (epstein et al., 2015; haas et al., 2018). the ways in which these two variables interact and relate to cannabis use frequency is currently unknown. prior research on the relation between cannabis accessibility and cannabis use frequency has largely used measures that are associated with state-wide accessibility (e.g. legalization status; parnes et al., 2018), while studies that utilize selfalexander j. tyskiewicz1, patrice a. arkfeld1, emma e. smith1, jonathan k. eilerman1, bradley t. conner1 1department of psychology, colorado state university cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.006 does accessibility of cannabis mediate the relation between method of acquisition and cannabis use frequency among adolescents? corresponding author: alexander j. tyskiewicz, colorado state university, fort collins, co 80525. email: alexander.tyskiewicz@colostate.edu. acquisition of cannabis among adolescents 62 report measures of accessibility are sparse. similarly, prior research on the relation between methods of acquisition and cannabis use frequency has neglected several methods of acquisition and is sparse. the ways in which adolescents acquire cannabis and the ease by which they can acquire it may be associated with cannabis use frequency via specific interactions. more specifically, it is likely that certain methods of acquisition are related to varying levels of accessibility, and in turn, are associated with use frequency. based on prior research, the relation between method of acquisition and cannabis use frequency may be partially explained by the relation between method of acquisition and accessibility, followed by the relation between accessibility and cannabis use frequency (harpin et al., 2018; epstein et al., 2020; anderson et al., 2019; haas et al., 2018). for example, if adolescents are able to acquire cannabis at cannabis stores via the use of a fake id, they may be able to access cannabis more easily, which would in turn partially explain how this method of acquisition may be associated with an increase in cannabis use frequency. the association between method of cannabis acquisition and cannabis accessibility is currently unknown. there is evidence that cannabis use among the general population tends to increase following legalization (epstein et al., 2020). research has shown that daily, weekly, and monthly cannabis use are significantly higher among individuals living in recreational states, (goodman et al., 2020) and legalization of recreational cannabis were associated with an increase in past year cannabis use (bailey et al., 2020). this association between legalization and cannabis use appears to apply to adolescents as well as adults, as increases in cannabis use and perceived accessibility among adolescents have been observed after medical and nonmedical cannabis legalization (mason et al., 2016; borodovsky et al., 2017; azofeifa et al., 2016). for example, cannabis use significantly increased among 8th and 10th graders after washington state legalized recreational use (anderson et al., 2019), and adolescents in colorado reported that acquiring cannabis is easier after the implementation of recreational stores (harpin et al., 2018). adolescent cannabis use in recreational states is significantly higher than in non-recreational states (harpin et al., 2018); this warrants research on how adolescents acquire cannabis in recreational states, and how easy it is for them to do so. cannabis legalization increases the number of methods by which an individual can acquire cannabis, as people over the age of 21 are able to purchase cannabis at cannabis stores and legally grow their own cannabis (epstein et al., 2020). these additional methods of acquisition may result in people using cannabis more frequently. further, the increased accessibility for adults may also impact the extent to which cannabis products are accessible to adolescents. that is, recreational legalization increases the amount of cannabis present in communities and the number of products accessible (kepple & freisthler, 2018), which may “trickle down” to the supply of cannabis products available to adolescents. few studies have examined the ways in which accessibility is associated with cannabis use. one such study found higher levels of community cannabis availability to be positively associated with chronic cannabis use trajectories in adolescents (epstein et al., 2015). additionally, a recent study exploring the interactions between adolescent use patterns, impulsivity, and ease of access to cannabis found that cannabis accessibility was positively associated with adolescent cannabis use (haas et al., 2018). researchers also identified a significant positive correlation between adolescent impulsivity and cannabis use was significantly moderated by the perceived level of access to cannabis (haas et al., 2018). similarly, few studies have examined how method of acquisition is associated with cannabis use. one such study found that buying cannabis in a home, apartment, or dorm was positively associated with frequency of cannabis use among adolescents (king et al., 2016). this study also found that ~60% of adolescents did not buy cannabis the last time they used it, while ~40% of adolescents paid for cannabis, and 1.4% of adolescents reported that they traded something else for the cannabis they acquired. further, researchers found that sex, ethnicity, age of initiation, and 30-day frequency were all associated with method of acquisition. adolescents who used cannabis frequently were more likely to acquire cannabis for free than individuals who reported using cannabis infrequently (king et al., 2016). there is evidence that the most common way adolescents acquire cannabis is from friends, cannabis, a publication of the research society on marijuana 63 though researchers did not ask participants to distinguish if they bought it or were given the cannabis for free (wagner et al., 2021). a study conducted in amsterdam found that among adolescents, the most common place to acquire cannabis was in coffeeshop/stores (harrison et al., 2007). moreover, one study found that the availability of cannabis stores was positively associated with a higher rates of use among 8th and 10th graders (shi, 2016). these studies provide evidence that the presence of stores be positively associated with adolescent cannabis use. research has supported the idea that method of acquisition is associated with adolescent cannabis use (king et al., 2016), although research examining why method of acquisition is associated with adolescent cannabis use is limited. one explanation of this association may be that the ability to acquire cannabis via certain methods may increase accessibility to cannabis. for example, if adolescents can acquire cannabis from stores using fake id’s, their ability to access cannabis may be greater, as they can acquire from a source that virtually always has a supply of cannabis products. higher accessibility to cannabis products has been shown to be positively associated with cannabis use (epstein et al., 2015). therefore, accessibility to cannabis may mediate the relation between primary method of acquisition and cannabis use. one aim of this study was to examine how primary methods of acquisition vary in the ways they are associated with cannabis frequency. another aim of this study was to examine if relations among primary methods of acquisition and cannabis use frequency are mediated by accessibility to cannabis. the purpose of these aims was to clarify the role accessibility plays in the associations between primary methods of acquisition and cannabis use frequency. one focus of the current study was to add to the existing literature regarding how cannabis legalization and policy may be related to adolescent cannabis use. therefore, hypotheses of the current study focus on acquiring cannabis from stores. based on the literature reviewed, we hypothesized that acquiring cannabis from a store would be significantly positively associated with cannabis use frequency compared to other primary methods of acquisition and that accessibility would meditate relations between primary methods of acquisition and cannabis use frequency. we hypothesized that the positive relation between primarily acquiring cannabis from a store and cannabis use frequency compared to other primary methods of acquisition would be partially explained by the positive relation between primarily acquiring cannabis from a store and accessibility, followed by positive the relation between ease of accessibility and cannabis use frequency. methods sample this study used data from high school students who completed the 2019 healthy kids colorado survey (hkcs), an anonymous biennial survey assessing the health and wellness of middle and high school students in colorado (colorado department of public health and environment [cdphe], 2020). given study hypotheses, we restricted the sample to only those adolescents who reported using cannabis in the 30 days prior to the day they completed the survey. hkcs is funded by the colorado departments of education, human services, public safety, and public health and environment and more than 30 additional organizations. the 2019 data were collected via a two-stage stratified cluster design from 46,537 students at 166 randomly selected high schools across 49 colorado counties with a 52% response rate (cdphe, 2020). for this study, we only analyzed data from participants who endorsed using cannabis in the 30 days prior to completing the survey (n= 4,370, described in participants section). schools were granted monetary compensation for participating in the survey and teachers were given verbal prompts and instructional videos to show to students before they completed the survey. the superintendents, school districts, principals, parents, and student participants were told they could withdraw from the survey at any time. hkcs was available in english and spanish and both online and on paper based on school and student needs (cdphe, 2020). colorado state university institutional review board approved the secondary data analyses of this data presented herein. the survey was administered during a regular scheduled class period, and students were released back to their normal activities after the survey was completed. there were two modules of the 2019 survey, module a and module b, that incorporated acquisition of cannabis among adolescents 64 table 1. sociodemographic characteristics of participants n % sex male 2211 51.28 female 2101 48.72 gender identity* not transgender 4052 95.14 transgender 76 1.78 unsure if they are transgender 54 1.27 do not understand the question 77 1.81 race non-hispanic, white 2190 51.00 hispanic/latino/a/x 1610 37.49 multiple races 238 5.54 black or african american 117 2.72 asian 62 1.44 american indian/alaskan native 58 1.35 native hawaiian or other pacific islander 20 0.47 note. n = 4,370. participants were on average 15.98 years old (sd = 1.17). * participants were provided answer options for “no, i am not transgender,” “yes, i am transgender,” “i am not sure if i am transgender,” and “i do not know what this question is asking,” so it is possible that participants whose gender identity was beyond transgender and cisgender (e.g., genderqueer, gender non-conforming, two-spirit) selected other answer options. planned missingness to reduce the number of questions each participant answered. the present study used data from respondents who completed a subset of cannabis questions that were included in module b assessing how one obtains cannabis, frequency of cannabis use, and accessibility of cannabis. participants the analytic sample consisted of 4,370 participants between the ages of 12 and 18 (m = 15.98, sd = 1.17) who endorsed using cannabis in the 30 days prior to test administration. when asked about biological sex, 48.7% of participants identified as female and 51.3% identified as male. see table 1 for a full summary of the sociodemographic characteristics. study measures to measure cannabis accessibility, students were asked, “during the past 30 days, how did you usually get the marijuana that you used?” students were instructed to select one of the following options: “i did not use marijuana in the past 30 days,” “i bought it at a marijuana store or center,” “i bought it from someone else,” “a parent or family member over the age of 21 gave it to me,” “a friend over the age of 21 gave it to me,” “someone under the age of 21 gave it to me,” and “i took it without permission from the owner.” for the purposes of the present study, the answer options for “a parent or family member over the age of 21 gave it to me” and “a friend over the age of 21 gave it to me” were combined into one answer option that represented participants obtained cannabis from someone over the age of 21. this variable was treated as a categorical independent variable that was dummy coded with purchase at a store or center as the reference category. frequencies for each option are presented in table 2. to measure ease of accessibility to cannabis, students were asked, “if you wanted to get some marijuana, how easy would it be for you to get some?” answer options included: “very hard,” “sort of hard,” “sort of easy,” and “very easy.” this variable serves as a pseudo-continuous mediator in the present study. the descriptive statistics for this variable a presented in table 2. cannabis, a publication of the research society on marijuana 65 table 2. variable descriptives variable cannabis acquisition % endorsed “i bought it at a marijuana store” 3.9 “i bought it from someone else” 37.5 “someone over the age of 21 gave it to me” 22.6 “someone under the age of 21 gave it to me” 31.1 “i took it without permission from the owner” 4.9 cannabis accessibility “if you wanted to get some marijuana, how easy would it be for you to get some?” % endorsed “very easy” 31.2 “sort of easy” 19.9 “sort of hard” 16.8 “hard” 32.1 cannabis use m (sd) “during the past 30 days, how many times did you use marijuana?” 3.6 (1.5) 30-day cannabis use frequency by acquisition category m (sd) “i bought it at a marijuana store” 4.7 (1.5) “i bought it from someone else” 3.9 (1.5) “someone over the age of 21 gave it to me” 3.6 (1.5) “someone under the age of 21 gave it to me” 2.8 (1.1) “i took it without permission from the owner” 3.9 (1.5) note. cannabis frequency scale 1 = “1 or 2 times,” 2 = “3 to 9 times,” 3 = “10 to 19 times,” 4 = “20 to 39 times” and 5 = “40 or more times.” students cannabis use was measured by a question asking, “during the past 30 days, how many times did you use marijuana?” answer options included: “0 times,” “1 or 2 times,” “3 to 9 times,” “10 to 19 times,” “20 to 39 times” and “40 or more times.” this variable was treated as a pseudocount variable, with 0 =0, 1 = 1 to 2 times, 2 = 3 to 9 times, 3 = 10 to 19 times, 4 = 20 to 39 times, and 5 is 40 or more times. descriptive statistics are presented in table 2. analyses the present study investigated the differential associations of methods of cannabis acquisition with 30-day cannabis use frequency and the mediating effect of accessibility of cannabis on the relation between methods of cannabis acquisition and 30-day cannabis use frequency in a sample of adolescents who reported using cannabis in the 30 days prior to the day they completed the survey. initially a little’s mcar test (little, 1988) was conducted in spss, version 27.0 (ibm corp, 2020) to determine if there were patterns of missing data. we treated method of acquisition as the independent variable, ease of acquisition as the mediating variable, and cannabis use in the previous 30 days as the dependent variable. given the distribution of the dependent variable (underdispersed pseudo-count), study hypotheses were tested using poisson regression (tutz, 2011). in r, version 4.0.5 (shake & throw; r code team, 2013). in poisson regression, parameter estimates are exponentiated to calculate the incidence rate ratio (irr) for ease of interpretation. given that the independent variable was categorical, we compared methods of acquisition via dummy coding. mediation was tested by multiplying the independent variable with the mediator, resulting in a dummy coded mediator. alpha was set to 0.05 for all analyses. results results of the little’s mcar analysis indicated that data were missing completely at random (c2 = 0.69, df = 2, p = 0.71). results of the poisson regression indicated that the hypothesized model acquisition of cannabis among adolescents 66 adequately fit the data (2270.634 4148 1(c2 = 22.70, 63, df = 4148, p = 0.51). when examining the direct effects, results indicated that the methods of acquisition were significantly obtaining cannabis from a store or center was more strongly associated with 30-day frequency of use than were the other methods of acquisition (p < 0.05). the results from the poisson regression are presented in table 3. the results also indicated that ease of accessibility was not significantly associated with 30-day cannabis use frequency (table 4). ease of accessibility also did not significantly mediate the relation between methods of acquisition and 30-day cannabis use frequency (figure 1). specifically, the interaction term between primary method of acquisition and ease of acquisition did not significantly predict 30cannabis use frequency for any method of acquisition. subsequent exploratory analyses of the results indicated that individuals who reported “i bought it at a marijuana store or center,” reported significantly higher 30-day cannabis use frequency than any other category (table 3). differences between the other categories were inconsequential, though individuals who reported that, in the last 30 days, they typically acquired cannabis by having a friend under the age of 21 give it to them reported the lowest 30-day cannabis use frequency. means for 30-day cannabis use frequency by acquisition category are reported in table 2. table 3. 30-day cannabis use frequency predicted by primary method acquisition b se p irr intercept 1.53 0.08 <0.001 4.62 “i bought it at a marijuana store” “i bought it from someone else” -0.19 0.04 <0.01 0.83 “someone over the age of 21 gave it to me” -0.27 0.04 <0.01 0.76 “someone under the age of 21 gave it to me” -0.53 0.04 <0.01 0.59 “i took it without permission from the owner” -0.19 0.05 <0.01 0.83 note. exploratory analyses were run between all methods of acquisition using kruskal wallis pairwise comparisons given that the dependent variable was count-distributed. pairwise comparisons revealed no significant differences between any of the other methods of acquisition and 30-day cannabis frequency. “i bought it at a marijuana store” was the comparison category and the intercept represents the relation between cannabis frequency and method of acquisition. figure 1. path model for cannabis acquisition predicting 30-day cannabis, mediated by cannabis accessibility note. “i bought it at a marijuana store” was the reference group. nonsignificant effects not reported. standardized coefficients and standard errors are shown in the figure. * p < .05, *** p < .001. cannabis, a publication of the research society on marijuana 67 table 4. correlation matrix between cannabis acquisition and cannabis accessibility variable mean sd 1 2 3 4 5 6 7 8 1. “very hard” 0.32 0.47 2. “sort of hard” 0.17 0.37 -0.31** 3. “sort of easy” 0.20 0.40 -0.34** -0.22** 4. “very easy” 0.31 0.46 -0.46** -0.30** -0.34** 5. “i took it without permission from the owner” 0.05 0.22 0.02 -0.02 -0.03 0.01 6. “someone under the age of 21 gave it to me” 0.31 0.46 -0.01 0.01 -0.01 0.01 -0.15** 7. “someone over the age of 21 gave it to me” 0.14 0.35 0.00 0.01 0.00 -0.01 -0.09** -0.27** 8. “i bought it from someone else” 0.09 0.28 -0.01 0.01 0.02 -0.01 -0.07** -0.21** -0.12** 9. “i bought it at a marijuana store” 0.37 0.48 0.00 -0.01 0.01 0.00 -0.18** -0.52** -0.31** -0.24** note. m and sd are used to represent mean and standard deviation, respectively. * indicates p < .05. ** indicates p < .01. acquisition of cannabis among adolescents 68 discussion results of the current study indicate that the ways in which adolescents primarily acquire cannabis are associated with how often they use cannabis. specifically, results indicated that individuals who reported “i bought it at a marijuana store or center,” reported the highest 30-day cannabis use frequency. this is consistent with previous research showing that access to stores is associated with increases use among adolescents (harpin et al., 2018; kepple & freisthler, 2018). this, in turn, may help explain the association between recreational cannabis legalization and increased cannabis use. future research on this issue may help to discern if impacts of legalization on use are a function of increased methods of acquisition, or changes in beliefs regarding cannabis use. as cannabis use has been shown to be associated with negative outcomes among adolescents (jacobus et al., 2009; d’amico et al., 2017), findings reported herein are particularly valuable as they identify a significant association with frequent adolescent use, which can be particularly harmful. it is important to note that about 4% of the sample of adolescents who reported cannabis use in the past 30 days reported getting cannabis from a store. note that, in the state of colorado, it is illegal for an individual under the age of 21 to purchase recreational cannabis and illegal for anyone without a medical card to purchase medical cannabis. given that colorado routinely assesses whether individuals under the age of 21 are able to enter stores and purchase recreational cannabis and that these assessments generally indicate a rate of at least 98% compliance with verifying age (https://norml.org/blog/2022/08/10/ colorado-licensed-marijuana-retailers-compliantwith-minimum-age-restrictions/), it is unclear how adolescents are purchasing cannabis from cannabis stores. the epidemiological nature of the data collected via the hkcs did not allow us to analyze how adolescents are purchasing cannabis from cannabis stores. future research should examine how adolescents are purchasing cannabis at a cannabis store. the fact that ease of acquisition did not mediate the relation between primarily acquiring cannabis at a store and increased cannabis use frequency may indicate that the ability to acquire cannabis at stores does not increase how easily adolescents think they can acquire cannabis, as they may be able to access cannabis elsewhere. instead, the relation between primarily acquiring cannabis at stores and increased use frequency may be a result of adolescents who are more invested in cannabis use using more frequently and going to greater lengths to acquire cannabis products. limitations one limitation of this study was that cannabis use was measured by 30-day frequency. measuring cannabis use with a measure of cannabis frequency fails to assess the quantity of cannabis used and the potency of the products being used. therefore, differences in use frequency may not be indicative of true differences in overall cannabis use if individuals are using cannabis in varying quantities and potencies. another limitation is that this study was a secondary data analysis study. that is, the patterns examined in the current manuscript did not inform the creation of the items used. the use of self-report data was a limitation in the current study. participant’s estimates of how often they acquire cannabis via varying methods, the ease at which they can acquire cannabis, and the frequency at which they use cannabis may have been inaccurate. moreover, participants may have felt particularly motivated to underestimate or deny cannabis use, as adolescent cannabis use is illegal in colorado. another limitation is that participants were asked how they “usually” acquired cannabis. this method of assessing how participants acquire cannabis prevented the research team from examining if participants used several methods of acquisition or solely used one method of acquisition. therefore, the current study was limited in its ability to accurately describe how participants acquired cannabis and examine how the nuances of participant’s methods of acquisition are related to accessibility and 30-day frequency. results of the current study can only be generalized to certain populations. results can be applied to adolescents who have recently used cannabis in states where recreational cannabis use and sales are legal for those over the age of 21. that is, results cannot be generalized to adults, children under the age of 12, adolescents who cannabis, a publication of the research society on marijuana 69 have not used cannabis in the past 30-days, or individuals in states where use and sales of recreational cannabis is not legal. conclusion and future directions research further examining the ways in which adolescents acquire cannabis from stores is warranted. strict guidelines regarding how cannabis stores accept identification should incentivize stores to effectively detect fake id’s, as consequences for failing to do so are severe (buller et al., 2016). firstly, understanding the extent to which both the use of fake id’s, and cannabis store lenience relate to this method of acquisition is imperative. testing if cannabis store lenience is associated with adolescent endorsement of acquiring cannabis via stores is necessary. further, testing if the age of adolescents is associated with endorsement acquiring from stores would further inform how fake ids are being used. overall, this study suggests that primarily acquiring cannabis from stores is a risk factor for using cannabis frequently among adolescents, and that the association between primarily acquiring from stores and frequent use is explained by something other than increased accessibility. references anderson, d. m., hansen, b., rees, d. i., & sabia, j. j. 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(2020). associations between marijuana use patterns and recreational legislation changes in a large colorado college student sample. addiction research & theory, 28(3), 211-221 funding and acknowledgements: data was collected under colorado department of public health and environment contracts (brooksrussell, pi). copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 180 abstract current literature on the effect of cannabis use on sleep quality is mixed, and few studies have used objectively-measured sleep measures or real-time sampling of cannabis use to examine this relationship. the prevalence of cannabis use among older adults and persons living with hiv has increased in recent years, and poor sleep quality is elevated in these populations as well. however, research examining cannabis-sleep relationships in these populations is lacking. thus, we aimed to examine the relationship between daily cannabis use and subsequent objectively-measured sleep quality in middle-aged and older adults with and without hiv. in this pilot study, seventeen (11 hiv+, 6 hiv-) adults aged 50–70 who consumed cannabis completed four daily smartphone-based surveys for 14 days, in which they reported their cannabis use (yes/no) since the last survey. participants also wore actigraphy watches during the 14-day period to objectively assess sleep quality (i.e., efficiency, total sleep time, and sleep fragmentation). in linear mixed-effects models, cannabis use was significantly associated with greater subsequent total sleep time (ß = 0.56; p = 0.046). cannabis use was not related to a change in sleep efficiency (ß = 1.50; p = 0.46) nor sleep fragmentation (ß = 0.846, p = 0.756) on days with cannabis use versus days without cannabis use. these preliminary results indicate cannabis use may have a positive effect on sleep duration in middle-aged and older adults. however, future studies with larger sample sizes that assess cannabis use in more detail (e.g., route of administration, dose, reason for use) are needed to further understand this relationship. key words: marijuana, sleep health, hiv/aids, aging, ambulatory assessment as state-based legalization of medical and recreational cannabis has expanded in the u.s., cannabis use has increased in middle-aged and older adults as well as people living with hiv (pwh; han et al., 2017; pacek, towe, hobkirk, nash, & goodwin, 2018). the estimated prevalence of sleep disorders is elevated in both pwh (30-73%; allavena et al., 2016; reid & cannabis 2020, volume 3 (2), 180-189 © author(s) 2020 researchmj.org doi: 10.26828/cannabis.2020.02.005 open access cannabis use is associated with greater total sleep time in middle-aged and older adults with and without hiv: a preliminary report utilizing digital health technologies laura m. campbell1,2, bin tang2, c. wei-ming watson1,2, michael higgins3, mariana cherner2, brook l. henry2, raeanne c. moore2 1 sdsu/uc san diego joint doctoral program in clinical psychology, san diego, ca, usa 2 department of psychiatry, university of california san diego, san diego, ca, usa 3 exercise and physical activity resource center, university of california, san diego, san diego, ca., usa corresponding author: raeanne c. moore, hiv neurobehavioral research program, 220 dickinson street, suite b (8231), san diego, ca 92103, usa, email: r6moore@health.ucsd.edu, phone: 619-5435378, fax: 619-543-1235, cannabis use and objective sleep quality 181 dwyer, 2005) and older adults (14-38%; morin, leblanc, daley, gregoire, & merette, 2006; ohayon, 2002) compared to the general population (10%; ram, seirawan, kumar, & clark, 2010). common sleep disturbances in pwh include difficulty falling asleep, short sleep duration, and overall insomnia, which have been linked to chronic daytime fatigue, declines in physical and social functioning, greater use of healthcare services, and reductions in healthrelated quality of life (reid & dwyer, 2005). literature on the relationship between cannabis use and sleep quality is mixed, with both positive and negative sleep outcomes tied to cannabis use. the variability in findings is likely due to the heterogeneous nature of whole plant cannabis and contextual factors of use such as dose, frequency of use, composition of cannabis product, and motivation/s for use (babson, sottile, & morabito, 2017). there is some evidence that chronic cannabis use is tied to worse sleep outcomes with habituation to sleep-inducing and sleep-enhancing properties leading to increased and problematic cannabis use and cannabis withdrawal-related issues such as trouble falling asleep, waking up during the night, and/or experiencing strange dreams (gates, albertella, & copeland, 2016). studies show that short-term, low-dose delta-9 tetrahydrocannabinol (thc) cannabis products have a mild sedative effect, decreasing sleep onset latency and rapid-eye movement (rem) sleep and increasing total sleep time and slow wave sleep, while high-doses of thc decrease rem and slow wave sleep, increase sleep onset latency, and have hallucinatory actions (garcia & salloum, 2015). preliminary research on non-intoxicating cannabis compound cannabidiol (cbd) suggests it may have potential therapeutic benefits at medium and high doses for insomnia and rem sleep behavior disorder (babson et al., 2017). to-date, the majority of cannabis-sleep studies have assessed sleep quality and/or cannabis use with self-report questionnaires that rely on retrospective recall, which is vulnerable to inaccuracy (lauderdale, knutson, yan, liu, & rathouz, 2008; althubaiti, 2016). additionally, many studies that have examined the relationship between cannabis and sleep administer cannabis in a lab setting or in clinical trials (babson, sottile, & morabito, 2017), which may lack generalizability to real-world contexts. studies utilizing digital health technologies in people’s everyday lives are needed to investigate these complex relationships. furthermore, investigations of cannabis use on sleep behaviors are lacking in the context of hiv disease and older age, two populations at high risk for sleep disturbances. therefore, this ecological momentary assessment (ema) and actigraphy study aimed to examine the relationship between real-world self-reported cannabis use and subsequent objective sleep quality in middle-aged and older adults with and without hiv. due to the mixed findings in the literature (as discussed above), as well as the limited literature examining cannabis use and sleep in middle-aged and older adults, we did not have a priori hypotheses and therefore took a more exploratory approach. method participants this study examines a subset of participants (11 pwh; 6 hiv-) who endorsed cannabis use at least once over a 14-day period from a larger-scale ongoing ema study at the hiv neurobehavioral research program (hnrp) at the university of california, san diego (ucsd) between 2016 and 2019. participants were recruited from other studies at the hnrp and from the community. study inclusion and exclusion criteria was kept to a minimum to increase generalizability. all participants were age 50 or older, able to provide written informed consent, and fluent in english. exclusion criteria included: neurological disease or disorder (e.g., stroke), serious mental illness (e.g., schizophrenia), and history of severe learning disorder. participants that had a positive alcohol breathalyzer or urine toxicology screening (excluding cannabis) at their laboratory baseline visit were rescheduled. all procedures were approved by ucsd’s institutional review board, and all participants demonstrated decisional capacity, provided written informed consent, and were compensated for their time. bonus compensation was provided for each ema survey participants completed at the rate of $1/survey. procedures lab visits. at the baseline lab visit, participants completed standardized cannabis, a publication of the research society on marijuana 182 neuromedical and neurobehavioral assessments (see heaton et al. (2010) for more details). medical comorbidities were determined via a combination of clinical interview and review of prescription medications. hiv serostatus was confirmed using a hiv antibody point-of-care rapid test (miriad, medmira, nova scotia, canada). a computerized, semi-structured interview was used to determine dsm-iv criteria for current and lifetime mood disorders and substance and alcohol use disorders (composite international diagnostic interview; world health organization, 1997). dsm-iv criteria were used because this study took place at a center in which data collection methodology is harmonized across studies, and the center’s methodology was instituted prior to the release of the dsm-5. in line with dsm-5 criteria, substance abuse and dependence were combined into one “use disorder” category (see table 1). lifetime total cannabis use days and quantity of cannabis use were also collected using the modified timeline follow-back interview (robinson, sobell, sobell, & leo, 2014). participants were given a samsung smartphone with 4g android operating system and the 3-axis actigraph gt9x link wrist accelerometer. a staff member provided an individually tailored 20-30 minute structured training session to orient participants to the smartphone to help ensure survey completion. participants were asked to carry the smartphone with them throughout the duration of the study, and the smartphone used an encrypted native application framework so data could not be accessed if the smartphone was lost or stolen. staff also oriented participants to the actigraphy watch, and instructed participants to wear the watch on their non-dominant hand 24 hours/day for the duration of the study except when the watch could get wet (e.g., bathing). participants were given a smartphone and actigraphy instruction manual and an actigraphy watch log to record when and why they removed the watch as well as what time they went to bed and woke up. after the participant had completed the 14day ema and actigraphy period, the participant completed a follow-up lab visit to return the devices and complete follow-up surveys. fourteen-day ema and actigraphy study period. over the fourteen-day ema study period, participants received alerts four times per day for total of 56 possible data points per participant. the surveys were dispersed throughout the day in four interval periods: morning, midday, afternoon, and evening. survey times were randomized within each interval period and customized to the participants’ sleep-wake schedule. the text messaging notification on the smartphone sounded every two minutes until the survey was answered or until 16 minutes had passed. if the participant did not respond within 16 minutes, the survey was considered “missed”. the ema survey included a question that queried about substance use: “since the last alarm, have you taken or used any of the following substances? (check all that apply): caffeine, tobacco, herbal supplements, weight-loss supplements, alcohol, cannabis/marijuana, cocaine/crack, crystal/meth, ecstasy/molly, heroin, other street drug(s), prescription drugs not prescribed to me, and no substance/drug use.” the convergent validity of the alcohol and marijuana portion of this question has been previously reported in this sample, and have shown to be correlated to number of days of past use and quantity of use (paolillo et al., 2017). objective sleep measures the wrist-worn actigraph gt9x link device was used to objectively assess sleep quality and has been previously shown to distinguish sleep versus wakefulness when worn at night (cole, kripke, gruen, mullaney, & gillin, 1992). actigraph data was processed by co-author mh at ucsd’s exercise and physical activity resource center, adhering to best practices for processing this dynamic data. the time window to assess sleep versus awake was assessed on a minute-byminute basis using a rolling window (cole et al., 1992; sadeh, sharkey, & carskadon, 1994). participants were asked to record the time they went to bed (i.e. tried to fall asleep) and time they first awoke in daily written logs in order to determine number of minutes in bed. if participant sleep records were missing entirely, sleep onset and awake time were manually determined by a specially trained research assistant. the first minute of 0 movement counts after a drop from 1000 counts was considered the start and the minute before an increase from 0 counts to over 1000 counts was considered the end. manual detection methods for determining cannabis use and objective sleep quality 183 table 1. participant characteristics (n=17) mean (sd), median [iqr], or n (%) demographic variables age (years), m (sd) 57.8 (6.1) male, n (%) 14 (82.4%) race/ethnicity - non-hispanic white, n (%) 9 (52.9%) african american, n (%) 6 (35.3%) hispanic, n (%) 1 (5.9%) other, n (%) 1 (5.9%) education (years), m (sd) 14.5 (1.9) employed, n (%) 2 (11.8%) household income, n (%) - <$10,000 2 (11.8%) $10,000-$19,999 9 (52.9%) $20,000-$34,999 4 (23.5%) $35,000-$49,999 0 (0%) $50,000-$74,999 2 (11.8%) number of other people living in household, median [iqr] 0 [0, 1] percent of time spent alone, median [iqr] 72.5% [39.0%, 81.5%] medical characteristics hypertension, n (%) 9 (52.9%) diabetes mellitus, n (%) 3 (17.6%) hepatitis c, n (%) 1 (5.9%) bmi >30, n (%) 6 (35.3%) psychiatric functioning lt mdd, n (%) 13 (76.5%) current mdd, n (%) 3 (17.6%) lt alcohol use disorder, n (%) 10 (58.8%) current alcohol use disorder, n (%) 1 (5.9%) lt cannabis use disorder, n (%) 7 (41.2%) current cannabis use disorder, n (%) 2 (11.8%) other current substance use disorder, n (%) 0 (0%) hiv characteristics a aids, n (%) 6 (54.5%) current cd4, median [iqr] 787 [688, 821] nadir cd4, median [iqr] 216 [98, 300] duration of hiv infection (years), median [iqr] 24.4 [15.7, 28.0] on art, n (%) 10 (90.1%) undetectable viral load, n (%) b 9 (100%) note. bmi, body mass index; lt, lifetime; mdd, major depressive disorder; a based on the subset of participants with hiv infection (n = 11); b n = 9 cannabis, a publication of the research society on marijuana 184 time in bed is outlined by full et al. (2018). values derived include: (1) total sleep time – the number of minutes asleep; (2) sleep efficiency – the number of minutes asleep divided by number of minutes in bed (ranges from 0-100 with higher values indicating more efficient sleep); and (3) sleep fragmentation index – an index of restlessness during sleep (ranges from 0-100 with higher values indicating more fragmented sleep; knutson, van cauter, zee, liu, & lauderdale, 2011; loewen, siemens, & hanly, 2009). statistical analyses cannabis use was classified per day into two groups: use (at least once in the day) and no use. a participant was considered to have used cannabis during a day if they self-reported cannabis use on the second, third, or fourth survey of that day or first survey of the next day. this methodology was selected because the survey asks “since the last survey”, and, after looking at the survey times and sleep times, the morning survey of the next day was more likely to represent the previous night than that morning. objective sleep measures were compared between cannabis use (i.e., use vs. no use), using a linear mixed-effects regression with subject-specific random intercepts, controlling for study day. the same model was then adjusted for potential confounders, including alcohol use, caffeine use, tobacco use, and hiv status, which were selected using the akaike information criterion (aic; akaike, 1974), a model selection criterion considering both model fit and complexity in evaluating a model. the models were reduced with backward elimination method based on the aic values. weekday versus weekend day (i.e., friday and saturday) were not included as covariates given that only a small proportion of the sample was employed (11.8%). upon examination, sleep and cannabis use did not differ on weekdays vs. weekends (matched t-tests p’s > 0.10). lower aic value indicates better model. results were considered statistically significant at p < 0.05. statistical analyses were implemented using r version 3.5.1 (2018). results overall sample characteristics participant demographic and clinical characteristics are presented in table 1. only 19.5% (n = 17) of participants from the parent study endorsed cannabis use during the study period. on average, these seventeen participants were 57.8 years old, with 14.5 years of education, 52.9% white, and primarily male (82.4%). two participants (11.8%) met criteria for a current cannabis use disorder, and seven (41.2%) participants met criteria for lifetime cannabis use disorder. ema, cannabis use, and sleep characteristics are presented in table 2. the median number of surveys completed was 50 out of 56 possible surveys (89% adherence), and the median percent of surveys in which cannabis was endorsed was 28.3%. the median number of days with sleep data was 11 days. the national sleep foundation recommends  85% sleep efficiency and between 7-9 hours of sleep for middle-aged adults (hirshkowitz et al., 2015; ohayon et al., 2017). on days with both ema and sleep data, the median percent efficiency was 77.2%. on average, 82.4% (n = 14) participants had less than 85% efficiency. the average total sleep time in hours was 5.3 hours. fourteen participants (82.4%) had less than 7 hours of sleep, and no participants had greater than 9 hours of sleep. three participants reported that they were prescribed sleep medications. cannabis and sleep relationships table 3 displays the results for all mixedeffects linear regression models. cannabis use was related to greater subsequent total sleep time ( = 0.559; p = 0.046). however, there was no significant relationship between cannabis use and subsequent sleep efficiency ( = 1.497; p = 0.461) or cannabis use and subsequent sleep fragmentation index ( = 0.846; p = 0.756). hiv status, alcohol use, caffeine use, and tobacco use were added to the models as covariates, and selected based on the aic. after model selection with aic, none of the potential covariates were retained in the models. cannabis use and objective sleep quality 185 table 2. sleep and substance use variables median [iqr], or n (%) sleep variables number of nights of sleep data, median [iqr] 11 [9, 13.5] average percent efficiency, median [iqr] 77.2% [67.4%, 82.9%] efficiency standard deviation, median [iqr]a 8.8 [5.1, 11.6] <85% efficiency, n (%) 14 (82.4%) average total sleep time (hours), median [iqr] 5.3 [4.8, 6.5] total sleep time standard deviation, median [iqr]a 0.87 [0.80, 1.63] <7 hours total sleep time, n (%) 14 (82.4%) average sleep fragmentation index, median [iqr] 38.6 [31.9, 49.8] sleep fragmentation standard deviation, median [iqr]a 13.9 [9.9, 17.0] prescribed sleep medications 3 (17.6%) returned sleep log, n (%) 12 (70.5%) ema cannabis use variables number of surveys completed b, median [iqr] 50 [46.5, 52] percent of surveys in which cannabis use was endorsed 28.3% [4.4%, 48.0%] percent of days in which cannabis use was endorsed 76.9% [42.9%, 92.9%] cannabis use characteristics lt total days of cannabis use, median [iqr] 2564 [684, 10712] lt total quantity of cannabis use (grams), median [iqr] 1728 [102, 5396] note. a a standard deviation was calculated for each participant’s objective sleep quality measures over the time they wore the actigraphy watch. this represents the median [iqr] of those values. b total number of surveys possible = 56. lt = lifetime table 3. relationship between cannabis use and objective sleep quality unstandardized coefficient 95% ci standardized coefficient p-value model 1: efficiency cannabis use (ref: no use) 1.497 [-2.475, 5.470] 0.149 0.461 day 0.027 [-0.386, 0.439] 0.003 0.899 model 2: total sleep time cannabis use (ref: no use) 0.559 [0.015, 1.104] 0.394 0.046 day 0.024 [-0.034, 0.082] 0.017 0.425 model 3: sleep fragmentation index cannabis use (ref: no use) 0.846 [-4.469, 6.161] 0.062 0.756 day -0.456 [-1.018, 0.106] -0.033 0.114 discussion while studies have highlighted that ema is a feasible way to examine substance use (e.g.,paolillo et al., 2018; shiffman, 2009), few studies have used multiple sources of digital health technologies to examine cannabis and health behaviors in the real world. participants demonstrated good adherence to completing the ema surveys and wearing the actigraphy watch, indicating that using both concurrently among older adults with and without co-morbid medical conditions is feasible. our results suggest cannabis use is associated with greater than a half an hour increase in sleep time. however, cannabis use was not associated with an increase or decrease in efficiency or sleep fragmentation. while being mindful of the small sample size and cannabis, a publication of the research society on marijuana 186 unknown cannabinoid content of the cannabis used, these results contribute to the decidedly mixed literature examining sleep and cannabis use that has focused primarily on younger participants in lab-based settings or using retrospective questionnaires (babson et al., 2017). the majority of participants in this study had poor objective sleep quality (i.e., <85% efficiency, <7 hours of sleep). in both older adults and pwh, poor sleep quality has been associated with a variety of negative outcomes such as worse cognitive functioning, everyday functioning, and quality of life (babson, heinz, & bonn-miller, 2013; magee, caputi, & iverson, 2011; mahmood, hammond, nunez, irwin, & thames, 2018; nebes, buysse, halligan, houck, & monk, 2009). the first line medications to treat insomnia, benzodiazepines and z-drugs, have been associated with negative cognitive (e.g., memory loss) and physical (e.g., falls) events, particularly in older adults (glass, lanctôt, herrmann, sproule, & busto, 2005). recent clinical trials have shown that cannabinoids (thc and combined thc/cbd preparations) may have a positive effect on sleep in multiple populations including pwh (bedi et al., 2010; kuhathasan et al., 2019). however, there is a need for further trials to determine the most advantageous composition and dosing of cannabis products that may be efficacious sedative-sparing treatments for insomnia. in particular, cbd, a nonpsychoactive cannabinoid, could be especially useful if proved effective for treating sleep problems in neurocognitively vulnerable populations (e.g., pwh and older adults). these types of trials may benefit from real-time behavioral assessments to show whether cannabinoid based treatments result in similar (or improved) sleep outcomes compared to treatment with sedative/hypnotic medications, and whether such treatment results in better neurocognitive outcomes. there are limitations to this study. first, while there were several ema surveys in which cannabis use was endorsed, only seventeen people were included in this study, thus limiting power to detect associations and the generalizability of the study. demographically, the majority of the sample was male, which is reflective of the hiv population in the surrounding community and the national hiv population (centers for disease control and prevention, 2017); therefore, larger studies with more diverse samples are needed. additionally, we did not have the power to test interaction effects to understand whether sleepcannabis relationships differ by hiv status. this is an important question for follow-up work given that other studies have found the relationship between cannabis and subjective sleep quality differs by hiv status (lim & thames, 2018). second, in order to limit participant burden, the ema study did not assess cannabis use in detail. future studies should examine additional cannabis use characteristics such as dose, route of administration, time of use, composition of cannabis product, and reason/s for use in order to further understand the relationship between cannabis and sleep. third, although we used lagged analyses, causality should not be assumed. cannabis use may be associated with other variables that are also related to sleep that may confound this relationship. overall, this study demonstrates that coupling smartphone-based ema and actigraphy devices to examine the relationship between cannabis use and sleep in the real-world can provide novel insights into the temporal relationships of these behavioral co-factors. in our small sample, findings showed cannabis use was associated with longer sleep duration later that night but was not associated with sleep efficiency nor sleep fragmentation. as recreational and medicinal cannabis use continues to rise, new methodologies that utilize technology such as digital phenotyping (e.g., utilizing phone sensors, keyboard interaction; 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(2018). predicting mood disturbance severity with mobile phone keystroke metadata: a biaffect digital phenotyping study. journal of medical internet research, 20, e241. funding and acknowledgements: we would like to thank the leadership and staff of the exercise and physical activity resource center (eparc) at the university of california, san diego for providing measurement and data processing support and the participants for their contributions. this work was supported by the national institutes of health (r.c.m., grant numbers nimh k23mh105297, nimh k23 mh107260 s1, nimh r21 mh116104) and (l.m.c. and c.w.-m.w. nida t32 da031098). the hiv neurobehavioral research center (hnrc) is supported by center award p30mh062512 from nimh. the san diego hnrc group is affiliated with the university of california, san diego, the naval hospital, san diego, and the veterans affairs san diego healthcare system, and includes: director: cannabis use and objective sleep quality 189 robert k. heaton, ph.d., co-director: igor grant, m.d.; associate directors: j. hampton atkinson, m.d., ronald j. ellis, m.d., ph.d., and scott letendre, m.d.; center manager: jennifer iudicello, ph.d.; donald franklin, jr.; melanie sherman; neuroassessment core: ronald j. ellis, m.d., ph.d. (p.i.), scott letendre, m.d., thomas d. marcotte, ph.d, christine fennemanotestine, ph.d., debra rosario, m.p.h., matthew dawson; neurobiology core: cristian achim, m.d., ph.d. (p.i.), ana sanchez, ph.d., adam fields, ph.d.; neurogerm core: sara gianella weibel, m.d. (p.i.), david m. smith, m.d., rob knight, ph.d., scott peterson, ph.d.; developmental core: scott letendre, m.d. (p.i.), j. allen mccutchan; participant accrual and retention unit: j. hampton atkinson, m.d. (p.i.) susan little, m.d., jennifer marquie-beck, m.p.h.; data management and information systems unit: lucila ohno-machado, ph.d. (p.i.), clint cushman; statistics unit: ian abramson, ph.d. (p.i.), florin vaida, ph.d. (copi), anya umlauf, m.s., bin tang, m.s. the views expressed in this article are those of the authors and do not reflect the official policy or position of the department of the navy, department of defense, nor the united states government. disclosures: dr. raeanne c. moore is a cofounder of keywise ai, inc. she is also a consultant for neuroux and receives compensation for these services. the terms of these arrangement have been reviewed and approved by the university of california, san diego in accordance with its conflict of interest policies. no other authors have conflicts of interest to report. copyright: © 2020 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v6i1a7_authors_final_p research article 79 ved abstract background: understanding, predicting, and reducing the harms associated with cannabis use is an important field of study. timing (i.e., hour of day and day of week) of substance use is an established risk factor of severity of dependence. however, there has been little attention paid to morning use of cannabis and its associations with negative consequences. objectives: the goal of the present study was to examine whether distinct classifications of cannabis use habits exist based on timing, and whether these classifications differ on cannabis use indicators, motives for using cannabis, use of protective behavioral strategies, and cannabis-related negative outcomes. methods: latent class analyses were conducted on four independent samples of college student cannabis users (project most 1, n=2,056; project most 2, n=1846; project psst, n=1,971; project cabs, n=1,122). results: results determined that a 5-class solution best fit the data within each independent sample consisting of the classes: (1) "daily-morning use”, (2) “daily-non-morning use”, (3) “weekend-morning use”, (4) “weekend-night use”, and (5) “weekendevening use.” classes endorsing daily and/or morning use reported greater use, negative consequences and motives, while those endorsing weekend and/or non-morning use reported the most adaptive outcomes (i.e., reduced frequency/quantity of use, fewer consequences experienced, and fewer cannabis use disorder symptoms endorsed). conclusions: recreational daily use as well as morning use may be associated with greater negative consequences, and there is evidence that most college students who use cannabis do avoid these types of use. the results of the present study offer evidence that timing of cannabis use may be a pertinent factor in determining harms associated with use. key words: = cannabis use; weekend; weekday; morning; night; time of use; cannabis motives negative consequences associated with cannabis misuse are of primary concern to cannabis researchers (pearson, 2019). there is evidence that cannabis-related negative consequences may include mental health concerns such as psychosis (d’souza et al., 2016; mchugh et al., 2017), depression and suicidality (kimbrel et al., 2018; roberts, 2019), impacts on cognitive function and educational achievement (arria et al., 2015; homel et al., 2014; meier et al., 2012), motor vehicle accidents (national academies of sciences, engineering, and medicine, 2017), and increased eleftherios hetelekides1, verlin w. joseph2, matthew r. pearson2, adrian j. bravo1, mark a. prince3, bradley t. conner3, crosscultural addictions study team**, protective strategies study team***, and marijuana outcomes study team**** 1department of psychological sciences, college of william & mary 2center on alcohol, substance use, and addictions, university of new mexico 3department of psychology, colorado state university cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.007 early birds and night owls: distinguishing profiles of cannabis use habits by use times with latent class analysis corresponding author: adrian j. bravo, phd, department of psychological sciences, college of william & mary, 540 landrum drive, williamsburg virginia 23815 usa, integrated science center, room 1081. work phone: (757) 221-3881. email: ajbravo@wm.edu latent class analyses based on timing of cannabis use 80 risk for developing prescription opioid use disorders (olfson et al., 2018), among others. a variety of risk and protective factors are associated with cannabis-related consequences, including characteristics of the individual using cannabis, the products they are using, and patterns of consumption. these may include an individual’s use of protective behavioral strategies (bravo, anthenien et al., 2017), the frequency (looby & earleywine, 2007), quantity (walden & earleywine, 2008; zeisser et al., 2012), and potency (prince & conner, 2019) of cannabis consumed, as well as the timing of use, both over the course of a week (i.e., weekend vs. weekday use; bravo, pearson et al., 2017; buckner et al., 2019) and over the course of a single day (earleywine et al., 2016). of these constructs, timing of use has received little empirical attention as a factor associated with cannabis use and related consequences, despite research that supports its relevance. with regard to timing of use over the course of a week, one daily diary study conducted among cannabis using college students found that they reported significantly greater cannabis use on weekend days compared to weekdays (bravo, pearson et al., 2017). another study found that the influence of cannabis motives on use and related problems were distinct based on whether the motives were related to weekend or weekday use (buckner et al., 2019). specifically, all 5 motives (social, coping, enhancement, conformity, and expansion; simons et al., 1998) for using cannabis on the weekdays, as well as enhancement and conformity motives for weekend use, were significantly positively associated with greater cannabis use frequency. with regard to cannabis related problems, all 5 motives for using cannabis on weekends, as well as expansion motives for weekday use, were associated with more problems experienced (buckner et al., 2019). timing of use over the hours of a single day has received even less research attention than weekend vs. weekday use. it is plausible that the acute subjective and cognitive effects of any intoxicant, when consumed earlier in the day, may alter mood, judgment, and decision making such that the experience of negative consequences becomes more likely. in the alcohol literature, an “eye-opener” is an alcoholic drink consumed early in the day and is often interpreted as an attempt to relieve withdrawal (earleywine et al., 2016). questions on consumption of “eye-openers” are commonly deployed in clinical instruments designed to identify problem drinking (e.g., cage, beresford et al., 1990; tweak, cherpitel, 1999; tace, sokol et al., 1989). similarly, the first item on the most used measure for nicotine dependence asks, “how soon after you wake up do you smoke your first cigarette?” (fagerstrom test for nicotine dependence, ftnd; heatherton et al., 1991). these examples clearly highlight that morning use of alcohol and cigarettes is associated with clinical problems, though the processes by which this occurs are thought to be complex (epler et al., 2014). alternatively, “wake and bake” is a colloquial term that refers to morning cannabis use and is integrated in the cannabis subculture, though “wake and bake” is discouraged by individuals who have been using cannabis for a long time (lau et al., 2015). morning cannabis use may be attributed to a number of psychological factors, including mood. testa and colleagues (2019) identified increased daily cannabis use among participants reporting lower positive affect (relative to their own norms) in the morning time. additionally, in one of the few studies to directly examine morning use of cannabis, earleywine and colleagues (2016) compared 257 college students who reported using daily before noon on all 7 days of a week to 76 participants who also used daily but reported never using before noon. the researchers found that morning use accounted for a unique portion of the variance in cannabis-associated problems when controlling for quantity of cannabis consumed, age, and gender, thus supporting morning use as an indicator of more problematic use. these findings suggest time of use may be associated with increased cannabis-related impairment, problems, and dependence. while current evidence on the relationship between morning cannabis use and related problems is not causal, previous studies indicate heavier cannabis use may be associated with more problems associated with dependence. for example, participants in a clinical trial reported decreases in subjective intoxication ratings after using cannabis on 4 consecutive days in accordance with patterns of increased tolerance (gorelick et al, 2013). understanding the association between timing of cannabis use patterns, dependence, and related consequences may yield insight toward preventing harmful use. cannabis, a publication of the research society on marijuana 81 purpose of the present study the present study aimed to examine whether distinct patterns of cannabis use exist based on timing of use (i.e., hour of day and day of week) using latent class analysis (lca). we also sought to examine whether latent classes differed on cannabis use indicators, motives for using cannabis, and cannabis-related negative outcomes. given the exploratory nature of lca, we conducted our analyses across four independent samples of young adult cannabis users to examine replicability. we hypothesized that a lca based on timing of cannabis use would produce groups that differ on weekend vs. weekday and morning vs. non-morning use. we also expected that classes characterized by morning use and more frequent use (i.e., number of days) would report overall greater levels of cannabis use, motives for using cannabis, and number of negative cannabis-related consequences. methods participants and procedures the present study is a secondary data analysis of four independent studies (projects most 1, most 2, psst, and cabs) focused on substance use and mental health among college students. detailed descriptions of study participants and procedures for the parent studies are found in prior published studies (project most [marijuana outcomes study team] 1, pearson, liese, et al., 2017; project most 2, richards et al., 2021; project psst [protective strategies study team], bravo et al., 2018; project cabs [cross-cultural addictive behaviors study], bravo et al., 2021). all data were collected crosssectionally among college students recruited from participating institution’s psychology department participant pools, based on retrospective selfreport surveys. the analytic samples of the present study were limited to u.s. college students who reported past month cannabis use and completed our primary measure of cannabis use (project most 1, n = 2,056, 59.5% female; project most 2, n = 1,846, 60.8% female; project psst, n = 1,971, 68.2% female; project cabs, n = 1,122, 66.3% female). measures cannabis use time indicators for lca across all four samples, cannabis use times was assessed using the marijuana use grid (mug; pearson, marijuana outcomes study team, & protective strategies study team, 2022). as done in prior studies utilizing the mug (e.g., bravo et al., 2021; pearson, kholodkov, et al., 2017), a table was created such that each day of the week (columns) was broken down into six 4hour time blocks (rows; 12a-4a, 4a-8a, 8a-12p, etc.), and participants were asked “during a week of typical marijuana use in the past 30 days, please indicate times, days, and approximate number of grams of marijuana that you used”. participants were provided with images of varying amounts of cannabis to facilitate accurate estimates of their quantity of use in terms of grams of flower. participants wrote into each cell of the table approximately how many grams of cannabis they used (if applicable). for the present study, we coded whether each participant endorsed using cannabis on a specific day regardless of time block (e.g., if a participant endorsed use on monday [at any time block] they were coded as a “1” for monday use) and specific time block regardless of day of use (e.g., if a student endorsed use during 4a – 8a time block [regardless of what day of the week] they were coded as a “1” for 4a – 8a use). taken together, 13 (7 days of week and 6 time blocks) dichotomous variables (0 = no use, 1 = use) were utilized as indicators in the lcas. auxiliary outcome variables all measures used have been validated among college student samples and prior published studies using these datasets have found good internal consistency for each measure among marijuana users within each dataset. cannabis use. typical use frequency and quantity were assessed using the mug (pearson, marijuana outcomes study team, & protective strategies study team 2022). in addition to asking which times participants used, they were also asked to report the quantity of grams of flower consumed during each time block they had used within. we calculated typical frequency of cannabis use by summing the total number of latent class analyses based on timing of cannabis use 82 time blocks for which participants reported using during the typical week (possible range = 0-42). typical quantity of cannabis use was calculated by summing the total number of grams consumed across time blocks during the typical week. this measure was collected in all datasets. cannabis motives. cannabis use motives were measured with the marijuana motives questionnaire short form (mmq-sf; simons et al., 1998). this 24-item scale uses a 5-factor model for measuring motives for using cannabis on the dimensions of enhancement (3 items), conformity (3 items), expansion (3 items), coping (3 items) and social (3 items) motives. participants respond on a 5-point scale from 1 = almost never/never to 5 = almost always/always. for each motive, items were averaged such that higher scores are associated with higher endorsement of that motive. this measure was collected in all datasets. cannabis-related problems and misuse. past 30-day cannabis-related problems were assessed using the 21-item brief marijuana consequences questionnaire (b-macq; simons et al., 2012) in most2, psst, and cabs datasets, and the longer 50-item version was used in the most1 dataset. we summed all items to create a cannabis-problems composite score characterized by the number of distinct problems experienced in the past 30 days. cannabis use disorder (cud) symptoms were assessed using the 8-item cannabis use disorders identification testrevised (cudit-r; adamson et al., 2010). items were summed to create a total score with greater scores indicating greater misuse of cannabis. this measure was collected in all datasets except project most 1. cannabis use norms. a 9-item scale for assessing injunctive norms related to cannabis use (montes et al., 2021) was employed to examine participants’ perceptions of others’ approval of behaviors related to use (i.e., using cannabis, using to get high, using daily). participants responded on a 7-point scale (1 = strongly disapproving to 7 = strongly approving) and were asked about three different groups: their best friends, the typical college student, and their parents. this measure was only collected in projects most 1 and most 2. cannabis internalized norms. internalized norms related to college cannabis use was assessed using the perceived importance of marijuana to the college experience (pimces; pearson, kholodkov, et al., 2017). this scale measures internalized norms related to college cannabis use and has been validated in college student populations. the measure includes 13 items (e.g., “to get high on marijuana is a college rite of passage”) and participants respond on a 5point scale from 1 = strongly disagree to 5 = strongly agree. this measure was only collected for projects most 1 and psst. cannabis protective behavioral strategies. cannabis protective behavioral strategies were assessed using the protective behavioral strategies for marijuana (pbsm; pedersen et al., 2016; 2017). two versions of this measure exist, the 50-item version (used in most 1 dataset; pedersen et al., 2016) and the 17-item version (used in most 2 and psst datasets; pedersen et al., 2017). this scale measures participant’s use of behavioral strategies for mitigating the negative impacts of cannabis use. these strategies include things like limiting use, reducing the likelihood that others would know they used, and reducing the likelihood of experiencing legal problems. participants were asked to report how often they used specific strategies on a scale from 1 = never to 6 = always. this measure was collected in all datasets except project cabs. cannabis identity. identification with being an individual who uses cannabis was examined with a 5-item scale modified from the smoker self concept scale (shadel & mermelstein, 1996). participants rated each item from 1 = strongly disagree to 7 = strongly agree on statements about how much cannabis plays a role in their life and personality, as well as others’ perceptions about the role of cannabis in their life (for example, “marijuana is a part of ‘who i am’”). this measure was only collected in projects most 1 and most 2. statistical analyses to test study aims, we conducted independent lcas based on cannabis use timing indicators on the four independent samples using mplus 8.3 (muthén & muthén 1998 2019). in all four datasets, to determine the optimal class solution, we examined goodness-of-fit indices (e.g., sample adjusted bayesian information criterion; sclove, 1987; akaike information criterion; akaike 1973, 1974), classification diagnostics (e.g., relative cannabis, a publication of the research society on marijuana 83 entropy), and the lo-mendell-rubin adjusted likelihood ratio test (lrt; lo et al., 2001; vuong, 1989). moreover, we substantively interpreted the class solutions and adopted advice from nagin (2005) suggesting that if it is difficult to identify the optimal number of latent classes (for example, if the lrt, goodness-of-fit indices and classification diagnostics provide an ambiguous optimal class solution), the most parsimonious class solution that contains a smallest class greater than 5% of the total analytic sample should be selected. after determining the optimal number of latent classes, equality of weighted means on the auxiliary outcome variables were tested across classes using the automatic bch method (asparouhov & muthén 2015; bakk & vermunt 2016), which utilizes posterior probability-based multiple imputations (asparouhov & muthén 2007). results table 1 reports commonly utilized fit statistics for each sample on 1 through 7 class solutions. across each sample, the lrt suggests that a higher class solution fit better than the previous class solution (e.g., 5-class solution fit significantly better than a 4-class solution). although the 6and 7-class solutions did fit significantly better than their k-1 class comparisons on the lrt, aic, bic, and adjusted bic, the smallest class sizes for 2 of 4 datasets fell below 5% of the total analytic sample for each class solution above 5. for the 5-class solution found in the cabs dataset, though the smallest class size was 4.3% of the total analytic sample from that dataset, in each other sample the smallest class size remained above 5%. further, the relative entropy for the 5-class solutions across samples was above 0.85 (above 0.90 in 2 of 4 datasets), which is considered excellent classification quality (>0.80 is considered ‘high’; clark & muthén, 2009). therefore, after examining each of these results in concert with substantive theoretical interpretation of the classes (marsh et al. 2009; nylund et al. 2007), we selected the 5-class solutions as best fitting the data across samples. the overall pattern of cannabis use endorsed was generally consistent across all four independent samples. this occurred such that, across all samples and classes, participants endorsed using: 1) at similar levels from sundaythursday (range across datasets = 36.6-46.3%), 2) more on fridays and saturdays (range across datasets = 70.4-79.5%), 3) the least between 4am8am (range across datasets = 6.8-8.0%), and 4) at progressively greater rates as the typical day progressed (8am-12pm range across datasets = 17.6-21.5%; 12pm-4pm range across datasets = 25.2-26.2%; 4pm-8pm range across datasets = 39.948.1%; 8pm-12am range across datasets = 77.182.4%), until the 12am-4am time block where use endorsement dropped (range across datasets = 22.0-31.6%; see figure 1). the 5 classes (see figure 2 and table 2) identified were also similar across the four independent samples and were characterized by 2 daily use classes (classes 1 and 2) and 3 weekend use classes (classes 3-5) of varying qualities. class 1 is referred to as the dailymorning class because individuals in this class were characterized by daily and common morning use (i.e., 8am-12pm). class 2 is referred to as the daily-non-morning class as individuals in this class were characterized by daily and uncommon use between 8am-12pm. class 3 is referred to as the weekend-morning class as individuals in this class were characterized by mostly weekend (i.e., friday and saturday) and common morning use. class 4 is referred to as the weekend-night class because individuals in this class were characterized by weekend use, uncommon morning use, and common nighttime use (i.e., 8pm-12am). class 5 is referred to as the weekend-evening class as individuals in this class were characterized by weekend use, and common use from 4-8pm but were the only class to endorse a decrease in use from 8pm-12am (in 3 of 4 datasets, use from 8pm12am was zero for this class). among the most 1, most 2, and psst samples, class 4 was the largest class, while in the cabs sample class 5 was the largest class. the daily use classes 1 and 2 similarly endorsed using around 90% of the time or greater on every day of the week (daily-morning, class 1: range across datasets = 96-100%, mean across datasets = 99.0%; daily-non-morning, class 2: range across datasets = 89.1-100%; mean across datasets = 96.5%) but diverged in their endorsement of morning use between 8am-12pm (daily-morning, class 1: range across datasets = 78.6-84.2%, mean across datasets = 81.6%; daily-non-morning, class 2: range across datasets = 13.3-18.5%; mean across datasets = 16.1%). for the three weekend classes, they endorsed using around 40-90% of the time on latent class analyses based on timing of cannabis use 84 table 1. fit statistics for 1 through 7 class solutions for latent class analysis (lca) across four independent samples number of classes most1 1 2 3 4 5 6 7 aic 30797.245 25081.738 24572.775 24871.021 23834.567 23589.674 23370.512 bic 30870.416 25233.708 24803.545 24491.589 24222.935 24056.841 23916.478 sample-size adjusted bic 30829.144 25147.927 24673.284 24316.850 24003.716 23793.143 23608.302 lo-mendell rubin lrt p-value --<.0001 <.0001 <.0001 <.0001 <.0001 <.0001 relative entropy --0.953 .822 .924 .910 .900 .851 smallest n (% of total sample) 2056 608.6 (29.6%) 576.6 (28.0%) 227.7. (11.1%) 207.0 (10.1%) 40.6 (2.0%) 41.1 (2.0%) most2 1 2 3 4 5 6 7 aic 28454.593 22947.702 22516.415 22184.800 21878.992 21672.366 21559.231 bic 28526.363 23096.763 22742.767 22488.443 22259.926 22130.590 22094.746 sample-size adjusted bic 28485.063 23010.984 22612.511 22313.709 22040.715 21866.901 21786.580 lo-mendell rubin lrt p-value --<.0001 <.0001 0.0489 <.0001 <.0001 .0008 relative entropy --.963 .836 .915 .903 .916 .863 smallest n (% of total sample) 1846 557.8 (30.2%) 541.9 (29.4%) 230.0 (12.5%) 206.5 (11.2%) 151.9 (8.2%) 152.5 (8.3%) psst 1 2 3 4 5 6 7 aic 29860.983 23345.254 22888.611 22502.494 22236.757 22029.845 21870.633 bic 29933.605 23496.084 23117.649 22809.741 22622.212 22493.507 22412.504 sample-size adjusted bic 29892.303 23410.304 22987.390 22635.004 22402.996 22229.813 22104.331 lo-mendell rubin lrt p-value --<.0001 <.0001 <.0001 <.0001 <.0001 <.0001 relative entropy --.971 .930 .853 .884 .890 .906 smallest n (% of total sample) 1971 629.0 (31.9%) 317.3 (16.1%) 289.1 (14.7%) 292.5 (14.8%) 142.9 (7.3%) 132.6 (6.7%) cabs 1 2 3 4 5 6 7 aic 16960.277 13585.165 13263.116 13039.313 12861.730 12737.292 13794.691 bic 17025.574 13720.782 13469.054 13315.571 13208.308 13154.191 14296.193 sample-size adjusted bic 16984.283 13635.023 13338.827 13140.76 12989.145 12890.560 13988.071 lo-mendell rubin lrt p-value ----< .0001 0.0037 .0048 < .0001 <0.0024 0.0006 relative entropy ----.953 .854 .905 .853 .845 .870 smallest n (% of total sample) 1122 384.4 (34.3%) 209.5 (18.7%) 72.2 (6.4%) 50.1 (4.3%) 34.3 (3.1%) 34.1 (2.6%) note. aic = akaike information criterion, bic = bayesian information criterion. lrt = lo-mendell-rubin adjusted likelihood ratio test. cannabis, a publication of the research society on marijuana 85 table 2. description of the 5 classes found in lca analyses across 4 independent samples class # class title % of total sample for each dataset class description 1 daily, morning use most 1: 10.4% of the total sample most 2: 14.5% of the total sample psst: 16.4% of the total sample cabs: 12.5% of total sample across each of the four samples, these classes displayed 96% or greater endorsement of use on each day of the week, as well as 78.6% or greater endorsement of use between the times of 8am12pm. these classes showed the lowest endorsement of use during the time period of 4am-8am (32.9% or lower) and the greatest endorsement of use between the times of 4pm-8pm and 8pm12am (93.4% or greater). 2 daily, nonmorning use most 1: 16.1% of the total sample most 2: 13.1% of the total sample psst: 14.4% of the total sample cabs: 22.7% of total sample across each of the four samples, these classes exhibited 88.3% or greater endorsement of use on each day of the week, and 18.5% or less endorsement of use between the times of 8am-12pm. these classes showed the lowest endorsement of use during the period of 4am-8am (3.7% or lower) and the greatest endorsement of use during the period of 8pm-12am (76.3% or greater). 3 weekend, morning use most 1: 9.2% of the total sample most 2: 10.0% of the total sample psst: 13.2% of the total sample cabs: 4.5% of total sample across each of the four samples, these classes displayed 69.2% or greater endorsement of use on both friday and saturday, while on the remaining days of the week endorsed 55.4% or less use. in 3 out of 4 samples, this class showed 40.1% or greater endorsement of use between the times of 8am-12pm (for the psst sample, 24.9% endorsed use from 8am-12pm). these classes showed the lowest endorsement of use during the time period of 4am-8am (66.9% for cabs sample, 24.2% or lower for all other samples) and the greatest endorsement of use during the period of 8pm-12am (78.2% or greater). 4 weekend, night use most 1: 49.7% of the total sample most 2: 44.2% of the total sample psst: 40.7% of the total sample cabs: 28.2% of total sample across each of the four samples, these classes showed 56.7% or greater endorsement of use on both friday and saturday, while on the remaining days of the week endorsed 19.9% or less use. these class 4 or “weekend, night use” classes endorsed using less than all other classes in their respective samples for the time blocks 12am-4am, 4am-8am, 8am-12pm, and 4pm-8pm (17.5% or less for all samples), while also showing the greatest endorsement of use compared to all other classes in their respective samples in the time block 8pm-12am (100% endorsement for all samples). the lowest endorsement of use within this class was during the time period 4am-8am (0% in all samples). 5 weekend, evening use most 1: 14.6% of the total sample most 2: 18.1% of the total sample psst: 15.3% of the total sample cabs: 34.0% of total sample finally, in 3 out of 4 (most 1, most 2, and psst) samples, these classes exhibited 41.7% or greater endorsement of use on both friday and saturday, while on the remaining days of the week endorsed 16.7% or less use. still in 3 out of 4 samples, these “weekend, evening use” classes endorsed a marked decrease in use in the time block 8pm-12am (0% endorsed use in the 3 samples) when compared to 4pm-8pm (between 57.2% and 35.8% endorsed use in the 3 samples). in the cabs sample, this class displayed similar patterns when compared to the other 3 samples, with some key differences. these are, for each day of the week, class 5 in the cabs sample showed greater levels of use than class 4, and the decrease in endorsed use from 4pm8pm (60.2%) to 8pm-12am (55.2%) was far less pronounced in contrast to the other samples. though these differences existed among the cabs sample compared to the other 3, the overall pattern observed is the same. the class 5 or “weekend, evening use” class in cabs also endorsed using on friday and saturday (65.3%) greater than the remaining days of the week (30.8%), and showed a slight decrease in use endorsed between the evening (4pm-8pm) and nighttime (8pm12am) time blocks. latent class analyses based on timing of cannabis use 86 figure 1. depiction of endorsement rates of cannabis use times across the four independent samples. note that days of the week and times of day are dichotomized variables, thus values are interpreted as the percentage of the sample that endorsed using marijuana on a particular day and at specific times over the course of a day (in terms of six 4-hour blocks of time). project most 1 figure 2. depiction of the five latent classes defined by the percent likelihood that a participant assigned to a class endorsed using cannabis on each day of a typical week and at specific times over the course of a day (in terms of six 4-hour blocks of time) across four independent samples. note that days of the week and times of day are dichotomized variables, thus values are interpreted as the percentage of each class that endorsed using marijuana on a particular day and at specific times over the course of a day. class 1 = daily, morning use; class 2 = daily, non-morning use; class 3 = weekend, morning use; class 4 = weekend, evening use; class 5 = weekend, afternoon use. cannabis, a publication of the research society on marijuana 87 project most 2 project psst project cabs figure 2, continued latent class analyses based on timing of cannabis use 88 fridays and saturdays (weekend-morning, class 3: range across datasets = 69.2-93.7%, mean across datasets = 80.4%; weekend-night, class 4: range across datasets = 62.0-75.4%, mean across datasets = 66.9%; weekend-evening, class 5: range across datasets = 41.7-59.5%, mean across datasets = 51.5%) and less than 56% of the time on all other days of the week (weekend-morning, class 3: range across datasets = 18.7-55.4%, mean across datasets = 37.1%; weekend-night, class 4: range across datasets = 7.9-30.8%, mean across datasets = 14.25%; weekend-evening, class 5: range across datasets = 4.7-16.7%, mean across datasets = 11.0%). the weekend-morning class 3 endorsed greater morning cannabis use (between 8am-12pm) compared to the other weekend classes (weekend-morning, class 3: range across datasets = 24.9-100%, mean across datasets = 51.5%; weekend-night, class 4: range across datasets = 0.5-4.4%, mean across datasets = 1.6%; weekend-evening, class 5: range across datasets = 0.0-13.5%, mean across datasets = 9.15%). the weekend-night (class 4) endorsed nighttime cannabis use (between 8pm-12am) 100% of the time in all datasets (weekend-morning, class 3: range across datasets = 78.2-93.7%, mean across datasets = 86.1%; weekend-night, class 4: range across datasets = 0 [all 100%], mean across datasets = 100%; weekend-evening, class 5: range across datasets = 0.0-55.2%, mean across datasets = 13.8%). the weekend-evening (class 5) endorsed greater cannabis use in the evening (between 48pm: range across datasets = 35.8-60.2%, mean across datasets = 41.54%) than they did at night (between 8pm-12am: range across datasets = 0.055.2%, mean across datasets = 13.8%), whereas no other class showed decreased endorsement in these time periods. thus, the classes are labeled to describe their defining characteristics relative to the other classes. the classes are not labeled to provide a holistic description of their characteristics and should not be interpreted as such. auxiliary tests comparing latent classes on outcomes equality of mean comparisons using the bch method across classes and within specific samples are reported in table 3. for brevity, we provide overall summaries of findings across datasets as opposed to specific findings within each dataset (see table 3 for those specific findings). further, we only discuss differences that were statistically significant. all other findings were inconclusive as to whether or not a mean difference was present across specific classes. cannabis use disorder symptoms and negative consequences the daily-morning class (class 1) tended to show significantly higher scores compared to other classes on the cudit-r. the daily-nonmorning class (class 2) tended to score significantly higher on the cudit-r than all the weekend classes. the weekend-morning class (class 3) tended to score significantly higher on the cudit-r than weekend-night (class 4) and weekend-evening (class 5) classes. regarding cannabis-related negative consequences, the daily-morning class (class 1) tended to show significantly higher negative consequences on the marijuana consequences questionnaire compared to other classes. the daily-non-morning (class 2) and weekend-morning (class 3) classes reported higher negative consequences than the weekend-night (class 4) and weekend-evening (class 5) classes. cannabis use for typical frequency of cannabis use, the daily-morning class (class 1) tended to report significantly higher frequency of use than all other classes. the daily-non-morning class (class 2) tended to endorse significantly higher frequency of use than all the weekend classes. the weekend-morning class (class 3) tended to endorse significantly higher frequency of use than the weekend-night (class 4) and weekend-evening (class 5) classes. the weekend-night class (class 4) tended to endorse significantly higher frequency of use than the weekend-evening class (class 5). for typical quantity of cannabis use, measured by the mug, the daily-morning class (class 1) tended to report significantly higher quantity of use than all other classes. further, the daily-non-morning (class 2) and weekend-morning (class 3) classes endorsed significantly higher quantity of use than the weekend-night (class 4) and weekend-evening (class 5) classes. cannabis, a publication of the research society on marijuana 89 table 3. auxiliary outcome variable means compared within datasets dataset daily morning (class 1) daily nonmorning (class 2) weekend morning (class 3) weekend night (class 4) weekend evening (class 5) summary of significant differences cannabis use, negative consequences, cannabis use disorder symptoms [brief] marijuana consequences questionnaire (macq) most 1 14.416a 10.686b 12.355ab 5.993c 5.919c 1 > 2, 4, 5 2, 3 > 4, 5 most 2 6.654a 5.605b 4.72b 2.547c 2.582c 1 > 2, 3, 4, 5 2, 3 > 4, 5 psst 6.781a 4.939b 4.68b 1.966c 2.147c 1 > 2, 3, 4, 5 2, 3 > 4, 5 cabs 7.639a 5.331b 4.455b 1.612c 2.857d 1 > 2, 3, 4, 5 2, 3 > 4, 5 5 > 4 cannabis use disorder identification test revised (cudit-r) most 1 most 2 13.892a 12.285ab 10.742b 5.971c 5.321c 1 > 3, 4, 5 2, 3 > 4, 5 psst 15.416a 11.864b 9.824c 5.204d 5.764d 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 cabs 15.793a 11.421b 9.197c 4.435d 6.604e 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 5 > 4 typical frequency of cannabis most 1 22.621a 9.563b 7.196c 2.301d 1.478e 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 4 > 5 most 2 23.873a 9.627b 6.86c 2.202d 1.509e 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 4 > 5 psst 24.803a 9.459b 7.517c 1.859d 1.569e 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 4 > 5 cabs 26.265a 9.057b 9.768b 1.269c 3.18d 1 > 2, 3, 4, 5 2, 3 > 4, 5 5 > 4 typical quantity of cannabis most 1 most 2 25.037a 9.209b 7.635b 2.135c 1.728d 1 > 2, 3, 4, 5 2, 3 > 4, 5 4 > 5 psst 26.189a 9.258b 7.719b 2.097c 1.639c 1 > 2, 3, 4, 5 (table continues) latent class analyses based on timing of cannabis use 90 2, 3 > 4, 5 cabs 20.993a 8.242b 10.935c 1.073d 3.347e 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 5 > 4 cannabis use motives social motives most 1 3.027a 2.725b 3.01a 2.611b 2.39c 1, 3 > 2, 4, 5 2, 4 > 5 most 2 2.815a 2.446b 2.462b 2.262c 2.136c 1 > 2, 3, 4, 5 2, 3 > 4, 5 psst 2.745a 2.416b 2.579ab 2.236c 2.151c 1 > 2, 4, 5 2, 3 > 4, 5 cabs 2.767a 2.564a 2.619ac 2.134b 2.304bc 1, 2 > 4, 5 3 > 4 coping motives most 1 2.749a 2.506b 2.588ab 1.98d 2.022d 1 > 2, 4, 5 2, 3 > 4, 5 most 2 2.611a 2.572a 2.172b 1.909c 1.836c 1, 2 > 3, 4, 5 3 > 4, 5 psst 2.53a 2.397a 2.412a 1.853b 1.861b 1, 2, 3 > 4, 5 cabs 3.204a 2.841b 2.409c 1.787d 2.165c 1 > 2, 3, 4, 5 2 > 3, 4, 5 3, 5 > 4 enhancement motives most 1 4.071a 3.898b 3.813b 3.61c 3.31d 1 > 2, 3, 4, 5 2, 3 > 4, 5 4 > 5 most 2 3.896a 3.721a 3.438b 3.292b 3.058c 1, 2 > 3, 4, 5 3, 4 > 5 psst 4.012a 3.719b 3.778b 3.299c 3.208c 1 > 2, 3, 4, 5 2, 3 > 4, 5 cabs 4.115a 4.144a 3.906ac 3.304b 3.676c 1, 2 > 4, 5 3 > 4 5 > 4 conformity motives most 1 1.489ab 1.382b 1.663a 1.447b 1.559a 2, 4 > 3, 5 most 2 1.461a 1.383a 1.469a 1.357a 1.411a none psst 1.363ab 1.325ab 1.459a 1.307b 1.39ab 3 > 4 cabs 1.263a 1.388ab 1.451ab 1.315ab 1.425b 1 > 5 expansion motives most 1 3.129a 2.902ab 2.816b 2.189c 2.122c 1 > 3, 4, 5 2, 3 > 4, 5 most 2 3.17a 2.734b 2.556b 2.044c 2.065c 1 > 2, 3, 4, 5 2, 3 > 4, 5 psst 3.004a 2.751b 2.847ab 2.036c 2.098c 1 > 2, 4, 5 2, 3 > 4, 5 cabs 2.976a 2.787a 2.646a 1.697b 2.203c 1, 2, 3 > 4, 5 5 > 4 (table continues) cannabis, a publication of the research society on marijuana 91 cannabis use norms injunctive norms: best friends most 1 6.112a 5.857b 5.387c 5.101d 5.041d 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 most 2 6.116a 5.819a 5.385b 5.122bc 4.949c 1, 2 > 3, 4, 5 3 > 5 psst cabs injunctive norms: typical college student most 1 5.335a 5.321a 5.085a 5.205a 5.154a none most 2 5.264a 5.357a 5.171a 5.128a 5.197a none psst cabs injunctive norms: parents most 1 3.228a 2.726b 2.845b 2.189c 2.187c 1 > 2, 3, 4, 5 2, 3 > 4, 5 most 2 3.343a 3.152a 3.067a 2.392b 2.147b 1, 2, 3 > 4, 5 psst cabs perceived importance of marijuana to the college experience scale (pimces) most 1 2.931a 2.797b 2.759b 2.476c 2.446c 1 > 2, 3, 4, 5 2, 3 > 4, 5 most 2 psst 2.773a 2.488bc 2.62b 2.374c 2.296c 1 > 2, 3, 4, 5 3 > 4, 5 cabs other constructs protective behavioral strategies for marijuana (pbsm) most 1 3.125a 3.679b 3.757b 4.502c 4.396c 1 < 2, 3, 4, 5 2, 3 < 4, 5 most 2 3.272a 3.767b 4.222c 4.748d 4.718d 1 < 2, 3, 4, 5 2 < 3, 4, 5 3 < 4, 5 psst 3.265a 3.821b 4.217c 4.844d 4.753d 1 < 2, 3, 4, 5 2 < 3, 4, 5 3 < 4, 5 cabs marijuana identity most 1 3.956a 3.231b 2.532c 1.704d 1.691d 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 most 2 3.793a 3.27b 2.717c 1.814d 1.774d 1 > 2, 3, 4, 5 2 > 3, 4, 5 3 > 4, 5 psst cabs latent class analyses based on timing of cannabis use 92 cannabis use motives for social motives, the daily-morning class (class 1) tended to score significantly higher than all other classes, except the weekend-morning class (class 3) where differences were inconclusive. the daily-non-morning (class 2) and weekend-morning (class 3) classes tended to score significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. for coping motives, the daily-morning (class 1) classes showed significantly higher scores compared to the daily-non-morning (class 2) classes and the weekend-morning (class 3) classes in 2 out of 4 datasets. the daily-non-morning (class 2) classes showed significantly higher scores than the weekend-morning (class 3) classes on 2 out of 4 datasets. the weekend-morning (class 3) classes tended to show significantly higher scores than the weekend-night (class 4) and weekend-evening (class 5) classes. for enhancement motives, the daily-morning class (class 1) tended to score significantly higher than other classes (differences were inconclusive compared to daily-non-morning class [class 2] in 2 out of 4 datasets). the daily-non-morning class (class 2) tended to score significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. in 2 out of 4 datasets, the weekend-morning (class 3) class was significantly higher than both the weekend-night (class 4) and weekend-evening (class 5) classes; the weekendnight (class 4) class scored significantly higher than the weekend-evening class (class 5). for expansion motives, the daily-morning class (class 1) scored significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes, and scored significantly higher than the daily-non-morning (class 2) and weekend-morning (class 3) classes in 2 out of 4 datasets. the daily-non-morning (class 2) and weekend-morning (class 3) classes scored significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. finally, for conformity motives, all classes across datasets showed inconclusive differences. cannabis use norms regarding participant’s best friends, the daily classes were significantly different in one (most 1) out of two available datasets (most 1 and 2), and each reported higher injunctive norms (i.e., higher approval by best friends) than all weekend classes. the weekend-morning class (class 3) showed significantly higher injunctive norms scores compared to the weekend-evening class (class 5). for injunctive norms regarding the typical college student, differences were inconclusive among classes on both of the two available datasets (most 1 and 2). for injunctive norms regarding parents, in one (most 1) out of two datasets (most 1 and 2) the daily-morning class (class 1) showed significantly higher scores than all other classes, and the daily-non-morning (class 2) and weekend-morning (class 3) classes scored significantly greater than the weekendnight (class 4) and weekend-evening (class 5) classes. in the most 2 dataset, the daily classes and the weekend-morning class (class 3) scored significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. for marijuana internalized norms, the daily-morning class (class 1) scored significantly higher than the other classes, indicating that they perceived marijuana use to be more integral to the college experience (i.e., internalized norms). the weekend-morning class (class 3) scored significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. cannabis identity and protective behavioral strategies for the cannabis user identity scale (shadel & mermelstein, 1996), assessing the extent to which individuals identify as a cannabis user, the dailymorning class (class 1) scored significantly higher than the other classes. the daily-non-morning class (class 2) scored significantly higher than the weekend classes. finally, the weekend-morning class (class 3) scored significantly higher than the weekend-night (class 4) and weekend-evening (class 5) classes. regarding marijuana protective behavioral strategies, the daily-morning class (class 1) reported scores significantly lower than the other classes (i.e., engaged in fewer harm reduction strategies). the daily-non-morning class (class 2) scored significantly lower than the weekend classes. the weekend-morning (class 3) classes scored significantly lower than the weekend-night (class 4) and weekend-evening (class 5) classes. cannabis, a publication of the research society on marijuana 93 discussion the present study identified five distinct latent classes of cannabis use patterns across four independent samples based on timing of use (i.e., day of week and hour of day). the classes were compared on indicators of cannabis use, userelated negative outcomes, motives for using, use of protective behavioral strategies, perceptions, and norms associated with use. visually (see figure 2), the classes emerged intuitively and mostly in line with our primary hypothesis, such that they differed on morning vs. non-morning use and weekend vs. weekday use. it is important to note that the classes are labeled to describe their defining characteristics relative to the other classes, and not to provide a holistic description of their characteristics. for example, there were some individuals in the daily-morning class (class 1) who did not endorse use in the mornings between 8am-12pm (i.e., averaged across datasets, 18.4% assigned to this class did not endorse use during this time). we labeled it dailymorning because it showed far greater endorsement of morning use relative to the other daily use classes, and this should not be interpreted to mean all individuals probabilistically assigned to this class endorsed morning use. what the label daily-morning is referring to is that individuals assigned to that class were more likely to endorse morning use relative to daily-using individuals not assigned to that class. in other words, any of the classes labeled as ‘morning’ classes should not be interpreted to be assessing the ‘effects of morning use,’ as those classes also endorsed use throughout the day. rather, differences between classes on the auxiliary variables may be partially explained by these differences in timing of use that are being highlighted. with this in mind, it is possible that, for example, some individuals in the weekend-morning class (class 3) are primarily using in the mornings on weekdays and not weekends, despite endorsing more use on the weekends and between 8am-12pm compared to the other classes. with regard to the auxiliary variables, morning and daily cannabis use classes reported lower use of protective behavioral strategies and greater scores on indicators of use, motives, related negative consequences, and perceptions/norms compared to weekend nonmorning use classes. in summary, all classes in all datasets that used in the morning or daily tended to report significantly higher scores (and lower use of protective behavioral strategies) than classes that did not use daily or in the morning. the weekend-night (class 4) and weekend-evening (class 5) classes (i.e., classes that did not use daily or in the morning) were routinely the lowest scoring classes (highest scoring for protective behavioral strategies). these results make sense intuitively and support the hypothesis that daily and morning use of cannabis are both associated with greater risks related to the auxiliary variables. it is theoretically coherent, and evident in the results of the present study, that classes characterized by both risk-associated factors (morning and daily use) generally report higher risk related to cannabis use than other classes. further, classes characterized by one riskassociated factor only (daily-non-morning [class 2] and weekend-morning [class 3]) scored similarly, but still greater than classes characterized by neither risk-associated factor (weekend-night [class 4] and weekend-evening [class 5]). though causal claims cannot be made due to the crosssectional nature of the study, differences in classes on morning vs. nighttime use in these analyses appear to be comparable to (though less impactful in magnitude) daily vs. weekend use as a risk-associated factor for intensifying cannabis use, variables related to use, and the experience of negative consequences. theoretically, this may be because morning use makes additional use later in the day more likely to combat the ‘come down’. further, consumption in the morning may cloud judgment or decision-making and increase the likelihood of using, or generally behaving, in riskier ways. it could also be the case that morning use/timing of use is associated with other indicators related to outcomes, for example social use vs. use while alone. it may be that individuals using more often in the mornings are using more often on their own, and this may partially account for the generally more severe consequences observed. future research should explicitly examine via longitudinal and experimental analyses if and how it may be the case that morning vs. nighttime use confers unique risks not explained by daily vs. weekend use or frequency of use more generally. latent class analyses based on timing of cannabis use 94 clinical implications importantly, in two of three datasets that contained data on individuals’ experience of cannabis use disorder (cud) symptoms, there were significant differences in the experience of these symptoms by class. specifically, the pattern of symptoms from highest to lowest was as follows: daily-morning (class 1) à daily-nonmorning (class 2) à weekend-morning (class 3) à weekend-night (class 4) and weekend evening (class 5). broadly, for the other auxiliary variables associated with use (i.e., not the cudit-r), the same pattern was found, except differences between daily-non-morning (class 2) and weekend-morning (class 3) classes were inconclusive. these findings may reflect the relative strength of association between daily vs. non-daily and common vs. uncommon morning use with cannabis-related outcomes. the present study supports the idea that daily use (i.e., more frequent use) may be a key risk factor compared to morning use, given that both daily use classes displayed generally higher risk of negative consequences regardless of morning use habits. after frequency of use is accounted for, morning vs. uncommon morning use remains a useful indicator for predicting the experience of cud symptoms and other outcomes. this interpretation is consistent with the results of earleywine and colleagues (2016), who found that morning use accounted for unique variance in cannabis-associated problems. the results of the present study indicate that it may be useful for clinicians to consider emphasizing reducing both daily and morning recreational cannabis use, especially given that harm reduction interventions on these specific types of use habits can be relatively straightforward (earleywine et al., 2016). a recent meta-analysis found that, compared to other motives, coping motives’ relations with negative outcomes were the strongest and most reliable, and coping motives were the only factor to emerge as a significant positive predictor of cannabis use frequency as well as problems (bresin & mekawi, 2019). in the present study, both daily use classes reported significantly greater coping motives for using cannabis compared to the weekend use classes (for 2/4 datasets; in the other 2/4 datasets, daily-nonmorning (class 2) and weekend-morning (class 3) did not differ significantly). these results are consistent with the findings of buckner and colleagues (2019), such that weekday, but not weekend, coping motives significantly predicted frequency of cannabis use and associated problems. the present study implies that individuals using cannabis daily and in the morning are using to cope more often than those who do not use daily or in the morning, and this corresponds with greater frequency, more problems experienced, and greater risk of developing cud symptoms. additionally, the results of two recent meta-analyses found a medium sized correlation (14% shared variance) between cannabis use frequency and related problems (bresin & mekawi, 2019; pearson, 2019). the authors suggest that additional risk factors need be identified to explain how (processes) and when (diagnostic criteria) cannabis use becomes problematic (bresin & mekawi, 2019). given the results of the present study, examining timing of use may be promising for predicting cannabis related problems (including cud symptoms) as the legal status of cannabis, and the corresponding number of individuals who choose to use, continues to change. limitations and future research this research has several limitations. first, given the cross-sectional approach, causal claims cannot be made about any of the classes and related auxiliary variables. in other words, daily and morning use may be a correlate rather than a cause of the differences among classes on indicators and outcomes measured. future research should employ longitudinal and experimental designs to examine whether the effects of morning use of cannabis on negative consequences is a proxy for more frequent use, or whether it accounts for unique variance in consequences, as previous studies have suggested. also, given the retrospective self-report nature of the data on a ‘typical week’ of cannabis use over the past 30-days, precise levels of use are not accounted for as they would be in a more intensive design, for example a daily diary. thus, artefacts like potential use-sessions that crossover from a late night into an early morning (i.e., 8pm-12am à 12am-4am) may not be sufficiently accounted for and may present a limitation of the current cannabis, a publication of the research society on marijuana 95 study. additionally, the sample includes only college students and the number of latent classes found in the present study may not be generalizable to other populations. relatedly, there were important differences between the cabs dataset and the other 3 datasets; the weekend-morning class (class 3) in cabs endorsed the greatest use between the times of 124am, 4-8am, and 8am-12pm compared to all other classes, and maintained similar endorsement of use from 4-8pm and 8pm-12am. these patterns were not observed in the other datasets, which highlights the need for future research to examine whether these classes replicate robustly in other diverse datasets. it is also important to note that the analytic samples included relatively few individuals with medical cannabis cards, therefore this work may not generalize to individuals who use cannabis for medical reasons. finally, the cannabis use measures employed in this study inquired about grams of flower used by participants, and therefore these results may not be generalizable to other forms of use (i.e., 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(2012). a 'standard joint'? the role of quantity in predicting cannabis-related problems. addiction research & theory, 20, 82–92. funding and acknowledgements: for all projects, dr. bravo was supported by a training grant (t32-aa018108) from the national institute on alcohol abuse and alcoholism latent class analyses based on timing of cannabis use 98 (niaaa) in the united states during the duration of data collection. data collection for project cabs was supported, in part, by grant t32-aa018108. dr. joseph is currently funded by grant t32-aa018108. for all projects, dr. pearson was funded by a career development grant (k01-aa023233) from the niaaa. niaaa had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. **this project was completed by the crosscultural addictions study team (cast), which includes the following investigators (in alphabetical order): adrian j. bravo, william & mary (coordinating pi); christopher c. conway, fordham university; james m. henson, old dominion university; lee hogarth, university of exeter; manuel i. ibáñez, universitat jaume i de castelló; debra kaminer, university of cape town; matthew keough, york university; laura mezquita, universitat jaume i de castelló; generós ortet, universitat jaume i de castelló; matthew r. pearson, university of new mexico; angelina pilatti, national university of cordoba; mark a. prince, colorado state university; jennifer p. read, university of buffalo; hendrik g. roozen, university of new mexico; paul ruiz, universidad de la república. ***this project was completed by the protective strategies study team (psst), which includes the following investigators: matthew r. pearson, university of new mexico (coordinating pi); adrian j. bravo, william & mary (co-pi); mark a. prince, colorado state university (site pi); michael b. madson, university of southern mississippi (site pi); james m. henson, old dominion university (site pi); alison looby, university of wyoming (site pi); vivian m. gonzalez, university of alaska-anchorage (site pi); amber m. henslee, missouri science & technology (site pi); carrie cuttler, washington state university (site pi), maria m. wong, idaho state university (site pi), dennis e. mcchargue, university of nebraska-lincoln (site pi). ****this project was completed by the marijuana outcomes study team (most), which includes the following investigators (in alphabetical order): amber m. anthenien, university of houston (most 1 & 2); adrian j. bravo, william & mary (most 1 & 2); bradley t. conner, colorado state university (most 1 & 2); christopher j. correia, auburn university (most 1); robert d. dvorak, university of central florida (most 1 & 2); gregory a. egerton, university at buffalo (most 1 & 2); john t. p. hustad, pennsylvania state university college of medicine (most 1 & 2); tatyana kholodkov, university of wyoming (most 1); kevin m. king, university of washington (most 1 & 2); bruce s. liese, university of kansas (most 1 & 2); bryan g. messina, auburn university (most 1); james g. murphy, the university of memphis (most 1 & 2); clayton neighbors, university of houston (most 1 & 2); xuan-thanh nguyen, university of california, los angeles (most 1 & 2); jamie e. parnes, colorado state university (most 1 & 2); matthew r. pearson, university of new mexico (most 1 & 2); eric r. pedersen, rand (most 1 & 2); mark a. prince, colorado state university (most 1 & 2); sharon a. radomski, university at buffalo (most 1 & 2); lara a. ray, university of california, los angeles (most 1 & 2); jennifer p. read, university at buffalo (most 1 & 2). copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 1 ved abstract objective: cannabis use is common among college students and many students use cannabis to cope with negative affect. the covid-19 pandemic was a particularly stressful time for college students. subsequently, the present study compared college students who reported increases in anxiety/depression symptoms since covid-19 stay at home orders to those who reported no change in anxiety/depression symptoms on cannabis coping motives, use frequency, and negative consequences. specifically, we examined whether self-reported changes (i.e., group that indicated increases) in poor mental health during covid-19 were associated with problematic cannabis use via higher cannabis coping motives. method: college students (analytic n = 291) completed an online survey for research credit regarding their personal mental health, covid-19 stressors, and cannabis use behaviors. results: individuals who reported increased depressive symptoms (57.4% of the current sample) due to covid-19 (as compared to individuals whose depressive symptoms remained the same) reported significantly higher cannabis coping motives (d = .79) as well as more cannabis consequences (d = .37). further, students who reported increased (61.5% of the current sample) anxiety symptoms (as compared to those whose anxiety symptoms stayed the same) also reported significantly higher cannabis coping motives (d = .47). moreover, we found that students who reported an increase in depressive/anxiety symptoms reported more cannabis consequences via higher endorsement of cannabis coping motives while controlling for gender, cannabis use frequency, and pastweek anxiety/depressive symptoms. discussion: providing resources for substance-free coping strategies to manage the mental health impact of covid-19 may be extremely useful for this population. key words: = cannabis, mental health, covid-19, college students, cannabis coping motives cannabis use has been prevalent on college campuses for decades and use rates continue to increase (miech et al., 2017). within a recent study, about 53.3% of college students reported that they have used cannabis, and 26.2% reported that they have used cannabis in the past month (pearson et al., 2017). further, excessive cannabis use is associated with numerous negative outcomes (see memedovich et al., 2018 for a review), including experiencing negative cannabis-related consequences (bravo et al., 2019b) and cannabis use disorder (gunn et al., 2020). in examining risk factors of problematic cannabis use, poor mental health has been identified as a key risk factor (phillips et al., 2018; walters et al., 2018). in the united states, rates of depression and anxiety have consistently increased between 2007 and 2018 and likely will continue to do so (duffy et al., 2019). although there are different types of treatments and therapies for mental health issues, students may take it upon themselves and use unhealthy methods to cope with their struggles. although students may use cannabis for a rebecca j. dunaief1, adrian j. bravo1, james m. henson2 1department of psychological sciences, william & mary 2department of psychology, old dominion university cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000163 changes in mental health symptoms as a predictor of cannabis coping motives and consequences: examining the impact of covid-19 among corresponding author: adrian j. bravo, ph.d., department of psychological sciences, william & mary. email: ajbravo@wm.edu college students cannabis, a publication of the research society on marijuana 2 variety of reasons (barker & moreno, 2021; lee et al., 2009; simons et al., 1998), some use cannabis to help deal with negative affect (i.e., coping motives, see cooper et al., 2016 for a review of cannabis motives). using cannabis to decrease issues such as anxiety, sleep, depression, pain, loneliness, social discomfort, and concentration is prevalent in this population, with one study finding that 76% of college students supported using cannabis to self-medicate (wallis et al., 2022). clinically, coping with negative affect by using cannabis leads to problematic cannabis use and negative cannabis outcomes (hartmann & mcleish, 2020). in support of the self-medication hypothesis (khanzstian, 1997) and other negative affect models of addiction (sher et al., 2005), research has found that depressive and anxiety symptoms are indirectly related to cannabis consequences via cannabis coping motives (bravo et al., 2019a, c; buckner et al., 2007; walukevichdienst et al., 2022). although the relationship between mental health issues, cannabis coping motives, and problematic cannabis use has been established, covid-19 has become another stressor for college students. the impact of covid-19 covid-19 destabilized life for college students (telli et al., 2021) and researchers are continuing to gather data to understand the impact covid-19 has had on mental health and cannabis use among college students. one study found that 60.8% of students had increased anxiety and 54.1% of these students had increased depression (lee et al., 2021). in a study at a large texas university, researchers found that more than 71% of students reported that their anxiety levels had increased during the pandemic (wang et al., 2020). however, less than half of the students reported that they were able to cope effectively with the stress related to the pandemic (wang et al., 2020). taken together, the growing literature (fruehwirth et al., 2021; kecojevic et al., 2020; son et al., 2020) suggests a clear increase in mental health struggles due to covid-19 among college students. particularly concerning is the possibility that struggling college students may turn to cannabis to self-medicate and temporarily feel better about their issues. in the fall of 2020, a national study found that 15.7% of 19-year-olds used cannabis to cope with covid-19 (patrick et al., 2022). moreover, at the beginning of the pandemic researchers found that young adults believed their peers had increased their cannabis use during covid-19 compared to their use in january of 2020, months before the lockdown (graupensperger et al., 2021). however, when examining changes in cannabis use and consequences, the evidence is mixed. for example, a recent study across seven universities demonstrated that cannabis use days were 24% higher in college students after schools were closed (i.e., classes were moved to remote platforms) due to covid-19, but cannabis consequences did not increase (schepis et al., 2021). another study found no changes in cannabis use as a result of covid-19 (graupensperger et al., 2021), whereas a different study found that cannabis use declined (merrill et al., 2022). purpose of present study in a pre-covid-19 world, college students were using cannabis to cope with mental health issues. however, in the present day as covid-19 continues to cause stress and mental health challenges, problematic cannabis use may be increasing because students may be using it to cope with poor mental health resulting from covid-19. the present study compared college students who reported increases in anxiety/depression symptoms since covid-19 stay at home orders to those who reported no change in anxiety/depression symptoms on cannabis coping motives, use frequency, and negative consequences. further, we examined whether self-reported changes (i.e., group that indicated increases) in poor mental health during covid-19 were associated with problematic cannabis use via higher cannabis coping motives. methods participants and procedure participants (n = 1, 318) were college students recruited from psychology department participant pools from two universities in virginia between fall 2020 and spring 2021. participants completed an online survey for research credit regarding their personal mental health, covidimpact of covid-19 on mental health and cannabis use 3 19 stressors, substance use behaviors, and coping strategies. for the present study, we only used data from students that: a) consumed cannabis on at least one day in the previous month (n = 330), b) answered questions about changes in mental health due to covid-19, c) completed assessments of cannabis coping motives, cannabis use frequency, and consequences, and d) reported their gender (final n = 291). among the analytic sample, most participants identified themselves as being either white, non-hispanic (n = 179, 61.5%) or black/african american (n = 103, 35.4%), female (n = 206, 70.8%), and reported a mean age of 20.31 (sd = 3.71) years. the study was approved by the institutional review boards at the participating institutions. measures self-reported changes in mental health due to covid-19. the impact of covid-19 on depressive and anxiety symptoms was measured using one question for each symptom. the questions asked, “since the covid-19 stay at home order went into effect in your state, has your general level of depression/anxiety” and the response options included “increased”, “decreased”, or “remained the same”. depressive/anxiety symptoms. past week depressive/anxiety symptoms were assessed using the 21-item depression, anxiety, stress scale (dass-21; lovibond & lovibond, 1995). participants responded to items related to depression symptoms (6 items; α = .89) and anxiety symptoms (7 items; α = .85) on a 4-point scale (0 = did not apply to me at all, 3 = applied to me very much, or most of the time). these subscales were used as covariates in the models. cannabis coping motives. cannabis use motives in the past 30-days were measured using the 15-item marijuana motives questionnaire short form (mmq-sf; simons et al., 1998). participants responded on a 5-point scale (1 = almost never/never, 5 = almost always/always) and only coping motives (3 items; α = .92) were used given the study aims. the three items that assessed coping motives were: “to forget my worries”, “because it helps me when i feel depressed or nervous”, and “to cheer me up when i am in a bad mood”. cannabis use frequency and consequences. cannabis use frequency was measured using a table in which participants were asked to approximate the number of grams of cannabis they used on a typical week in the last 30 days (pearson et al., 2022). the table included each day of the week sectioned off into four-hour time slots beginning with 12am-4am. participants indicated how much cannabis they used, when they used it, and the number of grams they used. frequency of use (covariate in the model) was calculated by summing the endorsed time blocks in which cannabis was used (range = 0 – 42). cannabis consequences were measured using the brief marijuana consequences questionnaire (bmacq; simons et al., 2012). participants were asked to indicate whether each of the 21 statements described happened (yes/no) to them in the last 30 days. a total score was created such that higher scores indicate greater number of consequences experienced (α = .88). data analysis plan before running the primary analyses (i.e., mediation models), we first computed bivariate correlations and conducted a series of mean comparisons on cannabis coping motives, frequency of use, and negative consequences between students endorsing differing selfreported changes in mental health due to covid19. next, mediation analyses (model 4 in process) were conducted using the process 4.0 macro for spss (hayes, 2017) examining the indirect effect of cannabis coping motives on the relationship between self-reported changes in anxiety/depressive symptoms and cannabis consequences. gender, frequency of cannabis use, and past week anxiety/depressive symptoms were estimated as covariates in the mediation models. statistical significance was determined by percentile-bootstrapped 95% confidence intervals that do not contain zero. results among students that reported past 30-day cannabis use (n = 330), 53.2% reported an increase, 38.5% reported that it remained the same, cannabis, a publication of the research society on marijuana 4 table 1. bivariate correlations of all observed variables among total sample (n = 291) 1 2 3 4 5 6 7 8 m sd 1. changes in depressive symptoms -- 0.57 0.50 2. changes in anxiety symptoms .47 -- 0.63 0.48 3. cannabis coping motives .37 .24 -- 2.35 1.35 4. cannabis use frequency .11 -.03 .33 -- 5.60 7.96 5. cannabis consequences .19 .10 .50 .37 -- 3.44 4.07 6. gender .13 .14 .10 -.08 -.12 -- 0.71 0.46 7. depressive symptoms – dass-21 .31 .25 .44 .13 .38 .04 -- 5.24 5.05 8. anxiety symptoms – dass-21 .22 .23 .29 .18 .31 .10 .68 --4.60 4.39 note. significant correlations (p < .05) are bolded for emphasis. changes in depressive /anxiety symptoms was coded: 0 = remain the same, 1 = increase in symptoms. gender was coded: 0 = men, 1 = women. dass-21 = 21-item depression, anxiety, stress scale. associations between dichotomous variables (i.e., gender and changes in depressive/anxiety symptoms) and continuous variables are represented as point-biserial correlation coefficients. associations between dichotomous variables are represented as spearman rho correlation coefficients. associations between continuous variables are represented as pearson r correlation coefficients. table 2. summary of mean differences on cannabis outcomes based on self-reported changes in mental health due to covid-19 changes in depressive symptoms due to covid-19 outcome variable: remained the same (n = 126) increased (n = 174) t cohen’s d cannabis coping motives 1.78 (0.98) 2.78 (1.43) t = -7.12 0.79 cannabis use frequency 4.62 (7.13) 6.21 (8.33) t = -1.73 0.20 cannabis consequences 2.56 (2.99) 4.03 (4.54) t = -3.40 0.37 changes in anxiety symptoms due to covid-19 outcome variable: remained the same (n = 106) increased (n = 185) t cohen’s d cannabis coping motives 1.97 (1.17) 2.59 (1.41) t = -4.05 0.47 cannabis use frequency 5.82 (8.28) 5.38 (7.46) t = 0.47 0.06 cannabis consequences 2.85 (3.67) 3.69 (4.18) t = -1.79 0.21 note. significant t-tests and cohen’s d estimates were determined by 95% cis that did not contain zero. significant mean differences are in bold typeface for emphasis. and 8.3% reported a decrease in depressive symptoms. further, 58.7% reported an increase, 34.6% reported that it remained the same, and 6.7% reported a decrease in anxiety symptoms. given low sample sizes for those reporting adecrease (n = 27 for depression, n = 22 for anxiety), all analyses focused only on comparisons between participants that reported an increase versus those that reported their symptoms remained the same (n = 291 for depression model; n = 282 for anxiety model). bivariate correlations and descriptive statistics of all study variables are presented in table 1. results from the independent t-tests are reported in table 2. for changes in depressive symptoms, we found significant mean differences between groups on cannabis coping motives and cannabis consequences. specifically, the group that indicated an increase in depressive symptoms due to covid-19 reported higher coping motives and consequences (coping: m = 2.78, sd = 1.43; consequences: m = 4.03, sd = 4.54) compared to the group that indicated their impact of covid-19 on mental health and cannabis use 5 depressive symptoms remained the same (coping: m = 1.78, sd = 0.98; consequences: m = 2.56, sd = 2.99) (cohen’s d coping = 0.79; cohen’s d consequences = 0.37). for changes in anxiety symptoms, we found only one significant difference such that students who indicated an increase in anxiety symptoms due to covid-19 reported higher coping motives (m = 2.59, sd = 1.41) compared to the group that indicated their anxiety symptoms remained the same (m = 1.97, sd = 1.17) (cohen’s d = 0.47). within our mediation models (depression model total effect r2 = 26.6%; anxiety model total effect r2 = 24.7%), we found significant direct effects between changes in depressive/anxiety symptoms (0 = remain the same, 1 = increase) on cannabis coping motives (depressive symptoms: b = 0.64, β = .47, unstandardized 95% ci [0.36, 0.92]; anxiety symptoms: b = 0.56, β = .41, unstandardized 95% ci [0.25, 0.86]). we also found significant direct associations between coping motives and cannabis consequences in both models (depressive symptoms model: b = 1.09, β = .36, unstandardized 95% ci [0.75, 1.43]; anxiety symptoms model: b = 1.22, β = .41, unstandardized 95% ci [0.90, 1.54]). as could be expected by these direct effects, we found significant indirect effects for both depressive symptom (indirect β = .171, standardized 95% ci [.07, .28]) and anxiety symptom models (indirect β = .166, standardized 95% ci [.07, .27]). specifically, for both models, students who reported an increase in depressive/anxiety symptoms (compared to students endorsing remaining the same) reported more cannabis consequences via higher endorsement of cannabis coping motives. discussion the present study found that students reporting an increase in internalizing symptoms due to covid-19 (compared to those reporting no change in their anxiety/depressive symptoms) reported higher cannabis coping motives and more negative consequences (for depression symptoms model only). prior research has found stronger associations between depressive symptoms and cannabis consequences compared to anxiety (pedersen et al., 2015); however, those reporting increases in both anxiety/depressive symptoms reported more coping motives supporting the self-medication hypotheses (khanzstian, 1997). moreover, we found that students who reported an increase in depressive/anxiety symptoms reported more cannabis consequences via higher endorsement of cannabis coping motives. our mediation findings are in support of prior research (bravo et al., 2019a, c; buckner et al., 2007; walukevich-dienst et al., 2022) and theory (e.g., self-medication hypothesis and negative affect models), but extends prior work by examining the impact of covid-19. previous research indicates that covid-19 has created higher levels of poor mental health in college students (lee et al., 2021; wang et al., 2020), and we found similar findings in our results (majority of participants reported in increase in anxiety/depression symptoms compared to remain the same or decrease). moreover, one study found that participants who were anxious about covid-19 had an increased desire to drink and use drugs (kleiman et al., 2020). this is consistent with our findings, which suggest that college students with increased anxiety/depression symptoms due to covid-19 also reported higher cannabis coping motives; which in turn was related to more experiences of negative cannabis-related consequences. limitations and future research a major limitation of our study is that all of the data collected was self-reported and crosssectional. thus, causal inferences cannot be made and future research employing longitudinal or ecological momentary assessment designs are needed to replicate our findings. moreover, given that our primary predictor focused on self-report of changes in mental health symptoms, further research using objective measures that examine how much change occurred is needed to further illuminate whether changes in mental health due to covid-19 are associated with cannabis outcomes. further, we only examined a few factors that may influence relationships between covid-19, mental health, and cannabis use outcomes. future research should examine how other factors, like stress (halliburton et al., 2021) and isolation (horigian et al., 2021) due to covid-19 restrictions, impact our study results. research has established that mindfulness and exercise can help with mental health struggles (goldstein et al., 2020), but future studies could explore how social support may also help college cannabis, a publication of the research society on marijuana 6 students. such a study could also explore ways to improve social support, even during periods of physical isolation. researchers should also explore how covid-19 has impacted mental health and drug use of among vulnerable student populations (e.g., students that identify as firstgeneration, a racial/ethnic minority, or as part of lgbtq+ community), as well as clinical populations. conclusions our preliminary findings suggests that college students reporting mental health struggles due to covid-19 are turning to cannabis to alleviate their struggles; 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(2020). investigating mental health of us college students during the covid-19 pandemic: cross-sectional survey study. journal of medical internet research, 22(9), e22817. https://doi.org/10.2196/22817 data availability statement: data and analytic outputs are available at https://doi.org/10.17605/osf.io/ynmg4 copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 123 ved abstract objective. this paper evaluated a novel, tablet-based neurocognitive and psychomotor test battery for detecting impairment from acute cannabis smoking using advanced quantitative methods. the study was conducted in a state with legal, recreational cannabis use and included participants who use cannabis occasionally or daily, and a no use comparison group. methods. participants completed a tablet-based test assessing reaction time, decision making, working memory and spatial-motor performance. the test was completed before and after participants smoked cannabis (or after a rest period in the case of controls). an exploratory factor analysis approach was implemented to reduce dimensionality and evaluate correlations across the four assessed domains. linear regression models were utilized to quantify associations between factor scores and cannabis use groups (daily vs. occasional vs. no use). results. seven factors were identified explaining 56.7% of the variance among the 18 measures. regression models of the change in factors after cannabis smoking indicated those who use cannabis daily demonstrated poorer performance on a latent factor termed displaced and delayed (standardized coefficient 0.567, 95% ci: 0.178, 0.955; p = 0.005) compared to those with no use. those who use cannabis occasionally exhibited a decline in performance on a latent factor termed recall and reaction (standardized coefficient 0.714, 95% ci: 0.092, 1.336; p = 0.025) compared to no use. conclusions. this analysis demonstrates an innovative, quantitative approach to study how cannabis consumption affects neurocognitive and psychomotor performance. results demonstrated that acute cannabis use is associated with changes in neurocognitive and psychomotor performance, with differences based on the pattern of occasional or daily use. key words: = factor analysis; cannabis use; drug tolerance; reaction time; neurocognitive and psychomotor performance; cannabis impaired driving with 38 u.s. states having legalized recreational and/or medicinal cannabis use, public policy related to cannabis impaired driving is of increasing significance. several desktop computer tests of psychomotor or neurocognitive performance have been utilized to assess the acute effects of cannabis on psychomotor and neurocognitive performance (mccartney et al., shelby j. smith1, julia wrobel1, ashley brooks-russell2, michael j. kosnett3,4, mary d. sammel1 1 department of biostatistics and informatics, colorado school of public health, university of colorado anschutz medical campus, aurora, colorado 2 injury and violence prevention center, colorado school of public health, university of colorado anschutz medical campus, aurora, colorado 3 department of medicine, cu school of medicine, university of colorado anschutz medical campus, aurora, colorado 4 department of environmental and occupational health, colorado school of public health, university of colorado anschutz medical campus, aurora, colorado cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000156 a latent variable analysis of psychomotor and neurocognitive performance after acute cannabis smoking corresponding author: julia wrobel, ph.d., department of biostatistics and informatics, colorado school of public health, university of colorado anschutz medical campus, aurora, colorado. email: julia.wrobel@cuanschutz.edu tablet-based markers of acute cannabis consumption 124 2021). tablet or cellphone-based applications suitable for application field investigations of workplace accidents or transportation crashes are attempting to objectively measure and assess impairment (chung et al., 2020; karoly et al., 2020; pal et al., 2016). (chung et al., 2020; karoly et al., 2022; pal et al., 2016). while these technologies are relatively widely used for general cognitive testing, applying these technologies to scenarios of assessing driving performance is a new application of these devices. these devices typically include multiple tasks measuring several neurocognitive and/or psychomotor domains such as reaction time, processing speed, working memory (visual or auditory), executive function, judgement, and spatial-motor control. these are areas of performance in which there is a history of research demonstrating relationships with drug impairment, and with cannabis use in particular (mccartney et al., 2021). this research has found that cannabis use history and the development of drug tolerance mitigate the impact of acute cannabis use on certain measures of psychomotor and neurocognitive performance (colizzi & bhattacharyya, 2018; mccartney et al., 2021). our team recently applied a within-subject, cross-over design to assess the effects of acute cannabis smoking on multiple aspects of human performance in subjects with a history of occasional use and daily use. a non-using control group was included to assess for learning (i.e., practice) effects. our findings on the impact of acute cannabis use on performance in a driving simulator have recently been reported (brooksrussell et al., 2021). in this same study population, we also conducted neuropsychological testing before and after acute cannabis smoking using a prototype computer tablet test battery (impirica, edmonton, canada). the tasks in that battery included measures of simple and choice reaction time, decision making, working memory and spatial-motor performance. our findings concerning the impact of acute cannabis use on each task separately is the subject of a separate report (brooks-russell et al, in submission). we herein present the application of exploratory factor analysis to the results of all the tasks and subtasks included in the impirica human performance test battery. by including multiple tasks and measures, these test batteries are operationalizing multiple indicators for a hypothesized latent construct that is acute druginduced impairment. however, rarely are latent variable methods applied in these analyses. exploratory factor analysis is a statistical technique postulating the existence of underlying latent factors derived from the correlation among observed outcome variables. this dimension reduction technique is an important tool for the analysis of multivariate data and explores the underlying structure of the data to observe groupings or relationships among the observed variables, often referred to as latent constructs or “factors”. these “factors” are estimated as weighted combinations of subsets of the observed data. typically, a smaller number of latent factors are selected relative to the total number of observed variables resulting in dimension reduction. testing associations between the latent factors and covariates of interest reduces the total number of statistical tests employed thereby reducing type i error and the burden of adjusting for multiple comparisons. in other words, if the information contained in the full set of variables can be conveyed in a much smaller set, our summary of the results can be drastically simplified. the challenge is to condense the many variables that we begin with into a much smaller set with minimal loss of information (bartholomew et al., 2011). methods participants eighty-six healthy adults (43 men, 43 women, ages 25 to 45; 31 with daily use, 23 with occasional use defined as 1 to 2 days per week over the past 30 days, and 32 with no cannabis use in at least the prior 30 days) completed the tablet-based test battery at two timepoints, referred to as the “pre” and “post” timepoints; see supplemental table 1 for additional participant demographics. before data collection was initiated for the pre-timepoint (baseline) session, participants were requested to abstain from smoked cannabis for at least 8 hours and edible cannabis for at least 12 hours (i.e., at least overnight) as verified by completion of a cannabis use diary. recent use of alcohol and other recreational drugs were among the study’s exclusion criteria. this was verified by each subject providing a negative alcohol breath test and cannabis, a publication of the research society on marijuana 125 negative urine drug screen (30 ml alere brand 13panel icup®) prior to data collection. additional details regarding inclusion and exclusion criteria, subject recruitment, the logistics of cannabis administration and the time-frame of data collection are reported elsewhere (brooks-russell et al., 2021). participants in the occasional and daily use groups were observed to smoke or vaporize cannabis flower while seated in a ventilated room. participants self-supplied cannabis flower containing 15% to 30% total thc (less than 2% cannabidiol (cbd)), which was brought in its original packaging from a state-licensed colorado dispensary. participants were instructed to smoke or vape “the amount you most commonly use for the effect you most commonly desire” for up to 15minutes. participants in the non-use group were invited to relax for the same amount of time. the “post” timepoint occurred approximately one hour after the smoking session. the test battery was administered on an ipad (apple ipad 9.7" 5th gen wi-fi only (model a1822) installed ios version 11.4.1) mounted on a portable stand and required approximately 12 minutes to complete. the assessment consisted of four tasks: decisionmaking, spatial-motor control, reaction time, and working memory, and was part of a larger study assessing multiple aspects of cannabis use and driving performance (brooks-russell et al., 2021). measures decision making. the decision-making task consisted of two trial stages with increasing difficulty. for this task, participants were presented with a rectangular object on the far-left screen of their tablet and a series of barriers placed to the right of their object. the first stage consisted of one row of barriers, and the second stage consisted of two rows of barriers. the participant was instructed to use the “go” and “stop” buttons to navigate the rectangular object across the screen without colliding with the barriers (see supplemental figure 1). participants had to wait to press the “go” button until the indicator light at the top of the screen turned green. failure to wait for this indicator resulted in an unsuccessful start, and a minimum of 10 successful starts were needed to complete each stage of this task. the priority emphasized for completing this task was to successfully navigate across the screen without colliding with the barriers, whereas the speed at which this was accomplished was not prioritized in the instructions. spatial-motor control. this task measured a participant’s ability to avoid objects, while still maintaining a desired location on the screen. on the screen, participants could see a ball inside a circular object called the reticle. as the task progressed, the ball inside the reticle seemed to be moving forward towards oncoming obstacles. participants were instructed to maneuver the ipad in a way that the ball would shift and move outside the reticle to avoid oncoming objects, and then maneuver back to the reticle after the object was avoided (see supplemental figure 2). a total of three laps were completed, each with increasing velocity. the priority emphasized for completing this task was success at object avoidance, while attempting to maximize time spent inside the reticle. reaction time. this task consisted of two stages respectively measuring simple and choice reaction time in milliseconds. in the first stage, participants were presented with an object in the middle of the screen, with start and stop buttons at the bottom of the screen, and a light indicator at the top of the screen. once the light turns green, participants were instructed to hit the start button, causing the object in the middle of the screen to begin to move. participants then needed to hit the stop button as quickly as possible to stop the object before it moved off the screen. a successful start for this task was indicated by not hitting the start button prior to the light turning green, and a minimum of 10 successful starts were needed to complete this task stage. the second stage of the reaction task measured not only reaction time, but reaction in the correct direction. like the first stage, participants were presented with a rectangular object in the middle of the screen, and a series of light indicators at the top of the screen. the bottom of the screen now had a start button with a stop button on either side. once the light turned green, participants were instructed to hit start, and the object would begin to move either to the right or the left. participants then needed to hit the stop button that corresponded with the direction in which the object moved. the top of the screen has green lights that could present in either direction, independent of the direction in which the object would move (see supplemental figure 3). a successful start for this task was indicated by not tablet-based markers of acute cannabis consumption 126 hitting the start button prior to the light turning green, and a minimum of 15 successful starts were needed to complete this task stage. trials in which the participant pressed the button corresponding to the incorrect direction were not counted. working memory. the memory task consisted of four trial stages. participants were shown a shape created from a set of 8 dots in a circle (see supplemental figure 4). a distracting screen was presented, followed by the participant being asked to replicate the shape they had been shown. in the first two stages of this task, participants are shown and asked to replicate one shape at a time. in the third and fourth stages of this task, participants are shown two shapes, and then asked to replicate both shapes shown. the priority for completing this task was placed on correctness of shape replication, rather than the time it took to replicate the shapes. driving performance. a car-based driving simulator (minisimtm) was used to measured standard deviation of lateral placement (sdlp) before and after acute cannabis use in simulated urban, straight-segmented driving scenarios. additional details about the driving simulator portion of the study have been previously published (brooks-russell et al., 2021). statistical approach all statistical analyses were carried out in rstudio version 1.3.1073. as described in the measures and presented in supplemental table 2, 18 outcome variables were aggregated from the information collected throughout the test battery. the assessment was administered, and data recorded, at two time points for each participant, referred to as “pre” and “post” smoking. we applied normality transformations and any variables which could not be suitably transformed were included in the analysis without transformation. to ensure the consistent interpretation of higher scores indicating increased impairment, the total replicated shapes variables in the memory task, and the proportion of correct reactions in the reaction time task were reverse coded to match the direction of the other variables in the analysis. we fit exploratory factor analysis (efa) models using the r function ‘factanal’ from the ‘stats’ package with an oblique, promax rotation which allows for correlated factors (taherdoost et al., 2022). the number of factors was chosen using a combination of the “scree test” (bartholomew et al., 2011) and kaiser’s ‘eigenvalue > 1’ criteria. using these criteria, we applied efa to the 18 transformed variables in the pre-smoking/baseline data after standardization and normality transformations. factor loadings for variables with loadings > 0.30 were retained, and loadings < 0.30 were coerced to 0. the revised factor loading matrix was used to estimate factor scores. the variables that contributed most strongly to each factor were used to define relevant titles for that factor. it is hypothesized that impairment cannot be directly measured by one observable outcome. for the current analysis we are also hypothesizing that there could be multiple latent factors which are functions of the observed variables measured by the 4 tasks. these multiple latent factors or constructs are designed to capture latent impairment, as opposed to measured impairment. construct validity of each estimated factor was evaluated by estimating the association of our “pre” factor scores with covariates of interest. these covariates included age, gender, frequency of video game use and sdlp (driving performance outcome from the minisimtm). in addition to analyzing the association between our obtained factors and the driving performance metrics from the minisim, we evaluated if our factors are related to characteristics of driving similar to those taken from a scenario simulating driving, justifying the effectiveness of our ipad battery to capture driving performance. after assessing associations, the factor loading matrix was then applied to the “post” timepoint to obtain scores after a smoking period for those in the occasional and daily use group, or after a rest period (for the no use group). the differences in factors scores (post minus pre) were examined, and the changes among the three use groups were compared. we hypothesized the no use group would demonstrate stable scores over time, while the groups that smoked cannabis may demonstrate a change in scores which would reflect increased impairment. the no use group, serving as our controls, allowed us to account for “learning (or practice) effects” given that participants repeated the same tasks twice. fitting a linear regression model with user type as our primary explanatory variable, while controlling for age, gender, and video game use, we identified differences in the change in factor scores from pre to post assessment across use-groups. for each factor, comparisons were made between the daily use group and the no cannabis, a publication of the research society on marijuana 127 use group, and between the occasional use group and the no use group. where necessary, a bonferroni correction for multiple comparisons will be applied and discussed. in the context of comparing factors scores for the three use groups, a new significance threshold of 0.025 will be implemented to account for each group being compared twice. the decision to implement a bonferroni correction was based on this being the most conservative approach to handling the case of multiple comparisons. results exploratory factor analysis we applied exploratory factor analysis to the 18 measured variables from the four tasks described above and chose to implement seven factors. the results for this model fit indicated that seven factors explained 56.7% of the total variability in our 18 measured variables (2 = 39.74, p = 0.796). a scree plot along with eigenvalues and variance contribution for each factor have been included as supplemental figure 5. four of the seven factors had loadings from outcomes across two tasks (figure 1). higher scores for each factor indicate increased impairment. participants that scored high on factor 1 (displaced & delayed) spent more time outside the reticle and on the edge of the ipad screen in the spatial-motor control task and, on average, took longer to make decisions in the decision-making task. figure 1. factor loadings for each of the 18 outcome variables onto the 7 obtained factors note. the vertical dividers delineate each of the four tasks. from left to right the tasks are: decision making, spatial-motor control, reaction time, and working memory. the magnitude of the bars indicates the loading strength of the measured variable onto the factor. the blue toned bars indicate positive loadings, while the orange toned bars indicates negative loadings of that variable onto the respective factor. the variables that end in “-1” and “-2” denote the trial stage with which that variable is describing. table 1. associations between use group and covariates with final latent factors at baseline displaced & delayed factor term estimate std. error test statistic p-value (intercept) 0.549 0.768 0.715 0.477 occasional use 0.085 0.261 0.326 0.745 daily use -0.175 0.241 -0.726 0.470 age -0.009 0.020 -0.438 0.663 gender (female) 0.437 0.210 2.081 0.041 sometimes video games -0.415 0.309 -1.343 0.183 occasional video games -0.423 0.300 -1.410 0.162 daily video games -0.867 0.262 -3.304 0.001 impaired recall factor term estimate std. error test statistic p-value (intercept) -1.496 0.908 -1.648 0.103 occasional use -0.119 0.309 -0.384 0.702 daily use -0.308 0.284 -1.084 0.282 age 0.054 0.024 2.272 0.026 gender (female) -0.098 0.248 -0.393 0.695 sometimes video games -0.305 0.365 -0.835 0.407 occasional video games 0.303 0.355 0.855 0.395 daily video games -0.340 0.310 -1.097 0.276 note. bolding indicates significance, p<.05 tablet-based markers of acute cannabis consumption 128 participants that scored high on factor 2 (impaired recall) demonstrated longer average time to complete memory tasks and replicated fewer shapes when presented with multiple shapes to replicate. participants that scored high on factor 3 (judgement errors) demonstrated overall less success in the decision-making task with fewer correct judgment decisions, in addition to a higher proportion of timeout trials and false starts. participants that scored high on factor 4 (delayed choice reaction) showed slower reactions, indicated by longer average and maximum reaction times, in the choice reaction task where reaction time and the correctness of their reaction direction are both assessed. participants that scored high on factor 5 (delayed simple reaction) showed slower reactions, indicated by longer average and maximum reaction times, in the simple reaction task where the participant simply had to react to a “go” stimulus. participants that scored high on factor 6 (inattentiveness) replicated fewer shapes in the memory task when presented with multiple shapes to replicate and suffered higher proportions of false starts or timeout trials in the simple reaction task, suggesting a degree of inattentiveness of the participant. participants that scored high on factor 7 (recall and reaction) demonstrated slower memory recall, and fewer replicated shapes when asked to replicate one shape at a time. higher scores in this factor indicated longer simple reaction times and fewer correct reactions in the choice reaction task. covariate associations at baseline before evaluating associations between each of the seven factors and use groups, we assessed if additional covariates of interest (age, gender and video game usage) were associated with each of these factors at the pre timepoint. as shown in table 1, there were two factors that demonstrated associations with our covariates of interest. for displaced & delayed, female participants demonstrated higher (poorer) scores on average as compared to males, and individuals that played video games daily scored significantly lower (better) on average. for impaired recall, older age was associated with higher scores. given these associations, we controlled for age, gender, and video game use in subsequent analyses for all factors. figure 2. differences in factor scores by cannabis use group note. the horizonal line at 0 suggests no change from pre to post, and the colors of the boxplots coordinate with the use group designated on the x-axis. distributions above the 0.0 line represent a decline in performance, those below the 0.0 line represent an improvement in performance. cannabis, a publication of the research society on marijuana 129 table 2. unadjusted and adjusted regression models for use group on difference in factor score (post – pre) [adjusted for age, gender, and video game use] unadjusted regression models for use group on difference in factor score estimate* 95% ci p-value adjusted r2 factor 1: incorrect positioning & delayed decision making 0.149 occasional use -0.080 (-0.494, 0.335) 0.704 daily use 0.667 (0.284, 1.049) 0.001** factor 3: decision making failure 0.0278 occasional use -0.236 (-0.675, 0.203) 0.289 daily use -0.427 (-0.832, -0.022) 0.039 factor 7: react & recall failure 0.0946 occasional use 0.721 (0.144, 1.298) 0.015** daily use -0.215 (-0.747, 0.317) 0.424 adjusted regression models for use group on difference in factor score estimate* 95% ci p-value adjusted r2 factor 1: incorrect positioning & delayed decision making 0.227 occasional use -0.131 (-0.550, 0.289) 0.537 daily use 0.567 (0.178, 0.955) 0.005** factor 3: decision making failure -0.0178 occasional use -0.220 (-0.697, 0.257) 0.362 daily use -0.399 (-0.840, 0.043) 0.076 factor 7: react & recall failure 0.0651 occasional use 0.714 (0.092, 1.336) 0.025** daily use -0.250 (-0.825, 0.326) 0.390 * standardized difference from no use group ** significant after bonferonni correction performance on latent factors by cannabis use history the mean, standard deviation, and range of scores on each factor at the “pre” (baseline) and “post” timepoints are presented in supplemental tables 4 and 5. the difference in individual factor scores (post – pre) represented the acute change in performance associated with cannabis smoking. figure 2 plots the distributions of post minus pre score by cannabis use group for each factor unadjusted for covariates. the horizontal line at 0 indicates no change, so distributions that lie above this line indicate worse performance after smoking, and distributions that lie below this line indicate improved performance after smoking. descriptively, the daily use group exhibited worse mean performance in factor 1displaced & delayed and the occasional use group exhibited worse mean performance on factor 7recall & reaction. in the unadjusted models, a statistically significant improvement in performance was observed for the daily use group on factor 3 judgment errors. however, this result was not significant after adjustment for covariates of age, gender, and frequency of video game use. the results from the covariate-adjusted linear models regressing use group on the difference in factor score further quantified differences in performance after acute cannabis smoking by use group. the coefficients from these models, reported in table 2 represent the standardized difference comparing occasional use to no use, and daily use to no use. because all measured variables were standardized prior to analysis, the coefficients directly comparable. positive estimates indicate participants scored higher, or were more impaired, after smoking as compared to baseline. those in the daily use group performed worse after cannabis smoking in factor 1 displaced & delayed (standardized coefficient 0.567, 95% ci: (0.178, 0.955), p = 0.005) compared to the change that occurred between the pre and post time points in tablet-based markers of acute cannabis consumption 130 the no use group, and participants in the occasional use group performed worse after cannabis smoking on factor 7 recall & reaction (standardized coefficient 0.714, 95% ci: (0.092, 1.336), p = 0.025) compared to the change in the no use group. after applying a bonferroni correction for multiple comparisons, both results reported above would still be statistically significant. factor association with simulated driving performance for analyses including sdlp, we had complete data for 83 of our 86 primary study participants. prior to analyzing the associations between sdlp and our obtained factors, we assessed correlation among these two types of measures of impairment in all participants considered together. pearson correlation matrices demonstrated significant correlations between sdlp and factor 1 displaced & delayed at the pre (r = 0.296, p = 0.007) and post timepoint (r = 0.290, p =0.008). we also observed marginally significant correlations between the change in sdlp and the change in factor 4delayed choice reaction (r = 0.203, p = 0.065). after identifying the correlations between these measures of impairment, a linear model was fit to determine if baseline sdlp varied by use group. these models demonstrated a significant difference in the sdlp of those in the occasional use group at baseline (-4.103, 95% ci: (-7.101, 1.105), p = 0.009), indicating differences in baseline driving performance between groups; thus, we controlled for sdlp at baseline (see supplemental material). fitting linear models to the relationship between the change in factor scores and the change in sdlp, controlling for baseline sdlp, change in the factor scores by any user group was not a significant predictor of change in sdlp. discussion this study utilized latent variable methods to evaluate performance on a neurocognitive and psychomotor assessment, allowing correlations across multiple tasks to utilize the information available from the measured outcomes in a smaller number of composite outcomes for detecting impairment from acute cannabis use. the finding of four factors with significant loadings across tasks supports the hypothesis that there are correlations among the outcome variables of this test battery. for example, factor 1displaced & delayed a combination of variables from the decision-making task (time to complete tasks) and spatial-motor tasks (object placement), accounted for the largest amount of variability in the data. in turn, this factor was correlated with the driving simulator measure of sdlp in the combined study population. prior research of psychomotor or neurocognitive performance using computer or tablet-based tests have typically examined outcome domains such as memory or reaction time independently (desrosiers et al., 2015; karoly et al., 2022). our findings suggest the combined analysis across domains or tasks may provide additional information. this methodological approach of efa could be useful in similar studies using multiple measures to identify a latent construct of impairment. other factors that revealed significant differences between group from pre to post included factor 3 judgement errors and factor 7 recall and reaction. similar to factor 1, these two factors included loadings of variables from across two tasks. we found the occasional use group had decrements in performance on factor 7 recall and reaction from pre to post, compared to the no use group and those in the daily use group had improvements in their performance on factor 3 judgment errors from pre to post use as compared to the no use group. from pre to post, the factor loadings indicated that the daily use group took longer to complete the decision-making task but did so with fewer errors. it is important to note that the decision-making task instructions prioritized accuracy over speed, and this interplay of variables and trade-offs is reflected in the factor. the occasional use group demonstrated slower reaction time in the reaction time tasks (in which speed was prioritized in the instructions) and less accuracy in the memory task. by using correlations among test battery outcomes in this analysis, we harness the ability to potentially identify different types of impairment not captured by strictly evaluating individual measured outcomes. despite the strengths of our approach, and significant findings, it is important to note the relatively small magnitude of the significant findings. a goal of this field of research is to identify impairment due to acute cannabis use with post-only measures. currently, the withincannabis, a publication of the research society on marijuana 131 person variability in performance across the groups overwhelms the between-group changes in performance related to cannabis use. although it may be possible to account for baseline performance in an occupational context, this would not be possible in a road-side application. furthermore, the lack of a significant relationship between change in factor scores by use group with sdlp indicates that the factors identified in this analysis, using this particular test battery, may not be mediators of the relationship between acute cannabis smoking and sdlp. the cannabis dosing aspect of this study, in which subjects smoked self-supplied cannabis ad libitum over a 15-minute interval, constitutes a limitation to the extent that the internalized (i.e., absorbed) dose of thc may vary considerably among the cannabis using subjects. as reported in our prior publication on this study population, on average those in the daily use group combusted a greater mass of thc present in their cannabis, and achieved higher blood thc concentrations, than those in the occasional use group (brooksrussell et al, 2021, tables 2 and 3). our study therefore represents a naturalistic observational design that compared performance changes pre and post acute cannabis use among occasional cannabis users and daily cannabis users where the latter group, as expected, received a higher dose of thc. our study design required all subjects to complete similar psychomotor tasks at the pre and post smoking time points. the inclusion of a control group that did not use cannabis but completed the tasks with the same timing allowed us to assess and adjust for a potential learning (or practice) effect. this analytical approach, in which preversus post-period least squared mean differences for each user group were contrasted with each other (occasional user versus non-user, daily user versus non-user) has been commonly used to account for possible learning or practice effects in repeated measures, within-subject designs. however, the existence of a differential impact of practice on performance in users versus nonusers independent of drug effect cannot be ruled out and may constitute a limitation. factor analysis performs best in scenarios with a sample size greater than 200 participants. so while our sample size is acceptable, it is smaller than the optimum for a factor analysis approach. finally, if future iterations of this study wished to include race and ethnicity as potential covariates, as more diverse participant enrollment would be needed in order to analyze these. references bartholomew, d. j., knott, m., & moustaki, i. (2011). latent variable models and factor analysis: a unified approach. john wiley & sons. brooks-russell, a., brown, t., friedman, k., wrobel, j., schwarz, j., dooley, g., ryall, k. a., steinhart, b., amioka, e., & milavetz, g. (2021). simulated driving performance among daily and occasional cannabis users. accident analysis & prevention, 160, 106326. chung, t., bae, s. w., mun, e.-y., suffoletto, b., nishiyama, y., jang, s., & dey, a. k. (2020). mobile assessment of acute effects of marijuana on cognitive functioning in young adults: observational study. jmir mhealth and uhealth, 8(3), e16240. colizzi, m., & bhattacharyya, s. (2018). cannabis use and the development of tolerance: a systematic review of human evidence. neuroscience & biobehavioral reviews, 93, 1–25. desrosiers, n. a., ramaekers, j. g., chauchard, e., gorelick, d. a., & huestis, m. a. (2015). smoked cannabis’ psychomotor and neurocognitive effects in occasional and frequent smokers. journal of analytical toxicology, 39(4), 251–261. karoly, h. c., milburn, m. a., brooks-russell, a., brown, m., streufert, j., bryan, a. d., lovrich, n. p., dejong, w., & cinnamon bidwell, l. (2022). effects of high-potency cannabis on psychomotor performance in frequent cannabis users. cannabis and cannabinoid research, 7(1), 107–115. mccartney, d., arkell, t. r., irwin, c., kevin, r. c., & mcgregor, i. s. (2021). are blood and oral fluid δ9-tetrahydrocannabinol (thc) and metabolite concentrations related to impairment? a meta-regression analysis. neuroscience & biobehavioral reviews. pal, r., mendelson, j., clavier, o., baggott, m. j., coyle, j., & galloway, g. p. (2016). development and testing of a smartphonebased cognitive/neuropsychological evaluation system for substance abusers. tablet-based markers of acute cannabis consumption 132 journal of psychoactive drugs, 48(4), 288– 294. taherdoost, h., sahibuddin, s., & jalaliyoon, n. (2022). exploratory factor analysis; concepts and theory. advances in applied and pure mathematics, 27, 375–382. funding and acknowledgements: data collection was funded by a grant from the colorado department of public health and environment (co-pi: brooks-russell, kosnett). wrobel, brooks-russell, and kosnett were supported by the national institutes of health (r01 da049800; brooks-russell). the vitals mobile software and device were loaned to the research team by impirica, at no cost to the research team. we would like to acknowledge the team at impirica, especially aaron granley, dan scott and farah visra. the study was approved by the colorado multiple institutional review board. conflict of interest statement: the authors have no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i2adk_authors_v2_doi_pages brief report 13 ved abstract novel cannabinoids require systematic research to inform policies and practices. there is a growing interest in semi-synthetic cannabinoids by consumers, manufacturers, and regulators. however, there is a scarcity of research on these substances. online discussion forums can provide guidance for research questions when current knowledge is scarce. the current project investigates the topics and issues covered in a social media forum devoted to thc-o-acetate (thco), a semi-synthetic cannabinoid with rapidly rising popularity. reddit comments posted on the thco subreddit from june 2021 through november 2021 were coded for major and minor themes by a team of five coders and a supervisor. major themes were established and clarified through group discussions. a second round of coding confirmed major themes and identified minor themes. the analysis identified several future research topics for thc-o-acetate, including the extent of variation in product composition, the characteristics of user experiences and comparisons with other substances, whether thc-o-acetate produces psychedelic effects, concerns and adverse experiences, and user harm reduction practices. as an acetate ester, thc-o-acetate may break down when heated and release toxic ketene gas. although several users expressed safety concerns regarding thc-o-acetate, some explicitly mentioning ketene risk, the most common administration method reported was heated inhalation. key words: = thc-o-acetate; ketene; qualitative analysis; social media; reddit there is a growing interest among consumers, manufacturers, and regulators of hemp and cannabis derived goods in semi-synthetic cannabinoids (caulkins, 2021). the term semisynthetic cannabinoids refers to the growing category of cannabinoids synthesized from hemp extracts being sold as psychoactive substances (devitt et al., 2022). the passage of the 2018 farm bill has increased the interest in and availability of new psychoactive cannabinoids, spawning several consumer networks and online communities (bone et al., 2022). researchers are beginning to document use patterns and experiences with recently marketed psychoactive cannabinoids, such as with the stereoisomer delta-8-thc (kruger & kruger, 2021), one of the most prevalent semi-synthetic cannabinoids in this emergent niche (szcypka et al., 2022). thco-acetate appears to be the latest semi-synthetic cannabinoid gaining in popularity, participation in the r/thco subreddit (reddit online discussion board) rose from nearly zero participants in july of 2021 to almost 6,000 one year later (figure 1). the steadily increasing participation in r/thco reflects the increasing interest in thc-o-acetate by consumers and the popularization of the slang term “thco.” thc-o-acetate is a thc analogue made through the acetylation of thc that first appeared as a consumer product during cannabis daniel j. kruger1, amila karahmet2,3, sydney m. kaplan2,3, john redfield2,3, taylor stacy2,3, vitush agarwal2,3, mutaz faqqouseh3, carlton cb bone4 1 institute for social research, university of michigan, ann arbor, mi 2 college of literature, sciences, and the arts, university of michigan, ann arbor, mi 3 undergraduate research opportunities program, university of michigan, ann arbor, mi 4 department of anthropology, portland state university, portland, or cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000164 a content analysis of social media discussions on thc-oacetate corresponding author: daniel j. kruger, ph.d., population studies center, institute for social research, university of michigan, 426 thompson st., ann arbor, mi 48109-1248. email: kruger@umich.edu social media & thc-o-acetate 14 figure 1. number of subscribers to the r/thco subreddit on reddit note. from https://subredditstats.com/r/thco prohibition and has evolved alongside the commercialization of cannabinoid markets (bone, 2021). as an acetate ester (the dominant form of commercial acetates, with the general formula ch3co2r, where r is an organyl group, thc-oacetate may break down when heated at or above 340°c (644 °f) and release ketene, a toxic gas that is potentially lethal at 5 parts per million (munger, 2022). ketene gas was implicated in the thousands of hospitalizations and at least 60 deaths that occurred in 2019 from e-cigarette or vaping-associated lung injury (evali; blagev, 2019). the highly toxic ketene gas was released when vitamin e acetate, used as a cutting or cheap diluting agent in thc cartridges, was heated (li, 2022). all policies and practices regarding cannabis and its products should be informed by empirical evidence from systematic research. the rapid emergence of novel cannabinoids in cannabis consumption markets outpaces the systematic research necessary to inform policies, regulations, and practices that minimize the costs, risks, and harms and maximize the benefits to individuals and society. thc-related cannabinoids may have divergent profiles of properties and effects, and thus full understandings of specific cannabinoids are more complex than comparisons of the intensity of experiences (kruger & kruger, 2021). given the scarcity of knowledge of the properties and effects of these cannabinoids, the naturalistic social media commentary in online user forums such as r/thco can be utilized to identify themes and issues discussed by users. scientists, from psychologists to chemists, have relied on online communities to develop informed lexicons and derive experimental conditions for analysis (anderson et al., 2018; meacham et al., 2018; meehan-atrash et al., 2017). social science research into online communities has utilized structured approaches such as netnography to ground research methods and questions (frude et al., 2020). researchers have conducted qualitative analysis of discussions on online forums related to substance use to identify themes and promote understanding of the use of these substances (holm et al., 2023). these analyses identify specific themes and quantify their prevalence in online discourse. reddit is an on-line social media platform where users submit content such as text, images, and links to news stories and other websites in posts. users can vote posts up or down, determining the prominence of the post’s placement on the site. posts are organized thematically into user-created boards called "communities" or "subreddits." the r/thco community on reddit represents a component of a larger ecosystem of online communities that intersect with other drug using communities (figure 2). well known substance related subreddits like “research chemicals,” a subreddit that involves extensive discussion of synthetic cannabinoids, are juxtaposed with other emerging communities like “cultofthefranklin,” a subreddit dedicated to hemp with high levels of cannabis, a publication of the research society on marijuana 15 figure 2. graph of cannabis-specific subreddits related to r/thco on reddit note. from https://anvaka.github.io/sayit/?query=thco. overlap is measured through a jaccard similarity, whereby the relationship is determined by a metric "users who posted to this subreddit also post to..." tetrahydrocannabinolic acid (thca); providing a web of connection that situates semi-synthetic cannabinoids throughout the broader online ecosystem for psychoactive substances. the r/thco community provides a reasonable starting point for our examination of the product’s ontology. the role of r/thco, like other online networks focused on cannabinoids, is to facilitate conversation and consumption. this is done through the sharing of images, links, and text comments on a variety of topics from the safety and potency of thc-o-acetate brands to flash product sales. the creation of a subreddit to facilitate product engagement is of interest because it affords unique insights into the role of this substance in the creation of cannabinoid subcultures, as well as a window into the general consumer experience with these products that seems to reflect similarities in composition to how online communities on reddit for other substances – namely “research chemicals” – operate. the current study documents the content of r/thco participant entries during the first six months of forum activity, providing insights into the ontology of this community (sharp, 2017). this content can be used to inform more systematic studies by allowing researchers to identify trends, language, as well as critical structures and stakeholders that enables better engagement with these communities. methods reddit entries on the thco subreddit from june 2021 through november 2021 were downloaded and copied onto spreadsheets. these include the original forum post and the comments made in reply to the original post or to other comments. a team of five coders and a supervisor coded the content in an iterative process. this timeframe was selected to provide an adequate volume of content and adequate time for completion of coding. first, coders read through at least one month of posts and generated suggestions for major theme coding categories, at least two coders reviewed each month of posts. there was considerable variation in the number of posts per month, so coding assignments were made to balance the volume of posts across posters. theme coding categories were established and clarified through group discussions. next, each coder completed an initial round of coding. each post was categorized as to whether it contained content consistent with the major themes. these themes were: discussion of thc-o-acetate production; discussion of thc-o-acetate use; reasons for thc-o-acetate use; discussion of chemical/physiological mechanisms; effects of thc-o-acetate (other than adverse experiences); adverse experiences; concerns; comparisons with other substances; mention of other substances (but not comparisons with thc-o-acetate); and comments on specific brands/products. posts consisting solely of images (including product pictures), emojis, or brief reactions (e.g., “ha!”) without usable content were excluded from coding. each coder was then assigned at least two specific major themes for elaboration of content (so there were at least two coders per theme). posts were re-sorted by theme and coders read through social media & thc-o-acetate 16 all posts tagged with their respective major themes. posts determined not to fit with the major theme on the second review were removed from the theme set. coders generated suggestions for subtheme categories for each major theme set, subtheme coding categories were established and clarified through group discussions. the following major themes were prioritized for elaboration: reasons for thc-o-acetate use, effects of thc-oacetate (other than adverse experiences), adverse experiences, concerns, comparisons with other substances, and mention of other substances (but not comparisons with thc-o-acetate). results there were 3437 posts coded from 974 unique forum members who made posts. users made four posts on average (sd = 6, median = 2), with a range from one to 88 posts. about half (49.8%) of users made only one post, 10% made 8 or more posts. the four most common themes were mention of other substances, effects of thc-o-acetate, comments on specific brands/products, and discussion of thc-o-acetate use frequency, administration methods, preparation methods (see table 1). table 1. compositions of thco reddit forum user’s posted comments (n = 3437) major themes n % of total % of theme mention of other substances 707 20.6 100 effects of thc-o-acetate 522 15.2 100 comments on specific brands/products 517 15.0 100 discussion of thc-o-acetate use (frequency, administration methods, preparation methods) 485 14.1 100 comparisons with other substances 434 12.6 100 concerns 333 9.7 100 discussion of chemical/physiological mechanisms 162 4.7 100 adverse experiences 136 4.0 100 discussion of thc-o-acetate production (how thc-o-acetate) is manufactured 99 2.9 100 reasons for thc-o-acetate use 34 1.0 100 themes with elaboration n % of total % of theme mention of other substances 707 20.6 100 mention of delta-8-thc 387 11.3 54.7 mention of delta-9-thc 288 8.4 40.7 mention of psychedelics (lsd, dmt, psilocybin) 32 0.9 4.5 mention of other substances 258 7.5 36.5 effects of thc-o-acetate 522 15.2 100 lack of any effects 95 2.8 18.2 ‘standard’ thc experiences 92 2.7 17.6 lengthy onset 53 1.5 10.2 psychedelic/spiritual experience 48 1.4 9.2 lengthy duration 39 1.1 7.5 sedating/calming 37 1.1 7.1 lack of psychedelic effects (but other effects present) 30 0.9 5.7 psychedelic hallucinations (visuals, hearing sounds, etc.) 25 0.7 4.8 physical/body sensation 20 0.6 3.8 decreased effects from tolerance 19 0.6 3.6 euphoria 16 0.5 3.1 medically beneficial for pain relief 11 0.3 2.1 energizing 9 0.3 1.7 cross-tolerance between cannabinoids 4 0.1 0.8 weird dreams 4 0.1 0.8 increased sexual arousal 4 0.1 0.8 lots of laughing 4 0.1 0.8 no changes in effects from tolerance reported 3 0.1 0.6 feeling drunk 2 0.1 0.4 improved sleep 2 0.1 0.4 disrupted sleep 2 0.1 0.4 (table continues) cannabis, a publication of the research society on marijuana 17 comparisons with other substances 434 12.6 100 comparison with delta-9-thc 241 7.0 55.5 comparison with delta-8-thc 235 6.8 54.1 comparison with psychedelics (lsd, dmt, psilocybin) 46 1.3 10.6 comparison with other substances 90 2.3 20.7 concerns 333 9.7 100 variation in product composition or effect 63 1.8 18.0 health 60 1.7 17.1 safety concerns from novelty of product, lack of research 57 1.7 14.1 legality 47 1.4 12.9 safety 43 1.3 8.1 inconsistencies in product quality 27 0.8 5.7 safety concerns from impurities 19 0.6 4.2 shelf life/stability 14 0.4 2.4 ketene risk 8 0.2 2.1 smell 7 0.2 1.8 building tolerance 6 0.2 1.2 variation in metabolism/effect 4 0.1 1.2 accessibility 4 0.1 1.2 concerns with specific brands 4 0.1 18.0 adverse experiences 136 4.0 100 physical adverse experience (e.g., coughing) 91 2.6 66.9 anxiety 14 0.4 10.3 pain 12 0.3 8.8 bad trip/unpleasant experience 9 0.3 6.6 bad taste 6 0.2 4.4 overconsumption from effect latency 3 0.1 2.2 unpleasant after-effects 3 0.1 2.2 poor sleep quality 2 0.1 1.5 feeling "drunk" 2 0.1 1.5 reasons for thc-o-acetate use 34 1.0 100 medical pain 8 0.2 23.5 unspecified medical/therapeutic 6 0.2 17.6 medical insomnia/sleep issues 5 0.1 14.7 medical anxiety 3 0.1 8.8 substitution for synthetic cannabinoids 3 0.1 8.8 recreational 2 0.1 5.9 medical arthritis 1 0 2.9 mention of other substances contained a wide variety of content, as may be expected for an open discussion form related to cannabis products, usually focused on other forms of thc: “my δ9 cannabis oil survives freezing with no discernable loss in potency, but again, we're talking about a different compound here, and i'm not a chemist.” ; “yeah even weak delta 9 flower these days keeps me from being productive.” ; “seriously, are you unaware delta-9 isn't hemp derived? lol”; “i could not care less if it was synthetic or not. spice wasn't dangerous because it was synthetic, it was just dangerous and synthetic. correlation does not equal causation.” users most frequently compared thc-oacetate with delta-9-thc and delta-8-thc: “overall high feeling was definitely stronger than that of d8 and d9 imo.” “thc-o is not 300% stronger than traditional d9thc. at most 1.5 to 3x.”; “i place it at 1.5 to 3x the strength of d9 depending on dosage.”; “my experience is that it's noticeably stronger than d8, but still weaker than d9, let alone 3x more potent as i've been told.” however, they also often mentioned and made comparisons with psychedelic drugs (e.g., lsd, dmt, psilocybin) and other substances: “ya i didn’t really believe its strong as lsd but i could see it being as strong as a low dose.”; “idk man i took a fat dab of thc-o and i actually felt like i was on a low dose of shrooms like 2g’s and i had social media & thc-o-acetate 18 minor visuals. and it all lasted for like 5-6 hours.” there were a mix of effects reported by users, some reported experiences typical for thc: "i experienced no psychedelic effects and instead got to experience a really nice normal thc feeling high.” ;“it is definitely a cannabinoid in the classical sense in how it feels” ; “i personally still prefer smoking really good d9 over thco but the effects are similar depending on how much puffs you take before you feel it.” ; “felt like a mild d8 buzz, lasted about half an hour. a tad different, felt a bit more spatial while it lasted.”; “it felt like a really good indica dominant hybrid high feeling.” others reported psychedelic or spiritual experiences: “then i took about 4 more rips and it was pretty psychedelic at first but after i ate it died down and it was more mellow.”; “very trippy and cerebral high mixed with a body sedation.” ; “dude i had this for like 6 hours then woke up out of my sleep tripping balls” ; “more spiritual almost psychedelic”; “the effects were definitely not visual like psychedelics, but the introspection and headspace was pretty psychedelic for sure.” ; “i noticed some stronger cev's (closed eye visuals) once but i have not taken high doses and i think edibles are more likely to have psychedelic effects.” ; “thc-o will be more visually trippy than normal stuff, just remember to stay grounded and stay safe.” some reported mild effects or no effect at all: “yeah for me the effects are very mild, i am on the fence of i would even call them intoxicating. just a mild calm, like smoking cbd [cannabidiol] weed.” ; "when i dab my thco i can feel it almost right away and there is a slight creeping come up but it's nowhere near the strength that people are claiming.” ; “i haven't been feeling it like, at all. i thought it was me and my tolerance. then i had my girlfriend try it…. she says she got a harder buzz from friggin hookah.” ; “thc-o so far hasn't even gotten me high lol” ; a poster affiliated with a company selling thco products remarked: “we have noticed this as well, at scale from consumer feedback. i would say it’s roughly 4-5% of people that thco literally does not effect. then there’s the other side of the spectrum in which it effects them drastically like a full blown psychedelic.” multiple users reported a relatively lengthy onset of effects and/or a lengthy duration of effects: “thco also takes ab 45 mins to fully hit you n last considerably longer then thc.” ; “takes an hour to fully kick in then for me the high lasts several hours” ; “the high from thc-o lasts significantly longer than d8/even d9. like, way longer.” variation in product quality, composition, and/or effect was a prominent concern: “i think whatever is going into the products is not thco or a very low concentration of it.” ; “i'm assuming thco carts are just like delta 8 and some of them are 75% or 7% thco, you can never know for sure. never believe a stupid box anybody can fake lab results.” ; “i think cheaper companies may have residual solvents left over in their batches imo” ; “i strongly caution anybody who vapes or inhales it in any way: please make sure you get a third party source analysis of the contents you hope to ingest.” several users explicitly expressed safety concerns regarding ketene formation: “i don’t feel comfortable smoking the acetate salt of any compound. could decompose into ketene when heated like vitamin e acetate” ; “apparently heating up thc-o-acetate has the same dangers of heating up and vaporizing vitamin-e acetate.” ; “people are saying the acetate group is making this chemical plain dangerous in the lungs. i’ve been vaping it with no problem, and everyone that’s saying not to smoke it isn’t explaining. supposedly the ketene formation?? vitamin e acetate for sure cause the evali problem with lungs, but why does this mean the same for thco?” other concerns were more ambiguous but could also refer to ketene risk: “there’s a lot of question whether smoking it is even safe” ; “it's highly unlikely that any "acetate ester" is safe to consume quite honestly.” ; “i’m pretty sure thc-o acetate is not meant to be introduced into the lungs.” some concerns were regarding other types of risks, such as whether inhaling thc-o-acetate was carcinogenic. adverse experiences included physical experiences such as coughing: “after about 10 minutes though i began to start coughing because of this weird itch or sensitivity feeling in my lungs and i couldn't stop coughing for 6 minutes or so after the fact” ; “if the voltage is too high i get very very bad coughing attacks” ; “it can make me feel like i'm going to overdose if i huff it the same way i would huff d8 or d9. by overdose i mean nausea and mild jitters and general physical discomfort.” “when i got some thco i noticed that i’ve had to go to pee more frequently.” ; “it feels like someone put a taffy puller in my mouth as my mouth starts contorting in extreme ways very slowly.” adverse experiences also included cannabis, a publication of the research society on marijuana 19 psychological effects such as anxiety: “it definitely can cause anxiety on the come up” ; “the high is intense and fun, but not always pleasant. i get sort of a low grade background anxiety that isn't usually present when i'm sober. i've also noticed i'm irritable when the high wears off; i smoke/consume at night and during the day i've got a short fuse and have been generally cranky pants.” ; “last time, it was way too much for me. i felt like my skin was too tight on my bones…i kept stretching my face out trying to loosen it. then i was always paranoid someone was breaking into my house, literally got up and peeked around the corner in horrible fear.” post-hoc analyses determined that users reported vaping thc-o-acetate in 130 posts (3.8%), oral consumption of thc-o-acetate (edibles/tinctures/capsules) in 117 posts (3.4%), dabbing thc-o-acetate in 40 posts (1.2%), inhalation of thc-o-acetate from unspecified method in 39 posts (1.1%), smoking thc-o-acetate in 24 posts (0.7%), and boofing thc-o-acetate (suppositories) in 5 posts (0.1%). discussion reports on cannabinoid use experiences posted on topical online discussion boards can provide guidance for research questions and hypotheses regarding novel substances to consumer markets by grounding exploratory research. results of this study demonstrate the value of online forums for informing studies and the need for further qualitative and quantitative research. the content analyzed in this study demonstrates the need for research into the properties and effects of thc-o-acetate products used by consumers. many forum users reported seeking or having psychedelic-like experiences with thc-o-acetate, whereas others reported null or typical thc-like effects. systematic testing for product composition could help inform on whether variation in product composition may explain variation in reported effects. only 1% of posts discussed reasons for thc-o-acetate use, most commonly for the treatment of health or medical issues, however the naturalistic nature of these data may underrepresent medicinal use, as users were not specifically asked about their reasons or motivations for use. although users reported concerns and adverse experiences, only a small proportion noted the risk of toxic ketene gas production from the combustion of acetates. inhaling heated thc-oacetate was the most popular form of consumption reported. confirmation of this chemical reaction had not been established and communicated to the public until after the timeframe in which survey responses were collected. however, a recent publication by benowitz et al. (2023) confirms the findings of munger et al. (2022) and points to an important role for research engaging with communities who are consuming new hempderived psychoactive substances. future research could engage with a broader section of products, manufacturers, and digital communities for semi and fully synthetic cannabinoids, especially as they compare to those focused on botanical cannabinoids derived from hemp and cannabis (baumgartner and pieper, 2017). the use of mixed methodologies and direct community engagement is a complement to the utilization of big data to understand similar trends (anderson et al., 2018; meacham et al., 2018). the current results describe the content of naturalistic posts on a public, online discussion forum. users are not systematically addressing research questions or providing comprehensive accounts of their experiences. they are sharing information and participating in discussions with other anonymous individuals who share interests in thc-o-acetate. structured research, such as quantitative and qualitative surveys, focus groups, and clinical trials will be needed to properly address the issues and concerns identified in these analyses. moreover, the existence of other communities focused on semisynthetic cannabinoid discourse uncovered during the coding process underscores the complex and expansive online web of connections facilitated by social media platforms like reddit. a consequence of which is that we cannot say the discourse and topics reflected in this subreddit or community are indicative of broader discourses online. there are growing on-line communities devoted to discussions of cannabinoids. although the information provided by these discussions has a very wide range of content and quality, the topics and issues discussed can inform systematic research such as the development of survey instruments, interview questions, and background information for chemical and clinical experimentation. the identification of hypotheses and research questions is especially important for social media & thc-o-acetate 20 substances such as thc-o-acetate, where so little is known about its naturalistic use and effects. we also believe that this approach could be modelled in other adjacent communities to provide a comparative understanding of the variety of new psychoactive substances derived from cannabis. in doing so we hope to set the foundation for a longitudinal perspective on the development of thc-o-acetate and other semisynthetic cannabinoids and explore how beliefs have changed with the introduction of new information. such longitudinal approaches may aid in understanding how the discovery of ketene formation from the vaporization of thc-o-acetate (benowitz et al., 2023) and subsequent discussions amongst online has shaped consumer habits and behaviors. empirical evidence from systematic studies is needed to inform policies and practices regarding cannabis. when novel cannabinoids emerge on the market, online discussion forums can provide guidance for research questions. the current study identified several topics for research on thc-o-acetate, including the extent of variation in product composition, the qualia of user experiences and comparisons with other substances, concerns and adverse experiences, user familiarity with ketene risk, and harm reduction practices. references anderson, l. s., bell, h. g., gilbert, m., davidson, j. e., winter, c., barratt, m. j., win, b., painter, j. l., menone, c., sayegh, j., & dasgupta, n. (2017). using ssocial listening data to monitor misuse and nonmedical use of bupropion: a content analysis. jmir public health and surveillance, 3(1), e6. baumgartner, p., & peiper, n. (2017). utilizing big data and twitter to discover emergent online communities of cannabis users. substance abuse: research and treatment, 11, 1178221817711425. benowitz, n. l., havel, c., jacob, p., o'shea, d. f., wu, d., & fowles, j. (2023). vaping thco acetate: potential for another evali epidemic. journal of medical toxicology, 19(1), 37–39. blagev, d. p., harris, d., dunn, a. c., guidry, d. w., grissom, c. k., & lanspa, m. j. (2019). clinical presentation, treatment, and shortterm outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study. lancet, 394(10214), 2073–2083. bone, c., munger, k., klein, c., & strongin, r. 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(2023). psychedelic discourses: a qualitative study of discussions in a danish online forum. the international journal on drug policy, 112, 103945. advance online publication. kruger, d. j., & kruger, j. s. (2021). consumer experiences with delta-8-thc: medical use, pharmaceutical substitution, and comparisons with delta-9-thc. cannabis and cannabinoid research. 10.1089/can.2021.0124. advance online publication. li, y., dai, j., tran, l. n., pinkerton, k. e., spindel, e. r., & nguyen, t. b. (2022). vaping aerosols from vitamin e acetate and tetrahydrocannabinol oil: chemistry and composition. chemical research in toxicology, 35(6), 1095–1109. meacham, m. c., paul, m. j., & ramo, d. e. (2018). understanding emerging forms of cannabis use through an online cannabis community: an analysis of relative post volume and subjective highness ratings. drug cannabis, a publication of the research society on marijuana 21 and alcohol dependence, 188, 364–369. meehan-atrash, j., luo, w., & strongin, r. m. (2017). toxicant formation in dabbing: the terpene story. acs omega, 2(9), 6112–6117. https://doi.org/10.1021/acsomega.7b01130 munger, k. r., jensen, r. p., & strongin, r. m. (2022). vaping cannabinoid acetates leads to ketene formation. chemical research in toxicology, 35(7), 1202–1205. szczypka, g., pepper, j. k., & kim, a. (2022). weed light: an exploratory study of delta-8 thc conversations on reddit. in rti press research brief. rti press. funding and acknowledgements: all authors have no competing financial interests to disclose. conflict of interest statement: the authors have no conflicts of interest to disclose. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i2a4_authors_final research article 47 abstract background: to date, no studies have directly assessed potential cannabis use disorder (cud) in medical cannabis (mc) patients prevs post-mc treatment. given that mc patients use cannabis for symptom alleviation rather than intoxication, we hypothesized that mc patients would exhibit few symptoms of cud after initiating mc treatment. methods: as part of an ongoing observational, longitudinal study, 54 mc patients completed baseline assessments prior to initiating mc use and returned for at least one follow-up assessment after three, six, and/or twelve months of a self-selected mc treatment regimen; detailed mc treatment information was collected and quantified. all patients completed the cannabis use disorder identification test revised (cudit-r) at each visit. changes in individual items scores and total scores were assessed over time, and we examined whether total cudit-r scores correlated with frequency of mc use, delta-9-tetrahydrocannabinol (thc) and cannabidiol (cbd) exposure. further, cronbach’s alpha analyses were conducted to provide preliminary data regarding the psychometric properties of the cudit-r when used among mc patients. results: although total cudit-r scores increased relative to baseline, on average, ratings fell below the ‘hazardous use’ threshold at each visit. analyses of individual items revealed that increases in total scores were primarily attributable to increases in frequency of use and not necessarily other aspects of problematic use. total cudit-r scores were not associated with number of mc uses or cbd exposure, but a significant relationship was detected between increased thc exposure and higher cudit-r scores. importantly however, analyses revealed that the cudit-r does not appear to be an appropriate tool for identifying cud in mc patients. conclusions: screening tools specifically designed to assess cud in mc patients are needed and should distinguish between frequent use and problematic use; exposure to individual cannabinoids must also be considered. key words: = medical cannabis; cannabis use disorder; cudit-r; longitudinal; thc; cbd although there is general consensus that most individuals who use cannabis for recreational purposes (i.e., using cannabis to feel high or alter one’s current state of being) do not develop cannabis use disorder (cud), estimated rates are highly variable. for example, data from two large epidemiological survey studies indicate that cud rates range from 11-15% (compton et al., 2016) to approximately 30% (hasin et al., 2015) in those who use cannabis recreationally. in addition, few studies have assessed cud in those who use cannabis specifically for medical purposes. interestingly however, one study found that increased access to medical cannabis (mc) programs was associated with higher rates of cannabis use among adults age 26 or older, but not higher rates of cud (williams et al., 2017), raising the question of whether mc use could be assessing cannabis use disorder in medical cannabis patients: interim analyses from an observational, longitudinal study cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.004 kelly a. sagar1,2,3, m. kathryn dahlgren1,2,3, rosemary t. smith1,2, ashley m. lambros1,2, & staci a. gruber1,2,3 1cognitive and clinical neuroimaging core (ccnc), mclean hospital, belmont, ma, usa 2marijuana investigations for neuroscientific discovery (mind) program, mclean hospital, belmont, ma, usa 3department of psychiatry, harvard medical school, boston, ma, usa corresponding author: staci gruber, ph.d., mclean hospital, 115 mill street, belmont, ma, 02478. email: gruber@mclean.harvard.edu. phone: 617-855-2762. fax: 617-855-3713. cud in medical cannabis patients 48 associated with a lower risk for cud than recreational cannabis use. as a full diagnostic assessment is timeconsuming and often not feasible in many clinical and research settings, several tools have been developed to screen for cud, including the severity of dependence scale (sds; gossop et al., 1995), cannabis abuse screening test (cast; legleye et al., 2012), alcohol, smoking and substance involvement screening test (assist; who assist working group, 2002), cannabis use problems identification test (cupit; bashford et al., 2010), cannabis use disorders identification test (cudit; adamson & sellman, 2003) and its revised version (cudit-r; adamson et al., 2010). while each has strengths, the cudit-r was selected for the current study as it is very commonly used in clinical and research settings as a self-report screening tool, designed based on diagnostic and statistical manual (dsm) criteria, and offers sound psychometric properties when used to assess those who use cannabis for recreational purposes (adamson et al., 2010). in addition, we have utilized the cudit-r in previous research studies assessing recreational cannabis use. to date, no studies have directly addressed whether mc patients develop symptoms or behaviors associated with problematic cannabis use. given the growing number of mc patients, it is important to accurately assess potential cud in this population. accordingly, using the cuditr, we examined symptoms and behaviors related to problematic cannabis use over 12 months of mc treatment. we hypothesized that mc patients would exhibit increased frequency of use relative to baseline, but endorse few problems associated with mc use given their primary motivation for use is symptom alleviation. further, we predicted that increased exposure to cannabidiol (cbd), a primary non-intoxicating constituent of cannabis, would not be associated with higher cudit-r scores in mc patients, whereas increased exposure to delta-9-tetrahydrocannabinol (thc), the primary intoxicating constituent of cannabis, may be related to higher cudit-r scores. in addition, as results raised the possibility that cudit-r scores may not accurately reflect problematic use in mc patients, we conducted a secondary set of analyses to assess internal consistency and reliability of the cudit-r in the current sample of mc patients; these analyses were designed to generate preliminary data regarding the psychometric properties of the cudit-r when used in mc patients. methods all participants completed an informed consent process in which study procedures, risks, benefits, and the voluntary nature of the study were explained. this study was approved by the partners healthcare institutional review board. participants as part of an ongoing, longitudinal study, we recruited individuals interested in using cannabis or cannabinoids specifically to treat one or more medical/psychiatric conditions (e.g., pain, mood, anxiety/ptsd, sleep-related symptoms) but who had not yet begun mc treatment. study participants were recruited from a variety of sources, including social media advertisements, mc certification centers, and through our institution’s online recruitment platform (rally with mass general brigham). individuals were considered eligible if they were 18 or older and planned to use cannabinoid-based products to treat medical/psychiatric conditions. all were required to have a certification for mc or plan to use products not requiring certification (i.e., hemp-derived products). at baseline, mc patients were required to be cannabis naïve (≤15 lifetime uses) or, if they reported a history of previous recreational cannabis use, were required to be abstinent from regular use (>1x/month) for one year or more to minimize the effects of previous cannabis exposure. all patients also had to test negative for urinary thc metabolites at baseline. in addition, as part of this in-depth study involving face-to-face assessments and cognitive testing (gruber et al., 2018; gruber et al., 2016; gruber et al., 2021; sagar et al., 2021), patients were required to have an estimated iq of at least 75 which was assessed using the wechsler abbreviated scale of intelligence (wasi; wechsler, 1999). all patients also completed medical and clinical history questionnaires and interviews, cognitive assessments, other selfreport ratings, and multimodal neuroimaging prior to initiation of mc treatment; however, only data from the cudit-r self-report scale are reported here. cannabis, a publication of the research society on marijuana 49 mc patients completed follow-up visits after three, six, and twelve months of mc use. at the time of analyses, 54 patients completed a baseline visit and had returned for at least one of the follow-up visits at 3, 6, and/or 12 months. of these 54 patients, 28 completed all four visits. six patients missed an interim visit(s), 10 patients are in-progress (currently enrolled and awaiting their next follow-up), and 10 discontinued from the study (n=3 stopped mc use; n=7 were lost to follow-up). of those lost to follow-up, three reported discontinuing for reasons unrelated to mc treatment (e.g., moved out of state, diagnosed with cancer); four stopped responding, and the reason for discontinuation could not be ascertained. as not all patients included in the current analyses completed all four study visits, those with missing data were divided into two discrete groups: 1) data missing at random (mar; n=47) and 2) unknown whether data were mar (n=7). data were considered mar for mc patients who completed the study but had missed a visit(s), enrolled individuals who are still considered “in progress,” and those who reported withdrawing from the study due to reasons unrelated to mc use. for those who stopped mc treatment or were lost to follow-up for unknown reasons, analyses were conducted to determine whether missing data could be considered mar. specifically, changes in ratings related to mc treatment (e.g., mood, anxiety, sleep, quality of life) between baseline and 3 months were compared between 1) those who remained enrolled throughout the 12month timepoint, are “in progress,” or withdrew from the study for reasons unrelated to mc use and 2) those who stopped using mc or were lost to follow-up for unknown reasons. no significant between-group differences emerged for any of these variables; therefore, it was determined that missing data could be treated as mar. cudit-r the cudit-r is an 8-item self-report screening tool for cud, which assesses frequency of use; hours stoned during days of use; inability to stop using once started; failure to meet expectations; time spent getting, using, or recovering from cannabis; memory or concentration problems after cannabis use; using in hazardous situations (e.g., driving, caring for children); and desire to stop/reduce cannabis use. seven items are scored on a scale ranging from 04 (higher frequency/severity of symptoms is reflected by higher ratings), while the final question regarding thoughts about cutting down use is scored as 0 (no), 2 (yes, but not in the past 6 months), and 4 (yes, during the past 6 months). scores are summed to generate a total score, ranging from 0 to 32. a total score of 8 or more reflects “hazardous cannabis use,” while scores of 13 or more indicate “possible cud” (adamson et al., 2010; adamson & sellman, 2003). although the cudit-r has been validated in recreational cannabis consumers, little data exists regarding the psychometric properties of the cudit-r when used to assess those who use cannabis for medical purposes. cannabinoid exposure as an observational study, patients chose their own mc treatment regimens, which were closely tracked using a number of metrics. all were asked to record mc treatment regimen information in mc diaries once they established a regular mc use regimen. further, study participants completed monthly phone check-ins to corroborate mc diary information using a modified timeline followback procedure (tlfb) optimized to collect recent cannabis use data (robinson et al., 2014; sobell et al., 1988). through these methods, patients were asked to provide qualitative information regarding product type and mode of use (i.e., joint, vaporizer, solution/tincture, edibles, capsules, topicals, etc.) and quantitative information regarding episodes of mc use/week and amount of product used. data were reviewed and clarified at in-person visits. additionally, patients sent samples of their most frequently used mc products to an outside laboratory for cannabinoid constituent profiling (proverde laboratories, inc.), which was used to quantify thc and cbd levels for each product. for products not analyzed, mc patients provided constituent information based on product labels and/or certificates of analyses from dispensaries or product websites. these data, in combination with mc diary information, were used to calculate standard metrics of cannabinoid exposure (thc mg/week and cbd mg/week) for each interval between study visits. cud in medical cannabis patients 50 statistical analyses over the course of mc treatment, mc patients’ cudit-r scores (total scores and individual item scores) were examined at baseline and after three, six, and twelve months of mc treatment. given the primary goal of assessing mc patients’ post-treatment changes compared to their own baseline, individual repeated measures analyses of variance (rmanovas) were selected as the most parsimonious model to assess cuditr ratings at each follow-up visit relative to baseline ratings (i.e., baseline vs 3 months [n=51], baseline vs 6 months [n=43], and baseline vs 12 months [n=30]). these methods maximized sample sizes for each contrast and increased statistical power. to examine the impact of mc use variables on symptoms of cud, pearson’s r (2-tailed) correlation analyses were utilized to explore the relationship between total cudit-r scores and mc use variables, including number of mc uses/week, thc exposure (mg/week), and cbd exposure (mg/week). lastly, cronbach’s alpha was calculated for the cudit-r to assess its internal consistency, a specific aspect of reliability, in mc patients. further, item-deletion analyses were completed to assess the internal consistency of each cuditr item. together, these analyses provided preliminary data regarding the psychometric properties of the cudit-r when used in mc patients. for these analyses, data from mc patients’ first follow-up visit after 3 months of treatment were utilized to maintain the largest sample size and greatest statistical power. results demographics mc patients (20 men, 34 women) were between the ages of 23-78, mostly white (88.89%), and exhibited above average iq. all individuals in this sample identified as cisgender. reported duration of abstinence from recreational cannabis use ranged from 3-47 years. patients reported using mc to treat a variety of symptoms/conditions. the majority used mc to treat pain-related conditions (n=33), such as musculoskeletal pain (e.g., arthritis, joint or muscle pain), nerve-related pain or fibromyalgia, and headaches. in addition, patients reported using mc to treat symptoms of anxiety or ptsd (n=31), sleep (n=22), mood/depression (n=14), attention (n=4), and other general medical conditions (n=4), including chronic lyme disease, psoriasis, restless legs syndrome, and fatigue related to multiple sclerosis. thirty-six patients reported using mc for more than one indication. over the course of the study, patients reported using mc 9-11 times/week on average, and thc exposure was notably lower than cbd exposure at each visit. table 1 includes additional demographic information as well as information regarding cannabis use patterns, including episodes of mc use/week, thc and cbd exposure, types of cannabis products used and modes of administration. cudit-r scores individual rmanovas demonstrated that total cudit-r scores significantly increased in mc patients at all follow-up visits relative to baseline (ps<.01; see table 2; figure 1). importantly, although ratings significantly increased, average total cudit-r scores were ≤6.73 across all follow-up visits, which is below the threshold for “hazardous use” (score of 8) and well below the cutoff for “possible cud” (score of 13). to determine which specific symptoms or behaviors contributed to total cudit-r score increases, changes in individual item scores were also examined (table 2; figure 2). “frequency of use” had the largest effect sizes and was the only item demonstrating a significant increase at all follow-up visits relative to baseline other than “thought about cutting down use” which had much smaller effect sizes. at some, but not all, follow-up visits, statistically significant increases were also intermittently noted for “failure to meet expectations”, “time spent getting cannabis or recovering from use”, “memory/attention problems”, and “use in hazardous situations”. observed power for all comparisons is provided in supplemental table 1. of the 54 patients included in the study, the number of mc patients who surpassed the threshold for possible cud at each visit was as follows: baseline = 0 (0.00%), three months = 2 (3.70%), six months = 2 (3.70%), twelve months = 3 (5.56%). cannabis, a publication of the research society on marijuana 51 table 1. demographics & medical cannabis/cannabinoid use demographics (n=54) frequency (%) sex assigned at birth 20 male (37.04%) 34 female (62.96%) race 48 white (88.89%) 2 asian (3.70%) 2 black/african american (3.70%) 1 other (1.85%) 1 prefer not to answer (1.85%) ethnicity hispanic (1.85%) non-hispanic (98.15%) mean (sd) age 49.17 (16.45) iq 121.02 (7.54) medical cannabis/cannabinoid use mean (sd) baseline cannabis abstinence (years)a 23.57 (14.20) average mc uses/week baseline to 3 monthsb 9.26 (6.33) 3 months to 6 monthsc 10.81 (8.35) 6 months to 12 monthsd 11.28 (8.60) average thc mg/week baseline to 3 monthse 64.48 (186.69) 3 months to 6 monthsf 43.14 (79.76) 6 months to 12 monthsg 38.37 (50.43) average cbd mg/week baseline to 3 monthse 158.04 (290.61) 3 months to 6 monthsf 204.97 (326.13) 6 months to 12 monthsg 97.76 (257.81) routes of administrationh smoke 13 (55.56%) vape 27 (50.00%) oromucosal (oil, tincture, solution) 33 (61.11%) oral (edible, tablet, capsule) 22 (40.74%) cutaneous (lotion, salve) 4 (7.41%) transdermal (patches) 0 (0.0%) transmucosal (suppository) 0 (0.0%) cbd=cannabidiol; mc = medical cannabis; thc=delta-9-tetrahydrocannabinol aaverage abstinence is reported for n=28 with a previous history of regular cannabis use; n=26 reported no previous regular cannabis use or were cannabis naïve; b n=49; c n=43; d n=29; e n=37; f n=31; g n=22; h n=54, participants could report multiple modes of use cud in medical cannabis patients 52 table 2. changes in cudit-r score over time baseline n=51 3 months n=51 3 months baseline rmanovaa baseline n=43 6 months n=43 6 months baseline rmanovab baseline n=30 12 months n=30 12 months baseline rmanovac variable mean (sd) mean (sd) mean difference [95% ci] f p (η2) mean (sd) mean (sd) mean difference [95% ci] f p (η2) mean (sd) mean (sd) mean difference [95% ci] f p (η2) total score 1.35 (1.98) 6.06 (2.78) 4.71 [3.98, 5.43] 168.78 <.01 (.77) 1.63 (2.18) 6.35 (3.13) 4.72 [3.68, 5.76] 84.09 <.01 (.67) 1.20 (1.42) 6.73 (3.85) 5.53 [4.19, 6.88] 70.57 <.01 (.71) frequency 0.55 (0.64) 3.55 (0.73) 3.00 [2.72, 3.28] 459.00 <.01 (.90) 0.63 (0.69) 3.51 (0.88) 2.88 [2.52, 3.25] 257.08 <.01 (.86) 0.60 (0.62) 3.67 (0.71) 3.07 [2.69, 3.45] 273.95 <.01 (.90) hours stoned 0.43 (0.76) 0.69 (0.99) 0.26 [-0.03, 0.54] 3.34 .07 (.06) 0.49 (0.77) 0.72 (0.93) 0.23 [-0.07, 0.53] 2.46 .12 (.06) 0.40 (0.67) 0.67 (0.92) 0.27 [-0.13, 0.66] 1.94 .17 (.06) can’t stop 0.00 (0.00) 0.10 (0.46) 0.10 [-0.03, 0.23] 2.33 .13 (.04) 0.00 (0.00) 0.07 (0.34) 0.07 [-0.03, 0.17] 1.83 .18 (.04) 0.00 (0.00) 0.20 (0.76) 0.20 [-0.08, 0.48] 2.07 .16 (.07) failure to meet expectations 0.02 (0.14) 0.22 (0.61) 0.20 [0.03, 0.37] 5.44 .02 (.10) 0.02 (0.15) 0.12 (0.32) 0.09 [-0.02, 0.21] 2.78 .10 (.06) 0.00 (0.00) 0.13 (0.35) 0.13 [<0.01, 0.26] 4.46 .04 (.13) time spent getting cannabis or recovering 0.04 (0.29) 0.14 (0.35) 0.10 [<-0.01, 0.20] 3.77 .06 (.07) 0.05 (0.31) 0.33 (0.78) 0.28 [0.02, 0.54] 4.59 .04 (.10) 0.00 (0.00) 0.33 (0.80) 0.33 [0.03, 0.63] 5.18 .03 (.15) memory/ attention problems 0.06 (0.24) 0.45 (.92) 0.39 [0.12, 0.66] 8.50 .01 (.15) 0.09 (0.29) 0.35 (0.72) 0.26 [0.01, 0.50] 4.51 .04 (.10) 0.03 (0.18) 0.30 (0.70) 0.27 [-0.01, 0.54] 3.90 .06 (.12) use in hazardous situation 0.06 (0.24) 0.22 (0.64) 0.16 [-0.02, 0.34] 3.03 .09 (.06) 0.07 (0.26) 0.47 (1.03) 0.40 [0.07, 0.72] 6.10 .02 (.13) 0.10 (0.31) 0.10 (0.31) 0.00 [-0.10, 0.10] 0.00 1.00 (.00) thought about cutting down use 0.20 (0.83) 0.71 (1.49) 0.51 [0.12, 0.90] 7.00 .01 (.12) 0.28 (0.93) .79 (1.52) 0.51 [0.03, 1.00] 4.51 .04 (.10) 0.07 (0.37) 1.33 (1.77) 1.26 [0.63, 1.90] 16.64 <.01 (.37) note. three of the 54 total mc patients missed the 3-month follow-up but completed later follow-up visits, resulting in n=51 for the baseline vs 3-month comparison. ci = confidence interval, rmanova = repeated measures analysis of variance, sd = standard deviation. significant values (p<.05) are bolded. a degrees of freedom (df)=1,50. b degrees of freedom (df)=1,42. c degrees of freedom (df)=1,29 cannabis, a publication of the research society on marijuana 53 figure 1. cudit-r total scores although total cudit-r scores increased in mc patients relative to baseline, on average ratings fell below the threshold for hazardous use or possible cud at each visit. figure 2. individual cudit-r item scores frequency of mc use increased significantly, and although statistically significant differences were noted for several other items, these scores do not appear to be clinically meaningful given that average scores do not reflect positive endorsement of these symptoms. cud in medical cannabis patients 54 correlation analyses: cudit-r and mc use variables correlations assessing the relationship between total cudit-r scores and mc use variables revealed that number of mc uses per week was not related to total cudit-r scores (r(47)=.12, p=.42). when the relationships between total cudit-r scores and exposure to individual cannabinoids (thc and cbd) were examined, results revealed higher exposure to thc (mg/week) was significantly associated with higher total cudit-r scores (r(35)=.35, p=.03). no significant relationship was detected between cbd mg/week and total cudit-r scores (r(35)=.01, p=.95). cudit-r internal consistency and reliability given that increases in total cudit-r scores appeared largely attributable to frequency of use, we conducted further analyses to examine internal consistency and reliability of the cuditr in our sample of mc patients. cronbach’s alpha analyses revealed that in the current sample of patients using mc for 3 months (n=51), the cudit-r had an unacceptable level of internal consistency (alpha=.30). moreover, item deletion analyses revealed that removing “frequency of use” from the analyses increased internal consistency (alpha=.40), as did removal of “thought about cutting down use” (alpha=.48). as alpha increased after removing these items, it appears that frequency of use and thought about cutting down cannabis use are not assessing the same construct (i.e., cud) as the remainder of cudit-r items in this cohort of mc patients. even after removal of these items, alpha remained below the level of acceptable internal consistency. discussion findings suggest that on the cudit-r, mc patients in this study generally endorse expected increases in frequency of cannabis use between baseline (pre-mc use) and follow-up visits occurring three, six, and twelve months after initiation of mc treatment. however, increases in other cud symptoms appear minimal, and on average, mc patients in the current study do not meet the threshold for “hazardous” cannabis use over the course of twelve months of mc treatment. when examining total cudit-r scores in each individual mc patient, a small number of patients did surpass the threshold for possible cud following initiation of mc treatment (two patients after both three and six months, and three patients after twelve months). however, cronbach’s alpha analyses assessing internal consistency revealed that the cudit-r demonstrates extremely low reliability in the study sample; such low reliability raises the question of whether this scale is a valid indicator of cud in mc patients. in fact, when these data are considered in conjunction with results of the correlation analyses demonstrating that number of mc uses is not related to cud in this population, as well as a qualitative examination of the cudit-r items (discussed below), our findings suggest that the cudit-r, which was validated only in recreational cannabis consumers, may not be an appropriate screening tool for assessing cud in mc patients. overall, although significant increases in frequency of cannabis use were observed, this change was expected, as patients in the study were not using mc at baseline, and follow-up assessments only occurred after initiation of regular mc treatment. importantly, correlation analyses revealed that number of mc uses/week was not significantly correlated with total cudit-r scores, further supporting the idea that frequency of mc use is not likely a useful indicator of problematic use in mc patients, and raising questions regarding the validity of the cudit-r in those who use cannabis for medical purposes. interestingly, higher levels of thc exposure were significantly associated with higher cudit-r scores, suggesting that thc exposure may be a more salient marker of problematic use than the “frequency of use” item. in fact, previous studies have shown that using cannabis with higher levels of thc is related to increased severity of cud symptoms (freeman & winstock, 2015). cbd exposure, however, was not related to cudit-r scores, which is not surprising given that cbd is non-intoxicating, has a low potential for abuse liability as it does not cause tolerance or withdrawal symptoms, and lacks rewarding effects (who expert committee on drug dependence, 2018) analyses of changes in individual cudit-r items also revealed that while “frequency of use” cannabis, a publication of the research society on marijuana 55 scores increased relative to baseline, other signs of problematic use were generally not endorsed after initiation of mc treatment. notably, statistically significant increases from baseline were intermittently observed for some of the other cudit-r items, but results do not appear to be clinically meaningful, given near zero scores and small effect sizes. in addition, statistically significant increases for “thoughts about cutting down” use may be explained by the unique scoring criteria for this item. average ratings remained below a score of 2, which is needed to reflect a positive endorsement of this symptom. as previously noted, cronbach’s alpha analyses revealed unacceptable internal consistency in the current sample (alpha =.30). although the cudit-r is considered a wellvalidated screening tool for cud, it was developed for use in recreational cannabis consumers, and not mc patients. to date, only one other study, (published while the current longitudinal study was already underway), has assessed the reliability of the cudit-r in mc patients (loflin et al., 2018). this study examined a specific subpopulation of mc patients (veterans) using a cross-sectional approach in which they examined baseline data from a longitudinal study; however, unlike the current study, study participants were already using mc at baseline. loflin and colleagues reported that although the cudit-r’s internal consistency fell within the acceptable range, the calculated cronbach’s alpha was considered modest (alpha=.73). it is possible that cronbach’s alpha was higher in the loflin et al. study than in the current study as mc patients described in loflin et al. may have also used cannabis for recreational purposes. although this was not explicitly reported, the study population included veterans who were members of an alliance that allowed those with a mc card to gain bimonthly access to free cannabis products. accordingly, a significant number of veterans enrolled in the loflin et al. study may have used cannabis for both recreational and medical purposes, while patients in the current study nearly exclusively used cannabis for medical purposes. given that the cudit-r has demonstrated acceptable psychometric properties in those who use cannabis for recreational purposes, this may account for the higher alpha observed by loflin and colleagues. further, in the current study, removal of “frequency of use” and “thought about cutting down use” increased the overall alpha of the cudit-r in mc patients, which suggests that these items do not reflect the same construct as the other items of this scale. in other words, “frequency of use” and “thought about cutting down use” do not appear to be reflective of cud symptoms in mc patients. qualitative examination of these items identified by our itemdeletion analyses offers some insight into why these items are not appropriate indicators of problematic use in mc patients. for example, increased frequency of use could indicate that a patient is suffering from more severe medical symptoms and therefore needs to use mc more often to achieve symptom relief. it is also possible that if mc is providing adequate symptom relief, patients will be motivated to use mc frequently and regularly. moreover, as frequent mc use is analogous to taking a conventional medication regularly, consistent use of a medication could actually be viewed as a sign of treatment adherence rather than a sign of problematic use. therefore, it may be more helpful to differentiate frequent use from using more than needed to achieve a therapeutic benefit, as the latter is likely to be more indicative of problematic use among mc patients. in addition, “thought about cutting down use” may indicate that patients feel as though they do not need as much mc to get the same effect, or endorsement of this item may be a function of patients feeling the financial burden related to the cost of mc, especially as it is not covered by insurance. other questions on the cudit-r may not be directly reflective of problematic use in mc patients either. specifically, “time spent getting cannabis” may reflect the distance some patients travel, or the time patients wait to purchase mc products. accordingly, although some patients in this study did surpass the threshold for potential cud at follow-up visits, these numbers are not likely an accurate representation of the number of mc patients who develop cud. specifically, as qualitative examination of individual cudit-r items indicates that most items (with the exception of frequency of use) would be more appropriate for mc patients if caveats were issued, it appears that the cudit-r is more likely to result in false cud positives among mc cud in medical cannabis patients 56 patients than false negatives (failures to identify cases of cud). taken together, current views of cud should be amended to capture signs of problematic mc use among patients. as in the case of opioid use disorder, for example, tolerance and withdrawal criteria are not considered for individuals who are using opioids under appropriate medical supervision. with regard to cannabis, similar exclusions from dsm-5 criteria may need to be applied. it is likely that signs of problematic use manifest differently in mc patients who have a markedly different motivation for cannabis use – symptom alleviation – relative to recreational consumers who use cannabis specifically to alter their state of being or to feel “high.” as a result, mc patients and recreational consumers often seek different cannabis products resulting in different levels of exposure to specific cannabinoids. typically, recreational cannabis consumers seek products with high levels of thc, which is generally associated with negative neurobiologic outcomes (kowal et al., 2015; ramaekers et al., 2006; rigucci et al., 2016), to achieve mood-altering effects. further, chronic exposure to thc is thought to alter excitatory and inhibitory signaling in certain brain regions that could ultimately affect reward processing (parsons & hurd, 2015). altered reward processing is closely linked to addictive disorders, given that intoxication produces pleasurable feelings, leading to repeated use as an individual seeks to achieve these rewarding effects (everitt & robbins, 2016). as previously noted, use of products with higher levels of thc has also been associated with increased addiction severity (freeman & winstock, 2015). although mc patients may use products containing thc, many seek products with varied cannabinoid constituent profiles that are often less or nonintoxicating (sagar & gruber, 2018). specifically, many mc patients choose products high in cbd, known for its therapeutic benefits and potential neuroprotective properties (blessing et al., 2015; de mello schier et al., 2014; fernandez-ruiz et al., 2013; iseger & bossong, 2015; zuardi, 2008). calculations of overall thc and cbd exposure suggest that this preference is reflected in the current study sample, as mc patients as a group had substantially higher cbd exposure relative to thc. cbd has been shown to limit or mitigate negative effects associated with thc (englund et al., 2013; morgan & curran, 2008; morgan et al., 2012; morgan et al., 2010; yucel et al., 2016; zuardi et al., 1982), and preliminary data suggest cbd may have efficacy in the treatment of substance use disorders, including nicotine (morgan et al., 2013), cocaine (lujan et al., 2018), and opioids (hurd et al., 2019; hurd et al., 2015). further, one case study suggests positive effects of cbd in treating cud (shannon & opila-lehman, 2015), which is supported by the current findings, as higher thc, but not cbd exposure was significantly correlated with increased cudit-r scores. findings from this study indicate that most mc patients in the current sample do not reach the threshold for cud using the cudit-r, a common screening tool for cud. however, these findings must be considered in light of several limitations. first, a definitive diagnosis of cud can only be made using a diagnostic interview such as the structured clinical interview for dsm (scid). the cudit-r was selected for use in this study as it is widely used screening tool to assess cannabis consumers in both clinical and research settings and sometimes serves as a proxy for diagnostic instruments given the significant overlap between cudit-r items and dsm-5 criteria for cud. however, it is important to note that this instrument is based on dsm-iv criteria as it was developed before the release of the dsm5. although most criteria are similar between the two dsm versions, “craving or desire to use cannabis” was added to the dsm-5; this is the only criterion not reflected in the cudit-r. nonetheless, until valid and reliable tools are available to screen for cud in mc patients, future studies examining cud in this population should utilize a diagnostic interview like the scid-5, which allows the clinician to use their judgement to determine if an individual’s behavior is actually representative of problematic use. currently, sample sizes are moderate. plans for the ongoing, longitudinal study involve monitoring symptoms of cud in larger samples and over longer durations (up to two years). however, longitudinal studies assessing patients over the course of several years may be necessary to detect potential development of cud. in addition, mc patients who were cannabis naïve or who had limited recent cannabis exposure were specifically recruited, and all patients reported a primary goal of symptom alleviation. given that cannabis, a publication of the research society on marijuana 57 most mc patients in the current sample report using cannabis exclusively for medical purposes, they may represent a unique group of patients. as such, results may not be generalizable to other populations such as “mixed” cannabis consumers who use cannabis both medically and recreationally. similarly, findings may not apply to mc patient populations who choose products with higher amounts of thc than cbd, as patients in the current sample overall reported notably higher exposure to cbd. findings may also not be generalizable to more racial and ethnically diverse samples, as the current sample was predominantly comprised of white individuals. despite potential limited generalizability, this study represents the first face-to-face, direct assessment of cud in mc patients prevs postmc treatment. although findings may appear to be in contrast with existing literature indicating that rates of cud in mc patients are comparable to cud rates in recreational cannabis consumers (lin et al., 2016; turna et al., 2020), this is likely related to recruitment criteria and assessment tools. for example, mc patients enrolled in lin et al. were permitted to use cannabis for recreational purposes, and turna et al. did not directly compare those who used cannabis exclusively for recreational purposes vs those who used exclusively for medical purposes. further, lin and colleagues’ data is based on the national survey on drug use and health, which utilizes questions similar to those asked in the cudit-r, while turna et al. implemented the cudit-r itself; both approaches are problematic as results from the current study demonstrate that these types of queries are not appropriate for assessing cud in mc patients, and may result in increased rates of cud false positives and reduced sensitivity. cud is likely a unique construct among those using cannabis medically, and existing tools developed for use in recreational consumers do not appear to be reliable, valid measures for assessing cud in mc patients. conclusions in the current study, mc patients generally exhibit low risk patterns of cannabis use, as average scores indicate mc patients generally do not meet cudit-r criteria for hazardous use or possible cud. although some patients did surpass the threshold for possible cud after initiation of mc use, 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(2008). cannabidiol: from an inactive cannabinoid to a drug with wide spectrum of action. revista brasileira de psiquiatria, 30(3), 271-280. zuardi, a. w., shirakawa, i., finkelfarb, e., & karniol, i. g. (1982). action of cannabidiol on the anxiety and other effects produced by delta 9-thc in normal subjects. psychopharmacology, 76(3), 245250. funding and acknowledgements: all authors declare no conflicts of interest. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 104 ved abstract background: research indicates separation from the military may result in increased risk of alcohol use. however, there is little data on cannabis use among military service members, particularly when examining the period after separation from military service. this research examines cannabis-related perceptions and use among u.s. army reserve/national guard (usar/ng) current and former soldiers. methods: data come from operation: safety (soldiers and families excelling through the years), an ongoing study examining health among male and female usar/ng soldiers. the current sample was comprised of 401 current and former usar/ng soldiers. logistic regression models examined the associations between pastyear cannabis use, military status (i.e., current versus former), attitudes towards recreational cannabis, perceived ease of access, and perceived risk of cannabis use, while controlling for age, problematic alcohol use, and current cigarette smoking. results: overall, 7.4% of current and 20.3% of former military service members used cannabis in the past year. favorable attitudes towards cannabis use and perceived ease of accessing cannabis were associated with increased odds of use among all soldiers. in adjusted models, former military members had greater odds (aor = 5.28, 95% ci = 2.16, 12.87) of past-year cannabis use compared to current service members. conclusions: findings indicate that separation from the military may be an important risk factor to consider when assessing cannabis use in the military. additional research is needed to examine socioenvironmental factors (e.g., access to post-deployment support services and healthcare, state legalization laws, other behavioral health conditions) that contribute to former service members’ cannabis use. key words: = cannabis; separation from military; reserve soldiers separation from military service has long been recognized as a stressful life event, associated with adverse health consequences (mcneil & giffen, 1967; parker, et al., 2019). despite the known stressors associated with military separation, a limited research base has examined the relationship between separation from military service and risks for substance use. in qualitative interviews, military service members indicated the transition out of the military was difficult and accompanied by heavier alcohol and illicit drug use, as well as use of a broader range of substances (vest, et al., 2021). quantitative data also indicates a higher risk for military service members’ substance use upon separation from military service, including problematic alcohol use (porter, et al., 2020; vest, et al., 2018) and cigarette smoking (nieh, et al., 2020). additional cross-sectional data indicates that former military service members had higher odds of cigarette smoking, nicotine dependence, nonmedical use of prescription painkillers, illicit drug use, drug dependence, and alcohol problems, compared to currently serving military service members (hoopsick, et al., 2017). one of the main limitations of the extant literature on separation from military service and substance use is that most publications have focused on alcohol use or have combined cannabis with the greater category of illicit drug use (e.g., hoopsick et al., 2017). accurate surveillance and measurement is vital to understanding cannabis use correlates and trends. given the rapid changes in the socioenvironmental landscape of jessica a. kulak1, d. lynn homish1, lynn t. kozlowski1, gregory g. homish1 1 department of community health and health behavior, university at buffalo, buffalo, ny, usa cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000150 cannabis use and perceptions among current and former military service members corresponding author: jessica a. kulak, phd, mph, 312 kimball tower, 3435 main street, buffalo, ny 14214. email: jakulak@buffalo.edu cannabis, a publication of the research society on marijuana 105 cannabis use, it is no longer sufficient to measure cannabis as one among many illicit substances. to our knowledge, only one study directly examines cannabis use in relation to separation from military service and data from this small cohort of operation enduring freedom or operation iraqi freedom veterans indicated that cannabis use increased after separation from military service (golub & bennett, 2014). this study was limited, however, by its focus on low-income and minority soldiers living in a single city, which limits generalizability. despite these emergent findings, the literature regarding substance use and dependence among those who have left the military is limited, particularly when examining cannabis use outcomes among reserve component service members. understanding cannabis use among military personnel is important for a number of reasons. first, there is a growing demand to increase access to medicinal cannabis for u.s. veterans (loflin et al., 2019). cannabis is being used among civilians to treat a number of health conditions that are prevalent among military service members, including conditions like chronic pain, traumatic brain injury, and posttraumatic stress disorder (loflin et al., 2019). despite being used medicinally, and that the mode of use (e.g., inhalation, transdermal, etc.) can effect the therapeutic and abuse potential of cannabis (bonn-miller et al., 2019), little is known about how military service members typically use cannabis products. second, cannabis is the most common illicit substance used among military recruits (golub & bennett, 2014). whereas the prevalence of cannabis use decreases when currently serving compared to new recruits, cannabis remains the most prevalent drug identified in drug testing among current soldiers (golub & bennett, 2014; larson, et al., 2016). finally, the general u.s. public opinion of cannabis use has shifted. for example, more citizens believe it should be legalized (pew research center, 2019) and fewer citizens consider cannabis use risky (pacek, et al., 2015). however, it is less clear if military service members’ perspectives mirror these changing societal views, underscoring the need for greater surveillance and monitoring of cannabis-related perceptions among military personnel. as of november 2022, 37 states allow medicinal cannabis use, and 21 states allow recreational use (national conference of state legislatures, 2022); at the same time, at the federal level, cannabis continues to be a schedule 1 drug under the 1970 controlled substances act. schedule 1 drugs are those deemed to have no accepted medical use and high potential for dependency (national conference of state legislatures, 2022). despite evolving state-level legislation regarding both medicinal and recreational use, the military maintains zero tolerance policies for federally illicit substances; using such substances can jeopardize one’s military career (platteborze, et al., 2013). over one million individuals are enlisted in a reserve component of the us military (office of the deputy assistant secretary of defense, 2016), but their experiences have been examined less frequently compared to those of active duty soldiers. research focused on this population is particularly important given that reserve component soldiers are at greater risk for substance use compared to their active duty counterparts with similar service-related experiences (cohen, et al., 2015; thomas et al., 2010). understanding issues related to cannabis use may be especially relevant to reserve and national guard soldiers, as they navigate potentially conflicting state-level laws and federal regulations in their roles as citizen soldiers. reserve component soldiers are civilians who are trained and qualified to be called to active duty military service; they must shift roles between civilians, who may live in a state with legalized markets for cannabis, and soldiers, who must follow federal drug policy. despite the changing societal context surrounding cannabis use in the u.s., there has been limited examination of the impacts of leaving military service on cannabis use. therefore, this study examined cannabis use among male and female us army reserve and army national guard (usar/ng) current or former soldiers. primary aims included (1) estimating the prevalence of cannabis use among a sample of usar/ng soldiers and describing perceived cannabis risk, attitudes of approval towards recreational cannabis use, and perceived ease of accessing cannabis among all soldiers; and (2) taking these perceptions into account, examining differences in the odds of cannabis use on the basis of military service status (former soldiers compared to currently serving). as mode of cannabis and military status 106 cannabis administration can impact bioavailability, therapeutic potential, and risks associated with use (bonn-miller et al., 2019), a secondary aim involved describing modes of cannabis use. methods participants & procedure data were drawn from operation: safety, an ongoing longitudinal study focused on the health of usar/ng soldies and their spouses/partners. detailed study recruitment and data collection procedures have been published elsewhere (devonish et al., 2017; kozlowski, et al., 2017; vest, et al., 2017). in brief, participants were recruited during drill weekends from reserve and national guard units across new york state and screened for eligibility. to enroll in the study, at least one partner needed to be currently serving in the usar/ng at the time of the baseline survey and both partners had to be willing to participate. participants complete annual surveys covering a broad range of topics, including physical and mental health, sleep, substance use, romantic relationships, and military service related information and events. the university at buffalo as well as the army human research protections office, office of the chief, army reserve and the adjutant general of the national guard approved the study protocol. participants recruited in the parent study were consistent with the military characteristics (i.e., rank enlisted v. officer) of reserve and guard soldiers nationally (office of the deputy assistant secretary of defense, 2016). soldiers in this analysis were 79% male (n = 317) and 21% (n = 84) female with a mean age of 32 years (sd: 6.5). the majority of the sample was non-hispanic white (80%; n = 319) and 90% had completed some college or had a college degree. on average, soldiers had served 10 years in the military (sd: 6.1). in this sample, 84% (n = 337) of soldiers were currently serving in the usar/ng and 16% (n = 64) were separated from military service. measures past year cannabis use. the nida modified assist 2.0 (alcohol, smoking, and substances involvement screenting test; (who assist working group, 2002) was used to assess use of cannabis in the past year with the item, “in the past year, which of the following substances have you used? cannabis?” responses were coded to create a binary variable of past year cannabis use. past 90 day cannabis use. the nida modified assist 2.0 (alcohol, smoking, and substances involvement screenting test; (who assist working group, 2002) was used to assess use of cannabis in the past 90 days with the item, “in the past three months, how often have you used any cannabis?” responses ranged from “never” to “daily or almost daily” and were coded to create a binary variable of past 90 day cannabis use. military status. participants were asked annually to report whether they were ever in the military and if so, whether they are currently serving. responses were categorized into current soldiers or former soldiers. civilians were not included in these analyses. perceptions of cannabis use. perceptions of cannabis use were measured using three questions: 1. soldiers’ attitudes towards recreational cannabis use was assessed using the item: “how do you feel about adults using marijuana for recreational use?” response options were: strongly disapprove, disapprove, neither disapprove nor approve, approve, strongly approve. 2. perceived risk of cannabis use was assessed with the item, “how much risk do you believe there is in smoking marijuana once or twice a week?” with the response options of: no risk, slight risk, moderate risk, great risk. 3. perceived ease of access to obtain cannabis was assessed with the item, “how difficult would it be for you personally to obtain marijuana, if you wanted to?” response options were: probably impossible, very difficult, fairly difficult, fairly easy, very easy. problematic alcohol use. the alcohol use disorders identification test (audit) was used to assess problematic alcohol use (saunders, et al., 1993). the audit consists of 10 items rated on a four-point scale from 0 (never) to 4 (daily or almost daily), with scores ranging from 0 40. the current analyses used audit total score as a continuous variable in adjusted models. current cigarette use. because the co-use of tobacco and cannabis is more common than cannabis use alone (smith et al., 2019), adjusted cannabis, a publication of the research society on marijuana 107 analyses also control for current cigarette smoking. current use of cigarettes was assessed with the item, “in your entire life, have you ever smoked 100 cigarettes?” participants who responded “yes” were asked, “do you currently smoke cigarettes?” responses were coded to create a binary variable of current cigarette use. age. soldiers self-reported age. modes of cannabis use. soldiers’ modes of using cannabis were assessed with two items. first, soldiers were asked, “have you ever used cannabis, marijuana, marijuana concentrates, marijuana waxes, thc, or hash oils in an electronic product such as an e-cigarette, vape, mod, personal vaporizer, e-hookah, or hookah pen?” response options were no or yes. participants who responded yes were asked, “how would you describe your usual marijuana or cannabis use? would you say…” and participants were presented with the following response options: i only smoke cannabis; i smoke and vape cannabis, but i smoke cannabis more often; i smoke and vape cannabis about the same amount; i smoke and vape cannabis, but i vape cannabis more often; i only vape cannabis. statistical analyses all analyses used stata version 17.0 software (stata corporation, college station, tx). descriptive statistics were used to characterize the study sample, including perceptions of cannabis use, routes of administration, and prevalence of cannabis use. to examine the association between past year cannabis use and military status, we used multivariable logistic regression analyses to produce adjusted odds ratios. final models were adjusted for age, problematic alcohol use, current combustible cigarette use, perceived cannabis risk, attitudes of approval towards recreational cannabis use, and perceived ease of access. results estimate the prevalence of cannabis use and cannabis-related perceptions the first aim was to characterize the prevalence of usar/ng service members’ cannabis use. among all current and former service members, nearly 1 in 10 service members (9.5%) had used cannabis in the past year (7.4% of current and 20.3% of former soldiers). among service members reporting past year use, 3.5% had used in the past 90 days. (see table 1). we also sought to characterize military service members’ perceptions of cannabis use. perceived risk of cannabis use were fairly low among all soldiers. over one-third (36.7%; 36.2% of current and 39.1% of former soldiers) indicated there is no risk to smoking cannabis one or two times per week. perceptions of the ease of accessing cannabis were high; nearly two-thirds (62.3%; (62.6% current; 60.9% former)) of soldiers indicated it would be fairly easy or very easy to personally obtain cannabis, if they wanted to. finally, 31.4% (32.0% current; 28.1% former) of soldiers approved or strongly approved of recreational cannabis use (see table 1). there were no significant differences in perceived risk, perceived ease of access, or attitudes of approval between current and former usar/ng service members. examine for differences in the odds of cannabis use on the basis of military service status the second study aim was to examine differences in the odds of cannabis use on the basis of military service status (specifically examining former soldiers compared to those currently serving). in unadjusted models, former soldiers had higher odds of past-year cannabis use, compared to currently serving service members (odds ratio (or) = 3.18, 95% confidence interval (ci) = 1.53, 6.62; see table 2). when taking into account cannabis-related perceptions, the adjusted odds ratio (aor) of past year cannabis use was significantly higher for former soldiers compared to current soldiers (aor = 5.28, 95% ci = 2.16, 12.87). soldiers indicating it was easier to obtain cannabis had higher odds of past year use (aor = 2.26, 95% ci = 1.38, 3.72), and soldiers who indicated greater approval for recreational cannabis use had higher odds of past year cannabis use (aor = 1.82, 95% ci = 1.19, 2.77; see table 2). soldiers who endorsed problematic alcohol use had higher odds of past year cannabis use (aor = 1.11, 95% ci = 1.03, 1.19). past year cannabis use was also associated with age, with lower odds of using for older service members (aor = 0.91, 95% ci = 0.84, 0.98). there was no significant associations between past year use and perceived risk of cannabis use (aor = 0.94, 95% ci = 0.52, 1.69) or current cigarette smoking (aor = 0.40, 95% ci = 0.10, 1.60; table 2). cannabis and military status 108 table 1. baseline demographics and current substance use of u.s. army reserve/ national guard soldiers (n = 401) % or m n or sd former soldiers 16.0% 64 years served 9.5 6.1 sex male female 79.1 21.0 317 84 race/ethnicity non-hispanic white non-hispanic black hispanic other 79.6 5.0 8.7 4.7 319 20 35 19 education high school or less some college college degree 10.0 57.1 32.9 40 229 132 median household income $60,0000 to $79,999 age 31.9 6.5 current smoking 10.0 40 past-year cannabis use 9.5% 38 past 90-day cannabis use 3.5% 14 no risk of using cannabis 1-2 times/week 36.7% 147 fairly or very easy to obtain cannabis 62.3% 250 strongly approve or approve of recreational cannabis use 31.4% 126 table 2. odds of past year cannabis use among u.s. army reserve/national guard soldiers or 95% ci aor 95% ci former soldier (v. current) 3.18** 1.53, 6.62 5.28*** 2.16, 12.87 risk of using cannabis 1-2 times/week 0.94 0.52, 1.69 ease of obtaining cannabis 2.26** 1.38, 3.72 approval of recreational cannabis use 1.82** 1.19, 2.77 problematic alcohol use 1.11* 1.03, 1.19 current cigarette smoking 0.40 0.10, 1.60 age 0.91* 0.84, 0.98 note. or = odds ratio; aor = adjusted odds ratio; ci = confidence interval. *p < .05. **p < .01. ***p < .001 describe modes of cannabis use a secondary aim was to describe usar/ng soldiers’ experiences with how they have used cannabis. when asked if they had ever used cannabis, marijuana concentrates, thc, marijuana concentrates or hash oils in an electronic product, a little more than 10% of service members had done so (see figure 1a). respondents who answered yes to that question were then asked to describe their usual use. typical use was described by 44% of service members as only smoking cannabis. an additional 37% of service members typically smoke and vape, but usually smoke cannabis more often, whereas 12.5% said they smoke and vape, but typically vape cannabis more often. only 6% of service members stated they usually smoke and vape cannabis equally (see figure 1b). cannabis, a publication of the research society on marijuana 109 figure 1 (a) electronic administration of cannabis use (b) electronic administration of cannabis use discussion national guard and reserve soldiers, in their roles as citizen soldiers, must negotiate competing norms and legal landscapes between military and cilivian societies. notwithstanding the changing societal context surrounding cannabis use in the united states, there has been limited examination of the impacts of usar/ng soldiers leaving military service on cannabis use. findings indicate that separation from the military may be an important risk factor to consider when assessing cannabis use among reserve component soldiers. former soldiers had significantly higher odds of past year cannabis use when compared to current soldiers, which persisted when considering key covariates. previous work has posited that the period after leaving the military is one of high stress (mcneil & giffen, 1967; parker et al., 2019); this may indicate that former soldiers are using cannabis to readjust to civilian life. in fact, qualitative data indicates that cannabis is used by former soldiers as a sleep aid, for stress relief, and as a coping mechanism (vest et al., 2021), indicating opportunities exist to better support veterans’ transition to civilian life. despite this, we hypothesize that after leaving the military, random drug monitoring is no longer an issue, which may in turn result in greater drug use. regardless, future research is needed to examine socioenvironmental factors, including access to post-deployment support services and healthcare, state legalization laws, and other behavioral health conditions to better contextualize former soldiers’ cannabis use. additional research is needed to examine whether separation from the military results in shortor long-term cannabis use risks. this may be particularly urgent in light of recent calls to increase access to medicinal cannabis for u.s. veterans (loflin et al., 2019). understanding usar/ng soldiers cannabis use may be particularly important in an era of evolving state and federal laws. the united states house of representatives has been presented with the marijuana opportunity reinvestment and expungement act (more act), which would federally decriminalize cannabis use and remove cannabis from the list of scheduled substances under the controlled substances act ("marijuana opportunity reinvestment and expungement act more act," 2021-2022). longitudinal studies that can examine temporal relationships pre-, during, and post-change to federal laws will be an important contribution of future research. this research additionally contributes to the literature by assessing soldiers’ perceptions of cannabis use. in the combustible cigarette literature, attitudes and perceptions about smoking are strongly correlated with future use cannabis and military status 110 (song et al., 2009). although drug use was assessed at only one time point, our results were generally consistent with this, as soldiers’ approval of recreational use was associated with higher odds of past-year use. nearly one-third of soldiers approved or strongly approved of recreational cannabis use. additionally, perceived risk of cannabis use was fairly low among this sample of soldiers, whereas perceptions surrounding the ease of accessing cannabis were high. importantly, at the time of data collection, recreational cannabis use was not legal in new york state, where this sample was recruited. since then, in july 2021, new york state has legalized recreational cannabis use (national conference of state legislatures, 2022); we hypothesize these prevalence estimates may change in future survey waves as a result of this change in state law. future work should consider examining how one’s perceptions of cannabis predict future use, particularly post separation from military service. there is limited available data on the modes of cannabis use among u.s. military service members. in one sample of veteran medical cannabis users, approximately 7.8% administered cannabis by vaping (loflin et al., 2019). a secondary aim of this study was to describe modes of soldiers’ cannabis use. just over 10% of soldiers had ever used cannabis, marijuana concentrates, thc, marijuana concentrates or hash oils in an electronic product. however, this finding should be interpreted with caution due to the small subsample of soldiers who responded to this question. despite the number of soldiers reporting how they are using cannabis, we chose to include these as preliminary findings, as we think questions of this nature are important for future research teams to consider, as the use of cannabis or related products (e.g., cannabidiol, or cbd) are being promoted directly to the military population through advertisements and price promotions. for example, the online retailer flower company offers a u.s. military veteran’s cannabis membership program, which provides 30%-50% off products after verifying their veteran status (flower company, 2022; hasse, 2019). given this, the surveillance and monitoring of modes of cannabis use among military service members is a missed but necessary opportunity, as mode of administration can impact bioavailability, therapeutic potential and risks associated with use (bonn-miller et al., 2019). limitations there are several limitations to these findings that should be considered. results are based on self-reported data. despite this, we use confidential, self-administered surveys, so common barriers to reporting, such as concerns about privacy, are reduced. in addition, participants were recruited from new york state. however, not all participants currently live in new york, and we are unable to examine and account for the state-level legal landscape of where participants currently live. this will be important for future research to consider. finally, this study was not specifically designed to study separation from the military; future longitudinal research is needed to better contextualize how leaving the military is associated with cannabis use. conclusion the current research indicate that separation from the military may be an important risk factor to consider when assessing cannabis use. former soldiers had higher odds of past year cannabis use than current reserve soldiers. soldiers with more favorable attitudes towards cannabis use and increased perceived ease of accessing cannabis also had higher odds of past year use. given the forecasted increase in the numbers of former soldiers in the u.s., additional research is needed to examine socioenvironmental factors that contribute to former service members’ cannabis use. references bonn-miller, m. o., pollack, c. v., jr., casarett, d., dart, r., elsohly, m., good, l., . . . abrams, d. 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(2002). the alcohol, smoking and substance involvement screening test (assist): development, reliability and feasibility. addiction, 97(9), 1183-1194. https://doi.org/10.1046/j.13600443.2002.00185.x funding and acknowledgements: this work was supported by the national institute on drug abuse of the national institutes of health under award number r01da034072 (ggh) and by the national center for advancing translational sciences of the national institutes of health under award number ul1tr001412 to the university at buffalo. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. conflict of interest statement: the authors have no conflicts of interest related to the manuscript to report. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 99 ved abstract background: despite the established relationship between substance use and self-control, it is unknown how the covid-19 pandemic may have played a role in this association. given the unique circumstances of the pandemic along with changing societal regulations surrounding cannabis use, and their collective impact on college students, there is a need to examine the relationship between cannabis and self-control during the pandemic era. methods: data was collected from a repeated cross-sectional sample of college students at a mid-sized, urban u.s. institution during 2020-2022. logistic and negative binominal regression analyses along with an ancova were conducted to examine associations between self-control and past 30-day cannabis use. results: lower self-control was significantly associated with using cannabis in the past 30-days with those individuals with self-reported low self-control using cannabis significantly more and more times per day. finally, we found that both past 30-day cannabis use and cohort significantly predicted self-control with both individuals who report past 30-day cannabis use and the 2020 cohort reporting lower levels of self-control. there was not a significant interaction effect. conclusions: despite evolving legislation regarding both medicinal and recreational cannabis use, colleges often maintain drugfree campus policies. given high rates of cannabis use among college students and continued development of self-control, this association should be examined longitudinally and considered when creating collegelevel cannabis policies. implications for college students surrounding covid-era environments, and selfcontrol are discussed. key words: = cannabis use, college-aged students, self-control policies regarding the legalization of cannabis are changing rapidly in the united states (espinosa et al., 2022). in 2016, 24 states and washington d.c. had legalized medical cannabis, and an additional 4 states had legalized recreational cannabis (wu et al., 2016). however, by 2022, 37 states, 3 territories, and the district of columbia had legalized medical cannabis, and 21 states, 2 territories, and the district of columbia had regulated recreational cannabis use (national conference of state legislatures, 2022). by 2019, approximately 48 million people aged 12 and over in the united states reported using cannabis in the past year (montgomery et al., 2022). one specific age group with a high prevalence of cannabis use is college students (espinosa et al., 2022). in 2020, the prevalence rate of past-year cannabis use in college students rose to 44%, which was historically high (espinosa et al., 2022; schulenberg et al., 2020). francesca m. giaquinto1, jessica b. knapp2, jessica a. kulak2, kimberly e. kamper-demarco1 1department of psychology, buffalo state university, the state university of new york, buffalo, ny, usa 2department of community health and health behavior, university of buffalo, the state university of new york, buffalo, ny, usa cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000197 correlates of cannabis use and self-control across a diverse sample of college students: 2020-2022 corresponding author: kimberly e. kamper-demarco, ph.d., buffalo state university, the state university of new york, 1300 elmwood avenue, buffalo, ny 14222. email: kamperke@buffalostate.edu. cannabis, a publication of the research society on marijuana 100 college students constitute a large segment of the population, as there are about 20 million students enrolled in postsecondary institutions in the united states alone (lederer & oswalt, 2017). college students include individuals who graduated from high school and who state that they are full time students enrolled at a two-year or four-year university (schulenberg et al., 2020). typical college age generally includes those aged 18-26 and many identify this as a unique developmental period due to further brain development that continues until about age 30 (lederer & oswalt, 2017). many college students report high rates of substance use and mental health problems (lederer & oswalt, 2017). college students tend to use cannabis in a concentrated form (i.e., thc rich products that are often inhaled by vaping or dabbing; nida, 2020) and tend to have an earlier age of first use compared to middle and older aged adults (prince & conner, 2019). in 2020, 7.9% of college students engaged in daily cannabis use compared to 3-4% of older adults reporting daily use (schulenberg et al., 2020). vaping cannabis was also high among college students, with 25% endorsing vaping cannabis (schulenberg et al., 2020). for college students, the first year of college in particular is a unique period where students’ long-term academic paths begin, and these trajectories are determined by how academic engagement is balanced; cannabis use can influence this balance (arria et al., 2015). first year college students who use cannabis are more likely to skip classes and earn lower grades compared to college freshmen who do not use cannabis and increases in cannabis use over time among college students predicted declines in gpa (arria et al., 2015). the onset of the covid-19 pandemic had a significant impact on the stress and well-being of college students (hoyt et al., 2021). before the onset of the covid-19 pandemic in early 2020, past month cannabis use rates were highest among college students not living with their parents, and the most common method of cannabis use in college students was at parties and in small groups of friends (merrill et al., 2022). during 2020 and after, there was a decrease in college student cannabis use. individuals moved from independent to dependent living following campus closures because of the pandemic (merrill et al., 2022). this decrease in use may be explained by the lack of social opportunities and limited access to cannabis, and parental involvement preventing cannabis use at home (merrill et al., 2022). however, many college age individuals continued engaging in social activities despite the recommendations, leading to an increase in social cannabis use with close friends during the pandemic (diguiseppi et al., 2022). the implications of self-control on college student cannabis use and behavior changes in cannabis use among college students, compared to middle aged and older adults, could be explained by differences in selfcontrol. according to baumeister et al. (2007), self-control can be defined as, “the capacity for altering one’s own responses, especially to bring them in line with standards such as ideals, values, morals, and social expectations, and to support the pursuit of long-term goals” (p. 351). selfcontrol allows an individual to deliberately choose to override or restrain themselves from acting upon an initial choice and enables the person to choose a different response (baumeister et al., 2007). low self-control, which includes traits such as being impulsive, insensitive, and taking risks, has been associated with an increased risk of cannabis use in college students (gottfredson & hirschi, 1990; ford & blumenstein, 2013). however, college students with high self-control have fewer impulse control problems, better psychological adjustment (i.e., higher selfesteem), and better interpersonal relationships compared to students with low self-control (tangney et al., 2004). self-control also has academic implications for college students, specifically, as students with high self-control demonstrate higher grades compared to students with low self-control (tangney et al., 2004). in addition to self-control, social influence is a significant correlate of cannabis use in college students as well (bierhoff et al., 2019). the most common way cannabis is consumed among college students is small groups of friends sharing cannabis use devices (diguiseppi et al., 2022). whereas college students tend to use cannabis at much higher rates, they tend to experience fewer negative consequences directly related to their use compared to older adults (prince & conner, 2019). despite this, about 1 in 10 college students have met criteria for cannabis use disorder, and cannabis use in college students 101 many students have met criteria for prior diagnoses like cannabis abuse and dependence as well (caldeira et al., 2008). among college age students, past studies have linked cannabis use to health risk behaviors including smoking tobacco and unsafe driving practices (caldeira et al., 2008). more specifically, and directly related to self-control (baumeister, 2002; sriram et al., 2018), concentration difficulties and missing class are consequences that occur most commonly in students with cannabis use disorder (caldeira et al., 2008). despite the known relationship between substance use and self-control, it is not known how the pandemic and its related effect on social influence has impacted this association. given the unique circumstances of the covid-19 pandemic along with changing societal regulations in cannabis use, and their impact on college students, there is a need to examine the bidirectional relationship between cannabis and self-control during the pandemic era. therefore, this study examined cannabis use among a repeated cross-sectional sample of college undergraduate students to address the following aims: (1) examining differential rates and correlates of cannabis use and self-control across different years (i.e., 2020, 2021, 2022); and (2) examining significant differences in self-control and past 30-day cannabis use. secondary analyses examined the association between self-control and number of times used on cannabis using days. this research examines the hypotheses that cannabis use (past 30 day use as well as times used) and self-control will demonstrate a negative relationship. methods participants and recruitment four hundred and forty-five college students were recruited in three unique cohorts of data in spring 2020 (n = 190; 42.7% of the total sample), spring 2021 (n = 161; 36.2%), and fall 2022 (n= 94; 21.1%) from a mid-sized, urban-engaged college in the northeast. tables 1 and 2 report descriptive statistics for the sample and each cohort, respectively. students were recruited through online course announcements in a wide range of psychology courses describing the study with the understanding that participation would result in course extra credit. during the 2020 and 2021 cohorts, courses were primarily offered online with few exceptions while in 2022, courses had returned to in-person; however, the nature of online course announcement recruitment was unchanged. students are assumed to be primarily psychology majors; however, given the broad nature of these courses, could include any major taking the course. table 1. sample descriptives, overall (n=445) var % (n) / m(sd) calendar year 2020 42.7% (190) 2021 36.2% (161) 2022 21.1% (94) year in school/college freshman 20.0% (89) sophomore 20.4% (91) junior 31.5% (140) senior 27.9% (124) missing 0.2% (1) age 20.8 (1.7) gender woman 82.7% (368) man 16.2% (72) other 1.1% (5) race white/caucasian 40.7% (181) black/african american 42.2% (188) asian/asian american 5.6% (25) native american 0.9% (4) multiracial 6.7% (30) other 2.7% (12) missing 1.1% (5) ethnicity hispanic/latino 13.7% (61) not hispanic/latino 85.6% (381) missing 0.7% (3) employment status employed full-time 11.0% (49) employed part-time 52.4% (233) not employed 34.2% (152) prefer not to answer 2.2% (10) missing 0.2% (1) cannabis use lifetime 56.0% (249) past 30-day 32.1% (143) self-control 3.3 (0.7) cannabis, a publication of the research society on marijuana 102 across all participants (n = 445), students, on average, were 20.84 years of age (sd = 1.67) ranging from 18 to 26 years of age. the sample was diverse with 42.2% of participants selfidentifying as black/african american, 40.7% as white/caucasian, 6.7% as multiracial, 5.6% as asian/asian american, 2.7% as other, and 0.9% as native american. 5 participants (1.1%) did not provide a response regarding race. of the total sample, 13.7% of the participants indicated that they were hispanic/latino (0.7% did not answer). most participants identified as juniors (31.5%) or seniors (27.9%) in college, with relatively even distributions across freshman (20.0%) and sophomores (20.4%). over half of participants reported that they were employed either full-time (11.0%) or part-time (52.4%). differences in sociodemographic characteristics were examined by cohort, revealing no significant differences in gender, race, and ethnicity across cohort [χ2s < 6.98, ps > .05]. there were significantly more individuals employed full time across later cohorts (i.e., 2021 and 2022) than during 2020 [χ2s > 13.37, ps = .04]; however, given the impact of the covid-19 pandemic on work (sáenz & sparks, 2020), this difference was not unexpected. table 2. sample descriptives, by cohort year (n=445) var % (n) / m(sd) 2020 2021 2022 calendar year 42.7% (190) 36.2% (161) 21.3% (95) year in school/college freshman 30.0% (57) 18.6% (30) 2.1% (2) sophomore 20.0% (38) 19.3% (31) 23.4% (22) junior 26.8% (51) 29.2% (47) 44.7% (42) senior 23.2% (47) 32.3% (52) 29.8% (28) missing 0.0% (0) 0.6% (1) 0.0% (0) age 20.7 (1.8) 20.8 (1.6) 21.2 (3.4) sex woman 80.0% (152) 85.1% (137) 84.0% (79) man 20.0% (38) 13.7% (22) 12.8% (12) other 0.0% (0) 1.2% (2) 3.2% (3) race white/caucasian 38.4% (73) 42.2% (68) 42.6% (40) black/african american 42.6% (81) 41.0% (66) 43.6% (43) asian/asian american 6.8% (13) 5.6% (9) 3.2% (3) native american 1.1% (2) 0.0% (0) 2.1% (2) multiracial 7.9% (15) 5.6% (9) 6.4% (6) other 2.1% (4) 4.3% (7) 1.1% (1) missing 0.0% (0) 1.2% (2) 1.1% (1) ethnicity hispanic/latino 13.2% (25) 13.0% (21) 16.0% (15) not hispanic/latino 85.8% (163) 86.3% (139) 84.0% (79) missing 1.1% (2) 0.6% (1) 0.0% (0) employment status employed full-time 7.9% (15) 13.0% (21) 13.8% (13) employed part-time 50.0% (95) 54.7% (88) 53.2% (50) not employed 40.0% (76) 29.8% (48) 29.8% (28) prefer not to answer 2.1% (4) 1.9% (3) 3.2% (3) missing 0.0% (0) 0.6% (1) 0.0% (0) cannabis use lifetime 54.2% (103) 50.9% (82) 68.1% (64) past 30-day use 28.9% (55) 30.4% (49) 41.5% (39) self-control 3.1 (0.7) 3.3 (0.7) 3.4 (0.7) cannabis use in college students 103 procedures participants completed an online survey that took approximately 45 minutes. surveys first describe the purpose of the study where individuals provided informed consent. they then completed a series of questionnaires and behavior tasks. participants were provided extra credit in requested courses upon completion and were entered into a raffle to win a $25 amazon gift card. all procedures were approved by the university institutional review board. to reduce participants completing the survey in multiple cohorts, the qualtrics survey was set to prevent multiple submissions. data was then examined to determine the number of multiple submissions based on basic identifying information. upon review of the data, less than 10% of the data included duplicate submissions. measures cannabis use. following procedures used by substance abuse and mental health services administration (samhsa, 2016), in each year of data collection, participants initially indicated whether they have ever used cannabis or marijuana in their lifetime. students who endorsed lifetime use were prompted with subsequent questions to indicate the frequency of their cannabis use on a 7-point likert scale (e.g., 0=never, 1=1-2 times, 2=3-5 times, 3=6-9 times, 4=10-19 times, 5=20-39 times, and 6=40 or more) during the last 30 days. cannabis items were updated for the 2022 survey administration to be more aligned with best practices in assessing cannabis use. items were used or adapted from several sources, including the international cannabis policy study (hammond et al., 2020) and the national survey on drug use and health (samhsa, 2016). specifically, questions regarding past 30-day use were adjusted to ask on how many days the individual used cannabis as well as the times per day that they used. in order to equate the questions, two steps were taken. first, the likert scale questions from cohorts 1 (i.e., 2020) and 2 (i.e., 2021) were adjusted to be average number of days endorsed by the participant. for example, if a participant chose 3, the number of days the individual used cannabis was adjusted to be 7.5 as it is the average number from the scale provided. in order to limit inferences from the likert scale, participants who endorsed 40 or more cannabis use events over the past 30 days were coded as 40. second, the 2022 data included two questions, the first asking the number of days used per month and the second asking the average number of times used per day. participants entered a numeric response for both questions. these two variables were multiplied to create a measure that aligned more closely with that from 2020 and 2021(i.e., average number of times used in the past 30 days). scores higher than 40 were adjusted to account for outliers within the data and provide consistency across cohorts. both included the prompt of ‘use over the past 30 days’. thus, the 2020 and 2021 cohorts answered questions regarding frequency of use over the past 30 days allowing for comparison across cohorts. self-control. to measure self-control, individuals across all cohorts completed the brief self-control scale (bscs; tangney et al., 2004). the bscs consists of 13 items assessing one’s ability to regulate and control their behavior using statements like “i say inappropriate things” and “i often act without thinking through all the alternatives” on a five points scale from not at all (1) to very much (5). nine of the items were reverse coded and all items were averaged so that higher scores indicate more self-control (m = 3.26, sd = 0.68). the measure demonstrated good reliability for the current sample (cronbach’s α = 0.82). analytic approach for this study, all analyses were conducted using ibm spss statistics, version 29.0 (ibm corp, 2022) and stata 14 (statacorp, 2015). pearson’s chi-square tests were used examine significant differences in past 30-day cannabis use (yes/no) and other correlates (i.e., age, gender) across cohort (2020 vs. 2021 vs. 2022). to examine how self-control and cohort were associated with past 30-day cannabis use (i.e., past 30-day cannabis use as an outcome), both logistic (whether one used cannabis in the past 30-days) and negative binominal regression analyses (frequency of use of cannabis in the past 30 days) were used due to the nonnormality of the data. secondary analyses were conducted with the 2022 cohort to examine the association between selfcontrol and the typical number of times cannabis, a publication of the research society on marijuana 104 individuals engaged in cannabis use on days when any use was reported (this data was not available in earlier cohorts). next, an ancova was conducted examining how past 30-day cannabis use predicted self-regulation across different cohorts (i.e., ivs were 30-day cannabis use and cohort, dv was self-regulation). the interaction between cohort and binary cannabis use was included in the model. all models included gender and age as covariates. although “other” was measured for gender, data was recoded to be dichotomous due to the low rate of individuals identifying as “other” and thus, not allowing an adequately sized category for analyses. a probability value of 0.05 and 95% confidence intervals will be used to determine significance. results descriptive statistics were first conducted to evaluate cannabis use rates in the current sample. among all students, 54.4% of the sample reported using cannabis at least once in their lifetime, and 32% reported using within the past 30 days (among students reporting lifetime use, 59% reported using within the past 30 days; see table 1). the average rating of self-control was 3.26 (sd = 0.68). there was a significant difference in past 30day cannabis use (coded yes/no) across the three cohorts (χ2 = 12.06, p < .01). pairwise comparisons showed significantly more past 30-day cannabis use in 2022 than in both 2021 and 2020 (see table 3). table 3. prevalence of past 30-day cannabis use (yes/no) by cohort 2020 2021 2022 column % (n) cannabis use in the past 30 days (binary; yes) 26.7% (56a) 30.7% (55a) 46.7% (43b) did not use in the past 30 days 73.3% (154a) 69.3% (124a) 53.3% (49b) note. χ2 = 12.06, p = .002. use of the same subscript letter denotes column proportions that do not differ from each other. binary cannabis use (yes/no) logistic regression was then conducted to examine whether self-control and cohort uniquely predicted whether participants used cannabis in the past 30 days. there were significantly lower odds of cannabis use for every one unit increase in selfcontrol (or = 0.47; 95% ci: 0.29, 0.77). regarding cohort, the 2022 group demonstrated significantly higher cannabis use (or = 1.42; 95% ci: 0.36, 5.65) than 2020. however, there was no significant interaction between self-control and cohort (or= 1.01; 95% ci: 0.66, 1.54). cannabis use (frequency per month) follow up analyses were then conducted to examine whether self-control predicted frequency of past 30-day cannabis use among those who use cannabis. given the skewed nature of count data, a negative binomial regression was used to examine how self-control predicted frequency of past 30-day cannabis use, controlling for cohort, age, and gender. when accounting for the distribution of past 30-day cannabis use, self-control significantly predicted cannabis use frequency (or= 0.60; 95% ci: 0.45, 0.81). there was a nonsignificant trend for the 2022 cohort (or= 0.59; 95% ci: 0.34, 1.02). no other variables within the model were significant. an interaction term was added into the model to examine whether there was an interaction effect of self-control and cohort; however, no variables were significant. cannabis use (times per day) we conducted secondary analyses of the data collected in 2022 to examine whether there was a significant correlation between self-control and the number of times individuals engaged in cannabis use on those days that they used cannabis in the past 30 days. skew and kurtosis were not violated (skew = 1.69, kurtosis = 2.12) suggesting normality of the data (kline, 2010). there was a significant negative correlation (r = -0.28, p = .04) such that the lower an individual’s self-control, the increased number of times during the day that they use cannabis (on days they report cannabis use). given these findings, cannabis use in college students 105 linear regression was conducted predicting number of times cannabis was used on use days by selfcontrol. gender and age were entered as covariates. the overall model was significant [f(3, 40) = 2.91, p < .05, r2 = 0.18] with lower self-control significantly associated with increased use (b = -0.76, p = .02). there was a nonsignificant trend for age with use (b = -0.11, p = 0.07) but no significant association with gender. self-control next, a two-way ancova was conducted to examine differences in self-control based on cohort (i.e., 2020 vs. 2021 vs. 2022) and whether individuals used cannabis (yes/no) in the previous 30 days. data were normally distributed (skew = -0.19; kurtosis = 0.42) and did not violate assumptions of equality of variance [f(5, 396) = 0.68, p = 0.64]. there was a significant main effect of both cohort [f(2, 401) = 5.69, p < .01] and past 30-day cannabis use [f(1, 401) = 26.22, p < .001]. for the latter, any past 30-day cannabis use (yes/no) was associated with lower selfcontrol (m = 3.05, se = 0.05, 95% ci: 2.95, 3.16) than those who did not use cannabis in the past 30 days (m = 3.41, se = 0.04, 95% ci: 3.32, 3.49; see figure 1). there was no significant interaction effect of cohort and cannabis use (yes/no) predicting selfcontrol, [f(2, 401) = .25, p = .78]. we then examined differences in self-control across cohorts (see table 4 for cohort ratings of self-control and other variables). pairwise comparisons demonstrated that self-control was significantly lower in 2020 (m = 3.07, se = 0.05, 95% ci: 2.96, 3.18) than in 2021 (m = 3.28, se = 0.06, 95% ci: 3.17, 3.39) and 2022 (m = 3.34, se = 0.07, 95% ci: 3.20, 3.48; ps < .01) but no significant difference in self-control between 2021 and 2022 (p = 0.48). gender and age were all included in the model but were not significantly associated with self-control in the overall model. table 4. regression analyses predicting past 30-day use past 30-day use log-odds se 95% ci p (yes/no) ll ul age 0.10 0.06 -0.01 0.20 0.08 gender -0.31 0.28 -0.87 0.24 ns group 2021 -0.42 1.23 -2.83 1.98 ns 2022 1.28 1.49 -1.64 4.20 ns self-control -0.86 0.27 -1.38 -0.33 0.001 past 30-day use b se 95% ci p (frequency per month) ll ul age 0.02 0.03 -0.05 0.09 ns gender -0.06 0.29 -0.62 0.50 ns group 2021 0.16 0.24 -0.31 0.63 ns 2022 -0.53 0.28 -1.08 0.02 ns self-control -0.51 0.15 -0.80 -0.22 0.001 past 30-day use b se 95% ci p (times per day) ll ul age -0.11 0.06 -0.23 0.01 0.07 gender 0.20 0.65 -1.11 1.50 ns self-control -0.76 0.31 -1.38 -0.14 0.02 note. 95% ci = 95% confidence intervals; ll = lower limit; ul = upper limit, ns = nonsignificant; odds ratios were determined using exp(b). cannabis, a publication of the research society on marijuana 106 figure 1. differences in self-control by past 30-day cannabis use and cohort. discussion this study examined past 30-day cannabis use and self-control among a sample of college students during cohort years 2020, 2021, and 2022. results indicate a bidirectional association between past 30-day cannabis use and poor selfcontrol among college students during the era of the covid-19 pandemic. we observed significant differences in past 30-day cannabis use (yes/no) across cohorts among our sample of college students. more specifically, self-control was significantly lower in 2020 compared to 2021 and 2022, and individuals who used any cannabis in the past 30-days (yes/no) had lower self-control overall compared to students who did not use cannabis in the past 30-days. to examine these associations in more detail, a negative binomial regression was conducted to examine how selfcontrol and cohort was associated with frequency of past 30-day cannabis use. again, there was a significant association in which self-control negatively predicted frequency of cannabis use over the past 30 days; however there was no interaction effect with cohort. secondary analyses among the 2022 cohort demonstrated a relationship between the number of times cannabis was used per day and self-control. findings indicated self-control is negatively associated with more cannabis use on each cannabis using day. thus, individuals with higher self-control are still using cannabis, but they are using fewer times per day compared to students with lower self-control. our results are consistent with previous work (e.g., dvorak & day, 2014) that demonstrated a relationship between selfregulation and the intensity of cannabis use. our findings indicate better self-control plays a significant role in college students’ choice to use cannabis and both the frequency of use overall as well as the amount of use per cannabis-using day. other literature indicates that emotional selfregulation plays a particularly important role in one’s experience of cannabis-related problems (dvorak & day, 2014), highlighting the development of emotional self-regulation as a potential intervention point for reducing the negative effects of cannabis use in college students. in the self-control model, past 30-day cannabis use (yes/no) was associated with lower selfcontrol. however, cannabis use (yes/no) did not predict self-control based on cohort year. as the study did not assess these measures prepandemic, more research is needed to make claims about the specific role of covid-19 in shaping the relationship between cannabis use and self-control. the timeframe of this study is notable, as data was collected in 2020, at the onset of the covid19 pandemic, and in subsequent years (i.e., 2021 and 2022) where pandemic measures, such as social distancing, were in flux. the timeframe of data collection influences the interpretation of our findings, as the covid-19 pandemic may have cannabis use in college students 107 had an impact on both cannabis use and selfcontrol in college students. for instance, a previous study found that lower self-control was associated with increased cannabis use among college students who reported increased opportunity of securing the substance (ford & blumenstein, 2013). it is possible that covid-19 social distancing measures during our data collection may have played a role in college students’ social interactions and ability to obtain cannabis. relatedly, previous work has proposed self-control as fluctuating in capacity, particularly when resources are depleted (baumeister, 2002). the depletion of social and other support during the covid-19 pandemic may support this notion given the current findings and highlights the effects of stress on one’s ability to exert control over their behavior. despite these findings, opportunities to better understand cannabis use and self-control considering the covid-19 pandemic still exist. instead of being considered a distinct, priority population, college students are often considered a convenience sample (lederer & oswalt, 2017). however, college students should be viewed as a unique and priority population (lederer & oswalt, 2017), as college is a unique setting, and the nuances of campus culture make it a distinct environment (lederer & oswalt, 2017). in addition, college students differ from the general adult population, as most traditional-aged students are young adults whose brains are continuing to develop (lederer & oswalt, 2017). emerging adulthood is a unique developmental period as it involves more health risks and negative outcomes compared to during adolescence or adulthood (arnett, 2007; lederer & oswalt, 2017). our findings have important implications for higher education, particularly as college students attempt to navigate post-covid learning and social environments. health and wellness are some of the top factors influencing college dropout rates, which demonstrates the importance of the overall commitment to improving college students’ health and well-being (lederer & oswalt, 2017; travia et al., 2022). in fact, exposure to stressful events (such as the covid19 pandemic) and substance use (including frequent use of cannabis) are among the most salient factors influencing college student retention (thomas et al., 2021). pre-covid-19 pandemic, students with higher self-control had better grades compared to students with lower self-control (tangney et al., 2004). thus, the impact of the covid-19 pandemic and cannabis use may have an impact on learning and students’ ability to exert control over their emotions and behavior in the post-covid-19 world. using innovative practices such as implementing wellbeing programs, that are inclusive of behavioral health broadly and substance use specifically, into college campuses could be effective in improving the health and well-being of college students (travia et al., 2022). how students engage in their college experience is just as important as where they attend college in determining their later success, which shows the significance of using innovative practices to improve student health and wellbeing on campus (travia et al., 2022). considering prior evidence that indicates self-control is not a static trait, but one that can be developed (baumeister, 2002; lee et al., 2023; sriram et al., 2018), campus administrators seeking to improve student retention should consider including initiatives aimed to increase self-control, given its association with both substance use and academic performance (duckworth & seligman, 2005; sriram et al., 2018). direct, didactic instruction, inclusive of self-monitoring skills and opportunities for repeated practice of behavioral strategies, has been effective for improving selfcontrol in college students (duckworth et al., 2016; lee et al., 2023). our findings support the hypothesis that improving self-control could potentially reduce cannabis use. while an intervention of this nature was not assessed here, it has important implications for tailoring future prevention and intervention efforts with college students. limitations although this study has several notable strengths, including a racially diverse sample and data collection that occurred directly during the covid-19 pandemic, there are limitations. first, this sample was drawn from a mid-sized, urbanengaged university in the northeast, therefore limiting the generalizability of our findings. the repeated cross-sectional nature of this study also limits the ability to make conclusions about within-person changes in cannabis use behaviors cannabis, a publication of the research society on marijuana 108 over time; since the surveys are cross-sectional, results cannot be used to establish causality. future research should examine changes in both cannabis use and self-control longitudinally to examine the direction of effect. specifically, it is important to understand whether self-control predicts increased cannabis use and if cannabis use can shape or change self-control. finally, this study also relied on self-report of past 30-day cannabis use and self-control, however self-report is the most common method of measuring substance use behaviors. given changing legislation around cannabis use, it may be that student use has increased over the previous years; however, there is also the possibility that individuals feel more comfortable reporting use given the less severe consequences associated with cannabis use. conclusions the mixed and evolving state-level legal cannabis landscape poses challenges to college administrators, whose goal is to promote the health and academic success of college students. our findings have implications for college administrators and others in higher education in that improving college students’ self-control may have potential as a harm reduction strategy for addressing cannabis use among college students. references arnett, j. j. 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(2016). trends in cannabis use disorders among racial/ethnic population groups in the united states. drug and alcohol dependence, 165, 181–190. https://doi.org/10.1016/j.drugalcdep.2016.06.0 02 funding and acknowledgements: there was no funding support for this project. the authors report no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i2a6_authors_final brief report 66 ved abstract background. the general use of cannabis in adolescence is associated with various sleep deficits. while traditional smoking remains the most common form of cannabis consumption amongst adolescents, novel methods of administration are becoming more popular and available due to legalization. the association of these novel methods of use with sleep in adolescence has yet to be studied and research is needed to inform public health initiatives. methods. high school (9th-12th grade) students from the healthy kids colorado survey with current cannabis use (n= 4,637) reported on numerous demographic variables, method of cannabis use (flower, edibles, dabs, and vaporizers) and average sleep duration on weeknights. logistic regression assessed the relationship between novel methods of use (edibles, dabs, and vaporizers) and sleep duration in comparison to cannabis flower. results. use of any edible, dab, or vaporizer product in the past 30-days was associated with being male and current tobacco use. reporting a novel method of use as the most common mode of cannabis use was associated with current tobacco use and higher mothers’ education. students who used any novel method products in the past 30 days or reported these products as the usual mode of cannabis use, were more likely to sleep 7 hours or fewer a night. conclusions. novel methods of cannabis administration such as edibles, dabs, and vaporizers are associated with getting less sleep than recommended (7 or less hours), in comparison to those who smoked flower. sleep outcomes should be a focus of study for novel cannabis products amongst high school adolescents. key words: = concentrates; marijuana; cannabis; adolescent substance use sleep is crucial for adolescent development and is critical for the processes of cognition, physiology, and mental health (tarokh et al., 2016). sleep issues are common among adolescence, with the prevalence of insomnia being as high 24% (hysing et al., 2013) and 41% of adolescence reporting feeling tired or sleepy during the day (kolla et al., 2019). while cannabis use is often thought to be a sleep aid among adults (altman et al., 2019), frequent cannabis use is associated with numerous sleep deficits (edwards & filbey, 2021). cannabis use during adolescence has been linked to poor sleep outcomes including higher rates of insomnia (roane & taylor, 2008), shorter total sleep time, later bedtimes (troxel et al., 2015), insufficient sleep on school nights (kwon et al., 2020; mcknight-eily et al., 2011), overall greater sleep problems (zhabenko et al., 2016), and minor sleep architecture alterations during the onset of abstinence (cohen-zion et al., 2009). the current body of research regarding cannabis and sleep in adolescence is based on studies that have measured any use of cannabis, with no focus or distinction on the method of administration. while smoking remains the most common mode of cannabis consumption among adolescents, alternative methods of administration (such as ingesting, vaporizing, and dabbing) that are often high in tetrahydrocannabinol (thc) (cinnamon bidwell et al., 2018) and have increased subjective evan a. winiger1, ming ma2, ashley brooks-russell2 1department of psychiatry, university of colorado anschutz medical campus, aurora 2colorado school of public health, department of community and behavioral health, university of colorado anschutz medical campus, aurora cannabis 2022 © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.006 novel methods of cannabis use and lower sleep duration among high school students corresponding author: evan a. winiger, phd, department of psychiatry, university of colorado anschutz medical campus, 13001 east 17th place, q20-c2000, aurora, co 80045. phone: (303) 724-4940. email: evan.winiger@cuanschutz.edu cannabis, a publication of the research society on marijuana 67 effects compared to flower (spindle et al., 2018), are more widely available because of legalization (knapp et al., 2019). a recent meta-analysis on cannabis vaping in adolescents estimate prevalence rates have increased in the last decade, estimating 13.6% for lifetime use, 13.2% for past 12-month use, and 1.6% for past 30-day use (lim et al., 2022). other recent studies estimate lifetime concentrate use (hash oil, wax, crumble, shatter) at 24% and past month concentrate use at 12.7% (meier et al., 2019), as well as lifetime edible use at 21% and past 30-day edible use at 4.9% (peters et al., 2018). the influence of these novel methods on health and behavioral outcomes in adolescence, particularly on sleep, has yet to be understood (bidwell et al., 2021). while little is known regarding the exact relationship between these novel products and sleep in general, there is evidence to suggest that thc is associated with sleep architecture alterations (such as reduced time in rapid eye movement) (edwards & filbey, 2021; schierenbeck et al., 2008) and that increased frequency of edibles could be associated with increased sleep issues in adults (winiger et al., 2021). due to the changing legal landscape and expansion of novel and often high thc cannabis products, research is needed to understand their relationship with sleep during adolescence, an activity critical for brain development (telzer et al., 2015). in this study, we examined the association of novel cannabis products (edibles, vaporizers, and dabs) with sleep duration in a statewide representative sample of high school students in colorado. methods data are from 2019 administration of the healthy kids colorado survey (hkcs) (colorado department of public health and environment, 2021), a biennial cross-sectional survey conducted in colorado that includes 9ththrough 12th-grade students (n=46,537). the current study included students who reported using cannabis in the past 30 days in one of the two survey modules that included questions about mode of cannabis use (n=4,637). the hkcs uses a stratified cluster design with random sampling of public high schools. teachers provided instructions that stated that students could choose to skip questions or not participate without consequence. students completed the survey on paper or online, as determined by school administration. parents were notified and could opt-out their child. this study was approved by the colorado multiple institutional review board. cannabis use was assessed by two questions: “during the past 30 days, how did you use marijuana? (select all that apply).” and “during the past 30 days, how did you usually use marijuana? (select only one response).” response options included: smoked it, ate it, used a vaporizer, dabbed it, and used it in some other way. we collapsed edibles, vaporizing, and dabbing into a novel methods of use category with the flower group as the reference group. one set of analysis focused on the first question in which students could choose all methods of use. among the 4,637 students, 1,202 reported only using flower and 860 reported using any novel use in the past 30 days, which were the two groups used in analysis. the 2,328 students who reported using flower, novel, and other products were removed (as using methods in both groups was exclusion criteria for this analysis). furthermore, 247 students who reported using other products and did not report using either flower or novel products were removed for the any use analysis. table 1. number of students endorsing each method of use before generating the flower and novel methods of use groups for each analysis method of cannabis use any use in the past 30 days usual method of use in the past 30 days smoking 3,530 2,463 edibles 1,593 440 vaping 1,436 389 dabbing 2,185 809 other way 404 86 note. the usual method of use was a single selection whereas the use of any method allowed students to check all that apply. cannabis use and sleep in high schoolers 68 table 2. novel methods of cannabis use in the past 30 days by individual characteristics among current cannabis users; public high school students in colorado, 2019 (weighted results, unweighted n=4,637) overall any novel method of use, past 30 days % (95% ci) (n = 860) only smoking flower, past 30 days % (95% ci) p novel method of use as usual mode, past 30 days % (95% ci) smoking flower as usual mode, past 30 days % (95% ci) p n (unweighted) 4,637 860 1,202 1,638 2,463 sex 0.03* 0.08 female 48.6 (47.1, 50.0) 44.9 (40.8, 49.0) 53.7 (50.5, 57.0) 46.8 (44.5, 49.0) 51.1 (48.7, 53.4) male 51.4 (50.0, 52.9) 55.1 (51.0, 59.2) 46.3 (43.0, 49.5) 53.2 (51.0, 55.5) 48.9 (46.6, 51.3) grade 0.31 0.34 9th 16.6 (15.3, 18.0) 15.3 (12.8, 17.8) 18.0 (15.0, 20.9) 16.0 (13.9, 18.0) 17.2 (15.3, 19.0) 10th 23.2 (21.7, 24.8) 24.5 (21.2, 27.9) 19.8 (17.2, 22.4) 23.5 (21.3, 25.8) 23.0 (20.5, 25.4) 11th 28.3 (26.4, 30.2) 31.1 (27.4, 34.8) 30.0 (27.0, 33.1) 30.5 (27.7, 33.4) 26.7 (24.6, 28.9) 12th 31.8 (29.6, 34.0) 29.1 (26.1, 32.0) 32.2 (27.6, 36.8) 29.9 (27.5, 32.4) 33.2 (29.9, 36.4) race/ethnicity 0.12 0.08 non-hispanic white 53.3 (50.3, 56.3) 54.1 (48.3, 59.9) 50.3 (45.5 55.0) 58.3 (53.8, 62.8) 51.9 (48.3, 55.5) non-hispanic black 4.5 (3.2, 5.8) 2.8 (1.1, 4.5) 8.0 (4.5, 11.5) 3.1 (1.9, 4.4) 5.5 (3.4, 7.7) hispanic 34.7 (31.3, 38.0) 35.0 (29.6, 40.4) 33.9 (29.3, 38.6) 30.5 (26.6, 34.4) 35.0 (31.0, 39.0) other/multi-racial 7.6 (6.8, 8.4) 8.1 (6.3, 10.0) 7.8 (6.3, 9.4) 8.1 (6.8, 9.4) 7.5 (6.2, 8.8) mother’s education 0.06 0.001* less than college 35.7 (32.5, 39.0) 31.9 (27.8, 36.0) 38.7 (34.6, 42.9) 29.9 (26.0, 33.9) 38.8 (35.3, 42.4) college or more 64.3 (61.0, 67.5) 68.1 (64.0, 72.2) 61.3 (57.1, 65.4) 70.1 (66.1, 74.0) 61.2 (57.6, 64.7) felt sad/depressed 0.54 0.10 no 45.9 (43.7, 48.1) 51.5 (47.7, 55.3) 48.6 (44.1, 53.1) 48.2 (45.4, 50.9) 44.1 (40.9, 47.2) yes 54.1 (51.9, 56.3) 48.5 (44.7, 52.3) 51.4 (46.9, 55.9) 51.8 (49.1, 54.6) 55.9 (52.8, 59.1) current tobacco use 0.03* 0.006* no 30.4 (28.3, 32.5) 35.4 (32.2, 38.7) 42.2 (38.1, 46.3) 26.9 (24.5, 29.4) 32.8 (30.0, 35.5) yes 69.6 (67.5, 71.7) 64.6 (61.3, 67.8) 57.8 (53.7, 61.9) 73.1 (70.6, 75.5) 67.2 (64.5, 70.0) current alcohol use 0.26 0.14 no 26.8 (25.0, 28.7) 29.7 (25.3, 34.0) 34.8 (30.3, 39.4) 23.9 (21.1, 26.7) 28.6 (25.4, 31.7) yes 73.2 (71.3, 75.0) 70.3 (66.0, 74.7) 65.2 (60.6, 69.7) 76.1 (73.3, 78.9) 71.4 (68.3, 74.6) number of times using cannabis, past 30 days 0.81 0.67 1 to 9 times 57.5 (55.6, 59.3) 75.3 (71.9, 78.7) 73.4 (70.1, 76.6) 60.4 (57.3, 63.4) 58.1 (55.7, 60.6 10 to 19 times 12.7 (11.6, 13.8) 8.3 (6.5, 10.2) 9.3 (7.4, 11.3) 12.4 (10.4, 14.4) 12.6 (11.1, 14.2) 20 times or more 29.8 (28.0, 31.6) 16.4 (13.1, 19.7) 17.3(14.6, 20.0) 27.2 (24.4, 30.1) 29.2 (26.8, 31.7) *p < .05. note. current substance use is any use in the past 30 days. the first comparison is exclusive novel use to exclusive flower smoking, excluding 2,328 students who used novel, other, and flower products, and 247 students who did not report using either flower or novel products. the second comparison is usual novel product use to smoking flower, inclusive of all students who currently use cannabis. current tobacco use is inclusive of cigarette and/or e-cigarette use. felt sad/depressed is reporting feeling sad for two weeks or more in the past 12 months. rao-scott chi-square tests were used to determined significant differences between novel mode of use vs. smoking within each demographic factor of individual level characteristic. cannabis, a publication of the research society on marijuana 69 the second set of analysis focused on the second question in which students choose only one method of use as their “usual” use. table 1 details the number of students endorsing each method of use for each of the questions (check all that apply and select only one). student responses were weighted to represent colorado public high school enrollment for grade, sex, and race/ethnicity. weighted prevalence estimates were calculated for any mode and usual mode of cannabis use. the rao-scott chi-square tests were used for comparing any and usual mode of novel method of cannabis use between different levels of each of the demographic, substance use, and mental health indicators (rao & scott, 2007). we used multivariable logistic regression, adjusted for sex, grade, race/ethnicity, mother’s education, current substance use (tobacco, alcohol), frequency of use, and feeling sad/depressed, to assess the relationship between novel methods of cannabis use and sleep duration (statistical significance, p < .05). analyses were completed using sas v9.4. results weighted prevalence rates for usual mode of cannabis use were 56.5% for smoking, 20.6% for dabbing, 10.7% for vaping, 10.0% for edibles, and 2.2% for some other way (not reported), while weighted prevalence rates for any mode of use were 77.9% smoking, 52.0% dabbing, 35.6% edibles, 34.3% vaping, and 8.4% some other way (not reported). among students who reported past-month cannabis use, there were significant differences in individual characteristics for using any form of edible, dab, or vaporizer products in the past 30 days, and for these novel methods being the usual mode of cannabis use (table 2). among those using any novel methods products, there was a significantly higher proportion of males and current tobacco use. among those who reported these methods as their usual mode of use, there was a significantly higher proportion with current tobacco use and higher mothers’ education (college or more). there was no significant difference between novel method of administration and mean hours of sleep in the unadjusted analysis (data not shown). in adjusted analysis including covariates, among students who used any novel method of administration in the past 30 days, they were 1.46 (95% ci: 1.05-2.02) times as likely to sleep 7 hours or fewer a night compared with those smoking cannabis flower (table 3). similarly, students who reported that these products were the usual mode of cannabis use were 1.41 (95% ci: 1.14-1.75) times as likely to report sleeping 7 hours or fewer a night compared to smoking flower. discussion colorado high school students who reported using either edibles, dabs, or vaporizing or using any of these methods as their most common method of use in the past 30 days, were more likely to be categorized as not getting enough sleep (7 or less hours) on average in comparison to those who smoked flower. these are the first known findings of a relationship between these novel cannabis use methods and low sleep duration among adolescents, implying that potential sleep issues, above and beyond traditional flower, are associated with the growing use of novel cannabis methods with adolescents. a possible biological explanation is that using exogenous cannabinoids (such as thc) activates the endocannabinoid system, which can cause disruptions in the sleep-wake cycle and circadian rhythms (prospéro-garcía et al., 2016). use of cannabis products, especially ones potentially high in thc such as concentrates, might alter adolescent’s sleep-wake cycle leading to lower sleep duration. the association found could also be spurious and reflect the cooccurrence of other substance use, peer substance use, and risk factors that are associated with newer forms of cannabis use (meier et al., 2019). provided the role of confounders in our results, additional risk factors or behaviors could have a strong influence on this association. future research is needed to understand the exact mechanisms responsible for this relationship. we found several demographic associations that support prior research as well as one association that is novel and elicits future investigation. prior findings of adolescent vaporizer use being significantly associated with the male sex (morean et al., 2021; peters et al., 2018) and tobacco use (kowitt et al., 2019; meier et al., 2019; morean et al., 2021) complement our results, yet research regarding these relationships for both edibles and dabs has yet to be established. studies regarding novel methods cannabis use and sleep in high schoolers 70 table 3. adjusted association between sleep and any or usual novel method of cannabis use in the past 30 days among current cannabis users; public high school students in colorado, 2019 note. novel method of cannabis use including edibles, dabs, and vaping with flower being the reference group. models control for sex, grade, race/ethnicity, mother’s education, current tobacco use, current alcohol use, frequency of use, and feeling sad/depressed. *p < .05. adjusted or (95% ci) of having insufficient sleep (7 hours or fewer) [ref: sufficient sleep (8 hours or more)] cannabis use smoked flower ref ref any novel method 1.46 (1.05, 2.02)* novel method as usual method 1.41 (1.14, 1.75)* estimate of other covariates gender female ref ref male 0.85 (0.65, 1.12) 0.72 (0.59, 0.87) grade 9th ref ref 10th 1.47 (0.84, 2.55) 1.35 (0.96, 1.90) 11th 1.74 (1.01, 3.02) 1.46 (1.07, 2.01) 12th 1.59 (0.99, 2.58) 1.54 (1.14, 2.08) race and ethnicity non-hispanic white ref ref non-hispanic black 2.04 (1.12, 3.69) 1.22 (0.80, 1.85) hispanic 1.70 (1.24, 2.33) 1.35 (1.07, 1.71) other and multi-racial 1.85 (0.97, 3.55) 1.68 (1.13, 2.52) mother’s education college or above ref ref less than college 1.26 (0.90, 1.77) 1.25 (1.01, 1.54) current tobacco use no ref ref yes 1.34 (1.00, 1.79) 1.27 (1.02, 1.59) current alcohol use no ref ref yes 0.95 (0.63, 1.44) 0.95 (0.74, 1.23) felt sad/depressed no ref ref yes 1.57 (1.21, 2.03) 1.91 (1.52, 2.41) number of times using cannabis, past 30 days 1 to 9 times ref ref 10 to 19 times 1.06 (0.66, 1.68) 1.49 (1.13, 1.96) 20 times+ 0.75 (0.50, 1.14) 1.03 (0.79, 1.35) cannabis, a publication of the research society on marijuana 71 of cannabis use and socio-economic status (ses) are mixed. there is evidence of lower ses factors being associated with lifetime edible (peters et al., 2018) and concentrate use (smoked or vaped marijuana concentrates such as hash oil, wax, crumble, shatter) (meier et al., 2019). however, other studies have failed to find significant relationships between cannabis vaporizing and ses (kowitt et al., 2019; meier et al., 2019; morean et al., 2021). interestingly, there are studies that show higher ses in adolescence is associated with general cannabis use in early adulthood (humensky, 2010), and that increased cannabis vaping frequency in young adults is associated with being from a higher ses family (jones et al., 2016). in relation to our finding of a significant relationship between novel methods of cannabis use being the most common method of use in the past 30 days and increased mothers education (a proxy for higher ses), we can speculate (as have others (peters et al., 2018)) that the high cost of these novel cannabis products in relation to flower is a financial barrier that could limit adolescents in lower ses from access or use, thus those in a higher-ses might have greater financial resource to use these types of novel methods. this finding warrants future research to better understand the relationship of ses and novel methods of cannabis use. limitations limitations of the study include the crosssectional design, utilizing self-report measures, the single-item report of sleep duration, lack of detail regarding the specific methods of cannabis administration used (such as a lack of differentiation between vaporizing concentrates or flower), and a lack of detail regarding quantity and thc concentration of cannabis use. additionally, the unadjusted analysis failed to find an effect, 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(2016). substance use as a risk factor for sleep problems among adolescents presenting to the emergency department. journal of addiction medicine, 10(5), 331. funding and acknowledgements: the data used for this study were collected under a contract with the colorado department of public health and environment (brooks-russell, principal investigator). this work was supported by national institute on mental health grant t32 mh015442 (winiger). the national institute on drug abuse and colorado department of public health and environment had no role in determining study design, data collection, analysis, or interpretation, writing the report, or the decision to submit the report for publication. the authors have no conflicts of interest to disclose. dr.’s winiger, ma, and brooks-russell conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i2a6_authors_final research article 69 abstract in response to the need of more rigorous data on medical cannabis and chronic pain, we conducted a 3-month prospective study incorporating ecological momentary assessment (ema) to examine the effects of medical cannabis on pain, anxiety/depression, sleep, and quality of life. data were collected from 46 adults (mean age=55.7±11.9, 52.2% male) newly initiating medical cannabis treatment for chronic pain. participants completed a baseline survey, ema for approximately 1 week preand up to 3 weeks postmedical cannabis treatment, and a 3-month follow-up survey. the self-reported ema data (2535 random and 705 daily assessments) indicated significant reductions in momentary pain intensity (b = -16.5, p < .001, 16.5 points reduction on 0-100 visual analog) and anxiety (b = -0.89, p < .05), and significant increase in daily sleep duration (b = 0.34, p < .01) and sleep quality (b = 0.32, p <.001) after participants initiated medical cannabis for a few weeks. at 3 months, self-reported survey data showed significantly lower levels of worst pain (t = -2.38, p < .05), pain interference (t = -3.82, p < .05), and depression (t = -3.43, p < .01), as well as increased sleep duration (t = 3.95, p < .001), sleep quality (t = -3.04, p < .01), and quality of life (t = 4.48, p < .001) compared to baseline. in our sample of primarily middle-aged and older adults with chronic pain, medical cannabis was associated with reduced pain intensity/inference, lower anxiety/depression, and improved sleep and quality of life. key words: pain; anxiety; depression; medical cannabis; ecological momentary assessment despite the inconsistent findings on its effectiveness, medical cannabis is increasingly accessible in the united states (u.s.) and other countries, with chronic pain as the most commonly cited condition for use (cooke et al., 2019). the 36 million adults 45 years and older in the u.s. living with chronic pain (dahlhamer et al., 2018) represent a fast-growing segment of cannabis users. a recent analysis of the national survey on drug use and health data showed a 10% annual increase of past year cannabis use for 50-64 years old and a 15% annual increase for 65 and older between 2002 and 2014 (salas-wright et al., 2017). this increasing trend in cannabis use among middle aged and older adults may reflect the trend of individuals seeking medical cannabis as an alternative pain treatment to more conventional options (boehnke et al., 2019). current evidence regarding cannabis’s efficacy on chronic pain current research evidence of cannabis’s efficacy on chronic pain is relatively restricted to clinical trials of fda-approved products (e.g., nabiximols) or low potency smoking cannabis (national academies of sciences, 2017). the studies have been primarily short-term (2-6 weeks) and often relied on retrospective selfreported outcomes from surveys (deshpande et health outcomes among adults initiating medical cannabis for chronic pain: a 3-month prospective study incorporating ecological momentary assessment (ema) cannabis 2021, volume 4 (2) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.02.006 yan wang1, jennifer jean jacques1, zhigang li2, kimberly t. sibille3, robert l. cook1 1department of epidemiology, university of florida, gainesville, fl 32610 2department of biostatistics, university of florida, gainesville, fl 32610 3department of aging & geriatric research, university of florida, gainesville, fl 32610 corresponding author: yan wang, ph.d., department of epidemiology, university of florida, gainesville, fl, 32610. phone: 352-294-5942. email: ywang48@ufl.edu. medical cannabis and chronic pain 70 al., 2015). several recent meta-analyses reached inconsistent conclusions: while some showed significant effects of cannabis on chronic pain (whiting et al., 2015), others showed no such effect (stockings et al., 2018). similarly, some research showed that medical cannabis has significant “opioid-sparing” effect, while others found no such effect (dyer, 2019; segura et al., 2019; shah et al., 2019; wen & hockenberry, 2018). the potential of medical cannabis as an alternative treatment for chronic pain needs to be carefully examined by weighing potential risks against benefits, based on quality scientific data (lev-ran et al., 2013; volkow et al., 2014). importance of investigating real-world medical cannabis use with increased accessibility of medical cannabis, there is an urgent need to investigate the real-world medical cannabis products, which usually have a higher concentration of tetrahydrocannabinol (thc) and/or cannabidiol (cbd) compared to recreational cannabis (i.e., cannabis that is not obtained from a licensed dispensary) and a greater diversity in administration modes (e.g., vape, capsule, tincture, cream). currently there are no guidelines for clinicians to discuss the risk and benefits of cannabis use in chronic pain management, including side effects (cooke et al., 2019). with the increasing prevalence of medical cannabis use as an alternative pain treatment, it would be a missed opportunity if data on efficacy and side effects associated with diverse medical cannabis products (e.g., vape vs. concentrate) are not investigated (vyas et al., 2018). ecological momentary assessment (ema) as a tool for medical cannabis research one of the significant barriers to medical cannabis research is the product diversity in administration mode, chemical composition, and lack of standard dosing. smartphone-based ecological momentary assessment (ema) provides an ideal tool for capturing detailed self-reported data about product information, patterns of use, symptom relief, and side effects in patients’ daily lives with high ecological validity and lower recall bias/errors (shiffman et al., 2008). some prior research has used ema to examine cannabis use and its consequences, but the majority focused on adolescents or young adults specific to recreational use (emery et al., 2020). studies characterizing medical cannabis use in patients’ daily lives and tracking real-time outcomes (i.e., measured in the moment via ema) such as pain intensity, anxiety/depressive symptoms, and sleep duration/quality can address a significant gap in current understanding. to the best of our knowledge, there has not been any research tracking health outcomes using ema among individuals initiating medical cannabis treatment over time. medical cannabis in florida florida has become the fastest growing medical cannabis market in the u.s. as of december 2020, approximately 447,400 persons hold an active medical cannabis card in florida (florida department of health, 2020). patients first go to a medical cannabis doctor for certification if they have one of the qualifying conditions for medical cannabis use. the doctor will write a recommendation (not prescription) specifying the upper limit of thc and cbd content (in mgs) that the patient can purchase in a defined period (first refill is 70 days, then every 210 days) and the recommended administration mode/s. then, the patient can go to the dispensaries to purchase whatever product as long as it is within the recommended dosage limit. each product is labeled with the minimum concentration of thc and/or cbd (in ratio, percentage, or milligrams) with a total amount of cannabinoids in milligrams. during the first few weeks, patients often experiment with different products, administration modes, and doses as they seek to find options that work well for their condition/s while minimizing potential side effects. therefore, ema also allows for the unique opportunity to capture the dynamic process of selftitrating medical cannabis use during this period and the associated health benefits and side effects, whereas a follow up after several months could provide evidence on medical cannabis’ effects after the self-titration is complete. purpose of the current study the main purposes of the study were: 1) to examine the real-time health outcomes before and cannabis, a publication of the research society on marijuana 71 after initiating medical cannabis treatment (i.e., real-time pain intensity, anxiety/depressive symptoms, and sleep) in adults with chronic pain using a smartphone-based ema, and 2) to examine effects of medical cannabis on pain, anxiety/depression, sleep, and quality of life at 3 months after initiation of medical cannabis treatment using survey questionnaires. this study is considered an initial step toward a larger prospective cohort study that assesses real-time and long-term (12-month) outcomes among older adults with chronic pain initiating medical cannabis vs. a control group who will not initiate medical cannabis. methods participants patients were eligible if they were 18 years or older, were seeking but had not yet initiated medical cannabis treatment, had a smartphone, and indicated that chronic pain was their primary reason for medical cannabis use. participants were excluded if they had terminal diseases (e.g., cancer) or a condition known to cause cognitive impairment (e.g., parkinson’s disease). the study protocol was approved by the university of florida institutional review board, and all participants provided written consent prior to participation. procedures this study included a baseline survey, an up to 4-week period of ema, and a 3-month follow-up survey. participants were compensated up to $210 for the ema portion of the study, and $25 for each survey. data reported in this paper were collected between april 2019 and september 2020. recruitment participants were recruited from four medical cannabis clinics in north-central florida. when new patients with chronic pain came in to seek medical cannabis treatment, doctors or clinical staff would briefly introduce the study and refer interested patients to research staff who were either present in the clinic or available by phone to complete a screening. after the physician assessment and submission of the medical cannabis card application for the patients, it took at least one week before the participants’ medical cannabis card was approved by the state. participants would not be able to obtain medical cannabis products before their application was approved. the waiting period provided an ideal opportunity for the baseline assessments including the survey and baseline ema. eligible participants were scheduled for an in-person baseline assessment at the medical cannabis clinic or a university research space. due to the covid-19 pandemic, participants recruited after march 2020 completed their baseline assessment remotely via zoom video-conferencing or over the phone with informed consent and survey links sent to them prior to the appointment. sample characteristics our sample included 46 participants (52.2% male, 47.8% female) with an average age of 55.7 (sd = 11.9). complete demographic information is summarized in table 1. the majority of the participants were non-hispanic white, which was consistent with the demographics of medical cannabis patients in florida (brown et al., 2020). most participants reported having some college education or higher, and were married or living with a long-term partner. more than half of the sample were not employed (either disabled or retired), and their income levels spanned across a wide range with relatively even distribution across four categories (i.e., under $20k, $20k40k, $40-60k, and over $60k). the baseline pain intensity in the past 24 hours measured by brief pain inventory (cleeland & ryan, 1994) was 8.2 (sd = 1.5) at its worst, 6.1 (sd = 1.9) on average, and 4.4 (sd = 2.0) at its least, indicating this sample suffered from moderate to severe pain. the majority (91.3%) of participants reported having used cannabis in their lifetime and 33.3% reported current non-dispensary cannabis use in the past 30 days. survey questionnaire: baseline and follow-up after consenting and before receiving their medical cannabis card, participants completed a baseline survey (either paper-and-pencil or online) which included questions such as demographics (e.g., age, gender, ethnicity/race, education, marital status, employment status, and income); history of and current cannabis use medical cannabis and chronic pain 72 (other than medical cannabis); and health outcomes such as pain intensity and pain interference, depression, anxiety, sleep, and overall health-related quality of life (detailed below). at approximately 3 months after their baseline survey, participants completed a followup survey. the follow-up survey included the same health-related questions as the baseline survey in order to evaluate possible changes in health outcomes over 3 months (e.g., pain, sleep, quality of life). table 1. sample characteristics of the study population (n = 46) variable value age in years mean ± sd 55.7±11.9 hispanic yes no 3 (6.5%) 43 (93.5%) race white black/african american 21(87.5%) 3 (12.5%) gender male female 24 (52.2%) 22 (47.8%) education high school graduate or ged some college or technical/trade school college or higher 8 (17.4%) 19 (41.3%) 19 (41.3%) marital status married/living with a long-term partner divorced/separated widowed never married and not living with a long-term partner 27 (58.7%) 13 (26.3%) 2 (4.3%) 4 (8.7%) employment status yes, employed for wages yes, self-employed no 14 (30.4%) 4 (8.7%) 28 (60.9%) income 0-$20,000 $20,001-$40,000 $40,001-$60,000 more than $60,000 don’t know/don’t want to answer 12 (26.1%) 11 (23.9%) 9 (19.6%) 8 (17.4%) 6 (13.0%) cannabis use prior to starting medical cannabis used in past 30 days not used in past 30 days, but within 12 months not used for more than 12 months 14 (33.3%) 8 (19.1%) 20 (47.6%) cannabis, a publication of the research society on marijuana 73 demographics. age was reported in years. gender was categorized into male, female, transgender, or other. ethnicity/race was assessed with two questions—one asking about whether they were hispanic/latino, the other asking about which race group they consider themselves belonging to (i.e., white, black/african american, native american, asian, multiracial, and other). education was categorized into elementary school or below, some high school, high school graduate or ged, some college or technical/trade school, college or trade school graduate, and graduate school or higher. marital status was categorized into married/living with a long-term partner, divorced/separated, widowed, and never married. employment was categorized into yes or no, with additional information regarding the nonemployment status (i.e., student, retired, disabled, unable to work, or other). income level was categorized into 0-$20,000, $20,001-$40,000, $40,001-$60,000, $60,001-$80,000, $80,001$100,000, and more than $100,000. for all questions, participants were also provided the option “don’t know/don’t want to answer”. history of and current cannabis use. participants were asked to report whether they had ever used cannabis in their lifetime, if so, when was their first use (age). if they reported yes, participants were also asked how long it has been since they last used cannabis that is not medical cannabis. answering options included “within the past 30 days”, “more than 30 days but within the past 12 months”, and “more than 12 months ago”. pain intensity. the brief pain inventory (bpi; cleeland & ryan, 1994) is a widely used measurement tool for assessing clinical pain, which allows participants to rate the severity of their pain using numerical levels. participants were first asked to report whether they had any pain that was “more than minor everyday kind of pain” in the past four weeks. if yes, they were further asked to report whether they had more than minor pain in the past 24 hours. if the answer was still yes, they used a scale from 0 to 10 to rate their pain intensity “at its worst”, “on average”, “at its least” in the past 24 hours, and “right now”, with higher scores indicating higher pain intensity. individual score ratings (especially pain at its worst) were used to represent participants’ pain intensity levels based on the bpi user guide (cleeland, 2009). pain interference. the promis short form v1.0-pain interference 4a (adult version) (amtmann et al., 2010) was used to measure pain interference at baseline and follow up. this measure is a four-item scale assessing to what extent pain has interfered with participants’ daily lives (e.g., household chores, social activities) in the past seven days, on a five-point likert scale ranging from 1-“not at all” to 5-“very much”. the mean score of the four items was calculated with a higher score indicating more pain interference. the cronbach’s alpha for this scale in the current study was .93, indicating excellent internal reliability. depression. the patient health questionnaire (phq-8) was used to measure depressive symptoms (kroenke et al., 2001). the phq is a widely used measure for assessing the severity of depressive symptoms in both clinical and research settings (kroenke et al., 2009). participants were asked to rate their depressive symptoms over the past two weeks on a four-point scale from 0-“not at all” to 3-“nearly every day”. a total score of the eight items was calculated to represent the overall severity of depressive symptoms, with a higher score indicating more severe depression. the cronbach’s alpha for this scale in the current study was .88. anxiety. the 7-item scale for generalized anxiety disorder (gad-7) was used for measuring generalized anxiety (spitzer et al., 2006). the gad-7 is also a widely used measure that has been applied in both clinical and research settings (löwe et al., 2008). participants were asked to rate their anxiety symptoms on a four-point scale from 0-“not at all” to 3-“nearly every day” in the past two weeks. a total score was calculated to represent the overall anxiety severity, with a higher score indicating higher level of anxiety. the cronbach’s alpha for this scale in the current study was .93. sleep quality. we adapted three questions from the widely used pittsburgh sleep quality index (psqi; buysse et al., 1989) to assess sleep quality. these included how long (in minutes) it has taken for the participant to fall asleep each night, how many hours of actual sleep they usually got, and how they would rate their sleep quality from 0 “very bad” to 3 “very good”, in the past 30 days. medical cannabis and chronic pain 74 health-related quality of life. the short-form health survey (sf-8; ware et al., 2001) was used to measure overall health-related quality of life. sf-8 is one of the most extensively validated and widely used measure for patient-reported quality of life worldwide (tomás et al., 2018). participants were asked to answer eight questions on general health, physical functioning, role limitations due to physical health problems, bodily pain, energy level, social functioning, mental health, and role limitations due to emotional problems during the past four weeks. the mean score of the eight items was calculated to indicate the overall healthrelated quality of life. the cronbach’s alpha for this scale in the current study was .83. ema participants completed approximately one week of baseline ema before they initiated medical cannabis treatment and three weeks of ema after they started the treatment. after completion of the survey, research staff instructed the participants to download the mema app (ilumivu inc.), which is a commercial ema app compatible with both ios and android systems, onto their smartphone and taught them how to use the app. the app allows researchers to program the schedule (e.g., randomized or at a specific time) for the assessments and automatically sends a push notification when it is time for the assessment on the participant’s smartphone. each participant received one daily assessment and 3-4 random assessments per day for approximately three weeks. they were given 60 minutes to complete the daily assessments and 30 minutes for the random assessments. participants received the daily assessment every day at 10am and the schedule for the random assessments was set up using the randomization function when we created the ema survey on the ilumivu platform. we used four hours as the approximate interval between random prompts during participants’ awake hours (between 8am and 10pm unless participants requested other timeframe), which automatically generates 3-4 time points for the random assessments in the system. the daily prompts included 10 questions asking about participants’ health in the past 24 hours, including sleep duration (in hours), sleep quality (from 1-“very poor” to 5-“very good”), and whether they used any other medication (e.g., opioid, sleeping pills). the random prompts included 18 questions on real-time feelings and symptoms, such as their real-time pain intensity level (i.e., 0-100 visual analog), anxiety and depressive symptoms using the respective subscale from the brief symptoms inventory (derogatis & melisaratos, 1983) on a five-point likert scale from 1-“not at all” to 5-“extremely”. after they started using medical cannabis, the daily and random prompts also included some additional questions (five for daily and six for random prompts, respectively) on medical cannabis use and outcomes (e.g., product composition, dosage, administration mode, and side effects). since this study was an initial step toward a larger project, we adjusted our ema procedures over time to make it more suitable for the specific population. we intended to capture at least oneweek baseline data before participants initiated medical cannabis use and track their outcomes for at least two weeks after they started using medical cannabis. therefore, the original plan was to have three weeks of ema assessments in total. we also originally planned for only one daily prompt and three random prompts per day (n = 84 in total for three weeks). to encourage participants to be more adherent to the ema procedure, the incentives were set to be $105 if participants completed at least 60% of all the prompts (n = 50), and another $105 if they completed at least 80% of all the prompts (n = 67). if they didn’t complete at least 60%, the incentives were prorated based on how many they completed. however, many of our participants encountered technological difficulties with the ema app where they either didn’t receive some prompts, or their responses were partially recorded. some of these difficulties were due to device or app issues, whereas others may have been attributable to participants not being technologically savvy. to account for these issues, we increased the frequency of random prompts from three to four times per day and allowed participants to extend their ema period if they desired to continue until they completed the 60% or 80% of the total prompts. this flexibility allowed us to collect more data points to capture the changes in symptoms, which was the main goal of this pilot study, but also resulted in a wider range of days of ema completed by participants. cannabis, a publication of the research society on marijuana 75 statistical analysis descriptive analyses (mean, standard deviation, frequency and percentage, etc.) were conducted on selected variables (i.e., demographics, history of and current cannabis use, pain level and interference) at baseline to describe the sample characteristics. cronbach’s alpha was calculated for established scales (described in the measures) to test the internal consistency of each scale. for ema data, to assess whether real-time health outcomes changed after participants started using medical cannabis, we used linear mixed effects models to estimate the changes in pain intensity, anxiety, depressive symptoms, sleep duration, and sleep quality during the pre and post-medical cannabis periods (bolger & laurenceau, 2013). missing data were minimal (< 5%) because participants need to provide an answer to each question before they could advance to the next question. missing data on questions only occurred when the survey was terminated in the middle due to technical difficulties (e.g., app crashed, internet connection issue). the analyses were based on available data points for each outcome without any imputation because there were sufficient data points for each outcome. pairwise deletion was the default when there was missingness in any variable included in the models. for each outcome of interest, we built three mixed effects models progressively to identify the model that best fit the data. preand post-medical cannabis changes in outcomes were contrasted by including a dichotomous variable in the model to indicate whether the datapoint was preor post-cannabis treatment (0 vs. 1). for example, we first built a mixed effects model with only a random intercept, which allows each participant’s baseline value to vary freely when examining whether pain level changed before and after participants started using medical cannabis. then we added a random slope in the model to allow the rate of change in pain intensity to also vary freely. finally, we added potential covariates such as gender, race, and age to control for these variables in the model. at each step of adding a new parameter in the model, we compared model fitness to the previous model using an anova test and aic/bic values, with a significant anova test and smaller aic/bic values indicating better fit. results from the model with the best fitness were presented for each outcome variable. for survey data, we used paired t-tests to examine changes in pain intensity, anxiety/depression, sleep quality, and healthrelated quality of life by comparing 3-month follow-up and baseline survey results. type i error was set at p < 0.05 for all statistical analyses. data cleaning and descriptive analyses were conducted using sas version 9.4 (sas institute, cary, nc). the linear mixed effects model analyses were conducted using the lme4 package (bates et al., 2015) with the open source software r version 3.6.2 (r core team, 2019). results real-time outcomes preand post-medical cannabis treatment during the ema period ema completion rates thirty-nine of the 46 participants completed the ema portion (one older participant found the mema app difficult and was unable to learn how to use it; two discontinued with the ema portion due to busy work schedules; four withdrew from the study after they completed the baseline survey). in the final analysis, we also excluded two participants who completed less than seven days of ema which was unlikely to be sufficient data for capturing the changes preand post medical cannabis treatment. these two participants were in the ema period for between two and four weeks, but had many glitches while using the ema app, so they only completed very few assessments. as a result, 37 participants’ ema data were included in the final analysis (2514 random and 705 daily assessments). the compliance rate was 80.8% and 90.3% for daily and random prompts respectively (based on 21 daily prompts, 63 random prompts as required). the range of random and daily assessments completed by each participant was 12-112 and 841 respectively. nature and composition of medical cannabis products and side effects a wide range of products were used by participants with many using at least two during medical cannabis and chronic pain 76 their treatment (e.g., sublingual drop plus vaping). sublingual/oral and vaping were the two most commonly used administration modes, reported in 554 (37.9%) and 544 (37.2%) out of 1461 random assessments after participants started medical cannabis. the composition of medical cannabis products used by the participants ranged from 100% cbd to 100% thc with various thc:cbd ratios in between (e.g., 1:1, 20:1, 60:1). the most commonly reported side effects included balance problems and dizziness, reported in 250 (17.1%) and 160 (10.9%) out of 1461 random assessments, respectively, after the initiation of medical cannabis treatment. changes in ema measured real-time health outcomes mixed effects models for each outcome contrasting preand post-treatment ema data with random intercept and random slope had the best model fitness and showed significant reduction in real-time pain intensity level (b = 16.5, p < .001, meaning that there was a 16.5 point reduction on the 0-100 visual analog), anxiety (b = -0.89, p < .05, meaning that there was a 0.89-point decrease of anxiety on the five-point likert scale), longer sleep duration (b = 0.34, p < .01, meaning that there was a 0.34 hour increase in sleep), and better sleep quality (b = 0.32, p <.001, meaning that there was a 0.32 point increase of sleep quality on the five-point likert scale), after participants started using medical cannabis. however, there was no significant improvement in real-time depressive symptoms (b = -0.17, p = .06). gender, age, and race were not significantly associated with changes in the outcomes in any of the mixed effects models, and the models including these covariates did not have significantly better model fitness than the ones without these variables. thus, the results reported above were based on models without these covariates. figure 1 presents the pain intensity trajectories of the 37 participants over the course of their ema period. the overall group trajectory showed an initial steep reduction in pain intensity after participants started medical cannabis treatment, and then the reduction became smaller in magnitude where the pain intensity level fluctuated to some extent but remained relatively stable. figure 1. pain intensity trajectory of 37 adults preand postmedical cannabis treatment note. the individual lines represent the real-time pain intensity ratings for each participant over time. the red dash line represents the overall trend of the 38 participants. data from all participants were aligned so that day 0 was the first day of starting medical cannabis for each participant. the time axis therefore indicates how many days before (negative numbers) or after (positive numbers) medical cannabis treatment. the overall trend curve was constructed using lowess with bandwidth of 0.3 (cleveland, 1979). the overall trend curve was constructed data up to 15 days before and 20 days after day 0, given that this was the period where the majority of participants had available data. cannabis, a publication of the research society on marijuana 77 table 2. main outcomes based on survey data at baseline and 3-month follow up, mean (sd) measures with respective score range or measuring unit baseline (n = 46) 3 months (n = 42) 3 months: mc subgroup1 (n = 37) pain no more than minor pain (%)* 13.0% 33.3% 35.1% at its worst (0-10)* 8.15(1.51) 7.25(2.25) 7.46(2.13) at its least (0-10) 4.37(1.98) 3.64(2.18) 3.87(2.19) on average (0-10)* 6.05(1.91) 5.21(2.35) 5.46(2.26) pain interference (1-5)* 3.64(1.09) 2.90(1.11) 2.96(1.16) anxiety (1-21) 6.50(6.10) 4.69(5.64) 4.54(5.73) depression (1-24)* 8.50(6.10) 5.67(5.42) 5.46(5.44) sleep time to fall asleep (minutes) 65.7(54.9) 50.8(45.8) 47.0(46.8) hours of sleep (hours)*** 5.31(1.83) 6.17(1.79) 6.36(1.72) sleep quality (1-5)** 1.17(0.93) 1.64(0.85) 1.73(0.84) quality of life (1-5)*** 2.72(0.68) 3.27(0.78) 3.23(0.77) note. 1mc subgroup refers to those who were still using medical cannabis at 3-month follow up. *p < .05, **p < .01, ***p < .001 changes in health outcomes measured by survey at baseline and 3 months a total of 42 participants (91.3% retention rate) out of the original 46 participants completed the 3-month follow-up survey. five (11.9%) out of the 42 participants reported discontinuation of medical cannabis use at three months. results reported in the sections below were based on all 42 participants who completed the follow-up survey. in table 2, main outcomes at baseline and three months are presented, with an additional column to show the results for only those who were still using medical cannabis at three months (n = 37), which were not significantly different from the results based on all 42 participants (“intention to treat”). pain intensity and pain interference at baseline, six (13.0%) out of the 46 participants reported that they had no more than minor everyday kind of pain in the past 24 hours, whereas 40 of them reported moderate to severe pain based on their bpi score as described in the sample characteristics. at the 3-month follow up, 14 (33.3%) out of the 42 participants who completed the follow up survey reported no more than minor pain in the past 24 hours. the proportion of participants who reported no more than minor pain at follow-up was significantly higher than baseline (χ2 = 6.59, df = 1, p < .05). for those who reported more than minor pain in the past 24 hours at baseline and follow-up, their worst pain (mean difference = -0.92, t = -2.38, df = 24, p < .05) and average pain (mean difference = 0.84, t = -2.31, df = 24, p < .05) were both significantly reduced compared to baseline average and worst intensity scores. pain interference was also significantly reduced compared to baseline (mean difference = -0.75, t = -3.82, df = 41, p < .05). anxiety, depression, sleep quality, and quality of life at 3-month follow up, participants did not show significant reduction in anxiety measured by gad-7 compared to the baseline (mean difference = -1.12, t = -1.51, df = 41, p = .14), but they showed significant improvement in their depressive symptoms compared to baseline (mean difference = -2.31, t = -3.43, df = 41, p < .01). with regard to sleep, participants reported no difference in how long it took them to fall asleep (mean difference = -8.33, t = -1.05, df = 40, p = .30), but they reported significant increases in actual sleep time (mean difference = 0.83, t = 3.95, df = 41, p < .001) and sleep quality (mean difference = 0.43, t = 3.04, df medical cannabis and chronic pain 78 = 41, p < .01). participants also reported significantly better overall health-related quality of life at three months than baseline (mean difference = 0.52 on a five-point likert scale, t = 4.48, df = 41, p < .001). discussion the purpose of the study was to prospectively track health outcomes among individuals who newly initiated medical cannabis for chronic pain via both survey questionnaire and smartphonebased ema. with the rapid increase of population using medical cannabis as an alternative to traditional pain treatment, high quality scientific evidence is urgently needed to inform patients, physicians, and policy makers. in this study, we investigated the real-time effects of medical cannabis using smartphone-based ema, which allows for the capture of changes in daily symptoms (e.g., pain, anxiety, depression, and sleep) over several weeks. we also conducted a baseline and follow-up survey which allowed for examination of effects of medical cannabis on pain and related health outcomes at three months after participants started using medical cannabis. the discussion below is organized by outcome domains. we also included some discussion on applying ema in medical cannabis research, as we believe that ema could be a potentially valuable tool for future research on medical cannabis use and its health/side effects. medical cannabis’s effects on pain in real-time and 3 months recent meta-analyses have reached inconsistent conclusions on whether cannabis is effective in treating chronic pain (fisher et al., 2021; national academies of sciences, 2017; stockings et al., 2018; whiting et al., 2015). for example, the national academies of sciences, engineering, and medicine (2017) report found substantial evidence to support the effectiveness of cannabis for chronic pain, whereas the international association for the study of pain (2021) position statement based on their two-year comprehensive review concluded that they do not endorse general use of cannabis or cannabinoids for pain relief due to the lack of high-quality clinical evidence (fisher et al., 2021). in this study, there was a significant reduction in patient reported momentary pain level after they started medical cannabis treatment compared to baseline pain level in the ema assessments. the magnitude of reduction was 16.5 points out of a 0 to 100-point visual analog. as illustrated in figure 1, the baseline real-time pain intensity score for the group was around 60 before initiating medical cannabis treatment, with a 16.5 point reduction representing 27.5% reduction, which is considered clinically significant improvement (salaffi et al., 2004). this was significantly larger than the pooled change in pain intensity generated from the meta-analysis in stockings et al.’s (2018) paper, which was 3 mm reduction on a 100 mm visual analogue scale. there could be several possible explanations for this discrepancy. most of the studies reviewed by stockings et al. (2018) used either lower potency smoking cannabis (i.e., flower) or fda-approved products (e.g., nabiximols, dronabinol). this study examined the effects of real-world cannabis products sold at various florida dispensaries, which have a higher potency (% of thc) and greater diversity of chemical components (e.g., thc:cbd ratio). the differences in cannabis products may have resulted in the different efficacy for pain reduction. also, prior studies mostly relied on retrospective self-report of pain as the outcome. ema may provide more accurate pain ratings as it captures real-time pain ratings in patients’ daily lives (may et al., 2018). also, there were significant individual differences in the pain trajectory as shown in figure 1. although our analysis did not show significant differences in the comparison of real-time outcomes before and after medical cannabis treatment by gender, age, and race, future research with larger samples is needed to investigate interpersonal factors (e.g., age, gender, health status) that may impact outcomes from medical cannabis use. our results also showed sustained improvement after medical cannabis treatment on pain and related outcomes over three months with a high follow-up rate (>90%). there was a significant increase in the proportion of participants reporting no more than minor pain in the past 24 hours at 3-month follow up compared to the baseline (33% vs. 13%). moreover, for those who reported more than minor pain, their worst and average pain intensity was significantly lower than their baseline ratings. in addition to pain intensity, there was also significant reduction in cannabis, a publication of the research society on marijuana 79 pain interference. participants reported significantly less impact of pain on their daily activities and functioning (i.e., pain interference), which is an important aspect in evaluating pain treatment (dworkin et al., 2005). medical cannabis’s effect on anxiety/depression, sleep and quality of life outcomes in real-time and 3 months anxiety, depression, and insomnia are common comorbidities associated with chronic pain (wilson et al., 2002). successful pain management strategies should also evaluate patients’ physical and emotional functioning as core measures (turk et al., 2003). our study showed significant reductions in participants’ real-time anxiety after they started medical cannabis, and significant reduction in depressive symptoms over 3 months. these findings are inconsistent with the conclusion from stockings et al’s (2018) meta-analysis that cannabis had no significant impacts on physical or emotional functioning in individuals with chronic pain. stockings et al. also concluded that there was lowquality evidence whether cannabis improved sleep among individuals with chronic pain. however, our study indicated significant improvement in sleep including a longer duration of sleep and better sleep quality both in daily ema assessments and at the 3-month follow up, which is consistent with a recent prospective study based on observational data from new medical cannabis patients with chronic pain (gruber et al., 2021). again, there are several potential explanations for the discrepancy as noted above. psychological factors such as expectancy or placebo effect could also play a role (kaptchuk, 2002). future research may consider using ema in a larger sample or adding objective measures (e.g., polysomnography for sleep) to further validate our findings. additionally, there are numerous causes and conditions that contribute to experiencing chronic pain. individuals living with chronic pain represent a highly heterogeneous group. medical cannabis research moving forward will need to pay more attention to the type of chronic pain being treated (e.g., neuropathic, musculoskeletal, cancer). participants also reported lower levels of depressive symptoms at three months, despite that medical cannabis did not show significant effect on improving real-time depressive symptoms. the result is plausible because improved sleep, reduced pain, and less anxiety over time can help improve mood and thus reduce depression. this is in line with prior research that shows improvement in anxiety often precedes the improvement in depression in people having cooccurrence of these two mental health issues (bomyea et al., 2015). our results also showed that sleep duration and self-reported sleep quality at three months were significantly improved, which is consistent with the results based on realtime data collected in the ema. this finding suggests that the effect of medical cannabis on sleep in first few weeks during the ema period persisted over three months. finally, participants reported significant better overall health-related quality of life at three months compared to baseline, which is an important clinical outcome when evaluating chronic pain treatment (dworkin et al., 2005). using ema for medical cannabis study there is an increasingly wide application of smartphone-based ema in various research areas including chronic pain and monitoring clinical interventions. we leveraged this tool to investigate medical cannabis use and real-time assessment of health and side effects in individuals with chronic pain (may et al., 2018). our findings suggest that even with the older adult population, an ema procedure combining one daily and 3-4 random prompts throughout the day is feasible and highly acceptable. it should be noted that 7 of the 46 participants didn’t complete the ema procedure either due to challenges in using the app or their busy work schedule (these tended to be younger participants who were employed). among those who completed the ema procedure, their compliance rate for the daily and random prompts, based on how many assessments they were required to complete, was 80.8% and 90.3% respectively. this finding is consistent with prior studies that shows relatively high compliance rates of ema procedures in older adult population (cain et al., 2009). participants reported their medical cannabis use in great detail, including several important aspects of their use such as administration mode and dosage, which is critical to advance the research on cannabis’s potential medicinal effects medical cannabis and chronic pain 80 (volkow & weiss, 2020). our results indicated that sublingual/oral and vaping were the most commonly used administration modes, reported in 37-38% of the post-medical cannabis treatment ema sessions. although participants reported the estimated dosage of their medical cannabis use, it was difficult to accurately measure and standardize the dose. as the ema data showed, participants used a wide range of medical cannabis products, which made it challenging to convert their use to a common metric across different products (e.g., using the mgs of thc and mgs of cbd as a standard measure), especially for vaping and smoking. more education on the dosing of medical cannabis for patients to be able to record their doses in mgs of thc or cbd may help address this challenge in future research. strengths, limitations, and future directions this study took an initial step toward capturing real-time and longer-term effects of medical cannabis on individuals with chronic pain. one strength of the study was the inclusion of both preand post-medical cannabis use periods where pain level, mental health symptoms, and sleep quality can be compared. another strength was the use of a smartphone-based ema allowed us to examine the fluctuations in daily symptoms with a large number of data points during the first few weeks after medical cannabis initiation. additionally, we had a high follow-up rate (over 90%), which helps to reduce the potential bias due to drop out. despite these strengths, our sample size was relatively small and predominantly white. future research with larger and diverse (e.g., oversampling of under-represented racial/ethnic groups) samples with a longer followup period (e.g., one year) is needed to further confirm the findings from this study. also, despite the advantage of collecting data in real-time using ema, our results were still based on self-report, which could be subject to biases resulted from social desirability or expectancy. future studies could add objective measures for various health outcomes, such as incorporating biological measures (e.g., inflammatory biomarkers) or wearable sensors (e.g., monitors for sleep and/or physical functioning) to better evaluate the impact of medical cannabis on individuals with chronic pain. finally, despite the current obstacles, randomized clinical trials of medical cannabis products may be a valuable next step to produce more rigorous evidence on medical cannabis and chronic pain. conclusions in this middle aged and older adult sample with chronic pain, our findings provided preliminary evidence to support significant effects of medical cannabis on real-time pain intensity, anxiety, and sleep 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(2002). major depression and insomnia in chronic pain. the clinical journal of pain, 18(2), 77-83. funding and acknowledgements: this project is supported by the university of florida center for research to investigate substance use and pain (uf-crisp) and part of the university of florida’s “creating the healthiest generation” moonshot initiative, which is supported by the uf office of the provost, uf office of research, uf health, uf college of medicine, and the uf clinical and translational science institute. the redcap service is funded by ncats grant ul1 tr000064. we would like to thank all the clinics (releafe now, cannamd, and florida marijuana doctor) who helped with the study recruitment. we especially appreciate the recruitment support from drs. john (jack) crump and justin davis, ms. debbie mendez-vigo, and ms. jessica walters. we are grateful to all the individuals who participated in our research. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 113 ved abstract background. chronic pain (cp) is experienced by as many as 50 million americans and can negatively impact physical and mental health. prescribing opioids is the most common approach to address moderate to severe cp though these potent analgesics are associated with a significant number of side effects. one alternative some americans are turning to for cp management is cannabis. in addition to serving as an alternative, many individuals with cp use cannabis in addition to using prescription opioids. this study examined individuals with cp who enrolled in the state of illinois’ opioid diversion program, the opioid alternative pilot program (oapp), which offers individuals aged 21 and older a separate pathway to access medical cannabis if they have or could receive a prescription for opioids as certified by a licensed physician. methods. cross-sectional survey data were collected from 450 participants. we described participants and compared those who use only cannabis with those who use cannabis and opioids. results. while 16% of the respondents were cannabis-only users, 84% of the respondents were co-users of opioids and cannabis. both groups considered opioid use risky (100% cannabis-only, 89% co-users,). the majority (73%) of respondents sought to completely stop or never start using opioids for cp. cannabis-only users reported lower levels of pain compared to co-users. co-users (85%) were more likely to have their routine provider as a cannabis certifying physician than cannabis-only users (69%). conclusion. with increasing clinical evidence, legalization and acceptance, researchers should continue to examine how cannabis may be a viable alternative to reduce the risk of prescription opioid side effects, misuse, or dependence. our findings also inform health care providers and state policymakers who increasingly are being asked to consider how cannabis may reduce the potential for harmful outcomes among persons with cp who use prescription opioids. key words: = older adults; prescription opioids; cannabis; policy chronic pain is experienced by as many as 50 million americans (u.s. department of health and human services, 2019). chronic pain (cp) can negatively impact physical and mental health, and uncontrolled cp can result in decreased mobility and premature mortality (u.s. julie bobitt1, hyojung kang2, kanika arora3, divya bhagianadh4, gary milavetz5, brian kaskie3 1university of illinois chicago, department of medicine, center for dissemination and implementation science 2university of illinois urbana champaign, college of applied health sciences, department of kinesiology and community health 3the university of iowa, college of public health, department of health, management and policy 4rutgers university, school of social work 5the university of iowa college of pharmacy cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000125 offering an alternative to persons with chronic pain: how access to cannabis may provide an off-ramp from undesired prescription opioid corresponding author: julie bobitt, university of illinois chicago, 818 s. wolcott avenue, chicago, il 60612. phone: 312-355-0427. email: jbobitt@uic.edu use offering an alternative to persons with chronic pain 114 department of health and human services, 2019; zhu et al., 2007). prescribing opioids is the most common approach health care providers use to address moderate to severe levels of cp (guerriero, 2017; national institute on drug abuse, 2018; zhu et al., 2007). though opioids may be effective with cp reduction in some conditions, these potent analgesics are associated with a significant number of side effects including constipation, dependence, dizziness, and sedation (ballantyne & shin, 2008; chou et al., 2015; guerriero, 2017; musich et al., 2019; steinman et al., 2014). researchers also have noted how problems with opioid overdoses, the need for opioid use disorder treatment, and the number of deaths attributable to opioid misuse persist at epidemic levels (cullinan et al., 2017; national institute on drug abuse, 2018; centers for disease control and prevention, 2022). as cp reduction continues to be a challenge and prescription opioid use continues to result in an undesirable number of unwanted harms, identifying viable alternatives to reduce cp and replace prescription opioids has become a public health imperative. one alternative some americans are turning to is cannabis. survey data indicate that 24.4 million adults aged 18 and older in the united states reported using cannabis in 2017 and these numbers continue to increase as state legalization for medical and recreational use continues to expand (carliner et al., 2017; poli et al., 2018). while the u.s. food and drug administration has yet to approve cannabis use for medicinal purposes, the national academies of sciences, engineering, and medicine (2017) found substantial evidence that cannabis is an effective treatment for cp, and up to 80% of individuals who take medical cannabis report doing so to manage cp (bonn-miller et al., 2014; ilgen et al., 2013). thirty-eight state governments offer legal access to cannabis for medical purposes and thirty-two of them include cp as a qualifying condition for program participation (procon.org, 2022). the most recent gallup poll revealed most americans support cannabis legalization, especially to reduce cp (daniller a, 2022). in addition to serving as an alternative, many individuals with cp use cannabis in addition to using prescription opioids (black & joseph, 2014; boehnke et al., 2019). whether this co-occurring use decreases or increases prescription opioid use remains unclear. some researchers have observed that states with legalized cannabis access have experienced a simultaneous decrease in opioid prescribing rates compared to states without legalized cannabis (bradford & bradford, 2016; mcmichael et al., 2020). others have observed that persons who use cannabis to limit their prescription opioid use have reported decreased cp, fewer side effects related to prescription opioids, and improved quality of life (boehnke et al., 2019; lucas et al., 2021). one study found persons with cp who used cannabis experienced a 78% reduction in mean opioid dosage and experienced improvements in all four of the world health organization quality of life domains (lucas et al., 2021). alternatively, studies exist that have shown co-occurring use of cannabis and opioids has been associated with the use of alcohol, tobacco, illicit substances, and poor health outcomes as well (rogers et al., 2019). cannabis use also has been associated with prescription opioid misuse and among adults with cp (lake et al., 2019; nugent et al., 2018) and overall overdose mortality (shover et al., 2019). while there certainly is reason to be concerned that co-occurring use of cannabis and prescription opioids may contribute to increased rates of substance misuse and other undesirable outcomes (caputi & humphreys, 2018; carr & schatman, 2019; choi & dinitto, 2021), it is difficult to overlook the benefits many persons reportedly derive when taking cannabis to manage cp with or without prescription opioids (boehnke et al., 2019; national academies of sciences, engineering, and medicine, 2017). indeed, it is possible that persons with cp use cannabis as an alternative to prescription opioids; others with cp may use cannabis to reduce side-effects and other risks associated with prescription opioids; and some may use cannabis to enhance the painrelieving effects of prescription opioids. some state public health officials have supported providing legal cannabis access for persons with cp as a viable opioid alternative or a form of harm reduction. in colorado, new jersey, new york, and pennsylvania, state cannabis programs have added opioid substitution and/or opioid use disorder as qualifying conditions for access to medical cannabis (new jersey department of health, 2020; procon.org, 2022; the new york state medical marijuana program information for patients, 2020). cannabis, a publication of the research society on marijuana 115 the opioid alternative pilot program the state of illinois took such efforts one step further by creating the opioid alternative pilot program (oapp) in 2019 (illinois department of public health opioid alternative pilot program, 2020). the oapp is the only program in the country that offers individuals aged 21 and older a separate pathway to access medical cannabis if they have or could receive a prescription for opioids as certified by a licensed physician. there are several other features that make the illinois program stand apart as a distinct and deliberate effort to offer cannabis as an alternative or harm reduction strategy. foremost, the oapp provided legal cannabis access to individuals with cp who otherwise would not qualify for the state medical cannabis patient program (mcpp). at the time, the illinois mcpp program did not identify chronic pain (or related conditions such as back spasms and osteoarthritis) as a qualifying condition even though cp is among the most common conditions experienced by persons who use medical cannabis. also, enrollment into the oapp was designed to offer a quick and less burdensome application process compared to the mcpp, and fees were reduced to $10 compared to the mcpp fees of $100 per year (illinois department of public health medical cannabis patient registry program, 2020). moreover, by requiring qualifying physicians to meet patients who sought to renew program eligibility after 90 days and authorizing them to revoke a patient’s certificate if cannabis was being misused, the oapp was considered to be more attractive to those who may be less familiar with using cannabis and value such provider engagement. research objectives following previous survey work conducted in collaboration with the illinois department of public health (bobitt et al., 2020), we conducted a point in time survey of individuals who enrolled in the state oapp. we used these survey responses to address three objectives. first, we sought to describe participants who enrolled in the program, considering their attitudes toward cannabis, motives for use, and whether they use cannabis as an alternative or in combination with prescription opioids. we then focused on individuals with cp and determined if those who only use medical cannabis differ from those who use cannabis and opioids concomitantly in terms of age, gender, education, diagnosed conditions and presenting symptoms. third, we considered the role of providers in facilitating enrollment into the oapp. we believe this work is important for illuminating individuals who participated in an entirely novel medical cannabis program explicitly designed to facilitate access to cannabis as an opioid alternative or harm reduction strategy and improve our understanding of individuals who are using cannabis for cps with or without prescription opioids. methods with the support of the illinois department of public health, we sent a secured electronic survey link to individuals who enrolled in the oapp between february and august of 2019. the link was sent three times over six weeks. of the 2,866 enrolled individuals, 651 (22.7%) responded and were found to be comparable to the sample population in terms of age, gender, and geography (urban, suburban, rural). we excluded individuals who did not use cannabis in the past year or only used cannabis for recreational purposes only (n=103). for complete case analysis, we excluded participant responses with missing values using a pairwise deletion approach (n=98). our analytic sample consisted of 450 individuals enrolled in the illinois oapp who reported using cannabis in the past year for medical purposes. institutional review of the study was provided by the university of illinois urbana champaign and all participants indicated their consent prior to starting the survey. survey measures since 2016, we have fielded five separate surveys and validated more than one hundred questions concerning cannabis use. our questions have been drawn from the national study on caregiving and national survey of drug use and health, and we also developed unique questions reflecting the biopsychosocial model of aging (engel, 1977) and the reasoned action model of decision-making and behavior change (fishbein & ajzen, 1977). our online survey was conducted using redcap, an electronic data capture tool that offers a secure, web-based survey hosted at the university of illinois urbana champaign. offering an alternative to persons with chronic pain 116 for this study, the participant survey included 49 questions covering individual characteristics (e.g., age, gender, education) and health status (e.g., cp, and cp-related conditions such as spinal/back conditions, cancer, rheumatoid arthritis (ra), osteoarthritis, multiple sclerosis (ms), fibromyalgia and others). we also asked participants to rate their current level of cp on a sliding scale of 0 to 100 where 0 = no cp and 100 = worst cp imaginable (jones et al., 2007). we measured attitudes toward cannabis and opioids by asking if the participant agreed or disagreed with the following statements “cannabis use is risky”, “opioid use is risky”, and by asking the following questions: “have you ever had a negative experience with opioids?” “do you know someone who has had a negative experience with opioids?”. table 1. cannabis-only and cannabis + opioids users enrolled in the oapp cannabis only co-users p-value total sample n=450 n (%) n (%) n=73 (16.2) n=377 (83.8) attitudes & experiences believe cannabis use is risky 9 ( 12.3) 52 ( 13.8) 0.883 believe opioid use is risky 73 (100.0) 335 ( 88.9) 0.006 had a negative opioid experience 47 ( 64.4) 209 ( 55.4) 0.199 know someone who had a negative opioid experience 53 ( 72.6) 207 ( 54.9) 0.008 reason for using cannabis <0.001 i will use in addition to my current opioids 0 ( 0.0) 16 ( 4.2) to reduce my current use of opioids 0 ( 0.0) 108 ( 28.6) to replace and stop my use of opioids 3 ( 4.1) 113 ( 30.0) to avoid prescription opioid medications altogether 70 ( 95.9) 140 ( 37.1) medical conditions osteoarthritis 18 ( 24.7) 92 ( 24.4) 1 spinal conditions/back pain 33 ( 45.2) 222 ( 58.9) 0.042 chronic pain 45 ( 61.6) 249 ( 66.0) 0.556 othera 13 ( 17.8) 64 ( 17.0) 0.998 symptoms sleep problems 31 ( 42.5) 182 ( 48.3) 0.434 emotional problems 20 ( 27.4) 91 ( 24.1) 0.658 digestive problems 7 ( 9.6) 54 ( 14.3) 0.371 pain level (mean (sd)) 54.9 (25.1) 60.8 (21.4) 0.04 demographics age: 65 years and older 21 ( 28.8) 121 ( 32.1) 0.673 sex: female 29 ( 39.7) 194 ( 51.5) 0.088 education: college or higher degree 34 ( 46.6) 159 ( 42.2) 0.571 employed 42 ( 57.5) 176 ( 46.7) 0.116 financially secure 54 ( 74.0) 231 ( 61.3) 0.054 type of provider who provided cannabis certification <0.001 general practitioner 28 ( 38.4) 151 ( 40.1) pain specialist 18 ( 24.7) 163 ( 43.2) other specialist 27 ( 37.0) 63 ( 16.7) certifying physician was a routine provider 50 ( 68.5) 321 ( 85.1) 0.001 acancer, rheumatoid arthritis, multiple sclerosis, fibromyalgia. cannabis, a publication of the research society on marijuana 117 we asked about past-year cannabis and opioid use, and intentions about using medical cannabis relative to the use of opioids: moderate (i.e., i will use cannabis in addition to my current opioid use), reduce, stop or avoid initiation of an opioid prescription. we also asked, “what type of provider certified your participation in the oapp?” and “was the physician who certified you one of your routine care providers?” analysis given sample sizes and cross-sectional nature of the data, we performed univariate analysis that compared characteristics between two groups: (a) those who use cannabis and prescription opioids, and (b) those who use only cannabis in the past year. the characteristics included in this study were coded as a categorical variable except for pain level. to identify group differences, we performed a chi-square test and an independent sample t-test for reported pain-levels. results our sample (n=450) included 223 men and 227 women. participant age ranged from 21 to 90 with an average of 51.1 (sd 13.6), and 31.6% were older adults (60 and older). of the program participants, 73 (16.1%) used cannabis-only and 377 (83.8%) used both cannabis and opioids. mean self-reported level of cp was lower in the cannabis-only group (55.0 v 60.8; p= 0.04). more than seven of every ten participants (72.4%) in our sample reported using cannabis to either altogether stop or never start using prescription opioids, and persons who used cannabis-only were significantly more likely to enroll in the oapp as a way to never start prescription opioid use (p <0.001). alternatively, less than 4.0% reported using cannabis to moderate (i.e., enhance) their opioid use. in terms of attitude toward cannabis, we observed no difference between cannabis-only and co-occurring users. all program participants held a negative attitude toward opioid use; all individuals in the cannabis-only group believed opioid use is risky as did 88.9% of individuals who used both cannabis and opioids in the past year. a significantly higher number of individuals used only cannabis (72.6%) indicated they knew someone who had a negative experience using opioids compared to those (54.9%) who used opioids as well (p = 0.008). there was no significant difference in medical symptoms (i.e., digestion, emotional and sleep problems) between the two groups. however, persons reporting spinal conditions/back pain were more likely to be cooccurring users. the univariate analysis of demographics showed no significant difference between cannabis only and co-occurring users. the proportion of older adults was slightly lower in the cannabis-only group (28.8% v. 32.1%) but not statistically significant (see table 1). significant differences between cannabis only and co-users were observed with respect to type of provider (i.e. primary care, pain specialist, other) who provided cannabis certification (p= <0.001). people who only used cannabis were more likely certified by a provider who was not their routine primary care provider (e.g., oncologists and other disease specialists were most often reported) and co-occurring users were more often certified by a pain management specialist (p< 0.001). discussion we surveyed individuals ranging in age from 21 to 90 years old who qualified for a unique program created by the state of illinois offering safe, legal, and easy access to medical cannabis for individuals who qualified for an opioid prescription from a licensed medical provider. we know of no other state cannabis program that has made such a deliberate effort to facilitate access to individuals who consider prescription opioids to be risky and decide to use cannabis as an alternative or harm reduction strategy. indeed, more than seven out of ten program participants indicated they desired to never initiate an opioid prescription and considered cannabis as a viable alternative or used cannabis to stop their current prescription opioid use. while this sort of selfselection into the program is to be expected, we also noted how few individuals enrolled in the program intending to use cannabis in addition to and without making changes to their opioid use. our findings also confirm that not all cannabis users are alike (arora et al., 2021). in this study, we distinguished persons who only used cannabis from those who used cannabis and prescription opioids as well. those who used cannabis were more likely to know someone who had a negative experience using prescription opioids and reported lower levels of pain. such individuals offering an alternative to persons with chronic pain 118 may be more reluctant to initiate a prescription especially if their pain may not be as prominent or persistent. in contrast, concomitant users appear more likely to experience more persistent sources of pain related to spinal conditions and experience clinically meaningful differences in pain compared to persons who only used cannabis (farrar et al., 2001). while it may not be surprising these individual already were using prescription opioids, we find it noteworthy how many chose to legally access cannabis under medical supervision as a deliberate harm reduction strategy, intending to reduce or altogether stop prescription opioid use. for these individuals, facilitating access to medical cannabis offers a viable alternative to prolonged opioid prescribing (krebs et al., 2010; lau et al., 2015). in our effort to further understand cannabis use, we were expecting to observe other individual differences related to age, education, gender, or financial status. research has shown that older persons, especially older white women, are the most likely to have been prescribed opioids in the past year compared to other age or demographic groups and are more likely to value legal access to cannabis as supervised by a qualified medical provider (serdarevic et al., 2017; bobitt et al., 2019). although older persons appear to be disproportionally represented in our sample, we found no reason to think they were using cannabis differently than other oapp participants. however, we did observe noteworthy results concerning the role that physicians can play in facilitating access to cannabis. individuals who used cannabis-only were less likely to rely on their routine provider to certify program eligibility and relied on another provider instead. although it is possible these individuals engaged in drug seeking behavior and sought providers who would more readily qualify oapp participation, our review of open field responses suggest these individuals were more likely qualified by providers who were providing specialized treatment (or performing surgery) and not considered routine providers. in contrast, the role that pain management specialists assumed in qualifying persons who were experiencing a chronic condition and already using a prescription opioid at time of oapp enrollment merits further investigation. it is possible that these particular providers are more likely to support cannabis use as a safe and effective prescription opioid mitigation strategy or are less apprehensive about recommending cannabis even though it remains classified as a schedule 1 narcotic (congressional research services, 2021). implication for policy and practice as the opioid epidemic persists (u.s. department of health and human services, 2021) and nearly $15 billion settlements related to nation-wide opioid litigation are disbursed (national opioid settlement, 2021), we intend to observe if and how other states (and substance abuse treatment system and clinic administrators) follow on the innovative programmatic approach taken by the state of illinois. will state policy makers continue to defer to prevailing clinical practice concerning opioid prescribing or will state leadership make a more deliberate and explicit effort to facilitate cannabis access for those patients and providers who consider cannabis as a viable alternative or harm reduction strategy (pitt et al., 2018)? our work also recognizes the importance of qualified medical care providers who encourage individuals to consider cannabis as a way to offer an alternative or deprescribe opioids. in our previous work, we noted how such clinicians served an important role informing persons, especially older adults, about cannabis as an alternative but how most providers appeared reluctant to do so (bobitt et al., 2019; zolotov et al., 2019). why specialists support cannabis use differently than routine care providers remains unclear. limitations we recognize these findings are specific to illinois, and the unique nature of the oapp may or may not serve as an example for other states especially those that also offer legal access to recreational cannabis. we also recognize the inherent limitations in relying on a small sample of self-selected program participants and the potential bias of self-report. the use of cannabis as an alternative or harm reduction strategy merits more rigorous evaluation afforded by randomized control trials or quasi-experimental observational research designs. last, future work must look to sample a greater number of cannabis, a publication of the research society on marijuana 119 individuals, collect a wider array of individuallevel data that may shape cannabis use, and observe individuals over an extended period to determine if and how cannabis use impacted opioid use and individual outcomes. our crosssectional design does not allow us to detect if cannabis use actually stopped or mitigated prescription opioid use, especially after a sufficient period of time when individuals may experience increasing amount of pain as their conditions persist. conclusion while listing cp as a qualifying condition for medical cannabis program participation or expanding recreational options may be sufficient for providing access for individuals and providers who support cannabis use as an alternative or harm reduction option, there appears to be some value in establishing a program that upholds deliberate strategies to engage, support, and protect users – especially older adults who prefer to be engaged with their health care providers and only use cannabis for medical purposes. the procedures the state of illinois put in place for their opioid alternative pilot program may be illustrative for other states to consider as the opioid epidemic requires an 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(2019). predicting physicians’ intentions to recommend medical cannabis. journal of chronic pain and symptom management, 58(3), 400–407. https://doi.org/10.1016/j.jpainsymman.2019.0 5.010 funding and acknowledgements: this research was funded by the illinois department of public health. agreement no. 93107003g. we would like to thank karen mancera-cuevas, paula atteberry and elaine ewing from the illinois department of public health for providing feedback during project development. the authors declare no conflict of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i1a5_authors_final_p research article 50 ved abstract in addition to traditionally assessed abuse, neglect, and household dysfunction, adverse childhood experiences (aces) include adversities like racial discrimination, community violence, and bullying. prior research established associations between the original aces and substance use, but few used latent class analysis (lca) to examine patterns of aces. examining patterns of aces may yield additional insights beyond cumulative risk studies focusing only on the number of different aces experiences. therefore, we identified associations between latent classes of aces and cannabis use. studies on aces rarely examine cannabis use outcomes, which is important as cannabis remains one of the most commonly used substances and is associated with negative effects on health. yet it is still unclear how aces influence cannabis use. participants were adults in illinois (n = 712) recruited through qualtrics’ online quota-sampling method. they completed measures of 14 aces, past 30-day and lifetime cannabis use, medical cannabis use (dfacq) and probable cannabis use disorders (cudit-r-sf). latent class analyses were performed using aces. we identified four classes, labeled: low adversity, interpersonal harm, interpersonal abuse and harm, and high adversity. the largest effect sizes (p<.05) were observed for those in the high adversity class, who had elevated risks for lifetime (or =6.2), 30-day (or = 5.05), and medicinal cannabis use (or = 17.9) relative to those in the low adversity class. those in the interpersonal abuse and harm and interpersonal harm classes also had increased odds (p<.05) for lifetime (or =2.44/or=2.82), 30-day (or = 4.88/or= 2.53), and medicinal cannabis use (or = 2.59/or =1.67(ns)) relative to those in the low adversity class. however, no class with elevated aces had higher odds for cud relative to the low adversity class. additional research could further disentangle these findings using extensive measures of cud. additionally, as participants in the high adversity class had higher odds of medicinal cannabis use, future research could carefully study their consumption patterns. key words: = adverse childhood experiences; cannabis use; community violence; racial discrimination; bullying; latent class analysis in the seminal study on adverse childhood experiences (aces; felitti et. al., 1998), kaiser permanente and the centers for disease control and prevention (cdc) identified ten aces that were associated with an increased risk for negative health outcomes in adulthood. these aces include abuse (e.g., physical, verbal/psychological, and sexual abuse), neglect (e.g., physical, and emotional neglect), and household dysfunction, including exposure to intimate partner violence, having an adult in the household with substance use problems or mental illness, or having a relative incarcerated. approximately 61% of adults in the united states have experienced at least one of these aces (jones et. al., 2019), which are associated with multiple health and psychosocial problems through the life course (albaek et al., 2018; hughes et al., 2017; patterson et al., 2014). since this work, increasingly more research, douglas c. smith1, rachel c. garthe1, alex lee1, shongha kim1, magdelene thebaud1, & lucy kovacevic1 1school of social work, university of illinois at urbana-champaign cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.005 expanded adverse childhood experiences (aces) and adult cannabis use: a latent class analysis corresponding author: douglas c. smith, ph.d., school of social work, university of illinois at urbanachampaign. 1010 w. nevada street, urbana, il 61801. email: smithdc@illinois.edu cannabis, a publication of the research society on marijuana 51 such as the philadelphia expanded ace study, focused on adding aces pertaining to ethnic minorities and those living in marginalized and distressed communities. they included several new items (i.e., expanded aces hereafter) such as witnessing violence, feeling discrimination, being bullied, living in foster care, or feeling unsafe in one’s neighborhood (cronholm et al., 2015). expanding aces research to racial and ethnic minority children was critical, as they are more likely to experience a higher number of aces (child and adolescent health measurement initiative, 2018), and also experience different types of adversities. for example, the philadelphia expanded aces study found that over 40% of the participants witnessed violence, over 30% felt discriminated against, and over a quarter of the participants felt unsafe in their own neighborhood (cronholm et al., 2015). the expanded aces broadened the concept of childhood adversity by including experiences at the neighborhood or community level. aces and substance use clinical and longitudinal studies show the cumulative effects of different childhood adversities are associated with adults’ substance use (bryant et al., 2020; davis et al., 2021; leza, et al., 2021). a recent scoping review (k =12) found elevated aces among those with substance use disorders (sud; leza et al., 2021). experiencing one or more of the aces was associated with the presence of a substance use disorder in a large sample of patients seen in federally qualified health centers (bryant, coman, & damian, 2020). young adults who experienced aces were also less likely to transition out of heavy substance use over time, implying that the presence of aces leads to more recalcitrant problematic use (davis et al., 2021). beyond cumulative risk models. although the overall quantity of childhood adversities matters, specific patterns of adversities may also be important. for example, wade jr. and colleagues (2016) found that for participants from lower socioeconomic backgrounds, the expanded aces were more strongly associated with substance use than the original aces. thus, although many studies have used the cumulative number of aces as predictors, it may be that some patterns of aces may be relevant. in other words, it may be that it is important to examine which specific aces are clustering together, which could extend the prior work on how the overall quantity of aces associate with substance use. latent class analysis (lca), one of several person-centered approaches, allows researchers to identify unobserved groups of individuals that share similar characteristics (nylund-gibson & choi, 2018). lca can be a potential alternative that addresses the limitations inherent to cumulative risk models (merians et al., 2019). for example, instead of cumulatively adding the total number of aces reported, lca enables researchers to identify the patterns among aces that occur frequently from a given sample (e.g., merians et al., 2019; shin et al., 2018). by just examining cumulative risk (i.e., counting the number of aces), researchers are unable to examine patterns of exposure to aces that are distinct for sub-populations. further, there is variation in the composition of aces asked across studies (jacobs et al., 2012); thus, examining combinations of specific aces for sub-populations using lca will provide a more nuanced and detailed examination than cumulative risk models. being included in these groups, or classes, can then be used to examine distinctive risks for outcomes (i.e., differences in risk variables by classes) while still explaining the co-occurrence of ace experiences (merians et al., 2019). prior lca studies on aces although some studies have used lca to identify specific patterns of aces, we could only locate one study that used the expanded set of aces and examined associations with substance use (shin et al., 2018). other studies have used the original, not the expanded aces (merians et al, 2019), or not examined associations with substance use. our study adds to this limited research by using lca with the expanded aces, and examining the associations between classes and cannabis outcomes. prior class solutions. using only nine aces, merians and colleagues (2019) found a four-class solution in a sample (n = 8,997) of college students. the four classes of aces were: 1) low aces, 2) emotional and physical child abuse, 3) moderate risk of non-violent household dysfunction, and 4) high aces. the high aces aces and cannabis use 52 group showed greater mental health problems, lower physical health outcomes, negative alcohol consequences, and poorer academic performance, compared to the low aces group (merians et al., 2019). lee and colleagues (2020) adolescent study (n = 10,784) used the expanded aces, but did not measure substance use as an outcome. they also identified four classes, including: 1) low adversity, 2) household dysfunction, 3) community violence, and 4) child maltreatment. youth in the community violence class experienced greater post-traumatic stress disorder (ptsd) symptoms than the low adversity class. the child maltreatment class had greater levels of depression, anxiety, and ptsd symptoms than the low adversity class. finally, shin and colleagues (2018) was the only study we could locate using lca with the expanded aces and measuring substance use. they, too, found four distinct classes when considering 13 types of aces, including the expanded aces. the classes were: 1) low aces, 2) household dysfunction and community violence, 3) emotional aces, and 4) high/multiple aces. adults in the high/multiple aces class had the highest risk for alcoholrelated problems, tobacco use, and negative psychological symptoms. adults experiencing household dysfunction and community violence were more likely to experience negative psychological symptoms compared to those with low adversity. in summary, studies using aces generally report four class solutions, and only one study used the expanded aces and reported substance use outcomes. lack of cannabis studies. these lca studies using expanded aces have largely ignored cannabis use as an outcome. this is unfortunate as cannabis use is highly prevalent and associated with numerous risk behaviors and health consequences (cha et al., 2016, galli, et. al., 2011; leung et al., 2020; leung et al., 2019; marel et al., 2019; national academy of sciences, engineering, and medicine (nasem), 2017; samhsa, 2020; volkow & baylor, 2019). many states have also passed laws permitting medicinal and recreational use of cannabis (national conference of state legislatures, 2022). to our knowledge, no studies have looked at how clusters of expanded aces are associated with medicinal cannabis use. current study as the presence of aces may exacerbate the risks for addiction and increase the stability of problematic cannabis use (davis et al., 2021), additional research is needed on which patterns of aces confer the most risk. the current study analyzes data from a large online survey completed in illinois. we used a latent class analysis (lca) to determine various classes of aces, and then test their association with cannabis use, medicinal use, and probable cannabis use disorder (cud). thus, this study addresses the field’s current overreliance on statistical approaches that use cutoff scores of numbers of aces, and the lack of research on cannabis outcomes. methods participants full demographic information appears in table 1. this sample included adults from 75% of the counties in illinois (76 of 102 counties). we compared population estimates to our quotasampled participants (us census bureau, 2022). representation of black, latino and multiracial participants matched up well with statewide estimates. however, we found that our sample included fewer non-hispanic whites (53.4% in our sample vs. 60% in statewide estimates), more native americans (10.3% versus 0.6%), more females (57.7% versus 50.6%), and more older adults (22.8% versus 16.6%). regarding income, the state median household income in 2020 was $68,428. we collected categorical income, so it was not directly comparable to census bureau data, as we were unable to calculate a median. procedure all procedures were approved by the office of human subject’s protection at the authors’ university before data collection. a qualtrics panel was utilized to quota-sample adults to approximate the socio-demographic characteristics of illinoisans as well as possible. cannabis, a publication of the research society on marijuana 53 table 1. socio-demographic information for the sample (n = 712) variable n % age categories 18 to 24 219 30.8% 25 to 40 204 28.7% 41 to 60 127 17.8% 61 and older 162 22.8% gender identity female 411 57.7% male 294 41.3% transgender or gender expansive 7 1.0% race white 380 53.4% hispanic or latino/latina/latinx 104 14.6% african american or black 81 11.4% native american, native hawaiian, pacific islander, or another identity 73 10.3% asian or asian american 67 9.4% biracial or multiracial 7 1.0% ethnicity hispanic or latino/latina/latinx 126 17.7% highest level of education some high school 30 4.2% high school diploma or ged 151 21.2% some college or technical school 147 20.6% completed technical program or associate degree 91 12.7% bachelor’s degree 173 24.3% graduate degree 118 16.6% current work status work full-time 294 41.3% work part-time 104 14.6% student 86 12.1% retired 105 14.7% unemployed or laid-off 45 6.3% unable to work/on disability 24 3.4% looking for work 29 4.1% keeping house or raising children 25 3.5% 2019 annual household income (before taxes) less than $10,000 75 10.5% $10,000-$29,999 131 18.4% $30,000-$54,999 159 22.3% $55,000-$99,999 203 28.5% more than $100,000 144 20.2% community type city of chicago 137 19.2% ten counties surrounding chicago 294 41.3% other suburban or urban counties 178 25.0% rural counties 103 14.5% aces and cannabis use 54 qualtrics (qualtrics, provo, ut) provides an online distribution service that can send a survey to a demographically and politically representative group of people (boas et al., 2018). qualtrics has panels of “participants” or individuals that will complete surveys for compensation. quota sampling constraints were included, and individuals were recruited based on race and ethnicity, sex, household income, age group, and community type, to approximate a representative sample of illinois adults. these participants were notified via email and invited to participate in the survey for a given incentive. the email invitation was simple and generic, with no specifics as to the topic of the survey itself. these participants were given a link and told to follow the link if they would like to participate for the given incentive and told the duration of the survey. qualtrics incentives, given directly from qualtrics (not the research team), are often given on a point system. these points accumulate and can be redeemed for prizes. if a participant wished to participate in the survey, they were provided with detailed informed consent information. qualtrics included a sensitive topic disclaimer at the start of the survey, and participants were able to skip any questions that they did not wish to answer. finally, resources were provided to participants in the case that the questions led to any feelings of discomfort. surveys were available to qualtrics panelists from mid-october 2020 to december 1, 2020. the surveys took approximately 30 minutes to complete, and a total of 712 illinois adult residents completed the survey. measures adverse childhood experiences & expanded items. participants were asked about fourteen aces that occurred before the age of 18. first, nine of ten original ace items were asked (felitti et. al., 1998), including childhood abuse (i.e., physical and verbal abuse), neglect (i.e., physical and emotional neglect), and household dysfunction (i.e., parental divorce or separation; exposure to intimate partner violence within the household; and having an adult or someone in the household with substance use problems, mental illnesses, or who was involved in the criminallegal system). the item on experiencing sexual childhood abuse was not asked per guidance from the qualtrics team. in addition, five extended aces were asked, including childhood experiences with community violence, racial/ethnic discrimination, bullying, dating violence, and foster care involvement. participants responded to each ace item using a 1 = yes or 0 = no response. these dichotomous items were individually entered into the latent class model. cannabis use. recency of cannabis use was assessed with one item, “when was the last time, if ever, you used cannabis, marijuana, hashish, blunts, or other forms of thc (vaped cannabis, edibles, herb, reefer, weed)?” participants selected the response option that best represented their frequency of use (i.e., responses included: never; over a year ago; 10-12 months ago; 7-9 months ago; 4-6 months ago; 1-3 months ago; less than a month ago; last week; this week; yesterday; today; i am currently high). for this study, response options were coded as lifetime (i.e., responses including: have used cannabis 30+ days ago to over a year ago), and past 30-day cannabis use (i.e., responses including: less than a month ago to i am currently high). in addition, we assessed for medicinal use of cannabis with one item: “do you have a physician or doctor’s recommendation to use cannabis for medicinal purposes?” responses included yes, no, and yes, but i use it for both medicinal and recreational purposes. any use of cannabis for medicinal purposes was coded as medicinal use (medicinal use of cannabis = 1; no medicinal use of cannabis = 0). items were derived from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaqcu; cuttler & spradlin, 2017). items on medicinal and recreational use are highly relevant in illinois. effective january 1st, 2014, illinois implemented the compassionate use of medical cannabis program act (410 ilcs 130), allowing patients with qualified medical conditions to access cannabis. since january 2020, individuals over 21 can legally possess, purchase, and consume recreational cannabis in illinois through the cannabis regulation and tax act (410 ilcs 705). cannabis use disorder screener. the cannabis use disorder identification testrevised (cudit-r-sf) is a three-item self-report screener for assessing participant’s problematic cannabis use within the past six months (bonnmiller et al., 2016). sensitivity (78%) and cannabis, a publication of the research society on marijuana 55 specificity (76% to 78%) for identifying cud was high across two samples at a cutoff score of two (bonn-miller et al., 2016). if participants indicated cannabis use in the past six months, they were asked these three items assessing problematic cannabis use (e.g., “how often during the past 6 months, did you find that you were not able to stop using cannabis once you had started?”), negative consequences of use (e.g., “how often do you use cannabis in situations that could be physically hazardous, such as driving, operating machinery, or caring for children?”), and intentions to quit using cannabis (“how often have you thought about cutting down, or stopping your use of cannabis?”). response options to these items ranged on a scale of 0 (never) to 4 (4 or more times a week), and the screener had adequate reliability (α = .80). items were summed, and individuals meeting the cutoff for probable cud were coded as meeting or not meeting the cudit cutoff (1=meets; 0 = does not meet). sociodemographic variables. additionally, we examined sociodemographic factors in relation to classes of adversity. these variables included: race (1 = white, 0 = non-white), gender identity (1 = male, 0 = female or another), highest education level (1= high school or ged diploma or lower, 2 = associate’s degree or higher; and 3 = some college or higher education), annual household income (0 = <$34,999/year, 1 = between $35,000$74,999/year, and 2 = >$75,000/year), and age (in years). data analysis a latent class analysis (lca) was used to explore subgroups of adults with similar itemresponse patterns to the 14 aces assessed (asparouhov & muthén, 2014a). all analyses were conducted using mplus version 8.1 (muthén & muthén, 1998-2018). first, models were identified with an increasing number of classes, examining which fit the data best. to assess and compare model fit, we used several statistical fit indices, including the bayesian information criterion (bic) and the sample size adjusted bic (abic), which were examined for the model with the lowest values. the bic is considered the most reliable fit statistic and a strong indicator of model selection (weller et al., 2020). entropy and average latent class probabilities were examined, looking for values closer to 1.00. finally, the lomendell rubin adjusted test was examined to see if adding another class significantly improved the model fit (nylund-gibson & masyn, 2016; tofighi & enders, 2008). second, once the best-fitting model was selected, the three-step auxiliary procedure was utilized to examine associations between latent class membership, sociodemographic variables, and cannabis use variables (asparouhov & muthén, 2014b). descriptively, we examined cross-tabulations and chi-square difference tests when examining categorical sociodemographic factors and class membership. next, we calculated odds ratios with 95% confidence intervals to see if there was an association between race, gender, education, income, and age and class membership. finally, odds ratios with 95% confidence intervals were calculated to see if adults in the different classes reported greater odds of using cannabis (i.e., lifetime, past 30-day, or medicinal use) or greater cud screening scores. results descriptive statistics approximately 63% of the sample had experienced at least one of the nine original aces; 29% had experienced four or more of these original aces. the most endorsed aces were experiencing emotional abuse (40%), having parents separated or divorced (33%), experiencing physical abuse (31%), experiencing emotional neglect (30%), or having someone with mental illness in the household (28%). additionally, five extended aces were asked, including exposure to community violence (48%), experiencing racial discrimination (43%), bullying at school (65%), experiencing dating violence (29%), and being in foster care (14%). in terms of cannabis use, about 49% of the sample had used cannabis at least once in their lifetime. about 19% had used cannabis in the past 30 days, and 16% used cannabis for medicinal use. approximately 16% of participants screened for having probable cud ( ≥2 on cuditr-sf). lca of aces model fit statistics appear in table 2. the fourclass solution had adequate fit when examining aces and cannabis use 56 table 2. model fit indices comparing two to six classes 2 classes 3 classes 4 classes 5 classes 6 classes log likelihood -4595.357 -4414.121 -4359.840 -4326.648 -4299.050 bic 9381.188 9117.237 9107.198 9139.333 9182.658 abic 9289.106 8977.526 8919.858 8904.365 8900.061 counts & proportions class 1 238 (33.43%) 132 (18.54%) 177 (24.86%) 97 (13.62%) 64 (9.00%) class 2 474 (66.57% 218 (30.62%) 239 (33.57%) 59 (8.29%) 112 (15.29%) class 3 362 (50.84%) 162 (22.75%) 155 (21.77%) 75 (10.53%) class 4 134 (18.82%) 162 (22.75%) 50 (7.02%) class 5 239 (33.57%) 175 (24.58%) class 6 236 (33.15%) entropy 0.890 0.841 0.773 0.784 0.778 average class probabilities 0.966-0.972 0.908-0.946 0.807-0.922 0.810-0.885 0.74-0.88 lo-mendell rubin adjusted test 2006.85* 358.83* 107.47* 65.72* 54.64 note. the four-class solution was selected, and the fit indices are bolded in the table. * p < .05. entropy and average class probabilities; the fourclass solution also had the lowest bic value. though the five-class solution also showed adequate model fit (i.e., both solutions had a significant lo-mendell rubin adjusted test), the bic value started to increase. also, the fifth class represented a small proportion of the sample (8%), and the fifth class did not contribute anything conceptually different from the four-class solution. based on these criteria and indices, we selected the four-class solution. we labeled the four classes identified as adults: 1) with low levels of aces, but experiencing bullying (low adversity, n = 239, 34%), 2) who reported community violence, racial discrimination, and bullying (interpersonal harm, n = 162, 23%), 3) who experienced abuse in addition to community violence, racial discrimination, and bullying (interpersonal abuse and harm, n = 177, 25%), or 4) who experienced many adversities (high adversity, n = 134, 19%). see figure 1 for a plot of these item probabilities. associations between class membership and sociodemographic variables first, we examined cross tabulations of class membership by race, gender, education, and income (see table 3). chi-square difference tests revealed significant differences in class membership by race, gender, and income. for example, individuals who identified as white were more likely to be in the low adversity class, while individuals who identified as another racial identity were more likely to be in the high adversity class. similar results were seen when examining the odds of class membership by race (see table 4). white participants had lower odds of being in the high adversity (or = 0.53) and interpersonal abuse and harm (or = 0.59) classes compared to the low adversity class. there were also significant differences by gender. individuals identifying as male were more likely to be in the high adversity class than individuals identifying as female or another gender identity. again, results from cannabis, a publication of the research society on marijuana 57 the odds ratio tests showed that male participants were more likely to be in the high adversity class compared to the low adversity (or = 2.48) and interpersonal abuse and harm (or = 2.09) classes. additionally, male participants were more likely to be in the interpersonal harm class than the low adversity (or = 2.44) class. the chi-square test revealed significant differences by income level; however, none of the odds ratio tests were significant. as shown in table 3, the cross-tabulated differences may exist specifically within the high adversity class. more participants with an annual income of less than $35,000 were in the high adversity class (44.8%), compared to those in the other two income categories. education was not associated with class membership or odds of class membership. finally, age was examined in relation to class membership. older adults had lower odds of being in the high adversity (or = 0.96), interpersonal harm (or = 0.98), and interpersonal abuse & harm (or = 0.98) classes compared to the low adversity class. in summary, class membership was associated with race, gender, and age. income and education were not associated with class membership. associations between class membership, cannabis use, and cud class membership was associated with differing levels of risk for cannabis use and cud. for all odds ratios with 95% confidence intervals, please see table 5. cannabis use. adults in the high adversity class had significantly greater odds of lifetime cannabis use (or = 6.20), past 30-day cannabis use (or = 5.05), and medicinal cannabis use (or = 17.90), compared to the low adversity class. adults in the interpersonal harm and interpersonal abuse and harm classes both had higher odds of lifetime cannabis use (or = 2.82, or = 2.44, respectively) and past 30-days cannabis use (or = 2.53, or = 4.88, respectively) compared to the low adversity class. adults in the interpersonal abuse and harm class also had higher odds of medicinal use (or = 2.59) than the low adversity class. adults in the high adversity class showed significantly greater odds of lifetime cannabis use (or = 2.19, or = 2.54, respectively), and medicinal cannabis use (or = 10.75, or = 6.90, respectively) compared to the interpersonal harm and interpersonal abuse and harm classes. for the cud outcome, those in the high adversity class had higher odds than those in both the interpersonal abuse and harm and interpersonal harm classes. however, these two latter classes were not significantly different from each other on cud. furthermore, the odds for cud in the low adversity class were not significantly different than those for the three other classes. discussion this study is one of only a few studies to examine patterns of expanded aces and determine their associations with substance use (lee et al., 2020; shin et al., 2018). it is a novel study of how the expanded aces cluster together and are associated with cannabis use and cud. classes of adversity the current study found that among a diverse sample of adults residing in illinois, 63% experienced at least one of the nine original aces. similar to other studies, the most endorsed adversity was experiencing emotional abuse (e.g., merians et al., 2019). in addition, we examine the expanded aces, which were experienced by many adults. about half of the sample had experienced exposure to community violence and/or racial discrimination. approximately two out of three adults experienced bullying at school. these numbers highlight the importance of screening for these expanded aces among adults, contributing to a growing body of literature (alvanzo et al., 2020; shin et al, 2018; merians et al, 2019). we selected a four-class model of adversity experiences: high adversity, interpersonal harm, interpersonal abuse & harm, and low adversity. although other researchers also found four classes of aces, the naming and composition of these classes differs depending on which aces were measured. low adversity classes (lee et al., 2020; merians et al., 2019; shin et al., 2018) and high adversity classes are common (merians et al., 2019; shin et al., 2018). however, some classes found here such as the interpersonal abuse and harm class appear similar to those in other studies (e.g., experienced emotional abuse and expanded aces; shin et al., 2018). yet, it is difficult to make complete comparisons given different measures used across studies. for example, some studies aces and cannabis use 58 figure 1. latent class analysis of aces and expanded aces. cannabis, a publication of the research society on marijuana 59 table 3. sociodemographic factors by class membership. low adversity (n = 239) high adversity (n = 134) interpersonal harm (n = 162) interpersonal abuse & harm (n = 177) n % within class n % within class n % within class n % within class c! p race white (53.4%) 154 64.4% 59 44.0% 82 50.6% 85 48.0% 18.98 <.001 non-white (46.6%) 85 35.6% 75 56.0% 80 49.4% 92 52.0% gender identity male (41.3%) 91 38.1% 63 47.0% 78 48.1% 62 35.0% 8.84 .032 female or another (58.7%) 148 61.9% 71 53.0% 84 51.9% 115 65.0% highest level of education hs/ged or lower (25.4%) 54 22.6% 43 32.1% 38 23.5% 46 26.0% 6.19 .402 some college or higher education (20.6%) 48 20.1% 24 17.9% 33 20.4% 42 23.7% associate’s or higher degree (53.9%) 137 57.3% 67 50.0% 91 56.2% 89 50.3% annual household income <$34,999 (33.0%) 63 26.4% 60 44.8% 50 30.9% 62 35.0% 21.47 .002 $35,000-74,999 (33.7%) 90 37.7% 26 19.4% 63 38.9% 61 34.5% >$75,000 (33.3%) 86 36.0% 48 35.8% 49 30.2% 54 30.5% note. hs/ged = high school diploma or general education development diploma. aces and cannabis use 60 table 4. associations between latent classes of expanded aces and sociodemographic factors note. a reference class is listed first. odds ratios that are significant at p < .05 are in bold. covariates were included in each multinomial logistic. table 5. associations between latent classes of expanded aces and cannabis use variables note. a reference class is listed first. odds ratios that are significant at p < .05 are in bold. covariates were included in each multinomial logistic regression. each variable was examined separately. cud = probable cannabis use disorder. odds ratios [95% confidence intervals] low adversitya to high adversity low adversity to interpersonal harm low adversity to interpersonal abuse & harm interpersonal harm to high adversity interpersonal abuse & harm to high adversity interpersonal harm to interpersonal abuse & harm white race 0.53 [0.31, 0.93] 0.56 [0.30, 1.05] 0.59 [0.35, 0.98] 0.96 [0.52, 1.76] 0.91 [0.50, 1.66] 1.06 [0.57, 1.95] male gender 2.48 [1.43, 4.31] 2.44 [1.31, 4.53] 1.19 [0.70, 2.01] 1.02 [0.58, 1.80] 2.09 [1.15, 3.80] 0.49 [0.26, 0.91] education: hs/ged or lower 1.03 [0.54, 1.97] 1.03 [0.54, 1.97] 1.02 [0.56, 1.84] 1.16 [0.59, 2.31] 1.01 [0.51, 2.01] 1.15 [0.57, 2.33] education: some college or higher education 0.88 [0.44, 1.76] 0.88 [0.44, 1.76] 1.32 [0.73, 2.41] 0.81 [0.37, 1.74] 0.66 [0.31, 1.39] 1.22 [0.59, 2.51] income <$34,999 (33.0%) 1.46 [0.76, 2.80] 1.46 [0.76, 2.80] 1.27 [0.67, 2.41] 0.95 [0.46, 1.99] 1.14 [0.56, 2.32] 0.83 [0.37, 1.87] income $35,000-74,999 (33.7%) 0.53 [0.27, 1.02] 0.53 [0.27, 1.02] 1.11 [0.62, 1.98] 0.35 [0.17, 0.75] 0.47 [.22, 1.00] 0.75 [0.36, 1.55] age 0.96 [0.94, 0.97] 0.98 [0.96, 0.99] 0.98 [0.96, 0.99] 0.98 [0.96, 1.00] 0.98 [0.96, 1.00] 1.00 [0.98, 1.02] odds ratios [95% confidence intervals] low adversitya to high adversity low adversity to interpersonal harm low adversity to interpersonal abuse & harm interpersonal harm to high adversity interpersonal abuse & harm to high adversity interpersonal harm to interpersonal abuse & harm past year use 6.20 [3.50, 11.00] 2.82 [1.43, 5.56] 2.44 [1.38, 4.32] 2.19 [1.26, 3.82] 2.54 [1.47, 4.39] 0.86 [0.48, 1.55] 30-day use 5.05 [2.45, 10.41] 2.53 [1.03, 6.22] 4.88 [2.42, 9.87] 2.00 [1.04, 3.85] 1.03 [.58, 1.84] 1.93 [.99, 3.78] medicinal use 17.90 [8.29, 38.68] 1.67 [.56, 4.99] 2.59 [1.10, 6.07] 10.75 [4.89, 23.6] 6.9 [3.55, 13.4] 1.56 [.62, 3.51] cud 1.36 [.92, 1.99] 0.94 [.53, 1.63] 1.03 [.71, 1.50] 1.45 [1.09, 1.92] 1.31 [1.14, 1.52] 1.10 [.82, 1.48] cannabis, a publication of the research society on marijuana 61 used childhood history of sexual abuse as an ace, but our study was not able to because of human subjects concerns (merians et al., 2019; shin et al., 2018). using common items in future lca analyses would facilitate comparisons across studies. associations with cannabis use outcomes use and medicinal use. not surprisingly, participants in the high adversity class had higher odds of lifetime, past 30-day and medicinal use of cannabis, when compared to all three other classes. this finding echoes prior research, which states exposure to multiple aces is associated with a numerous behavioral health risks, including substance use (merians et al., 2019; shin et al., 2018). providers treating clients with many aces should consider routinely screening for cannabis use and educating themselves about emerging research on cannabis (e.g., vaping, concentrates, dabbing, cbd to thc ratio). there were no differences in cannabis or medicinal use between members of the interpersonal harm and interpersonal abuse and harm classes. both groups experienced community violence, racial discrimination, and bullying, and the latter also experienced verbal, physical and emotional abuse. it is unclear why the addition of abuse did not elevate the odds of cannabis use for members of the interpersonal abuse and harm class relative to the interpersonal harm class. future research may clarify this finding. additionally, although members of both these classes had higher odds of use, this may be partially explained by having more young people in these classes. the prevalence of cannabis use is lower among older individuals (compton et al., 2019). exposure to community violence, perceived discrimination, and dating violence, were all elevated in the interpersonal harm group relative to the low adversity class. thus, these factors may explain some differences in increased odds for substance use for the former relative to the latter. most prior studies on the association between aces and substance use only use the original aces (leza et al., 2018). our findings validate the importance of using these expanded aces in future cannabis use research. probable cannabis use disorder (cud). it is curious that relative to the low adversity class, none of the other three classes had higher odds of screening positive for a probable cud. the only differences found here were that there were elevated odds for cud among those in the high adversity class relative to those in both the interpersonal abuse and harm and interpersonal harm classes. we offer two possible explanations for the nonsignificant differences between the low adversity group and the other three groups. first, those in the low adversity group had elevated bullying, which is associated with adult cud (vaughn et al., 2010). second, those in the low adversity group were slightly younger, and younger age is associated with increased frequency of cannabis use (samhsa, 2020). third, our measure of cud was the short form of a screening measure for cud. thus, although it has high sensitivity and specificity in predicting cud, it may not be a good proxy for cud severity. this is important because nationally the prevalence of mild cud has increased, but severe cud has not (compton et al., 2019). finally, our models are unadjusted, so several unmeasured variables may have impacted these findings (e.g., receipt of treatment, current traumatic symptoms). limitations this study’s findings should be interpreted keeping the following limitations in mind. first, the aces were measured via retrospective recall, which results in larger correlations with outcomes than when they are prospectively measured (reuben et al., 2016). furthermore, we completed this study during the covid-19 pandemic, so it is unclear how pandemic related lockdowns affected cannabis use and disordered use, which could have impacted study results. for example, the prevalence of probable cud in this study was higher than what we would expect from representative prevalence surveys. we found that about 16% of participants screened positive for a probable cud, whereas national surveys from 2019, the most recently available from before the pandemic, reveal that only 5.8% of adults ages 1825 and 1% of adults over age 25 meet criteria for cud (substance abuse and mental health services administration, 2020). additionally, this study was cross-sectional, so it is not possible to infer causation from study results. next, our variable for race/ethnicity was dichotomous, only aces and cannabis use 62 comparing white vs. non-white participants. future research could use more granular comparisons with specific races and ethnicities in comparisons. additionally, we were unable to ask about sexual abuse as an ace due to human subjects concerns, which could have affected our analyses. finally, the study participants were sampled from a qualtrics panel, and because quota sampling was used, this study is not truly representative of the adults in illinois and may not be generalizable to adults outside of illinois. implications and future research directions we conclude with discussing two main implications of this study. first, we suggest that researchers gain a better understanding of how exposure to violence and racial discrimination are associated with cannabis use. the odds of cannabis use were elevated in our interpersonal abuse and harm and interpersonal harm classes, which were characterized by high levels of these types of aces in addition to bullying and abuse. second, we discuss how it is important to study cannabis consumption patterns of individuals experiencing many adversities. classes with racial discrimination and community violence, with or without other adversities, were associated with risks for cannabis use. there is increasingly more emphasis on studying substance use from a social determinants of health (sdoh) perspective, including racism and community violence (bluthenthal, 2021). this study affirms the importance of additional research in this area. additionally, adults with high adversity had higher odds of medicinal cannabis use, yet did not have elevated odds for probable cud relative to the low aces group. however, they did have elevated risks for probable cud relative to the two interpersonal harm groups. these findings should be replicated and disentangled in future prospective longitudinal research. some individuals with high levels of aces may use medicinal cannabis safely without considerably higher risk of cud relative to those with low levels of aces, especially if they are following lower risk cannabis use guidelines such as not inhaling deeply, using lower thc concentration products, and avoiding smoking cannabis (fisher et al., 2017). future research could examine the cannabis consumption patterns of individuals experiencing high childhood adversity who are using for medical purposes. conclusion this study found elevated risks 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(2020). latent class analysis: a guide to best practice. journal of black psychology, 46(4), 287–311. https://doi.org/10.1177/0095798420930932 funding and acknowledgements: we have no known conflict of interest to disclose. the development of this article was supported through an interagency agreement between the illinois criminal justice information authority and the university of illinois at urbanachampaign school of social work (pi: garthe). the opinions, however, are those of the authors and do not reflect official positions of the state of illinois. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 47 ved abstract background: co-use of cannabis and tobacco has become increasingly popular among young adults. interactive voice response (ivr) based ecological momentary assessment (ema) allows for measurement of behavior in or near real-time, but has limitations including non-compliance, missing data, and potential for reactivity (e.g., behavior change) from frequent assessments. methods: this study examined tobacco and cannabis use characteristics and factors associated with ivr compliance and self-reported reactivity in 97 young adults who reported cannabis and tobacco co-use at baseline and completed daily ivr surveys of couse behavior at three random times per day for 28 days. results: overall ivr compliance was 55%, with a modal compliance of 60%. compliance rates did not differ across morning, midday, and evening surveys, but significantly declined over time. the sample was divided into high frequency responders (>70% calls completed, n=35) and low frequency responders (<70%, calls completed n=62). there were no differences between high and low frequency responders on any baseline demographic, tobacco use (nicotine dependence severity), alcohol, or cannabis use characteristics (past 30-day frequency of use). participants were receptive to ivr-based ema monitoring and, 16.5% reported purposely decreasing nicotine/tobacco use due to monitoring, while 19.6% reported purposely decreasing cannabis use, which predicted lower cannabis use post-ema monitoring. conclusions: real-time assessment of co-use behavior among young adults does not appear to be impacted by specific demographics or substance use severity (nicotine dependence, heavy drinking). data suggest some predictive utility of ivr-based ema monitoring on short-term behavior change. more intensive approaches are needed to improve compliance among young adult cannabis and tobacco co-users. key words: = ecological momentary assessment; compliance; behavior change; tobacco; cannabis over the last 15 years, legalization and changing positive attitudes towards cannabis use have been accompanied by increased prevalence of adult use in the us. according to the 2019 national survey on drug use and health, adult past year cannabis use has increased from 10.4% taylor niznik1, sarah j. ehlke1, robin mermelstein2, ryan vandrey3, donald hedeker4, andrea c. villanti5, amy m. cohn1,6 1tset health promotion research center, stephenson cancer center, oklahoma city; university of oklahoma health sciences center, tset health promotion research center, oklahoma city, ok 2institute for health research and policy, university of illinois at chicago, chicago, il 3department of psychiatry and behavioral sciences, johns hopkins university, baltimore, md, usa 4department of public health sciences, university of chicago, chicago, il 5rutgers center for tobacco studies and department of health behavior, society and policy, rutgers school of public health, new brunswick, nj 6department of pediatrics, university of oklahoma health sciences center, oklahoma city, ok cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000139 parameters of ema compliance and self-reported reactivity in a longitudinal study of young adult cannabis and tobacco co-users corresponding author: amy m. cohn, ph.d., university of oklahoma health sciences center, 655 research parkway, suite 400, tset health promotion research center, oklahoma city, ok 73104, usa. email: amy-cohn@ouhsc.edu ema compliance in young adult cannabis and tobacco users 48 in 2002 to 18.0% in 2019. past-month cannabis use is also two times higher for young adults (youg adults; ages 18-25) than the national average for all adults (23.0% vs 11.9%, respectively) and has increased in this age group over the last 15 years (national academies of sciences & medicine, 2017). there is considerable overlap of cannabis use with tobacco products, particularly in this age group (cohn et al., 2016; cohn, johnson, et al., 2018). rates of co-use have also increased over time in young adults (schauer et al., 2015a, 2015b), with approximately 20% of young adults reporting past month co-use (cohn, abudayyeh, et al., 2019). tobacco and cannabis co-use is correlated with a variety of mental and physical health consequences including cannbis and tobacco dependence, cancer, and psychiatric symptoms (botchway & deshpande, 2015; cohn et al., 2021; gage et al., 2015). one promising strategy for precisely measuring cannabis and tobacco co-use is the use of ecological momentary assessment (ema), which allows for the collection of cognitive, affective, and behavioral phenomena in natural settings, and in, or near real-time. as such, processes can be captured “in the moment” and closer to real-time occurrences. because data are “time-stamped”, behaviors can be recorded and verified as occurring at a particular point in time, relative to others, reducing recall bias and maximizing causal inferences (conner et al., 2009; tennen & affleck, 2002). interactive voice response (ivr) is one ema method that uses automated pre-recorded survey items to which participants respond by pushing buttons on the keypad of their phone (ankawi et al., 2022; cheong & tucker, 2022; gorfinkel et al., 2021). lastly, because behavior is collected over multiple days, ema approaches increase the number of data points one has to predict an outcome (barta & tennen, 2008; nelson & hayes, 1979). this also allows for detailed consideration of the variability in substance use patterns that occurs withinindividuals and in a longitudinal fashion which eliminates sources of confounding when data are aggregated. this is notable, given discrepancies between real-time reporting surrounding substance use behavior and recall-based reporting of the same events (carney et al., 1998; shiffman et al., 1997; todd et al., 2005). recall methods are less accurate than prospective daily assessments because they are prone to cognitive heuristics and emotional experiences that bias information retrieval and processing (piasecki et al., 2007). because of these methodological strengths, ema data collection can add significant clinical and predictive value to our understanding of processes related to substance use behavior (piasecki et al., 2007). ema does have limitations worth noting, including missing data, the potential for low compliance, and possible reactivity or behavior change in response to frequent and repeated assessments of the same behavior. to ensure valid statistical analysis and representativeness of one’s data, it is important to understanding sources linked to the occurrence of missing data and possible reactivity, so that these factors can be minimized in the study design and controlled for in analytical models. one study of smokers who engaged in risky drinking found that 80% of respondents indicated increased awareness of their behavior and 40% reported some form of behavior change specifically in response to completing twice daily ivr assessments for 28 days (cohn, elmasry, et al., 2018). similarly, another study of heavy-episodic drinkers showed that mobile assessments both with and without intervention were associated with decreased heavy-episodic drinking when compared to minimal assessments with and without intervention (witkiewitz et al., 2014). other studies have reported either no significant reactivity to daily monitoring, or that when reactivity has been found to exist (m. r. hufford et al., 2002), it accounts for only a small proportion of the variance in behavior change (clifford et al., 2007; maisto et al., 2007; rowan et al., 2007). according to barta and colleagues, reactivity to ema survey can be mitigiated when multiple behaviors are monitored (barta et al., 2012; hufford et al., 2002), as respondents are likely unaware of the specific behaviors they are being “primed” to monitor. statistical validity may also be impacted by data that are missing systematically or at random. data that are missing at random can result in decreased statistical power (graham, 2009); however, low compliance may be indicative of systematic bias challenging the representativeness of the sample (stone & shiffman, 2002). efforts to minimize bias and improve statistical power prompt examination of factors theorized to be associated with missing cannabis, a publication of the research society on marijuana 49 data and low compliance. frequent assessment schedules may place a greater burden on participants and thus reduce overall compliance (robbins & kubiak, 2014), while too few may result in participants forgetting to notice prompts. daily interruptions over long periods caused by random prompts can also be inconvenient and contribute to decreased compliance over time (burke et al., 2017; johnson et al., 2009). in some studies with multiple weeks of ema, lower compliance has been reported for later weeks (hoeppner et al., 2014; yang et al., 2015). additionally, ivr technology instructs participants to push buttons on the keypad of their phone to answer pre-recorded survey questions. this requires continuous audio attention and is less conducive to multi-tasking when compared with other more visual ema methods such as sms (text messaging) systems (buu et al., 2017) or smartphone-based applications, where survey response options are immediately visible. the population sampled may also affect compliance. although younger populations may demonstrate greater proficiency with digital technology interfaces often used for ema, a metaanalysis found an average compliance rate of 78.3% for youth participants in 42 mobile-ema protocols (wen et al., 2017). this rate is lower than the recommended 80% (stone & shiffman, 2002). compliance rates in ema studies with substance users vary across studies as a function of monitoring period and population of study. a meta-analysis of 126 ema studies involving substance users enrolled in studies from 1998 to 2017 found an overall compliance rate of 75.06% (jones et al., 2019). other reports of ema compliance involving substance users, and one specific to ivr technology, show compliance ranging from 50% to 70% (buu et al., 2017; kaminer et al., 2006). ema studies involving substance use have shown that responsiveness to random prompts may be influenced by several factors (e.g., social context, affect, location) and that substance use behaviors can influence low compliance (sokolovsky et al., 2014), suggesting that compliance may be further negatively impacted by substance co-use and severity of use (messiah et al., 2011). additionally, dispositional factors associated with inattentiveness and impulsivity, which are correlated with cannabis use (cohn et al., 2015; haas et al., 2018; o'donnell et al., 2021), may also drive lower compliance rates. studies have also shown that the degree of compensation for survey completion may impact survey compliance (wrzus & neubauer, 2021). often, ways of addressing missing data in outcomes analyses include controlling for variables associated with missing data or imputing missing data based on either average ratings from the sample or from a participant’s own data (cursio et al., 2019; rendina et al., 2016). reporting compliance rates and correlates thereof is important for determining the quality of a study, as this information could be used to determine inclusion in a systematic review, and could also assist other researchers determine whether ivr is a good fit for their study or selected population. given increasing prevalence of cannabis and tobacco co-use, particularly among young adults, and the popularity of studies utilizing ema to understand substance use, additional research is needed to understand factors associated with daily ema monitoring of co-use in younger age groups. to address this need, this study’s primary objective was to examine the prevalence and correlates of ivr-based ema compliance and selfreported reactivity (e.g., behavioral and attitudinal change) to ivr monitoring in 97 young adult cannabis and tobacco co-users who completed ivr surveys three times a day for 28 consecutive days. co-users were defined as individuals using cannabis >2 times a week in the past month and reporting “someday or every day” tobacco use. a secondary objective was to examine associations between ivr-based ema compliance and self-reported reactivity, hypothesizing that respondents with higher compliance would report greater reactivity compared to respondents with lower compliance. a final objective was to examine whether self-reported reactivity would be associated with self-reported changes in tobacco and cannabis use behavior assessed from baseline to a post-ivr follow-up. methods participants and procedures data were collected in two large northeastern cities in the u.s. between 2017 and 2019. participants were 97 young adult cannabis and tobacco co-users who took part in an intensive ema compliance in young adult cannabis and tobacco users 50 longitudinal ivr-based ema study about tobacco and cannabis use and co-use behavior. participants were recruited via print and web-based advertisements and by word of mouth. eligibility criteria included: 1) aged 18-24; 2) used cannabis ≥2 times a week in the past month; and 3) reported current “someday or every day” tobacco use (including e-cigarettes). exclusion criteria were: 1) severe psychiatric disturbance; 2) potential for lethal alcohol consumption at least once in the past 3-months (as evidenced by bac ≥0.20 based on reported drinks, gender, and weight); 3) dependence on substances other than alcohol, cannabis, caffeine, or nicotine; and 4) pregnant, planning to become pregnant, or breastfeeding. after determining eligibility, participants completed a baseline session. after a brief training on the ivr system, participants engaged in a 28day ivr-based ema regimen in which they received calls at three random times per day to their phone (morning, midday, and evening), resulting in a total of 84 possible surveys. ema responses were recorded using an ivr system. following the 28-day period of ema, participants completed a brief online assessment to query about satisfaction with and reactivity to ema, as well as past 30-day tobacco and cannabis use behavior. participants were compensated $25 for completing the baseline survey, $20/week for 4 weeks of ivr monitoring, an additional $1 for each random assessment completed (maximum of $3/day), and a bonus of $2/week for completing assessments 6 of 7 days or $5/week for completing assessments for all 7 days. compensation totaled a maximum of $184 for completing the ivr surveys and $10 for completing the post-ivr survey at the 30-day follow-up. more details about the study methodology can be found here (wilhelm et al., 2020). this study was approved by the battelle memorial institute institutional review board. materials baseline measures demographic information. basic demographic information was collected including age, sex, race/ethnicity, and employment status. cannabis use. participants reported the number of days they used cannabis in the past 30 days. participants were also asked about average cannabis intoxication in the past 30 days (“on a typical day in the past 30 days, how high did you get when you used cannabis?”), where response options were on a scale from 1 to 10 with 10 being “the highest you’ve ever been.” participants also reported their motivation to quit using cannabis by answering “how motivated are you to quit using cannabis right now?” response options were measured on a 10-point scale with 1=“being not at all” and 10=“being highly motivated”. the cannabis use disorder identification test-revised (cudit-r) is an 8-item self-report measure that was used to assess likelihood of a cannabis use disorder (cud) (adamson et al., 2010). scores >12 indicate probable cud. the cudit-r has strong reliability and predictive validity with external diagnostic measures (schultz et al., 2019). tobacco use. participants were asked to report the number of days in the past 30 days they used each of five different tobacco products (cigarettes, large cigars, little cigars/cigarillos, e-cigarettes, hookah/shisha/waterpipe). a sum variable was created capturing the number of tobacco products used in the past 30 days (range=0–5). past 30-day cigarette smokers were also asked to report the number of cigarettes smoked per day (cpd). as a proxy for nicotine dependence, and consistence with other published work (baker et al., 2007; branstetter et al., 2020; cohn, rose, et al., 2019), participants were asked “how soon after you wake up do you use your first nicotine/tobacco product?”, with response options “within the first 5 minutes”, “6 to 30 minutes after waking”, “31-60 minutes after waking”, and “after 60 minutes”. the modified contemplation ladder (cl) assessed participants’ motivation to quit nicotine/tobacco using a 10-point scale where 1=“no thoughts of quitting” and 10=“taking action to quit” (biener & abrams, 1991). the cl has shown good convergent validity with other measures of motivation to change and predicts longer term readiness to quit smoking in samples of adults (mcdermut & haaga, 1998). participants were asked about co-use behavior including “how long has it been since you last smoked part or all of a cigar/cigarillo with cannabis in it?” with response options “within the past 30 days”, “more than 30 days ago but within the past year”, and “more than a year ago.” alcohol use. participants were asked: “how many drinks of alcohol did you have per drinking episode in the past 30 days?”, with answer choices ranging from 0-10+ drinks per episode. male participants who indicated >5 drinks per episode cannabis, a publication of the research society on marijuana 51 and female participants who indicated >4 drinks per episode were categorized as binge drinking in the past 30 days. alcohol frequency in the past 30 days was assessed with the question, "during the past 30 days, on how many days did you use alcohol?" mental health. anxiety was measured using the 7-item generalized anxiety disorder-7 (gad7) (spitzer et al., 2006), which assesses current symptoms of an anxiety disorder. participants used a scale of 0=“not at all” to 3=“nearly every day” to indicate how often they experienced each item in the past 2-weeks. a score of >8 indicates symptoms consistent with a generalized anxiety disorder (kroenke et al., 2007). the gad-7 has good reliability and validity (löwe et al., 2008). depression was measured using the 10-item centers for epidemiologic studies depression scale-revised (cesd-r) (eaton et al., 2004). participants indicated how often they experienced each item in the past week using a scale where 0=“rarely or none of the time (less than 1 day)” to 4=“all of the time (5-7 days)”. scores >10 are indicative of current depression. the cesd-r has demonstrated high internal consistency, test-retest reliability, and external validity with other measures of mental health (van dam & earleywine, 2011). personality characteristics. the 4-item brief sensation-seeking scale (bsss) was used to examine sensation-seeking personality disposition (stephenson et al., 2003). participants indicated the extent to which they agree or disagree with statements about their behavior or attitudes (e.g., “i would like to explore strange places”) with response options on a 5-point likert scale (1=“strongly disagree” and 5=“strongly agree”). a sum score was created, where higher scores indicated greater sensation-seeking. the bsss has shown good reliability and validity (hoyle et al., 2002). the 8-item barratt impulsivity scale (bis) was used to measure impulsivity. participants are asked to indicate how often, if ever, they engage in different behaviors or thoughts (e.g., “i plan tasks carefully”) with response options on a 4-point likert scale (1=“rarely/never” and 4=“almost always/always”). a sum score was created where higher scores indicated greater levels of impulsivity. the 8-item bis has shown good construct validity (steinberg et al., 2013). ivr assessments participants were asked about cannabis and tobacco use since the last survey and assessed on current positive and negative mood, cannabis craving, any cannabis use and individual modes of cannabis use (e.g., blunt, spliff, bong, joint, edible, vaporizer, concenrates, etc), combined cannabis and tobacco use and type of tobacco product used (if applicable; e.g., cigarette, large cigar or little cigar, hookah, e-cigarette), subjective rating of cannabis intoxication, use of cannabis with others or alone, alcohol use (number of standard drinks consumed), and immediate negative perceived risks and benefits of cannabis use (e.g., getting into an argument, doing better on a task, drinking too much, feeling more creative, feeling more motivated to get things done, etc.) more detail about combined use with cannabis and tobacco are reported in wilhelm et al. (2020). ivr surveys were programmed to occur at three random times a day (morning, midday, and evening) using an adaptive random prompting schedule corresponding to the sleep-wake cycle of each participant. no surveys were deployed within one hour of each other. ivr entries lasted approximately 5 minutes, were date and time-stamped, and recorded immediately. for each survey, participants received a prompt (i.e., call) to their phone. if a participant delayed a prompt or did not answer, two additional follow-up prompts were sent, each 5 minutes apart, giving the participant a 15-minute completion window. after the third unaccepted prompt, the trial was recorded as missed. post-ema survey the post-ivr survey was completed at the 1month follow-up (e.g., immediately post-ivr). the survey was developed specifically for this study and has been used in previously published work (cohn, elmasry, et al., 2018). receptivity. participants were asked: (1) “did you feel that the daily phone calls took too much time?”, (2) “were the questions easy to understand?”, (3) “did it become easier and faster to complete the survey each day as time went on?”, and (4) “did you find that the calls were disruptive to your regular schedule?” using a response scale of 0=“not at all”, 1=“slightly”, 2=“moderately”, 3=“very much”, and 4=“extremely”. perceived reactivity. participants were asked about increased awareness of their behavior and purposeful change to their behavior with the ema compliance in young adult cannabis and tobacco users 52 following items: “to what extent did you feel that the daily phone calls may have caused you to be more aware of your behavior?” and “did you find that you purposely started to make changes to your behavior because of the daily monitoring?” response options for these two questions were 0=“not at all”, 1=“slightly”, 2=“moderately”, 3=“very much”, and 4=“extremely”. participants were then asked: “did you begin to notice any behaviors more than before, and if so, which ones? please select all that apply” with 15 choices including “cannabis use” and “smoking cigarettes or other nicotine/tobacco use.” lastly, an item about purposeful behavior change asked: “which behaviors did you purposely make changes to? select all that apply” with 13 choices including “using cannabis less often”, “smoking cigarettes or using other nicotine/tobacco less often”, and “none of the above”. substance use. at the follow-up, participants were asked to report the number of days they used the following products in the past 30 days: cigarettes, cigars, little cigars/cigarillos/bidis, ecigarettes, hookah, alcohol, and cannabis. data analysis descriptive statistics and repeated measures analysis of variance (anovas) tests were used to examine the prevalence of, and differences in overall compliance rates by time of day (morning, midday, evening) and week of assessment (weeks 1-4). mauchley’s test of sphericity was significant for the analysis of weekly differences in compliance (chi-square=34.04(5), p<.001), indicating a violation of the assumption of equal variances. the greenhouse-geisser epsilon of 0.791 was greater than 0.75, so the huynh-feldt corrected f-test was reported for weely differences in compliance (verma, 2015). compliance was defined as the number of calls completed in a given time period (i.e., overall, morning, midday, evening, or week) divided by the number of total possible calls during that same time period. using the same aproach as simpson et al. (2012), the sample was dichotomized into high and low frequency responders. participants who completed ≥70% of the calls were considered high frequency responders, and those who completed <70% of the calls were considered low frequency responders. anovas and chi-square tests were then performed to examine differences in high and low frequency responders on baseline factors (demographic characteristics, cannabis/tobacco use behavior, alcohol use, mental health, and personality factors). next, differences in receptivity and selfreported reactivity to the ivr calls were examined across high and low frequency responders using anovas. lastly, four hierarchical regression models were used to examine the predictive utility of self-reported reactivity on the frequency of past 30-day (1) cigarette and (2) cannabis use assessed at the post-ivr survey (i.e., 1-month follow-up), controlling for baseline reports of the outcome. specifically, the self-reported reactivity items used were: increased awareness of cigarette smoking, increased awareness of cannabis use, purposeful behavior change of cigarettes, and purposeful behavior change of cannabis. reactivity items were examined in separate models. step 1 of the model included the baseline report of the outcome, and step 2 included the requisite ivr index of selfreported reactivity. spss 27.0 was used for all analyses. results survey compliance by time of day and day of week overall, participants completed 4,507 (55.3%) of the 8,148 total possible ivr surveys. compliance for morning, midday, and evening was 54.6%, 56.8%, and 54.5% respectively. there were no differences in compliance by time of day [f(2, 192)=2.56, p=.080, partial η2=.026]. compliance by assessment week (week 1,week 2, week 3, week 4) was 70.3%, 56.6%, 51.2%, and 43.3% respectively. compliance signficantly decreased across the 4 weeks of ivr-based ema [f(2.44, 233.85)=62.75, p < .001, partial η2=.395]. sample characteristics and differences across high and low frequency responders sample characteristics for the full sample and across high and low frequency responders are shown in table 1. a third of the sample (36.1%; n=35) were high frequency responders (completed >70% of ivr calls). on average, participants were 21.32 years old (sd=1.90), and the majority were male, white, and employed. at baseline, participants consumed cannabis most days out of the month (24.67 days; sd=7.98), reported moderate cannabis, a publication of the research society on marijuana 53 table 1. baseline sample characteristics and differences across high and low frequency ivr responders total high frequency responders (n=35) low frequency responders (n=62) m/n sd/% m/n sd/% p age (m, sd) 21.32 1.90 21.79 (1.90) 21.05 (1.85) .067 sex female 41 42.3% 13 (31.7%) 28 (68.3%) .470 male 54 55.7% 21 (38.9%) 33 (61.1%) race/ethnicity non hispanic black 20 20.6% 6 (30.0%) 14 (70.0%) .827 non hispanic white 48 49.5% 17 (35.4%) 31 (64.6%) non hispanic other 19 19.6% 8 (42.1%) 11 (57.9%) hispanic 9 9.3% 4 (44.4%) 5 (55.6%) employment status employed (full or part time) 50 51.5% 16 (32.0%) 34 (68.0%) .501 unemployed/disabled 18 18.6% 6 (33.3%) 12 (66.7%) student 29 29.9% 13 (44.8%) 16 (55.2%) cannabis use m sd m (sd) m (sd) days cannabis used in past 30 days 24.67 7.98 24.03 (8.48) 25.03 (7.74) .555 perceived cannabis intoxication in past 30 days 6.55 1.55 6.66 (1.19) 6.48 (1.73) .599 motivation to quit cannabis 4.37 2.34 3.75 (2.34) 4.70 (2.31) .263 n % n (%) n (%) cannabis dependence (cudit-r > 12) 60 61.9% 19 (31.7%) 41 (68.3%) .249 tobacco product use m sd m (sd) m (sd) number tobacco products used in past 30 days 2.27 1.11 2.26 (1.40) 2.27 (0.93) .943 number days smoked cigarette in past 30 days 16.65 12.43 15.39 (12.41) 17.38 (12.53) .546 cigarettes per day 5.49 6.14 5.91 (7.04) 5.24 (5.63) .691 motivation to quit nicotine/tobacco 5.80 2.56 5.86 (2.50) 5.77 (2.61) .875 nicotine dependence n % n (%) n (%) tobacco use within 5 minutes of waking 15 15.5% 3 (20.0%) 12 (80.0%) .373 tobacco use within 6-30 minutes of waking 24 24.7% 7 (29.2%) 17 (70.8%) tobacco use within 31-60 minutes of waking 15 15.5% 6 (40.0%) 9 (60.0%) tobacco use after 60 minutes of waking 42 43.3% 18 (42.9%) 24 (57.1%) alcohol use m sd m (sd) m (sd) drinks per drinking episode in past 30 days 3.01 2.35 2.77 (2.37) 3.15 (2.35) .455 number days used alcohol in past 30 days 6.27 6.64 7.54 (8.14) 5.55 (5.57) .157 n % n (%) n (%) binge drinking in past 30 days 24 24.7% 7 (29.2%) 17 (70.8%) .434 mental health anxiety (gad-7 > 8) 36 37.1% 12 (33.3 %) 24 (66.7%) .665 depression (cesd-r > 10) 45 46.4% 15 (33.3%) 30 (66.7%) .600 personality characteristics m sd m (sd) m (sd) sensation-seeking (bsss-4) 14.96 3.20 15.09 (3.48) 14.89 (3.06) .771 impulsivity (bis-8) 15.92 4.33 15.97 (4.67) 15.89(4.17) .927 note. gad-7, seven-item generalized anxiety disorder scale; cesd-r, center for epidemiologic studies depression scale-revised (cesd-r); bsss-4, four-item brief sensation-seeking scale; bis, eight-item barratt impulsivity scale *** p < .001. ** p < .01. * p < .05 levels of cannabis intoxication when they used cannabis (m=6.55 out of 10; sd=1.55), and reported low motivation to quit using cannabis (m=4.37 out of 10; sd=2.34). most also reported symptoms consistent with a cannabis use disorder (cud) (61.9%). participants used alcohol 6.27 days (sd=6.64) in the past 30 days with an average of 3.01 drinks (sd=2.35) per drinking episode. nearly a quarter of the sample (24.7%) reported binge drinking in the past 30 days. in terms of individual tobacco product use in the past 30 days at baseline (not shown in table 1), 65% reported cigarette use, 62.9% reported ecigarette use, 59.8% reported little cigar/cigarillo use, 28.9% reported hookah use, and 10.3% reported large cigar use. on average, particants ema compliance in young adult cannabis and tobacco users 54 used 2.3 tobacco products in the past 30 days (sd=1.1). participants reported smoking cigarettes slightly more than half the days in the past month (16.65 days; sd=12.43) and those who reported smoking a cigarette at least once in the past 30 days, smoked an average of 5.49 cigarettes per day. average motivation to quit nicotine/tobacco was (m=5.80 out of 10; sd=2.56). in terms of nicotine dependence, 15.5% of past 30day cigarette smokers reported using tobacco within 5 minutes of waking up indicating high dependence. 73.2% of participants reported smoking part or all of a cigar/cigarillo with cannabis in it within the past 30 days. in terms of mental health factors, 46.4% of the sample reported symptoms consistent with current depression and 37.1% reported symptoms consistent with anxiety. high and low frequency responders did not differ significantly on any baseline factors (all p’s>.05). ivr receptivity and self-reported reactivity a total of 84 participants (87%) completed the post-ivr survey. a significantly higher proportion of completers reported symptoms consistent with anxiety compared to non-completers (41.7% vs 7.7%), χ2(1)=5.57, p=.015. no other baseline factors were associated with post-ivr survey completion. figure 1 shows how respondents answered receptivity items. when asked if the daily phone calls took too much time, 66% of participants answered “not at all” or “slightly” (panel a). the majority (83%) reported that the surveys were “very much” or “extremely” easy to understand (panel b). when asked whether it became easier and faster to complete the surveys as time went on, 73% said “very much” or “extremely” (panel c), and when asked if the calls were disruptive to their regular schedule, 52.6% answered “not at all” or “slightly” (panel d). figure 1. proportion of respondents reporting that ivr surveys were burdensome (a), easy to understand (b), became easier to take over time (c), and disruptive (d) (a) (b) (c) (d) 29.9% 36.1% 8.2% 9.3% 3.1% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% not at all slightly moderately very much extremely did you feel that the daily phone calls took too much time? 0.0% 1.0% 3.1% 29.9% 52.6% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% not at all slightly moderately very much extremely were the questions easy to understand? 15.5% 37.1% 17.5% 8.2% 8.2% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% not at all slightly moderately very much extremely did you find that the calls were disruptive to your regulary schedule? 1.0% 3.1% 9.3% 32.0% 41.2% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% not at all slightly moderately very much extremely did it become easier and faster to complete the survey each day as time went on? cannabis, a publication of the research society on marijuana 55 table 2. receptivity and reactivity to ivr among high and low rrequency responders note. response options range from 0 to 4 with 0 = “not at all”, 1 = “slightly”, 2 “moderately”, 3 = “very much”, and 4 = “extremely” significant differences bolded for emphasis. figure 2. self-reported increased awareness and purposeful change to nicotine/tobacco and cannabis use behavior from ivr monitoring anova tests examining differences in receptivity and self-reported reactivity ratings among high and low frequency responders are shown in table 2. low frequency responders reported that the daily surveys took too much time relative to high frequency responders [f(1,82)=6.48, p=.019]. relative to low frequency responders, high frequency responders reported that it became easier and faster to complete the surveys over time [f(1, 82)=3.82, p=.025] and that calls were less disruptive [f(1, 82)=18.62, p<.001]. in terms of self-reported reactivity, high and low frequency responders did not differ on increased awareness of behavior [f(1, 82)=1.10, p=.297] or degree of purposeful behavior change [f(1, 82)=0.150, p=.699]. figure 2 shows the proportion of respondents who reported increased awareness and purposeful behavior change of nicotine/tobacco and cannabis use in response to ivr assessments. with respect to increased awareness, 11.3% (n=11) reported increased awareness of nicotine/tobacco use and 18.6% (n=18) reported increased awareness of cannabis use; while16.5% (n=16) reported purposefully using nicotine/tobacco less often, and 19.6% (n=19) reported purposefully using cannabis less often. full sample high frequency (n=35) low frequency (n=62) p m (sd) m (sd) m (sd) receptivity took too much time 1.07 (1.10) 0.74 (0.9) 1.31 (1.2) .019 easy to understand 3.55 (0.63) 3.49 (0.7) 3.59 (0.5) .449 became easier and faster 3.26 (0.88) 3.51 (0.7) 3.08 (1.0) .025 calls were disruptive 1.50 (1.18) 0.94 (0.8) 1.9 (1.2) <.001 reactivity increased awareness 2.10 (1.13) 1.94 (1.2) 2.20 (1.1) .297 purposeful behavior change 0.89 (0.99) 0.94 (1.1) 0.86 (0.9) .699 ema compliance in young adult cannabis and tobacco users 56 table 3. hierchical regression models results of the associations between indices of ivrbased ema reactivity with post-ivr past 30-day cigarette and cannabis use past 30-day cigarette use past 30-day cannabis use b p b p increased awareness of nicotine/tobacco use 0.01 .933 purposely used nicotine/tobacco less -0.08 .462 increased awareness of cannabis use 0.12 .124 purposely used cannabis less -0.29 >.001 note. models controlled for baseline levels of the outcome in step 1. significant associations bolded for emphasis. associations of self-reported reactivity to behavior change table 3 shows results of hierarchical linear regression models that examined associations of indices of self-reported reactivity (increased awareness and purposeful behavior change) with actual behavior change outcomes. only purposely using cannabis less was associated with fewer cannabis use days at the post-ivr survey (b= 0.29, p>.001), controlling for baseline levels of cannabis use. no other significant associations were found. discussion this study is the first to examine ivr-based ema compliance among young adult tobacco and cannabis co-users and adds to the work examining factors associated with ema compliance, receptivity, and perceived reactivity. the compliance rate for this study was 55.3%, which is lower than the recommended 80% (stone & shiffman, 2002), but falls in the 50-70% range reported for ema studies involving substance use in similar samples of young adults or adolescents (buu et al., 2017; kaminer et al., 2006). in this study, compliance decreased across all four weeks, consistent with results from other ema studies (battista et al., 2015; hoeppner et al., 2014). this study characterized 36.1% of the sample as high frequency responders for having completed >70% of the calls and found no differences between high and low frequency responders on any demographic variables or baseline measures of cannabis use, tobacco use, nicotine dependence, alcohol use, mental health, and personality characteristics. a few studies have found associations between low ema compliance and substance use factors such as alcohol use and smoking (litt et al., 1998; sokolovsky et al., 2014), while meta-analyses report little evidence of associations between low ema compliance and study design, participant characteristics, or substance type (jones et al., 2019; wrzus & neubauer, 2021). a meta-analysis of 126 ema studies involving substance use reported a pooled compliance that was lowest for studies assessing cannabis (66.16% pooled compliance) compared to studies primarily assessing tobacco (77.79% pooled compliance) or alcohol (76.36% pooled compliance) (jones et al., 2019). while our findings did not show any specific impact of baseline cannabis use frequency on compliance, the sample’s overall low compliance may be because the sample consisted of regular cannabis users. mental health conditions, such as susbstance use disorder, may compromise one’s ability to self-regulate thus impacting compliance. a variety of unmeasured factors associated with cannabis use (e.g., use motives, use consequences) may also have influenced overall compliance. ways of improving overall compliance include offering financial incentives commensurate with time and burden associated with surveys and offering incentive escalation over time. in terms of receptivity, the majority of participants reported that the surveys were easy to understand and not burdensome. not surprisingly, a greater proportion of high frequency responders reported high receptivity to the surveys. it could be that participants who perceive surveys as becoming easier to complete over time may be more likely to continue completing surveys. this also suggests that participants who perceived greater burden over time are less likely to complete surveys over time. nearly two thirds of participants (72.2%) reported increased awareness of at least one behavior in response to ivr assessments, and just over half (56.7%) reported purposefully changing at least one behavior. regression models showed that purposely decreasing cannabis use was correlated with lower cannabis, a publication of the research society on marijuana 57 past 30-day cannabis use behavior at one month follow-up. this suggests that behavior monitoring via ema has some relationship to changes in behavior over time, consistent with other studies that used-ema monitoring (cohn, elmasry, et al., 2018; gass et al., 2021). while observational studies using ema are not intentionally attempting to influence change in behavior, this may be an unintended consequence of using frequent assessments. plans to mitigate reactivity in ema in observational studies should be considered when these methods are applied (barta et al., 2012). these include examining responseshifts over time, reducing survey time and frequency, and incorporating post-ema surveys of reactivity for covariate analyses. on the other hand, results suggest self-monitoring can be an effective tool for behavior change, even for cannabis use. mobile health ema technology, such as smartphone-based apps, has been utilized successfully as a treatment modality for a variety of substance use disorders (businelle et al., 2016; sherman & mcrae‐clark, 2016). the increasing popularity of mobile health interventions offers promise as a potential treatment for cannabis and tobacco co-use. similar principles of mobile health treatments for substance use could apply to the “treatment” of low compliance in ema studies, such asintervening in the moment when a survey prompt has been missed or delayed, and providing daily feedback about progress. limitations there were several limitations of this study worth noting. first, the study utilized ivr, despite smartphpone-based apps becoming increasingly popular. second, nicotine dependence was measured using a 1-item assessment. while this has been shown to be a robust proxy for nicotine dependence, (baker et al., 2007; branstetter et al., 2020) the item was broad and not specific to any particular tobacco product. third, in an attempt to minimize participant burden and reduce survey completion time, questions assessing late night use of cannabis were not asked despite sleep disturbance being a common reason for use. it is possible that poor sleep could have had an impact on compliance. additionally, participants were asked to elucidate specific reasons for survey noncompliance and data was not normally distributed potentially impacting type 1 error. finally, generalizability of study findings is limited given that this study did not recruit individuals across the age continuum or non-users of both tobacco and cannabis. it is possible non-users may have higher compliance rates than current substance users, but study methodology prevents this determination. conclusion given the growing number of states with legal cannabis and high rates of the co-use of cannabis with tobacco among young adults, it is imperative to capture changes in co-use in this population. this study evaluated parameters of ivr-based ema compliance in young adult tobacco and cannabis co-users, to elucidate factors that could be targeted in future studies using similar methodologies, in an effort to improve compliance. we found no differences in baseline characteristics between high and low frequency responders. even with several assessments per day for a month, findings show high ivr receptivity and suggest that self-reports of behavior and attiduinal change occur, and may predict some modest behavior change after monitoring. measures of reactivity to daily monitoring highlight the effectiveness of mobile health technologies to improve substance use. ensuring high compliance could also improve the effectiveness of such technology. references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2015). feasibility and acceptability of smartphonebased ecological momentary assessment of alcohol use among african american men who have sex with men in baltimore. jmir mhealth and uhealth, 3(2), e67. funding and acknowledgements: research reported in this publication was supported by the national institute on drug abuse of the national institutes of health under award number by r21da041548-0 awarded to the first author amc, as well and university of oklahoma health sciences center, oklahoma tobacco settlement endowment trust (tset) contract tset contract # r22-02 and nci grant p30ca2255520 awarded to the stephenson cancer center. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. data were shared with the first author via a data sharing agreement from the institution at which the data were collected. the first author does not have permission to share data with others. we thank the efforts of the haneen abudayyeh and lexie perreras for project management, survey development, and data collection. we thank bonnie king and jess wilhelm for data cleaning and data management. conflict of interest statement: no conflicts of interest to declare. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ 2020 rsmj abstracts for publication special section conference abstracts 1 special section editor benjamin o. ladd, ph.d. keynote address "stoned driving: what we know and what we don't know" godfrey pearlson yale university school of medicine “stoned driving” is a topic with important public health implications, given the increasing legalization/decriminalization of recreational marijuana and legalization of medical marijuana in the us, that has led to more drivers being exposed to increasing potencies of thc. the talk covers a series of questions regarding marijuanaimpaired driving. does marijuana impair driving behaviors? if so, which ones, to what extent and for how long, after an acute marijuana dose? does this driving impairment profile resemble that of alcohol? is cannabis’ impairment of driving related temporarily to dose, or to blood levels of thc or its metabolites? what impairment results when alcohol and cannabis are used in combination? what are the barriers to reliable detection of stoned drivers at the roadside? poster presentations all poster presentations and symposia were peerreviewed by the 2020 conference program committee of the research society on marijuana (rsmj) (bradley t. conner, colorado state university, benjamin o. ladd, washington state university vancouver, kristina t. phillips, university of northern colorado, verlin joseph, university of florida). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. marijuana use among young adults: findings from the 2015-2018 national survey on drug use and health andrew yockey, shanna stryker (university of cincinnati) marijuana is the most commonly used drug for young adults. a greater understanding of risk factors associated with recent use can inform health prevention messaging. pooled data from the 2015-2018 national survey on drug use and health were utilized among 89,446 individuals ages 18-34. weighted logistic regression analyses, controlling for covariates, were utilized to determine conditional associations to past-30-day use. a sizeable percentage (18.5%) of individuals reported smoking marijuana in the past 30 days. individuals who identify as african american or multi-racial, gay/lesbian, bisexual, reported their health as poor, not covered by health insurance, reported prior drug use, or who had reported any thoughts/plans of suicide were at risk for use. of concern, high rates of alcohol (14.7%) and cocaine (1.50%) were found among users. we believe our findings can inform harm reduction efforts and policy creation. cannabis 2021, 4 (1), 1-26 © author(s) 2021 researchmj.org abstracts from the 2020 virtual scientific meeting of the research society on marijuana july 24th, 2020 conference abstracts 2 risk and protective factors associated with cannabis use in massachusetts youth julie k. johnson, samantha m. doonan (commonwealth of massachusetts, cannabis control commission) cannabis policies are continuously evolving, over half of u.s. youth now live in a state with a form of legalized cannabis. monitoring risk and protective factors is critical to ensure evidencebased youth prevention in this post cannabisprohibition era. massachusetts has enacted and implemented three forms of legalization: (1) decriminalization (2008), (2) medical cannabis (2012), and (3) adult-use cannabis (2016). this study used state youth risk behavior survey (yrbs) data of participants in grades 9-12 from 2007-2017 (n=17,691). logistical regression models were run to assess effects of varying cannabis policy and risk or protective behaviors on cannabis use outcomes: (1) lifetime use; (2) past 30-day; and (3) past 30-day heavy use. the enactment of cannabis policies was not associated with greater odds of youth reporting lifetime and past 30-day cannabis use behaviors. any adultsupport [heavy use or=0.43 (95% ci=0.37,0.50), p&lt;.001], better grades [heavy use or=0.25 (95% ci=0.21,0.29), p&lt;.001], and being heterosexual [heavy use or=0.42 (95% ci=0.34,0.51), p&lt;.001] were associated with lower odds of all cannabis use outcomes. multiple risk factors broadly categorized under: risky sexual behaviors, non-heterosexual orientation, weapon carrying/exposure, hopelessness and suicidality behaviors, driving behaviors, and disability were associated with greater odds of cannabis use. sensitivity analyses showed only one risk behavior was moderate by cannabis policy enactment. results suggest that cannabis prevention efforts should not occur in a silo, rather evidence-based models for reducing risky behaviors generally may have the largest impact. building and supporting relationships with trusted adults for youth at higher risk should be emphasized. participation in the massachusetts adult-use cannabis industry by race/ethnicity and gender across job titles samantha m. doonan, julie k. johnson (commonwealth of massachusetts, cannabis control commission) states across the u.s. are increasingly legalizing cannabis for recreational purposes (“adult-use”) through licensure of privately-run cannabis establishments. legalization efforts have partially emerged in response to unequal prohibition enforcement which disproportionately affects black and hispanic/latino communities. however, the extent to which people from communities most affected by prohibition are included in the legal industry is unknown. this study is a preliminary analysis of participation by race/ethnicity and gender across job titles in the massachusetts adult-use cannabis industry from its inception through april 2020 (18-month time span). data were extracted from cannabis establishments (i.e., licensed adult-use cannabis businesses that collectively form the cannabis industry in massachusetts). agent registration forms are required for board members, directors, executives, managers, employees, and volunteers across all license types (e.g. retail, cultivation, product manufacturing). as of april 2020, there were 4,907 unique agents (volunteers excluded) across 205 cannabis establishment licenses. among agents, 77% were white, 9% were hispanic/latino, and 6% were black/african american, <3% identified other racial and ethnic groups, and data were missing for approximately 6% of the sample (exceeds 100%, as persons can be included in more than one race/ethnicity). excluding agents with missing race/ethnicity or gender (n=347) and grouping persons at twolevels: (1) white or not-white identifying, and (2) male or female, we found 53% of agents were white and male, 29% were white and female, 12% were an ethnicity and/or race(s) that did not include white (“non-white”) and male, and 5% were non-white and female. approximately 8% of agents held senior-level positions (i.e., board members, directors, executives) versus less senior positions (i.e., employees, managers). however, white males held 72% of senior positions, white females held 17%, non-white males held 9%, and non-white females held 1%. this study is subject to limitations, including that persons who identified as white and another race(s) (n=103) are included in white-identifying categories; future work will address this limitation. further, all data is typically reported by supervisors rather conference abstracts 3 than self-reported, therefore race/ethnicity and gender are subject to misidentification. nonetheless, findings suggest that at approximately one and a half years after retail stores opened, participation in the massachusetts adult-use cannabis industry skews white and male, and this trend is pronounced in senior-level positions. average intoxication as a proxy for cannabis use brianna r. altman, maha n. mian, luna f. ueno, mitch earlywine (university at albany, state university of new york) assessing cannabis use is challenging due to the lack of standardized doses, differing potencies among products, and the potential for sharing with others. although legalization of cannabis might give users a better sense of the quantity purchased and thc/cbd composition of products, issues in assessment and measurement can still preclude researchers from understanding use patterns. given these challenges, the present work examines whether an individual’s average level of intoxication after cannabis consumption might serve as a better proxy for cannabis use than quantity of use. data was aggregated from several studies related to cannabis use and health behaviors and collapsed across common variables (n = 2,659, mean age = 34.08, 61.9% male, 84.8% caucasian). our sample reported using cannabis either six or seven days per week, consuming approximately 1.12 ounces of cannabis per month (sd = .35 ounces), attaining an average intoxication of 3.49 on a scale from 0 (“not at all”) to 6 (“extremely high;” sd = 1.21), and experiencing a mild amount of cannabis-induced impairment as measured by the cannabisassociated problems questionnaire (capq; m = 8.21, sd = 9.08). in this sample of frequent users, average intoxication levels were significantly related to cannabis problems (r = .153, p < .001) while quantity per month appeared to be unrelated (r = .005, p = .798). using meng’s (1992) procedure for comparing correlated correlation coefficients, these relations were found to significantly differ from each other (z = 5.53, p < .001). our results provide preliminary evidence supporting cannabis-induced intoxication as a better proxy for cannabis use than quantity consumed. individuals might more accurately remember their experiences of being high as opposed to recalling how much they consumed over a month’s span. future work should continue to examine relations between intoxication and other indices of cannabis use to confirm and extend our findings. cannabis’s link to schizotypy: phenomenon, measurement bias, or delusion? brianna r. altman, maha n. mian, luna f. ueno, mitch earlywine (university at albany, state university of new york) links between cannabis use and psychosis continue to generate research and media attention. cannabis users have outscored non-users on the schizotypal personality questionnaire-brief (spq-b) by a small amount in multiple studies, but previous work on biased items suggests that the groups do not differ if these items are removed. the present study examined links between schizotypal personality, as measured by the spq-b, and cannabis use in a large sample recruited from amazon’s mturk platform. over 500 participants (72.5%) reported lifetime cannabis exposure, 259 participants (36.7%) reported current cannabis use, and on average, used 3.5 days per week. users and nonusers failed to differ significantly on total spq-b scores or any of the three established subscales, with effect sizes all lower than d = .20. the null results inspired a re-examination of the spq-b’s factor structure, which identified a novel 3-factor solution (difficulty opening up to others, hyperawareness, and odd or unusual behavior). only the “odd or unusual behavior” factor showed cannabis-related differences (g = .234), but a differential item functioning test revealed that one item on that subscale showed potential bias against users. removing this item dropped the group differences to a non-significant g = 0.149. these results suggest that links between schizotypy and cannabis require cautious interpretation with careful attention to potential measurement bias. in addition, the schizotypal personality questionnaire-brief might have an alternative factor structure that could help answer important questions in psychopathology. conference abstracts 4 effects of age and sex on primary method and form of cannabis use marika huffer, anita cservenka (oregon state university) while cannabis is the most commonly used illicit substance, few studies have focused on the relationship between sociodemographic factors and primary method or form of cannabis use. the primary aims of this study were to understand the effects of age and sex on primary form (marijuana, concentrates, edibles) and method (joints, blunts, hand pipe, bong, hookah, vaporizer, edibles) of cannabis use. participants (n=852; n=536 male) completed an online survey that included the ‘daily sessions, frequency, age of onset, and quantity of cannabis use inventory’ used to collect information on the primary method and form of cannabis use in male and female participants divided into young adults ages 18 to 25 (y) and adults 26 and older (o). chi square analysis showed a significant effect of sex for primary method (χ2 (1)=122.4, p<.001) and primary form (χ2 (1)=24.6, p<.001) of cannabis use. post hoc comparisons using bonferroni corrections (adjusted p=0.002) showed that males were significantly more likely to report blunts (m=35%; f=10%), while females were significantly more likely to report joints (f=16%; m=8%) and edibles (f=15%; m=4%) as their primary method of cannabis use. males were also significantly more likely to report marijuana (m=66%; f=55%), while females were significantly more likely to endorse edibles (f=17%; m=10%) as their primary form of cannabis use. chi square analysis showed a significant effect of age for primary method (χ2 (1)=139.9, p<.001) of cannabis use. young adults were significantly more likely to report using bongs (y=19%; o=11%), vaporizers (y=26%; o=9%), and edibles (y=12%; o=5%), while participants 26 or older were significantly more likely to report using blunts (o=39%; y=10%) as their primary method of cannabis use. there were no significant differences between age groups for the primary form of cannabis use. findings from this study suggest there are significant effects of age and sex on primary method and form of cannabis use. future studies should examine how other sociodemographic factors may affect cannabis use and how method and form of cannabis use affect long-term health outcomes. the cannabis retail environment for young adults in los angeles: which metrics matter caislin firth (simon fraser university; rand corporation) rachana seelam, anthony rodriguez, regina shih, joan tucker, elizabeth d’amico (rand corporation) eric pedersen (university of southern california, rand corporation) background: currently, there is no consensus on how to measure cannabis retailer density. researchers and policy makers need clear measures to support policies that mitigate unintended harms of legalization. to address this gap, our unique study leverages cannabis retailer location data in los angeles county (la), california, and home addresses from an la-based cohort of young adults (21-25 years) to develop a series of cannabis retailer density metrics and assess their relationship with cannabis use. methods: drawing from gis-based measures of alcohol outlet density, we developed a series of cannabis retailer density metrics: proximity, counts within 51015-, and 30-minute driving distances, and considered retail licensure. retailer addresses were compiled by webscraping cannabis registries (e.g. weedmaps) and conducting field visits (march 2019). home addresses were geocoded for participants who completed a 2019 survey (n 1097). a series of retailer metrics was created for each person. we fit a series of multi-level logistic regression models with a random intercept by census tract (ct) (models adjusted for age, gender, race/ethnicity, college student, and ct median household income) to assess which retailer metrics were associated with any past month cannabis use. results: thirty percent of participants used cannabis in the past month, and 430 retailers were operating in la in 2019. thirty-nine percent of participants had a retailer within a mile from home and an average of 14 retailers within a 10minute drive. licensed retailers were less prevalent; the nearest licensed retailer was on average 2.4 miles from home. the odds of past month cannabis use significantly increased by 3% (or:1.03, 95% ci:1.00–1.07) for every additional licensed retailer within a 10-minute drive in adjusted model; use was also significantly associated with licensed retailers within a 30conference abstracts 5 minute drive (or:1.01, 95% ci:1.00–1.01). proximity metrics were not significantly associated with past month cannabis use. emotion dysregulation moderates the association between stress and problematic marijuana use jessica m. cavalli, anita cservenka (oregon state university) objective. marijuana is the most widely used illicit substance in the united states and in 2018 alone, an estimated 40.3 million adults reported using marijuana in the past year. this is concerning since growing research suggests that marijuana use is associated with adverse health and life outcomes, such as mental health issues, and cognitive impairment. thus, determining factors that influence marijuana use-related problems is critical for understanding how to effectively implement prevention, intervention, and treatment efforts. because research has proposed that emotion dysregulation is a transdiagnostic risk factor for substance use and addiction, the investigation of emotion regulation capabilities in marijuana users is warranted. furthermore, since prior studies suggest that stress may lead to greater marijuana use-related problems, additional research into how emotion dysregulation may affect these relationships is needed. thus, the current study examines how emotion dysregulation moderates the association between stress and problematic marijuana use in adults through an online survey. methods. 852 adults reporting any lifetime marijuana use completed an online survey through qualtrics. participants completed a brief demographic questionnaire and were asked to report their past 30-day use of marijuana, alcohol, nicotine, and illicit substances. to assess past month problematic marijuana use, participants completed the marijuana problem scale (mps). to assess emotion dysregulation, participants completed the difficulties in emotion regulation scale (ders). participants completed the perceived stress scale (pss) and the holmesrahe life stress inventory (h-rlsi) to assess past month perceived stress and past year stressful life events, respectively. we investigated the association between scores on the ders, pss, and h-rlsi with scores on the mps. additionally, we conducted hierarchical multiple linear regression models to test whether emotion dysregulation, stress, and their interaction predicted problematic marijuana use. results. scores on the ders (r = .53, p < .001), pss (r = .13, p < .001), and h-rlsi (r = .32, p < .001) were significantly correlated with scores on the mps. additionally, emotion dysregulation (b = .32, p < .001), stressful life events (b = .21, p < .001), and their interaction (b = .07, p = .003) were significant predictors of problematic marijuana use. finally, emotion dysregulation (b = .44, p < .001), perceived stress (b = -.18, p < .001), and their interaction (b = -.06, p = .04) were significant predictors of problematic marijuana use. conclusion. these findings indicate that when examined separately, greater emotion dysregulation, experiencing more stressful life events in the past year, and experiencing more perceived stress in the past month were associated with greater problematic marijuana use in the past month. however, when examining the moderating role of emotion dysregulation, more stressful life events and less perceived stress predicted greater problematic marijuana use, and these associations were stronger at higher levels of emotion dysregulation. overall, these results suggest that emotion dysregulation and greater stress may be risk factors for developing problematic marijuana use, and could be possible targets for prevention, intervention, and treatment efforts. what’s pain got to do with it?: young adults with and without chronic pain perceive minimal risks and moderate benefits from cannabis use bethany shorey-fennell, renee e. magnan, benjamin o. ladd, jessica l. fales (washington state university vancouver) many young adults experience chronic pain and given its wide availability and potential pain reducing properties, young adults may use cannabis to self-medicate for pain. however, little is known about young adult users’ perceptions of potential health risks and benefits of cannabis, and whether these perceptions differ by chronic pain status. as a part of a larger study, young adult recreational cannabis users (n=176, ages 18-29) who reported using at least once a week completed assessments of use frequency and perceived cannabis-related risks and benefits. the conference abstracts 6 sample had a high proportion of participants who met criteria for chronic pain (51.1%). the majority of the sample reported using daily or multiple times daily (80.7%) with an average of 2.68 (sd=1.42) sessions per day across administration modes (e.g. smoking, edibles, tinctures). participants answered questions about their lifetime chances of experiencing five cannabisrelated risks (personal harm, negative health outcome, negative mental health outcome, harming someone else, increased pain) and benefits (personal benefit, positive health outcome, positive mental health outcome, benefitting someone else, decreased pain; 1=very low to 7=very high). overall, young adult users perceived their risk to be very low (m=1.62, sd=.73) and 40.3% of the sample had an average risk score (combined across the five risk items) of 1.00, while only one participant reported an average risk above 4.00. in particular, participants reported a low lifetime chance of experiencing personal harm (m=1.51, sd=.90), harming someone else (m=1.20, sd=.58), or experiencing increased pain (m=1.24, sd=.74) due to their cannabis use. in contrast, young adult users perceived somewhat high chances of experiencing benefits related to their cannabis use (m=4.78, sd=1.46). in particular, participants perceived a high chance of experiencing reduced pain (m=5.88, sd=1.55), personal benefit (m=4.84, sd=1.86), and positive mental health outcomes (m=4.82, sd=1.77). there was no difference based on pain status on frequency of use, average daily sessions, or perceived risks, and only one difference in perceived benefits. participants without chronic pain anticipated more personal benefit from cannabis use (m=5.15, sd=1.74) than those with chronic pain (m=4.53, sd=1.94, t(171)=2.21, p=.03). overall, results suggest young adult recreational users perceive very low risks of their cannabis consumption and moderately high benefits, regardless of pain status. looking at individual areas of potential risk and benefits may yield targets for future health education campaigns. for example, perceptions of low risk/high benefits regarding mental health outcomes may not be accurate for this heavy using sample. co-use of tobacco/nicotine and cannabis among veterans: a preliminary investigation of prevalence and associations with mental health outcomes reagan e. fitzke, jordan p. davis, eric r. pedersen (university of southern california) while tobacco and cannabis use rates remain high in the general u.s. population, veterans from the conflicts in iraq and afghanistan (i.e., oef/oif veterans) are at particularly high risk of high rates of cannabis and tobacco use. co-use of tobacco/nicotine and cannabis (i.e., using both substances within a specified period of time or combining the drugs within the same device for use) is of growing prevalence in the united states. tobacco/nicotine and cannabis use is often associated with poor mental health outcomes such as stress, anxiety, and depression. however, little is understood about the prevalence rates of tobacco/nicotine and cannabis co-use among u.s. veterans as well as associations with mental health symptomology. the current study aimed to investigate types of tobacco/nicotine and cannabis co-use among veterans, as well as associations between co-use and mental health outcomes of stress, depression, anxiety, and posttraumatic stress disorder. participants (n= 1,548) were recruited through social media websites and completed an online survey as part of a larger study. the majority (80%) endorsed tobacco/nicotine and/or cannabis use in the past 30 days. descriptive analyses were run to assess prevalence of use within the sample. mean comparisons were conducted to assess differences in past 30-day frequency of use and for mental health outcomes between co-users and single users of either substance. among the larger sample, 90% endorsed lifetime use of tobacco/nicotine, 23% endorsed lifetime use of cannabis, and 21% endorsed any lifetime co-use of both substances. these participants also endorsed past 30 day use of tobacco/nicotine (77%), cannabis (10%), and co-use (7%). among the past 30-day cannabis users, 66% reported also using tobacco/nicotine, while 9% of past 30-day tobacco/nicotine users also reported cannabis use. when comparing cannabis-only users to co-users of cannabis and tobacco/nicotine, anxiety symptoms were reported as significantly higher among co-users. tobacco/nicotine-only users endorsed higher past 30-day frequency of cigarettes and e-cigarettes compared to co-users; conference abstracts 7 however, co-users endorsed significantly higher levels of stress and symptoms of ptsd, depression, and anxiety compared to tobacco/nicotine-only users. results suggest that the addition of cannabis use in conjunction with tobacco/nicotine use may be associated with greater mental health symptoms among veterans. findings have implications for future veteran mental health care and substance use treatment among tobacco/nicotine and cannabis co-users. impulsivity and childhood physical abuse predict past 30-day cannabis use among bisexual women megan m. drohan, christina t. schulz, emily m. glatt, amy l. stamates (university of rhode island) michelle l. kelley (old dominion university) previous research suggests that bisexual women’s rate of cannabis use is 2 to 7 times higher than their heterosexual peers; however, factors contributing to this are unclear. trait impulsivity (i.e., tendency to act without forethought) and history of childhood physical abuse (cpa) are two risk factors that may be relevant for bisexual women’s cannabis use. specifically, bisexual women indicate high levels of risk-taking and commonly report histories of cpa. while both impulsivity and cpa have been identified as predictors of cannabis use in heterosexual women, research has yet to explore these factors as predictors of cannabis use among bisexual women. consequently, the present study examined cpa and trait impulsivity as predictors of cannabis use in a sample of bisexual women. it was hypothesized that both trait impulsivity and exposure to cpa would predict greater frequency of cannabis use. participants were 225 bisexual women aged 22.77 years (sd = 3.45) recruited from a southeastern university and community area. participants completed an online survey including questions about their past 30-day frequency of cannabis use (5-point scale ranging from 0 = never to 4 = daily), cpa using the child maltreatment scale-physical abuse subscale, and impulsivity using the barratt impulsiveness scale-version 11. a majority of the sample reported cannabis use in the past 30 days (60.3%), with 23.2% using once or twice, 12.9% using weekly, 11.2% using almost daily, and 12.9% using daily. to account for the large number of zero values on the cannabis use score, we tested a poisson hurdle model to evaluate the effects of cpa and impulsivity on cannabis use. frequency of cannabis use was modeled first as a binary logistic model (0 versus any use) and then as a truncated regression model for non-zero responses. results indicated that across all participants, greater impulsivity predicted any cannabis use in the past 30 days (p = .003), but cpa did not (p = .942). among participants who reported past 30-day cannabis use only, cpa was associated with increased frequency of cannabis use (p = .003), and impulsivity did not predict frequency of cannabis use (p = .683). overall, results indicated that greater trait impulsivity was associated with past 30-day cannabis use, but not frequency of cannabis use. conversely, greater cpa exposure was not associated with whether one used cannabis in the past 30 days but instead was related to increased frequency of past 30-day cannabis use. thus, although trait impulsivity may identify cannabis users, cpa may identify sexual minority women who are at risk for increased frequency of cannabis use. given the potential long-term harms associated with increased cannabis use (e.g., changes in brain morphology, cognitive impairment, and respiratory issues), prevention efforts targeting bisexual women may want to consider impulsivity and cpa. cannabis use and sleep: a look at the expectations, outcomes, and the role of age. evan a. winiger, leah n. hitchcock, angela d. bryan, l. cinnamon bidwell (university of colorado, boulder) objectives: estimate the associations between cannabis use with expectations of cannabis being a sleep aid, subjective sleep outcomes, and the influence of age on these relationships. methods: in 152 moderate cannabis users (67% female, mean age = 31.45, sd = 12.96, age range = 21-70) we assessed the influence of cannabis use history and behaviors on expectations of cannabis being a sleep aid and subjective sleep outcomes via the pittsburgh sleep quality index (psqi). we used moderation analysis to examine the role of age in the relationship between cannabis use and subjective sleep outcomes. conference abstracts 8 results: cannabis use along with more frequent cannabis use were associated with increased expectations that cannabis use improves sleep (all β > 0.03, p < 0.04). frequency of recent cannabis use and reported average thc or cbd concentration were largely not associated with subjective sleep outcomes. however, endorsing current cannabis use was associated with worse subjective sleep quality (β = 1.34, p = 0.02) and increased frequency of consuming edibles was associated with worse subjective sleep efficiency (β = 0.03, p = 0.04), lower sleep duration (β = 0.03, p = 0.01), and higher global psqi scores (worse overall sleep) (β = 0.10, p = 0.01). furthermore, age was determined to have a moderating influence on the relationship between increased concentration of cbd and both better sleep duration and sleep quality (both p < 0.03). conclusion: cannabis users have higher expectations of cannabis being a sleep aid, but few associations existed between cannabis use and subjective sleep outcomes with the exceptions of endorsing any cannabis use and frequency of edible use. additionally, age may be an important moderator of the potential positive influence cbd concentration can have on sleep. an examination of relationships between mental health symptoms, marijuana use motives, and marijuana use outcomes among late adolescents in washington state elliot c. wallace, li-hui chu, jason j. ramirez (university of washington) adolescence is a critical period of development which can be affected by the initiation and escalation of marijuana use. examining risk factors of marijuana misuse among adolescents is a public health priority. previous research examining depression and anxiety as risk factors for marijuana use among young adults is mixed. some studies found a positive relationship between mental health symptoms and marijuana use, while other studies have found genderspecific relationships or no relationship at all. despite this research, little is known regarding mental health symptoms and marijuana use among adolescents. the aims of current analysis were to 1) examine associations between mental health symptoms and marijuana use behavior among adolescents, and 2) examine coping motives as a moderator of the relationship between mental health symptoms and marijuana outcomes. the current study included 170 late adolescents (15-18 years old, mage = 16.86, sdage = 0.94, 50% female) recruited from washington state. the sample was stratified by gender and marijuana use such that participants ranged from never using marijuana to reporting heavy, regular marijuana use. participants were asked to complete three online assessments over the course of six months. data described here come from the first online assessment. this included a 4-item measure of mental health symptoms (depression and anxiety) in the past 2 weeks, in addition to measures of marijuana use, marijuana-related consequences, and marijuana use motives. a series of initial linear regression models that controlled for age and sex found that mental health symptoms were not significantly associated with typical marijuana use (p > .05) but were significantly positively associated with marijuana-related consequences (β = 0.33, p < .001). additional models that also included coping motives found that stronger endorsement of using marijuana to cope with negative affect was associated with more hours high in a typical week (β = 0.25, p < .05) and more marijuana-related consequences (β = 0.24, p < .05). there were no significant interactions between coping motives and mental health symptoms in predicting either marijuana use or consequences (ps > .05). the findings suggest that adolescents who report more mental health symptoms do not necessarily use more marijuana than those who report fewer symptoms, but may be at greater risk for experiencing negative consequences as a result of their usage. additionally, the results suggest a stronger endorsement of using marijuana to cope with negative affect is related to greater marijuana use and risk for experiencing negative consequences. no evidence of moderation was found suggesting the relationships between mental health symptoms and marijuana use outcomes do not vary as a function of coping motives. screening during adolescence for early signs of mental health symptoms to predict risk may be beneficial towards preventing negative outcomes and providing early interventions for marijuana misuse. marijuana use grid: a brief, comprehensive measure of marijuana use jude g. chavez, matthew r. pearson conference abstracts 9 (university of new mexico) marijuana outcomes study team protective strategies study team the present study introduces a brief, yet comprehensive retrospective self-report measure of frequency and quantity of marijuana use: the marijuana use grid (mug). using two large samples of college student marijuana users recruited from several universities throughout the united states, we characterized how various indicators of marijuana use frequency and quantity relate to consequences and symptoms of cannabis use disorder (cud), and whether marijuana use frequency and quantity as assessed by the mug predict outcomes above and beyond the effect(s) of a simple measure of marijuana use frequency. typical frequency and quantity estimates from the mug interacted to predict marijuana-related outcomes. the mug has shown utility in its association with important outcomes and given its brief nature, the mug can easily be integrated in future marijuana studies. additional work is needed to examine the predictive utility of the mug in the context of other marijuana-related assessments. cannabis protective behavioral strategies: moderating the effects of antecedents on consequences? alexander j. win, dylan k. richards, matthew r. pearson (university of new mexico) protective strategies study team the purpose of the present study was to replicate and extend tests of interaction effects between cannabis protective behavioral strategies use and a wide range of risk/protective factors for cannabis-related consequences. we recruited 2,226 college students (mage = 20.28, sd = 3.37; 68.8% female; 75.4% white) from 10 universities throughout the u.s. who reported using cannabis in the past month to complete an online survey. measures included in the survey assessed cannabis use, cannabis-related consequences, cannabis protective behavioral strategies use, and 35 risk/protective factors (including sociodemographic characteristics [e.g., biological sex]). cannabis protective behavioral strategies use was negatively correlated with cannabis-related consequences while controlling for the risk/protective factors. most importantly, 33% and 54% of the interaction effects tested were statistically significant, depending on the covariates entered into the model. the interaction effects had a consistent pattern such that the positive association between greater risk and cannabis-related consequences was weaker as cannabis protective behavioral strategies use increased. these findings suggest that none of these interaction effects are particularly specific for any given risk/protective factor. we draw parallels to research on alcohol protective behavioral strategies and offer suggestions for moving the cannabis protective behavioral strategies field forward. self-reported symptoms of cannabis use disorder (srscud): psychometric testing and validation melissa sotelo, dylan k. richards, matthew r. pearson (university of new mexico) protective strategies study team findings from national surveys demonstrate that cannabis use peaks in young adulthood and that the annual prevalence of marijuana use among young adults (34.0%) is the highest it has been in decades (johnston et al., 2016). we developed a 13 item measure designed to characterize the 11 symptoms of cud as described in the dsm 5 (apa, 2013). to evaluate the performance of this self reported symptoms of cannabis use disorder (srscud) measure, we examined its associations with other measures of cud symptoms, negative cannabis related consequences, and other known risk factors for cud (i.e., coping motives). colleges students (n =7000) recruited from 9 universities in 9 states throughout the u.s. our analyses focus on past month cannabis users (n = 2077). we split our sample in half to conduct exploratory factor analysis (efa,n = 1011) and confirmatory factor analysis (cfa, n = 1012). all items loaded saliently on a single factor of cud symptoms in both efa (.553 = λ = 805) and cfa models (.524 = λ = 830) (see table 1). in our final model, we allowed correlated errors between the two indicators of tolerance (items 10 and 11) and the two indicators of withdrawal (items 12 and 13), and obtained acceptable model fit across most indices: cfi = .941, tli = .927, rmsea = .059, conference abstracts 10 srmr = .042. as shown in table 2, the total score of the srscud was strongly correlated with other cud symptoms measures (.617 &lt; r s &lt; .697), demonstrating convergent validity. srscud was moderately positively correlated with a well known risk factor for cud (coping motives) and moderately negative correlated with a well known protective (cannabis protective behavioral strategies). we conducted receiver operator characteristic (roc) curve analyses to identify well how our continuous measure of cud symptoms could identify individuals who exceed the cutoffs for probable cud on these other symptom measures. for the most well validated measure (cudit r), we had excellent sensitivity/specificity (mean score of 1.5 on srscud) for predicting probable cud. although more research evaluating performance of the srscud compared to a clinical diagnosis is needed, we have preliminary evidence for construct validity of this measure. changes in late adolescent marijuana use during the covid-19 outbreak vary as a function of typical use li-hui chu, elliot c. wallace, jason j. ramirez (university of washington) adolescent marijuana use is a significant public health concern given that many individuals first begin using during this developmental period and an earlier age of onset is prospectively associated with numerous marijuana misuse outcomes. the outbreak of covid-19 has resulted in stay-athome orders and social distancing guidelines across the united states. for many adolescents, these orders resulted in a number of changes that could alter one’s marijuana use including changes to marijuana availability, parental supervision, amount of free time, and stress levels. despite these possible changes, the impacts of the covid19 outbreak on adolescent marijuana use are unknown. the aims of this analysis were to 1) assess changes to marijuana use among late adolescents related to the covid-19 outbreak, and 2) examine whether these changes vary as a function of one’s pre-covid-19 levels of use. data described here come from a screening survey for a larger study which was completed by 156 adolescents (ages 14-18, 78% male) after the stayat-home order was put in place in washington state on march 23rd, 2020. all participants completed a self-report questionnaire that included demographic information, marijuana use, and changes to marijuana use following the state’s stay-at-home order. in the sample, 55 participants described themselves as never having tried marijuana, and none of these participants reported having used during the covid-19 outbreak. of the 101 participants who reported any prior marijuana use, 44 reported stopping or decreasing their use as a result of covid-19, 30 reported using similar amounts as before, and 27 reported increased marijuana use as a result of covid-19. a chi-square test of independence revealed that changes in use significantly varied as a function of pre-covid-19 levels of use, x2 (2, n = 98) = 29.79, p &lt; .001. the odds of irregular and light marijuana users decreasing their use was 13.73 times higher than moderate and heavy users. moderate and heavy users had higher odds of maintaining their current use (5.04 times higher) and increasing their use (3.07 times higher) compared to irregular and light users during the covid-19 outbreak. primary reasons given for decreasing use included decreased availability and less socialization. primary reasons for increasing use included more free time, fewer responsibilities, and coping with stress and anxiety. the findings suggest that although marijuana use may appear to decrease on average across a range of late adolescents that vary according to their regular use, these decreases are not likely among moderate and heavy users who may actually be at increased risk of marijuana misuse during the covid-19 outbreak. covid-19’s impact on cannabis use: can we trust retrospective cross-sectional data? sara j. bartel, simon b. sherry, sherry h. stewart (dalhousie university) background: emergent research suggests there has been an increase in cannabis use levels during the covid-19 pandemic; however, several gaps remain. it is unclear what impact the pandemic has had on the frequency vs. quantity of cannabis use. additionally, research has not focused on emerging adults, a population often more likely to use cannabis. moreover, as existing studies are cross-sectional and retrospective, it is not clear whether participant reports of increasing conference abstracts 11 cannabis use during covid-19 are accurate. we sought to fill these gaps to provide further information about the impact of covid-19 on cannabis use and the accuracy of related retrospective self-reports. design and methods: seventy emerging adults in an ongoing longitudinal study on alcohol and cannabis users completed surveys on covid-19 and substance use between march 23rd-june 5th. their substance use four months earlier was extracted from the existing dataset. results: 54% of participants reported an increase in cannabis use frequency during the pandemic, while 39% reported an increase in cannabis quantity. an examination of objective change scores indicated 50% of participants actually increased their cannabis use frequency during the pandemic, while 32% actually increased their cannabis quantity. a comparison of retrospective subjective change with longitudinal objective change scores indicated participants were relatively accurate in their retrospective reports of change in cannabis use frequency but were relatively inaccurate in their retrospective reports of change in cannabis use quantity. discussion: the covid-19 pandemic appears to increase cannabis use frequency in the slight majority of cannabis using emerging adults. our results suggest that retrospective cross-sectional reports may be a reasonable proxy for covid-19 related cannabis use change in the case of cannabis use frequency. but our results question their use for determining how the pandemic is impacting cannabis use quantity. importantly, our results suggest the covid-19 pandemic poses health threats that extend beyond the virus itself. it is essential that public health efforts address the increasing frequency of cannabis use in emerging adult users. the role of motives in understanding the link between personality and cannabis misuse karen t. y. tang, elijah otis (dalhousie university) alexandra loverock, t. cameron wild (university of alberta) igor yakovenko (dalhousie university) background and aim: a robust association exists between substance use and personality, with personality risk factors representing phenotypes of vulnerability to substance misuse. as such, personality risk factors may be valuable constructs for understanding specific motivations for substance misuse. given the loosening of restrictions on cannabis worldwide, research focusing on understanding cannabis use in young adults, a particularly at-risk population, remains a vital area of research. the existing data provides extensive support for the mediating role of coping motives on personality risk factors and problematic cannabis use; however, the role of other types of motives has remained largely unexplored. our study examined the mediating role of cannabis use motives between personality and cannabis misuse among university students. we also explored the predictive value of personality phenotypes for cannabis use problems. research question and hypothesis: do motivations for cannabis use mediate or explain the relationship between personality type and cannabis use problem severity? hypothesis 1: sensation-seeking (ss) and impulsivity (imp), but not anxiety sensitivity and hopelessness, will be associated with greater cannabis use problem severity. hypothesis 2: motives for use (i.e., coping, conformity, social, enhancement, expansion) will mediate the association between personality risk and cannabis use problem severity. method: a survey was administered to 1073 undergraduate students. we examined whether motivations for use (mediator variable) explained the relationship between personality (predictor variable) and cannabis use disorder severity (outcome variable) using an ordinary leastsquares (ols) based mediation analysis. results: as hypothesized, ss and imp predicted greater cannabis use problems. a noteworthy finding was that conformity motives were a significant mediator between ss and imp and cannabis use, whereby higher levels of ss/imp led to greater endorsement of conformity motives, which in turn led to lower cannabis misuse. enhancement motives were also a significant mediator between imp and cannabis use. expansion motives were a significant mediator between ss and cannabis use. conclusion: understanding reasons for use (i.e., motives) allows us to identify those at greatest risk for cannabis misuse. findings from this study may help explain the underlying mechanisms by conference abstracts 12 which personality risk factors lead to cannabis use disorder in young adults. a greater understanding of these personality phenotypes may have implications for the development of personalityspecific interventions for cannabis use. poison center reports of cannabis exposures among children in washington state, 2016 natasha close, julia dilley, janet baseman (university of washington) washington state began legal cannabis retail sales in 2014. legalization of adult use cannabis and retail sales may result in more cannabis products in homes and opportunities for accidental exposures among young children. consumption of cannabis by young children can result in significant adverse health effects. this study examined details of cannabis exposure events involving children under age 12 that were reported to the washington state poison center (wapc) during january – december 2016. redacted charts were obtained from the wapc “toxicall” database. 50 eligible events were identified. structured data were used to describe child age and gender and to obtain information about the involved products, route of administration, exposure setting, and clinical effects. additional information about the exposure event was available in case notes; qualitative methods were used to develop themes and categorize the cases. most exposure events (62%) were for children ages 0-2, and 26% were for ages 3-5. none of the exposures were reported as intentional. of those where the source of the product could be determined (n=29) either a parent (n=20, 69%) or grandparent (n=6, 21%) was the most common source. nearly all (94%) exposures occurred at the patient’s home and involved a single substance (90%). of those that noted the type (n=13), 85% indicated that the cannabis was obtained for medical purposes. most exposures were by ingestion (86%), and edibles were the most often reported form (52% of 41 cases with product specified). nearly all edibles were brownies, cookies, and candies (96%). baked goods were reported to be both homemade and purchased. three cases were exposures to cannabidiol (cbd) among children being treated for seizures by their parents: one was the result of a therapeutic error, one an adverse reaction, and one an unintentional exposure. a single child was reported as exposed through breastmilk. of those with known medical outcomes (n=33), nearly all caused no or minor clinical effects (78%), and nearly all had symptoms for less than 24 hours, most commonly lethargy and drowsiness (50%), but five children were hospitalized for non-critical care and one child with a history of seizures, who was given cbd oil containing thc, required intensive care and intubation. risk for accidental exposures to cannabis among young children may be increasing as legal cannabis markets become more common. although most exposures do not cause longlasting harms, some children can experience significant harm requiring medical intervention. caregivers of young children are advised to safely store cannabis products in the home so that they are out of reach of children, and to use caution and consult with a healthcare provider about use of cannabis products for medical treatment of a child or adult use while breastfeeding. clinicians may play a role by screening for household cannabis use among parents and other caregivers, and advising about safe home practices. continued regulatory approaches to limit exposure, such as limits on thc potency and single-serving packaging designs, may also be useful. longitudinal effects of acute cannabis exposure on automobile driving behavior in a naturalistic simulated environment shashwath a meda (hartford hospital/iol) erwin boer (entropy control inc) nicolas ward (university of montana) gregory a book (hartford hospital/iol) michael c stevens (yale univeristy/hartford hospital) catherine boyle, muhammad mubeen (hartford hospital/iol) godfrey d pearlson (yale university/hartford hospital) background: driving is a complex day-to-day activity that employs a variety of cognitive and psychomotor functions in harmony, many of which are known to be affected acutely by cnb intoxication which could in turn pose a significant conference abstracts 13 public health risk. the recent legalization of both recreational and/or medicinal marijuana in several states has thus created an urgent need to better understand the effects of cnb on such functions in the context of driving. the present study employs a longitudinal, double-blind, placebo2 active dose study to investigate the effects of cnb on a variety of driving-related behaviors in a controlled, naturalistic simulated environment. methods: the current study employed n=37 subjects (n=25 male, frequent cannabis users, mean age 24.25+7.01), each exposed to a placebo, low and high dose of cnb on three separate days. on each day, following a single acute inhaled 0.5 g dose of either 0%, 3% or 5-7% of thc via a desktop vaporizer, subjects drove a virtual driving simulator (rti simvehicle platform) three times inside an mri scanner and once out of scanner, randomized, and dispersed throughout an eight hour daily period. during each driving session three distinct real time behavioral tasks corresponding to lane-keeping following simulated wind gusts (operational), lead car following (tactical) and safe overtaking (strategic) were assessed and corresponding behavioral data were computed using custom matlab scripts. data were analyzed using a mixed model framework in spss v24 which included dose, session, instrument (desktop v mri), dose*session, dose*instrument and session*instrument as primary factors, covarying for age and sex. results: intoxicated subjects made significantly fewer gas pedal corrections (p<0.02) during the car following task and similarly fewer corrections to the steering reversal rate (p<0.02) during the lane weaving task, suggesting reduced awareness under the influence of cannabis. in addition we found that several variables showed significant differences in terms of estimates captured throughout the day suggesting that overall risk taking lessened as the day progressed and cnb effects wore off. also, data trends suggested that under the high dose subjects took longer to return to baseline from their ‘impaired’ driving patterns. key metrics that showed such significant daily effects included mean headway (p<0.001) and time to collision (p=0.02) from the car following task, deviation of lane position (p=0.03) from the lane weaving task, median gap (p=0.02) and overtaking speed (p=0.02) from the overtaking task. although many driving measurements differed depending on whether driving was done in mri or at a desktop setting, these differences had no relationship to different drug dose levels. conclusion: in summary, key driving functions affected under higher doses of cnb largely agreed current cross sectional literature. generally, largest impairments in driving behavior seemed to occur within 1-4 hours after drug exposure, which might have important implications for real life driving situations. our preliminary analyses yield numerous metrics that changed throughout the day, suggesting broad-based impairment on many metrics commonly used to quantify driving performance and risk. information sources and training needs on medical marijuanapreliminary results from a state-wide provider survey ruba sajdeya, jennifer jean-jacques, anna shavers, yan wang (university of florida) r. nathan pipitone, martha rosenthal (florida gulf coast university) almut g. winterstein, robert l. cook (university of florida) medical marijuana (mmj) is legal in the state of florida for the treatment of specific qualifying medical conditions.1,2 as of july 2020, over 2,450 physicians are authorized to order mmj, and 360,000 patients are registered in florida’s mmj program.3 with this rapid uptake come concerns regarding physicians’ knowledge about mmj,4–7 and the lack of preparing physicians-in-training to manage mmj.4,7,8 we conducted a state-wide survey of certified mmj providers in florida. the survey was developed by the consortium for medical marijuana clinical outcomes research team. the aim of the survey was to inform physicians of the mission of the consortium, which is to support and disseminate research. the survey items were developed accordingly, and the survey was pilot tested with a small group of physicians. we identified all physicians licensed to certify patients for mmj who care currently practicing in the state of florida (n=1609), to investigate their information sources and training needs regarding mmj. the survey was disseminated via mail and email, including a $40 incentive for survey completion. preliminary responses from 51 (5%) providers (mean age 56, 74% male) are conference abstracts 14 summarized here. the sample included providers from 22 florida counties and represented a broad range of medical specialties. the majority (92%) practiced in both medical marijuana and traditional medical practice. to learn about mmj, 98% used research articles, 90% used online sources, 86% learned from dispensary staff, 84% learned from discussions with other providers, 72% used books, 65% used conferences, 61% used magazines, and 35% had a personal experience with marijuana. the sources most cited as “very useful” were conferences (51%), research articles (50%), discussions with other providers (47%), and online sources (47%). topics rated as a high priority for training included drug-mmj interactions (80%), strategies to help patients reduce their use of opioids or other drugs (80%), information about the selection of doses and cbd: thc ratios (80%), evidence for managing specific medical conditions or symptoms (78%), information about the effect of different phytocannabinoids and terpenes (75%), advantages and disadvantages of specific modes of delivery (71%), general updates on research findings (71%), educational information about the endocannabinoid system (67%), the safety of medical marijuana use (55%), identification and management of cannabis use disorder (51%), and comparison of products available in different dispensaries (49%). the majority of providers either strongly agreed or agreed (77%) that they could provide better care if they knew which products their patients receive at dispensaries. physicians use a blend of primary research, online sources, and exchanges with colleagues to learn about mmj. perceived needs for more pharmacological information and indicationspecific detail for treatment regimen were high. most physicians believe that details on dispensed mmj would improve patient care. contexts of marijuana use: a latent class analysis among argentinean college students angelina pilatti (universidad nacional de cordoba) adrian j. bravo (william & mary) yanina michelini, gabriela rivarola montejano, ricardo m pautassi (universidad nacional de cordoba) background: substance use and the association between substance-related variables and outcomes seem to be context dependent. we employed latent class analysis (lca), a personcentered approach, to identify distinct subpopulations based on contexts of marijuana use. we also examined whether the resulting classes differ in a set of marijuana-related variables that hold promise as potential targets of interventions. method: a sample of 1083 argentinean college students (64% women; m age = 19.73±3.95) completed an online survey that assessed substance use and related variables (motives for substance use, protective behavioral strategies [pbs] and internalization of the college marijuana use culture). for the present study, only data from students that reported last month (i.e., past 30-day) marijuana use (n = 158) were included in the analysis. participants reported whether or not they used marijuana in different places (i.e., own house, party at home, friends’ house, parties at friends' house, university party, non-university party, bar, dance-club, outside [street, park], or pregaming) or social contexts (i.e., alone, with family members, strangers, boyfriend/girlfriend, close friend, small group of same-sex friends, ≥10 same-sex friends, small coed group of friends, ≥10 co-ed friends). results: lca identified a 2-classes model for marijuana use context. class 1 comprised 40% of last-month marijuana users. students within this class endorsed a high probability of consuming marijuana across different places (e.g., at home, at parties, outdoors) and social contexts (e.g., close friend and in small same sex and coed groups). participants in class 2 exhibited a low endorsement of marijuana use across contexts, yet they reported a moderate to high probability of using marijuana with a small group of same-sex friends or with the close friend, at a friend’s home. the two classes significantly differed, as shown by student’s t, on all marijuana outcomes (i.e., use and negative consequences) and marijuanarelated variables (motives, pbs and internalization of the college marijuana use culture). students in class 2 exhibited significantly less marijuana use, both in terms of frequency and quantity, and less marijuanarelated negative consequences than those in class 1. the latter class exhibited more normative perceptions about marijuana use in college, more marijuana use motives -particularly social, coping conference abstracts 15 and expansion motivesand less use of pbs than students in class 2 did. conclusions: our findings revealed subpopulations of college students that are heterogeneous regarding contexts of marijuana use, patterns of use and in a number of relevant variables. these distinctive subpopulations require different targeted interventions. validation of the spanish version of the marijuana consequences questionnaire (smacq) angelina pilatti (universidad nacional de cordoba) adrian j. bravo (william & mary) yanina michelini, gabriela rivarola montejano, ricardo m pautassi (universidad nacional de cordoba) background: the marijuana consequences questionnaire [macq] assesses marijuanarelated problems. this 8-factor (50-items) measure covers a broad array of multiple dimensions encompassing 50 negative consequences of gradient severity that are particularly relevant in the context of college. the present study aimed to validate the spanish version of the 50-item marijuana consequences questionnaire (s-macq) by analyzing the psychometric properties of internal, convergent, and concurrent validity and estimating internal consistency. we also examined the correlation between the brief (sb-macq) and the full smacq and whether they similarly correlate with marijuana outcomes and marijuana-related variables. method: college students from the two largest public universities of cordoba city (argentina) completed an online survey as part of a broader study focused on marijuana use and risky sexual behaviors. only data from students that reported last-year marijuana use (n=470; 70.6% women; mean age 22.67±3.52 years; 45.7% enrolled in psychology) were included in the study. we conducted independent samples t-tests to evaluate differences in the number of negative consequences (for the total scale and for each smacq dimension) as a function of biological sex or frequency of use. confirmatory factor analyses (cfa) was conducted to examine the factor structure of the s-macq. we conducted pearson correlation analyses to examine the association between the number of marijuana-related consequences as measured by the s-macq and scores (a) in the cudit, a standardized measure of marijuana-related problems (i.e., convergent validity), (b) frequency and quantity of marijuana use (i.e., concurrent validity), (c) motives for marijuana use (i.e., concurrent validity). we examined the pearson correlation between the sb-macq and the s-macq and then we estimated the difference between the pearson correlation of the sb-macq and the s-macq with all the marijuana outcomes and marijuanarelated variables. results: results from the cfa supported an 8-factor structure. the scores of the s-macq showed appropriate internal, concurrent and convergent validity, alongside with adequate internal consistency. the s-macq was largely correlated with the sb-macq and the correlations between these two versions and marijuana outcomes/marijuana-related variables did not significantly differ. discussion: findings supported the s-macq as a valid measure to assess marijuana-related problems in spanishspeaking students. the instrument can be used to identify a broad diversity of marijuana problems in this population. a mapping literature review of medical cannabis clinical outcomes and quality of evidence in approved conditions in the united states, from 2016 to 2019 sebastian jugl, aimalohi okpeku, brianna costales, earl j. morris, golnoosh alipourharris, juan m. hincapie-castillo, nichole e. stetten, ruba sajdeya, shailina keshwani, verlin joseph, yahan zhang, yun shen, lauren adkins, amie goodin (university of florida) background: medical cannabis is available to patients by physician order in two-thirds of the united states (u.s.) as of 2020, but remains classified as an illicit substance by federal law. states that permit medical cannabis ordered by a physician typically require a diagnosed medical condition that is considered qualifying by respective state law. objectives: to identify and map the most recently (2016-2019) published clinical and scientific literature across approved conditions for medical cannabis, and to evaluate the quality of identified recent systematic reviews. conference abstracts 16 methods: literature search was conducted from five databases (pubmed, embase, web of science, cochrane, and clinicaltrials.gov), with expansion and update from the national academies of sciences, engineering, and medicine’s (nasem) comprehensive evidence review through 2016 of the health effects of cannabis on several conditions. following consultation with experts and stakeholders, 11 conditions were identified for evidence evaluation: amyotrophic lateral sclerosis (als), autism, cancer, chronic pain, crohn’s disease, epilepsy, glaucoma, hiv/aids, multiple sclerosis (ms), parkinson’s disease, and posttraumatic stress disorder (ptsd). the following exclusion criteria were imposed: preclinical focus, non-english language, abstracts only, editorials/commentary, case studies/series, and non-u.s. study setting. data extracted from studies included: study design type, outcome, intervention, sample size, study setting, and reported effect size. studies classified as systematic reviews with or without meta-analysis were graded using the amstar-2 tool by two raters to evaluate the quality of evidence, with additional raters to resolve cases of evidence grade disagreement. results: a total of 438 studies were included after screening. five completed randomized controlled trials (rcts) were identified, and an additional 11 trials were ongoing, and 1 terminated. cancer, chronic pain, and epilepsy were the most researched topic areas, representing more than two-thirds of all reviewed studies. the quality of evidence assessment for each condition suggests that few high-quality systematic reviews are available for most conditions, with the exceptions of ms, epilepsy, and chronic pain. in those areas, findings on chronic pain are mostly in alignment with the previous literature, suggesting that cannabis or cannabinoids are potentially beneficial in treating chronic neuropathic pain. in epilepsy, findings suggest that cannabidiol is potentially effective in reducing seizures in pediatric patients with drug-resistant dravet and lennox-gastaut syndromes. in ms, recent highquality systematic reviews did not include new rcts, and are therefore not substantially expanding the evidence base. in sum, the most recent clinical evidence suggests that for most of the conditions assessed, we identified few studies of substantial rigor and quality to contribute to the evidence base. however, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic pain), with the higher quality of evidence for epilepsy driven by fda-approved formulations for cannabis-based seizure treatments. conclusion: the body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions. a comparison of engagement in cannabisrelated protective behavioral strategies across sex and cultures dylan k. richards, frank j. schwebel (university of new mexico) adrian j. bravo (college of william & mary) matthew r. pearson (university of new mexico) cross-cultural addictions study team cannabis-related protective behavioral strategies (pbs) are behaviors used before, during, and/or after using cannabis to reduce its associated harms. despite the effectiveness of pbs in reducing both cannabis use and negative cannabis-related consequences, few studies have examined whether there are sex and cultural differences in pbs use. in the present study, we compare pbs use across males and females and across five countries. we also examine whether the associations of pbs use with cannabis-related outcomes differ by sex and country. we recruited 1,175 college students (63.3% female; mage = 20.96, sd = 3.95; 45.1% freshman, 20.2% sophomore, 16.6% junior, 9.7% senior, 8.4% other) who reported past-month cannabis use from eight universities in five countries (u.s., spain, argentina, uruguay, and the netherlands) to complete an online survey. the online survey included the marijuana use grid (mug; pearson & marijuana outcomes study team, 2020), protective behavioral strategies for marijuana scale (pbsm; pedersen et al., 2016; revised by pedersen et al., 2017), and brief-marijuana consequences questionnaire (b-macq; simons et al., 2012). results of a series of anovas suggested differences across countries on the conference abstracts 17 pbsm total score, f(4, 1,126) = 20.93, p < .001, such that participants in the u.s. (m = 4.53, sd = 1.11) and spain (m = 4.48, sd = 0.95) endorsed the most frequent pbs use and participants in the netherlands (m = 3.46, sd = 1.49) endorsed the least frequent pbs use. there were many itemlevel differences in pbs use across countries with a pattern similar to that for the pbsm total score. results of a series of independent sample t-tests suggested that females (m = 4.51, sd = 1.11) scored higher than males (m = 4.17, sd =1.09) on the pbsm total score, t(1,123) = -4.88, p < .001, as well as nearly every item. the correlations between pbsm total score and cannabis-related outcomes across gender and countries were mostly in the expected direction: more frequent pbs use was associated with less cannabis use and fewer cannabis-related consequences. these correlations were largest for the u.s. sample. interestingly, however, the correlation between the pbsm total score and b-macq was positive for the argentina sample and every correlation between the pbsm total score and cannabisrelated outcome was positive for the netherlands sample. the results of the present study suggest there are several gender and cultural differences in the use of cannabis-related pbs. however, future studies are needed to replicate these findings, especially given the relatively small samples for some of the countries in the present study (our smallest sample size was for uruguay [n = 46]). gender and cultural differences in pbs use should be considered in developing and tailoring pbs interventions, especially because the pbsm was validated with a u.s. sample and most existing interventions were developed for use with u.s. participants. do cannabis use motives mediate the relationship between ptsd symptoms and cannabis craving to trauma cues? kyra n. farrelly, pablo romero-sanchiz, ioan t. mahu, sean t. barrett, pamela collins, daniel rasic, sherry h. stewart (dalhousie university) cannabis use is common in individuals with posttraumatic stress disorder (ptsd). the ptsdcannabis relationship is important as cannabis use can worsen ptsd outcomes. cannabis use motives are a useful construct for understanding the ptsd-cannabis relationship. frequent pairing of a trauma cue with substance use to cope can lead to conditioned substance craving. the extant research has not yet examined potential mechanisms to explain this effect. we recruited 51 cannabis users with a trauma history for a cannabis cue-reactivity study to examine coping motives as a potential mediator of the hypothesized relationship between ptsd symptoms and cannabis craving to trauma cues. participants first completed a validated cannabis use motives measure. they were then exposed to a personalized audio and visual cue based on their trauma experience and reported on their cannabis craving immediately following using a standardized measure. coping motives were contrasted with enhancement motives as the mediator. results supported our first hypothesis: ptsd symptoms were associated with increased cannabis craving following personal trauma cue exposure. however, our second hypothesis of an indirect effect through coping motives was not supported. we did find an independent main effect of coping motives on cannabis craving triggered by trauma cue exposure. the lack of an interaction between ptsd symptoms and coping motives on trauma-cue induced craving is potentially due to other factors we did not examine that help strengthen the relationship (e.g., sleep). these findings have important clinical implications for targeting both ptsd symptoms and coping motives to prevent the development of conditioned cannabis craving to trauma reminders. gender and age differences in comorbid cannabis use disorders and suicidality in a national sample lourah m. kelly (university of connecticut) nicholas r. livingston (university of wyoming) tess k. drazdowski (oregon social learning center) kristyn zajac (university of connecticut) approximately 40 million adults use marijuana annually, making marijuana one of the most commonly used substances in the united states (samhsa, 2019). men and emerging adults (ages 18-25) report higher prevalence of cannabis use disorders (cuds) relative to women and older conference abstracts 18 adults (cbhsq, 2015; khan et al., 2013). more frequent marijuana use is associated with greater likelihood of suicidal ideation (ilgen et al., 2009), and past year use in emerging adults is associated with future suicide attempts (pedersen, 2008). similar to correlates of marijuana use, emerging adults and men have higher rates of suicidality (samhsa, 2019; krug et al., 2002). limited research has tested gender and age differences in comorbid cuds and suicidality. the current study evaluated gender and age differences in cuds only, suicidality only, or comorbid cuds and suicidality in a national sample of adults. we hypothesized that men and emerging adults would be over-represented in comorbid cuds and suicidality and cuds only groups. data were from four consecutive years (20152018) of the national survey of drug use and heath. multinomial logistic regressions tested gender and age differences in adults with dsm-iv cannabis abuse or dependence (cuds) only, suicidality only, and comorbid cuds and suicidality, all compared to adults with neither cuds or suicidality. four separate regressions were conducted for passive suicidal ideation, active suicidal ideation, suicide planning, and suicide attempts. gender was coded as male or female. age groups were 18–25, 26–34, 35–49, and 50 years or older. analyses controlled for survey year, race/ethnicity, sexual orientation, education, household income, past year major depressive episode, past year dsm-iv alcohol abuse or dependence, and past year illicit drug abuse or dependence other than cuds. men disproportionately reported cuds only (ors=1.73-2.19, p’s&lt;.001) and comorbid cuds and passive suicidal ideation, active suicidal ideation, and suicide planning (ors=1.72-2.12, p’s&lt;.01), but not attempts (or=1.16, p=.45) relative to women. men reported 22% higher odds of active suicidal ideation than women. women reported 15% higher odds of suicide attempts than men. gender differences in passive suicidal ideation and planning were not statistically significant. compared to older age groups, emerging adults were significantly more likely to report cuds only (ors=1.74-10.49, p’s&lt;.01) and showed 2.36 to 14.24 times greater odds of comorbid cuds and all four forms of suicidality (p’s&lt;.001). emerging adults were at 18% to 66% higher odds of either passive or active suicidal ideation alone compared to all older age groups (p’s&lt;.001). this study investigated the relations between cuds, suicidality, gender, and age in a nationally representative sample of adults. results indicated that men and emerging adults consistently reported the highest likelihood of negative outcomes. next steps include determining the direction of the relationship between cuds and increasing severity of suicidality. further, development and investment in programs for emerging adults with cuds and suicidality are vitally important given the striking risk profile compared to other age groups. future research should include program development and evaluation as well as gathering more information on risk and protective factors for these populations. evaluating expectancies: do communityrecruited adults believe that cannabis is an effective stress reliever? toni c. spinella, sean p. barrett (dalhousie university) there is growing interest in using cannabis or specific cannabinoids (e.g., thc, cbd) as therapeutic agents for various stress-related psychiatric disorders (e.g., ptsd, anxiety). while beliefs about a drug, such as expecting to feel a certain way, have strong influences over the actual effects experienced by individuals, they are rarely evaluated in clinical research. in the present exploratory report, we sought to (1) evaluate the extent to which individuals believe that cannabis relieves stress, and (2) examine whether individual characteristics (i.e., age, sex, psychiatric illness, cannabis use frequency) are related to these beliefs. a sample of 234 adults (54.7% female; mean age=31.37, sd=11.03, 19-69 years old) from the halifax regional municipality community took part in a brief telephone screening interview to assess their eligibility for a larger study (in progress). information was gathered about the frequency of current (i.e., past month) cannabis use (days per week), the presence of current psychiatric disorder(s) ("yes"/"no"), and the extent to which they believed that cannabis was an effective stress reliever (rating scale from 1 (“not at all”) to 10 (“extremely”)). subjects reported a mean belief rating of 6.39 (sd=2.26). a multiple regression conference abstracts 19 analysis was run to evaluate whether the belief that cannabis relieves stress was related to age, sex, psychiatric illness, and frequency of current cannabis use. overall, the model significantly predicted cannabis belief ratings (p&lt;.001, adjusted r2=.17). among all variables, only frequency of cannabis use contributed significantly to this prediction (b=.544, 95% ci: [.387, .701], p&lt;.001). in general, the present sample of community-recruited adults believed that cannabis was somewhat effective at relieving stress. additionally, cannabis use frequency was the only variable that predicted the strength of this belief, such that more frequent use was associated with higher belief ratings. this is consistent with prior research indicating that heavier cannabis use is linked to positive cannabis expectancies. given that stimulus expectancies influence substance-related responses, such findings would further the case for evaluating and controlling for these expectancies in clinical work with cannabis for stress-related conditions. indeed, clinical cannabis research evaluating samples of heavy or frequent cannabis users may be subject to bias due to higher positive expectancies. cannabis use among women: does daily assessment reactivity affect usage patterns? jason y. isaacs, sean p. mackinnon, kayla m. joyce, sherry h. stewart (dalhousie university) background: daily diary measurements are a common way to assess substance use behaviours, however researchers and clinicians are often cognizant of assessment reactivity (or “reactivity”) in daily substance use measurement. reactivity involves changes to behaviours that result simply from self-monitoring those behaviours. when reactivity to substance use measurement has been found to exist, it has been identified both as a possible confound in daily diary research and a potential intervention tool in clinical practice. reactivity to daily self-monitoring of alcohol and tobacco use has been investigated in prior research, however this research has been inconsistent. reactivity to daily self-monitoring of cannabis use quantity has yet to be documented at all. method: the current study involved secondary analyses of data from n=88 women who self-monitored their cannabis use for 32 consecutive days (joyce et al., under review). we examined objective reactivity of cannabis use to daily self-monitoring both for the probability of use each day as well as the quantity of cannabis used on each cannabis-using day. at study completion, participants were asked the degree to which they felt self-monitoring impacted their cannabis use (i.e., subjective reactivity). we explored the reported degree of subjective reactivity, and we examined correspondence between objective and subjective reactivity. results: hurdle models were the best fit for the data. participants’ probability of daily cannabis use and the quantity of cannabis use did not change significantly over the study period. for subjective reactivity, many respondents (45%) reported no subjective reactivity, though a majority (55%) reported some degree of subjective reactivity with 24% reporting moderate or more reactivity. a three-step hierarchical linear model was used to investigate the relationship between objective and subjective reactivity. time was the only predictor in the first step, subjective reactivity was added as a predictor in the second step, and the time x subjective reactivity interaction was explored in the final step. subjective reactivity was not found to moderate the relationship between time and cannabis use, although there was a significant relationship between self-reported subjective reactivity and variability of cannabis use across the data collection period. conclusions: this study determined that participants who report greater subjective reactivity to cannabis measurement are more likely to demonstrate variability in their cannabis usage. while this study did not find a significant change in cannabis scores over time because of reactivity, the non-significant results are valuable from both a research and a clinical standpoint. for research, the lack of change is an indicator that reactivity is likely not a confounding factor in studies involving cannabis daily diary research. from a clinical perspective, the non-significant change indicates that simply self-monitoring cannabis is unlikely to provide standalone benefits when daily self-monitoring is used in clinical practice. it is relevant to note that our study involved a non-help-seeking sample, and future research could benefit from determining whether cannabis reactivity may be moderated by help-seeking behaviours or motivations to change. conference abstracts 20 mobile phone sensor-based detection of subjective cannabis “high” in young adults: a feasibility study in real-world settings sang won bae (stevens institute of technology) tammy chung (rutgers, the state university of new jersey) brian suffoletto (stanford university) mohammad islam (stevens institute of technology) jiameng du, serim jang (carnegie mellon university) yuuki nishiyama (the university of tokyo) raghu mulukutla (carnegie mellon university) anind k dey (university of washington) "aim: acute cannabis intoxication can impair motor skills and cognitive functions. given possible impairment related to acute cannabis intoxication, we explored whether mobile phonebased sensors (e.g., gps, text/phone logs) can detect episodes of acute cannabis intoxication (subjective “high” state) as self-reported in natural environments by young adults. methods: young adults (ages 18-25), who reported cannabis use at least twice per week, were recruited by research registry and craigslist to participate in a mobile phone data collection study (up to 30 days) in pittsburgh, pa (2017-2019). participants responded to fixed time phone surveys (3 times/day) and self-initiated reports of cannabis use (start/stop time, rating of subjective high: 0-10, 10=very high). our mobile aware app continuously collected phone sensor data, which was segmented into 5-minute windows for analysis. we built and tested multiple machine learning classifiers (e.g., support vector machine, light gradient boosting machine (lgbm)) on training (60%), validation (20%), and test (20%) datasets to determine which classifier performed best in distinguishing subjective cannabis “high” (rating=1-10) vs “not high” (rating=0). to minimize the influence of imbalanced data on model performance in the training dataset, we used both over-sampling with synthetic minority over-sampling technique (smote) and random under-sampling of the majority class, so that both classes (“high”, “not-high”) had the same number of training samples. we also tested the importance of time features (i.e., day of week, time of day: morning, afternoon, evening) relative to smartphone sensor data only on model performance, since time features alone might predict “routines” in cannabis use. results: young adults (n=57; 58% female; mean age=19.82 [sd=1.76]; 71.92% white, 15.78% black, 12.28% asian and other ethnicity) reported 451 episodes of cannabis use, mean subjective high rating=3.77 (sd=2.64). the sensor dataset included 1,648 datapoints representing reports of subjective ""high"" and 60,580 data points representing ""not high"" reports. for the two time-based features only model, the lgbm classifier had 91% accuracy in detecting subjective cannabis intoxication (vs “not-high”) in the test dataset (area under the curve [auc]=0.75). combining smartphone sensor data with the two time-based features (day of week, time of day) improved model performance, with 95% accuracy (auc=0.93), indicating that smartphone features contribute unique information, and that time features further improve model performance in detecting rating of subjective cannabis ""high"". among the 102 phone sensor features entered into the analyses (smartphone sensors + time model), some of the most important features (the top 2 were the time features) included travel (gps: smaller travel radius within a day when feeling ""high”), movement (e.g., smaller number of activity changes when feeling ""high”), and communication/sociability (e.g., increased phone usage interactions, greater voice and noise level around individuals). conclusion: results from this proof-of-concept study indicate the feasibility of using phone sensors to detect effects of cannabis intoxication in the natural environment in a population-based model among young adults. mobile phone sensors show promise for automated and continuous detection of cannabis use in daily life in a sample of young adults, with potential implications for triggering the delivery of just-in-time interventions to minimize marijuana-related harm. conference abstracts 21 effort expenditure and cannabis use: testing the amotivational hypothesis samuel f. acuff, nicholas w. simon, james g. murphy (the university of memphis) cannabis is the most commonly used illicit drug in the us and appears to have an indirect effect on dopamine (da) output in the mesolimbic projection, a circuit implicated in reward processing and effort expenditure. thus, some have suggested that cannabis use might be associated with aberrant effort-based decision making. the most popular theory positing changes in motivation due to cannabis use is the amotivation syndrome hypothesis, which suggests that chronic cannabis use results in impaired executive functioning, arousal, and affective reactivity leading to reduced capacity for goaldirected behavior other than drug seeking. however, only one study has examined this among cannabis users, and the results suggested no difference between cannabis and non-cannabis users. further, other studies suggest greater effort expenditure among the substance using groups compared to controls. the current study extends these findings by examining the relation between cannabis use and effort-related decision making in a sample of college students. cannabis using (n = 25) and non-cannabis using (n = 22) students completed the effort expenditure for rewards task (eefrt), in which participants choose between a ‘hard’ task that requires pressing a button 100 times with the nondominant little finger for a large sum of money (high effort/high reward) or an ‘easy’ task that requires pressing a button 30 times with the dominant index finger for a smaller sum of money (low effort/low reward). results were then compared between the cannabis and non-cannabis using groups. on average, participants selected the hard trials 46% of the time (sd = 19%). participants successfully completed the hard trials 74% of the time (sd 29%), while they completed the easy trials 97% of the time (sd = 6%). no participant selected only hard or easy trials during the duration of the task. cannabis users (m=41.40, sd=3.55) completed significantly fewer trials compared to nonusers (m=43.64, sd=3.74). further, nonusers (m=26.82, sd=10.01) selected easy trials significantly more often compared to cannabis users (m=21.40, sd=8.34), and nonusers (m=99%, sd=2%) also successfully completed easy trials more often compared to cannabis users (m=95%, sd=7%). however, cannabis users and nonusers did not differ in the number of hard trials selected (cannabis users m=16.82, sd=5.67; nonusers m=16.82, sd=7.68) or the percentage of successfully completed hard trials out of the total number of hard trials (cannabis users m=72%, sd=27%; nonusers m=76%, sd =32%). both the reward magnitude and probability of reward receipt predicted greater likelihood of selecting a hard trial. in generalized estimating equation models, past month cannabis days and cannabis use disorder symptoms predicted the likelihood of selecting a hard trial, such that greater levels of both cannabis use days and symptoms were associated with an increased likelihood after controlling for reward value, probability, and expected value. the results suggest that college students who use cannabis are more likely to expend effort, even after controlling for the magnitude of the reward and the probability of reward receipt, suggesting the possibility for aberrant reward processing, albeit in the opposite direction of the amotivational syndrome hypothesis. a perfect storm: unintended effects of homeschooling on parents’ mental health and cannabis use behaviors during the pandemic mariam elgendi, helene deacon (dalhousie university) lindsey rodriguez (university of south florida st. petersburg) fiona e. king (mcgill university) simon b. sherry, allan abbass, sandra meier, raquel nogueira-arjona, amanda e.f. hagen, sherry h. stewart (dalhousie university) the covid-19 pandemic resulted in families selfisolating under incredible stress. viral containment strategies included school closures with parents left to homeschool their children with few supports from the educational system. recent data show that those with children at home were more likely to drink heavily during the pandemic (rodriguez et al., in press). gaps remain, however, in understanding whether these effects are due to the stresses of homeschooling conference abstracts 22 and whether they extend to cannabis use. sevenhundred-and-sixty canadian romantic couples (total n=1520 participants; mean age = 57 years; 50% women) who were self-isolating together during the month of april 2020 were recruited through qualtrics panel surveys. measures were completed retrospectively in early july 2020; participants were asked to report on their feelings and behavior in april 2020 during lockdown. they completed the gad-7 (spitzer et al., 2006) and the phq-9 (kronke et al., 2001) to assess anxiety and depression, brief versions of four subscales of the covid-19 stress scales (taylor et al., 2020) to assess stress around the pandemic, and the life orientation test – revised (chiesi et al., 2013) to assess optimism. they completed a measure of role strain (statistics canada, 2015) and a measure of conflict with their partner (murray et al., 2003). they also completed a validated measure of cannabis use frequency and quantity (cuttler et al., 2017), as well as two validated items from the brief cannabis motives measures (bartel et al., 2020) to assess cannabis use to cope with depression and anxiety, respectively. all measures were completed for a 30-day timeframe during the month of april. participants also reported on whether they were homeschooling one or more children in grade 1-12 during the month of april. data was analyzed with a one-way (homeschooling group) analysis of covariance (ancova) controlling for group differences in age; a bonferroni-correction was applied to account for multiple tests. compared to those who did not homeschool (n=1116), those who did homeschool (n=404) experienced significantly more depression (p=.001), more covid-19related stress around socioeconomic consequences (p<.001) and traumatic stress (p<.001), and less optimism (p=.002). and those who homeschooled experienced more role strain between their home and work responsibilities (p<.001) and more conflict both toward and from their partner (p’s<.001) than those who did not homeschool. those who homeschooled also used cannabis significantly more frequently in the month of april than those who did not homeschool (p=.003). compared to cannabis users who did not homeschool (n=122), cannabis users who did homeschool (n=61) reported more frequent cannabis use to cope with both depression and anxiety (p’s = .003). these findings suggest that unintended consequences of our societal viral containment strategies include more depression, pessimism, role strain, inter-parental conflict, and certain covid-related stresses, and extend to more frequent cannabis use to cope with negative affect, among parents required to homeschool during the pandemic. these unintended mental health and substance misuse consequences for parents need to be considered when planning for an educational strategy in the fall and for any future waves of the pandemic. pms affective symptoms indirectly linked to cannabis use frequency and problems via cannabis coping motives sherry h. stewart (dalhousie university) kayla m. joyce (university of manitoba) phillip tibbo (dalhousie university) nacera hanzal (university of ottawa) kimberley good (dalhousie university) background: women with pms have higher rates of substance use disorders but underlying mechanisms remain poorly understood. research on the links of pms to problematic substance use has largely omitted consideration of cannabis use. design/method: to fill these gaps, 87 cannabis using women (mean age = 28.9 years) completed a cross-sectional survey involving self-reports on their pms symptoms on the pre-menstrual scale – short form (pms-sf), their usual motives for cannabis use on the marijuana motives measure (mmm), their frequency of cannabis use in the last 30 days on the cannabis timeline followback (ctlfb), and their level of cannabis use problems on the cannabis use disorder identification test (cudit). analyses/results: a series of multiple regressions were performed, along with sobel tests of indirect effects, to examine the potential mediational role of cannabis motives in explaining the expected links of pms symptoms with cannabis use frequency and problems. separate models were run with cannabis use frequency and problems as outcomes, and with pms affective and physiological symptoms as predictors. in each case, both coping motives and social motives (as a control to determine specificity) were tested as simultaneous mediators. pms affective (but not physiological) symptoms were indirectly conference abstracts 23 positively related to both cannabis use frequency and problems through coping (but not social) motives for use (sobel tests = 2.01 and 2.26, respectively, p’s &lt; .05). discussion: findings suggest that it is the affective symptoms of pms (e.g., depressed mood), rather than the physiological symptoms (e.g., bloating, pain), that drive more frequent and problematic cannabis use in women. moreover, the mechanism to explain this link appears to be coping (but not social) motives for cannabis use. thus, those women with greater levels of pms affective symptoms appear to use cannabis more frequently and problematically than other women by way of their greater use of cannabis to cope with negative mood. why young adults obtain a medical marijuana card: associations with health symptoms, risk, and heaviness of use justin f. hummer, rachana seelam (rand corporation) eric r. pedersen (university of southern california; rand corporation) joan s. tucker, elizabeth j. d’amico (rand corporation) objective. prior studies documenting more frequent and problematic use among young adults who have acquired medical marijuana (mm) cards have broadly compared those who use medically to those who use recreationally. gaining a better picture of how health symptoms and problematic use vary both within those who have a mm card for specific condition domains and between those who do not have a mm card, can provide key information for medical practitioners and states interested in adopting or updating mm policies. method. the current study categorizes young adults authorized to use mm into four mutually exclusive groups based on endorsements of qualifying conditions: (1) physical health only; (2) mental health only; (3) sleep only; and (4) multiple conditions. analysis of covariance examined differences across marijuana use, problems, mental and physical health, and sleep for mm condition categories, and for those that only use marijuana recreationally. results. mm card holders, particularly those with physical health or multiple health conditions, reported heavier, more frequent, and more problematic and risky marijuana use compared to those using recreationally. despite this pattern, those in different mm condition categories were generally not found to be more symptomatic in domains of functioning relevant to their respective conditions, compared to different category groups or to those using recreationally. conclusions. findings emphasize the importance of providers conducting a careful assessment of reasons for needing a card, along with use, to reduce potential harms while adding credibility to a medical movement with genuine promise of relief for many medical conditions. anxiety, expectancies for cannabis-induced anxiolytic effects, and frequency of cannabis consumption paul l. guay, maha n. mian, brianna r. altman, luna f. ueno, mitch earleywine (university at albany, state university of new york) this study explored relations among anxiety, expectancies for cannabis’s anxiolytic effects, and frequency of use. undergraduate users (n=242, mage = 19.1, 64.5% male, 46.6% white, 18.6% african american, 13% hispanic/latino, 12.7% asian, 9.1% mixed) rated their anxiety on the tsc-40. they reported expectancies for cannabis’s anxiolytic effects using the same tsc items with a rating from -2 (making the symptom worse) to +2 (making the symptom better). average expectancies were 2.41, suggesting that users expected some impact of cannabis on anxiety symptoms. these expectancies showed a dramatic skew that required transformation. we regressed anxiety and expectancies and their centered interaction term on days of use per month. expectancies (b=.917) served as a significant predictor, however anxiety did not (b=.215). the interaction term was not significant, (b=.155). these results suggest that users choose the number of days they use based on their expectations of cannabis-induced improvement of anxiety, not on their level of anxiety. the interaction was not an important contributor. these results suggest that alternative approaches for handling anxiety might decrease the frequency of cannabis consumption. in addition, challenging cannabis expectancies about anxiety could also decrease frequency of consumption. conference abstracts 24 associations between cannabis use characteristics, impulsivity, and mindfulness sam feck, rebecca j. houston (rochester institute of technology) impulsivity has been implicated as a factor in cannabis use and cannabis-related problems. however, impulsivity is a multi-faceted construct. recent work in substance use has used the uppsp impulsive behavior questionnaire (upps-p), which is designed to assess five facets of impulsivity. research examining these facets of impulsivity and cannabis use characteristics is somewhat inconsistent, but generally has suggested that sensation seeking and lack of premeditation may be related to cannabis use and negative urgency may be associated with cannabis-related problems. in addition, a substantial literature exists suggesting that mindfulness, the ability to focus one’s attention on the present moment in a non-judgmental, nonreactive, and tolerant manner, is decreased in substance users. however, the literature specific to mindfulness and cannabis use characteristics is relatively inconsistent. thus, the aim of the current study was to replicate and extend prior research on the associations between impulsivity, mindfulness, and cannabis use. a community sample of adults (n = 289, 137 female) completed an online survey that included the short upps-p (supps-p) impulsiveness questionnaire, mindfulness attention awareness scale (maas), and questions about cannabis use and cannabisrelated problems. a logistic regression in the full sample revealed that supps-p lack of premeditation and maas total scores, as well as alcohol consumption, were significant positive predictors of cannabis user status (i.e., use in the past 30 days). the lack of premeditation finding is consistent with prior studies, but the association between increased mindfulness and cannabis user status was unexpected. it’s possible that the mind set and physical setting in which cannabis is used has influence on the subjective experience, and thus, users may be seeking effects relevant for an overall sense of well-being similar to that seen in research on psychedelic drug use. in the subsample of cannabis users that reported use in the past 30 days (n = 87), no significant associations were revealed between impulsivity facets or mindfulness and cannabis use frequency. no impulsivity or mindfulness variables emerged as significant predictors of cannabis-related problems in users; although, consistent with prior studies, the association with supps-p negative urgency approached significance. alcohol-related problems were associated with cannabis-related problems as well. these findings extend the previous literature and have implications in identifying risk for problematic/disordered use as well as improving upon interventions and treatment approaches for problematic cannabis use. an interactive personalized feedback and textmessaging intervention is associated with reductions in substance-impaired driving shelby a. king, sterling m. hubbard, jenni b. teeters (western kentucky university) background: substance-impaired driving continues to be a national public health concern and data suggests that up to one-third of college students report driving after drinking and/or cannabis use in the past year. to date, little research has investigated whether brief, technology-based interventions can be used to reduce substance-impaired driving among young adults. recent research indicates that interventions that incorporate personal contact lead to larger effect sizes than fully automated interventions. the present study compared an interactive text-messaging intervention to an automated text-messaging intervention in the context of a brief, mobile-phone based substanceimpaired driving intervention. method: participants were recruited through the university’s subject pool (n = 46) and completed measures that assessed impaired driving at baseline and three-month follow-up. in order to be eligible, students had to be at least 18 years or older, have access to a motor vehicle, and report driving after drinking two or more drinks and/or driving after cannabis use at least three times in the past three months. participants were randomly assigned into four conditions: personalized feedback plus text-messaging (n = 12), personalized feedback plus automated text messaging (n = 11), an active control condition (substance use information, n = 12), and an assessment only control condition (n = 11). results: repeated measures anovas were run to compare the number of times driving while conference abstracts 25 impaired over time across conditions. analyses revealed the personalized feedback plus textmessaging led to significantly greater reductions over time in the number of times driving while impaired compared to participants in the assessment-only condition (p = .022). additionally, participants in the personalized feedback plus text-messaging condition reported a greater reduction over time in the number of times driving while impaired than those in the personalized feedback plus automated text messaging condition, though this difference was not significantly significant (p = .066). surprisingly, the text-messaging conditions did not result in significantly greater reductions in substance-impaired driving compared to the active control condition (p = .227). discussion: overall, these findings provide preliminary support for the short-term efficacy of a mobile-delivered personalized feedback intervention with interactive text-messaging in reducing substance-impaired driving among young adults. due to covid-19, three-month follow-up data could not be collected from half of the originally enrolled sample, resulting in underpowered analyses. additional data will be collected as part of this pilot trial in the coming year. examining associations between trauma exposure and cannabis use frequency, quantity, duration, and age of onset kelsey c. woodward, annalee s. ellis, jenni b. teeters, matthew j. woodward (western kentucky university) prior research has identified an association between trauma exposure and cannabis use, such that a history of trauma exposure is associated with greater likelihood of lifetime cannabis use. however, little research has expanded upon this association, making it unclear whether trauma exposure is associated with cannabis use outcomes beyond lifetime history of use. given that heavy cannabis use and trauma exposure are risk factors for a number of deleterious outcomes, it is important to further examine the influence of trauma exposure on cannabis use. the purpose of the current study was to further explore this relationship by examining associations between trauma exposure and various indices of cannabis use. participants included a sample of 722 female undergraduates at least 18 years or older (m = 19.0) who were recruited through a campus-wide online study pool. participants completed measures on trauma exposure (calculated as number of traumas experienced), cannabis use (i.e., daily sessions, frequency, age of onset, and quantity of cannabis use [dfaq-cu]; cutler & spradlin, 2017), and mental health symptoms. specific indices of cannabis use were lifetime history of cannabis use, age of onset of cannabis use, current frequency of use, current quantity of use (in grams), and length of use. logistic regression analyses and correlations were used to explore the associations between trauma and cannabis use variables. subsequent analyses were conducted controlling for posttraumatic stress disorder (ptsd) symptoms to determine whether relationships between trauma exposure and cannabis use remained after accounting for ptsd symptoms. thirty-seven percent (n = 266) of the sample indicated a lifetime history of cannabis use. similar to previous research, greater trauma exposure was significantly associated with a greater likelihood of a lifetime history of cannabis use (or = 1.14, p &lt; .001). additionally, number of traumas experienced and age of onset of cannabis use were significantly negatively correlated, r(262) = -.16, p &lt; .01, indicating that greater trauma exposure was associated with earlier onset of use. number of traumas experienced was positively correlated with duration of cannabis use, r(236)=.14, p = .03, indicating greater trauma exposure was associated with greater duration of use. number of traumas experienced was also positively correlated with quantity of cannabis use, r(175)=.20, p &lt; .01, showing that greater trauma exposure was associated with higher amounts of cannabis used. these associations remained significant even after controlling for ptsd symptoms. frequency of cannabis use was not significantly correlated with trauma exposure, r(266) = -.01, p = .82. the results of the present study indicate that trauma exposure is associated with a range of indices of cannabis use beyond lifetime history of use, even after accounting for the influence of ptsd. these findings highlight the importance of extending examination of trauma and cannabis beyond frequency of use. although trauma conference abstracts 26 exposure may serve as a risk factor for elevated cannabis use, it is also possible that cannabis use may increase the risk of trauma exposure. future studies should explore these associations longitudinally as well as examine the mechanisms that link these outcomes together. copyright: © 2021 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i1a6_authors_final_p research article 65 ved abstract prior research has linked deficits in executive control (ec) to marijuana use in adolescents but has relied either primarily on adolescent self-report of ec or tasked-based ec, and focused on limited aspects of ec, usually inhibitory control. we examined unique associations of three established aspects of ec (inhibitory control, working memory, and flexible shifting) assessed with both performance on laboratory tasks and self-report in relation to marijuana initiation. participants were 260 youth (ages 14-18 years) from a small midwestern city in the united states enrolled in the adolescent phase (beginning in 2017) of an ongoing study of ec development recruited originally between 2006 and 2012 (46% male, 72% european american). the three aspects of executive control were measured in a laboratory setting with well-established performance-based measures and with a psychometrically-sound self-report survey instrument. youth also provided self-report of marijuana initiation in a phone survey administered during their laboratory visit. multiple logistic regression analysis indicated that flexible shifting as measured by a performance-based task was negatively and uniquely associated with marijuana initiation (aor = 0.68, 95% ci = 0.48 – 0.91), and self-reported deficits in inhibitory control were positively associated with marijuana initiation (aor = 1.92, 95% ci = 1.15 – 3.21). although larger-scale longitudinal research is needed, findings of this study suggest that screening efforts to identify youth at risk of marijuana initiation might rely on more costeffective self-report assessment of inhibitory control, but further valuable information can come from more resource-intensive but sensitive performance-based assessment of flexible shifting. keywords: executive control; adolescence; marijuana; initiation marijuana is a commonly used substance among adolescents in the united states. the overall prevalence of lifetime and annual marijuana use has remained relatively stable; for example, there was no change in the lifetime prevalence of marijuana use among 12th grade ying guo1, charles b. fleming2, irina patwardhan3, tiffany d. james4, jennifer m. nelson4, kimberly a. espy5, timothy d. nelson6, w. alex mason1 1department of preventive medicine, university of tennessee health science center 2center for the study of health and risk behaviors, university of washington 3child and family translational research center, boys town 4office of research and economic development, university of nebraska-lincoln 5office of the provost and vice president for academic affairs, university of texas at san antonio 6department of psychology, university of nebraska-lincoln cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.006 a comparison of task-based and questionnaire assessments of executive control aspects in relation to adolescent marijuana initiation corresponding author: w. alex mason, phd, department of preventive medicine, university of tennessee health science center, 66 n. pauline street, suite 637, memphis, tn 38163. email: wamason@uthsc.edu executive control and marijuana initiation 66 students from 2019 to 2020 (43.7% in both years; miech et al., 2021). by contrast, the prevalence of daily or near-daily marijuana use in the past 30 days has increased recently (e.g., from 6.4% in 2019 to 6.9% in 2020 among 12th grade students; miech et al., 2021), corresponding to the declines in perceived harm of marijuana use among adolescents (johnston et al., 2021). early initiation of marijuana may adversely affect youth’s mental health (e.g., affective disorder; levine et al., 2017), and increase their chances of developing marijuana dependence in adulthood (paige & colder, 2020). executive control in adolescence research to elucidate modifiable factors associated with adolescent marijuana use can help guide the design of interventions for preventing such use and its potential adverse consequences (mason et al., 2016). one important factor is executive control (ec; also termed executive function), which refers to high-level cognitive processes involved in the regulation of behavior (diamond, 2013). ec becomes organized and can be measured as a unitary construct in early childhood (espy, 2016). with increasing brain maturation throughout childhood and into adolescence, differentiation of ec occurs (lee et al., 2013; nelson et al., 2022). although additional research on the structure of ec among adolescents is needed, current models suggest that ec differentiation into early adulthood increasingly can be partitioned into three aspects, including inhibitory control (the ability to inhibit prepotent responses), working memory (the ability to hold information temporarily and work with it), and flexible shifting (the ability to shift between changing task demands) (friedman & miyake, 2017; lee et al. 2013; miyake et al., 2000; nelson et al., 2019). research on composite ec and adolescent substance use ec has been studied as a composite measure in relation to adolescent substance use, which has most often referred to alcohol and tobacco use or general substance use in a combined measure (sometimes including marijuana). shoal and giancola (2001) examined the relationship between composite ec and substance use frequency and problems in a sample of adolescent males. substances included alcohol, marijuana, and other drugs measured as a combined variable. they used a battery of neuropsychological tests (e.g., the porteus maze test, the stroop test) and combined them to form a latent ec factor. results showed that a high-risk group of individuals with a family history of substance use disorder had significantly lower ec than a low-risk group of individuals without a family history of substance use disorder. better ec predicted less substance use frequency and less substance use problems in the high-risk group, but not in the low-risk group. composite ec also has been shown to be significantly related to adolescent cigarette and alcohol use (pentz & riggs, 2013; pentz et al., 2015). for example, pentz and riggs (2013) examined the relationship between executive control and substance use in a sample of fourth grade children. this study used the self-report behavioral rating inventory of executive function (brief) to measure executive control and combined lifetime cigarette and alcohol use into an overall measure of substance use. strong ec was significantly related to less substance use 6 months later, controlling for gender, ethnicity, out-of-school physical activity, exercising with parent, baseline substance use, and socioeconomic status. pentz and colleagues (2015) found that executive function problems, also measured via the brief, were significantly positively related to e-cigarette, cigarette, and alcohol use. adolescents with executive function problems were more than two times as likely to use cigarettes and alcohol and around five times as likely to use e-cigarettes, as adolescents without such problems. research on specific ec dimensions and adolescent substance use important as these studies have been, they leave significant gaps in knowledge because each of the three aspects of ec may have independent associations with adolescent substance use. for example, inhibitory control can be a factor in inhibiting substance use when it is available, such as in response to offers from peers. working memory is crucial in holding and manipulating substance use-related information that might help prevent substance use in the moment. flexible shifting is critical in choosing healthy, safe behaviors and in diverting attention away cannabis, a publication of the research society on marijuana 67 from substance-related cues (fleming et al., 2020; nelson et al., 2019). however, research on specific ec aspects has tended to focus on measures of inhibitory control to the exclusion of other aspects (see nelson et al., 2019), and studies typically have not examined marijuana use, specifically, or have incorporated such use into combined measures of general substance use. for instance, studies have consistently shown that inhibition predicts substance initiation and use among adolescents (mahmood et al., 2013; squeglia et al., 2014; tarter et al., 2003, 2004; wills et al, 2006). tarter and colleagues (2003) used three constructs to measure neurobehavioral disinhibition, including affective disinhibition (measured by the revised dimensions of temperament survey), behavioral disinhibition (measured by the number of conduct disorder, odd, and adhd symptoms reported on k-sadse and the total score on the disruptive disorders rating scale), and cognitive disinhibition (measured by the stroop, porteus maze, vigilance, motor restraint, forbidden toys, and block design tests). the frequency of general substance use (alcohol, tobacco, marijuana, and other drugs combined) was measured at age 16 with reference to the prior 30 days, and substance use disorder diagnosis and severity were measured at age 19. this study found that neurobehavioral disinhibition at age 16 significantly discriminated boys at low and high risk for substance use disorder at age 19. mahmood and colleagues (2013) used the go/nogo task during an fmri session to measure response inhibition and conducted a detailed interview to measure substance use and dependence in a sample of 80 adolescents aged 1619 years (39 with a history of high frequency substance use and 41 with low frequency use). substance use was measured by questions about lifetime and past 3-month use of alcohol, marijuana, nicotine, and eight other illicit drugs at baseline, and by past 18-month use of those substances at follow-up. of note, alcohol was measured alone, and marijuana was incorporated into a combined measure with other substances. they found that atypical activation patterns in the prefrontal cortex during the go/no-go task (particularly during no-go trails) were associated with greater alcohol and other substance use 18 months later. studies examining other ec aspects in relation to adolescent substance use are few in number. for example, working memory has been shown to predict alcohol and tobacco use (khurana et al., 2013; romer et al., 2011). khurana and colleagues (2013) indicated that preexisting deficits in working memory predicted both concurrent alcohol use and increased frequency of drinking over four-year follow-ups among early adolescents, though this effect was mediated fully by impulsivity. this study used the digit span, visual spatial working memory, corsi block tapping, and letter two-back tasks to measure working memory. romer and colleagues (2011) found that working memory was inversely related to subsequent alcohol and tobacco use; however, substance use was measured together with fighting and gambling as one construct. working memory was measured by the corsi block tapping, letter two-back, digit span, and spatial working memory tasks. working memory has also been shown to be unrelated to alcohol, tobacco, and other substance use (nigg et al., 2006; romer et al., 2009). research on composite ec and specific ec dimensions and adolescent marijuana use taken together, the literature reviewed above indicates that additional studies addressing all three ec aspects simultaneously are needed. moreover, many prior studies have excluded marijuana or only incorporated it into measures of general substance use. still, similar to studies of ec in relation to other substances, studies that have examined marijuana use as a separate outcome have restricted their attention to composite ec or to particular ec aspects. for example, deficits in composite ec in childhood, at ages 10-12-years of age, have been shown to predict early adolescent marijuana, tobacco, and alcohol use measured separately at 2-year followup (aytaclar et al., 1999). findings from extant research indicate that inhibitory control problems are associated with the early initiation and use of marijuana (e.g., tarter et al., 2003; squeglia et al., 2014; wills et al., 2006). wills and colleagues (2006) found that poor behavior control and poor emotion control were positively associated with marijuana, alcohol, and tobacco use among adolescents aged 12-16-years. squeglia and colleagues (2014) reported that inhibitory executive control and marijuana initiation 68 functioning, measured via neuropsychological tests, in early adolescence was related to subsequent marijuana use frequency and intensity by late adolescence; however, early adolescent cognitive functioning including shortterm memory was not related to alcohol and marijuana use in late adolescence. moreover, attention dysfunction, a measure of flexible shifting deficiency, has been shown to predict substance use (e.g., alcohol, marijuana, and stimulants; tapert et al., 2002). tapert and colleagues (2002) reported that poorer attention, measured via performance-based tasks (i.e., digits forward, digits backward, arithmetic and coding, and trails tasks) was associated with greater substance use frequency, and particularly with more marijuana use, in a community sample of adolescents, above and beyond preexisting substance use levels. summary of research gaps in summary, there are at least three significant gaps in prior research on ec and adolescent substance use. first, relevant studies often have represented ec as either a general construct (e.g., aytaclar et al., 1999) or as only one aspect, usually inhibition (e.g., squeglia et al., 2014). second, studies in this area of research have either relied on questionnaire-based assessments of ec (e.g., pentz & riggs, 2013; wills et al., 2006) or performance-based tasks (e.g., tapert et al., 2002; mahmood et al., 2013) only, but typically have not used multiple assessment methods and compared them in adjusted analyses. in one known exception, hagen and colleagues (2016) compared performancebased executive function tasks and a self-report questionnaire assessment of executive function problems, finding that executive function tasks displayed modest, and self-report assessment displayed robust, ability to distinguish adults with and without substance use disorder. toplak and colleagues (2013) concluded that the relationships between brief self-report and performance-based measures of ec were fairly weak in both clinical and non-clinical samples of children, adolescents, and young adults, suggesting that self-reported and performancebased measures of ec assess different underlying constructs to some degree. self-report measures (e.g., brief) tap into the difficulties experienced in everyday activities, whereas performancebased measures refer to individual’s decisionmaking abilities under standardized conditions and consider individual’s response time and accuracy (toplak at el., 2013). to extend hagen et al. (2016), similar studies comparing self-report questionnaire and performance-based ec assessments during adolescence, a period of ongoing brain maturation and associated ec development (bava & tapert, 2010), are needed. third, many studies in this area of research have focused on alcohol and tobacco use or general substance use. prior research that has examined marijuana-related outcomes, specifically, has been informative (e.g., tapert et al., 2002), but has been limited by narrow, mono-method ec assessment. thus, little is known about the degree to which the three aspects of ec might have independent associations with adolescent marijuana use, and whether associations are evident when using both performance-based tasks and a questionnaire-based assessment completed in a laboratory setting. the current study this study addresses key gaps in the literature by examining the independent associations of performance-based abilities as well as self-reported deficits in inhibitory control, working memory, and flexible shifting in relation to marijuana initiation in adolescents (ages 14-18 years) from the general population. it was expected that ec aspects as reflected by both performance-based and self-reported tasks would be associated with marijuana use initiation. given prior research, we expected associations to be strongest for measures of inhibitory control. methods participants participants were 260 adolescents (45.7% male), aged 14-18 years (m = 16.22, sd = 1.32), who are part of an ongoing study of the development and consequences of ec (espy, 2016). families with preschool age children (m = 4.12, sd = 0.97) from a small midwestern city enrolled in the study between 2006 and 2012 and have been followed over time. here, we used data from enrolled youth who participated in the cannabis, a publication of the research society on marijuana 69 adolescent phase of the study. the analysis sample is 72% european american, 4% african american, <1% asian, and 23% multiracial; 13% are latino/hispanic ethnicity. a third of their families (33%) were headed by one parent upon enrollment into the larger study and the median household income was $42,000 per year. slightly less than half (44%) of mothers had a college or post-graduate degree. more information on recruitment and assessment procedures is provided in james et al. (2016). procedures families enrolled in the original study have been asked to participate in the adolescent phase of the ongoing study. specifically, beginning in 2017, participating youth have been assessed annually around the time of their birthdays from ages 14-18 years. these assessments involve both an in-person laboratory visit and a phone survey. due to the larger study’s original cohortsequential design, participants ranged in age from 10 to 16 years at the beginning of the adolescent data collection. thus, some participants were not yet age 14, the age at which participants became eligible for the adolescent phase of the study, when the new phase began. in the current analyses, we use data collected through may 2021, by which time the youngest cohort had aged into the adolescent phase of the study at age 14. adolescents who completed at least one phone survey (n = 260) and, therefore, gave information on adolescent marijuana initiation make up the analysis sample for the current study. parents/legal guardians gave informed consent for both adolescent participation and their own participation. adolescent participants gave informed assent. the institutional review board of the university of nebraska-lincoln approved all procedures. measures task-based measures of ec abilities. measures of adolescent ec included wellestablished neuropsychological tasks capturing abilities in inhibitory control, working memory, and flexible shifting. tasks were administered to individual participants by trained research assistants during laboratory visits. for all three tasks, higher scores indicate better ec abilities. each task is described briefly below, and further details are available elsewhere (nelson et al., 2020). inhibitory control was assessed with the computerized version of the go/no-go task (adapted from bezdjian et al., 2009). during this task, the participant is asked to press a button when any letter except x, y, or z appears on the computer screen. a buzzer sound is provided if the participant presses the button incorrectly, when any of the excluded letters are present on the screen. there are 300 trials including 225 “go” trials and 75 “no-go” trials. the standardized difference between hit rate and incorrect hit rate is used as the outcome variable (d-prime). working memory was assessed using the nebraska barnyard task, which was adapted for the current study from the noisy book task (hughes et al., 1998). in this performance-based task, the participant is asked to remember animal names in a sequence and press matching boxes on screen in the correct order. in the initial training stage, the participant is provided with a set of nine barnyard animals in a 3 × 3 grid of colored boxes on the screen. the corresponding sound of an animal is produced when the participant presses each animal. the participant is asked to complete nine trials during which animals are removed. the examiner names the animal individually, and the participant is asked to press the colored box that matches the animal. then, the examiner administers the sequences of animals, which begins with only two animals and increases progressively to a maximum of nine animals until the participant demonstrations deterioration of performance. the participant is scored 0.33 for correctly pressing the box for one animal and is scored 1 for correctly pressing the boxes for a sequence of several animals. the outcome variable is the final summed score throughout all nine trials. flexible shifting was assessed with the computerized version of the shape schoolswitching condition task (espy, 1997; espy et al., 2006). during this task, the participant is presented with the stimuli of cartoon figures that come in two colors and two shapes, and either wearing a hat or not. the task requires the participant to switch between naming the color of stimuli without a hat and naming the shape of the stimuli with hat. about one-third of the trials are shifted trails, which means the subsequent stimulus is different from the preceding stimulus; executive control and marijuana initiation 70 two-third of the trials are not shifted trials, which means the subsequent stimulus is the same as the preceding stimulus. the outcome variable is percent correct across the shift trials, which combines accuracy and response time into a single score. questionnaire-based measures of ec deficits. adolescents also completed the behavior rating inventory of executive function, second edition (brief-2; gioia et al., 2015) in the laboratory to provide a measure of daily symptoms of problems with ec. the brief-2 has been norm-referenced for youth ages 11-18 years and is widely used. among the instrument’s available scales, we used the three subscales that correspond to the three main aspects of ec: inhibit (8 items; e.g., problems with impulsivity); working memory (8 items; e.g., problems remembering things); and shift (8 items; e.g., problems adjusting to changes in routine). each item was rated on a 3-point likert-type scale with response options of “never,” “sometimes,” or “often.” in the current analyses, we used adjusted scores, which are raw scores corrected for missingness. the brief-2 has demonstrated acceptable reliability (inhibit: α = 0.87; working memory: α = 0.86; shift: α = 0.82; gioia et al., 2015) and construct validity (jacobson et al., 2020). for all three brief-2 subscales, higher scores indicate greater ec problems. marijuana use initiation. in each adolescent phone survey, participants were asked about substances used, including marijuana. marijuana use initiation was a dichotomous measure (0=never, 1=at least once) based on whether a participant reported lifetime use of marijuana by the last age 14-18 survey completed, which was age 14 for 31 participants, age 15 for 56 participants, age 16 for 53 participants, age 17 for 65 participants, and age 18 for 55 participants. for example, initiation was based only on the age 14 survey for those who only completed the age 14 survey, but was based on initiation by age 18 for those who completed an age 18 survey. if a participant reported initiation at a given age, they were not asked the initiation question at subsequent ages. there were 80 marijuana initiators (30.8% of the full sample). of these, the last survey was at age 14 for 2 (2.5%), age 15 for 16 (20%), age 16 for 13 (16.3%), age 17 for 22 (27.5%), and age 18 for 27 (33.8%). those who reported ever using marijuana were asked, “at what age did you first use marijuana?” of the 79 initiators who answered this question, age of first use was 11 for 2 (2.5%), 12 for 10 (12.7%), 13 for 17 (21.5%), 14 for 13 (16.5%), 15 for 15 (19.0%), 16 for 14 (17%), 17 for 7 (8.9%), and 18 for 1 (1.3%). covariates. youth age, sex, maternal education, family socioeconomic status (ses), and family history of alcohol problems were included in the analyses as covariates. the age of participants was determined at the last phone survey completed, ranging from ages 14 to 18 years. sex of participating youth was female (coded 0) or male (coded 1). mother’s highest level of education was measured in the background survey at enrollment into the larger study. family ses was a summary measure based on caregiver reports of family income, student free/reduced lunch status, and family public health insurance status (e.g., medicaid, chip, champus). families reporting low income-to-needs ratio (below the poverty line), qualifying for free/reduced lunch status, and/or using public health insurance were classified as “at risk” (coded 1) versus “low-risk” (coded 0 for all other families). a single item completed by caregivers as part of the background survey at enrollment measured if any of the child’s biological parents or grandparents had ever been “diagnosed or treated” for an alcohol problem (coded 1 for family history of alcohol problems and 0 for no family history of alcohol problems). we did not have a measure of other substance use disorders (suds) in the family; therefore, this variable was used as a proxy for family history of cannabis use disorder (cud). since auds are often comorbid with other suds, including cud (duncan et al., 2015), having a family history of alcohol problems might increase risk for adolescent marijuana initiation. previous publications this is an ongoing and long-term longitudinal study that began when target children were in preschool. in addition to published reports from earlier phases of the project, we have begun to publish results from analyses in the adolescent phase that examine long-term prediction of childhood ec on co-occurring adolescent psychopathology and substance involvement (fleming et al., 2020), including tobacco use (mason et al., 2021). no prior project publications have used adolescent ec data to examine links cannabis, a publication of the research society on marijuana 71 with marijuana use, a prevalent substance in this sample. analysis plan a logistic regression model assessing unique associations between different ec measures and marijuana initiation was estimated with mplus version 8 (muthén & muthén, 2017). all six measures of ec were z-scored (standardized) by adopting the “standardize” option in mplus, as was the measure of mother’s education, while other covariates were dichotomous. the standardization procedure was intended to put all scores on a common metric (mean = 0, standard deviation = 1) by subtracting the mean and dividing by the standard deviation. therefore, the interpretation of model coefficients was in terms of one standard deviation unit change. maximum likelihood robust estimation was used. overall, 27 individuals in the analysis model did not complete a laboratory visit and another 11 were missing data on the go/no-go task, which was not included in an abbreviated laboratory visit administered during the coronavirus pandemic. multiple imputation conducted in mplus was used in order to include cases with partially missing data. the imputation model included all study variables, and dichotomous variables were treated as categorical. forty datasets were imputed, and the logistic regression analyses were conducted on each dataset and then the results were averaged using rubin’s rules. this approach makes the assumption that data are missing at random conditional on non-missing data on other study variables. a statistical significance criterion of p < .05 was used. results table 1 shows bivariate correlations among, and descriptive information for, all study variables. all three brief measures were positively associated with marijuana use initiation (r = 0.22 – 0.27) and were strongly correlated (r = 0.60 – 0.73) with one another. the three laboratory measures were moderately positively correlated with one another (r = 0.26 – 0.54), modestly to moderately negatively correlated with the brief measures (r = -0.27 – 0.08), and had small associations (r = -0.12 – 0.02; d = -0.03 – 0.28) with marijuana use initiation. although not shown in the table, the spearman’s correlation between the oldest age and marijuana initiation was (r = 0.32, p < .001). table 2 reports t-tests comparing marijuana initiators versus non-initiators. the standard deviation unit difference between initiators and non-initiators ranged from d = -0.58 – -0.49. table 3 shows the estimates for the multiple logistic regression model. among the ec performance-based tasks, the measure of flexible shifting was statistically significantly associated with marijuana initiation; among the brief-2 self-report subscales the measure of inhibitory control was statistically significantly associated with the outcome. a one standard deviation unit increase in the flexible shifting task score was associated with 32% lower odds of marijuana use initiation (aor = 0.68, 95% ci = 0.48 – 0.97). a one standard deviation unit increase in the brief-2 measure of poor inhibitory control was associated with 92% greater odds of marijuana use initiation (aor = 1.92, 95% ci = 1.15 – 3.21). the last age assessed was also statistically significant (aors = 2.05, 95% ci = 1.54 – 2.75). with one standard deviation unit increase of age, the odds of marijuana initiation increased by 105%, indicating that as children get older, they are more likely to initiate marijuana. figures 1 and 2 show model-predicted probabilities for marijuana initiation up to age 17 (which is slightly above the mean oldest age at which initiation was assessed) by flexible shifting task score and brief-2 measure of poor inhibitory control, respectively, with other model covariates at their sample means. none of the other tasks or brief-2 subscales were reliably associated with marijuana initiation. discussion the current study extends prior research by examining three aspects of ec (inhibitory control, working memory, and flexible shifting) assessed across two methods (performance-based tasks and questionnaire) in relation to adolescent marijuana initiation. findings support prior research indicating the important role of disinhibition in marijuana use among youth (squeglia et al., 2014; tarter et al., 2003), and the increasing risk of initiating marijuana with age (chen et al., 2017; kosterman et al., 2000). in a previous study, inhibitory control measured by neuropsychological executive control and marijuana initiation 72 table 1. correlations and descriptive statistics mi male fhap mea li laa ict wmt fst pic pwm ps (1) mi 1.00 (2) male -0.06 1.00 (3) fhap 0.13 0.01 1.00 (4) mea -0.07 0.00 -0.16 1.00 (5) li 0.00 -0.06 0.20 -0.44 1.00 (6) laa 0.24 0.01 -0.08 0.30 -0.43 1.00 (7) ict -0.06 -0.02 -0.02 0.30 -0.18 0.24 1.00 (8) wmt 0.02 0.02 -0.01 0.28 -0.22 0.32 0.41 1.00 (9) fst -0.12 0.01 -0.06 0.12 -0.12 0.17 0.54 0.26 1.00 (10) pic 0.27 0.06 0.10 -0.12 0.10 -0.08 -0.27 -0.08 -0.16 1.00 (11) pwm 0.22 -0.04 0.14 -0.08 0.12 -0.05 -0.19 -0.08 -0.15 0.73 1.00 (12) ps 0.24 -0.13 0.12 -0.07 0.11 -0.07 -0.12 -0.12 -0.08 0.60 0.70 1.00 m 0.31 0.46 0.31 14.83 0.53 16.22 3.31 15.55 308.31 13.27 13.71 13.38 sd 0.46 0.50 0.46 2.12 0.50 1.32 0.68 2.28 67.18 2.90 3.18 2.90 note. numbers that are significant at p < .05 are in boldface. mi=marijuana initiation; fhap=family history of alcohol problems; mea=mother’s educational attainment; li=low income; laa=last age assessed; ict=inhibitory control task; wmt=working memory task; fst= flexible shifting task; pic=brief-2 poor inhibitory control; pwm=brief-2 poor working memory; ps=brief-2 poor shifting. table 2. t-tests comparing initiators with non-initiators on task and brief scores (means/standard deviations) not initiated initiated t df p inhibitory control 3.35 0.69 3.24 0.66 1.12 219 0.264 working memory 15.53 2.28 15.61 2.29 -0.24 231 0.808 flexible shifting 314.09 66.37 295.39 67.65 1.98 231 0.049 brief-2 poor inhibitory control 12.75 2.84 14.43 2.70 -4.24 230 0.000 brief-2 poor working memory 13.22 2.97 14.78 3.39 -3.53 230 0.000 brief-2 poor shifting 12.90 2.75 14.44 2.96 -3.83 230 0.000 cannabis, a publication of the research society on marijuana 73 table 3. estimates for logistic regression model predicting marijuana use initiation predictor aor 95% ci low high male 0.69 0.37 1.28 family history of alcohol problems (0/1) 1.76 0.90 3.42 mother’s educational attainment (zscore) 0.75 0.53 1.06 low income (0/1) 1.32 0.62 2.78 last age assessed (in years) 2.05 1.54 2.75 inhibitory control task (zscore) 1.12 0.73 1.72 working memory task (zscore) 1.02 0.70 1.48 flexible shifting (zscore) 0.68 0.48 0.97 brief-2 poor inhibitory control (zscore) 1.92 1.15 3.21 brief-2 poor working memory (zscore) 0.76 0.43 1.32 brief-2 poor shifting (zscore) 1.50 0.96 2.35 note. aor = adjusted odds ratio; ci = confidence interval. figure 1. probability of marijuana initiation by flexible shifting task note. model-predicted probability of marijuana initiation by age 17 by flexible shifting task score with 95% confidence band. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 -1 -0.5 0 0.5 1 flexibile shifting task (zscore) executive control and marijuana initiation 74 figure 2. probability of marijuana initiation by brief inhibitory control note. model-predicted probability of marijuana initiation by age 17 by score on brief inhibitory control subscale with 95% confidence band. tests in early adolescence predicted marijuana use by late adolescence (squeglia et al., 2014). in the current study, we found that self-reported inhibitory control problems in daily life, but not performance on the go/no-go task, was associated with marijuana initiation in a model that adjusted for all aspects of ec across both questionnaire and task-based methods. this extends prior research indicating that self-report assessment of ec is robustly associated with adolescent cigarette and alcohol use (pentz & riggs, 2013; pentz et al., 2015) by showing a similar association with marijuana use. the stronger association observed for the self-report measure of inhibitory control may be due to the more contextualized nature of the brief compared to the task-based assessment. individuals with poor inhibitory control may be less likely to refuse marijuana use offers from peers and, thus, more likely to initiate use. on the contrary, individuals with strong inhibitory control may be able to ignore the cues related to marijuana use from the environment and/or to refuse offers by peers. results also indicated that flexible shifting, represented as ability according to performance on a switching task, was negatively associated with marijuana initiation. similarly, tapert and colleagues (2002) found that low scores on a performance-based test of attention were related to greater marijuana use among adolescents. since self-reported and performance-based measures of ec assess different underlying constructs to some degree (toplak et al., 2013), it is possible that the ability of flexible shifting is better captured as a performance-based ability in a neutral context than as the self-perceived difficulties of flexible shifting in a daily life context (self-report measure of brief). prior research on adolescent substance use has paid less attention to this aspect of ec, but youth with good flexible shifting ability assessed by performance tasks may be better able to evaluate alternative courses of action and consider the negative consequences of using marijuana (e.g., being found out by parents), and then redirect their attention away from substance-using cues to prosocial activities. only working memory was unrelated to marijuana onset regardless of assessment methods in this study. the non-significant relation between working memory and marijuana use is consistent with one prior study (squeglia et al., 2014), suggesting that the ability to hold and use information in service of cognitive tasks does not appear to be related to adolescents’ marijuana 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 -1 -0.5 0 0.5 1 brief-2 poor inhibitory control (zscore) cannabis, a publication of the research society on marijuana 75 initiation. this may be because working memory is not instrumental in helping adolescents weigh the long-term benefits of prosocial behaviors (e.g., getting good grades in school) against the shortterm benefits of using marijuana in the moment. there have been mixed results in prior studies of working memory in relation to other substances and general substance use. poor performancebased working memory (digit span, visual spatial working memory, corsi block tapping, letter two-back) has been shown to predict adolescent alcohol use and increased frequency of alcohol use (khurana et al., 2013), as well as onset of first drink and first binge drinking episode above and beyond response inhibition (self ordered pointing task; peeters et al., 2015). however, other studies have shown that working memory did not predict substance use in high-risk adolescents (nigg et al., 2006; romer et al., 2009). limitations there are a few limitations to this study. all aspects of ec and marijuana initiation were assessed in adolescence (indeed, the youngest cohort had only completed a single laboratory visit at age 14); therefore, temporal ordering could not be established with these cross sectional analyses. also, only the lifetime initiation of marijuana use was examined as one dimension of marijuana involvement, due to the relatively young age of the youngest cohorts in the sample at this point in time. given the timing of assessments, initiation might have occurred prior to when ec was assessed for some participants. longitudinal studies of ec in relation to prolonged and heavier marijuana use later in adolescence and into young adulthood are needed. family history of alcohol use problems was the only measure available to adjust for substance-related risks in the family. having a family history of alcohol problems might increase risk for adolescent marijuana initiation because of the comorbidity of alcohol use and marijuana use disorders (duncan et al., 2015). it was important, therefore, to include this variable as covariate in the current study, but future studies should assess family history of cannabis use disorder to better account for different levels of risks related to adolescent marijuana use. finally, the sample was drawn from one region of the united states and results might not generalize broadly. notwithstanding its limitations, this study extends prior studies of ec and adolescent marijuana use that have only examined global ec or a single aspect, usually inhibitory control, and that have used only a single method for ec assessment. findings hold promise for identifying effective screening methods to identify youth with patterns of ec that might increase or decrease risk for marijuana initiation. whereas inhibitory control problems might be readily identifiable through cost-effective self-report methods, flexible shifting might represent a more subtle cognitive function that is best assessed via more resourceintensive but sensitive task-based procedures when it comes to understanding marijuana initiation. moreover, because ec has been shown to be modifiable (diamond, 2013; 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(2006). behavioral and emotional selfcontrol: relations to substance use in samples of middle and high school students. psychology of addictive behaviors, 20(3), 265– 278. funding and acknowledgements: we have no conflicts of interests to disclose. funding was provided by the national institute of mental health (mh065668), the national institute of general medical sciences (p20gm130461), and the national institute on drug abuse (da041738) of the national institutes of health. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health or the funding agencies. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v4i1a2_authors_v2 research article 40 abstract therapeutic and recreational marijuana use are common among people living with hiv (plwh). however, the distinction between perceived "therapeutic" and "recreational" use is blurred, with little information about the specific reasons for use and perceived marijuana effectiveness in adults with chronic conditions. we aimed to compare reasons for use and reason-specific perceived marijuana effectiveness between therapeutic and recreational users among plwh. in 2018-2019, 213 plwh currently using marijuana (mean age 48 years, 59% male, 69% african american) completed a questionnaire assessing their specific reasons for using marijuana, including the "main reason." participants were categorized into one of three motivation groups: therapeutic, recreational, or both equally. for each specific reason, participants rated marijuana effectiveness as 0-10, with 10 being the most effective. the mean effectiveness scores were compared across the three motivation groups via anova, with p <0.05 considered statistically significant. the most frequent main reasons for marijuana use in the therapeutic (n=63, 37%), recreational (n=48, 28%), and both equally (n=59, 35%) categories were "pain" (21%), "to get high" (32%), and "to relax" (20%), respectively. compared to recreational users, therapeutic and both equally users provided significantly higher mean effectiveness scores for "pain," and "to reduce anger." the "both equally" group also provided significantly higher mean effectiveness scores for "to feel better in general," "to get high," and "to relax" compared to the other two categories. there is a significant overlap in self-reported reasons for marijuana use in primarily therapeutic or recreational users. perceived marijuana effectiveness was lowest among recreational users. key words: = hiv; marijuana, cannabis, effectiveness, reasons for use, therapeutic versus recreational as of 2020, a total of 35 states, including florida, have approved marijuana use for medical reasons (national conference of state legislatures, 2020) . hiv/aids is among the approved conditions for florida's medical marijuana program (legal medical marijuana states and dc medical marijuana procon.org, n.d., 2020). past research has shown some evidence that marijuana use may be effective in reducing several hiv-associated symptoms, reasons for marijuana use and its perceived effectiveness in therapeutic and recreational marijuana users among people living with hiv in florida cannabis 2021, volume 4 (1) © author(s) 2021 researchmj.org doi: 10.26828/cannabis/2021.01.002 ruba sajdeya1, verlin joseph1, nichole e. stetten2, gladys e. ibañez3, yan wang1, lauren powell1, charurut somboonwit4, karen f. corsi5, robert l. cook1 1department of epidemiology, college of public health and health professions, college of medicine, university of florida, gainesville, fl, usa. 2department of occupational therapy, college of public health and health professions, college of medicine, university of florida, gainesville, fl, usa. 3department of epidemiology, florida international university, miami, fl, usa. 4department of internal medicine, morsani college of medicine, university of south florida, tampa, fl, usa. 5department of psychiatry, university of colorado school of medicine, denver, co, usa. corresponding author: ruba sajdeya, department of epidemiology, college of public health and health professions, college of medicine, university of florida, emerging pathogens institute 2055 mowry road, po box 100009, gainesville, fl 32610, tel: 419-205-7560, e-mail: rubasajdeya@ufl.edu. cannabis, a publication of the research society on marijuana 41 including inflammation (costiniuk & jenabian, 2019), sensory neuropathic pain (abrams et al., 2007), loss of appetite and weight loss, and depressive symptoms (haney et al., 2007). however, both medical and recreational marijuana use are common among people living with hiv (plwh) (mannes et al., 2018), with rates ranging from 40% to 74% (costiniuk et al., 2019). these numbers continue to increase as medical marijuana use in hiv/aids management increases (mercurio et al., 2019; dai & richter, 2019). nonetheless, the evidence remains limited, with conflicting findings on the actual benefits and risks associated with marijuana use for hivrelated symptom mitigation (national academies of sciences, 2017; merlin et al., 2019). the motivation to start and maintain marijuana use is important for understanding health behaviors and outcomes related to marijuana. in plwh or other chronic conditions, motivation for use is often defined broadly as either therapeutic (medicinal), recreational, or both, as motives for using marijuana are frequently not mutually exclusive (pacula et al., 2016; schauer et al., 2016). these broad categories of use are important, not only for legal or policy reasons, but because different motivations for use could be associated with mental and physical health functioning (towe et al., 2018), adherence with hiv medications (mannes et al., 2018), or problematic use of marijuana (lee et al., 2009). the distinction between therapeutic versus recreational use can be challenging, because individuals who use marijuana therapeutically may state many different specific reasons for use, many of which could extend beyond the management of medical diseases or symptoms (dʼsouza et al., 2012; mannes et al., 2018). therefore, it can be difficult to map specific reasons for use into the broader categories of medical versus recreational, as specific reasons for use such as "to relax" could be considered either recreational or therapeutic (or both) depending on the user's perception. previously-developed instruments to measure motives for marijuana use were primarily developed in adolescents and young adults (e.g., lee et al., 2009; simons et al., 1998) in whom medical reasons for use were not a primary focus. previous studies of plwh indicate that many, but not all, marijuana users perceive that marijuana is effective for their main reason for use (fairfield et al., 1998, costiniuk et al., 2019). an improved understanding of factors that influence the perceptions of effectiveness could improve clinical recommendations. it is possible that the perceived effectiveness of marijuana could be associated with a user's overall reason for use, in that persons who consider themselves to be primarily recreational users might perceive marijuana to be more effective for a specific type of symptom or condition compared to therapeutic users. examining factors associated with perceived effectiveness for specific reasons for use may also help guide therapeutic marijuana recommendations for hiv symptom management and influence marijuana-related policies. many persons using marijuana for specific health indications may have identified specific strategies to use marijuana that they find to be most effective, and we can learn from their experience. the present study the specific objectives of this study were to 1) identify and compare the main reasons for marijuana use according to overall motivation for use (therapeutic, recreational, or both), 2) describe the perceived effectiveness of marijuana for different specific reasons for use, and 3) compare perceived marijuana reason-specific effectiveness among plwh whose use motives are therapeutic, recreational, or both equally. methods study design data for this study were obtained from an ongoing prospective cohort, the marijuana and potential long-term effects (maple) study. the study was designed to investigate the longitudinal impact of marijuana use on cognitive functioning and hiv-related health outcomes among plwh in the state of florida. data collection started in 2018 and is currently ongoing. in this paper, we analyzed the baseline data from 213 participants who were current (past 30 days) marijuana users enrolled in the maple study. however, 43 participants did not provide data on their marijuana use motives by skipping the question. therefore, the primary analyses were restricted to 170 marijuana users who provided such data. marijuana use reasons and effectiveness in plwh 42 study participants and recruitment study participants were recruited in three florida counties (alachua, hillsborough, and dade) between 2018-2019. the participants were recruited by direct referral from the florida department of health (doh), same day access (sda) clinics in tampa, and care resource clinics and borinquen health clinics in miami, or were identified from the florida cohort, health street, and consent2share databases. other participants were recruited by word of mouth and distributed study fliers. inclusion and exclusion criteria both current marijuana users and current non-users were recruited in the maple study. marijuana users were defined as those who used at least four times in the past month. non-users were defined as those who last used more than five years ago and never used more often than once monthly in their lifetime. those who used marijuana one to three times in the past month were not eligible for the study. participants were eligible for the study if they met the following inclusion criteria: 18 years of age or older, hiv positive, willing to give blood and urine samples, had a self-reported marijuana use status that matched the result of a urine drug screening test at enrollment, not planning to move out of florida in the next 12 months, willing to participate in thinking and memory tests, and be able to understand the study steps, procedure, and purpose. only current marijuana users at baseline were included in this analysis. all study participants signed a consent form after the research assistants explained the study steps and procedures, and all the study protocols were approved by the institutional review boards at the university of florida and the florida department of health. data collection participants completed self and intervieweradministered questionnaires during baseline study visits. collected data included sociodemographic data, reasons for marijuana use, the effectiveness score of marijuana for each reason, preferred methods of marijuana administration, and use motivation. an in-person timeline follow back (tlfb) questionnaire was administered with guided instructions from trained interviewers to collect data on marijuana use frequency and methods of administration within the past thirty days (robinson et al., 2012). a day of use is considered from the time participants wake up until the time they go to bed. hence, if a participant smoked at 12:30 am on wednesday morning we considered it as tuesday night. to assess the most frequent method of administration, we asked the participants if they had a typical way the used marijuana (e.g., blunts, joints, or bowls). when participants reported using multiple methods of administration, we further asked them to specify which method they used the most. we could not find any validated tools specifically designed to assess the reasons or effectiveness of marijuana use among plwh. we conducted a literature review to identify elements that represent reasons for using marijuana; however, most of these elements were not specific for plwh. our research team developed and revised a questionnaire consisting of 25 items representing possible marijuana use reasons that demonstrate a range of social factors and physical and mental health symptoms and effects that are common among plwh. the questionnaire was pilot tested among different small samples of maple participants to improve the understandability of the questions and to identify or exclude elements based on the participants' feedback. however, an internal or external validity analysis was not conducted to test the questionnaire’s validity and reliability. the key questionnaire items, including the 25 marijuana use reasons, are available in the supplement. the full questionnaire is available upon request from the authors. measures reasons for using marijuana. at the time of survey development, there were few existing tools to measure marijuana use motivations, and they had been developed with a younger, non-medical population (lee et al., 2009; simons et al., 1998). therefore, we included possible reasons for use based on a previous measure we used in a separate hiv cohort study (mannes et al., 2018), but also included additional items from the literature (dʼsouza et al., 2012), the approved cannabis, a publication of the research society on marijuana 43 indications for medical marijuana in florida (patients and caregivers, 2020, office of medical marijuana use), and additional suggestions from pwlh who piloted the measure for this study. for the final measure, participants indicated yes or no as to whether they currently used marijuana for each of 25 possible reasons for marijuana use, and each was asked to choose one item from the list that they identify as the main reason for using marijuana in the past 30 days. perceived marijuana effectiveness. previous research on the perceived effectiveness of marijuana for specific conditions included categorical ratings (e.g., "extremely," "quite a bit") (costiniuk et al., 2019; fairfield et al., 1998). however, for our study, participants were asked to give a numerical score that ranged from zero to ten to how effective marijuana is for each chosen reason, with ten being the most effective. the participants only provided effectiveness scores for the specific reasons for which they indicated using marijuana in the past 30 days. marijuana use motivation. the participants were asked to estimate the percentage of their marijuana use in the past 30 days that they attribute to recreational and therapeutic use, with the total percentage adding to 100%. the participants were considered as therapeutic or recreational users if the percentage for one category exceeded the other. participants who estimated their use to be exactly 50% for both therapeutic and recreational use were categorized in a third category named "both equally." sociodemographic variables. male or female sex was determined by self-reported sex at birth. race/ethnicity was grouped as hispanic, not hispanic white, not hispanic black/ african american, not hispanic american indian or alaska native, and not hispanic other. the age groups were (18-39), (40-39), (50-59), and (60-70) years old. marijuana frequency. the frequency of using marijuana was measured using the tlfb questionnaire. participants were categorized as using 5-7 days/week, or less than five days a week. method of administration (e.g., smoke, vape, edibles) was identified as the type used most often in the past 30 days. data analysis descriptive statistical analyses were used to describe the characteristics of the full sample of 213 plwh (age group, sex at birth, and race/ethnicity), main reasons for using marijuana, use motivation (therapeutic, recreational, and both equally), use frequency, and methods of administration. data to determine marijuana use motivation were missing in 43 participants who were excluded from further analysis and comparisons, yielding a final sample of n = 170. for each of the 25 different reasons for use, we calculated the mean and standard deviations of the effectiveness scores (0-10). we then compared the mean scores for the ten most frequent reasons for use across the three use motivation categories (therapeutic, recreational, and both equally), using analysis of variance (anova) to assess the statistical significance of any differences. all statistical analyses were performed using sas 9.4 statistical software, and a p-value of less than 0.05 was considered statistically significant. results the study sample consisted of 213 plwh who were using marijuana. the mean age was 48±12 years, 59% were male, and 69% were african american. mean marijuana use frequency per week was 5±2 days per week, and 69% used marijuana for 5-7 days per week. nearly all (99.5%) of the study sample used inhalation methods for marijuana intake. smoking blunts was the most frequent method of administration (53%). among those who provided a percent estimation of their use motivation (n=170), 37% were categorized as therapeutic, 28% as recreational, and 35% as both equally (table 1). the ten most frequent main reasons for marijuana use in the total sample were: "to relax" (18%), "pain" (13%), "to get high" (13%), "to feel better in general" (10%), "anxiety or stress" (10%), "appetite stimulation" (8%), "depression" (5%), "to reduce anger/ calm down" (5%), "insomnia/ sleep" (5%), and "hiv/aids" (3%). marijuana use reasons and effectiveness in plwh 44 table 1. sample descriptives for 213 people living with hiv reporting past twelve-month marijuana use characteristic n (%) age group 18-39 years old 40-49 years old 50-59 years old 60-70 years old 50 (23.5) 42 (19.7) 84 (39.4) 37 (17.4) sex at birth female male 87 (41.2) 124 (58.8) race/ ethnicity hispanic not hispanic, white not hispanic, black/african american not hispanic, american indian or alaska native not hispanic, native hawaiian or pacific islander not hispanic, asian not hispanic, other 31 (14.8) 28 (13.3) 144 (68.6) 4 (1.9) 1 (0.5) 2 (1.0) 3 (1.4) taking hiv medication yes no 198 (93.0) 15 (7.0) marijuana use frequency in the last 30 days less than 5 days/week [5-7] days/week 55 (31.4) 120 (68.6) method used most often in the last 30 days joints [rolled paper marijuana cigarettes] blunts [cigar wrappers filled with marijuana] pipes [water pipes, bongs, one-hitter] vaporizing device [vape pen, volcano] food or drink item [cookie, brownie, candy, tea] 61 (36.3) 89 (53.0) 12 (7.1) 5 (3.0) 1 (0.6) marijuana use motivation therapeutic recreational both equally 63 (37.1) 48 (28.2) 59 (34.7) cannabis, a publication of the research society on marijuana 45 figure 1. comparison of the main reasons for using marijuana in the three motivation categories (therapeutic (n=63), recreational (n=48), and both equally (n=59)) among 170 people living with hiv who used marijuana in the past twelve months. a. percent frequencies of the main reasons for marijuana use in the therapeutic category. b. percent frequencies of the main reasons for marijuana use in the recreational category. n=63 5 10 15 20 25 muscle spasms post-traumatic stress disorder (ptsd) to reduce use of alcohol, drugs or pain… other reason insomnia/ sleep to gain weight to reduce anger/ calm down appetite stimulation depression hiv/aids to get high anxiety or stress to feel better in general to relax pain percent a. main reasons for using marijuana in the "therapeutic" category n=48 percent 0 5 10 15 20 25 30 35 anxiety or stress depression hiv/aids nausea or vomiting to be more thoughtful to reduce anger/ calm down to reduce use of alcohol, drugs or pain pills insomnia/ sleep pain to feel better in general appetite stimulation to relax to get high b. main reasons for using marijuana in the "recreational" category marijuana use reasons and effectiveness in plwh 46 c. percent frequencies of the main reasons for marijuana use in the both equally category. the main reasons for using marijuana among the 170 participants in the three motivation categories were as follows. among therapeutic users, the most frequent main reason for marijuana use was" pain" (21%), followed by "to relax" (15%), "anxiety or stress" (11%), and "to feel better in general" (11%). among recreational users, the most frequent main reason for marijuana use was "to get high" (32%), followed by "to relax" (23%), "appetite stimulation" (11%), and "to feel better in general" (9%). among users categorized as both equally, the most frequent main reason for marijuana use was "to relax" (20%), followed by "anxiety or stress" (12%) and "pain" (12%) and "to reduce anger/ calm down" (11%) (figure 1). it is noteworthy that "to relax" was a common reason for using marijuana across the three categories. the numerical summaries of marijuana effectiveness scores in the total sample are summarized in table 2. the results showed high scores in general; although the mean scores did vary for the different reasons, the numbers of participants who contributed to the scoring of each reason varied because only those who used for that reason in the past month were asked to rate the effectiveness. the mean effectiveness score was greater than 8 out of 10 for all reasons except "hiv/aids," "peer pressure," and "to lose weight." the maximum score was ten for all reasons, while the minimum scores varied (zeroten). for some reasons for use, such as cancer, glaucoma, and seizures, the sample size was too small to compare the scores across the three motivation categories. figure 2 illustrates the differences in the effectiveness scores for the 170 participants classified in each of the three motivation categories as assessed by the anova. differences were statistically significant in six out of the ten reasons. the degree of freedom was 2 in all of the analyses. among those whose motivation was primarily therapeutic, the mean effectiveness score for "pain" was significantly higher than for those whose motivation was recreational (p= 0.02, t=2.46), and in the full model (p=0.03, f=3.46). in contrast, the mean effectiveness score for "to get high" was significantly lower in therapeutic users than for recreational or both equally motivation categories (p=0.002, f=6.46) in the full model. persons whose motivation was both equally had significantly higher mean effectiveness scores for "to feel better in general" (p= 0.02, f=3.99), "to get high" (p= 0.002, f=6.46), "to reduce anger/ calm down" (p= 0.04, f=3.57), and "to relax" (p= 0.04, f=3.71) compared to persons whose motivation was primarily recreational or primarily therapeutic, in the full model. in n=59c. main reasons for using marijuana in the "both equally" category 0 5 10 15 20 25 peer pressure to gain weight to improve sexual performance other reason insomnia/ sleep depression to get high appetite stimulation to feel better in general to reduce anger/ calm down anxiety or stress pain to relax percent cannabis, a publication of the research society on marijuana 47 general, people who rated their motivation for use as both equally tended to provide higher effectiveness scores for each of the top 10 most frequent reasons for use than those who were motivated primarily for either therapeutic or recreational reasons. table 2. numerical summaries of “marijuana effectiveness scores (0-10)” for reasons for marijuana use among 213 persons living with hiv who used marijuana in the past twelve months reason for marijuana use mean effectiveness score (0-10) sd* min† median max‡ n§ anxiety or stress 8.3 2.12 0 9 10 133 appetite stimulation 8.7 1.91 0 10 10 116 cancer 8.9 1.88 5 10 10 14 depression 8.1 2.21 0 9 10 105 glaucoma 9.3 1.30 6 10 10 12 hiv/aids 7.7 2.76 0 8 10 106 insomnia/ sleep 8.6 1.80 4 10 10 89 muscle spasms 8.2 1.82 4 9 10 53 nausea or vomiting 8.4 1.84 4 9.5 10 36 pain 8.1 2.17 0 8 10 117 peer pressure 6.6 2.46 2 6 10 19 post-traumatic stress disorder (ptsd) 8.1 2.07 2 8 10 45 reduce medicine side effects 8.0 2.34 0 8 10 33 seizures 8.4 1.92 5 9 10 8 to be creative 8.8 1.72 4 10 10 51 to be more thoughtful 8.6 2.08 1 10 10 64 to feel better in general 8.9 1.59 4 10 10 142 to feel comfortable around others 8.2 2.30 2 9 10 82 to gain weight 8.3 2.23 1 10 10 52 to get high 9.1 1.75 0 10 10 139 to lose weight 6.1 4.02 0 6 10 7 to improve sexual performance/ sensation 8.6 2.02 2 10 10 44 to reduce anger/ calm down 8.6 1.89 2 10 10 112 to reduce use of alcohol, drugs or pain pills 8.8 1.50 5 10 10 46 to relax 9.2 1.45 5 10 10 158 other reasons 9.7 0.78 8 10 10 12 note.*sd=standard deviation. †min= minimum score. ‡max= maximum score. §n= number of participants. only persons who used marijuana for a specific reason in the past month gave an effectiveness rating; hence, number of participants does not add up to 213 for each reason. marijuana use reasons and effectiveness in plwh 48 figure 2. comparison of "marijuana effectiveness score" for the ten most frequent reasons for marijuana use clustered by the motivation categories (therapeutic (n=63), recreational (n=48), and both equally (n=59)) among 170 people living with hiv who used marijuana in the past twelve months. note. the x-axis represent the specific reasons for marijuana use. the y-axis represent the effectiveness scores ranging from zero to 10, with 10 being the most effective. each motivation use category is represented by a different color. scores are illustrated by vertical boxplots to show the minimum, first quartile, median, third quartile, and maximum score. circles, plus signs, and xs represent the mean score for each category. analysis of variance (anova) was done to compare the effectiveness scores among the three motivation categories. differences are statistically significant at p-value <0.05. a nxiety or stress a ppetite stimulation depression hiv/a ids insomnia/ sleep pain to feel better in general to get high to reduce anger/ calm down to relax marijuana use reason 0 2 4 6 8 10 m ar iju an a ef fe ct iv en es s sc or e (0 -1 0) recreationalboth equallytherapeuticmotivation p=0.2 p=0.9 p=0.5 p=0.2 p=0.2 p=0.04 p=0.02 p=0.002 p=0.04 p=0.04 cannabis, a publication of the research society on marijuana 49 discussion we categorized 170 plwh based on their marijuana use motivation into three categories, therapeutic, recreational, and equally both, and compared their main reasons for using marijuana as well as their self-reported perceived marijuana effectiveness for a range of medical conditions, general feelings, and recreational purposes. consistent with the findings of costiniuk et al. (2019), we found that seeking pleasure and reducing pain, anxiety, and stress are among the top reasons for marijuana use in plwh. the main reasons for using marijuana differed across the three motivation categories. in therapeutic users, the most frequent main reason for marijuana use was for pain followed by relaxation and anxiety or stress relief, and to feel better in general, while in recreational users, the most frequent reason was to get high, followed by relaxation, appetite stimulation, and to feel better in general. without asking the participants to define their own motivation (therapeutic vs. recreational), one might have assumed that "relaxation" and "feeling better in general" are recreational reasons for using marijuana. however, our findings show that effects such as relaxation and feeling better in general are important components for both therapeutic and recreational users of marijuana for plwh, which should lead researchers and clinicians to consider broadening the potential therapeutic categories for medical marijuana. the high mean effectiveness scores in our total sample suggest that marijuana is perceived to be effective for a wide range of use reasons. the scores may have overestimated the perceived effectiveness of marijuana as only participants who indicated using marijuana for a specific reason in the past 30 days provided a numerical score to rate the effectiveness of marijuana. it is possible that effectiveness scores may have been lower if they included those who may have tried marijuana for a specific reason in the past but stopped using it for that reason after finding it ineffective. however, a minimum score of 0 or 1 was given for ten out of the 25 listed reasons, suggesting that some people do use marijuana for specific indications, even though they do not find it effective for that reason. interestingly, the average effectiveness score for "hiv" was the third-lowest score for all reasons; this could be in part explained by hiv being an uncurable condition, until now, and participants might perceive marijuana as less effective for treating the virus or specific condition, compared to other reasons, such as pain, where fast symptom relief may be achieved. however, for some medical reasons, such as pain and depression, we do not know if describing marijuana as effective indicates reducing the symptoms or merely helping the patients cope with them by distraction and getting high. qualitative studies are needed to better understand patients' perspectives of changes in symptoms they experience when using marijuana. we found statistically significant differences in perceived marijuana effectiveness scores for five main reasons for use across the three motivation categories. those reasons were pain, to feel better in general, to get high, to reduce anger, and to relax. interestingly, participants who categorized themselves as "both recreational and therapeutic equally" tended to give higher effectiveness scores compared to the other two groups for all ten reasons, adding to the complexity of this group, where classifying reasons such as relaxation, reducing anger, and feeling better, as therapeutic or recreational is even more challenging. limitations we acknowledge that our study is not without limitations. first, the cross-sectional design did not allow us to examine the temporal effects of using marijuana on hiv-related symptoms, such as pain. second, we did not use existing validated and reliable measures to assess reasons for marijuana use, motivations for use, or perceived effectiveness. at the time that the study questionnaire was developed, the most commonly used tool to assess motivations for marijuana use had only been validated in adolescents and young adults, although it has since been validated in adult users of medical cannabis (bohnert et al., 2018). however, our questionnaire was developed from a measure we had used in a previous study (mannes et al., 2018) and covered a wide range of psychological, social, and medical reasons for using marijuana that are common among plwh. as assessing marijuana's effects on hiv-related symptoms continues to mainly rely on self-report, marijuana use reasons and effectiveness in plwh 50 standardized tools to assess the reasons for using marijuana and its effects on specific hiv-related symptoms are needed. finally, we only evaluated marijuana effectiveness among those who used it for specific indications in the past 30 days, and we did not yet assess how perceived effectiveness may vary according to different demographic characteristics (e.g., age, gender, race/ethnicity, level of education), marijuana use characteristics (e.g., frequency of use, methods of administration) or other factors. identifying variations in individuals or marijuana use patterns that are deemed more effective for specific conditions can help to inform future clinical care recommendations, and also identify specific types and patterns of marijuana use to be evaluated and compared in future randomized clinical trials. however, our study did have several strengths. it was conducted in a relatively large sample of plwh who use marijuana, a unique population that is hard to find and recruit. to our knowledge, our study is among the first to report self-scored marijuana effectiveness for different reasons for marijuana use among plwh and the first to compare the reasons for use and the perceived effectiveness of marijuana across different groups of marijuana use motivation. conclusion even as the evidence regarding the risks and benefits of marijuana use is limited, marijuana is perceived to be effective for a range of use reasons among plwh. however, there are significant differences in the reasons for use and perceived marijuana effectiveness among those whose use motivation is therapeutic, recreational, or both equally. our findings emphasize the need to better understand the potential distinctions as well as the overlap of specific reasons for use in persons who consider themselves to be using marijuana for therapeutic vs. recreational reasons, especially when we seek evidence regarding the therapeutic effects of marijuana. there is also a continued need to develop unbiased, standardized tools to assess marijuana effectiveness for hiv-related symptoms and conditions via self-report in clinical studies. qualitative research is also needed to help further understand the nuances of use motivation and marijuana effectiveness, as more and more plwh use marijuana on a regular basis. references abrams, d. i., jay, c. a., shade, s. b., vizoso, h., reda, h., press, s., kelly, m. e., rowbotham, m. c., & petersen, k. l. 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(2018). a comparison of motivations for marijuana use in hiv-positive and hivnegative adults. aids and behavior, 22(9), 2807–2814. https://doi.org/10.1007/s10461018-2123-4 funding and acknowledgements: this study is funded by the national institutes of health (nih) (r01da042069). dr. robert cook receives funding related to marijuana research from nih (r01da042069) and the florida department of health. verlin joseph is funded by nida f31da047200. nichole stetten receives funding from the office of rural health north florida / south georgia veterans healthcare system and through nida r21 da048067-01a1. all authors declare no conflicts of interest. the authors would like to thank all the study team members and the study participants who have contributed their time and efforts to the completion of this study. copyright: © 2021 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. brief report 1 ved abstract despite increased rates of cannabis use among patients with cancer, there are gaps in our understanding of barriers to accessing cannabis. social determinants of health (sdoh) are associated with access to healthcare, but few studies have evaluated how sdoh relate to cannabis access and use among cancer patients. we examined whether access to and modes of cannabis use differed across indicators of sdoh among patients receiving treatment from a large national cancer institute (nci) designated cancer center. this anonymous cross-sectional survey was developed in collaboration with the nci cannabis supplement consortium, which funded 12 supplements to nci center core grants across the united states. we evaluated the association of race, gender, income, and age with mode of cannabis use, source of obtaining cannabis, what influences their purchase, and medical cannabis certification status. overall, 1,053 patients receiving treatment for cancer in pennsylvania completed the survey and 352 (33.4%) reported using cannabis since their cancer diagnosis. patients who identified as black/african-american were less likely to have medical cannabis certifications (p=0.04). males and black/african-americans were more likely to report smoking cannabis (vs other forms, ps<0.01) and to purchase cannabis from an unlicensed dealer/seller (p<0.01). lower-income patients were more likely to be influenced by price and ease of access (ps<0.05). although cannabis users were younger than nonusers, age was not associated with any outcomes. the current data shed light on how critical drivers of health disparities (such as race, gender, and income) are associated with where patients with cancer obtain cannabis, what forms they use, and what may influence their purchase decisions. key words: = cannabis; cancer; social determinants of health; marijuana; race as of the end of 2022, 37 states and the district of columbia have approved cannabis for medical use, and all of these states list cancer as a ‘certifying’ condition. between 24%-40% (bar-lev schleider et al., 2018; pergam et al., 2017; tringale et al., 2019) of cancer patients use rebecca l. ashare1,2, esther turay2, brooke worster3, reagan r. wetherill1, l. cinnamon bidwell4, abigail doucette5, salimah h. meghani6 1department of psychiatry, perelman school of medicine at the university of pennsylvania 2department of psychology, university at buffalo 3department of medical oncology, sidney kimmel cancer center/thomas jefferson university 4institute of cognitive science, university of colorado boulder 5abramson cancer center, university of pennsylvania 6department of biobehavioral health sciences and the newcourtland center for transitions and health and the leonard davis institute of health economics, university of pennsylvania cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000151 social determinants of health associated with how cannabis is obtained and used in patients with cancer receiving care at a cancer treatment center in pennsylvania corresponding author: rebecca l. ashare, ph.d., 334 diefendorf hall, south campus, buffalo, ny 14214. email: rlashare@buffalo.edu cancer patients’ access to cannabis 2 cannabis at some point during their treatment and among those, 75% use cannabis to manage symptoms including pain, anxiety and insomnia (martell et al., 2018; turgeman & bar-sela, 2017). nevertheless, gaps exist between expanding state laws and the scanty scientific evidence base on cannabis use in persons with cancer. for instance, the ‘accepted’ medical diagnoses vary by state, not due to scientific evidence but rather state politics (ncsl, 2022). this results in a confusing landscape for patients about who may—or may not—benefit from cannabis. it is not surprising that national guidelines lack recommendations about possible therapeutic uses of cannabis, which poses challenges for oncology clinicians (worster et al., 2021). the lack of scientific evidence, real-world clinical guidance, and an explosion of new cannabis products has created further complexity. for example, there is substantial product variability in state-regulated medical and adultuse dispensaries; some oral formulations contain up to 100mg of thc in a single ingestible product, whereas others contain 5-10mg in the same sized product. high concentrations of thc have a higher likelihood of adverse side effects including palpitations, anxiety, panic attacks, and psychosis (dobbins et al., 2022). health risks may also vary according to the form used (choi et al., 2021). cannabis used for perceived medical purposes often involves lower potency products and noncombusted modes of use (smith & goniewicz, 2020). many patients who use cannabis medicinally report dry herb/flower vaporization (shiplo et al., 2016), which contains lower thc concentrations and fewer potential inhalation health risks compared to most liquid cannabis concentrates administered through vaping (smith & goniewicz, 2020). conversely, blunt use (i.e., hollowed-out cigar wrappers filled with cannabis and smoked) is associated with greater health risks compared to other combustible (e.g., pipes) and noncombustible (e.g., edibles) methods (cooper & haney, 2009; fairman, 2015; peters et al., 2012). edible cannabis products are also not without risk and have been associated with accidental over ingestion (noble et al., 2019). social determinants of health (sdoh) have come to the forefront as critical drivers of a wide range of health outcomes and risks (healthy people, 2030). cannabis use is no exception. evidence is emerging that access to regulated cannabis products in dispensaries varies by persons’ race, gender, age, and the ability to pay out of pocket (cooke et al., 2018; novak et al., 2021). studies have also found that blunt use is highest among black/african-americans compared to whites (cohn et al., 2016; montgomery & mantey, 2017), with rates of daily blunt use among black/african-americans more than double that of whites (25% vs. 10%) (mantey et al., 2021). this represents another important health disparity, given increased health risks associated with blunt use. however, very little is known about sdoh associated with cannabis use in patients with cancer. the current study aimed to examine sdoh that may be associated with access to forms of cannabis associated with lower risk (i.e., edible, vaping flower/herb) among patients from a large national cancer institute (nci) designated cancer center. we investigated differences by race, gender, age, income in rates of medical cannabis certification (the process a state resident goes through to obtain cannabis for a medically approved condition), forms of cannabis use, source of obtaining cannabis, and factors that influence the purchase of cannabis. given racial disparities in both cancer pain management (meghani et al., 2014) and symptom burden (bulls et al., 2022), as access to cannabis expands, it will be essential to identify possible barriers to access to avoid widening health disparities in cancer care. methods setting we conducted an anonymous cross-sectional survey of patients with cancer receiving treatment at an nci-designated cancer center in pennsylvania from july 2021 through november 2021. during this time, the pennsylvania medical marijuana program made medical cannabis available for pennsylvania residents with an approved “serious medical condition” (including cancer); adult use of cannabis was not legal. pennsylvania residents are required to register in a state-run online database and see a physician who confirms they have a medically eligible diagnosis (e.g., pain, cancer, anxiety). this enables residents to get access to state-regulated cannabis dispensaries. eligibility criteria included: >18 years old, able to communicate in english and cannabis, a publication of the research society on marijuana 3 provide informed consent, cancer diagnosis, and currently receiving or received cancer treatment in the last year. electronic health records identified 14,483 patients, and survey invitations were sent to a randomly selected representative sample of 5,808 patients. all data were collected via redcap electronic database (harris et al., 2019; harris et al., 2009). patients had the option to receive compensation for completing the survey. the institutional review board determined this study to be exempt. measures the survey was developed in collaboration with the nci cannabis supplement consortium, which funded 12 supplements to nci center core grants across the united states. the survey included questions about current and past use (quantity, frequency, modes of use), reasons for use, perceptions of benefits and risk, conversations with providers, stigma, access and barriers to access, and intersection with opioids. the survey also collected demographic characteristics and cancerrelated information (type, stage, treatment). the current analysis focuses on medical certification rates for cannabis (yes/no), modes of use, where patients get cannabis, and what influences their use (see tables 2 & 3). except for mode of use, which asked respondents to select the “most common” mode used, multiple options could be selected for other outcomes. data analysis survey weights were calibrated to population totals via iterative raking on age, gender, race, ethnicity, and cancer types. per recommendations from the nih, we included two variables: race and ethnicity. race included the categories asian, black or african american, white, multiple races, and other/unknown. ethnicity included hispanic and non-hispanic. summary statistics for clinical and demographic characteristics were computed for the 1,053 patients who completed the survey and stratified by cannabis use since cancer diagnosis (yes/no). means and standard deviations were used for continuous measures, and frequencies and percentages were used for categorical measures. primary analyses were conducted on patients who used cannabis since their diagnosis using weighted estimates (n=352). outcomes (mode of use, source of obtaining cannabis, influence on use, and medical certification) were compared between racial groups (black/african-american vs white), age (<65 vs >65 years), gender, and income (<$35,000, $35,000$74,999, $75,000-$99,999, >=$100,000) using chisquared models. for outcomes associated with multiple sdoh, follow-up logistic regression models evaluated the unique contribution of each sdoh. for all models, alpha=0.05. results participant characteristics table 1 shows descriptive information for the full sample and subset who used cannabis since their cancer diagnosis. overall, 63.4% (n=667) were female, 10% identified as black/africanamerican, 51% had an income >$100k per year, and the average age was 60.6 years (sd=13.1). there were significant differences in ethnicity, age, health insurance status, and occupation status such that individuals who identified as hispanic, were younger, were insured by medicaid, or identified as students or disabled were more likely to have used cannabis. additionally, patients with breast cancer and those diagnosed with stage i/ii cancer were less likely to use cannabis. because of the small number of patients who identified as hispanic, our analyses focus on race and because most (96%) of the sample identified as either white or black/african-american, analyses focused on these groups. cannabis medical certification overall, 42.9% of patients reported being medically certified for cannabis. patients who identified as black/african-american were significantly less likely to be medically certified compared to white patients (p=0.04; table 2). medical certification rates did not differ by gender, age, or income. source of obtaining cannabis the most common sources of obtaining cannabis were friend/family member (n=134, 38.1%) and medical dispensary (n=166, 47.2%). cancer patients’ access to cannabis 4 table 1. participant characteristics total (n= 1053) used cannabis since cancer diagnosis (n=352) have not used cannabis since cancer diagnosis (n=701) participant characteristics unweighted n weighted % (95% ci) unweighted n weighted % (95% ci) p-value1 sex2 male 381 (36.4%) 124 30.5 (25.8, 35.5) 257 69.6 (64.5, 74.2) 0.68 female 672 (63.4%) 228 31.8 (28.2, 35.5) 444 68.3 (64.5, 71.8) race3 asian 16 (1.5%) 2 11.2 (0.03, 0.37) 14 88.8 (63.4, 97.3) 0.06 black or african american 100 (9.5%) 44 41.0 (31.6, 51.7) 56 58.7 (48.3, 68.4) white 896 (85.1%) 293 30.1 (27.1, 33.2) 603 69.9 (66.8, 72.9) multiple races 10 (1%) 4 39.3 (14.3, 71.4) 6 60.7 (28.6, 85.7) other/unknown 31 (2.9%) 9 31.2, 28.4, 34.2) 22 76.1 (58.9, 87.6) ethnicity hispanic 38 (3.6%) 19 47.9 (31.5, 64.9) 19 52.1 (35.7, 68.0) 0.034 non-hispanic 1,015 (96.4%) 333 30.8 (27.9, 33.8) 682 69.2 (66.2, 72.1) age < 65 years 599 (56.9%) 246 40.0 (35.9, 44.2) 353 60.0 (55.8, 64.1) <0.001 > 65 years 454 (43.1%) 106 22.2 (18.5, 26.5) 348 77.8 (73.5, 81.5) health insurance private (employer-based) 524 (51.6%) 188 34.8 (30.6, 39.3) 336 65.2 (60.7, 69.4) <0.001 private (self) 48 (4.7%) 21 40.2 (26.7, 55.3) 27 59.8 (44.7, 73.3) medicare 388 (38.2%) 97 22.5 (18.5, 27.0) 291 77.5 (73.1, 81.5) medicaid/ other state program 37 (3.6%) 20 52.0 (35.2, 68.4) 17 48.0 (31.6, 64.8) tricare, va, or indian health service, tribal health services 8 (0.8%) 2 27.4 (6.5, 67.1) 6 72.6 (32.9, 93.5) some other source 11 (1.1%) 5 46.0 (19.8, 74.5) 6 54.1 (25.5, 80.2) income < $35,000 93 (8.9%) 38 37.7 (28.0, 48.5) 55 62.3 (51.5, 72.0) 0.22 $35,000 $74,999 250 (23.9%) 87 32.9 (27.0, 39.4) 163 67.1 (60.7, 73.0) $75,000 $99,999 169 (16.1%) 60 34.0 (27.0, 41.8) 109 66.0 (58.2, 73.0) >=$100,000 536 (51.2%) 166 28.3 (28.4, 34.3) 370 71.7 (67.6, 75.5) occupation status employed 475 (45.1%) 173 36.0 (31.6, 40.7) 302 64.0 (59.3, 68.4) <0.001 unemployed 24 (2.3%) 6 20.8 (8.8, 41.7) 18 79.2 (58.3, 91.2) homemaker 39 (3.7%) 12 29.4 (17.0, 45.9) 27 70.6 (54.1, 83.0) student 6 (0.6%) 5 68.1 (19.4, 95.0) 1 31.9 (5.0, 80.6) retired 423 (40.2%) 109 23.2 (19.4, 27.6) 314 76.8 (72.4, 80.7) disabled 73 (6.9%) 45 59.5 (46.9, 70.9) 28 40.5 (29.1, 53.1) other 13 (1.2%) 2 18.9 (4.6, 52.8) 11 81.1 (47.2, 95.4) cancer type gastrointestinal 126 (12.0%) 50 36.7 (27.8, 46.5) 76 63.4 (53.5, 72.2) 0.22 genitourinary 136 (12.9%) 36 24.7 (18.0, 33.0) 100 75.3 (67.0, 82.0) 0.08 hematologic 166 (15.8%) 62 36.9 (29.4, 45.1) 104 63.1 (54.9, 70.6) 0.11 breast 347 (33.0%) 98 25.9 (21.5, 30.9) 249 74.1 (69.2, 78.5) 0.01 other 338 (32.1%) 130 35.2 (28.4, 34.2) 208 64.8 (59.2, 70.1 0.06 cancer stage at diagnosis stage i/ii 584 (55.8%) 178 28.1 (24.5, 32.0) 406 71.9 (68.0, 75.5) 0.03 stage iii/iv 386 (36.9%) 141 34.2 (29.3, 39.4) 245 65.8 (60.6, 70.7) unknown/in situ 77 (7.4%) 32 41.3 (30.3, 53.2) 45 58.7 (46.8, 69.7) note. ci = confidence interval. 1the p-values are from weight adjusted chi-square tests comparing those who used cannabis since diagnosis and those who have not. 2analyses were conducted with sex (assigned at birth) and gender identity. results were unchanged and sex was retained. 3when comparing rates of cannabis use between black/african-american and white patients only, the difference was significant (p=0.04). cannabis, a publication of the research society on marijuana 5 table 2. outcomes by sex, race, and age for patients who used cannabis since cancer diagnosis (n=352) gender, % within category race, % within category age, % within category outcomes male female p-value white black/africanamerican p-value < 65 > 65 p-value medical certification (% yes) 35.8 (27.2,45.4) 45.6 (39.1, 52.4) 0.09 46.0 (40.1, 51.9) 28.2 (16.2, 44.4) 0.04 41.6 (35.3, 48.1) 42.3 (32.4, 52.7) 0.91 source of obtaining cannabis grow it 2.5 (.7, 8.1) .81 (.1, 5.5) 0.3 1.3 (.3, 4.1) 2.6 (.4, 16.8) 0.52 0 4.2 (1.5, 11.2) 0.01 internet 2.0 (.62, 6.2) 3.5 (1.6, 7.3) 0.41 2.6 (1.3, 5.2) 4.6 (1.1, 16.8) 0.45 2.3 (.9, 5.7) 3.9 (1.6, 9.4) 0.40 friend/family 44.9 (35.9, 54.9) 34.5 (28.7, 41.7) 0.08 36.2 (30.7, 42.1) 51.5 (35.7, 67.0) 0.07 40.0 (33.7, 46.6) 37.1 (27.8, 47.4) 0.63 unlicensed dealer/seller 17.4 (10.9, 26.5) 8.2 (5.0, 13.1) 0.01 8.6 (5.7, 12.6) 27.2 (15.0, 44.1) 0.0009 11.8 (8.0, 17.1) 11.6 (5.9, 21.6) 0.97 dispensary (prescription) 38.0 (29.3, 47.6) 49.7 (43.0, 56.4) 0.05 47.7 (41.9, 53.6) 35.3 (21.8, 51.6) 0.15 46.9 (40.4, 53.5) 41.8 (32.2, 52.1) 0.41 dispensary in another state (recreational) 19.5 (13.1, 28.1) 13.5 (9.3, 19.1) 0.17 15.2 (11.4, 19.8) 17.1 (7.9, 33.3) 0.76 15.4 (11.1, 21.0) 16.6 (10.4, 25.5) 0.79 factors that influence purchase price 34.6 (26.1, 44.2) 23.3 (17.9, 29.7) 0.03 24.0 (19.3, 29.5) 42.1 (27.5, 58.2) 0.02 30.1 (24.4, 36.6) 23.2 (15.3, 33.6) 0.24 availability/variety of products 39.0 (30.4, 48.4) 38.9 (32.4, 46.0) 0.98 36.9 (31.4, 42.7) 49.7 (34.2, 65.3) 0.13 39.6 (33.3, 46.3) 37.8 (28.4, 48.2) 0.76 ease of access 57.7 (48.1, 66.7) 48.4 (41.7, 55.1) 0.12 50.2 (44.4, 56.0) 62.7 (46.8, 76.3) 0.14 49.4 (42.6, 55.7) 57.4 (47.4, 66.9) 0.18 safety of product 40.9 (32.0, 50.6) 52.5 (45.6, 59.3) 0.05 48.3 (42.4, 54.2) 45.8 (30.8, 61.6) 0.77 51.0 (44.4, 57.6) 42.4 (32.8, 52.6) 0.16 quality of product 52.9 (43.4, 62.3) 52.6 (45.7, 59.5) 0.95 51.4 (45.4, 57.4) 56.6 (40.5, 71.5) 0.55 52.5 (45.8, 59.1) 53.2 (43.0, 63.2) 0.91 need for medical registry id card 13.9 (8.6, 21.8) 29.8 (23.8, 36.5) 0.002 23.2 (18.6, 28.5) 25.9 (14.7, 41.3) 0.71 23.8 (18.7, 29.9) 23.1 (15.8, 32.5) 0.89 method of payment 4.8 (1.6, 13.4) 2.7 (1.1, 6.9) 0.18 2.1 (1.0, 4.4) 10.2 (3.1, 28.8) 0.01 4.0 (2.0, 8.1) 2.6 (.4, 16.3) 0.68 more than 1 mode of cannabis (% yes) 55.9 (46.3, 65.1) 58.3 (51.4, 64.9) 0.68 55.3 (49.4, 61.0) 66.6 (49.6, 80.1) 0.21 61.4 (54.8, 67.6) 49.9 (39.8, 60.1) 0.06 most common mode of use smoking 31.4 (23.3, 40.7) 16.3 (11.8, 22.0) p<0.001 17.1 (13.1, 22.0) 39.0 (22.5, 54.4) 0.01 21.9 (16.8, 27.9) 22.8 (15.0, 33.0) 0.66 eating/ingesting 41.8 (33.2, 50.9) 52.8 (45.9, 59.7) 53.2 (47.1, 59.1) 32.9 (20.6, 48.0) 49.1 (42.6, 55.6) 47.5 (37.5, 57.7) vaping 24.0 (16.8, 33.0) 17.0 (12.4, 22.9) 20.0 (15.6, 25.1) 17.7 (8.3, 33.9) 21.0 (16.0, 27.0) 17.4 (10.9, 26.6) applying topically 2.8 (.9, 8.5) 13.9 (9.6, 19.7) 9.7 (6.7, 13.9) 10.4 (6.9, 13.9) 8.1 (5.2, 12.4) 12.3 (6.9, 21.1) note. all values are weighted estimates and 95% confidence intervals. cancer patients’ access to cannabis 6 table 3. outcomes by income category for patients who used cannabis since cancer diagnosis (n=352) income, % within category outcomes <$35,000 $35,000-$74,999 $75,000-$99,999 >=$100,000 p-value medical certification (% yes) 44.0 (28.2, 61.2) 39.0 (28.6, 50.5) 35.7 (24.1, 49.3) 44.5 (36.8, 52.6) 0.68 source of obtaining cannabis grow it 0 1.9 (.3, 12.2) 0 2.2 (.7, 7.1) 0.64 internet 5.4 (1.1, 21.7) 1.0 (.1, 6.9) 6.9 (2.5, 17.5) 1.8 (.5, 5.5) 0.13 friend/family 46.5 (30.4, 63.4) 41.2 (30.5, 52.8) 40.2 (27.8, 53.8) 35.6 (28.2, 43.7) 0.65 unlicensed dealer/seller 6.4 (1.5, 23.6) 23.8 (14.9, 35.8) 13.2 (6.1, 26.1) 5.7 (2.8, 11.3) 0.003 dispensary (prescription) 43.6 (28.3, 60.1) 43.5 (32.7, 54.9) 45.3 (32.6, 58.7) 45.8 (38.1, 53.8) 0.99 dispensary in another state (recreational) 22.2 (10.0, 42.3) 7.3 (3.2, 15.5) 16.8 (9.1, 29.1) 19.0 (13.6, 26.1) 0.11 factors that influence purchase price 38.3 (23.1, 56.1) 39.0 (28.4, 50.6) 36.5 (24.6, 50.2) 15.1 (10.2, 21.9) 0.0003 availability/variety of products 55.5 (38.2, 71.6) 42.3 (31.8, 53.6) 30.9 (20.1, 44.3) 35.1 (27.8, 43.1) 0.08 ease access 70.2 (53.6, 82.8) 57.7 (46.4, 68.3) 40.1 (27.9, 53.6) 47.9 (40.0, 56.0) 0.02 safety of product 50.9 (34.0, 67.7) 41.5 (30.9, 53.0) 54.2 (40.9, 66.8) 48.0 (40.1, 56.0) 0.53 quality of product 53.4 (36.3, 69.8) 52.4 (41.2, 63.4) 56.4 (43.3, 58.8) 50.8 (42.7, 58.8) 0.92 need for medical registry id card 18.8 (9.1, 34.7) 33.7 (23.8, 45.1) 15.1 (7.9, 27.1) 21.3 (15.5, 28.5) 0.05 method of payment 9.1 (3.6, 20.9) 5.9 (1.7, 18.9) 0 2.1 (.5, 8.3) 0.15 more than 1 mode of cannabis (% yes) 69.7 (52.3, 82.9) 55.8 (44.3, 66.8) 49.9 (36.9, 63.0) 57.4 (49.4, 65.1) 0.33 most common mode of use smoking 32.3 (17.9, 51.0) 28.3 (19.0, 39.8) 18.4 (10.1, 31.0) 17.5 (12.1, 24.7) 0.55 eating/ingesting 48.1 (31.7, 64.9) 45.9 (34.8, 57.3) 54.4 (41.0, 67.1) 48.5 (40.6, 56.6) vaping 16.1 (7.4, 31.4) 16.5 (9.7, 26.7) 18.4 (10.0, 31.4) 23.5 (17.1, 31.3) applying topically 3.6 (.4, 21.7) 9.4 (4.4, 18.8) 8.9 (3.9, 19.2) 10.5 (6.4, 16.7) note. all values are weighted estimates and 95% ci. cannabis, a publication of the research society on marijuana 7 other sources included: unlicensed dealer/seller (n=35, 9.9%), recreational cannabis store/dispensary in another state (n=55, 15.6%), internet (n=10, 2.8%), and growing it (n=4, 1.1%). source of obtaining cannabis differed by gender, race, and income, but not age. male patients, black/african-american patients, and patients with a self-reported income between $35,000 and $74,999 were more likely to obtain cannabis from an unlicensed dealer/seller than their counterparts (ps<0.02, tables 2-3). only race remained significant for the follow-up logistic regression model including gender, income, and race (or=3.3, 95%ci 1.2,9.0, p=0.02). female patients were also more likely to obtain cannabis from a dispensary with a medical certification card (p=0.05). factors that influence purchase of cannabis approximately half the sample reported that product quality (n=184, 52.3%) and safety (n=173, 49.2%), and ease of access/convenience (n=179, 50.9%) influenced their cannabis purchase. availability/variety of products (n=132, 37.5%), price (n=93, 26.4%), need for medical certification (n=83, 23.6%), and payment method (n=10, 2.8%) also influenced their purchase. factors affecting cannabis purchase differed by gender, race, and income, but not age. male patients, black/africanamerican patients, and patients with a selfreported income <$100,000 reported being more influenced by price than their counterparts (ps<0.05, tables 2-3). for the logistic regression, income (or=0.63, 95%ci 0.49,0.82, p=0.001) and gender (or=0.54, 95%ci 0.31,0.95, p=0.03) were significantly associated with being influenced by price, but the race effect was mitigated. female patients and patients with a self-reported income between $35,000 and $74,999 reported being more influenced by the need for a medical registry id card, compared to their counterparts (ps<0.05, tables 2-3). in the logistic regression, only gender was significantly associated with being influenced by the need for a medical registry id card (or=2.5, 95%ci 1.4,4.7, p=0.004). lastly, patients reporting the lowest income (<$35,000) were more influenced by ease of access/convenience compared to other income groups (p=0.02). being influenced by the safety or quality of the product were similar across sdoh variables. mode of use more than half the sample reported more than one mode of cannabis use (n=202, 57.4%). the most common modes of use were: ingested/oral (i.e, tinctures, edibles, drinking) (n=175, 50.0%), smoked (n=73, 21.0%), vaped (n=70, 20.0%), and topical (n=32, 9.1%). mode of use differed by gender (p<0.001) and race (p=0.01), but not age or income (tables 2-3). male and black/africanamerican patients were more likely to report smoking as their most common mode of use. the logistic regression indicated that gender and race significantly predicted smoking as the most common mode of use (gender: or=0.38, 95%ci 0.23,0.62; race: or=3.9, 95%ci 2.0,7.8; ps<0.001). in contrast, female and white patients were more likely to use ingested formulations. when gender and race were included in the logistic regression model, only race remained significant (or=0.44, 95%ci 0.23,0.88; p=0.02), indicating that black/african-american patients were 56% less likely than white patients to use ingested/oral forms of cannabis. discussion we examined the association of select sdoh variables (i.e., gender, race, age, income) with access to and use of forms of cannabis associated with lower risk among outpatients with cancer in pennsylvania. we found that overall cannabis use rates, medical certification rates, sources of obtaining cannabis, and forms of cannabis used differed by respondent race. patients who identified as black/african-american were more likely to report using cannabis in forms associated with adverse health outcomes, such as smoking cannabis. we also found differences by gender and income, suggesting males and lower-income patients may be more likely to use riskier forms of cannabis (i.e., smoked, obtained via unlicensed dealer/seller). although cannabis users were younger than non-users, age was not associated with any outcomes. taken together, these findings suggest that certain sdoh play an important role in how patients with cancer may access and use cannabis. the current data suggesting that black/african-american patients with cancer are more likely to report using cannabis compared to white patients are consistent with epidemiological cancer patients’ access to cannabis 8 studies in both the general population and in cancer survivors (do et al., 2021; jeffers et al., 2021). our data also show that black/africanamerican patients with cancer are less likely to be medically certified for cannabis in pennsylvania. although our data did not explore why medical certification rates differed, it is possible that mistrust arising in response to historical and contemporary structural racism in healthcare (primm et al., 2010; webb hooper et al., 2020) may have reduced black/african-american patients’ willingness to enroll in the program. because adult cannabis use has not been legalized in pennsylvania, it was not surprising that black/african-american patients in our study were also more likely to obtain cannabis from an unlicensed dealer/seller and were slightly more likely to obtain cannabis from family /friend. without access to products at a dispensary, black/african-american patients may be less likely to have access to forms of cannabis associated with reduced health risks (e.g., ingested formulations). indeed, black/african-american patients were more likely to use smoked forms of cannabis, potentially increasing their exposure to carcinogens (cooper & haney, 2009) and risk for smoking-related illnesses that may interfere with cancer treatment (schauer et al., 2017; nasem, 2017). this access issue is important as selfreported cannabis use has been found to ameliorate disparities in cancer pain relief for black/african-american patients (meghani et al., 2021). although correlational, these findings may represent a cascading impact of sdoh on health disparities related to cannabis use. further research is necessary to address lack of access to medical cannabis among black/african-american patients. our findings also suggested that patients with lower self-reported income were more influenced by ease of access and the need for a medical registry card, whereas those at the highest income level were least influenced by price. those at lower income levels were also more likely to obtain cannabis from an unlicensed dealer/seller, but this effect was no longer significant when accounting for race. this suggests costs also limit cannabis access, often inequitably by race. recent studies of dispensary locations have found disparities related to age, gender, race, and ability to pay out of pocket (cooke et al., 2018; novak et al., 2021). insurance coverage and social support programs to reduce the financial stress of cannabis use exist in europe and should be further studied (schmidt-wolf & cremer-schaeffer, 2019). although nearly half the sample reported that product safety and quality influenced their purchases, a substantial portion of patients reported they obtained cannabis from sources less likely to be monitored for safety (e.g., unlicensed dealer/seller). this highlights the importance of ehealth literacy (leader et al., 2021) and gaps in patient education, given that many cannabis users are unaware of product labeling and safety standards. in addition to race, males were more likely to obtain cannabis from an unlicensed dealer/seller and less likely to get it from a dispensary. moreover, males were more likely to smoke cannabis, and their purchases were more influenced by price. rates of medical certification did not differ by gender suggesting that males tended to engage in riskier cannabis use-related behaviors and may be less influenced by medical certification. more research is needed to better understand these gender differences. limitations several limitations warrant mention. first, these data were cross-sectional and causal inferences cannot be made. second, our sample was predominantly white, and a relatively small group of patients identified as black/african-american, asian, hispanic, or other race; therefore, findings may not be generalizable, in particular to patients with cancer outside of pennsylvania. we used race as a social construct and proxy for a multitude of social disadvantages in the united states (hill et al., 2022; meghani & chittams, 2015). however, unmeasured sdoh variables (e.g., racism, health literacy) may also account for some of our findings. lastly, although selection bias in survey responses may have influenced our findings, the data were adjusted to account for differences in response rate across demographic groups. conclusion the prevalence of cannabis use for symptom management among patients with cancer has risen considerably in recent years, highlighting the need to understand factors that impact access and safer use. these data shed light on how drivers of health disparities (e.g., race, income) are associated with cannabis, a publication of the research society on marijuana 9 where patients with cancer obtain cannabis, what forms they use, and what influences their purchase decisions. more research is needed to understand the health outcomes associated with these differences in cannabis use and access-related factors such as the role of clinician-patient communication on certification, education around safe cannabis use, and the impact of statewide policies intended to increase access to cannabis. references healthy people 2030. retrieved 07/26/2022 from https://health.gov/healthypeople/priorityareas/social-determinants-health national conference of state legislatures: state medical marijuana laws. retrieved october 30, 2022 from https://www.ncsl.org/research/health/statemedical-marijuana-laws.aspx ambekar, a., ward, c., mohammed, j., male, s., & skiena, s. 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(2017). cannabis use in palliative oncology: a review of the evidence for popular indications. isr med assoc j, 19(2), 85-88. https://www.ncbi.nlm.nih.gov/pubmed/284570 56 wang, x., dworkin, j. d., zhou, d., stiso, j., falk, e. b., bassett, d. s., zurn, p., & lydonstaley, d. m. (2021). gendered citation practices in the field of communication. annals of the international communication association, 45(2), 134-153. https://doi.org/10.1080/23808985.2021.196018 0 webb hooper, m., nápoles, a. m., & pérezstable, e. j. (2020). covid-19 and racial/ethnic disparities. jama, 323(24), 2466-2467. https://doi.org/10.1001/jama.2020.8598 worster, b., ashare, r. l., hajjar, e., garber, g., smith, k., & kelly, e. l. (2021). clinician attitudes, training, and beliefs about cannabis: an interprofessional assessment. cannabis and cannabinoid research. https://doi.org/10.1089/can.2021.0022 zhou, d., bertolero, m. a., stiso, j., cornblath, e., teich, e. g., sizemore blevins, a., oudyk, k., cleanthis, m., urai, a., matelsky, j., virtualmario, camp, c., alacantra castillo, r., saxe, r., dworkin, j. d., & bassett, d. s. (2022). dalejn/cleanbib: v1.1.1. in (version 1.1.2) zenodo. https://doi.org/10.5281/zenodo.4104748 funding and acknowledgements: this research was funded by an administrative supplement to the university of pennsylvania abramson cancer center (award number p30-ca016520-44s7) from the national cancer institute (nci), nih, dhhs. we acknowledge icf for providing technical https://link.springer.com/journal/103 https://link.springer.com/journal/103 https://link.springer.com/journal/103 cancer patients’ access to cannabis 12 support to the supplement grantees, including advising on sampling plans and computing survey weights, and in collaboration with nci, developing a core set of survey questions. the contents of this manuscript are the sole responsibility of the authors and do not necessarily represent the official views of the nci. recent work in several fields of science has identified a bias in citation practices such that papers from women and other minority scholars are under-cited relative to the number of such papers in the field (bertolero et al., 2020; caplar et al., 2017; chatterjee & werner, 2021; dion et al., 2018; dworkin et al., 2020; wang et al., 2021). here we sought to proactively consider choosing references that reflect the diversity of the field in thought, form of contribution, gender, race, ethnicity, and other factors. first, we obtained the predicted gender of the first and last author of each reference by using databases that store the probability of a first name being carried by a woman (dworkin et al., 2020; zhou et al., 2022). by this measure (and excluding self-citations to the first and last authors of our current paper as well citations listed in this statement), our references contain 20.83% woman(first)/woman(last), 12.5% man/woman, 40.22% woman/man, and 26.44% man/man. this method is limited in that a) names, pronouns, and social media profiles used to construct the databases may not, in every case, be indicative of gender identity and b) it cannot account for intersex, non-binary, or transgender people. second, we obtained predicted racial/ethnic category of the first and last author of each reference by databases that store the probability of a first and last name being carried by an author of color (ambekar et al., 2009; sood & laohaprapanon, 2018). by this measure (and excluding self-citations), our references contain 2.95% author of color (first)/author of color(last), 16.8% white author/author of color, 20.74% author of color/white author, and 59.5% white author/white author. this method is limited in that a) names and florida voter data to make the predictions may not be indicative of racial/ethnic identity, and b) it cannot account for indigenous and mixedrace authors, or those who may face differential biases due to the ambiguous racialization or ethnicization of their names. we look forward to future work that could help us to better understand how to support equitable practices in science. rebecca l. ashare has an investigator-initiated grant from novo nordisk, inc for a study unrelated to current paper. all other co-authors report no conflict of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ microsoft word v3i1a3_final.docx research article 19 abstract marijuana is the most widely used illicit substance in the united states, and its use is especially prevalent among young adults. over the past two decades, there has been an overall decline in perceived harmfulness of marijuana use in young adults ages 18-30, despite growing evidence that chronic marijuana use may be associated with cognitive impairment. there have been mixed results regarding the effects of chronic marijuana use on inhibitory control. furthermore, previous literature has shown inconsistent results regarding processing speed in marijuana users. the current study examined inhibitory control and processing speed in chronic marijuana-using young adult college students and healthy controls ages 18-22. 33 healthy controls (mean age: 19.18 ± 1.13; 18 male) and 28 chronic marijuana users (mean age: 20.25 ± 1.17; 19 male) were included in the study. chronic marijuana users had to have used marijuana ≥5 times/week over the past year to be eligible. participants were instructed to remain abstinent from marijuana use for 12 hours prior to the study visit. the 30-day timeline followback (tlfb) was used to assess recent marijuana use and participants were asked to estimate age at first marijuana use and lifetime days of marijuana use. participants completed the stroop color word task (scwt), and the interference t-score was used as a measure of inhibitory control. furthermore, we examined marijuana use characteristics (i.e. age at first use, lifetime marijuana use, and past 30-day marijuana use) in relation to performance on the scwt. additionally, exploratory analyses investigated differences in the color and word conditions of the scwt between the two groups and as a function of marijuana use characteristics. results indicated no significant group differences on the interference, word, and color conditions of the scwt. furthermore, there were no significant correlations between age at first use, lifetime marijuana use, and past 30-day marijuana use with any conditions of the scwt, but, there was a trend for greater past 30-day marijuana use to be associated with poorer performance on the color condition (r(26) = -0.26, p = 0.09). these findings indicate that chronic, heavy marijuana use may not be associated with impairments in inhibitory control or processing speed, which is consistent with other studies examining current use, heavy use, and chronic use in adolescents, young adults, and adults. further research is needed to determine whether chronic, heavy marijuana use during young adulthood affects higher-order cognitive functioning skills needed for success in college, starting a career, and transitioning into adulthood. key words: marijuana, inhibitory control, young adults, executive function, processing speed marijuana (mj) is the most widely used illicit substance in the united states, and its use is especially prevalent among young adults; 6% of 18-20 year-olds, and 9% of 21-22 year-olds reported daily mj use in 2017 (nida, 2018; schulenberg et al., 2018). the highest prevalence cannabis 2020, volume 3 (1), 19-30 © author(s) 2019 researchmj.org doi: 10.26828/cannabis.2020.01.003 open access chronic marijuana use, inhibitory control, and processing speed in young adult college students corresponding author: anita cservenka, school of psychological science, oregon state university, 2950 sw jefferson way, corvallis, or, 97331, email: anita.cservenka@oregonstate.edu, phone: 1-541-737-1366 jessica m. cavalli1, anita cservenka1 1 school of psychological science, oregon state university, corvallis, or, usa marijuana, inhibitory control, and processing speed 20 rates of annual and 30-day mj use were among 18-22 year-olds (schulenberg et al., 2018), which is concerning as this age group is still undergoing critical changes in biopscyhosocial maturation (baggio et al., 2017; sowell et al., 1999). over the past two decades, there has been an overall decline in perceived harmfulness of mj use in adults ages 18-30 (schulenberg et al., 2018), despite growing evidence that chronic mj use may be associated with cognitive impairment (becker et al., 2014; broyd et al., 2016; crean et al., 2011; yusoff et al., 2013). heavy mj use may negatively impact protracted brain maturation during young adulthood, possibly hindering the ability of youth to hone important cognitive skills needed for success in college, starting a career, and transitioning into adulthood. thus, it is critical to determine whether heavy mj use during young adulthood affects higher-order cognitive functioning skills that are still undergoing maturation (fuster, 2002). inhibitory control is one domain of executive functioning defined as the ability to inhibit impulsive, habitual responses, subsequently allowing the selection of a more appropriate response; it allows for the possibility of change and choice (diamond, 2013). one definition of inhibitory control is self-control, which involves the regulation of one’s own behavior and emotions. self-control allows for the resistance of temptations, discipline to stay on task, and delayed gratification (diamond, 2013). however, another aspect of inhibitory control is interference control, which requires selective attention and allows the suppression of all stimuli except the target stimulus. impaired inhibitory control has been associated with drug abuse and implicated in the maintenance of drug dependence (crews & boettiger, 2009; goldstein & volkow, 2002; lubman, yücel, & pantelis, 2004). on the stroop task, a measure of interference control, poorer performance on stroop interference has been found in college student binge drinkers, methamphetamine-dependent individuals, cocaine polysubstance users, and other illicit drug users relative to healthy controls (hallgren & mccrady, 2013; salo et al., 2002; verdejo-garcía & pérez-garcía, 2007; lillis et al., 2012); the current study aims to identify if heavy mj use during young adulthood is associated with similar deficits in interference control. examining inhibitory control in young adult heavy mj users may help determine if chronic mj use increases mj users’ risk of maladaptive behavioral outcomes. while mj use has been associated with impairments in many cognitive domains, including learning, memory, and attention, the findings regarding executive functioning, including inhibitory control, are mixed (crean et al., 2011; becker et al. 2014; broyd et al., 2016; yusoff et al., 2013). research has consistently shown that acute mj use is associated with impaired inhibitory control, but there have been mixed results regarding the effects of chronic mj use on inhibitory control. specifically, acute mj intoxication has been associated with significantly increased stop reaction time and the proportions of commission and omission errors in the stop signal task, a common measure of inhibitory control (ramaekers et. al, 2006; ramaekers et al., 2009; metrik et al, 2012; theunissen, et al., 2015). in addition, a number of studies have found that chronic mj users show increased errors of commission and omission, and significantly poorer performance on the interference condition of the stroop task (gruber et al., 2012a; sagar et al., 2015; battisti et al., 2010; dahlgren et al., 2016). however, there have been multiple studies indicating no difference in performance on inhibitory control measures between mj users and non-users (gruber & yurgelun-todd, 2005; murphy et al., 2011; price et al., 2015; takagi et al., 2014; takagi et al., 2011; whitehurst et al., 2015). it is possible that smaller sample sizes for mj users, such as the ones found in the latter studies (e.g. n= 10, 13, 27, 19, 19, and 17) may have contributed to the lack of group differences due to inadequate power to detect significant effects. mixed findings on the effects of chronic mj use on inhibitory control may also be related to length of abstinence prior to study participation, which is variable or unspecified in previous studies. a recent metaanalysis (scott et al., 2018) found that studies requiring an abstinence period of 72 hours or more had effect sizes near zero, which may suggest that neurocognitive deficits are more likely to be present in individuals who are actively using mj relative to those who have entered a period of abstinence. in addition, variables such as age at initiation of mj use and frequency of mj use have been found to predict poorer inhibitory control (sagar et al., 2015; dahlgren et al., 2016; gruber cannabis, a publication of the research society on marijuana 21 et. al, 2012b). therefore, including these measures could better explain the impact of mj use on inhibitory control. in addition to mixed results in the current literature, it remains unclear whether deficits in inhibitory control predate, or are a result of chronic mj use. poorer inhibitory control prior to the initiation of substance use has been found to predict increased substance use, including mj, and dependence symptoms (mahmood et al., 2013; norman et al., 2011; squeglia, jacobus, nguyen-louie, & tapert, 2014; wetherill, squeglia, yang, & tapert, 2013). thus, it is difficult to determine whether premorbid impaired inhibitory control increases risk for chronic mj use, or chronic mj use relates to impairments in inhibitory control. therefore, cross-sectional studies should also examine mj use characteristics in relation to inhibitory control to help address this question. objectives the current study aims to identify the effects of chronic mj use on inhibitory control in young adult college students. we recruited chronic mj using college students 18-22 years of age, who completed measures of substance use history and the stroop task as part of a larger neurocognitive battery. in line with previous studies (becker et al., 2014; gruber et al., 2012; solowij et al., 2011), participants were required to abstain from using mj for 12 hours prior to the study visit to avoid the effects of acute intoxication on neurocognitive measures at the time of the study visit. this study recruited young adults within a narrow age range in order to determine how mj use may affect inhibitory control during the protracted maturation of executive functioning; to our knowledge, the current study is one of few studies that have examined chronic mj use on inhibitory control during young adulthood (crane, schuster, & gonzalez, 2013; lisdahl & price, 2012). participants completed the stroop color-word task (scwt), which is considered to be one of the most robust measures of inhibitory control (macleod, 1991). in the current study, we adopted the scoring method proposed by golden (1978) to obtain an interference t-score for each participant. thus, our study specifically measures interference control, a component of inhibitory control that involves selective attention, cognitive inhibition, and suppression of prepotent responses (diamond, 2013). to understand how mj use characteristics impact inhibitory control, the study also examined the relationship between lifetime days of mj use, past 30-day occasions of mj use, and age at first mj use with stroop performance. previous studies found mj use to be associated with reduced information processing speed (fried, watkinson, & gray, 2005; kelleher, stough, sergejew, & rolfe, 2004; lisdahl & price, 2012); one of these studies found slower processing speeds on the processing speed index in young adult current heavy mj users (fried, watkinson, & gray, 2005). the current study also explored differences in processing speed during the scwt between the mj users and healthy controls to identify potential deficits in processing speed in young adult chronic mj users. hypotheses the current study had three main hypotheses; first, we hypothesized that chronic mj users will exhibit impaired interference control on the stroop task compared to healthy controls; second, we predicted that lifetime days of mj use and frequency of past month mj use in mj users would be negatively correlated with interference control; third, we predicted age at first mj use in mj users would be negatively correlated with interference control in mj users (i.e. using mj at an earlier age predicts more severe impairment in inhibitory control). method participants participants were recruited through flyers, word of mouth, snowball sampling, and social media advertising. participants who contacted the laboratory reviewed the consent form with study staff and informed consent was obtained from participants who were interested in completing the eligibility interview. eligible participants were 18-22 year old college or university students who met inclusionary criteria for the healthy control (hc) (n=33) or chronic mj user (n=28) group. exclusionary criteria for all participants included: <18 or >22 years of age; inadequate knowledge of the english language (e.g. not fluent); pregnancy; uncorrected visual impairments; self-reported lifetime history of a marijuana, inhibitory control, and processing speed 22 diagnosed psychiatric disorder; learning disability; self-reported current use of psychotropic medications; major neurological/medical illness; significant head trauma; prenatal exposure to drugs or alcohol; premature birth (<35 weeks gestation); and reported history of psychotic disorders in immediate biological relatives (e.g. schizophrenia or bipolar i). because exclusionary criteria included a lifetime history of a diagnosed psychiatric disorder, participants with attention deficit hyperactivity disorder (adhd) have been excluded from the study; thus, some participants with impairments in inhibitory control may have been excluded from the sample since deficits in inhibitory control have been identified as a core component of adhd (jacobson, schneider, & mahone, 2017). these criteria were set in place to exclude participants who may have atypical performance on measures of executive functioning not associated with mj use. hcs were excluded for significant substance use history (>51 lifetime drinks [pfefferbaum et al., 2016], lifetime history of >5 drinks/occasion for males/>4 drinks/occasion for females, >90 lifetime cigarettes, mj use more than once/month in the past year, and any other illicit drug use). mj users reporting >15 lifetimes occasions of past use of other illicit drugs or recreational use of over-the-counter medications were also excluded to limit the effects of polysubstance use on executive functioning. inclusionary criteria for participants in the mj group were at least 5 occasions of mj use/week in the past year. alcohol use was not exclusionary for the mj group given the prevalence of alcohol and mj co-use among young adults (norton & colliver, 1988; o’hara, armeli, & tennen, 2016). since problem drinking and recent binge drinking have been associated with impaired inhibitory control (gan et al., 2014; hallgren & mccrady, 2013; hu, zhang, chao, krystal, & li, 2016; lawrence, luty, bogdan, sahakian, & clark, 2009), appropriate statistical measures were performed to control for alcohol use in the current sample. all procedures were approved by oregon state university’s institutional review board (irb) and followed the ethical guidelines of the irb. data on other tasks of executive functioning from this participant sample has been previously published in another manuscript (lahanas & cservenka, 2019). procedures eligible participants were invited into the lab for a study visit in which they completed measures of substance use, psychosocial functioning, and neuropsychological tasks to assess executive functioning, including the stroop task. following consent, participants provided a urine sample for a 12-panel urine toxicology test (clia waived, inc.), which was used to identify recent substance use and a breathalyzer (bactrack breathalyzer) to ascertain absence of alcohol intoxication. participants were asked to abstain from mj use for at least 12 hours prior to the study visit to limit the effects of acute intoxication on neurocognitive measures. furthermore, a longer abstinence period was not required as this study was interested in examining how ongoing heavy mj use affects inhibitory control, as opposed to examining how neurocognitive performance is affected by abstinence from mj use, and withdrawal symptoms, which typically begin 24-48 hours after abstinence (greydanus, hawver, greydanus, & merrick, 2013; haney et al., 2004). as mj users may have reported some illicit substance use, they were not excluded from analyses due to positive urine toxicology for any substance. one hc tested positive for tetrahydrocannabinol at the time of the study visit, but as hcs may have used mj within the past month (mj use ≤ once/month in the past year), they were not excluded from analyses. one hc participant tested positive for opiates at the time of the study visit but did not report opiate use during the eligibility interview. measures participants completed a brief demographic questionnaire and measures of substance use. recency, and frequency of mj, alcohol, nicotine, and other substance use was assessed with the timeline followback (robinson et al., 2014; sobell & sobell, 1992), which asked participants to indicate their substance use in the 30 days prior to the study visit, including the day of the study visit. participants were also asked to estimate the total number of days they used mj in their lifetime and their age at first mj use. general intelligence was assessed by the 2subtest version of the wechsler abbreviated scale of intelligence-ii (wasi-ii) (wechsler, 2011), cannabis, a publication of the research society on marijuana 23 while inhibitory control was examined with the stroop color-word test (scwt) (golden, 1978). for the scwt, participants read three different tables as quickly and as accurately as they could for 45 seconds each. two of the tables represent a “congruent condition”, for which participants read names of colors printed in black ink (word condition, or w) and named different color patches (color condition, or c). the “incongruent condition” uses a table of color-words (color-word condition, or cw) printed in inconsistent color ink (e.g the word “green” is printed in red ink); the participants were required to read the name of the color of the ink instead of reading the word. the cw condition challenges participants to inhibit the interference coming from a more automated task (i.e. reading the word). the current study uses the scoring method proposed by golden (1978). in this method, the number of items correctly named in 45 seconds in each condition (i.e. w, c, cw) is calculated and used to determine the predicted color-word score (pcw). then, the pcw value is subtracted from the actual number of items correctly named in the cw condition to obtain an interference t-score (ig) (i.e. ig = cwpcw); a lower score represents greater difficulty in interference control, while a negative ig value represents severe impairment in interference control (scarpina & tagini, 2017). statistical analysis for all statistical analyses, spss version 25.0 (ibm corp., 2017) was used. demographic variables and dependent variables from the scwt were examined for skewness and kurtosis values to determine whether parametric or nonparametric tests (skewness or kurtosis >2) were appropriate for analyses. furthermore, levene’s test was used to assess equality of variances for the mj and hc groups. demographic and substance use variables were compared between groups using chi-square, independent samples ttests, or mann-whitney u-tests as appropriate. demographic and substance use variables significantly different between the groups were examined in relation to scwt performance, and those variables significantly related to scwt performance were included as covariates in analyses. to determine group differences in interference control on the scwt, an independent samples t-test was used to compare groups on ig. pearson or spearman correlations were performed to examine the relationship between days of lifetime mj use, past 30-day mj use occasions, and age at first mj use with performance on the scwt. to examine the effects of mj use on processing speed, t-scores for the word and color conditions of the scwt were used to conduct exploratory data analyses. groups were compared on color and word t-scores using independent samples t-tests and the effects of substance use variables on word and color t-scores were examined using pearson or spearman correlations. a significance level of p < 0.05 was set for all statistical tests. results the hc and mj groups were well matched on all demographic variables except for age and iq (see table 1), as mj users were significantly older than hc and had a significantly lower mean iq score relative to hc. however, age and iq were not significantly associated with interference tscores, color t-scores, or word t-scores (all p’s > 0.10) and thus were not included as covariates in our analyses. as expected, groups differed on a number of substance use measures (see table 1) as a result of eligibility criteria for participation in the study. given that the majority of hc had never used mj (n = 27), mj use characteristics were examined in relation to the dependent variables only within the mj group. none of the alcohol or cigarette use measures were correlated with the dependent variables (all p’s > 0.10). thus, they were not included as covariates in our analyses. there were no significant differences between the mj and hc groups on the interference t-score (t(59) = 1.0, p = .17), color t-score (t(59) = .811, p =.42), or word t-score (t(59) = 1.62, p = .11). within the mj group, there were no significant correlations between log transformed lifetime mj use (r(26) = -0.25, p = 0.11), square root transformed past 30-day mj use (r(26) = -0.005, p =.49), or age at first mj use (r(26) = 0.22, p = .13) and interference t-scores. there were no significant correlations between log transformed lifetime mj use (r(26) = -0.05, p =.39), or age at first mj use (r(26) = -0.06, p = 0.38) and color tscores, but there was a trend towards a significant relationship between square root transformed marijuana, inhibitory control, and processing speed 24 table 1. demographic characteristics and substance use measures demographics controls (n=33) mj users (n=28) t or χ2 p m(sd) m(sd) age 19.19(1.13) 20.25(1.17) -3.61 .001 sex (m/f) 18/15 19/9 1.13 .290 hispanic/latino (n) 3 3 0.05 .832 race (n) 1.8 .614 white 22 22 asian 4 1 more than one race 6 4 unknown 1 1 ses 1.66 .789 poor 1 1 lower middle class 1 1 middle class 20 14 upper middle class 11 11 wealthy 0 1 wasi-ii full-scale iq 118.42(13.63) 107.14(12.6) 3.34 .001 substance use measures controls (n=33) mj users (n=28) u p age at first mj use 17.57(1.5) 16.39(1.55) 47 .090 lifetime mj use days 23.06(126.94) 1041.89(609.53) 9.5 < .001 past 30-day mj use 0.06(.24) 48.54(31.79) 0 < .001 age at first drink 17.38(1.47) 16.71(1.72) 274.5 .250 lifetime drinks 15.67(17.07) 409.14(629.24) 67.5 .001 past 30-day drinks 1.98(3.66) 19(17.93) 119 < .001 age at first cigarette 18(1) 17.94(1.47) 8.5 .930 lifetime cigarettes .03(.17) 41.75(135.19) 170 < .001 past 30-day cigarettes .03(.17) 17.68(3.34) 391 .050 lifetime illicit substance use 0 3.21(3.36) 148.5 < .001 past 30-day mj use and color t scores (figure 1; r(26) = -0.26, p = 0.09). there were no significant correlations between log transformed lifetime mj use (r(26) = -0.02, p = 0.46), square root transformed past 30-day mj use (r(26) = -0.03, p =0.43), or age at first mj use (r(26) = -0.01, p = 0.47) and word t-scores. discussion the current study investigated whether chronic mj use is associated with impairments in inhibitory control in young adult college students. there were no significant group differences on inhibitory control between healthy controls and chronic mj users, nor were there significant correlations between mj use measures (i.e. lifetime mj use, past 30-day mj use, and age at first mj use) and dependent variables (i.e. interference t-scores, color t-scores, and word tscores). however, there was a trend such that mj users who reported greater past 30-day mj use tended to name fewer colors during the color condition of the scwt, suggesting that greater recent mj use may be associated with slower processing speeds. while previous studies have reported mixed findings when examining the association between cannabis, a publication of the research society on marijuana 25 figure 1. trend between more past 30-day mj use and smaller color t-scores suggesting longer response times and slower processing speeds on the color condition of the scwt. chronic mj use and impairments in inhibitory control, our study has found results similar to others (cousijn et al., 2013; gonzalez et al., 2012; griffith-lendering, huijbregts, vollebergh, & swaab, 2012; gruber, et al., 2012a; gruber et al., 2012b; price et al., 2015; takagi et al., 2011; whitehurst, fogler, hall, hartmann, & dyche, 2015). gruber et al. (2012a; 2012b) found that chronic mj users and healthy controls performed similarly on the interference condition of the multisource interference task and the scwt. additionally, takagi et al. (2011) did not find any differences in inhibitory control on the scwt or go/no-go task between healthy controls and cannabis users. another study found no group differences on the delis-kaplan executive function system color-word interference in a sample of emerging adults (price et al., 2015). these studies had sample sizes similar to our user group of 28 (i.e. 34 users, 23 users, 19 users, and 27 users). similar to our lack of significant findings between mj use frequency and the scwt, another study found no associations between mj consumption and accuracy on the scwt (thayer et al., 2015). further, our results support previous work that has not found cannabis use to be associated with slower processing speed (becker et al., 2014; hanson et al., 2010; nguyen-louie et al., 2015). for example, becker et al. (2014) did not find slower processing speeds in 18-20 year-old chronic mj users on the digit symbol. there are several potential explanations for the absence of significant findings regarding inhibitory control in the current study. limited statistical power due to our small sample size (28 chronic mj users and 33 healthy controls) may have played a role in our inability to detect any significant associations. post-hoc power analysis for group differences on the interference t-score [g*power (faul, erdfelder, lang, & buchner, 2007)] revealed that we obtained statistical power of 0.26 given the sample size (n = 61) and effect size of 0.26. interestingly, even though the current study did not find significant group differences on inhibitory control between mj users and hcs, a recent meta-analysis found that published studies examining the effect of mj use on inhibitory control had similar effect sizes to ours (d = 0.25; scott et al., 2018). also, given that recent research has shown that initiating regular cannabis use at an earlier age is related to poorer neurocognitive performance (dahlgren et al., 2016; ehrenreich et al., 1999; gruber et al., 2012; lisdahl, gilbart, wright, & shollenbarger, 2013; pope et al., 2003; sagar et al., 2015), considering age of onset may have yielded more insight into the relationship between mj use and inhibitory control; we did not find any significant associations between age at first use and inhibitory control, possibly because using a substance for the first time does not accurately reflect regular use and associated consequences. furthermore, many previous studies finding no group differences on measures of inhibitory control between mj users and controls also examined this relationship in young adults (gonzalez et al., 2012; griffith-lendering et al., 2012; price et al., 2015; whitehurst et al., 2015). alternatively, many previous studies that reported inhibitory control impairments in mj users compared to controls had examined either adolescents or adults (battisti et al., 2010; behan et al., 2014; dahlgren et al., 2016; dougherty et al., 2013; fontes et al., 2011; sagar et al., 2015). thus, it is possible that the current study was unable to observe impairments due to our restricted age range, or due to the age range itself. possibly, impairments are most evident with active heavy mj use in adolescence, when cognitive maturation may be more vulnerable to potential neurotoxic effects of mj use, or in adulthood after a longer exposure to mj use has occurred. 0 5 1 0 1 5 0 2 0 4 0 6 0 8 0 s q u a re r o o t-tra n s fo rm e d p a s t 3 0 -d a y m a riju a n a u s e c o lo r tsc o re marijuana, inhibitory control, and processing speed 26 the current study has a few limitations of note. while we required abstinence from mj users 12 hours prior to the study visit, we cannot ascertain whether participants adhered to this requirement, though no participants appeared intoxicated at the time of the study visit. furthermore, our sample was limited to college students, thus our findings may not be generalizable to non-college young adults, who have three times the rate of daily mj use relative to college students (non-college: 13.2%; schulenberg et al., 2018). finally, because our sample specifically examined chronic mj use (i.e. using 5+ times/week over the past year), our findings may not reflect cognitive performance in infrequent young adult mj users. in the current study, chronic mj users did not show any significant impairments in inhibitory control or processing speed compared to healthy controls, and mj use characteristics were not associated with impairments in inhibitory control or processing speed. because the findings of the current literature remain mixed, the current findings could help inform future researchers’ decisions to further investigate these relationships. further investigation is warranted to determine whether there exists a relationship between chronic mj use and impaired inhibitory control. if such a relationship exists, chronic mj users may be at risk of developing a substance use disorder due to their difficulty in inhibiting impulsive, habitual drug use behaviors. in this way, intervention efforts could emphasize techniques aimed at reducing impulsive behaviors. longitudinal studies measuring inhibitory control before mj use initiation, during a period of chronic mj use, and after a period of mj abstinence would be invaluable in determining the effects of mj on inhibitory control and if potential impairments are reversible with abstinence. references baggio, s., studer, j., iglesias, k., daeppen, j.b., & gmel, g. 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(2013). a longitudinal examination of adolescent response inhibition: neural differences before and after the initiation of heavy drinking. psychopharmacology, 230(4). https://doi.org/10.1007/s00213-013-3198-2 whitehurst, l. n., fogler, k., hall, k., hartmann, m., & dyche, j. (2015). the effects of chronic marijuana use on circadian entrainment. chronobiology international, 32(4), 561–567. https://doi.org/10.3109/07420528.2015.100407 8 yusoff, n., yuan, j., & yang, j. (2013). a review of neuropsychological status in cannabis users. procedia social and behavioral sciences, 97, 2–11. https://doi.org/10.1016/j.sbspro.2013.10.198 funding: this study was supported by the medical research foundation new investigator grant to ac. copyright: © 2019 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i1a3_authors_final research article 18 ved abstract objective. some adverse cannabis effects are greater in individuals on the psychosis spectrum compared to healthy individuals. we have previously reported that smoked cannabis acutely worsened psychoticlike states and reduced cognitive performance selectively in cannabis users at clinical high-risk (chr) for psychosis. the objective of the present study was to further investigate the acute effects of cannabis on cognition and reward processing in chr cannabis users. method. six chr cannabis users and six psychiatrically-healthy cannabis users comparable in intellectual, demographic, and cannabis use characteristics (including nontreatment-seeking status), participated in the study. objective and subjective measures of cognition and cannabis reward, were completed before and after smoking half of an active (5.5% δ9tetrahydrocannabinol [δ9-thc]) or half of a placebo (0.0% δ9-thc) cannabis cigarette, under randomized/double-blind conditions. repeated measures anova tested main effects of drug condition (active vs. placebo) and/or the drug condition × time (baseline vs. post-administration) interactions; groups were analyzed separately due to the small sample size. results. chr participants exhibited evidence of decreased objective response inhibition and aversive intoxication following active cannabis, relative to placebo. psychomotor speed and cannabis-related attentional bias were also affected by cannabis intoxication. no such effects were observed in psychiatrically-healthy cannabis users. conclusion. these findings provide further preliminary evidence of a deleterious cognitive and rewardrelated response to cannabis in individuals with preexisting risk for psychosis. key words: marijuana; thc; cognition; prodromal psychosis; response inhibition cognitive functioning is an area of concern for individuals who use cannabis regularly (crane et al., 2013). cannabis with proportionally higher δ9-tetrahydrocannabinol (δ9-thc) cannabinoid content may produce a wide range of acute cognitive effects in cannabis users, including temporary decreases in attention and working memory (crane et al., 2013; bhattacharyya et al., 2015), reduced inhibitory control and slowed decision-making (oomen et al., 2018; vadhan et al., 2007), and other related executive impairments (cohen & weinstein, 2018). however, these effects are not universal due to participant moderating factors, such as varying cannabis 2022, volume 5 (1) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.01.003 smoked cannabis effects in cannabis users at clinical high-risk for psychosis: a further investigation of cognition and reward corresponding author: nehal p. vadhan, phd, department of psychiatry, northwell health. 1010 northern blvd, suite #311, great neck, ny 11021. phone: 516-837-1685. fax: 516-837-1699. email: nvadhan@northwell.edu sean p. madden1,2, john g. keilp2, olivia wu3, cheryl m. corcoran4, ragy r. girgis2, & nehal p. vadhan1,5 1 institute of behavioral science, feinstein institutes for medical research, manhasset, ny, usa 2 department of psychiatry, columbia university irving medical center and the new york state psychiatric institute, new york, ny, usa 3 herald square psychology, 19 w. 34th st., new york, ny, usa 4 department of psychiatry, icahn school of medicine at mount sinai, new york, ny, usa 5 departments of psychiatry and molecular medicine, donald and barbara zucker school of medicine at hofstra/northwell cannabis, a publication of the research society on marijuana 19 cannabis use histories and tolerance (nordstrom & hart, 2006; ramaekers et al., 2016) and vulnerability to psychosis (vadhan et al., 2017). cognitive functioning is also an area of concern for individuals across the psychosis spectrum in general (bora et al., 2014; thai et al., 2019), and cannabis use is common among these individuals (myles et al., 2016). a recent review found that nearly half of all individuals at clinical high-risk for psychosis (chr) reported using cannabis at some point in their life, and a quarter reported current cannabis use (farris et al., 2020). disturbances in response inhibition and working memory, which can be also produced by acute δ9thc administration, are characteristic of psychosis-spectrum disorders (ethridge et al., 2014). additionally, the endocannabinoid system has been implicated in the pathophysiology of these disorders (ferretjans et al., 2012; murray et al., 2017), with findings of increased cb1 receptor binding density and anandamide levels in cerebrospinal fluid (leweke et al., 2018; minichino et al., 2019). cannabis users with a psychotic disorder (e.g. schizophrenia) may exhibit comparable or even enhanced cognition when not intoxicated, relative to non-cannabis users with a psychotic disorder (e.g., menendez-miranda et al., 2019). however, when cannabis or δ9-thc has been directly administered to samples of cannabis users across the broad psychosis spectrum, a variety of adverse cognitive and behavioral effects have been observed. these effects include worsening of psychotic states and memory function (sherif et al., 2016), and are of greater magnitude than those observed in cannabis users who are not on the psychosis spectrum (mason et al., 2009; vadhan et al., 2019); these differential effects may be additionally moderated by genetic factors (di forti et al., 2012). moreover, under conditions of non-intoxication, the learning and attentional performance of cannabis users who report psychotic-like states after naturalistic cannabis use, have been shown to be poorer than cannabis users who report primarily euphoric states (barkus et al., 2016). consistent with these findings, we found that administration of active smoked cannabis (5.5% δ9-thc) relative to placebo smoked cannabis (0.0% δ9-thc) increased subjective psychotic-like states (e.g., paranoia) and cognitive/perceptual disturbances (e.g., inattention, slowed time perception), while slowing logical reasoning (i.e., a not b task) and reducing attentional control (i.e., stroop), in cannabis users at clinical highrisk (chr) for psychosis (vadhan et al., 2017). no such effects were observed in psychiatricallyhealthy cannabis users, although active cannabis increased heart rate and subjective intoxication in both groups. given the burgeoning evidence of a distinct and adverse acute response to cannabis in chr individuals (vadhan et al., 2019) that ordinarily should lead to cannabis cessation (sami et al., 2019), open questions remain regarding the reasons such individuals use cannabis (which they may do at disproportionate rates). the endocannabinoid system interacts with other neurotransmitter systems (i.e., dopaminergic) for reward processing functions (solinas et al., 2008). thus, it is possible that anhedonia (i.e., difficulty in experiencing pleasure), a prominent symptom in chr individuals (cressman et al., 2015), may motivate cannabis use (gill et al., 2015; fischer et al., 2014), but also diminish its acute rewarding effects. fischer et al. (2014) found that both smoked cannabis (3.6% δ9-thc) and oral administration of δ9-thc (15 mg capsules) increased connectivity between the nucleus accumbens and prefrontal cortical brain regions in cannabis users with schizophrenia, who showed impaired brain reward circuitry at baseline relative to healthy controls, supporting a hedonic role for cannabis in psychosis. further, cognitive deficits may increase vulnerability to initiation and maintenance of cannabis use (li et al., 2020), and be negatively impacted by further cannabis use as well. thus, further examination of acute cannabis effects on cognition, euphoria and reward processing in chr individuals is warranted (lawn et al., 2016; vadhan et al., 2009), in line with calls for more experimental research in this area (ksir & hart, 2016). a better understanding of how chr individuals respond to cannabis may have important implications for reducing risk of psychosis in vulnerable individuals. thus, this report further characterizes the acute effects of active cannabis (compared to placebo) on cognitive, as well as reward and related measures, in chr and control cannabis users. we hypothesized that active (relative to placebo) would produce: 1) deleterious changes in objective and subjective cognition (i.e., decreased cannabis, cognition/reward, and psychosis risk 20 response inhibition, working memory, and alertness), but 2) attenuated subjective rewarding effects, in the chr but not the control group. methods1 participants participants were 12 non-treatment-seeking, adult regular cannabis users. six were at clinical high-risk (chr) for psychosis, and six were not (see ascertainment details below). all participants were physically and neurologically healthy (as assessed by a physician exam), and had an estimated intelligence quotient (iq) >80. all participants were required to be young adults (aged 18-30), and must have reported weekly cannabis use for at least one month and regular cannabis use within the 6-month period before enrollment. current cannabis use was verified by positive urine toxicology tests for δ9-thc metabolites on two different days. all participants were administered the structured interview/schedule of psychosis risk symptoms version 4.0 (sips/sops; mcglashan et al., 2001), which assesses the presence of 3 clinical high-risk syndromes (described below). all participants were also administered the structured clinical interview for dsm-iv axis i disorders – patient edition (scid-i/p; first et al., 1995), except for the psychotic disorders module, to assess for the presence of dsm-iv psychiatric disorders. participants could not: 1) be seeking treatment for cannabis use; 2) have had a prior serious adverse reaction to cannabis (assessed by self-report); 3) meet dsm-iv criteria (assessed by the scid-i/p) for any substance dependence, aside from cannabis dependence; 4) have a personal history of a psychotic or bipolar disorder; or 5) be on any psychoactive medication other than antidepressants. antidepressant use was permitted given its prevalence in the chr population (goines et al., 2019; mcguire et al., 2011) and the corresponding difficulty in recruiting such individuals without such use. two out of 6 chr participants (but no control participants) were receiving antidepressants at the time of the study (the regimens were stable prior to and during participation). additionally, female participants could not be pregnant (confirmed by a negative urine pregnancy test at each laboratory visit). chr participants were required to meet criteria for a clinical high-risk syndrome, with psychosis-risk symptoms not occurring exclusively in the context of cannabis use, as assessed by the sips/sops. attenuated positive symptom syndrome (apss) is characterized by recent attenuated positive symptoms (e.g., suspiciousness, grandiosity) occurring at a subthreshold level of intensity; to meet criteria for apss, a patient must have received a rating˛≥ 3 on scales p1-p5 of the sops. brief intermittent psychotic syndrome (bips) is characterized by psychotic symptoms that are recent (began in the past three months) and fleeting in duration; to meet criteria for bips, a patient must have received a sops score = 6, and begun experiencing psychosis symptoms within the previous 3 months, for several minutes per day, at least once per month. genetic risk and deterioration syndrome (grds) is characterized by the presence of a psychotic disorder in a firstdegree relative, with accompanying recent functional decline in the patient; to meet criteria for recent functional deterioration, a patient must have shown a decrease in global assessment of functioning (gaf) score during the last month relative to his or her highest gaf score in the previous 12 months. in this study, all chr participants met criteria for apss. controls could not meet criteria for any of these chr syndromes or possess first-degree familial risk for a psychotic disorder (sips/sops), nor for a current or lifetime history of a dsm-iv psychiatric disorder (scid-i/p). this study was approved by the institutional review board at the new york state psychiatric institute. all data reported in this manuscript were obtained in compliance with regulations of the new york state psychiatric institute and the new york state office of mental health, and all participants provided written informed consent. recruitment chr participants were primarily recruited from the center for prevention and evaluation (cope), an outpatient research program at the new york state psychiatric institute (nyspi) for 1additional methodological detail can be found in the online supplement. cannabis, a publication of the research society on marijuana 21 chr patients. control participants were primarily recruited via newspaper advertisement and word-of-mouth referral in new york city. secondary recruitment from the nyspi substance use research center (surc) outpatient cannabis laboratory also occurred (potential chr participants were identified with a screening instrument [miller et al., 2004] and then received formal ascertainment [sips/sops]). demographic, clinical and substance use characteristics chr participants were 23.2 (sd=4.0) years of age, had 14.4 (sd=1.7) years of formal education, a mean estimated full scale iq (fsiq) of 105.7 (sd=10.9), and consisted of 5 males (3 hispanic, 1 african-american, 1 caucasian) and 1 female (hispanic). similarly, control participants were 24.3 (sd=3.0) years of age, had 13.5 years (sd=2.7) of formal education, an estimated fsiq of 102.2 (sd=13.9), and consisted of 4 males (2 hispanic, 1 african american, 1 asianamerican) and 2 females (1 hispanic and 1 mixed hispanic/african american). the groups did not differ statistically on any of these characteristics (p > 0.05). chr and control participants were also comparable on substance use characteristics (p > 0.05; see table s1), including age of onset of cannabis use (~16 years on average for both groups), frequency of cannabis use (~4 times per week on average for both groups), and frequency of alcohol use (~2 times per week on average for both groups). other than occasional hallucinogen/stimulant use by two chr participants, no one in either group reported current use of other illicit substances, which was verified by urine toxicology tests. the chr participants exhibited greater levels of psychopathology relative to controls (table s1; p < 0.05), including anxiety disorders (n=4 vs n=0), mood disorders (n=2 vs n=0), and symptoms of psychosis-risk (sops), depression (beck depression inventory – second edition; bdi-ii; beck et al., 1996) and anxiety (beck anxiety inventory; bai; beck et al., 1988), but not anhedonia (p > 0.05; chapman anhedonia revised scales; chapman et al., 1976). the chr group also endorsed greater levels of expectancy of negative cannabis effects than the control group (p < 0.05; marijuana effect expectancy questionnaire; schäfer & brown, 1991). cannabis administration sessions participants were scheduled to attend 3 separate laboratory sessions (scheduled at least 72 hours apart), during which they smoked half of a cannabis cigarette containing 0.0%, 2.02%, or 5.05% δ9-thc (all containing 0.01% cannabidiol [cbd]), in a randomized and double-blinded fashion. cannabis cigarettes were provided by the national institute on drug abuse (nida) and smoked according to a standardized paced puffing procedure (see s1.1). all participants completed the 0.0% and 5.05% δ9-thc sessions; however, 2 chr participants were unable to attend their 2.02% δ9-thc sessions. thus, only data from the 0.0% and 5.05% δ9-thc sessions were formally analyzed and reported here. see figure 1 for the session timeline. all participants were required to abstain from using cannabis on the morning of each session, as well as any other psychoactive drugs, with the exception of usual caffeine and prescribed medication (for chr participants). compliance was confirmed via self-report and co2 breath tests. additionally, field sobriety tests were administered before cannabis administration; no participant was found to be intoxicated before any of the laboratory sessions. two meals were served during each laboratory session. after the first meal, participants completed the primary cognitive battery and subjective measures (see below), and consumed the second meal approximately 2.5 hrs post-active or –placebo cannabis administration. objective measures participants completed the computerized cognitive battery in the 45 min period before cannabis administration and repeated the battery in the 20-80 min period after smoking. the primary measures were the gng and n-back tasks. the secondary measures were the digit recall task (drt) and digit symbol substitution test (dsst) (additionally administered approximately 3 hrs post-administration) and the drug stroop (carpenter et al., 2006) task (administered at 130 min post-administration). cannabis, cognition/reward, and psychosis risk 22 figure 1. session timeline *urine toxicology, breath-co and -alcohol tests, and a recent substance use questionnaire. min -75 -45 0-15 15 20 85 90 130 140 150 155 195 200 245 end session -recent substance use tests* -field sobriety test -meal 1 -heart rate (hr) -visual analogue scale – psychosis form (vas-p) cognitive battery cannabis admin. -hr -vas-p -cannabis rating form (crf) cognitive battery -hr -vas-p -crf break drug stroop task -hr -vas-p -crf meal 2 -hr -vas-p -crf -digit recall task -digit symbol substitution test -hr -vas-p -crf cannabis, a publication of the research society on marijuana 23 the n-back task (cohen et al., 1997; keilp et al., 2014) assessed visual working memory though a continuous-recognition task where numeric stimuli that appeared 2 trials (2-back condition) and 3 trials back (3-back) were identified. d’ scores were computed for an aggregate summary score of total hit rate, false alarms (i.e., incorrect matches), and random responses. the go/no-go task (gng; abbreviated version, keilp et al., 2014) assessed response inhibition by measuring identification of a specific combination of visual and auditory stimuli. the total number of incorrect responses (i.e., commission errors) was examined. the digit recall task (drt; hart et al., 2001) assessed immediate visual memory through a task where numeric stimuli (i.e., 8-digit number strings) were reproduced both while and immediately after they appeared on the computer screen. the total number of correctly copied number strings (before recall) and percent correctly reproduced during immediate recall were examined. the digit symbol substitution test (dsst; computerized version, mcleod et al., 1982) assessed psychomotor speed though a procedure in which geometric stimuli associated with different numbers were reproduced under timed conditions. the total percent correct was examined. the drug stroop task (carpenter et al., 2006) assessed drug-related attentional bias by measuring reaction time to name the font color of drug-related and neutral words. interference from cannabis-related words and from mixed drug words were examined. for more detailed descriptions of these cognitive measures see s1.3. subjective measures participants completed a computerized and modified visual analogue scale (vasp; vadhan et al., 2017) preand post-cannabis administration at 5 timepoints (15-, 85-, 150-, 195, and 245-min); see table s4. the primary measures were “i feel a good drug effect”, “i feel a bad drug effect”, “i feel alert”, and, i feel sleepy”. the secondary measure was a computerized cannabis rating form (crf; haney et al., 2016), given only postadministration at 5 timepoints (15-, 85-, 150-, 195, and 245-min); “strength” and “desire to take again” were examined here. both measures consisted of items for rating displayed one at a time below a 100-mm line, with anchors of “not at all” and “extremely.” statistical analyses a similar analytic approach as the previous article from this study (vadhan et al., 2017) was employed. smoking topography and acute cannabis effects were assessed for each group independently given the small sample size. within-participant repeated measures anova examined the main effects of drug condition (active [5.50% δ9-thc] vs. placebo) and/or the interactions between drug condition and time (baseline vs. post-administration) on most dependent measures, with simple effects tests (comparing active vs. placebo at each timepoint) to probe significant interactions. this approach demonstrated adequate power (kyonka, 2019; see s1.4.1). statistical significance thresholds for anovas varied from α=0.013 to 0.05 based on the magnitude of correction required for family-wise error rate (see s1.4.2), and missing data procedures are described in s1.4.3. questionnaire measures were compared directly between groups with independent sample t-tests with α= 0.05. results all main effects of drug condition and drug condition × time interactions are described below (including statistical results for significant and matching nonsignificant tests); raw data and all f-test results can be found in supplemental tables as indicated. there were no main effects of drug condition for the number of puffs inhaled for either the chr (4.0 [sd=0.4] vs. 3.5 [sd=0.2] puffs [active vs. placebo cannabis]; f = 1.4(1,5), p = 0.30, ηp2 = 0.21) or control group (4.7 [sd=0.3] vs. 4.2 [sd=0.3] puffs [active vs. placebo cannabis]; f = 1.4(1,5), p = 0.30, η p2 = 0.21). go/no-go task (figure 2a). on number of commission errors, there was no main effect of drug condition for either group (p > 0.025). however, for the chr group, there was a significant drug condition × time interaction (f = 16.7(1,4), p < 0.025, ηp2 = 0.81), with a decreased number of commission errors at baseline relative to placebo under active cannabis (p < 0.05), but no differences between drug conditions at postadministration (p > 0.05). no drug condition × cannabis, cognition/reward, and psychosis risk 24 time interaction was observed for the control group (f = 1.5(1,4), p > 0.025, ηp2 = 0.28). for rewarding intoxication (“i feel a good drug effect”; figure 2b1), there were no main effects of drug condition for either group (p > 0.013). however, there was a drug condition × time interaction for the control group (f = 3.8(5,25), p < 0.013, ηp2 = 0.43), but not the chr group (f = 2.0(2.0,10.2), p > 0.013, ηp2 = 0.28). the control group reported an increased good drug effect following active cannabis administration, relative to placebo. for aversive intoxication (“i feel a bad drug effect”; figure 2b2), there was a main effect of drug condition for the chr group (f = 14.0(1,5), p < 0.013, ηp2 = 0.74), but not the control group (f = 1.0(1,5), p > 0.013, ηp2 = 0.16). the chr group reported an increased bad drug effect during the active cannabis condition relative to placebo. figure 2. go/no-go performance (a) and subjective good (b1) and bad (b2) drug effect before and after cannabis administration as a function of group (clinical high-risk [chr], left side; controls, right side). note. error bars reflect sem. †main effect of drug condition; $drug condition × time interaction. *active (5.5% δ9-thc) differs from placebo (0.0% δ9-thc); p < 0.025 (go/no go) and p < 0.013 (“good/bad drug effect”); full anova results in tables s2 and s4. cannabis, a publication of the research society on marijuana 25 for n-back task d’ scores there was no main effect of drug condition, nor any drug condition × time interaction, for either group (p > 0.025; table s2). for digit-recall task (drt) number correct, there was a main effect of drug condition for the chr group (f = 32.7(1,4), p < 0.013, ηp2 = 0.89), but not the control group (f = 0.0(1,5), p > 0.017, ηp2 = 0.01). chr participants copied fewer number strings correctly under the active cannabis condition relative to placebo (table s2a). no drug condition × time interaction was found for either group (p > 0.017). on drt percent immediate recall, there was no main effect of drug condition nor a drug condition × time interaction for either group (p > 0.017). for digit symbol substitution test total percent correct, there was no main effect, nor a drug condition × time interaction for either group (p > 0.017). for drug stroop task (table s3) interference reaction time, there was no main effect of drug condition, nor a main effect of word type for either group (p > 0.05). however, there was a drug condition × word type interaction for the chr group (f = 7.9(1,4), p < 0.05, ηp2 = 0.67). chr participants exhibited decreased interference from cannabis-related words (relative to mixed drug-related words), under the active cannabis condition. no drug condition × word type interaction was observed for the control group (f = 0.1(1,5), p > 0.05, ηp2 = 0.01). for sleepiness and alertness (“i feel sleepy”, “i feel “alert”), there were no main effects of drug condition, nor any drug condition × time interactions, for either group (p > 0.013). for perceived cannabis potency (“strength”), there were main effects of drug condition for both the chr (f = 10.8(1,5), p < 0.025, ηp2 = 0.68) and control groups (f = 19.0(1,5), p < 0.025, ηp2 = 0.79), with both groups reporting increased cannabis strength for the active cannabis condition (relative to placebo). there was no drug condition × time interaction for either group (p > 0.025). there was no main effect of drug condition, nor any drug condition × time interaction, for “desire to take again” (p > 0.025; table s4). discussion smoked active cannabis (5.5% δ9-thc), relative to placebo (0.0% δ9-thc), decreased objective response inhibition, and increased subjective aversive intoxication in cannabis users at clinical high-risk for psychosis (chr). additionally, psychomotor speed and cannabisrelated interference on a measure of attentional bias (drug stroop) were reduced under the active cannabis condition (relative to placebo). in contrast, control participants exhibited no objective cognitive alterations, and increased rewarding intoxication, under the active cannabis condition (relative to placebo). these data are partially consistent with our hypotheses. disruptions in working memory, response inhibition, attention, and psychomotor speed are hallmark features of psychotic disorders (mihaljević-peleš et al., 2019) and their risk syndromes (mourik et al., 2017). these disruptions can also be acutely produced by cannabis intoxication in individuals with current or past cannabis use (ramaekers et al., 2016; vadhan et al., 2009). however, although the groups in the current study were not compared directly, the results may suggest a preferential acute deleterious effect of cannabis on these and related functions in chr cannabis users. different effects were also seen for the rewardrelated measures, with a global negative effect for active cannabis emerging for the chr group (though the nonsignificant positive effect was about twice the size), and a global positive effect for the control group. these findings are consistent with the pattern of cognitive and psychiatric effects reported here and previously (vadhan et al., 2017), as well as with the groups’ preexisting expectations (meeq). these participant-predicted and experimenter-observed aversive effects in the chr group, as well as the lack of group differences on anhedonia symptoms, deepen the question of their reasons for regular cannabis use (di forti et al., 2007). speculatively, the change in drug stroop task performance under the active cannabis condition – an apparent shift in cannabis-stimuli-related attentional bias from interference to facilitation – may reflect an appetitive process related to cannabis intoxication. it is also possible that chr cannabis users, who show similar abnormalities in brain function to cannabis users with schizophrenia (millman et al., 2019), may also exhibit similar δ9thc–induced changes in brain reward system functioning (e.g., fischer et al., 2014; whitfieldgabrieli et al., 2018). cannabis, cognition/reward, and psychosis risk 26 in sum, these data indicate that cognitive impairment and an aversive drug state were increased during cannabis intoxication in chr but not healthy cannabis users, providing further preliminary evidence of a distinct and adverse response to cannabis in individuals with preexisting risk for psychosis. the primary methodological limitation is the small sample size, which is likely responsible for the high baseline performance variability (e.g., gng errors), only some effects reaching statistical significance, and our inability to statistically account for antidepressant use in the chr group. however, the small sample should not necessarily contribute to a preferential effect for the chr individuals, and correction for multiple comparisons was employed. it is interesting that these chr individuals with extensive cannabis experience do not appear tolerant to the observed adverse effects in the manner that the psychiatrically healthy cannabis users with similar experience appear to be (also see schwope et al., 2012). this leads us to conclude that the risk for psychosis, including its accompanying psychiatric symptoms, may play a role in these differing effects. while increasing evidence does indicate that cannabis differentially impacts individuals on the broad psychosis spectrum (vadhan et al., 2019), research with methodological improvements such as larger sample sizes and mixed withinand betweengroup analyses is needed to confirm and expand on these results. references barkus, e., morrison, r., di forti, m., & murray, r.m. 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(2018). understanding marijuana’s effects on functional connectivity of the default mode network in patients with schizophrenia and co-occurring cannabis use disorder: a pilot investigation. schizophrenia research, 194, 70-77. funding and acknowledgements: all data were collected at the new york state psychiatric institute. we gratefully acknowledge the assistance of elisa payne, kristy nguyen, michael harakas, olivia derella, bennett wechsler, richard foltin, gary brucato, kelly gill, leigh arndt, tanya lalwani and morgan wu for their study contributions. we thank drs. margaret haney and gill i. bedi for reading a draft of this manuscript. funding for this study was provided by a brain and behavior research foundation young investigator award, nih grants da19239, da09236, da034877, mh086125, mh093398, mh066279 and cumc irving scholar awards. all authors declare that they have no conflicts of interest. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources are not modified, and the source is not used for commercial purposes. research article 139 ved abstract introduction: marijuana use is at historic highs amongst college-aged adults, who are more likely to engage in simultaneous alcohol and marijuana use (sam) than other age cohorts. for college students, the covid19 pandemic is a unique transitory phenomenon that led to isolation, as well as changes in socialization, academic environments, and substance use. this exploratory qualitative study aims to understand sam socialization and motivation behaviors among college students. methods: semi-structured qualitative interviews (n=32) were conducted across the united states from january 2021-april 2021via zoom. interviews were then transcribed, then a thematic analysis was conducted in atlas.ti. results: the sample was primarily college juniors (mage=21). since the pandemic, half of the participants increased sam, whereas the other half decreased sam. sam was reported in different categories including primarily with friends, but, much less with partners and with roommates. more than half of the sample indicated that they used sam alone. motivations to engage in sam included relaxing, socializing, offsetting stressors specific to the covid-19 pandemic, and relieving general stress, anxiety and boredom. conclusion: the covid-19 pandemic impacted college students’ substance use in interesting ways. understanding the behaviors of sam in the context of the covid-19 pandemic is crucial due to the legalization of marijuana in many states. this understanding has significant implications for prevention strategies and potential policy interventions. our study yielded findings regarding the impact of socialization on sam. we discovered that not only does socialization affect sam, but the specific contexts and motivations behind these behaviors also play a crucial role, which adds to our developing understanding of sam behavior. key words: = sam; college students; alcohol; marijuana; socialization; covid-19 alcohol and marijuana use is common among young adults, particularly college students (american college health association, 2018; fleming et al., 2021; samsha, 2017). substance use rates in college students have changed during the covid-19 pandemic. for alcohol, drinking behaviors were found to have increased during the early stages of the pandemic (march-july 2020; pakdaman & clapp, 2021). pandemic specific studies on marijuana use, however, had mixed findings, with reports of both increases (fendrich et al., 2021; manthey et al., 2021; papp & kouros, 2021) and decreases (graupensperger et al., 2021) the combination of alcohol and marijuana use at the same time where there is an overlap in effects is known as simultaneous alcohol and marijuana use (sam) and has historically increased (lee, 2022). however, understanding sam and the contexts of college students during the pandemic is largely understudied, and information is not sheila pakdaman1,3, melinda longtin2, jennifer weck2, john d. clapp1,2,3 1 university of southern california, department of population and public health science 2 university of southern california suzanne dworak-peck school of social work 3 usc institute for addiction science cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000169 “what was the vibe you were going for?” sam behaviors and socialization during the covid-19 pandemic, a qualitative approach corresponding author: sheila pakdaman, ph.d. m.s., university of southern california, 2011 n soto street, los angeles, ca 90032. phone: (323) 442-7200. e-mail: sheila.pakdaman@gmail.com cannabis, a publication of the research society on marijuana 140 provided on pandemic rates from large, national databases. risks related to drinking among college students are well-documented (crum & pratt, 2001; niaaa, 2019) and vary in severity from hangovers to injury, legal troubles and even death. outcomes related to marijuana use among this population include social-interpersonal consequences such as saying or doing things that are embarrassing (pearson et al., 2017) to more serious reasons such as affecting brain health, mental health, vehicle driving and reaction times, and coordination (samsha, 2022). for sam specifically, college student reported risks included drinking more alcohol when using marijuana (when compared to drinking alcohol alone), as well as more harms on the days where both substance are used versus one or the other, and engaging in risky behaviors (nida, 2021). these risky behaviors include unsafe driving (duckworth & lee, 2019; terry-mcelrath et al., 2014) and mental health outcomes (patrick et al., 2020), however, other risks according to a scoping review published in 2022 are largely understudied (lee, 2022). there are different contexts (i.e., motivations for use) in which college students may engage in sam. for example, some common sam socialization motives include coping and reducing negative moods (conway et al., 2020; patrick et al., 2018). more specifically, participants across studies examining college students found motives for sam included the desire to “calm down” and “cope with anxiety” (conway et al., 2020; patrick et al., 2018). previous research has found that a correlation between coping, calming, and sam is demonstrated, such that individuals with a history of alcohol and marijuana use are more likely to engage in sam in the future (patterson et al., 2020). for example, social acceptability (i.e., if peers engage in use) has a significant impact on participation in alcohol consumption, marijuana use and sam (beck et al., 2009; conway et al., 2020; cooper, 1994). drinking during college transition is greatly influenced by peer drinking norms (park et al., 2009). alcohol consumption during and after college is impacted by peer drinking, friend socialization and social reinforcement, in which students may encourage drinking through their interactions (bartholow et al., 2003; cooper, 1994; halim et al., 2012; park et al., 2009). likewise, marijuana use is largely driven by social facilitation and acceptance among college students (beck et al., 2009). it follows that sam engagement is influenced, at least in part, by the desire to meet peer expectations and the perception of student norms (conway et al., 2020; linden-carmichael & allen, 2021). in addition to peer norms and relationships, another context of sam is that in the past it has not been a heavily studied indicator of future sam (linden-carmichael et al., 2019). in a 2019 study that examined 1,035 participants, 84.6% of the persons who engaged in sam were single and 72.3% of them were enrolled in college (lindencarmichael et al., 2019). one study found that having a romantic partner who drinks can have an impact on higher alcohol consumption in emerging adults (bartel et al., 2020). on the other hand, it was found that a lack of a significant other was associated with greater alcohol and marijuana use, particularly among persons aged 19-20 (fleming et al., 2010). the same publication also found that for those in relationships, the more serious the romantic bond was, the more protective factors the couple had against the use of alcohol and marijuana (fleming et al., 2010). the current covid-19 pandemic has led to a global increase in engagement in substances to alleviate feelings of uncertainty. in 2020, alcohol sales and consumption increased throughout the united states (bactrack, 2020; bremner, 2020; emerson, 2020; grossman et al., 2020). additionally, marijuana use in the united states increased during covid-19 (brenneke et al., 2022; schulenberg et al., 2020). throughout the first few months of the pandemic, a survey of 1,761 u.s. adults analyzed from the understanding america study revealed spikes in covid-19-related marijuana intake (brenneke et al., 2022). further, according to the national survey results on drug use 1975-2020, marijuana utilization rose to 44% for college students and 43% for those not enrolled in higher education in 2020 when compared to previous years (schulenberg et al., 2020). though the data collected during the pandemic has examined alcohol and marijuana statistics separately, information on sam prevalence is unavailable from national databases. for instance, nationally administered surveys, like monitoring the future and samhsa’s annual substance use indicator report did not include sam measures specific to qualitative study on sam behaviors during covid-19 141 the current covid-19 pandemic (samsha, 2022; schulenberg et al., 2020). though current literature examines some elements leading to sam among college students, little is known concerning how social motives contributed to sam within the covid-19 context. past literature recommends exploring specific motives and relevant contexts for the situation to inform sam interventions (patrick et al., 2018). thus, our study aims to learn how socialization motivations, referred to in our study questions as “vibes,” (i.e., defined by merriam-webster as “distinctive or quality capable of being sensed;” merriam webster, 2022), a term used frequently among college students, was for college students during the pandemic. we aim to explore students’ sam inductively by conducting qualitative interviews (bingham et al., 2022). we aim to explore what can drive these behaviors by assessing socialization, environmental contexts and motives during the pandemic. methods participant recruitment and study procedures participants were recruited (n=32) for semistructured interviews between november 2020april 2021. during this time, in the us, covid19 case rates ranged from over 400,000 to 1,000,000, and deaths rates ranged from 4,000 to 14,000 individuals (world health organization, 2023). recruitment took place on various social media and community platforms, such as instagram, facebook, and craigslist. eligibility criteria included: (1) being at least 21 years of age; (2) a user of both alcohol and marijuana simultaneously; and (3) actively enrolled in college in the us. participants were scattered across the us, as the pandemic called for many students to move back to their family homes due to university pandemic-related restrictions. all participants were screened for eligibility via email by providing their student id and emailing from a university or college-issued email address. after signing the informed consent form, participants were invited to a scheduled 25-minute zoom interview where they were asked about their alcohol and marijuana behaviors separately, and then their sam behaviors. participants received $25 in compensation at the end of both the online survey and zoom interview. this study was approved by the university of southern california institutional review board [#up-20-00629]. semi-structured interviews two research assistants conducted the interviews (n=32) via the zoom video conferencing application. participants were asked about their alcohol, marijuana and sam behaviors during the pandemic. the interviewers first asked about alcohol behaviors, then marijuana behaviors. alcohol-related questions included the number of drinks consumed, which setting the drinks were consumed in, what kind of alcohol beverages they preferred, and if drinks were consumed alone or around others (i.e., with another person, in a small group environment, at a party, or in a bar). for marijuana, participants were asked about their smoking (i.e., blunts, joints, bowls, or vapes) and/or ingestion preferences (i.e., edibles, such as baked goods, candies, or tinctures). similar to the alcohol-related questions, participants were asked how many “hits” of the marijuana or “milligrams” of edibles they consumed, if they typically were alone or with others while using marijuana, and how they obtained the marijuana (i.e., it was given to them by a friend; they bought it at a dispensary or baked or rolled their own marijuana. lastly, sam questions included asking about alcohol and marijuana behaviors as detailed above, with the addition of asking what the mood or “vibe” the participant was hoping to achieve by engaging in sam. data analysis the audio recordings of the zoom interviews were sent to a transcription service and then analyzed by 2 separate coders on the research team using atlas.ti (atlas.ti scientific software development gmbh [atlas.ti 22 mac], 2022). thematic analysis was then conducted until data saturation was found. a codebook was created based on several discussions amongst the research team. the first author and senior author agreed with the codes. the agreement for the codes used in the present analysis was high (golafshani, 2003). thematic analysis after conducting thematic analysis, the first author and experienced research assistants read through the coded data relevant to the study’s cannabis, a publication of the research society on marijuana 142 research questions, created themes and subthemes, and then compared the different themes that emerged within the independently generated codes. the team met to discuss the topics, and no disagreements were found (kappa intercoder rating of at least 0.85) (golafshani, 2003), so a singular set of topics and subthemes were used to analyze the study. the themes that emerged were sam behaviors during the covid19 pandemic (1) sam with friends; (2) sam with partners; (3) sam with roommates; and (4) sam alone. motivation themes for sam included (1) to relax; (2) to socialize, (3) to offset the current covid-19 pandemic stressors, and (4) to relieve general stressors, anxiety and boredom. results participant characteristics and sam products most frequently used the majority of participants were juniors in college (mage=21). the geographic distribution of participants was spread out, with 58% from the west coast, 23% from the east coast, 16% from the south, and 3% midwest. cannabis products included brownies, flower/bud, vape pens, and joints. sam interview data since the pandemic began, half of the participants said they decreased their sam, while the other half increased their sam usage. sam was split into three different categories with the majority reporting use with friends, and nearly a third reporting use with partners and roommates. however, slightly less than half of the sample indicated that they used sam alone. motivations for sam included to relax, to socialize, to offset the current covid-19 pandemic, and to relieve general stress, anxiety and boredom. sam with friends. according to the responses provided by the majority of participants, they engaged in sam primarily when they were in the company of their friends who they did not cohabitat with. this included situations such as oneon-one interactions, being in a small group "bubble" adhering to covid-19 precautions, or in a kick-back party setting. participants indicated that engaging in sam was normal, and something they were accustomed to doing when socializing with friends during the pandemic. an interesting finding was that participants engaged in sam to offset their busy college schedules, and bond with their closest friends: “i’d say, it’s more of a hangout with close friends, because we all really know each other in the group. and because of that, we’re all pretty close to each other. and usually, whenever we meet, we all have pretty busy schedules, so we don’t really get to meet each other often” (male, 21 years old). another participant indicated that every time they went out to socialize with friends, they would participate in sam. sam with partners. participants discussed if they have engaged in sam with their partners. one participant alluded to their partner introducing them to marijuana whereas others shared that the experience was included as part of daily routine. sam with intimate partners was found to be an activity where partners first engaged in marijuana use with each other, and then had friends join them to consume alcohol. however, another college student shared that she engages in sam with her husband around dinner time to experience the effects of both substances: “it would usually be at my house with my husband and watching tv or something and have a glass of wine with dinner. and then, maybe use my vape, so i'll get both effects” (female, 24 years old). sam with roommates. a third of participants indicated that sam was prevalent in their home environment when living with roommates. in interviews, it was shared that participants engaged in sam with their roommates as a way to be safe with covid-19 social distancing precautions. one 30-year-old male participant shared that his roommates participating in sam are the “bad influences.” sam alone. some participants preferred to engage in sam alone, but some did specify that this was due to the inability to socialize during the covid-19 social isolation restrictions. a 21-yearold male participant shared that after his college closed on-campus housing services, and he had to move back to his family, he did have a lot going on outside of his college classes and was not able to see his friends in person, thus he began to engage in sam every day for the first month and a half of lockdown. interestingly, this participant indicated that their use went down when the restrictions subsided. qualitative study on sam behaviors during covid-19 143 alternatively, some participants indicated that they engaged in sam alone to offset the effects of either marijuana or alcohol and that they preferred to do this alone, rather than in a social setting. however, one participant indicated that they engaged in sam alone because the effects are more relaxing, whereas in a social setting, the effects induce more anxiety: “i like to use it alone because it makes me just feel more relaxed. whereas, if i am smoking with a group of other people, it actually makes me more anxious. so i feel like typically just doing it alone is more like when i'm trying to calm down or get ready for bed, or something like that” (female, 22 years old). sam motivations relaxation. participant interviews indicated that relaxation was a motivating factor to engage in sam, especially in high-stress moments of college life, such as academic examinations and other life stressors. other participants indicated that it was positive for them to engage in sam and have shared moments with their friends, and a chance to wind down: “i think it's just to wind down. sometimes, i used to go to the park and just lay in a hammock with my friends” (female, 21 years old). socialization. sam was normative among participants and often a social event: “normally, everyone is doing it. there's no one who’s left out, sort of” (female, 21 years old). sam in social settings was further explained by a male participant, who shared that he starts off usually drinking alcohol, and once he has had a few drinks, he feels more comfortable with engaging in “what everyone else is doing”, which includes using a “dab pen or taking hits from a bong.” additionally, some college students indicated that most people in their lives engage in sam, and that does influence their own sam behavior: “all of the above, partner, friends, housemates. pretty much every single person, besides my family, in my life [engages in sam]” (female, 21 years old). offset the covid-19 pandemic. some participants indicated that sam was exclusively motivated by the desire to offset negative feelings associated with the covid-19 pandemic. a participant indicated that prior to the pandemic, she was generally happy, however, during the pandemic, she feels “dead inside.” using sam as a coping mechanism is something that came up with several participants. one participant explained that sam is a method to cope with the pandemic and to get to sleep: “i try my best to be mindful of my drug and alcohol use, to not make it an escape or coping strategy. that’s because it could be unhelpful. but, to be honest, it’s just… i just need to wind down most times and i'm exhausted most of the time. so yeah, in the pandemic, absolutely, i think it has definitely become more of an outlet for coping, than prior to” (female, 29 years old). on the other hand, a participant said they engaged in sam more so to offset the stress of academics while taking care of things around her house or to have fun with her partner at home while social venues were closed. lastly, a participant shared that sam pre-pandemic was exclusively for socializing, whereas now she engages in sam to relax, sometimes unsuccessfully, but that does not stop her from trying to use sam: “yeah. i think when i used to do it, it would be exclusively for social reasons. and now, because that's not a thing, it tends to just be an attempt at distressing and that doesn't necessarily always work. but i feel like every other week or so, i come back and try it again” (female, 24 years old). offset general stress and anxiety and boredom. however, some participants indicated that they engaged in sam as a means of coping for general stress and anxiety, and to offset boredom, which they indicated was unrelated to the covid-19 pandemic. academics were brought up by participants as a general stressor that was felt amongst college students: “i guess it’s a feeling of more like, sort of stress and anxiety, especially as finals come. all of us are done with our finals and anxious about our grades. some of us have one final left in a couple of days and are really stressed out about it. so, it's mostly, i guess it would be a way to like combat the stressful atmosphere of college” (male, 21 years old). some participants indicated that they used sam to feel “cooler” and make household tasks more enjoyable such as “doing the dishes…or go walk the dog” (male, 23 years old). offset marijuana or alcohol by itself. there are some side effects associated, respectively, with marijuana or alcohol use. thus, some participants used either substance as a means to offset the side effects of the other. this included physiological cannabis, a publication of the research society on marijuana 144 and affective mood responses. however, it was found among participants that sam was a means of offsetting the effects of marijuana with alcohol. “i'd say that when i only use marijuana by itself, i do feel kind of like an anxiety side effect, if you want to call it. or just some sort of nervousness, almost being fidgety. whereas, i find that when i use both, they kind of, i don't want to say they cancel each other out. but some of those more negative side effects of the marijuana that i feel tend to be lessened, i guess, presumably through the alcohol use” (female, 22 years old). discussion we speculate that examining sam engagement in college students during covid-19 from a socialization perspective (i.e., motivations for use) has been understudied for multiple reasons. however, a few studies have gathered information on sam socialization motives prior to covid-19 (conway et al., 2020; lindencarmichael et al., 2019; midanik et al., 2007; patrick et al., 2018; patterson et al., 2020). our study aimed to fill the relevant gap by exploring sam social motivations among college students during the covid-19 coronavirus pandemic. in our interviews, our participants indicated that half increased their participation in sam, while the other half reduced it. we speculate that the observed increase in sam during the covid-19 pandemic can be attributed to the heightened levels of stress experienced during this time, particularly among college students who faced various challenges such as transitioning to online learning, campus shutdowns and financial strains. these stressors may have contributed to an increase in sam behaviors as a coping mechanism. on the other hand, we speculate that the decrease in sam during the pandemic could be influenced by concerns related to the ingestion of marijuana through smoking and the respiratory implications associated with covid19. given the respiratory risks associated with the virus, individuals may have been more cautious about engaging in sam behaviors that involve smoking. additionally, the relocation of college students from their dormitories to their family homes during the pandemic may have played a role in the decrease of sam. the presence of family members in the home environment may have deterred individuals from engaging in sam behaviors, considering the potential discomfort or disapproval that may arise from indulging in such activities in the presence of their family of origin. follow-up questions regarding change in use brought to light several themes. many socialization motives emerged for those that engaged in sam during covid-19. however, none were specific to only participants that increased or decreased utilization. one of the main themes participants reported was to offset covid-19. reasoning within this item included coping with lockdown/quarantine, lack of social engagement, stress, and anxiety. these motivations are reflected in existing literature determining covid-19 incentives to use alcohol or marijuana by itself (bartel et al., 2020; graupensperger et al., 2021; jackson et al., 2021; sarangi & eskander, 2021). while our study identified a correlation between sam behaviors and the challenging circumstances brought about by the pandemic, it is important to delve deeper into understanding whether individuals specifically turned to alcohol or marijuana to cope with these factors individually or in combination. the other sam motivations we found were not specific to covid-19 stressors. however, they occurred during the covid-19 pandemic. the sam motivations included to socialize, relax, and relieve general stress anxiety and offset boredom. our participants described the social norms and peer pressure that their friends, roommates and peers supported. these results support precovid-19 studies regarding social reinforcement (conway et al., 2020; linden-carmichael et al., 2019). the relaxation and relief of stress and anxiety incentives also strengthen existing research from before covid-19, because they overlap with the prevalent reports for calming and coping (conway et al., 2020; patrick et al., 2018). overall, our observations regarding socialization, relaxation, and coping with general stress and anxiety demonstrate important consistency between sam social motives from before and during covid-19. effects that were motives in previous research included social norms, coping, and calming (conway et al., 2020; patrick et al., 2018). questions about increasing pleasant experiences and reducing negative ones from using alcohol or marijuana by themselves were grouped into the same motivational category (conway et al., 2020; patrick et al., 2018). however, we separated them qualitative study on sam behaviors during covid-19 145 in the thematic analysis because we theorized that the distinction was important. positive effects did not emerge as a significant factor in our results. it was a popular response to offset the negative effects of alcohol or marijuana use on their own. this differentiation can provide more direction as interventions adapt to sam behaviors during covid-19. we investigated sam with friends and roommates. it was noted that peers or friends influenced sam engagement before covid-19 (bartholow et al., 2003; borsari & carey, 2006; cooper, 1994; halim et al., 2012; park et al., 2009). our finding that friends were the most common link for sam reinforces their importance during covid-19. linden-carmichael and his colleagues (2019) found who users lived with, but the distinction between roommates is less studied. based on our results, we suspect that quarantining with roommates interacted with the sam socialization motives within our thematic category, offsetting covid-19. the associated motivations in this category included coping with lockdown/quarantine, boredom, stress, and anxiety. furthermore, our study looked into college students using with partners and alone. more participants engaged in sam alone than with partners. however, in our results, having a significant other acted as encouragement to utilize sam, rather than serving as a protective factor. our data support statistics before covid19 in which people use more alone than with partners (linden-carmichael et al., 2019; midanik et al., 2007). on the other hand, when using marijuana alone, partners can be a protective factor (fleming et al., 2010). while previous research has indicated that having a supportive partner can act as a protective factor against marijuana, our study indicates that this may not be uniformly applicable to sam. given the qualitative nature of this study, we were able to understand sam motives and socialization by hearing from college students directly about their experiences during covid-19. understanding the sam behaviors that were described during this study informs future directions as it provides a means to better understand why college students engage in both substances simultaneously and how they are impacted by their peers. furthermore, this study adds to the growing covid-19 literature by providing insight on college student sam behaviors. limitations in light of our findings, some limitations were noted. recall bias is a limitation to consider, as participants may not accurately recall their sam during the pandemic due to the evolving nature of the virus. social desirability bias is always a concern when discussing substance use. that is, participants may not always feel comfortable or be honest with a researcher when discussing substance use behaviors. however, based on our data, this does not appear to 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(2023). who (covid-19) homepage. who health emergency dashboard. https://covid19.who.int/region/amro/country/u s funding and acknowledgements: this work was supported by the usc provost award. the authors declare no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v6i1a5_authors_v1_mj research article 9 ved abstract background. β-myrcene, one of the most common terpenes found in cannabis, has been associated with sedation. we propose that β-myrcene contributes to driving impairment even in the absence of cannabinoids. aim. to conduct a double-blind, placebo-controlled crossover pilot study of the effect of βmyrcene on performance on a driving simulator. method. a small sample (n=10) of participants attended two experimental sessions, one in which they were randomized to receive 15 mg of pure β-myrcene in a capsule versus a canola oil control. each session, participants completed a baseline block and three followup blocks on a stisim driving simulator. results. β-myrcene was associated with statistically significant reductions in speed control and increased errors on a divided attention task. other measures did not approach statistical significance but fit the pattern of results consistent with the hypothesis that β-myrcene impairs simulated driving. conclusions. this pilot study produced proof-of-principle evidence that the terpene β-myrcene, an agent commonly found in cannabis, can contributes to impairment of driving-related skills. understanding how compounds other than thc affect driving risk will strengthen the field’s understanding of drugged driving. key words: = cannabis; β-myrcene; terpene; driving impairment; simulator recent legalization of cannabis has spurred interest in the relationship between acute cannabis use and impairment. cannabis — measured through the presence of tetrahydrocannabinol (thc) — is the most prevalent drug (including alcohol and prescription medications) found among u.s. drivers (kelleybaker et al., 2017; ramirez et al., 2016). in fact, the number of drivers testing positive for cannabis appears to be on the rise (berning et al., 2015; johnson et al., 2012; masten & guenzburger, 2014; salomonsen-sautel et al., 2014). a recent report by the centers for disease control and prevention (azofeifa et al., 2019) found that over 12 million americans drove after using cannabis in the past year, and the national roadside survey found that 12.6% of weekend nighttime drivers tested positive for thc (up from 8.6% in 2007) (kelley-baker et al., 2017; lacey et al., 2009). while double-blind, placebo-controlled studies have routinely found that cannabis impairs cognitive and psychomotor skills, as well as simulated driving (hartman et al., 2015; hartman & huestis, 2013), recent epidemiological research has proved more inconsistent. four major relative crash risk studies conducted in the past decade have produced varying results (bernhoft et al., 2012; brubacher et al., 2019; drummer et al., 2020; lacey et al., 2016), and a meta-analysis also found that 1 in 3 studies reviewed found no significant association between cannabis and mark b. johnson1, scott mcknight1, eileen p. taylor1, laszlo mechtler2, christopher c. ralyea, jr.2 1pacific institute for research and evaluation, usa 2dent neurologic institute, usa cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.002 the effects of β-myrcene on simulated driving and divided attention: a double-blind, placebo-controlled, crossover pilot study corresponding author: mark b. johnson, phd, pacific institute for research and evaluation, 4061 powder mill road, suite #350, beltsville, md 20705. phone: (301) 755-2710. email: mjohnson@pire.org β-myrcene effects on driving and divided attention 10 crash risk (gjerde et al., 2015). other recent reviews (e.g., pearlson, stevens & d’souza, 2021) suggests relatively low risk, with some metaregression odds ratios as small as 1.22 and considerable variability among individual studies (rogeberg & elvik, 2016). in contrast, across decades and locations, results of alcohol crash risk studies have been relatively consistent (blomberg et al., 2005; borkenstein et al., 1964; krüger & vollrath, 2004; lacey et al., 2016). thus, while the methods for estimating relative crash risk can produce stable results, fundamental differences between alcohol and cannabis may account for the wide variability in observed crash ratios attributed to cannabis use. the pharmacokinetics of cannabis may be one contributing factor. for example, thc can be detected in both blood and oral fluid for weeks after last use, long after impairing effects would have disappeared (andås, krabsth, enger, et al., 2014; bergamaschi, karschner, goodwin, et al., 2013). the separation between detection of the drug and impairment might hamper observing clear dose-response relationships. but another factor may be the chemical complexity of the cannabis plant. cannabis consists of over 400 cannabinoids, terpenes, and flavonoids, few of which have received careful examination (atakan, 2012). however, research on cannabis and crash risk to date has focused almost exclusively on thc, the primary psychoactive agent in cannabis, as the cause of cannabis-induced driving impairment. however, cannabis compounds other than thc may play a role as well, and their presence may obfuscate the true driving risk associated with cannabis use. for example, while thc and thc-based medications are themselves associated with drowsiness (issa, narang, jamison, et al., 2014; schimrigk, marziniak, neubauer, et al., 2017; may & glode, 2016), research has suggested that cannabis high in cannabidiol (cbd) produces particularly strong sedating effects (crippa et al., 2004; pearce et al., 2014; zhornitsky & potvin, 2012). we have argued (johnson, 2020; johnson, 2022) that the sedating properties of alcohol and drugs, not just the intoxicating properties, are understudied agents of crash risk, and accordingly, in earlier research investigated both thc and cbd as predictors of driving impairment. in johnson (2019), habitual cannabis users drove an instrumented vehicle for a period of 6-10 days and provided one or more oral fluid samples each driving trip they took; we were able to link thc and cbd concentrations to vehicle performance. the study found that only high cbd/high thc levels predicted driving impairment. in fact, we found no evidence of driving impairment at any thc level when subjects tested negative for cbd (johnson, 2019). similarly, arkell, lintzeris, kevin et al. (2019) experimentally examined cognitive performance as a function of thc-dominant cannabis, thc/cbd equivalent cannabis, and a placebo. although subjective ratings of experience (e.g., feeling “stoned”) did not differ as a function of cbd content, performance on some attentional tasks was significantly worse under thc/cbd than versus thc-dominant dosing. and while not all research has found that cbd exacerbates cannabis impairment (arkell et al., 2020), it is noteworthy that the food and drug administration recently issued a warning about driving under the influence of a cbd-based medication specifically because of its sedating effects (u.s. food and drug administration, 2019). interpretation of these findings is further complicated by the suggestion that cbd is not, by itself, sedating. although cannabis high in cbd can produce lethargy (crippa et al., 2004; pearce et al., 2014; zhornitsky & potvin, 2012), it has been argued (russo, 2011, 2016, 2017) that those effects actually are caused by the terpene βmyrcene, which often co-occurs with cbd. and because concentrations of β-myrcene vary considerably among strains, it follows that sedating properties of these strains, and possibly the crash risk, may vary as well. however, β-myrcene is not limited to cannabis; it also occurs in plants such as basil, lemongrass, and hops. in fact, β-myrcene is thought to be the sedating agent in some traditional sleep aids based on hops and lemongrass preparations (lorenzetti et al., 1991; wichtl, 2004). furthermore, animal studies show that βmyrcene acts as a muscle relaxant and demonstrates other sedating effects (vale et al., 2002; vale et al., 1999). we have a broad interest in better clarifying the role between cannabis use and motor vehicle crash risk, and this involves exploring cannabis compounds other than thc. based on the cannabis, a publication of the research society on marijuana 11 evidence that β-myrcene has sedating properties, we conducted an experiment to test the hypothesis that β-myrcene can directly impair driving skills. in this proof-of-principle pilot study, we examined β-myrcene as an isolate, derived from noncannabis sources (citrus fruit), and free from thc, cbd, and other cannabinoids, and examined its impact of simulated driving performance and divided attention. to our knowledge, no other research on cannabis-impaired driving, whether epidemiological or experimental, has measured or modeled β-myrcene as a predictor of driving skills or behavior. methods this pilot study was internally funded and designed to generate proof-of-principle evidence of the effect of β-myrcene on simulated driving. sample size (n=10) was not based on a power analysis, but rather on the availability of funds and time restrictions. all procedures were reviewed and approved by the pacific institute for research and evaluation (pire) institutional review board (irb). participants and recruitment participants were recruited by placing advertisements in craigslist that sought occasional cannabis users to take part in paid research. cannabis users were selected because of likely prior experience consuming β-myrcene. interested persons were directed to an online prescreening instrument, from which qualified individuals were contacted and invited to take part in two 2.5-hour experimental sessions. an incentive of $150 was offered for participation, along with up to $20 each session (as necessary) to help cover the costs of rideshare service; participants were not allowed to drive away from the research sessions as a precaution against drowsy driving. data collection during the time of covid-19 required a variety of methodological adjustments to reduce risk of transmission. these including using a spacious physical location, providing n95 masks, social distancing, sanitization, and symptom screening. however, because of the isolation of the data collection space, and the fact that all research staff present were male, the irb only approved for us to recruit male participants in order to avoid any discomfort or concern that female participants might experience. we were also limited by participant age, as individuals older than 50 were deemed to have higher risk of serious complications due to covid-19. eligibility was based upon gender (male) and age (21-50), as well as lifetime cannabis use. respondents who reported using cannabis more than weekly were excluded, as were respondents who reported use of other illicit drugs in the past year. protocol each subject was scheduled for two sessions. in a randomized order, in one session participants were dosed with 15 mg (19 µl) of β-myrcene extract (www.elevationterpenes.com) in a vegetarian capsule (mixed with ~ 480 µl canola oil). in the second (control) session, participants received a vegetarian capsule containing only canola oil. neither the subject nor the data collector knew which dose participants received during a given session. for this proof-of-principle study, the dose was meant to exacerbate impairment; but it was also determined by the physician on our team to reflect what a particularly sedating daily dose of medical cannabis might contain. as a concrete example, the cannabis strain blue dream has been reported to have β-myrcene concentrations as high as 2.7% (see https://cannigma.com/strains/blue-dream). accordingly, it is feasible that a person could consume 27 mg (at 100% absorption) in 1 gram of cannabis from a strain with a particularly high βmyrcene content; consuming 15 mg of β-myrcene in 1 gram of cannabis is realistically possible. only one participant was scheduled per day, and sessions averaged 4 days apart. upon arrival to the session, the data collector recorded the participant’s temperature completed a covid-19 symptoms checklist. participants were breathalyzed to ensure alcohol sobriety at the start of the research (participants with bacs ≥ .02 g/dl were rescheduled). this pilot study did not have the resources to screen participants for drugs, although we excluded self-reported heavy/frequent users from taking part in the research with the prescreening questionnaire. we relied on random assignment to balance out any potential drug-positive participants. β-myrcene effects on driving and divided attention 12 at the start of each session, subjects first completed a 10-minute guided warm-up drive on the driving simulator (described below) to acclimate to the controls. this warm-up included all the measures used in the study routes, and so participants had the opportunity to become familiar with the specific tests. participants then completed a 20-minute baseline driving session. this was followed by a dosing period, where subjects took the capsule provided to them. after the dosing period there were three 20-minute post-dosing simulator blocks. at the end of the final driving scenario, participants were released and took their arranged transportation home. driving simulator, scenarios, and measures the research used a stisim m100 driving simulator. the research scenarios consisted of driving on a rural road with one lane in each direction and occasional oncoming cars. two similar versions of the scenario were created, which were counterbalanced and used to reduce the likelihood that participants would be able to memorize features of the drive. the scenarios included static speed control and dynamic speed control tasks, which alternated over the course of the drive. the static task involved explicit instructions for the participant to drive as close to the posted speed limit as possible; there was an audio announcement of each speed limit change so that participants were less likely to simply miss the new speed sign. the dynamic speed task involved the appearance of another vehicle (a cargo van) in the driver’s lane. this vehicle would begin at 35, 45, or 55 miles per hour and would change speeds twice before vanishing. participants were tasked with maintaining a constant distance behind the vehicle (i.e., matching that vehicle’s speed based on observation) as it accelerated and decelerated. over the course of each 20-minute driving block there were 17 static speed control trials and 16 dynamic speed control trials. the mean difference (based on 30 readings per second) between participants’ driving speed and the target speed (posted speed limit or speed of the cargo van) was recorded for each of the 33 trials. in addition, we recorded the standard deviation of lane position (sdlp) for each of the 33 trials. whereas the speed control measures reflect longitudinal control of the vehicle, sdlp reflects lateral control (or lack thereof). in addition, for the 16 dynamic speed trials per block, we also recorded the minimum time-to-collision (ttc) with the cargo van. time-to-collision reflects the combination of speed and distance from the vehicle in front and is used as a measure of risktaking (van dyke & fillmore, 2017) (although risk-taking is not necessarily a hypothesized effect of β-myrcene). the simulator scenarios also included an embedded measure of divided attention. in the lower left and right corners of the screen were grey boxes with red diamond shapes. during the session, the diamonds were occasionally replaced by red left-pointing arrows in the left box or red right-pointing arrows in the right box. these arrows remained for 5 seconds or until the participant responded by pushing the appropriate button on the steering wheel. arrows appeared during periods in which participants were attending to speed limits or the speed of the cargo van, creating a need to divide attention. there were 41 divided attention trials per driving block. we recorded mean reaction time as well as divided attention errors (missed signals, incorrect responses). due to our desire for conducting as brief a study as possible (for covid protection), as well as because of our small sample size (which would produce low statistical power outside of numerous repeated measures), we did not include self-report assessment of subject experience. analytic approach data were analyzed using generalized linear mixed modeling (proc glimmix) in sas, where subject was treated as a random effect. logit link functions (logistic regression) were modeled for analysis of data with dichotomous outcomes. per the manufacturer, vegetarian capsules take 25-30 minutes to dissolve before the contents can be absorbed. normally, a dosing experiment would include a drug absorption period before data collection. however, due to the desire to limit the duration of the research (because of possible covid-19 exposure) our irb would not approve an empty 30-minute time block for this purpose. rather, after discussion with the irb, we decided to a priori that for analytic purposes we would combine the baseline and first post-dosing block into the pre-drug effect category and the second cannabis, a publication of the research society on marijuana 13 and third post-dosing blocks into a post-drug effect category. it seemed unreasonable to test for drug affects when the β-myrcene would still sitting in an undissolved capsule. our statistical model, therefore, was a pre versus post-dose, β-myrcene versus placebo control design factorial design with multiple measures within each session. analyses compared the block (baseline v post-dose) × condition (βmyrcene v control) interaction, but also included the main effect of session (1st versus 2nd) to control for the effects of time. the analytic approach did not assume equivalency at baseline, but rather tested for changes from baseline. we predicted increased driving impairment post-dose for subjects under β-myrcene compared to potential changes in the placebo-controlled condition (which might experience improved performance due to learning). specifically, for the post-dose βmyrcene condition we expected: significantly greater deviations between participant speed and the target speed for both static and dynamic speed control tasks, significantly greater sdlp, significantly lower ttc, and significantly slower divided attention responses and increased attention error rates. in addition to presenting test statistics (focusing on the block x condition interaction), we depict results using bar graphs and 95% confidence intervals. it is important to note, however. that eyeballing overlap between confidence intervals is not identical to interpreting the results of significance tests. significance tests are based on pooled errors around differences, not errors around independent estimates, and thus confidence intervals are underpowered reflections of actual tests (cumming & finch, 2005; goldstein & healy, 1995). furthermore, confidence intervals do a poor job reflecting crossover interactions. results participants a total of 41 individuals responded to the prescreening survey. we selected 10 eligible individuals, mean age 34.9 (median age=32.5), of whom 6 were white, 3 were black, and 1 was of south asian descent. all 10 participants completed both experimental sessions, although one participant needed to be rescheduled for arriving at the session with a bac of .06 g/dl. most non-selected respondents were female, reported using cannabis too frequently, and/or reported illicit drug use other than cannabis. speed control the block × condition interaction was statistically significant, f(1, 1266) = 3.9, p = .049, on the static speed control task, with increased speed deviations (reduced speed control) under βmyrcene (versus placebo control) (see figure 1a). for the dynamic speed task, the block × condition interaction was not statistically significant (p = .30), but the pattern mirrored that observed for the static speed task (see figure 1b). figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. 0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 β-myrcene effects on driving and divided attention 14 figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. sdlp and ttc block × condition interactions were not significant for both sdlp (p = .58) and ttc (p = .20), although patterns were generally consistent with predictions (see figure 2). divided attention under β-myrcene, participants made significantly more errors on the divided attention task (i.e., missing the cue, indicating the incorrect direction) relative to the placebo control. for attention errors, the block × condition interaction was statistically significant, f(1, 3267) = 7.7, p = .006 (see figure 3a). for reaction time, the block × condition interaction was not statistically significant on the divided attention task (where responses were capped at 5 seconds), f(1, 3267) = 1.4, p = .24). four-block patterns because we could not include a drug absorption period in our design, we aggregated the first data collection after dosing with the baseline period given that the β-myrcene would not yet have been dissolved. however, given that little is known about pharmacokinetics of βmyrcene, for descriptive purposes, in figures 4 – 6 below we present the predicted outcomes for each measure and for each of the four time-blocks as a function of drug. 0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 cannabis, a publication of the research society on marijuana 15 figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. discussion participants dosed with 15 mg of β-myrcene performed significantly worse than placebo controls on divided attention and static speed control tasks. non-significant patterns consistent with those findings emerged for the dynamic speed control test, sdlp, and ttc. somewhat surprising is that the lack of significant, or even suggestive, findings regarding sdlp, which is among the measures most sensitive to thc. it is possible that β-myrcene and thc interfere with driving skills through different mechanisms. to our knowledge, this is the first research examining the effects of a cannabis terpene on behavior related to driving. importantly, β0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 2 4 6 8 10 12 14 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) -3 -2 -1 0 1 2 3 4 5 st ati c s pe ed (f t/s ec ) -0.5 0 0.5 1 1.5 2 dy na mi c s pe ed (f t/s ec ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n e rro rs (% ) 1.1 1.15 1.2 1.25 1.3 1.35 1.4 at ten tio n r ea cti on t im e ( ms ) -4 -2 0 2 4 6 8 st ati c s pe ed (f t/s ec ) -1 -0.5 0 0.5 1 1.5 2 2.5 dy na mi c s pe ed (f t/s ec ) 0 0.2 0.4 0.6 0.8 1 1.2 at ten tio n e rro rs (% ) 0 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 at ten tio n r ea cti on t im e ( ms ) 0 2 4 6 8 10 12 14 16 sd lp (in ch es ) 0 20 40 60 80 100 120 140 160 180 tt c (se co nd s) figure 2. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc). figure 3. the effects of β-myrcene on (a) divided attention errors and (b) divided attention reaction time. figure 1. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control. placebo myrcene (a) (b) (a) (b) (a) (b) figure 4. the effects of β-myrcene on (a) static speed control and (b) dynamic speed control over four time blocks. (a) (b) figure 5. the effects of β-myrcene on (a) standard deviation of lane position (sdlp) and (b) time-to-collision (ttc) over four time blocks. (a) (b) figure 6. the effects of β-myrcene on (a) attention errors and (b) attention reaction time over four time blocks. (a) (b) baseline post-dose baseline post-dose placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene placebo myrcene block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 0 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene block 0 block 1 block 2 block 3 placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose placebo myrcene baseline post-dose baseline post-dose block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 block 0 block 1 block 2 block 3 β-myrcene effects on driving and divided attention 16 myrcene was dosed outside of any cannabis product, based on earlier research that β-myrcene alone might have sedating properties. given that thc by itself can be sedating, the combined effects of thc and high concentrations of βmyrcene might be considerably stronger. a crossover trial comparing high β-myrcene cannabis, low β-myrcene cannabis, versus βmyrcene without cannabis, might be a more thorough approach. undoubtedly, this pilot study was underpowered, and the design suffered several limitations. although we capitalized on the extensive repeated measures data, a sample of 10 subjects was likely too few to overcome individual differences in responses to the β-myrcene. still, in nearly all of the driving simulator measures, the patterns were suggestive. although we breathalyzed participants at the start of each experimental session, and we excluded individuals with self-reported recent and frequent cannabis use, this pilot study did not have the resources to screen for recent cannabis use. thus, thus we relied on random assignment within our crossover design to mitigate bias, treating possible recent cannabis use like any other uncontrolled or unmeasured variable that might have affected driving (e.g., mood, distraction, etc.). however, by definitively identifying and excluding drug positive participants we may have been able to reduce noise. further, collecting measures of subjective experience, such as drowsiness, as mediators of performance impairment would strengthen future research. the observed relationship between cannabis use and motor vehicle crashes has been inconsistent and widely varying across studies (e.g., rogeberg & elvik, 2016). this inconsistency is attributed, in part, to the pharmacokinetics thc and the fact that the substance can be detected weeks after use. however, we have argued that the complexity of cannabis is also an important but understudied factor (johnson, 2019). while research on cannabis use and crash risk has focused almost exclusively on thc, the drug itself contains hundreds of other compounds (atakan, 2012), some of which may have implications for safe driving (arkell et al., 2019; crippa et al., 2004; johnson, 2019; pearce et al., 2014; zhornitsky & potvin, 2012; vale et al., 2002). we believe that by failing to measure and model these other cannabis compounds in relative crash risk research, the field is undermining its ability to inform the public health consequences of cannabus-involved driving. basic experimental research can be essential step in identifying compounds that impair driving skills. in this proof-of-principle study, we found suggestive evidence that β-myrcene, a terpene common in some strains of cannabis, can reduce drivers’ ability to maintain consistent speed and interfere with attention. our understanding of the relationship between cannabis and crash risk, and of cannabis in general, can only be improved through the examination of compounds other than thc that comprise the cannabis plant. references arkell, t. r., lintzeris, n., kevin, r. c., ramaekers, j. g., vandrey, r., irwin, c., haber, p. s., & mcgregor, i. s. 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(2012). cannabidiol in humans—the quest for therapeutic targets. pharmaceuticals, 5(5), 529-552. https://doi.org/10.3390/ph5050529 funding and acknowledgements: the authors declare that there is no conflict of interest. this research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 9 ved abstract objective: concurrent and simultaneous cannabis and alcohol co-use confers risk for daily negative alcohol consequences. however, studies often treat co-use as a dichotomy, precluding examination of higherand lower-risk co-use days. additionally, little is known about specific alcohol consequences associated with daily co-use. therefore, the current study 1) differentiated days based upon alcohol consumption, co-use, and simultaneous use, and 2) tested whether certain day-level use patterns conferred risk for daily alcohol consequences. methods: college student co-users (n=489) completed an online timeline followback, reporting daily alcohol consumption, negative alcohol consequences, concurrent cannabis and alcohol couse, and simultaneous co-use (sam) on drinking days over the past month. day-level latent profile analysis differentiated days based upon drinking quantity, co-use, and simultaneous use, and tested whether patterns of use conferred risk for overall and specific negative alcohol consequences. results: four day-level profiles emerged, including moderate consumption of alcohol-only days (57.5%), moderate consumption sam use days (29.1%), higher consumption alcohol-only days (7.4%), and higher consumption sam use days (6%). higher consumption sam use days were associated with more negative alcohol consequences than all other days; however, higher consumption sam use days differed from higher consumption alcohol-only days in acute dependence symptoms. higher consumption alcohol-only days were associated with more negative alcohol consequences than moderate consumption sam days, particularly those that were action-oriented (i.e., dependence symptoms, blackout drinking, impaired control, risky behavior, social/interpersonal consequences). conclusions: findings suggest that there are in fact lowerrisk co-use days, and that links with unique negative alcohol consequences depend on levels of alcohol consumption and co-use. key words: = alcohol; cannabis; co-use; negative alcohol consequences; timeline followback cannabis and alcohol are the most frequently used substances on college campuses (lindencarmichael & lanza, 2018; schulenberg et al., 2020; slutske, 2005). cannabis and alcohol are independently associated with a variety of negative alcohol consequences and harms (e.g., meier et al., 2012; volkow et al., 2014; waddell, 2022; waddell et al., 2022a), however risk is increased when cannabis and alcohol are used together (yurasek et al., 2017; gunn et al., 2022; lee et al., 2022). at the person-level, co-users (i.e., individuals who report using alcohol and cannabis) report heavier cannabis and alcohol consumption and more negative alcohol consequences/harms compared to single substance users (brière et al., 2011; lindencarmichael et al., 2019; midanik et al., 2007; waddell, 2021; waddell, blake, & chassin, 2021). jack t. waddell1, abigail e mcdonald1, rishika shah1, & william r. corbin1 1arizona state university, department of psychology cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000171 daily relations among alcohol and cannabis co-use, simultaneous use, and negative consequences: a day-level latent profile analysis corresponding author: jack t. waddell, m.a., arizona state university, department of psychology, 900 s mcallister, tempe, az 85281. phone: 480-965-1616. fax: 480-965-8544. e-mail: jtwaddell@asu.edu mailto:jtwaddell@asu.edu cannabis, a publication of the research society on marijuana 10 in addition, co-use (vs. single substance use) days are associated with heavier day-level consumption and negative alcohol consequences/harms experienced (e.g., lee et al., 2020; linden-carmichael et al., 2020; mallet et al., 2017; 2019; metrik et al., 2018; waddell et al., 2021b). although relations among co-use and negative daily outcomes are well documented, most studies consider co-use a dichotomy (i.e., co-use vs. single substance use). however, it is possible that there are both low-risk and high-risk co-use days that get grouped together when testing day-level risk. in support of this possibility, mallett et al. (2019) used daily diary data to group days into four theoretical categories indicative of non-binge alcohol-only, non-binge co-use, binge alcohol-only, and binge co-use days in college students. mallet et al. (2019) found that binge co-use days were associated with more day-level negative alcohol consequences than non-binge alcohol-only and non-binge co-use days, but binge co-use days did not differ from binge alcohol-only days in terms of alcohol consequences. in addition, mallet et al. (2019) found that non-binge alcohol-only days were associated with fewer alcohol consequences than binge alcohol-only and binge co-use days but did not differ from non-binge co-use days. although informative, the results of this study leave remaining questions. first, lower-risk couse was not used as a reference group, and thus mallet et al. (2019) was not able to test whether lower-risk co-use differed from higher-risk alcohol-only use in terms of negative alcohol consequences. person-level studies suggest that level of alcohol consumption is a stronger predictor of negative alcohol consequences than co-use (e.g., waddell, 2022b), but day-level studies have yet to examine whether co-use days coupled with lower drinking quantity differ from higher consumption alcohol-only days. second, mallet et al. (2019) assessed total alcohol consequences, social alcohol consequences, and blackouts, but there are a variety of other unique alcohol consequences that may be related to co-use patterns at the day-level in college students. thus, it is important to understand associations between day-level co-use and specific alcohol consequences in college students, such as alcohol consequences affecting a student’s academics/occupation, as well as higher severity (e.g., day-level dependence symptoms) vs. lower severity alcohol consequences (e.g., day-level lack of self-care). third, the mallet et al. (2019) study did not specify whether alcohol and cannabis were used simultaneously (sam), which is defined as using alcohol and cannabis so that their effects overlap (gunn, aston, & metrik, 2022). since prior research suggests that simultaneous use confers risk above and beyond non-simultaneous couse (jackson et al., 2020), it is important to disentangle relations between co-use (i.e., using both substances but not overlapping) and sam use (i.e., using both substances so that their effects overlap). finally, mallet et al. (2019) created theoretical categories of alcohol-only and co-use at the day-level rather than examining data-driven profiles of day-level use. importantly, only 1.8% of days were categorized as non-binge co-use days, suggesting that there may be other patterns that emerge using a data-driven strategy. therefore, the current study sought to test whether days characterized by cannabis and alcohol co-use, simultaneous use, and levels of alcohol consumption were differentially associated with total and specific day-level negative alcohol consequences. the current study used day-level latent profile analysis (lpa), a modern mixture modeling technique that generates latent profiles using daily diary data while correcting for personlevel clustering (i.e., linden-carmichael et al., 2022). it was hypothesized that there would be at least four profiles of day-level use behavior, indicative of lower-risk alcohol-only use, higher-risk alcohol-only use, lower-risk co-use, and higher-risk simultaneous use (sam). it was further hypothesized that higher-risk sam use would be associated with the highest level of negative alcohol consequences, and that higher-risk alcohol-only use would be associated with more negative alcohol consequences compared to lower-risk profiles, even if co-use was present. analyses related to unique negative alcohol consequences were considered exploratory. methods participants college students who reported past-month simultaneous cannabis and alcohol use (n=489) were recruited from a large southwestern university as part of a study focused on co-use expectancies (waddell et al., 2022). a total of n=657 students were recruited, however the daily relations among co-use and consequences 11 current study was limited to participants who completed an online, modified timeline followback (tlfb) interview and reported at least one co-use day via the tlfb, making the analytic sample n=489. past 30-day co-use was selected as inclusion criteria so that each participant would have at least one co-use day to analyze, in line with other tlfb studies (e.g., gunn et al., 2019; metrik et al., 2018; waddell et al., 2021). participants were 68.7% female, had a mean age of 19.89 (sd=1.90), and identified as 74.4% white/caucasian, 4.7% black/african american, 8.8% asian, .7% pacific islander/hawaiian, 1.6% native american/indigenous, and 9.9% other; 25.1% identified as hispanic/latinx . procedure college students were informed they could earn extra credit in psychology undergraduate courses for participating in research studies. interested participants were directed to an online survey to complete a modified, online timeline followback interview (sobell & sobell, 1992) followed by a qualtrics survey. for the timeline followback, participants were shown a pastmonth calendar and asked to indicate which days they drank alcohol. participants were encouraged to reference memory aids such as text messages, snapchat memories, and photo captions. after indicating past-month drinking days, participants were shown singular webpages for each drinking day, which assessed day-level alcohol use, cannabis use, and negative alcohol consequences. after completion of the tlfb and the subsequent survey, participants were compensated one extra credit point and thanked for their time. the arizona state university institutional review board (irb) approved all study procedures. timeline followback measures co-use and simultaneous use. participants reported if they used cannabis on drinking days (0=no, 1=yes) and if the effects of cannabis overlapped with those of alcohol (0=no, 1=yes). drinking quantity. participants reported how many standard drinks they consumed on drinking days from 1-20+ drinks. participants were shown a standard drink chart when reporting on alcohol consumption, indicating that a standard drink is equal to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor. negative alcohol consequences. participants reported whether they experienced a list of 24 negative alcohol consequences on drinking days, which came from the brief-young adult alcohol consequences questionnaire (b-yaacq; kahler et al., 2005). alcohol consequences covered domains of academic/occupational consequences, social/interpersonal consequences, physiological dependence, risky behavior, impaired control, blackout drinking, lack of self-care, and diminished self-perception. a sum of negative consequences was created for each day, ranging from 0 to 24. in addition, a binary indicator of each unique negative consequence domain was created for each day. data analytic plan the current study used day-level latent profile analysis (lpa) to characterize data-driven profiles of alcohol-only and co-use days. day-level lpa is a newer analytic approach, that characterizes days into profiles based upon daylevel indicators of interest (linden-carmichael et al., 2022). using a generalized estimating equations framework (gee), day-level lpa corrects for nested data with a clustering statement, which accounts for clustering of days within participants. for the day-level lpa, profile solutions between 1 and 6 profiles were examined, and the optimal class solution was determined based upon aic and bic values, entropy values, the lo-mendell-rubin adjusted likelihood ratio test (llr), and by theoretical fit of the profile solution (nylund et al., 2007). for the day-level lpa, intraclass means are given for continuous predictors (i.e., drinking quantity) and probabilities are given for binary predictors (i.e., co-use, sam use), such that a 0% probability is indicative of the event never occurring on days within that profile, and a 100% probability is indicative of the event always occurring. once the optimal profile solution was determined, negative alcohol consequences were predicted by profile membership at the day-level. specifically, the bch method was used to predict distal outcomes from profile membership, which adjusts standard errors to account for classification error in the most likely profile membership (asparouhov, & muthén, 2014). chisquare difference testing was used to test whether profiles differed on negative alcohol consequences cannabis, a publication of the research society on marijuana 12 experienced each day. first, difference testing was used to determine if the number of alcohol consequences experienced at the day-level differed across profiles. second, difference testing was used to compare whether the probability of experiencing unique alcohol consequences from the b-yaacq differed across profiles; difference testing compared intraclass proportions of days within each profile in which each unique alcohol consequence was experienced vs. not experienced. all models used maximum likelihood estimation with robust standard errors (mlr), and full information maximum likelihood was used to estimate missing data. the current analyses were not pre-registered, and data is available upon reasonable request. results day-level latent profile analysis profile solutions with 1 to 6 profiles were examined (see table 1). aic and bic values declined across profiles, but δbic leveled off after the 4-profile solution. entropy values remained high across solutions (entropy>.86), and the llr test was statistically significant for all solutions. the 5and 6-profile solutions had individual profiles with <3% of the sample1, whereas the 1-, 2-, 3-, and 4-profile solutions all had >6% of the sample in each profile. thus, the 4-profile solution was deemed the best fit. the first profile (n=2,030; 57.5%), named moderate consumption alcohol-only days, was indicative of moderate drinking quantity (m=3.49) coupled with a 17.9% probability of cannabis use and 0% probability of simultaneous use. the second profile (n=213; 6%), named higher consumption simultaneous use (sam) days, was indicative of heavier drinking quantity (m=11.26) coupled with a 100% probability of cannabis use and simultaneous use. the third profile (n=1,027, 29%), named moderate consumption simultaneous use days, was indicative of moderate drinking quantity (m=4.01) coupled with a 100% probability of cannabis use and 98.7% probability of simultaneous use. finally, the fourth profile (n=263, 7.4%), named higher consumption alcohol-only days, was indicative of heavier drinking quantity (m=10.42) coupled with a 9.6% probability of cannabis use and 0% probability of simultaneous use (see figure 1). figure 1. day-level latent profiles note. likelihood of co-use and sam use is plotted on a 0-100% scale; moderate consumption alcohol-only days encompassed 57.5% of days, moderate consumption sam use days encompassed 29% of days, higher consumption alcohol-only days encompassed 7.4% of days, and higher consumption sam use days encompassed 6% of days across n=489 participants. prediction of total negative alcohol consequences higher consumption sam use days were associated with more negative alcohol consequences than moderate consumption sam use days, moderate consumption alcohol-only days, and higher consumption alcohol-only days. moderate consumption sam use days were associated with less negative consequences than higher consumption alcohol-only days but more negative alcohol consequences than moderate consumption alcohol-only days. finally, higher consumption alcohol-only days were associated with more negative alcohol consequences than 0 2 4 6 8 10 12 moderate consumption alcohol-only days moderate consumption sam use days higher consumption alcohol-only days higher consumption sam use days d rin ki ng q ua nt ity daily drinking quantity 0 0.2 0.4 0.6 0.8 1 moderate consumption alcohol-only days moderate consumption sam use days higher consumption alcohol-only days higher consumption sam use days pr ob ab ili ty probability of daily co-use and sam use likelihood of co-use likelihood of sam use 1it is worth mentioning that, when investigating the 5and 6-profile solutions for theoretical fit, neither solution derived a profile indicative of co-use that was not simultaneous use. daily relations among co-use and consequences 13 moderate consumption alcohol-only days (see table 2). prediction of unique negative alcohol consequences higher consumption sam use days were associated with a greater likelihood of physiological dependence symptoms, but no other negative alcohol consequences, compared to higher consumption alcohol-only days. however, higher consumption sam use days were associated with higher proportions of all alcohol consequences compared to moderate consumption sam use and moderate consumption alcohol-only days, with the exception that higher consumption sam use days did not differ from moderate consumption sam use days in the likelihood of experiencing lack of self-care consequences. higher consumption alcohol-only days were associated with a higher proportion of all alcohol consequences compared to moderate consumption sam use and moderate consumption alcohol-only days, with the exception that higher consumption alcohol-only days did not differ from moderate consumption sam use days with respect to academic-occupational, lack of self-care, and diminished self-perception consequences. finally, moderate consumption sam use days were associated with greater likelihood of blackouts, lack of self-care, impaired control, and socialinterpersonal consequences compared to moderate alcohol only days (see table 2). table 1. model fit indices for day-level latent profile analysis aic bic δbic llr lmr test entropy % in each class 1 class 28103.052 28,127.73 -14047.526 1 100 2 class 25284.702 25334.061 2,793.67 -12634.351 < .001 1 65, 35 3 class 24959.562 25033.6 300.461 -12467.781 0.02 0.926 58, 31, 11 4 class 24494.267 24592.986 440.614 12231.134 < .001 0.916 58, 29, 7, 6 5 class 24421.298 24544.696 48.29 -12190.649 0.01 0.909 53, 27, 10, 8, 2 6 class 24219.486 24367.564 177.132 -12085.743 0.004 0.86 45, 25, 14, 7, 6, 3 note. lmr = lo-mendell-rubin log-likelihood ratio test; the 4-class solution deemed to have the best fit. table 2. comparison of means and interclass proportions by day-level profiles higher consumption sam days moderate consumption sam days higher consumption alc-only days moderate consumption alc-only days total alcohol consequences 6.411a,b,c 2.170d,e 4.726f 1.635 academic-occupational consequences 0.295a,c 0.125 0.187f 0.103 social/interpersonal consequences 0.467a,c 0.185d,e 0.493f 0.133 diminished self-perception 0.275a,c 0.119 0.159f 0.096 lack of self-care 0.510c 0.406e 0.482f 0.269 risky behaviors 0.493a,c 0.115d 0.383f 0.093 impaired control 0.569a,c 0.246d,e 0.454f 0.192 blackout drinking 0.751a,c 0.258d,e 0.665f 0.205 physical dependence 0.534a,b,c 0.177d 0.352f 0.145 note. a = means for moderate consumption sam differs from moderate consumption sam, b = higher consumption sam differs from higher consumption alcohol-only, c = higher consumption sam differs from moderate consumption alcohol-only use, d = moderate consumption sam use differs from higher consumption alcohol-only use, e = moderate consumption sam use differs from moderate consumption alcohol-only, and f = higher consumption alcohol-only differs from moderate consumption alcohol-only significantly at the p < .05 level. cannabis, a publication of the research society on marijuana 14 discussion in the current study, a day-level lpa identified four profiles of day-level use behavior, indicative of moderate consumption alcohol-only and sam use days, as well as higher consumption alcohol-only and sam use days. moderate consumption days ranged between 3.5-4 drinks, and higher consumption days ranged between 10.4-11.3 drinks. thus, the day-level lpa did not generate a lower-risk profile where 1-2 drinks were consumed. in addition, both higher and moderate consumption co-use days were characterized by a high likelihood of simultaneous use on each day, suggesting that, with a datadriven approach, the current study was not able to separate co-use from simultaneous use days. most days were moderate consumption alcoholonly (57.5%) or moderate consumption sam use (29%), compared to higher consumption alcoholonly (7.4%) and higher consumption sam use (6%) days. higher consumption sam use days were associated with more negative alcohol consequences than any other day-level profile, including higher consumption alcohol-only days. thus, in contrast to mallett et al. (2019), the current study found that, at nearly equivalent levels of higher-risk alcohol consumption (i.e., higher consumption co-use days m=11.26; higher consumption alcohol-only days m=10.42), co-use of cannabis conferred risk for day-level negative alcohol consequences. however, it is important to note that, when testing unique alcohol consequences, the only pairwise difference between higher consumption sam use and higher consumption alcohol-only days was for acute dependence symptoms. alternatively stated, higher consumption sam use (vs. alcohol-only) days were associated with the highest severity alcohol consequence (i.e., dependence symptoms) but not necessarily lower-severity alcohol consequences (i.e., academic/occupational, risky behavior). in line with study hypotheses, higher consumption alcohol-only days were associated with more negative alcohol consequences than both moderate consumption alcohol-only and moderate consumption sam use days. thus, the current results support the notion that there are in fact moderate consumption sam use days, and that heavier alcohol consumption days increase risk compared to lower consumption days, even when cannabis is simultaneously/co-used. furthermore, in terms of unique alcohol consequences, pairwise differences suggested that higher consumption alcohol-only days vs. moderate consumption sam use days conferred risk for dependence symptoms, blackout drinking, impaired control, risky behavior, and social/interpersonal consequences, but not lack of self-care, diminished self-perception, or academic/occupational consequences. one interpretation of such findings is that higher consumption alcohol-only days vs. moderate consumption co-use days differ in behavioral and interpersonal consequences (e.g., social/interpersonal consequences, risky behavior, impaired control), whereas negative consequences that are more internalized and self-specific (i.e., a lack of self-care, diminished self-perception, academic/occupational consequences) are relatively similar across these days. findings may inform prevention efforts. first, results suggest that higher-risk day-level co-use and alcohol-only patterns were relatively infrequent, encompassing only 7.4% and 6% of days, respectively. thus, testing earlier-day predictors of higher-risk alcohol-only and co-use days may inform intervention development to reduce negative alcohol consequences on these infrequent yet riskier days. similarly, results suggest that targeted interventions on heavier use days, particularly those when alcohol and cannabis is co-used, may be particularly important. just-in-time interventions may benefit from frequent assessment of alcohol consumption and the presence of cannabis use during a drinking episode, as such interventions could use motivational tactics (i.e., personalized feedback, goal-directed behavior; rollnick & miller, 1995) to curb riskier behavior. in addition, findings point to increased risk in several behavioral and interpersonal consequences on higher risk days, such as impaired control, risky behavior, and social/interpersonal consequences. therefore, just-in-time interventions that motivate the use of protective behavioral strategies may also be effective at reducing negative alcohol consequences on higher-risk days. however, future intervention research is needed to test these assertions. daily relations among co-use and consequences 15 although the current study yielded novel insights, the findings must be interpreted in light of limitations. first, the current study used daylevel data from a timeline-followback, and thus responses may have been subject to recall bias. however, studies suggest that the timeline followback is a reliable way to assess past 30-day alcohol use, cannabis use, and negative alcohol consequences (e.g., carey, 1997; merrill et al., 2020; searles et al., 2002). second, the current study did not assess cannabis use quantity, and it is possible that co-use days may have differed based upon amount of cannabis used (e.g., stevens et al., 2021). unfortunately, cannabis use quantity is difficult to assess (e.g., hindocha et al., 2018), but future research in this area is needed. similarly, the current study did not assess negative cannabis consequences, which may differ from negative alcohol consequences. since most of the literature focuses on negative alcohol consequences, future research on negative cannabis consequences is warranted. third, the current study did not compare co-use days to cannabis-only days as the timeline followback only asked about cannabis use on drinking days. thus, future research is also needed to test similar models comparing co-use to cannabis-only days. finally, the current findings were in a college student sample and future research should replicate findings in community samples. in summary, the current findings suggest that higher consumption sam use days are associated with the highest levels of daily negative alcohol consequences, but higher consumption sam use days differed from higher consumption alcoholonly days only in terms of physiological dependence symptoms. in addition, lower consumption sam use days were associated with significantly fewer negative alcohol consequences than higher consumption alcohol-only days, suggesting that there are, in fact, lower-risk couse days. findings suggest that relations among day-level sam use (vs. alcohol-only use) are complex, and that heaviness of alcohol consumption (with or without sam use) is a strong, and perhaps primary driver of day-level negative alcohol consequences. references asparouhov, t., & muthén, b. 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184193. funding and acknowledgements: this study was supported by funding from the national institute on alcohol abuse and alcoholism grant f31-aa030167 (pi: jack waddell). the authors report no conflicts of interest. the current study was not preregistered. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 62 ved abstract objectives: patient-reported outcomes are critical to evaluate the effectiveness of medical cannabis as an alternative treatment for chronic pain. this study examined the perceived effectiveness of medical cannabis for chronic pain management among middle-aged and older adults newly initiating medical cannabis. methods: interview data from participants in a three-month pilot study were analyzed to assess the perceived effectiveness of medical cannabis on chronic pain and related outcomes. the interview was conducted after approximately one month of usage and responses were analyzed using the radar (rigorous and accelerated data reduction) technique. results: 51 adults initiating medical cannabis for chronic pain were interviewed (24 women, 27 men, mean age 54.4, sd = 12.0), with the majority (n=41) identifying as non-hispanic white followed by non-hispanic black (n=7), multi-racial (2), hispanic white (1). most study participants (62.7%) reported mc being overall effective. common benefits included reduced pain intensity, anxiety, and dependency on pain and psychiatric medications. improvements in physical functioning, sleep quality, and mood were reported. common challenges included difficulty finding a suitable product or dose, experiencing side effects such as ‘undesired high’, ‘stomach issues’, and a limited ‘threshold of pain’ treatable by the product. discussion: findings suggest most participants perceived medical cannabis to be overall effective for chronic pain management. participants reported improved physical and mental functioning and reduced use of pain and psychiatric medications. future research systematically assessing side effects, dosage and mode of consumption is needed to further evaluate the outcomes among adults initiating medical cannabis. key words: = medical cannabis; chronic pain; qualitative interviews; symptom management chronic pain is a challenging and common condition burdening millions of united states (u.s.) adults. in 2019, an estimated 50.2 million u.s. adults (20.5%) reported chronic pain symptoms most or every day (yong et al., 2022). not only is chronic pain a difficult condition to treat; it is costly, linked to increased healthcare expenses, and reduced productivity (berger et al., 2004; gewandter et al., 2015; knight et al., 2013). seeking alternative treatments for pain management is a beneficial step to improve the quality of healthcare delivery and expand treatment options for chronic pain patients in the u.s. medical cannabis has been sought after more frequently as an alternative treatment for chronic pain (boehnke et al., 2019; mahabir et al., 2020). the expansion of legalized medical cannabis throughout the u.s. contributes to the increased accessibility and prevalence of this practice. as of alexandra n. mcmahon1, deepthi s. varma1, hannah fechtel1, kimberly sibille2, zhigang li3, robert l cook1, yan wang1 1 department of epidemiology, university of florida 2 department of aging & geriatric research, university of florida 3 department of biostatistics, university of florida cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000149 perceived effectiveness of medical cannabis among adults with chronic pain: findings from interview data in a three-month pilot study corresponding author: alexandra mcmahon, mph, department of epidemiology, university of florida, gainesville, fl, 32610. email: axm8143@miami.edu. phone: 941-725-4032. cannabis, a publication of the research society on marijuana 63 april 2023, 38 states and four territories have legalized cannabis for medical usage (legislatures, 2023). with the spread of medical cannabis throughout the u.s., the number of patients seeking medical cannabis as an alternative treatment option has grown exponentially, and chronic pain is cited as the most frequent reason patients obtain medical cannabis (boehnke et al., 2019; hill, 2015). given the substantial increase of medical cannabis use among patients with chronic pain, studying its potential benefits and risks is essential as there remains inconsistency in research findings on the effectiveness of medical cannabis as a treatment for chronic pain management (wang et al., 2021). some recent meta-analyses suggest that cannabinoids may help mitigate pain among chronic pain patients (whiting et al., 2015; wong et al., 2020; yanes et al., 2019) while others reported minimal to no effect in pain reduction with cannabinoid usage (aviram & samuelly-leichtag, 2017; stockings et al., 2018). along with the inconsistent findings on medical cannabis's effectiveness for chronic pain management, there is limited guidance for physicians to discuss this treatment (e.g., dose, modes of consumption) and associated side effects with patients (cooke et al., 2019). recent studies have consistently shown deficits in provider knowledge on clinical applications of cannabis (ananth et al., 2018; kansagara et al., 2020; mendoza & mcpherson, 2018; rice et al., 2022). a nationally representative survey assessing pain physicians’ concerns for recommending medical cannabis reported only 25% of physicians scored 65 or higher on a 101-point overall scale (narouze et al., 2020). the lack of guidance and self-reported knowledge by providers illustrates the need for additional research to address the gap between clinical knowledge and the implementation of this rapidly growing medication. in addition to the need for greater evidencebased research and randomized control trials to address this growing alternative treatment for chronic pain, there is a general lack of qualitative findings on medical cannabis and chronic pain management. there is a corresponding deficit in research focused on patient experiences, perspectives, and perceived symptom relief with medical cannabis usage (mercurio et al., 2019). recent studies have suggested a potential overemphasis on pain scores to define medical cannabis efficacy which may contribute to the inconclusive and limited findings in this field (bhaskar et al., 2021). as pain research can be challenging to quantify, qualitative findings offer insight into patient experiences that are inaccessible to other research approaches (osborn & rodham, 2010). to address the lack of qualitative, patient-oriented feedback on medical cannabis, utilizing open-ended interviews is crucial as they offer insight from the patient perspective on perceived effectiveness of medical cannabis treatment which could help customize and improve this practice around patient needs. the main goal of this study is to use an openended interview questionnaire to obtain qualitative data on the overall perceived effectiveness of medical cannabis for chronic pain management and explore patient perspectives regarding potential benefits and risks. utilizing open-ended interview questions provides a more in-depth understanding of individual experiences as well as barriers. this direct feedback from patients using medical cannabis offers important insights into this growing medical practice which could contribute to an improved understanding of individual differences and identifying factors warranting further investigation. methods participants participants were recruited as a part of a 3month pilot study investigating the shortand longer-term effects of medical cannabis among adults newly initiating medical cannabis for chronic pain as detailed by wang et al. (2021). study participants were recruited from four medical cannabis clinics in north-central florida prior to applying for their medical cannabis card. inclusion criteria included: 18 years of age or older, smartphone owners, seeking to start medical cannabis soon but had not yet initiated, and reported chronic pain as the primary reason for seeking treatment. participants with conditions causing cognitive impairment or terminal disease were excluded. procedure clinic staff or physicians at each collaborating medical cannabis clinic first introduced the study to new patients when they came in for their appointment to obtain medical cannabis medical cannabis and chronic pain management 64 certification/card. participants who were interested could either talk with the research staff at the clinic to learn more about the study and complete the screening for eligibility or provide their contact information with an authorization to contact form so that the research staff could follow up. once enrolled, participants were asked to complete 1) a baseline survey, 2) 3-4 weeks of ecological momentary assessments (ema), 3) open-ended phone interview questions at the end of the ema period, and 4) a 3-month follow-up survey. in florida, patients can obtain medical cannabis products at any dispensary after they receive their medical cannabis card. the time window between their appointment to obtain the card and their actual purchase of medical cannabis products allowed us to obtain baseline data. the study procedures are detailed by wang et al. (2021). prior to study initiation, written consent was obtained by participants and the study protocol was approved by the university of florida institutional review board. an open-ended survey was administered to enrolled participants after approximately one month of usage when participants had an opportunity to experiment and try to find the optimal treatment protocol that could include doses, specific modes of consumption, etc. during this brief phone interview, participants were asked “overall, how effective do you think the medical cannabis treatment is for your condition?”. through the openended survey, participants could share any insight into the overall effectiveness of the product, including any observed benefits and side effects, but were not provided with follow-up prompts to address these topics. the interviews were transcribed verbatim, identifying information was removed and responses were edited to be reviewed in first-person. data analysis two coders individually coded the interview data using the radar (rigorous and accelerated data reduction) technique, a well-established and standardized procedure by qualitative experts in prior published literature (watkins, 2017b). this technique utilizes tables to assign appropriate codes to qualitative responses and then identifies overarching themes in the data. using this technique, two coders independently coded the data and met weekly to reach a consensus regarding the codes and their definitions. during these meetings, coders identified broader themes based on established codes and consulted the study team to discuss any variances in established codes. after two rounds of coding, a consensus code was created factoring in perceived pain relief, health benefits and reported side effects. in the analysis of the overall effectiveness of treatment methods for chronic pain, various aspects of physical and mental functionality were observed and evaluated using the initiative on methods, measurement, and pain assessment in clinical trials (immpact) recommendation. using this model, the following outcome domains were evaluated: pain, physical and emotional functionality, participant’s perceived satisfaction and improvement with treatment method, reported symptoms, side effects and treatment regimen (turk et al., 2003). sample characteristics the sample included 51 adults initiating medical cannabis or chronic pain (24 women, 27 men, mean age 54.4, sd = 12.0), with the majority (80.4%) identifying as non-hispanic white followed by non-hispanic black (13.7%), multiracial (3.9%), hispanic white (2.0%). complete demographic information is summarized in table 1. the sample characteristics were consistent with the demographics of medical cannabis patients in florida with the majority of participants identifying as non-hispanic white (brown et al., 2020). most participants reported having some college education or higher and were married or living with a long-term partner. more than half of the sample were not employed (either disabled or retired). there were variations in past cannabis usage, with 46.8% of study participants not using cannabis in the past 12 months, 17.0% reported using within the past 12 months, and 36.2% reporting cannabis use within the past 30 days. results a total of 51 medical cannabis users answered the open-ended survey assessing overall perceived effectiveness of medical cannabis for their condition. based on participant feedback on the overall effects of medical cannabis as a treatment for chronic pain, the following themes were identified: overall perceived effectiveness of medical cannabis, health benefits, side effects, and cannabis, a publication of the research society on marijuana 65 table 1. sample characteristics of the study population (n = 51) variable value age in years mean ± sd 54.4 ±11.9 hispanic yes 3 (5.9%) no 48 (94.1%) race white 42 (82.4%) black/african american 7 (13.7%) multi-racial 2 (3.9%) gender male 27 (52.9%) female 24 (47.1%) education high school graduate or ged 10 (19.6%) some college or technical/trade school 18 (35.3%) college or higher 23 (45.1%) marital status married/living with a long-term partner 33 (64.7%) divorced/separated 12 (23.5%) widowed 2 (3.9%) never married and not living with a long-term partner 4 (7.8%) employment status yes, employed for wages 17 (33.3%) yes, self-employed 6 (11.8%) no 28 (54.9%) cannabis use prior to starting medical cannabis used in past 30 days 17 (36.2%) not used in past 30 days, but within 12 months 8 (17.0%) not used for more than 12 months 22 (46.8%) treatment methods.  overall perceived effectiveness based on participant feedback on the overall perceived effectiveness of medical cannabis as a treatment for chronic pain, more than half of the participants, both males and females, reported medical cannabis effectively reduced their chronic pain symptoms. “it’s [medical cannabis] very effective. there was only one day out of two weeks where i felt uncomfortable due to the pain, but it went away within an hour.” [58 years, male] “very effective. on a 1-100% scale it was 90% effective.” [26 years, female] two participants suggested limits in level the pain it can treat. “jury is still out some products help reduce my back pain when i am working but once a certain threshold of pain comes around no medical cannabis treatment has helped. useful in reducing table 2. qualitative themes, codes and definitions from open-ended interview medical cannabis and chronic pain management 66 themes codes definitions perceived effectiveness of medical cannabis medical cannabis was effective. participant reported that medical cannabis was effective for chronic pain management. medical cannabis had limited effect in pain reduction. participant reported limits in the level or quantity of pain treatable by medical cannabis product. unsure of overall effectiveness of medical cannabis. participant was undecided on the overall effectiveness of medical cannabis treatment. medical cannabis overall no effect. no clear effects were observed from medical cannabis treatment. health benefits medical cannabis improved sleep quality. participant experienced improvements in sleep quality after starting medical cannabis product. medical cannabis helpful for reducing other medications. participant reported reduction in previous pain medication and opioid usage. medical cannabis improved physical health and functionality. participant experienced improvements in physical health, functionality, and mobility with medical cannabis. mental health benefits participants reported benefits with mental health including improved focus, mood, and stress levels after beginning treatment. side effects undesired ‘high’ participant reported undesirable high because of medical cannabis product. stomach discomfort experienced participant reported experiencing stomach discomfort after initiating medical cannabis treatment. choking on ‘vape’ participant reported experiencing ‘choking’ when consuming medical cannabis through vape. medical cannabis treatment regimen product components participant stated preferences with product ingredients and thc to cbd ratio. mode of consumption participant was uncertain about most effective mode of consumption. determining proper dosage participant reported difficulties determining optimal dosage and ‘sweet spot’ with medical cannabis usage. pain in moderate levels but not high levels like opioids.” [69 years, male] “i think it [medical cannabis] helped a lot until i hurt my back. i seemed to have to smoke more after that. but for the everyday normal pain it was awesome.” [45 years, female] a few participants reported not noticing any reduction of pain or being undecided on overall effectiveness of medical cannabis treatment. “…i don’t believe it is that effective for me, i need to experiment more with products. i looked online at products and did not find much to help me.” [30 years, female] “i have not noticed much of a difference if i will be honest with you.” [52 years, female]. overall, most study participants reported medical cannabis effectively reduced their chronic pain, but several study participants mentioned not observing changes in pain intensity and limits in the pain treatable by medical cannabis products. health benefits participants reported various health improvements attributed to medical cannabis in addition to perceived effectiveness for chronic pain relief. improvements in sleep quality several participants reported improvement in their sleep quality as an additional benefit of medical cannabis use. “before i was very restless at night, i didn’t get any sleep at all and now i do. i don’t have the twitchy leg or the pain that would make me moan and groan at night. my husband is really happy about that!” [60 years, female] cannabis, a publication of the research society on marijuana 67 “overall, medical cannabis treatment was helpful …i have been able to sleep through storms for the first time in months.” [61 years, female] reduced need for medications participants also reported that medical cannabis reduced their need for other medications and effectively substituted prescription medications including xanax, meloxicam, tramadol, and oxycontin while leading to fewer side effects. “it’s [medical cannabis] great. i’ve never used medical cannabis before. with pain, i haven’t had to take any medication and i’ve been taking medication for years. all those narcotics and other meds. i was surprised, i didn’t know it was going to help me like that. it really works.” [43 years, female] “i’d give it a b+. i still need celebrex, something to help inflammation. i’ve gotten off some medications, but still take celebrex daily…i’m not on hydrocodone, i didn’t like the way it made me feel. i’m off the other opioids and meloxicam. life is good.” [62 years, male] “at this point the cbd oil, there’s a dramatic change in my body. usually, i get up and i’m achy/sore but now i can get up and not have to take a pain pill. pain in thumb from arthritis is almost gone. i would put cream on it every day, now it would be every other day or 3 days. i cut back on 3 or 4 pills (pain meds). i take less valium when i go to sleep because i take medical marijuana.” [67 years, male] one participant mentioned preferring medical cannabis over the side effects of tramadol. “overall medical cannabis is helpful. it makes it much easier to control pain and not take pills. the side effects are way better than tramadol medication. on medical cannabis you can live life, work and do stuff, but on tramadol, you can’t live pain-free and do stuff...all you can do is sit on the couch and watch tv while drooling” [47 years, female] improvements in physical health functioning participants reported improvements in physical health and functionality including increased mobility, delay of surgery. one participant believed their medical cannabis treatment improved diabetes management. “for me it’s [medical cannabis] very helpful. it helps me move. i would get home from work, i would take the vape, and it would help me move around even after a busy day. normally, when i come home from work, i would be a lump on a log and couldn’t move and now i can move around freely interacting with my family members.” [48 years, male] “i can get up and move around and not be miserable. the morning is when i notice the most.” [67 years, male] one participant discussed decreased dependency on walker attributed to physical benefits experienced with medical cannabis usage. “pretty damn effective [medical cannabis treatment]. i’m no longer using my walker. i only take my meds [opioid/pain medication] one time a day instead of three, and i haven’t had a xanax in 30 days.” [51 years, female] another participant reported being able to delay surgical procedures and maintain an intensepaced lifestyle with medical cannabis usage. “without medical cannabis, i would have to get surgery immediately. using drops and opioids i have been able to put off surgery and live life to the fullest even at the high intense pace i am at right now.” [64 years, male] one participant believed that medical cannabis helped with his diabetes management. “it [medical cannabis] helps me with my joint pain and in bringing my sugar levels down. i have diabetes.” [53 years, male] impact on mental health and functioning many participants stated that medical cannabis use for pain reduction also helped improve aspects of their mental health including medical cannabis and chronic pain management 68 focus, mood, stress levels, and engagement in daily life activities. “i think it helped me out a lot especially with my mood. it helped with my pain and depending on what i smoke it allows me to be more focused as well. i did a lot of cleaning.” [39 years, male] “there is one [product] where it makes me more active if i don’t sit down. it makes me focus and i do dishes and clean my house and stuff. i get so much done, … anxiety wise, being on the cbd and using the vape, my anxiety has gone from a 10 to a 4.” [45 years, female] a participant suggested medical cannabis helped reduce suicidal ideation and made her feel ‘human again’. “medical cannabis is very effective in helping my pain. when everyone had to go down on opioids [doses reduced] because of the high death rates, i felt suicidal. it [medical cannabis] takes the edge off plenty where i feel human again.” [56 years, female] one participant addressed cognitive functioning and reported a perceived increase in cognitive functioning with the medical cannabis product. “medical cannabis has been wonderful. it has been absolutely fantastic as i have found the perfect mix for the right time of day. have absolutely no cognitive loss during the day has seen increase cognitive ability has been able to properly go to sleep at night instead of using medication to pass out.” [56 years, female] although most participants who addressed mental health spoke of the benefits, one participant stated not experiencing mental health benefits or pain relief. “[medical cannabis] helps with insomnia. not so much with pain or mental issues.” [56 years, female] based on participant feedback of overall product effectiveness, many participants reported health benefits including improvements in sleep quality, reduced dependency on pain and psychiatric medications, and improved physical functioning and overall mental health. side effects participants also offered insight into side effects experienced; specifically, stomach discomfort, an undesirable ‘high feeling’, and ‘choking’ on the vape. undesirable high “[medical cannabis is] not really effective with my job. i handle lots of heavy machinery. i don’t have the capability to be high or incapacitated mentally. it feels good sometimes, but i don’t like the side effects or being unable to work.” [49 years, male] “hard to find a sweet spot when using vape since i am high on the first hit. i would like to not feel my neuropathy and not be high. medical cannabis is effective but does not enjoy being high.” [65 years, male] another participant reported experiencing stomach issues with medical cannabis usage. “overall, the medical cannabis treatment was effective, but i couldn’t take the oil because it gave me stomach issues.” [58 years, female] one participant reported difficulty with 'choking’ on vape during the initial week of usage. “to be honest, i had trouble at the beginning with the vape. i would choke on it for the first week, but the past week i’ve been able to use it.” [58 years, female] one participant mentioned experiencing different side effects based on product type mentioning sleep impairment and an ‘overdose’ on thc product. “i don’t know that it does anything. after i had the overdose, i stopped taking the indica thc. the other one, cbd, turned out bad because i’d stay awake until 3-4 in the morning. i’ve used the cream on my shoulders, but i haven’t seen any help from it either.” [73 years, female] based on participant feedback, side effects experienced during medical cannabis treatment cannabis, a publication of the research society on marijuana 69 varied from an undesired high, stomach issues, ‘choking’ during vape usage, sleep impairment and reported overdose on indica thc product. treatment regimen participants reported experimentation with various product types and modes of consumption to find an optimal treatment routine. a common concern expressed by participants was difficulty finding the right dosage or the ‘sweet spot’ with medical cannabis. product components participants addressed their preferred medical cannabis product ingredients, including sativa and indica products, and preferences with the cbd to thc ratio. “i’d say it’s [medical cannabis] pretty effective. if you’re doing a sativa product and your back is hurting you, the sativa would give you energy to move. the indica would help put me to bed if i’m not feeling sleepy and keep me knocked out.” [38 years, male] few participants commented on customizing their cbd to thc ratio and the benefits experienced based on the different products. two participants noted improved sleep with thc. “overall medical cannabis treatment is good. cbd in combination with vegan diet helps a lot. i haven’t felt this good in 20 years. the thc is good on days that i do lawn work because it helps me sleep. the thc also gives me an increased appetite, but that’s a good thing.” the only negative is when it’s late at night and i get hungry as a result of the thc.” [63 years, male] “i’ll be 100% honest with you. i think it works wonderful for my condition. it really helps to take the thc when i go to sleep. during the day it helps cut down my inflammation and to be able to customize it so that i’m not high is really nice.” [40 years, male] “i can actually tell a difference. the first time i tried one strain and i didn’t tell a difference then i went back and tried a different strain with higher thc and i was able to see a difference in my lower extremity (back problems). my pain was more tolerable.” [67 years, male] modes of consumption participants mentioned the role different modes of consumption such as vape/ inhalation, topical cream, oil, drops, sublingual tablets and capsules played on overall product effectiveness. “as far as delivery, the inhalation is better, the oil tastes disgusting. thc didn’t work, taking the product was worse than not taking it. i still take the cbd.” [65 years, male] “the only thing i get benefits from is the vape.” [68 years, male] “since i’ve only been on it [medical cannabis] for a short time. i started off smoking the marijuana and i didn’t like it. i didn’t like the way it made me high. i got the drops and the pills. the pills didn’t do anything. the drops worked better, but i’m still trying to figure out what works for me.” [61, male] determining optimal dosage participants reported experiencing difficulties in finding the optimal dosage and ‘sweet spot’ for their condition and suggested this affected their perception of the overall effectiveness. “i'm using sublingual and capsules have not found my sweet spot. it is making a difference but not that much of one.” [72 years, male] “i am still trying to figure out the right concoction, i need to go and try a couple of more types. there’s this one [product] that knocks me out. it works because i don’t feel any pain, but i fall asleep within 20 min. there is one [product] where it makes me more active... but then i’m hurting because i’ve overdone it and been moving all day. i need to learn to balance…it’s effective in that it does what it says it would do. it reduces some of my pain. it is going to take a couple of months to figure out. i really like the cbd oil but that alone doesn’t do it 100%.” [45 years, female] a participant reported difficulty balancing getting good sleep and waking up feeling tired due to the dosage used while vaping. medical cannabis and chronic pain management 70 “it [vape pen] puts me to sleep really quick, within 30min, which is a big help because i wouldn’t fall asleep until 1 or 2 am. i think it makes me more tired during the day so it’s a work in progress. i need to tweak it, right now i’m taking it how my doctor told me to, but he said to adjust as needed. so, i need to play around with it a little.” [58 years, female] overall, participants reported experimentation with different strains of medical cannabis and adjusting the cbd to thc product ratio to maximize treatment benefits. additionally, some participants struggled to identify the most effective mode of consumption and ‘sweet spot’ during their experimentation with medical cannabis. discussion the current study was designed to evaluate data from an open-ended interview to assess the perceived effectiveness of medical cannabis as a potential treatment for chronic pain. with the rapid expansion of this practice, evidence-based research is essential to understand and properly implement this alternative treatment for chronic pain management. based on the feedback interviews evaluating the perceived effectiveness of medical cannabis products for chronic pain, the following themes emerged: 1) overall perceived effectiveness, 2) health benefits, 3) side effects, and 4) treatment regimen. as chronic pain encompasses a wide array of health symptoms beyond perceived pain, we assessed a multitude of physical and mental health domains to accurately evaluate pain outcome measures. the themes observed in this study aligned well with the immpact recommendation on core outcome measures for chronic pain treatment as various health domains in addition to perceived pain were assessed to best evaluate pain outcomes with medical cannabis treatment (turk et al., 2003). based on qualitative findings from this study, more than half of adult female and male participants found medical cannabis to be effective for the management of their chronic pain. these findings align well with past metaanalyses suggestive of improved pain management with medical cannabis treatment (whiting et al., 2015; wong et al., 2020; yanes et al., 2019). a small percentage of participants interviewed were undecided on the overall effectiveness of medical cannabis, and only three participants reported no observed effect from the treatment. additionally, two study participants suggested a ‘threshold’ of pain treatable by product. further research may be beneficial to evaluate limits in pain treatable by medical cannabis products and variances observed in the perceived effectiveness of medical cannabis. in addition to the alleviation of chronic pain symptoms, multiple other health benefits were reported with medical cannabis usage. a common benefit mentioned was improved sleep quality. participants reported being able to ‘sleep through storms’, improvements with insomnia, and experiencing ‘well and uninterrupted’ sleep. this feedback aligns with previous findings suggestive of small improvements in sleep quality during medical cannabis treatment (aminilari et al., 2022; sarris et al., 2020). a couple of participants reported difficulty finding the balance between receiving adequate sleep and being tired throughout the day due to product dosage. a few participants also reported a ‘knocking out’ effect after the consumption of medical cannabis products. additionally, two participants reported greater ease of falling asleep with higher thc products. although this finding contributes to past research suggestive of the potential therapeutic effects of thc on decreasing sleep latency, there is also emerging evidence of potential impairments in long-term sleep quality with higher thc products (babson et al., 2017). as the research is still limited and inconclusive on medical cannabis and sleep quality with some past reviews reporting insufficient evidence to support the clinical use of cannabinoids for sleep therapy (corroon, 2021; suraev et al., 2020), further research is needed to explore the varying effects and potential therapeutic uses of medical cannabis for sleep disturbances. additionally, participants reported reduced need and replacement of other medications while experiencing fewer side effects with medical cannabis treatment. reduced intake of a variety of benzodiazepine and pain medications including xanax, meloxicam, tramadol, and oxycontin were stated. these findings enhance preliminary evidence of the potential to use medical cannabis in substitution for other substances (lucas et al., 2019; walsh et al., 2017). a couple of participants mentioned using medical cannabis in addition to low dosages of pain medication or substituting cannabis, a publication of the research society on marijuana 71 pain medications completely with medical cannabis while experiencing fewer side effects. although our findings suggest potential analgesic properties of medical cannabis, some metaanalyses have found low-quality evidence to back this potential alternative to common prescription medications (noori et al., 2021). further research is needed to clarify the substitutive and ‘opioidsparing’ effects of medical cannabis treatment in addition to assessing proper dosing to achieve potential analgesic properties, but our findings contribute to a growing body of evidence suggestive of the potential to use medical cannabis as an alternative to common prescription medications. improvements in physical health and functionality were observed in the qualitative findings. participants stated perceived benefits including increased ability to ‘move freely’, decreased dependency on walker, improvements in blood sugar management, and increased muscle relaxation with medical cannabis usage. based on the participant feedback, it was suggested that improved physical mobility may be an additional benefit experienced attributed to the reduction in pain symptoms with medical cannabis usage. although there is limited literature on medical cannabis and its effects on mobility, a review assessing medical cannabis in patients with huntington’s disease found significant improvement in motor symptoms including tremors and rigidity after medical cannabis treatment (akinyemi et al., 2020). further research would be beneficial to determine the physical benefits and potential changes in motor functioning with medical cannabis. changes related to mental functionality, including improvements in focus, mood, and stress levels were also observed. this supports previous findings of health benefits such as mood improvement, reduction in anxiety, and improved stress management with medicinal cannabis usage (peterson et al., 2021). a common concern with medical cannabis is cognitive decline; although past findings have shown a correlation between long-term exposure and a reduction in cerebral blood flow, neuroimaging studies have shown no effect from cannabis in gross brain anatomy (shrivastava et al., 2011). one study participant even suggested a potential perceived increase in cognitive function attributed to medical cannabis products. although multiple participants commented on the positive effects of the treatment on their mental health and overall functioning, a couple of participants did report impaired functioning due to undesired high and not experiencing benefits in their mental health. it is important to consider and further evaluate how medical cannabis affects various facets of cognitive functioning and mental health to properly implement and advise patients on this treatment. further, a comprehensive understanding of potential side effects is essential to properly understand and regulate medical cannabis usage. in addition to an undesired high, impaired work performance, stomach issues and ‘choking on vape’ were side effects mentioned by a few study participants. the observed side effects by study participants contribute to past findings suggestive of impaired performance and neurocognitive impairment with chronic usage (bridgeman & abazia, 2017). future research and a thorough risk assessment would be beneficial to determine the long-term side effects of chronic cannabis usage and properly assess the risks associated with this practice. lastly, the treatment regimen was evaluated to better understand the effectiveness of medical cannabis in pain management. in the state of florida, once a patient receives a medical cannabis recommendation, they can purchase their product of choice within the recommended thc to cbd ratio (wang et al., 2021). the delivery methods for medical cannabis in the state of florida include inhalation, sublingual, oral, topical, edibles, and suppository (risola, 2020). products mentioned by participants included vape, oil, drops, pills, patches, and cream. based on the feedback from the open-ended survey, determining the proper mode of consumption and finding the ‘desired sweet spot’ were common concerns reported by participants. participants mentioned struggling to find a regimen that allowed them to experience maximum product benefits while also minimizing potential side effects. additionally, participants mentioned experimentation adjusting the cbd to thc ratio to customize product effects to best fit their lifestyle and pain management needs. limitations our sample size was relatively small and predominantly non-hispanic white adults which medical cannabis and chronic pain management 72 may limit applicability to larger, more diverse groups. although the population interviewed is largely representative of the demographic seeking out medical cannabis treatment for chronic pain management in the u.s., greater diversity would strengthen and increase the generalizability of these findings. the smaller sample size could limit the observed themes of the qualitative data. additionally, the radar coding technique may not be applicable to larger datasets as it requires manual sorting and reviewing of qualitative data (watkins, 2017a). as the interviews were administered after a month of usage, the findings may not reflect more long-term effects observed from the usage of medical cannabis products. another limitation of this study was the use of our own interview questions, which could be further validated for rigor and reproducibility. finally, this study was an observational one, so our findings could not rule out the potential impact of factors such as the placebo effect. assessing the potential ‘placebo effect’ associated with medical cannabis products may be another important consideration when evaluating perceived effectiveness. conclusions this study provided preliminary findings that contribute to an improved understanding of individual experiences using medical cannabis for chronic pain management. the open-ended interview highlighted information from patient perspectives which may guide future investigations with the longer-term goal of optimizing patient 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(2022). prevalence of chronic pain among adults in the united states. pain, 163(2), e328-e332. https://doi.org/10.1097/j.pain.00000000000022 91 funding and acknowledgements: the findings for this study were supported by the university of florida center for research to investigate substance use and pain (uf-crisp) and part of the university of florida’s “creating the healthiest generation” moonshot initiative. this initiative was made possible by the support of uf office of the provost, uf office of research, uf college of medicine, uf health, and the uf clinical and translational science institute. ncats grant ul1 tr000064 funded the redcap service used for this research. we are extremely grateful for the clinics (releafe now, cannamd, and florida marijuana doctor) and drs. john (jack) crump and justin davis, ms. debbie mendez-vigo, and ms. jessica walters for their dedication to study recruitment and medical cannabis research. we are also grateful to participants who participated in the study. conflict of interest statement: this work has not been previously published nor is it under consideration for publication elsewhere. past findings with study subjects (survey data) have been reported by wang et al. (2021) and referenced in the manuscript. study findings were presented as a poster at the 2022 ags annual meeting and as an oral presentation at the cannabis clinical outcomes research conference 2022. there are no conflicts of interest to disclose. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 30 ved abstract introduction. the legal landscape surrounding purchasing cannabis without a medical cannabis card (i.e., without mcc) is changing rapidly, affecting consumer access and purchasing behaviors. cannabis purchasing behaviors are related to subsequent use and experiencing greater cannabis-related negative consequences. however, purchasing behaviors of individuals who use cannabis without mcc are understudied. methods. the current study analyzed qualitative data from focus groups with adults who use cannabis without mcc (n = 5 groups; 6-7 participants/group; n = 31 total participants). focus groups followed a semi-structured agenda, and were audio recorded and transcribed. two coders applied thematic analysis to summarize topics pertaining to cannabis purchasing attitudes and behaviors. focus groups occurred in 2015 and 2016 in rhode island, when purchasing and use of cannabis without mcc was decriminalized but still considered illegal. results. on average, participants (72% male) were 26 years old (sd = 7.2) and reported using cannabis 5 days per week (sd = 2.1). thematic analysis revealed three key themes related to cannabis purchasing behaviors: (1) regular purchasing routines (i.e., frequency, schedule, amount of purchases), (2) economic factors (i.e., financial circumstances), and (3) contextual factors (i.e., quality of cannabis, convenience/availability) were perceived to influence purchasing decisions. dealers’ recommendations affected participants’ purchases, who also reported minimal legal concerns. participants reported saving money and using more cannabis when buying in bulk. discussion. purchasing behaviors were found to vary and were perceived to be affected by individual-level (e.g., routines) and contextual factors (e.g., availability) that, in turn, may impact use patterns. future research should consider how factors (e.g., availability) that differ across contexts (e.g., location) and demographic groups interact to affect purchasing behaviors. key words: buying marijuana; cannabis purchase; qualitative methods; marijuana purchase task; focus groups the past decade has seen a rapid increase in the legalization of cannabis use and purchasing (i.e., sale, possession) for recreational purposes. in the united states (u.s.), recreational cannabis legalization is associated with increased use among adults (hasin et al., 2017). recent evidence suggests that recreational cannabis legalization has led to a ~20% increase in frequency of nioud mulugeta gebru1,2, elizabeth r. aston2, benjamin l. berey2, l. morgan snell3, robert f. leeman1,4, jane metrik2,5 1 department of health education & behavior; southern hiv and alcohol research consortium (sharc); center for addiction research and education (care); university of florida, gainesville, fl 2 center for alcohol and addiction studies, department of behavioral and social sciences, brown university school of public health, providence, rhode island 3 department of health behavior and policy, virginia commonwealth university, richmond, va 4 department of health sciences, northeastern university, boston, massachusetts 5 providence veterans affairs medical center, providence, rhode island cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000168 “that’s pot culture right there”: purchasing behaviors of people who use cannabis without a medical cannabis card corresponding author: nioud (neo) gebru, center for alcohol & addiction studies, brown university school of public health, 121 s. main st., box g-121s-3, providence, ri 02912. email: neo_gebru@brown.edu cannabis, a publication of the research society on marijuana 31 cannabis use among adults in the u.s. (zellers et al., 2023). higher prevalence of cannabis use is of concern to public health because it has been associated with several deleterious outcomes, including increased risk for cannabis-related emergency department and urgent care visits (wang et al., 2018), cannabis use disorder (cerdá et al., 2020), motor vehicle crashes (rogeberg & elvik, 2016), and negative effects on individuals’ cardiovascular health (cohen et al., 2019). individuals who purchase cannabis use it more frequently relative to those who do not purchase cannabis but obtain it from other sources, such as their friends (osilla et al., 2014). purchasing cannabis is also associated with experiencing more cannabis-related negative consequences, more time spent with people who use cannabis, and is prospectively associated with higher likelihood of developing any substance use disorder (osilla et al., 2014). however, purchasing behaviors of people who use cannabis without a medical cannabis card (mcc), and factors affecting purchases, are understudied. examining purchasing decisions/behaviors in the context of the evolving legal landscape is particularly important to inform future interventions and policy decisions. legalization of recreational cannabis use is also associated with more favorable social norms surrounding use (wallace et al., 2020), increased susceptibility for initiation among those who have never used cannabis (palamar et al., 2014), and increased perceived ease of access (azofeifa et al., 2016; harpin et al., 2018). cannabis legalization also facilitates rapid expansion of new dispensaries and allows for people to cultivate their own cannabis plants, resulting in increased access to cannabis. indeed, the burgeoning legal retail marketplace has, in effect, decreased the price of illicit cannabis (anderson et al., 2013; hall & lynskey, 2020; hao & cowan, 2020). from 2002 to 2014 – a time period when widespread recreational cannabis legalization was starting to occur – there was an increase in the rate of people endorsing buying and growing cannabis versus getting it for free and sharing it (azofeifa et al., 2016). during the same time period, the number of people who reported that cannabis was fairly easy or very easy to obtain also increased (azofeifa et al., 2016). given that increased access to cannabis (e.g., increased access to retail cannabis stores) is associated with increased use (everson et al., 2019), it is important to better understand how both price and perceptions of access are related to cannabis purchasing behaviors among individuals without mcc. further, although the illicit market remains the primary source of cannabis in the u.s., research on purchasing behaviors has thus far primarily aimed to characterize access to, and sources of, cannabis in the context of medical use and dispensaries (capler et al., 2017; reed et al., 2020). a recent systematic review on characteristics that affect purchase choices for cannabis products highlighted how our knowledge about relevant characteristics affecting consumers’ choices is lacking and called for more research to elucidate cannabis purchasing behaviors (donnan et al., 2022). prior research has shown that purchasing factors, such as source (i.e., cannabis supplier/provider/seller) and product availability, are associated with different cannabis use outcomes. specifically, in a newly legalized market in los angeles, young adults who obtained cannabis from medical or non-medical retailers spent more money, used more cannabis products, and reported more consequences from use than young adults who obtained cannabis from family and friends (d’amico et al., 2020). results from a recent study in canada indicated that living in closer proximity to legal cannabis retail outlets was associated with a higher likelihood of purchasing dried flower (wadsworth et al., 2021). similar patterns were observed in washington state in a longitudinal study of over 85,000 individuals between 2009 and 2016 (everson et al., 2019). although rates of current cannabis use and frequency of use did not significantly change immediately following legalization, significant increases were observed following greater access to retailers (i.e., decreased distance to cannabis retailers) (everson et al., 2019). taken together, evidence indicates that certain purchasing factors like accessibility and source may affect certain cannabis use behaviors (e.g., number of cannabis products used, increased use quantity). in the u.s., although the number of states that have legalized recreational cannabis is growing (19 states and washington, d.c., as of march 2023), non-medical cannabis remains illicit in the majority of states and at the federal level (national conference of state legislators., 2022). use of cannabis for medical purposes is also now cannabis purchasing behaviors 32 legal in most states in the u.s. legalization of cannabis for medical use is followed by increased access to cannabis overall, in part via dispensary diversions, where people with a medical card resell cannabis to others (reed et al., 2020). even though cannabis remains federally illicit and several u.s. states restrict its use for medical and/or recreational purposes, perceived legal consequences for cannabis use and possession have decreased. moreover, policies that are ostensibly intended to deter use have had little effect in decreasing actual purchasing and use. rather, these policies have engendered a detrimental impact on society by increasing involvement with the criminal legal system (lenton, 2000). indeed, there has been a significant increase in the number of people who support a fine as the maximum legal penalty for cannabis possession of an ounce or less versus harsher punishments (e.g., probation, incarceration) (azofeifa et al., 2016). correspondingly, cannabis purchasing is still occurring at high levels in many areas where it remains illegal. for example, prior qualitative research with people who use cannabis in rhode island demonstrated that they are generally satisfied with the cannabis decriminalization policies in rhode island including interactions with law enforcement, such that “cannabis already feels legal” (benz et al., 2021). relevant laws in one state also influence purchasing behaviors of individuals in neighboring states. hao and cowan (2020) described this phenomenon as the “cross-border spillover” effect, after finding that legalization of recreational cannabis was associated with increased use in neighboring states compared to non-neighboring states. taken together, more research is needed to better understand how perceived legal consequences are related to purchasing behaviors of persons who use cannabis without mcc. recent years have also seen an increase in cannabis potency (i.e., levels of tetrahydrocannabinol [thc]). specifically, the potency of illicit cannabis flower increased from ~4% in 1995, to ~12% in 2014, reaching up to 1417% in 2019, and cannabis available on the current legal market is over 20% (chandra et al., 2019; elsohly et al., 2016, 2021). in places where use of cannabis for recreational purposes is legal, retail sales indicate an increased demand for cannabis extracts, which are over three times more potent than traditional cannabis flower (e.g., 60-65% thc level in extracts versus 15-20% for flower) (hammond, 2021; smart et al., 2017). while increased access to cannabis is expected following legalization, concomitant increases in cannabis use may be especially concerning, in part, because of the increased potency of the cannabis that is being purchased and used. highpotency cannabis concentrates are implicated in the increasing cannabis use disorder (cud) rates (meier, 2017) and more severe cud symptoms (freeman et al., 2019). thus, more research is needed to explicate relations among cannabis’ legal status, availability of different cannabis products (e.g., flower, concentrates), quality of available cannabis, cannabinoid potency, and associated effects on purchasing behaviors and use. the integrated behavioral and economic paradigms framework may allow for better understanding of purchasing behaviors related to cannabis (johnson & golub, 2007; sifaneck et al., 2007). the behavioral paradigm emphasizes use patterns and purchase experiences associated with cannabis use/purchasing, whereas the economic paradigm emphasizes purchase prices, dollar values, and overall understanding of illegal markets (johnson & golub, 2007). from these perspectives, contextual factors that might impact, and are related to, cannabis purchasing include the shifting legal landscape and changing policies relevant to cannabis. growing legalization has also been accompanied by the rapidly expanding cannabis industry, changes in cannabis potency, and overall availability of cannabis. thus, previous research has characterized cannabis purchasing in various contexts, including designer and commercial markets (sifaneck et al., 2007), open-air cannabis markets (moeller, 2016), post-legalization markets (donnan et al., 2022) as well as medicalized cannabis purchases (reed et al., 2020). although much remains unknown about factors affecting cannabis purchase decisions, the existing research indicates that perceived quality and price influence cannabis purchase choices, such that consumers seek the lowest-cost cannabis to avoid reducing consumption (donnan et al., 2022). however, less is known about cannabis purchased without mcc from various sources, particularly within the shifting legal landscape and changing policy contexts that cannabis, a publication of the research society on marijuana 33 engender reduced stigma and increased cannabis availability. in part because of the complicated and rapidly changing legal environment for cannabis, empirical research on purchasing behaviors of individuals who use and/or purchase cannabis without mcc in states where recreational use is illegal has been limited. thus, in the present study, we aimed to characterize purchasing behaviors of people who use cannabis without mcc using qualitative data from focus groups, which provide rich and contextual information about participants’ behaviors. prior studies have employed qualitative methods to investigate sources of cannabis (e.g., reed et al., 2020), which have resulted in several unique insights, as noted above. understanding purchasing behaviors surrounding cannabis used without mcc is especially important because purchasing behaviors are related to use patterns and negative consequences, and this information could inform future interventions and policy decisions. thus, among people who use cannabis without mcc, we sought to answer the following research questions: (1) what are participants’ purchasing routines? and what are (2) economic and (3) contextual factors that are perceived to affect purchasing of cannabis without mcc? methods participants individuals who reported using cannabis without mcc were recruited from rhode island and massachusetts via advertisements on flyers and social media to participate in qualitative focus group interviews about their cannabis use and purchasing behaviors. focus groups were conducted, in part, to inform the design of a larger experimental laboratory cannabis administration study (aston et al., 2021). for inclusion in the study, individuals had to be 18 – 50 years of age; endorse weekly cannabis use, on average, during the past 6 months; purchasing cannabis ≥ 2 times in past 6 months; not seeking treatment for cud; and not holding a medical cannabis card (mcc). focus groups were conducted in 2015-2016, with participants from rhode island, during which time, cannabis use without mcc was considered illegal, but was decriminalized. cannabis use with mcc was legal, and at the time of data collection rhode island had three medical cannabis dispensaries. legal consequences for cannabis use without an mcc included a fine of up $150, but no jail time and no criminal record. based on this context, and given that there were no other main avenues for purchasing cannabis use without mcc, the most likely source for purchasing cannabis for people without mcc in the state of rhode island was via nonmedical providers. rhode island, and neighboring states, massachusetts and connecticut, legalized cannabis without mcc after these data were collected, at the end of 2022, 2016, and 2021, respectively. procedure a total of 31 individuals participated in 5 inperson focus groups, with 6-7 participants per group. before focus group discussions, participants first completed self-report measures of their demographic background and cannabis use. focus groups followed a semi-structured interview guide, sessions were audio recorded, and on average lasted approximately an hour. sample questions are in table 2. participants were compensated $40. the study’s principal investigator (e.a.) led the focus groups, with a trained research assistant who took notes during the discussions. all study procedures were approved by the university’s institutional review board. data analysis audio recordings of each focus group discussion were transcribed verbatim. debriefing discussions were held following each focus group. a deductive coding approach was implemented for the current analyses (skjott linneberg & korsgaard, 2019a). using the semi-structured interview agenda, a qualitative coding structure was developed. the coding structure was refined through an iterative process to incorporate topics that emerged in the discussions. transcripts were manually coded separately by two research assistants using an open coding process (saldana, 2022; skjott linneberg & korsgaard, 2019b). codes were then entered into nvivo software for thematic analysis to identify key topics (guest et al., 2012). data mining tools were used to identify relevant themes of interest (e.g., cost, amount, purchase). cannabis purchasing behaviors 34 transcripts were thematically analyzed, first using descriptive coding followed by conceptual coding. first, all codes pertaining to cannabis purchasing behaviors were reviewed descriptively. intensive coder discussion, coder adjudication, and simple coder consensus were used to resolve discrepancies and used to indicate agreement (colditz et al., 2018b; harry et al., 2005a; kvale & brinkmann, 2009; sandelowski & barroso, 2006). secondary coding was implemented for relevant conceptual content to facilitate synthesis and organization of codes by the first and second authors. discrepant codes were subsequently brought into concordance through discussion. all codes pertaining to cannabis purchasing were reviewed again, towards categorization, integration, synthesis, and conceptualization of topics (saldana, 2015). the final set of codes was then reviewed by the first four authors, and summarized to identify key themes, which are reported here. representative quotations were selected and presented to illustrate the general idea of each theme. in line with presentation of emergent data, themes are described in detail, but number of participants endorsing a theme is not quantified as this would not be an accurate representation of the prevalence of a given behavior or belief in focus group discussions where all participants are not asked to answer all questions (hannah & lautsch, 2011). quotations include the assigned participant study number, sex (male/female), and age in parentheses. table 1. sample descriptive characteristics general characteristics; n = 31 mean (sd), range or n, % age, in years 26.10 (7.20), 18 – 41 sex (n, % male) 22 (71.0) education level (n, %) less than high school 1 (3.2) high school diploma (or equivalent) 8 (25.8) some college 15 (48.4) college degree or higher 7 (22.6) individual annual incomea (n, %) $19,999 or less 17 (56.7) $20,000 – $39,999 9 (30) $40,000 – $59,999 3 (10) $60,000 or higher 1 (3.3) employment (n, % employed) 27 (87.1) ethnicity (n, % hispanic) 7 (22.6) race (n, %) american indian / alaskan native 1 (3.2) asian 2 (6.5) black 6 (19.4) native hawaiian / pacific islander 1 (3.2) white 18 (58.1) other 3 (9.7) cannabis-related variables past-month use days/week 5.00 (2.15), 1 – 7 duration of regular cannabis use, in years 6.94 (6.05), 0 – 22 notes: aincome reported for n = 30 results sample characteristics sample descriptive characteristics are presented in table 1. the majority of participants were male (72%). reported mean age was 26.1 years old (sd = 7.2). participants were of relatively diverse racial identity, with the majority identifying as white (58.1%). the rest of the participants identified as african american (19.4%), asian (6.5%), american indian/alaska native (3.2%), native hawaiian/pacific islander (3.2%), or other (9.7%). a majority of participants cannabis, a publication of the research society on marijuana 35 reported using 1/4 ounce (29%) or more than 1/4 ounce (29%) of cannabis per week. several others reported using less than 1/16 ounce (9.7%), 1/16 ounce (9.7%), or 1/8 ounce (22.6%) of cannabis per week. on average, in the past 30 days, participants reported using cannabis 5 days per week (sd = 2.1) and spent $129.20 (sd = $99.50) on cannabis. participants started regularly using cannabis at 19 years of age (sd = 5.0 years), on average. qualitative themes three main topics were queried during focus group discussions regarding: (1) regular purchasing routines for cannabis used without mcc, (2) economic factors, and (3) contextual factors perceived to influence cannabis purchasing behaviors. each theme, along with subthemes and exemplar quotes, is further described below, with a complete list presented in tables 2 and 3. table 2. summary of qualitative themes sample focus group agenda questions theme sub-theme • how often are you buying marijuana? o probes: do you have a schedule? do you plan ahead? • how much marijuana do you usually purchase? o probes: why? 1. regular purchasing routines 1.1. purchasing frequency 1.2. purchasing schedule 1.3. amount per purchase • about how much do you spend each time you buy marijuana? o probes: why? • do you buy for yourself or do you typically buy for someone else in addition to yourself? (significant other, friend?) o probe: why? 2. economic factors affecting cannabis purchasing behaviors 2.1. finances/cost 2.2. factors affecting cost 2.3. effects of price increases • tell me about your relationship with your supplier. o probe: would you buy from elsewhere? why? 3. contextual factors affecting cannabis purchasing behaviors 3.1. quality of cannabis 3.2. convenience/availability 3.3. legal concerns table 3. study themes and representative quotes concerning purchasing behaviors of persons who use cannabis without mcc sub-theme id # quote theme: regular purchasing routines purchasing frequency 1 i usually buy anywhere from one to three times a week, depending on how heavily i'm using 5 every week or couple weeks. 7 every day, almost 9 if i'm smoking regularly, maybe once a week or once every two weeks for the—for that duration of time 10 i usually get it four—, i'm pretty consistent with four days. 11 every day, unless i buy a quarter for the week 14 if i had unlimited money, i could probably do,—a comfortable thing would be an eighth every day. a little more….but, right now i'm an eighth every other day. so every two days i'll probably get an eighth. 16 four—i’d say four or five times—four times—four to five times a week. 21 yeah. i would say once a week. 22 but usually just once a week. i know what i want. 26 about once a month. 27 it might be different amounts every day, but definitely every day. i’m a pothead, every day. 28 usually, once a week. 30 a couple of times a week 32 i would say maybe two or three times a week. 33 i buy every few days purchasing schedule 2 i usually try to get some before i'm completely out. 4 running out 15 yeah, before i run out, usually 17 i usually go by how much i have left. 18 no particular schedule…and then i’ll try to go as long as possible without smoking. 21 pretty regular. i’d say go around between once a month to once a week. kinda fluctuates. 22 overall i’m pretty set in my ways 31 when you’re out. amount per purchase 1 eighths, pretty much always. 2 half-ounce at a time every two weeks. cannabis purchasing behaviors 36 sub-theme id # quote 3 there's no set amount. 6 half-ounce. 8 i usually get eighth, quarter. 9 anywhere from a gram to a quarter….an eighth or a q or something. 10 a quarter ounce. …i'd say the eighth is probably the most popular thing to go, the most go-to 11 it depends on the day…sometimes when i hit the lottery or no. just kidding. [laughter] it just depends on the money situation. bills and—…so, like, today i get a 20, but friday i might get a quarter.…half-ounce, ounce….i get medical grade—if i buy an ounce for 220, which if i buy an eighth, it's 40, so it's worth spending the extra money to – but then i end up smoking more 12 varies 14 right now i'm an eighth every other day. you know? 16 cuz i’m cheap—i don’t even wanna buy more than a 20 sack…—a half eighth, probably he gives me 1.7. 17 usually if i—when i buy bigger amounts i find that i smoke more.… i almost went through an eighth in like two hours. and i was like whoa, okay. time to step back. 29 about an ounce at a time 33 i buy every few days. i buy 20 at a time theme: economic factors affecting cannabis purchasing behaviors finances/cost 1 $100.00 for five months. 3 $35.00 to $40.00. 4 i want to get a 20 bag, i might buy a 20 bag, but usually, i'll purchase in bulk— just for cost's sake and convenience, really. depends how much money i have. between two and $700.00 5 how much money you have. $20.00. 6 depending how much money you have, honestly….you really do what you want depending on how much money you have, find out what you're dealing with. like, $40.00. 7 depends on what you get, you know? might spend 10 on a gram, 40 on a eighth. you know? 10 i'm definitely all about the money on that one. 11 lately i haven't had a lotta money, so i've been buying a 20 sack to get me through the day. but usually, when my boyfriend and i are both working, we buy a quarter or maybe a little more a week. but, lately it's been day to day cuz we've been temping. so i spend 15 on a gram, 40 on an eighth, 20 for 1.8. 14 yeah. money—money's definitely— 21 i’d say $20.00 would be the average. 22 between $40, $80.00, depending on what we get. 24 i get about $50.00 a week. because you figure four days a week, so. 27 it depends on how much money i got at the beginning of the week. factors affecting cost 4 if you go to a dispensary, if they have some betty kush or something, something made up by some dude, and then they have og kush typically—i know at the dispensary, it's usually somewhere between 15 and 17 bucks a gram, but for og kush or purple urkle, it's up to 27, 30 bucks a gram. it gets kind of excessive, especially in the medical marijuana market. 5 it's really all just weight, and then i think if somebody's trying to make more money off of shitty weed, then they'll just sell you shitty weed for the same price. 11 it's really expensive in massachusetts. i'm from there, and when i was living there, i was paying 55 an eighth of good bud. …i get medical grade. if i buy an ounce for 220, which if i buy an eighth, it's 40, so it's worth spending the extra money 12 it's more the quality of it….if i'm goin' in on a bulk of some sort, then yeah. but, you see who's tryin' to get it. they'll pool in some money. 13 our dealer’s straight out of the pineapple express and really wants to be friends with us. and he tries to have us watch tv with him and shit.…but it’s cool cuz he really likes us, so i notice that we’ve been kinda getting more for a better price. 15 i would say that like what he said, when i was back home, i was buying dimes and dubs cuz eighths were $50.00, but now that i’m here, i can get eighths for 35, and then that’ll be cool with me. 16 it’s always cheaper, the more you buy. 17 sometimes for some dealers it might be the strain. 18 i know it depends on the area, too. 19 and the only thing that’s changed is the fact that you can get it medically for that cheap, and that so many people have been able to obtain medical cards, grow it out of their own home, so then you call all these assholes out of the middle. and…the supply and demand [sic] completely changes at that point. just because there’s way more supply of it now, so the demand stays the same. but since the supply goes up it lowers the cost cuz you can get it from anywhere and everywhere….so that’s why it’s completely changed in the last couple of years, is because of that reason. the demand is always going to be the same-same demand, i mean you can change that a little bit by changing the supply. because if there’s not as much with it, like before when it was a criminal offense and it wasn’t medical and the other thing, the supply was always the same, but the risk was larger also, you know?...so the thing is you’re not like i need to make $200.00 extra on this thing to go and try to spend, to save it for if i end up going to prison or something like that…like there’s all sorts of different underlying factors that would change the price. for instance, like cocaine, it’s not more expensive because of what it is, it’s more expensive because of the amount of felonies you get from it. 22 obviously if you need to buy more you’re gonna get a little better price. 27 if you can buy over an ounce you’re getting some good prices. cannabis, a publication of the research society on marijuana 37 sub-theme id # quote 28 prices in general have gone way down in just the last two years….i think we’ve gotten a lot better about medical marijuana here, it was decriminalized here in 2013…so after it got decriminalized, everything went way down. 32 i feel like those prices would be if you know the person. effects of price increase 11 it's really expensive in massachusetts. i'm from there, and when i was living there, i was paying 55 an eighth of good bud. and out here, so i used to drive to—my friend lives in [redacted location]. i used to drive to [redacted location], go get my weed, and then go home. 16 you’re not paying any more…then i can go down the road and pay 40 here— 28 before, it was 50 [for an] eighth. now, if you’re charging 40 an eighth, people will laugh in your face and walk away. theme: contextual factors affecting cannabis purchasing behaviors quality of cannabis 4 if i find exceptional weed—, i don't typically buy weed, but i actually bought weed today just because it was really good weed, so i was like i'll buy some weed. so i bought an ounce of that, but that'll last me a while….if you go to a dispensary, if they have some betty kush or something, something made up by some dude, and then they have og kush typically—i know at the dispensary, it's usually somewhere between 15 and 17 bucks a gram, but for og kush or purple urkle, it's up to 27, 30 bucks a gram. it gets kind of excessive, especially in the medical marijuana market. 17 it’s usually if it’s something that they’re like this is some bomb shit and i have to up the price a little bit. but it never varies a lot. it’s usually every once in a while, it’s something really, really great. 22 the only time i buy more than once a week [is] if someone calls or i know they might have something special, i might try them for a sample—to see how it smokes. maybe i’ll pick up something during the week and just take a couple puffs of it, and then decide if i wanna buy it when i make my major purchase at the end of the week. all right, you got that same stuff? let me sample out and i’ll buy a quarter or a half ounce or something like that.…that usually tides me over. quarter if it’s good stuff, a half—a half if it’s midgrade stuff. 28 [price differences are] usually, not by strain. usually by quality.…so if you want super-dank shit, then that’ll run you 250, maybe even 300 an ounce, if they’re gouging you. but the best dude that i have charges 240 an ounce for his premium top-quality shit. convenience/availability 4 i want to get a 20 bag. i might buy a 20 bag, but usually, i'll purchase in bulk just for cost's sake and convenience, really. 6 420 birthdays 16 the kid that—the kid i get it from lives close with me, so i don’t have to worry about going to get it, driving to go get it or this or that. so, probably four times a week. 17 well, currently as of right now, i know somebody who i can get medical for free right now, pretty much. 18 yeah, for me i used to at least buy at least two grams a week. but that’s when i lived with my friends, and i was doing that for six years. and i recently just moved back with my mom, so now i really don’t buy weed. and if i smoke it’s if i’m down in [redacted location] where people have it. 21 if someone offers you a gift, you’re gonna take it. for sure 22 where you gonna keep it? 24 well, me and my roommate, we split it, so…four times a week we smoke. so i just give him—sometimes i give him $10.00 a day, twice, but then maybe 15. 26 so i’m not really purchasing, but i’m using from other people….yeah, when i’m at a festival or maybe something else and it’s offered to me from other people who already have…so i’m not really purchasing, but i’m using from other people. 28 if they have multiples, then, yeah, i’ll usually get half of one, half of the other, and if i’m buying in bulk, it’s gotta be good. i gotta know what i’m getting. i gotta know that it’s gonna be worth the buy. whereas, if i’m just grabbing a 20 off of someone, as long as it’s not dirt weed, it’s like i’m only out 20 bucks. 31 so if we’re going to an event— usually that’s where we’re on edibles or something. something that you won’t have to worry about, and then it’ll take effects later….it depends on what’s available. it’s depending on who i go to. some—one of my friends will get—like if i can get three or four different types at the same time, depending on what she has, and then i have another friend. it just depends on what it is in the cycle, so sometimes, if he, certain points have already—that he’s just cultivated that week, if he only has one strain, i’ll get an ounce of the one strain, but if he’s got a couple of different, i’ll get different— legal concerns 4 as long as you have less than 1,000 grams on you in rhode island, you're not going to jail. you're just paying fines. so—and if you have any weed at all, you're paying at least $150.00 if you get pulled over. so, i think the most you'll pay is $1,400.00 in fines or something, and that's if you have 999 grams, which is a ton of weed 50 ounces of weed or something like that. that's not right, but an excessive amount of weed. no one needs that much weed unless they're selling that much weed. 6 it's almost legal everywhere. 7 not really [a concern], to be honest. every time i get pulled over by a cop with weed, they—they don't really give me a hard time, you know? if it's a quarter, even a half, they don't really give me a hard time. just tell me to go home. that's it. 10 [cops] are not really out for the potheads anymore. 11 drinking is worse….[cops] are not as bad as they were. it's just certain people [cops] wanna get. that's it. 14 i think of weed different. i smoked so long i just—i forget it's illegal sometimes. i really do. i always have it on me. i don't really hide it. i mean, it's near me. if i get pulled over, i'll try to do somethin' with it, but— …like someone said earlier, the cops really don't even care. i think i've gotten pulled over and actually caught with weed three times—by state troopers, though—and they've let me go every time, so it's not really that big of a deal. 22 that’s that thin gray line between casual user and distributor. cannabis purchasing behaviors 38 purchasing routines for cannabis without mcc participants were asked about the frequency and schedule with which they habitually purchased cannabis, the amount (i.e., unit) of purchase, and how purchasing decisions (e.g., amount purchased) may have affected cannabis use. purchasing frequency. most participants reported purchasing cannabis on at least a weekly basis, whereas only one participant reported purchasing cannabis “about once a month” (#26, m, 28) and another described how they will “try to go as long as possible without smoking” (#18, m, 24) when they run out of cannabis, colloquially known as a tolerance check. many reported that they purchased cannabis daily or several times a week, with a handful of participants each reporting buying it “every day” (#7, 11, 27), “every few days” (#10, 14, 33), or “a couple of times a week” (#1, 30, 32). purchasing schedule. participants indicated that they generally do not plan or have “a particular schedule” (#18, m, 24) for purchasing cannabis, but still described their purchasing behavior as “pretty regular” (#21, m, 21). one participant reported being “pretty set in my ways” (#22, m, 41). participants also reported that their decision regarding when to buy cannabis was generally prompted by “how much [they] have left” (#17, f, 20), or “when [they] run out” (#4, m, 19). amount per purchase. most participants reported buying a consistent amount per purchase (i.e., usually buying the same amount). however, there was still considerable variability in the amount per purchase between participants. some participants reported buying a “20 sack” (#16, m, 29), which is equivalent to 1/16 ounce of cannabis, about 1.75 grams, whereas others reported buying up to half-ounce or “an ounce at a time” (#29, f, 38). many others reported buying an eighth or a quarter, with one participant noting that they buy “a quarter ounce”, but “i’d say the eighth is probably the most popular thing [sic], the most goto” (#10, m, 18) amount per purchase. notably, participants relayed how the amount of cannabis purchased influenced their use, with one saying, “when i buy bigger amounts, i find that i smoke more” (#17, f, 20). economic factors affecting cannabis purchasing behaviors participants were queried about economic factors that are perceived to affect their purchase of cannabis, including individuals’ financial circumstances, how they handled price increases, and strategies they used to save money. finances / cost. participants consistently reported the importance of their financial circumstances, noting that the quantity of cannabis they purchased depended on “how much money i have” (#4, 5, 6, 27). the general sentiment was captured by participant #14 (m, 35), who reported “if i had unlimited money, i could probably do…a comfortable thing would be… an eighth every day. a little more. but…right now i'm…an eighth every other day. you know? so every two days i'll probably get an eighth.” (#14, m, 35). there was a wide range in the dollar amount participants paid for cannabis, with one participant saying: “well… lately, i haven’t had a lotta money, so i’ve been buying… just like a 20 sack to get me through the day. but usually, when my boyfriend and i are both working, we buy… a quarter or… more a week” (#11, f, 36). on the other hand, others reported spending considerably more, “between, like two and $700” (#4, m, 19). in contrast, participants reported comparable prices for how much they paid per unit of their cannabis purchases, indicating consistent pricing. participants reported purchasing cannabis for “$15 for a gram, $40 on an eighth, and $20 for like 1.8” grams (#11, f, 36), with one participant noting that “$20 would be the average” (#21, m, 21) amount of money they spent per purchase factors affecting cost. participants were queried about factors that affected the cost of (i.e., how much they are willing to spend on) cannabis purchases. factors related to cost included cannabis quality and strain (i.e., better quality cannabis costs more). others reported it largely depends on the quantity purchased, reporting “it’s really all just weight” (#5, f, 25). participants also described how they saved money when buying cannabis, with one capturing the groups’ sentiments as, “it’s always cheaper, the more you buy” (#16, m, 29). participants also reported that if “i’m going in on a bulk of some sort…[we] will pool in some money” (#12, m, 29). cannabis, a publication of the research society on marijuana 39 some participants reported that the relationship with their dealer influenced price and indicated that it may cost less “if you know the person” (#32, m, 20). a few participants also noted that cannabis “prices in general have gone way down in like just the last two years…there’s more of it. i think we’ve gotten…a lot better about medical marijuana here, and…after it got decriminalized, everything went way down” (#28, m, 21). effects of price increases. participants said if prices are much more than expected, “people will laugh in your face and walk away” (#28, m, 21) because “it’s just like you’re not paying any more…you know then i can go down the road…and pay $40 here” (#16, m, 29). indeed, some participants explained how cannabis used to be “really expensive” in areas where they resided, “so i used to drive to [redacted location far from residence], go get my weed, and then go home” (#11, f, 36). contextual factors influencing cannabis purchasing behaviors participants said if prices are much more than expected, “people will laugh in your face and walk away” (#28, m, 21) because “it’s just like you’re not paying any more…you know then i can go down the road…and pay $40 here” (#16, m, 29). indeed, some participants explained how cannabis used to be “really expensive” in areas where they resided, “so i used to drive to [redacted location far from residence], go get my weed, and then go home” (#11, f, 36). quality of cannabis. similar to factors perceived to affect the cost of cannabis, participants noted the importance of cannabis quality in their purchasing decisions and indicated that they were more likely to purchase cannabis that was perceived to be of better quality. one participant reported “i don’t typically buy weed, but i actually bought weed today just because…it was really good weed, so i was like, yeah i’ll buy some weed. so i bought an ounce of that, but…that’ll last me a while” (#4, m, 19). another said, “the only time i buy more than once a week [is] if someone calls or i know they might have something special, i might…try them for like a sample to see how it smokes...then decide if i wanna buy it when i make my major purchase at the end of the week…and i’ll buy…a quarter if it’s good stuff, and [an eighth] if it’s like midgrade stuff.” (#22, m, 41). convenience/availability. participants discussed the importance of easy access to cannabis in their purchasing decisions. participants who resided near their supplier (i.e., had convenient access) reported purchasing cannabis frequently, noting “the kid i get it from lives…close with me, so i don’t have to worry about going to get it, driving to go get it, or this or that. so probably like four times a week” (#16, m, 29). availability of free cannabis and types of cannabis were also perceived as important factors. one participant (#21, m, 21) described free cannabis as gifts, saying “if someone offers you a gift, you are gonna take it. for sure” with another participant noting “that’s pot culture right there” (#22, m, 41). participants indicated that they would purchase more cannabis if it were readily available from others. participants also described obtaining and using cannabis from other people and “not really purchasing” (#26, m, 28) when at festivals or other events where cannabis is more readily available. participant #17 (f, 20) also reported getting their cannabis from “somebody who can get medical for free right now.” participants also reported buying different amounts of cannabis if their supplier had multiple types of cannabis available, with participant 28 (m, 21) reporting “if they have multiples [sic] [kinds of cannabis], then yeah, i’ll usually get like half of one, half of the other.” other factors that were brought up by a few participants included individuals’ living situations and special occasions. one participant said they purchased more when living with roommates/friends, compared to parents, reporting, “i used to buy…at least two grams a week, but…i recently just moved back with my mom, so now i really don’t buy weed (#18, m, 24).” others reported purchasing cannabis if they are “going to a concert” (#4, m, 19) and for “420 [and] birthdays” (#6, m, 25). legal concerns. as noted, use of cannabis without mcc was decriminalized, but still considered illegal, at the time focus groups were conducted. nevertheless, participants reported minimal concerns regarding legal consequences from their purchase and possession of cannabis, reporting that they perceived cannabis “is almost legal everywhere” (#6, m, 25) and another cannabis purchasing behaviors 40 reporting that “as long as you have less than [an excessive amount of weed] on you in rhode island, you’re not going to jail. you’re just paying fines (#4, m, 19).” participants also characterized their experiences with law enforcement as “not really [a concern], to be honest. every time i get pulled over by a cop with weed, they don’t really give me a hard time….just tell me to, you know, go home. that’s it” (#7, m, 18). others observed that “[cops] are not really out for the potheads anymore” (#10, m, 18) and that “[cops] are not as bad as they were. it’s just certain people [cops] wanna get. that’s it (#11, f, 36)”. discussion the current study used qualitative focus group data to assess cannabis purchasing behaviors among individuals who frequently used cannabis without mcc. the rapid expansion of the cannabis industry necessitates a better understanding of consumers’ purchasing behaviors given ongoing legislation decriminalizing and permitting cannabis use without mcc. specifically, identifying common factors perceived to influence purchasing and use behaviors can inform future cannabis prevention, intervention, and policy decisions. in the present study, participants’ cannabis purchasing and use behaviors were perceived to be influenced by economic factors and the larger environmental and social context. participants reported relatively consistent purchasing routines despite not having set schedules. participants also reported a consistent price structure when purchasing cannabis (e.g., $15/gram), but they expressed a willingness to pay more when it was perceived to be of higher quality. this finding is consistent with results from a recent systematic review (donnan et al., 2022) and other behavioral economic research demonstrating that individuals allocate more hypothetical monetary resources for higher (versus lower) quality cannabis when both are available (amlung et al., 2019; amlung & mackillop, 2018; vincent et al., 2017). likewise, recent research indicated that adolescents and young adults perceived cannabis obtained from legal (versus illegal) markets to be of higher quality, and safer to use and purchase (amlung et al., 2019; fataar et al., 2021). indeed, cannabis obtained illegally (i.e., not purchased from legal cannabis dispensaries) has been shown to contain harmful contaminants such as pesticides and mycotoxins (stempfer et al., 2021). thus, enacting policies that seek to regulate, rather than punish, cannabis markets and implement quality and safety standards may appeal to consumers and reduce the sale and use of illegal cannabis. alternatively, informational campaigns that emphasize safety standards and convey the quality of legal cannabis products relative to alternative, illegal ones may also affect purchasing behaviors and diminish the illegal marketplace. regarding economic factors, participants reported, as expected, that their financial circumstances dictated much of their purchasing behaviors. participants also explained how bulk purchasing decreased the unit cost, which parallels traditional patterns of consumer demand for other commodities (e.g., alcohol, tobacco; bray et al., 2009; golden et al., 2016). notably, participants also reported that when they purchased more cannabis than normal, they tended to increase their use as well, also mirroring patterns observed with alcohol and tobacco (bray et al., 2009; golden et al., 2016). a better understanding of germane factors that affect purchasing behaviors may also help identify who is at elevated risk for negative outcomes. as noted, legalization of recreational cannabis use leads to increased frequency of cannabis use (zellers et al., 2023), and heavy cannabis use increases risk for cannabis use disorder (cud) (cerdá et al., 2020). thus, it is important to ascertain whether bulk purchasing facilitates the types of heavier use patterns that lead to the development of cud or increased severity of cud symptoms. equally important, future research should attempt to identify factors specifically related to bulk purchasing. one study found that older individuals and those who received a budtender’s recommendation for anxiety and/or sleeping problems (relative to recommendations for chronic pain) spent more money on products in a medical cannabis dispensary setting (kepple et al., 2016). moving forward, an important public health consideration will be to engage a wide-range of stakeholders (e.g., clinicians, public health agencies, law enforcement, community members, etc.) to ensure that policies concerning recreational cannabis use minimize cannabis initiation, particularly among vulnerable individuals, and prevent more frequent, and higher-risk use patterns. policy efforts could include strategies to regulate bulk purchasing and discounting among cannabis, a publication of the research society on marijuana 41 licensed cannabis purveyors. particularly at retail outlets, the effectiveness of price policies such as limiting bulk discounting, and discounting in general, is supported by empirical evidence from federal and state-level tobacco control efforts (tobacco control legal consortium, 2018). the maximum purchase amount allowed per customer varies across states with legal access to cannabis, and there is a need to evaluate how maximum purchase amounts, or policies that limit bulk discounts, may influence consumer purchasing and use patterns (pacula et al., 2021). certain states (e.g., colorado) have already started implementing such measures to limit purchases up to 28 grams of flower (one ounce) in a single transaction, however enforcement of these measures varies. policy changes related to purchasing high quantities of thc, such as additional taxes on high thccontent cannabis products, may be considered to reduce public health risks. further research is needed before considering full policy implications of such efforts and current results. yet, current results indicate that it is important to consider factors that may encourage bulk purchasing (e.g., budtender recommendations) that may facilitate increased use. for instance, policies may address the amount and type of information budtenders are able to share with customers at medical dispensaries or on reputable websites. greater legalization will also enable public health efforts to enhance the public’s awareness and knowledge of evidence-based decision making (e.g., educational campaigns). on the other hand, strategies from other commodity purchasing environments (e.g., food cafeterias, grocery stores) may be adapted to promote healthier cannabis use choices (i.e., choice architecture; thorndike et al., 2019; walmsley et al., 2018). especially in the context of cannabis dispensaries, future research should examine how product placement, pricing, and labeling influences cannabis purchasing behaviors and the extent to which these factors can be leveraged to reduce patterns of behavior associated with harmful outcomes. regarding contextual factors, cannabis was decriminalized in rhode island and massachusetts in 2013 and 2008, respectively. participants in the current study universally reported being unconcerned about potential legal consequences involving cannabis. this finding replicates earlier, nationally representative data suggesting that the perceptions of serious legal consequences from using and possessing cannabis have declined over time (azofeifa et al., 2016). as legislation continues towards widespread decriminalization, decreased criminal penalties, and expanded record clearing for lower-level cannabis offenses in the u.s. (national conference of state legislators., 2022), cannabis use or possession without mcc remains federally illegal and repercussions still exist in many regions. this is important given that perceptions of laws governing cannabis use are related to actual cannabis use (amonini & donovan, 2006). in context, these findings point to the need for geographically tailored public policy interventions that provide timely and accurate information about the legal environment for cannabis use and possession, as well as cannabis’ potential therapeutic benefits and negative health consequences. cannabis policy and legislation has thus far largely focused on its sale, possession, cultivation, distribution, and purchase, including setting limits and punishments for possessing different amounts of cannabis, creating guidelines on who can grow cannabis, and where sales can take place. although cannabis legalization advances important social justice goals (hajizadeh, 2016), much remains to be done to address racial disparities in cannabis use outcomes, such as experiencing cannabis-related negative consequences and involvement with the criminal legal system. these racial disparities persist despite marginal differences in rates of use and neighborhood police presence (mitchell & caudy, 2015, 2017). one potential driver of such disparities may be purchasing behaviors. for example, using data from the national survey on drug use and health (nsduh), ramchand and colleagues (2006) found that black/african americans were significantly more likely to buy cannabis outdoors, to buy from a stranger, and to buy away from their homes – purchasing behaviors that significantly increased black/african american individuals’ likelihood of arrest by 2-3 times. characterizing purchasing behaviors of persons who use cannabis without mcc, as we have sought to do in the current investigation, may be a first step in identifying potential explanations for disparities in rates of experiencing certain cannabis-related negative legal consequences. the current study has limitations. focus groups were conducted, in part, to inform a larger study involving laboratory cannabis administration, and thus excluded adults over 50 cannabis purchasing behaviors 42 years of age due to potential cardiovascular risks from smoking cannabis and individuals with a diagnosis of affective, psychosis, or panic disorders. prevalence of cannabis use among middle-aged and older adults has increased (han & palamar, 2020), and depression and anxiety are some of the most common reasons for cannabis use (kosiba et al., 2019). thus, future research should examine purchasing behaviors of older adults and individuals with mental health conditions. participants reported, on average, using cannabis five days a week. purchasing behaviors may vary among those with different use patterns (e.g., monthly users). further, given that focus groups were conducted when purchasing cannabis without mcc was not legally permitted, implications for cannabis purchasing behaviors in other contexts may be limited. although legality of recreational cannabis use is increasing, these data are still informative as cannabis without mcc is still not legal in much of the u.s. moreover, although greater details characterizing participants’ own purchasing behaviors would have been ideal, care was taken to limit specificity of cannabis purchasing behaviors to protect confidentiality of potential suppliers. given the context of where and when the focus groups were conducted (i.e., in rhode island between 2015 and 2016, when cannabis use without mcc was decriminalized), primary source of cannabis purchases were nonmedical sources. other sources of cannabis without mcc likely included growing cannabis, receiving cannabis for free (i.e., gift), traveling to other places where cannabis purchasing without mcc was licit, or buying cannabis online. further, because participants primarily used flower cannabis, much of the focus group discussions were on purchasing flower cannabis. as noted, at the time when focus groups were conducted in rhode island, it was difficult for people without mcc to purchase other kinds of cannabis (e.g., edibles) easily. as legalization of recreational cannabis purchases increases, future research will be able to address such limitations, and more fully characterize participants’ cannabis purchasing and use behaviors, including potential differences by type of cannabis formulation (e.g., flower, non-flower). moreover, data for the current study were collected prior to the covid-19 pandemic. thus, it is unclear whether prepandemic purchasing behaviors generalize to purchasing behaviors after the onset of the pandemic as direct-to-consumer delivery services for cannabis have increased exponentially (fertig et al., 2020; opp & mosier, 2020). additional research is also needed that explores how purchasing behaviors may differ based on sociodemographic characteristics (e.g., race/ethnicity, having a medical cannabis card) or environmental contexts (e.g., states with permissive/restrictive cannabis laws). lastly, although beyond the scope of the current investigation, contextual factors may also interact with other correlates of substance use outcomes, including individual level factors (e.g., impulsivity) (jensen et al., 2017; ray et al., 2016) and community level (e.g., networks) (hyshka, 2013) social determinants of health – important areas for future research. taken together, findings from this study indicate that consumers believe several economic and contextual factors influence how they purchase cannabis. accordingly, policymakers and public health agencies should invest in public education campaigns about the legal and health impacts of cannabis use, and implement policies that deter purchasing behaviors that facilitate greater consumption (e.g., through limits on bulk purchasing and bulk discounts). further, enacting better policies that regulate the sale, manufacturing, and marketing of cannabis used without mcc and that establish quality and safety standards may appeal to consumers and shift their purchasing behaviors away from illicit cannabis markets. references amlung, m., & mackillop, j. 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(2023). impacts of recreational cannabis legalization on cannabis use: a longitudinal discordant twin study. addiction, 118(1), 110–118. https://doi.org/10.1111/add.16016 funding and acknowledgements: funding for this research was supported by grants k01da039311 (aston), nigms cobre p20gm130414 (aston), f31aa028751 (gebru), t32aa007459 (berey, gebru), t32da016184 (snell), and r01aa024091 (metrik), along with the state of florida and the mary lane endowed professorship. all funding sources had no other role in study design or manuscript preparation other than financial support. conflict of interest statement: all authors list no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i3a4_authors_v3 research article 36 abstract introduction. in the united states, 19 states permit recreational use of cannabis, with 16 more permitting medical use (marijuana policy project, 2021). concerns remain about whether liberalized policies result in increased adolescent cannabis use. to date, limited evidence exists that the statewide prevalence of adolescent cannabis use increased in states with liberalized policies. however, analyses at local levels show some negative impacts. thus, we analyzed if living in a zip code with a dispensary (zcwd) was associated with adolescent cannabis use. methods. dispensary zip codes from public records were matched to selfreported zip codes on the illinois youth survey (iys). we compared past 30-day and past-year cannabis use among youth living in a zcwd and not living in a zcwd. results. about one in eight adolescents (12.8%, n = 1,348) in the weighted sample (n=10,569) resided in a zcwd. overall, past 30-day use was lower among youth who lived in zip codes with dispensaries (or = .69, p < .05), with variation by grade. for example, only 10th (or = .62, p < .05) and 12th graders (or = .59, p < .05) living in a zcwd had lower odds of past 30-day cannabis use. additionally, only 12th graders in a zcwd had lower odds of past-year use (or = .70, p < .05). finally, suburban youth living in a zcwd also had lower odds of cannabis use (or = .54, p < .01). conclusion/discussion. cannabis use was significantly lower among 10th and 12th graders living in a zcwd. additional research should continue to monitor evolving state policies and whether they are associated with adolescent cannabis use. key words: = adolescent; cannabis; marijuana dispensaries; epidemiology adolescent cannabis use represents a significant health issue, especially when highfrequency use (e.g., daily or multiple times per week) evolves into chronic use. associated physiological and behavioral effects that adversely affect health outcomes include impaired short-term memory, motor coordination, and judgement (volkow et al., 2014). chronic, frequent use also increases the risk for deviant and risky behaviors, such as driving under the influence, unprotected sex, poor educational attainment, mental illness, and addiction (moss et al., 2019). these behaviors have severe individual and community consequences, including poorer health outcomes, involvement with the criminal justice system, and economic impacts. given the behavioral sequelae of adolescents’ heavy cannabis use, there is substantial interest in monitoring whether teen cannabis use increases due to its increasing legality. nationally, however, there have not been major shifts in adolescent cannabis use in the united states despite a number of states adopting liberalized policies. among adolescents aged 12 to 17, the percentage of past-year cannabis users decreased from 15.8% (or 3.9 million people) in 2002 to 13.2% (or 3.3 million people) in 2019. the 2019 estimate was lower than that for 2002-2004, but was similar to years 2005-2018. approximately 1.4 million people initiated cannabis use in the past year, comparable to estimates from 2002-2018 (nsduh, 2020). on average, about 3,700 douglas c. smith1, shahana begum1, allison a. carrington1, corey c. campbell1, shaneil e. taylor1, crystal a. reinhart1, james a. swartz2 1university of illinois urbana-champaign, school of social work 2university of illinois chicago cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.004 adolescent cannabis use among youth in zip codes with medical dispensaries corresponding author: douglas c. smith, ph.d., university of illinois urbana-champaign, 1010 w. nevada st., urbana, il 61801, office 2119. phone: (217) 333-5308. email: smithdc@illinois.edu cannabis, a publication of the research society on marijuana 37 adolescents per day initiated cannabis use for the first time in 2019. among adolescents in illinois, the location of this study, past-month and past-year cannabis use among 8th, 10th, and 12th graders held steady from 2012 to 2018 (see figure 1). why dispensary proliferation may impact adolescent substance use two potential drivers of adolescent substance use are ease of access and perceived harmfulness. it is plausible that living in zip codes with medical cannabis dispensaries (zcwd) influences these two drivers. ease of access. access to cannabis may increase due to an elevated supply once dispensaries open. cannabis has been accessible to high school students since the 1970s, with 8090% of 12th graders reporting that cannabis was fairly easy or very easy to access (johnston et al., 2010). younger adolescents have less access to cannabis, with only 40% of 8th graders responding that it is fairly easy or very easy to obtain. with the passing of medical and recreational cannabis laws (mmls and rmls, respectively), adolescent access may actually decline due to difficulties obtaining cannabis through dispensaries instead of drug dealers. that is, if legalized and regulated, it may be riskier to sell to adolescents (anderson & rees, 2014). thus, the presence of a legal market could plausibly increase or decrease supplies to adolescents. adolescents may have more access to illicit markets, which have no age restrictions on purchases. conversely, if excess competition from dispensaries decreases the size of the illicit market, adolescents may ultimately have less access. ease of access could also increase due to diversion of cannabis purchased by adults at dispensaries. regarding diversion, adolescents obtain cannabis from dispensaries, dealers, friends, family members, and strangers (reed et al., 2020). king and colleagues (2016) found that 59% of adolescents obtained cannabis free of charge, whereas 39% purchased cannabis. whether they paid for it or not, most adolescents receive cannabis from friends (king et al., 2016). existing self-report measures do not capture diversion from dispensaries very well. notably, however, kelleghan and colleagues (2022) found that adolescents who purchased cannabis from family members, friends, or a medical dispensary exhibited a higher frequency of use. therefore, it is important to determine whether mmls increase diversion, and in turn, increase adolescents’ use of cannabis. perceived harm. the presence of dispensaries may also lower perceived harmfulness of cannabis among adolescents. monitoring trends in perceived harmfulness is important, as it is negatively associated with adolescent cannabis use (bachman et al., 1998; johnston, o’malley et al., 2010). however, keyes and colleagues (2016) showed that perceived harmfulness increased and cannabis use decreased after the passage of mmls. perceived harmfulness generally declined with the passage of mmls among older adolescents. among states with recreational cannabis laws, cerdá and colleagues (2017) found that 8th and 10th graders in the state of washington had decreased levels of perceived harmfulness and increased use after the passage of rmls. however, findings did not replicate in colorado, another early adopter of legalized recreational use. cannabis outlet density and adolescent use alcohol and tobacco retail outlet density, as well as residential proximity to outlets, are positively associated with the initiation of use of these substances, heavier and more problematic use, and more difficulty quitting (cantrell et al., 2016; chen et al., 2009; kuntsche et al., 2008; pacula et al., 2014; reitzel et al., 2011; scribner et al., 2000). similar relationships emerged in the early cannabis policy literature, although the results are mixed. mair and colleagues (2015) found positive associations between medical dispensary density and cannabis hospitalizations, as well as poorer health outcomes among disadvantaged communities. more medical cannabis dispensaries per square mile also predicted more frequent cannabis use (freisthler & gruenewald, 2014) and higher cannabis use disorder (cud)-related hospitalizations (mair et al., 2015). last, a greater number of medical dispensaries per capita predicted early onset cannabis use, vaping, and the use of edible products (borodovsky et al., 2016; borodovsky et al., 2017). medical dispensaries and adolescent cannabis use 38 figure 1. prevalence of adolescent cannabis use in illinois: 2012-2018 source (illinois youth survey 2012-2018) note. 2018 prevalence differs from analytic sample due to missing zip code data. another study showed that intentions to use did not increase in areas with higher medical cannabis dispensary density, but results differed among racial/ethnic groups (shih et al., 2021.) specifically, only whites and asians had higher intentions to use if living in proximity to more medical dispensaries. a slightly different picture emerged for recreational outlets. that is, pedersen and colleagues (2020) found recreational dispensary density in la county to be positively associated with intentions to use, any use, and heavy use of cannabis. however, these studies are limited to the california context and focus on young adults rather than adolescents. young adults and adolescents are distinct populations known to differ on motivation to change (smith et al., 2010) and treatment outcomes (smith, et al., 2011). density versus living in a zip code with a dispensary (zcwd). studies on density are useful for capturing changes in adolescent use once extensive dispensary proliferation has occurred. in this study, however, we measure the effect of living in a zip code with a medical dispensary (zcwd) prior to the existence of a large legal market. this allows for understanding the effects of early implementation of mml, after dispensaries were operational yet prior to an extensive network of dispensaries forming. by using zip codes we obtain more precise estimates of adolescent cannabis use at the local (vs. state) level. this is important because state-level estimates may not capture local differences in prevalence possibly attributable to living in a zcwd. mmls and adolescent cannabis use several statewide and national surveys have measured cannabis use among adolescents both preand post-passage of mmls and rmls. additional research is needed due to variation in policies across the states (cambron et al., 2017). although cannabis use is higher among adolescents in mml states, the risk for using does not appear to increase after the passage of mmls (hasin et al., 2015). sarvet and colleagues (2018) conducted a meta-analysis to assess the effect of mmls on past-month adolescent cannabis use, finding no significant changes compared to nonmml states. in fact, four of the 11 studies 21.6% 20.0% 21.8% 20.9% 14.7% 13.4% 14.8% 14.4% 0% 5% 10% 15% 20% 25% 30% 2011 2012 2013 2014 2015 2016 2017 2018 cannabis use in illinois past year cannabis use past 30-days cannabis use licenses issued cannabis, a publication of the research society on marijuana 39 included found higher rates of past-month use in mml states prior to passage. this is consistent with other studies (wall et al., 2011; lynnelandsman et al., 2013; martins et al., 2016). also, choo and colleagues (2014) paired mml states in the northeastern us with neighboring non-mml states and found no increase in use. finally, states with mmls have more treatment admissions for youth cannabis use compared to medical cannabis states that do not legally protect dispensaries (pacuel et al., 2015). to our knowledge, no existing study has focused exclusively on a midwestern state in the united states that has implemented an mml. purpose of study because of the changing policy landscape, additional research should shed light on whether living in a zcwd influences adolescent cannabis use. much of the early research on cannabis outlet density is from california and other western states. thus, this study in a midwestern state could yield insights into the associations between living in a zcwd and adolescent cannabis use earlier on in the process of dispensary proliferation. such data could increase the generalizability of the findings on whether living in a zcwd influences adolescent cannabis use. methods survey data and sampling procedure this study used data from the 2018 illinois youth survey (iys), a self-report biennial survey administered to adolescents in 8th, 10th, and 12th grades. survey questions asked about a variety of health and social issues. while all schools can voluntarily participate, the survey contractor (the center for prevention research and development) generates a random sample for each administration. in 2018, all public schools with at least 16 students in 8th, 10th, and 12th grades were included in the sampling frame. the iys uses a stratified two-stage cluster sampling design with selection based on probability proportional to grade level enrollment size (pps). first, schools were stratified by four regions and three grade levels. afterward, schools were selected within each region and grade using pps to ensure an adequately represented student population within each stratum. students were surveyed between january and june 2018. after receiving surveys back and validating data, 50 surveys were selected randomly from each participating school within each region and grade to finalize the cluster sampling design. the state sample is weighted to balance different probabilities of selection at each stage of sampling. additionally, the weighted sample accounts for student absenteeism, which is associated with substance use (gakh et al., 2020). thus, adolescents reporting more absences received larger weights. furthermore, a poststratification weight was assigned to adjust for any racial, gender, and socioeconomic differences between the sample and the sampling frame. the final sample included 11,259 surveys from 162 schools statewide. measures cannabis dispensary data. on august 1, 2013, illinois passed the compassionate use of medical cannabis act (pa 098-0122), legalizing the use of medical cannabis and allowing patients to apply for a medical cannabis registry card (illinois department of public health, 2021). illinois began approving licenses for medical cannabis dispensaries in august 2015. there were 20 licenses approved in 2015, 29 in 2016, four in 2017, and two approved through july in 2018. we obtained a list of dispensaries with their exact locations and license dates from the illinois department of public health. furthermore, we obtained sales data from the illinois department of professional regulation (idfpr) to determine when sales began. fifty-three of the approved dispensaries were operational in advance of the 2018 iys survey administration. the minimum length of operation prior to iys data collection was 6 months (range: 6 months to 3 years). at the time of this study, no zip code housed more than one dispensary. participant zip codes. participants’ selfreported zip codes served as a measure of living in a zcwd. we matched zip codes reported on the survey to those known to have an operational cannabis dispensary before the time of the study. if a participant’s zip code was the same as the zip code of a dispensary, they were coded as living in a “zcwd.” if there was not a match between the medical dispensaries and adolescent cannabis use 40 participant’s zip code and the dispensary zip codes, they were coded as “not living in a zcwd.” cannabis use. two questions on the iys measured cannabis use. one asked “on how many occasions (if any) have you used marijuana during the past 30 days?” the second was “in the past year, on how many occasions (if any) have you used marijuana?” response choices ranged from “0 occasions” to “20 or more occasions.” data were highly skewed toward “0 occasions.” thus, responses were dichotomized as “never used” or “ever used.” statistical analysis among 11,259 statewide surveys, 690 (6%) left their zip code blank. so, the analytic sample included 10,569 surveys containing 536 selfreported student zip codes. all analyses used the statistical software packages stata version 15 and spss v28. preliminary analyses. to examine adolescents’ characteristics across their zcwd status, χ2 tests of independence and univariate anovas were used (table 1). for continuous demographic variables, (i.e., age) we used adjusted wald tests (koch et al., 1975). we considered whether zip code size may influence participants’ awareness of dispensaries, and in turn, affect substance use. for example, students living in large zip codes may not be as aware of the presence of a dispensary. the average area within a zip code was approximately 32.54 square miles (sd =37.02). the average land area was smaller, albeit non-significantly, for zcwd (m = 23.77, sd = 39.49) relative to zip codes with no dispensaries (m = 33.26, sd = 36.77, p > .10). moreover, there was no significant correlation between zip code size and adolescent cannabis use in the past 30 days (p = -0.08) and past year (p = -0.05). main analyses. we used multivariate logistic regression to test if living in a zcwd was associated with adolescent cannabis use. we completed one analysis collapsed across all grades and regions (row 1 of table 3) and then ran separate models for each grade level and geographic region. these models controlled for gender, race, free/reduced lunch status, and zip code size. the exponential function of the regression coefficient is the odds ratio reported in table 3. odds ratios with values above one indicated higher odds of cannabis use, and conversely those lower than one indicated lower odds of use. results respondent characteristics table 1 displays adolescents’ characteristics in the final analytic sample by zcwd status. approximately one in eight of the participants (12.8%) lived in a zcwd (table 1). overall, more than half of the adolescents were white (53.4%) followed by latino/latina (16.9%). the majority of adolescents were from suburban chicago (46.8%), received free or reduced-price lunch (51.7%), and were female (51.4%). the average age of participants was 15.7. the sample had more 10th graders versus 8th or 12th graders. among the 12.8% of participants living in a zcwd, 49.7% were from suburban chicago, 31.8% were from chicago, 15% were from other urban areas, and 3.5% resided in rural areas (table 1). the majority self-identified as white (43%), followed by latino/latina (26%). there were more 8th graders (39.2%) and more females (50.5%) living in a zcwd. table 1 also shows demographic characteristics between respondents living in a zcwd and those not living in such zip codes. significantly more latinos (26%) and fewer whites (43%) lived in a zcwd versus a zip code without a dispensary. also, significantly more 8th graders and less 10th and 12th graders were living in a zcwd. finally, a significantly larger number of youth from chicago (31.8%) and a smaller number of youth from rural (3.5%) areas lived in a zcwd. overall, 15.2% reported cannabis use in the past 30 days, which was lower for youth living in a zcwd (12.0%) versus those outside of such zip codes (15.6%; see table 2). regarding past-year use, the overall prevalence was 21.9% in the total sample, and lower (18.3%) in zcwd versus those with no dispensaries (22.4%). table 2 also shows the typical age-related trend for cannabis use, where prevalence rates significantly increase as adolescents move from 8th grade to 12th grade (p < .001) independent of whether they live in a zcwd. finally, cannabis use prevalence was significantly higher in chicago compared to other geographic areas (p < .001). cannabis, a publication of the research society on marijuana 41 table 1. respondent characteristic in the statewide sample and among the proximity status variable sample living in a zcwd not living in a zcwd p n (%) n (%) n (%) all 10,569 1,348 (12.8%) 9,221 (87.2%) gender female 5,426 (51.4%) 680 (50.5%) 4,746 (51.6%) >.10 male 4,941 (46.8%) 635 (47.2%) 4,306 (46.8%) transgender 61 (0.58%) 11 (0.8%) 50 (0.5%) do not identify 121 (1.2%) 20 (1.5%) 101 (1.1%) race white 5,617 (53.4%) 579 (43.0%) 5,038 (54.6%) <.001 black/african american 1,271 (12.1%) 177 (13.1%) 1,094 (11.9%) latino/latina 1,785 (16.9%) 351 (26.0%) 1,434 (15.6%) asian american 543 (5.2%) 79 (5.9%) 464 (5.0%) any other 1,307 (12.4%) 160 (11.9%) 1,147 (12.4%) age (n, mean) 10,559 (15.7) 1,348 (15.4) 9,211 (15.7) >.10 grade 8th 3,234 (30.6%) 529 (39.2%) 2,705 (29.3%) <.001 10th 3,884 (36.7%) 439 (32.6%) 3,445 (37.4%) 12th 3,451 (32.6%) 380 (28.2%) 3,071 (33.3%) free/reduced lunch free lunch 4,707 (45%) 648 (48.6%) 4,059 (44.4%) >.10 reduced price lunch 704 (6.7%) 77 (5.8%) 627 (6.9%) neither 5,056 (48.3%) 608 (45.6%) 4,448 (48.7%) region suburban chicago 4,944 (46.8%) 670 (49.7%) 4,274 (46.4%) <.001 chicago 1,532 (14.5%) 429 (31.8%) 1,103 (12.0%) other urban 2,131 (20.2%) 202 (15.0%) 1,929 (20.9%) rural 1,962 (18.5%) 47 (3.5%) 1,915 (20.8%) note. zcwd – zip code with a medical dispensary table 2. past 30-day and past year cannabis use in the sample and by zip code status cannabis use sample n (%) living in a zcwd n (%) not living in a zcwd n (%) past 30-day use 1,561 (15.2%) 157 (12.0%) 1,404 (15.6%) grade level 8th grade 186 (5.5%)* 41 (6.6%) 146 (5.2%) 10th grade 478 (13.4%)* 42 (10.6%) 436 (13.7%) 12th grade 849 (25.7%)* 77 (20.1%) 772 (26.4%) geographic level suburban chicago 766 (13.5%) 68 (8.2%) 698 (14.4%) chicago 293 (20.9%)* 69 (17.7%) 225 (22.1%) other urban areas 322 (15.2%) 20 (12.4%) 302 (15.5%) rural areas 132 (11.8%) 3 (11.7%) 129 (11.8%) past year use 2,249 (21.9%) 239 (18.3%) 2,010 (22.4%) grade level 8th grade 292 (8.6%)* 58 (9.7%) 233 (8.4%) 10th grade 716 (19.9%)* 68 (16.9%) 648 (20.3%) 12th grade 1,172 (35.5%)* 119 (30.9%) 1,052 (36.1%) geographic level suburban chicago 1097 (19.4) 123 (15%) 975 (20.1%) chicago 402 (28.7%)* 94 (24.2%) 308 (30.3%) other urban areas 458 (21.9%) 25 (15.7%) 433 (22.4%) rural areas 222 (19.9%) 4 (16.1%) 218 (20%) note. zcwd-zip code with a medical dispensary. *p < .001 medical dispensaries and adolescent cannabis use 42 association between living in a zip code with a dispensary (zcwd) and cannabis use table 3 summarizes the logistic regression models, including sample sizes (n), adjusted odds ratio (or), 95% confidence interval (ci), and p values. overall, adolescents living in a zcwd had significantly lower odds of past-30-day cannabis use than those not living in one (or = 0.69, 95% ci: 0.51 – 0.95, p <.05). however, there were no significant differences in past-year cannabis use (or=0.79, 95% ci: 0.61 – 1.02, p > 0.10). because cannabis use increases with age and significantly varies between grade levels (p < .001), we ran additional models for each grade level (8th, 10th, and 12th). living in a zcwd was not associated with past-30-day cannabis use for 8th graders. however, 10th (or = 0.62, 95% ci: 0.39 – 0.96) and 12th graders (or = 0.59, 95% ci: 0.42 – 0.83, p < .05) living in a zcwd had significantly lower odds of past-30-day cannabis use. for past-year use, living in a zcwd was not associated with cannabis use for 8th and 10th graders. however, our analyses found significantly lower odds of past-year cannabis use among 12th graders living in a zcwd (or = 0.70, 95% ci: 0.51 – 0.98, p < .05). when considering geographic areas, suburban adolescents living in a zcwd had significantly lower cannabis use in the past month compared to those not living in proximity (or = 0.54, 95% ci: 0.38 to 0.78, p <.001). in other geographic regions, there were no differences in cannabis use based on living in a zcwd. discussion as cannabis policies evolve, it remains important to track trends in adolescent cannabis use. this study on living in a zcwd and adolescent cannabis use adds to the existing literature due to its careful timing within 3 years after medical cannabis dispensaries were operational. for example, prior national research on the association between cannabis use and mmls through 2014 (hasin et al., 2015) included illinois but before any of illinois’ dispensaries were operational. this study also showed the association of adolescent cannabis use and the presence of a dispensary at the zip code level, which may be more precise than taking a state average for cannabis prevalence, as done in national studies. consistent with the literature, cannabis use increased with age. however, adjusted models, collapsed across grade level, revealed lower odds of past-30-day cannabis use among those living in a zcwd. additionally, 10th and 12th graders living in a zcwd had significantly lower rates of past30-day cannabis use. these findings suggest that in 2018, when 53 dispensaries were selling cannabis for medical purposes, there was a negative association between living in a zip code with medical dispensaries and adolescent cannabis use. although we did not test moderators, it is possible that these findings reflect the already high level of access to cannabis use among 10th and 12th graders prior to the opening of medical dispensaries. as noted, one table 3. associations between living in a zip code with a medical dispensary (zcwd) and adolescent cannabis use variable past 30-day cannabis usea past year cannabis usea n aor (95% ci) n aor (95% ci) living in a zcwd 9,920 0.69 (0.51 0.95)* 9,900 0.79 (0.61 1.02) grade level 8th graders in a zcwd 3,043 1.11 (0.40 3.05) 3,021 1.05 (0.52 2.12) 10th graders in a zcwd 3,631 0.62 (0.39 0.96)* 3,633 0.73 (0.52 1.04) 12th graders in a zcwd 3,254 0.59 (0.42 0.83)* 3,253 0.70 (0.51 0.98)* geographic region in a zcwd /suburban chicago 4,655 0.54 (0.38 0.78)** 4,659 0.76 (0.56 1.04) in a zcwd /chicago 1,418 0.81 (0.46 1.41) 1,415 0.85 (0.52 1.38) in a zcwd /other urban 1,985 0.75 (0.46 1.23) 1,970 0.67 (0.39 1.14) in a zcwd /rural 1,870 0.71 (.24 – 2.09) 1,863 0.62 (0.14 – 2.65) note. aadjusted odds ratio. analyses controlled gender, race, free/reduced lunch, grade, region, and zip code size; zcwd: zip code with a medical dispensary. *p < .05, **p ≤ .001. cannabis, a publication of the research society on marijuana 43 robust annual trend is that 80-90% of 12th grade students in the monitoring the future study report that obtaining cannabis is fairly or very easy (johnston et al., 2010). thus, their already high access to cannabis may not have increased when medical dispensaries started operating in illinois. yet, we caution readers that this access could change once more dispensaries open, as this study’s findings apply specifically to the time when just over 50 medical dispensaries existed. these findings are similar to those reported in hasin et al. (2015). however, in our study we found significantly less use among 12th graders living in a zcwd. further, hasin and colleagues found that 8th graders in mml states had significantly lower use, and we found no significant differences in use between 8th graders who did or did not live in a zcwd. because early onset of cannabis use is associated with negative outcomes (lynskey et al., 2003), additional attention to trends in 8th grade cannabis use is recommended. it is likely that the number of dispensaries will continue to grow over time. illinois legalized the recreational use of cannabis in january 2020. thus, the associations reported in this study are from just a snapshot in time when there were 53 operational medical dispensaries and two that were approved but not operational. by contrast, there were approximately 900 dispensaries in los angeles county alone at the time of pedersen et al.’s (2020) study. this was due to the longer legacy of medical cannabis in california. future research in illinois may consider using sales data or density of dispensaries within zip codes as more dispensaries become operational. notwithstanding the challenges, tracking longitudinal trends in cannabis use and the proliferation of dispensaries is also important. regrettably, one research challenge with illinois data will be that the implementation of recreational use in illinois (january 2020) corresponded closely with the onset of the global covid-19 pandemic (march 2020). the pandemic likely affected both surveillance methodology and substance use trends. nationally, past-year cannabis use decreased among adolescents ages 12-17 from 13% in 2019 to 10% in 2020 (substance abuse and mental health services administration, 2021). however, the authors cautioned readers that 2020 estimates may be inaccurate due to pandemic year survey changes. similarly, our illinois youth survey (iys) was shortened in 2020, ceasing all surveying in march 2020. thus, the 2020 iys sample, although very large, was not representative of the youth in illinois. nevertheless, additional research should continue tracking trends over time after recreational policies have been implemented for several years. many states with recreational use implemented their policies within the past five years (marijuana policy project, 2021). so, findings from this and other studies on the associations between policy changes and adolescent cannabis use should be considered preliminary. this study’s findings should be interpreted in light of its strengths and weaknesses. regarding strengths, our study used a sample from a midwestern state, used local data with respondents’ zip codes, and confirmed policy implementation timing through license approval dates and sales data. however, the study was limited by its cross-sectional design, and it is unclear whether zip codes are adequate measures of actual proximity to dispensaries. for example, some youth may technically live outside dispensary zip codes, but may be in very close proximity to a dispensary, depending on their exact location. also, the analysis did not account for the nested structure of the data. in addition, few youth in rural areas in the iys lived in dispensary zip codes, affecting power for some analyses. finally, youth self-reported their cannabis use. future research recommendations we have three recommendations for future study. first, future studies should use longitudinal designs. second, whenever possible, it would be more accurate to use a proximity measure by using distance in miles or buffers rather than zip codes. finally, research could also track perceived harmfulness and types of cannabis consumption in illinois. this study only focused on cannabis use in general. however, it is reasonable to hypothesize that some forms of use, such as concentrates or edibles, would be more prevalent among youth in closer proximity to dispensaries. conclusion despite its limitations, this study found no evidence for increased cannabis use among youth living in zip codes with active medical cannabis dispensaries. in fact, 12th graders living in zip medical dispensaries and adolescent cannabis use 44 codes with dispensaries had lower past-year and past-30-day cannabis use. additional research should monitor how evolving cannabis policies influence adolescent cannabis use. references anderson, d. m., hansen, b., rees, d. i., & sabia, j. j. 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(2011). adolescent cannabis use from 2002 to 2008: higher in states with medical cannabis laws, cause still unclear. annals of epidemiology, 21(9), 714-716. https://doi.org/10.1016/j.annepidem.2011.06.001 funding and acknowledgements: a prior version of this manuscript was presented at the 2019 conference of the research society of marijuana (vancouver, wa). this study was funded by illinois department of human services’ division of substance use prevention and recovery (contract # 43cxz03292). however, the views expressed in this article are those of the authors, and do not reflect official positions of the state of illinois. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i2a3_authors_final research article 28 ved abstract links between cannabis use and psychosis generate research and media attention. cannabis users have outscored non-users on the schizotypal personality questionnaire-brief (spq-b) in multiple studies, but previous work suggests that groups do not differ if biased items are removed. the present study examined links between schizotypal personality and cannabis use in a large sample recruited from amazon’s mturk platform (n = 705). over 500 participants reported lifetime cannabis exposure. of those, 259 participants reported current cannabis use, and on average, used 4.53 days per week. users and non-users failed to differ significantly on total spq-b scores or any of the three established subscales. the null results inspired a re-examination of the spq-b’s factor structure, which identified a novel 3-factor solution (difficulty opening up to others, hyperawareness, and odd or unusual behavior). only the “odd or unusual behavior” factor showed cannabis-related differences, but a differential item functioning test revealed that one subscale item showed potential bias against users. removing this item diminished group differences. these results suggest that links between schizotypy and cannabis use require cautious interpretation with careful attention to potential measurement bias. in addition, the spq-b might have an alternative factor structure that could help answer important questions in psychopathology. key words: = cannabis; schizotypy; schizotypal personality disorder previous work suggests that cannabis consumption and schizotypy correlate (see szoke et al., 2014). cannabis remains the most commonly used federally illicit substance in the united states, with rates increasing in the last several years (charilaou et al., 2017; hasin et al., 2017). approximately 15% of us adults used cannabis in 2017 (keyhani et al., 2018). schizotypal personality disorder (spd), a diagnosis typified by social anxiety, odd behaviors, unusual beliefs (e.g. superstitiousness, clairvoyance), unusual perceptual experiences, and paranoia (american psychological association, 2013; raine & benishay, 1995), affects approximately four percent of us citizens (pulay et al., 2009). while only those who meet specific criteria as outlined by the diagnostic and statistical manual of mental disorders (dsm-5) qualify for an spd diagnosis, schizotypal personality traits appear to exist on a continuum. initial evidence for an spd taxon or category failed to replicate once investigators learned to employ modern statistical analyses that included robust simulations and comparable fit indices (haslam et al., 2020). a large proportion of the population might possess clinically subthreshold schizotypal traits, which are often captured by self-report instruments. these measures often capture schizotypy along three dimensions: negative (interpersonal), positive (cognitive-perceptual), and disorganized. covariation between schizotypy and cannabis use consistently exceeds chance, inspiring concerted efforts to explain the link. some authors view cannabis as a potential cause of symptoms; others view the link as spurious or stemming from measurement problems. popular writers assert that cannabis causes these symptoms (berenson, 2020). other research blames dopaminergic drugs brianna r. altman1, mitch earleywine1, maha n. mian1, dev k. dalal1 1department of psychology, university at albany, state university of new york, usa cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.003 cannabis’s link to schizotypy: phenomenon, measurement bias, or delusion? corresponding author: brianna altman, department of psychology, university at albany, state university of new york, usa. 1400 washington ave. ss 217, albany, ny, 12203. phone: (908) 839-2541. email: baltman@albany.edu cannabis, a publication of the research society on marijuana 29 (e.g. psychomotor stimulants such as crack and cocaine, ecstasy) that correlate with cannabis consumption for the exaggerated schizotypy symptoms (van dam et al., 2008). longitudinal work reveals that symptoms of schizotypy precede cannabis use, suggesting that self-medication might play a role (schiffman et al., 2005) but other studies are less clear, citing complicated relations between the dose-dependent effects of cannabis and prior psychiatric vulnerabilities (see hamilton, 2017). additional data highlight the potential of other constructs to underlie both cannabis use and symptoms of schizotypy, such as childhood trauma (airey et al., 2020; frydecka et al., 2020; houston et al., 2011; velikonja et al., 2015). further, the different dimensions of schizotpy appear differentially related to cannabis use; a meta-analytic review of cross-sectional studies reports that the negative dimension appears least related to cannabis use while the disorganized dimension shows the strongest associations, especially among current cannabis users (szoke et al., 2014). continued work examining the etiological underpinnings of cannabis use, schizotypy, and experiences of psychosis is necessary. links between cannabis use, schizotypy, and related distress remain unclear; thus, the notion that ending cannabis use might decrease spd symptoms or negative outcomes might be unfounded. not all individuals with spd traits experience symptoms in distressing ways; those higher in schizotypy experience psychotic-like symptoms with less distress than those lower in schizotypy (kline et al., 2012). other variables might better account for poor outcomes. psychotic illnesses covary with cannabis use in a dosedependent fashion and those afflicted tend to fare poorly if they use cannabis (hasan et al., 2020). recent heritability research reveals that lifetime cannabis use and spd share considerable genetic overlap (vaissiere et al., 2020), mirroring comparable findings with schizophrenia (verweij et al., 2017). nevertheless, despite identification of recent longitudinal links between cannabis use early in life and subsequent development of schizophrenia (di forti et al., 2019), links between spd and schizophrenia are not clear. many with spd distinctly do not develop schizophrenia later in life (debbane et al., 2015). theoretically, heavy cannabis use might not relate to spd itself while a significant link to schizophrenia could remain. heavy users of high-potency strains, for example, might have a psychotic break and qualify for schizophrenia without ever receiving an spd diagnosis. thus, the current data could not only help resolve concerns about links between cannabis and spd, they could also support a focus on potential links with the rarer, and more severe, schizophrenia. given the way cannabis intoxication appears to mimic some of the magical ideation and perceptual aberrations common in spd (stirling et al., 2008), the idea that the drug contributes to symptoms has considerable appeal. schizotypy appears to be a better predictor of unusual experiences than cannabis use; however, it is difficult to parse out causal relations between these variables (airey et al., 2020). some data show modest increases in schizotypy among cannabis users (szoke et al., 2014), but spd traits increase with alcohol and nicotine use as well, perhaps due to deviant attitudes about substance use (esterberg et al., 2009). explanations for the link are numerous and few results in the relevant literature seem definitive. one under-investigated explanation for the link involves measurement bias. previous work revealed that items from the schizotypal personality questionnaire-brief (spq-b; raine & benishay, 1995) had the potential for bias (differential item functioning; dif) against cannabis users (earleywine, 2006). cannabis users were more likely to endorse the item “i sometimes use words in unusual ways,” than non-using peers, even after controlling for levels of schizotypy. dropping the item eliminated significant differences between groups without damaging the scale’s internal consistency (earleywine, 2006). to the authors’ knowledge, the aforementioned study remains the only one examining dif between cannabis users and non-users in measures of schizotypy in the literature. nevertheless, several studies have examined measurement bias in schizotypy measures, including the multidimensional schizotypy scale and wisconsin schizotypy scales, highlighting the important nature of examining the psychometric properties of such instruments (cicero et al., 2019; li et al., 2020). in sum, these results raised the idea that at least the spq-b, if not a number of measures of schizotypy, might show cannabis-related differences for reasons beyond the effects of the drug or the disorder. complex hypotheses about cannabis and schizotypy 30 cannabis playing a role in schizotypy seem inappropriate if the relevant measures are simply biased against cannabis users. despite these findings, researchers continue to use the full scale as evidence for a link between cannabis and schizotypy. given continued concerns about replication in the social sciences (e.g. ioannidis, 2005), we sought to examine group differences between lifetime and current cannabis users and non-users on the spq-b, as well as reexamine the spq-b’s potential for bias to see if dif might help explain the link between schizotypy and cannabis consumption again. replications of dif are rare (see embretson & reise, 2013). the prevalence of cannabis consumption and any associated stigma might also have changed in recent years (carliner et al., 2017). links between use of the drug and any deviance might have decreased over time as well, making dif potentially a moot point. thus, we examined spqb scores and cannabis use in a large sample. we hypothesized that while cannabis users (both lifetime and current) might initially outscore nonusers in their spq-b endorsements, these differences might decrease or fail to reach significance should items evidencing dif be identified and removed. we did not have any a priori hypotheses about which items might be flagged with dif, given the lack of replication studies of dif. methods participants individuals on amazon’s mturk platform viewed a brief description of the research. upon providing informed consent, participants were directed to qualtrics, a survey hosting platform. only individuals over the age of 18 and living in the united states were permitted to participate; no other exclusion criteria were designated. participants completed a questionnaire assessing demographics, cannabis use and related problems, and schizotypal personality characteristics. of the initial 871 participants, 38 were removed for failing to correctly answer attention-check questions. an additional 88 participants responded “no” to the following prompt, “if you did not answer questions honestly or were in someway impaired during this survey, please let us know. you will not be penalized in any way for an honest response to this question. should we include your data in our analyses?” an additional 40 participants were removed for excessive missing variables, leaving a final sample of n = 705. all study procedures were approved by the local institutional review board. table 1. sample demographics sample characteristics full sample (n = 705) lifetime users (n = 511) lifetime abstainers (n = 194) current users (n = 259) age (sd) 36.15 (12.27) 36.33 (12.45) 35.68 (11.78) 35.15 (12.04) % female 61.1% 62% 58.8% 60.6% % white 67.8% 73% 54.1% 66.8% % bachelors or greater 48.1% 44.2% 58.2% 40.5% % lifetime cannabis users 72.5% measures demographics. participants reported their age, gender, race/ethnicity, and highest level of education. the average age was 36.15 (sd = 12.27, range = 1873). on average, the majority of the sample identified as caucasian (67.8%) and female (61.1%), with 48.1% (n = 339) reporting attaining a bachelor’s degree or greater (range = “some high school” to “advanced degree”). sample characteristics appear in table 1. cannabis use. all participants answered the question, “have you ever used marijuana/cannabis?” participants who answered “no” to this question were designated as “lifetime non-users.” participants who endorsed lifetime cannabis use (“lifetime users”) reported whether they were current users (“current users”) or current non-users (“current non-users”), their frequency of cannabis use in the past week and in a typical week, average monthly consumption (in ounces), and average level of intoxication (ranging cannabis, a publication of the research society on marijuana 31 from 0 “not at all” to 7 “extremely”). among our sample, 72.5% (n = 511) used cannabis at least once in their lifetime. among lifetime users, 36.7% (n = 259) reported being current users. current users reported using cannabis approximately 4.53 days per week (sd = 2.58, range = 0-7), consuming approximately .56 ounces of cannabis per month (sd = .47 ounces, range = “less than .025 ounces” to “greater than 3 ounces”) and attaining an average intoxication of 3.93, signifying a moderate typical high (sd = 1.57, range = 0-7). cannabis problems. participants who endorsed lifetime use completed the cannabis-associated problems questionnaire (capq; lavender et al., 2008). this 19-item measure is derived from the marijuana problems scale (mps; stephens et al., 2000; stephens et al., 1994) to assess for lifetime cannabis-related problems on a scale from 0 (“not at all”) to 5 (“extremely.”). domains assessed include interpersonal problems, occupational impairment, and physical and psychological health concerns. to measure global cannabis problems, individual items are summed. on average, participants reported mild cannabis-related problems (m = 10.27, sd = 14.80, range = 0-89). cronbach’s alpha (.942) indicated excellent internal consistency. schizotypal personality. participants completed the schizotypal personality questionnaire-brief (spq-b; raine & benishay, 1995). this 22-item measure asks individuals to report if a statement applies to them by endorsing either “yes” (coded as 1) or “no” (coded as 0). individual items are summed to create a global schizotypy score (cronbach’s alpha = .857) and three subscale scores: cognitive perceptual (alpha =.718), interpersonal deficits (alpha = .776), and disorganized (alpha = .737). the average global score on the spq-b was 10.45 (sd = 5.34, range = 022). average subscale scores were 3.37 (sd = 2.25, range = 0-8), 4.64 (sd = 2.42, range = 0-8), and 2.39 (sd = 1.92, range = 0-6) for the cognitive perceptual, interpersonal deficits, and disorganized subscales, respectively. data analytic plan tests of assumptions for parametric statistics revealed significant positive skew that responded well to box-cox transformations (osborne, 2013). the effort to identify dif and potential for bias often requires group differences in global or subscale scores, which we assessed using independent samples t-tests. in the absence of significant group differences, we re-examined the factor structure of the spq-b and searched for cannabis-related differences on new subscales as a first step toward identifying dif. using this new factor structure, we reassessed for group differences, dif, and relations between the spq-b, factor scores, and indices of cannabis use. the exploratory factor analysis was conducted using r; all other analyses were conducted using spss version 25.0. results examining differences between cannabis users and non-users (lifetime and current) on the spq-b t-tests between lifetime cannabis users and non-users on the global spq-b and its subscales failed to reach p-values less than < .01 (.05/4; wilcox, 2013) or hedge’s g values above 0.20. we focus on hedge’s g due to differences in sample size and standard deviations across groups (lifetime users = 511, lifetime non-users = 194). no group differences appeared between lifetime users and lifetime non-users on the aggregated spq-b (t = 1.82, df = 668, p = .07; musers = 10.68, sdusers = 5.30, mnonusers = 9.84, sdnonusers = 5.44; g = .157). in fact, a single extra “yes” answer for each of the lifetime non-users would have raised their mean above the mean of the lifetime users. similarly, no group differences existed between lifetime users and lifetime non-users for the subscales, including the cognitive-perceptual (t = 2.34, df = 687, p = .63; g= 0.20), interpersonal deficits (t = 0.48, df = 689, p = .07; g = .04) or disorganized subscales (t = 2.24, df = 691, p = .03; g = .193). similarly, we examined differences between current users and non-users on the spq-b and its subscales. cohen’s d effect sizes are reported given similar group sizes and standard deviations. no significant differences were noted in global spq-b scores (t = 1.37, df = 484, p = .171, mcurrent = 11.01, sdcurrent = 5.42, mnoncurrent = 10.35, sdnoncurrent = 5.15, cohen’s d = .12) nor the cognitive-perceptual (t = 1.70, df = 496, p = .090; d = .15), interpersonal deficits (t = -.23, df = 500, p = .82; d = .02), or disorganized subscales (t = 1.90, df = 502, p = .058; d = .17). cannabis and schizotypy 32 table 2. spq factor loadings item factor 1 factor 2 factor 3 people sometimes find me aloof and distant. .432 .290 i feel i have to be on guard even with friends. .533 .274 some people find me a bit vague and elusive during a conversation. .474 .109 .270 i feel very uncomfortable in social situations involving unfamiliar people. .824 -.165 i tend to keep in the background on social occasions .718 do you feel that you are unable to get "close" to people? .655 .137 i find it hard to communicate clearly what i want to say to people. .574 .149 .136 i feel very uneasy talking to people i do not know well. .746 i tend to keep my feelings to myself. .755 -.245 have you ever had the sense that some person or force is around you, even though you cannot see anyone? .631 .108 are you sometimes sure that other people can tell what you are thinking? .388 .141 have you ever noticed a common event or object that seemed to be a special sign for you? -.148 .722 do you often pick up hidden threats or put-downs from what people say or do? .152 .608 when shopping do you get the feeling that other people are taking notice of you? .215 .403 .129 have you had experiences with astrology, seeing the future, ufos, esp, or a sixth sense? .604 do you ever suddenly feel distracted by distant sounds that you are not normally aware of? .156 .402 .233 do you often have to keep any eye out to stop people from taking advantage of you? .286 .549 people sometimes comment on my unusual mannerisms and habits. .761 some people think that i am a very bizarre person. .939 i sometimes use words in unusual ways. .212 .515 i am an odd, unusual person. .214 .110 .613 % of variance 19.4% 12.9% 11.2% re-examining the factor structure of the spq-b given the absence of cannabis-related effects on the standard subscales, we decided to reexamine the factor structure in the current sample. an exploratory factor analysis using tetrachoric correlations was conducted on the spq-b using the full sample given our null findings with regard to group differences. based on visual examination of the scree plot and eigenvalues greater than 1.0, two or three factors appeared to best fit the data. the three-factor model yielded a better fit and accounted for a greater proportion of variance. thus, only the three-factor model will be described in detail. the kaiser-meyer-olkin (kmo) measure of sampling adequacy (.72) and bartlett’s test of sphericity (χ2 = 675.01, df = 171, p < .001) demonstrated that these data were factorable. three factors with eigenvalues greater than 1.0 (4.26, 2.85, 2.47) cannabis, a publication of the research society on marijuana 33 accounted for approximately 49% of the measure’s variance. of the initial 22 items, only one item (“have you found that it is best not to let other people know too much about you?”) had substantial cross-factor loadings (.469 onto factor 1 and .368 onto factor 2) and was excluded from analysis. no other items had cross loadings greater than .290 onto more than one factor. using an oblimin rotation to account for high inter-factor correlations, we determined that nine items loaded onto factor 1, eight items loaded onto factor 2, and four items loaded onto factor 3 with factor loadings of .39 or greater. factor 1 accounted for 19.4% of the scale’s variance and included items such as, “people sometimes find me aloof and distant” and “some people find me a bit vague and elusive during a conversation.” based on factor loadings, this factor was named, “difficulty opening up to others” (cronbach’s alpha = .803). factor 1 appears similar to the original “interpersonal” subscale with the addition of two items (“some people find me a bit vague and elusive during a conversation” and “i find it hard to communicate clearly what i want to say to people”) and the exclusion of the item that was removed prior to analysis. factor 2 accounted for 12.9% of the scale’s variance and was comprised of items such as, “have you ever had the sense some person or force is around you, even though you cannot see anyone?” and “do you often pick up hidden threats or put-downs from what people say or do?” we named factor 2 “hyperawareness” (alpha = .718). factor 2 matched the original “cognitiveperceptual” spq-b subscale. factor 3 accounted for 11.1% of the scale’s variance and was named “odd or unusual behavior.” this factor included items such as, “people sometimes comment on my unusual mannerisms and habits.” and “i sometimes use words in unusual ways.” cronbach’s alpha was acceptable (.736). factor 3 appeared similar to the “disorganized” subscale with the exclusion of two items that better mapped onto factor 1. factor loadings and cross loadings appear in table 2. cronbach’s alpha for the shorter, full scale (.851) was nearly identical to the original full scale. table 3. examining group differences on the new spq-b subscales t musers (sdusers) mnonusers (sdnonusers) effect size lifetime users vs. non-users 1. “difficulty opening up to others” 0.47 4.80 (2.74) 4.69 (2.68) 0.040 2. “hyperawareness” 2.34 3.49 (2.25) 3.04 (2.25) 0.200 3. “odd or unusual behavior” 2.91* 1.71 (1.48) 1.37 (1.38) 0.234 current users. vs. non-users 1. “difficulty opening up to others” 2. “hyperawareness” 3. “odd or unusual behavior” 0.13 1.70 2.25 4.80 (2.80) 3.66 (2.26) 1.86 (1.49) 4.80 (2.69) 3.32 (2.23) 1.56 (1.46) 0.001 0.152 0.201 note. * p < .01 group differences on the spq-b’s new subscales our three new factors inspired a second look at differences between lifetime cannabis-users and non-users, as well as current users and nonusers. using the same procedure as the prior analysis, we compared lifetime users and nonusers’ scores on the subscales with independent samples t-tests corrected using a bonferroni adjusted p-value of < .01 (.05/4; wilcox, 2013). only the “odd or unusual behavior” subscale revealed significant differences, with lifetime users outscoring lifetime non-users (t = 2.91, df = 694, p < .01; musers = 1.71, sd = 1.48, mnonusers = 1.37, sd = 1.38, g =0.234). note that this difference is less than half of one extra “yes” per person on the subscale. users and non-users scored similarly on the other subscales (p > .01; see table 3). we then compared differences between current users and current non-users; however, no significant differences were noted. (p > .01; see table 3). assessing differential item functioning among “odd or unusual behavior” items cannabis and schizotypy 34 to test for the presence of user-status-based differential item functioning (dif) in the spq-b, logistic regression analyses were conducted to predict each spq-b item of factor 3. each item was regressed on the centered subscale score, lifetime user status (dummy coded as lifetime users = 0.5, lifetime non-users = -0.5), and the interaction of the subscale score and user status (“odd or unusual subscale” x user status). should use status significantly predict item scores, the item would demonstrate uniform dif based on user status. should the interaction term be a significant predictor of item scores, the item would demonstrate non-uniform dif. using an adjusted p-value of .001, only item 19 evidenced uniform dif based on user status. even after controlling for the total subscale score, lifetime users were 2.58 times more likely to endorse “yes” to “i am an odd, unusual person” than lifetime non-users (b = .947, se = .294, wald = 10.391). this same item had not shown dif previously (earleywine, 2006). removing this item brought the means for the user and non-user groups closer together; they no longer reached statistical significance (t=1.81, df = 694, p =0.07; musers = 1.23, sd = 1.16, mnonusers = 1.06, sd = 1.07; g =0.149). table 4. correlations among spq-b original subscales (raine & benishay, 1995), new subscales, and indices of cannabis use 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. spq-b global 2. original f1 .792** 3. original f2 .816** .401** 4. original f3 .831** .537** .542** 5. new f1 .836** .408** .959** .636** 6. new f2 .792** 1.00** .401** .537** .408** 7. new f3 .721** .500** .391** .929** .424** .500** 8. capq scores .317** .246** .197** .324** .231** .246** .286** 9. mj per month .209** .155** .129** .178** .132** .155** .165** .332** 10. average high .074 .066 .038 .095* .044 .066 .099* .268** .251** note. *p < .05, ** p < .001 spq-b global = participant responses to the spq-b (schizotypy) original f1 = original factor 1 “cognitive-perceptual” original f2 = original factor 2 “interpersonal deficits” original f3 = original factor 3 “disorganized” new f1 = new factor 1 “difficulty opening up to others” new f2 = new factor 2 “hyperawareness” new f3 = new factor 3 “odd or unusual behavior” capq scores = participant responses to the capq (cannabis problems) mj per month = quantity of cannabis consumed per month average high = participant’s self-reported average level of intoxication assessing relations between spq-b scores and cannabis-related variables our newly identified factors were highly correlated with the original three factors proposed by raine and benishay in 1995 (r’s ranging from .391 to 1.00; all p’s < .001; see table 4). links between spq-b factors and cannabis problems ranged from r = .197 to r = .324. links with quantity used per month ranged from r = .129 to r = .178 (all p’s < .01). average intoxication appeared only significantly related to the “odd/unusual factor” (r = .095; p <.05). age appeared negatively associated with all three subscale scores and the global spq-b score; as individuals aged, they appeared to endorse fewer items consistent with spd (r’s ranging from -.136 to -.182; all p’s < .01). cannabis, a publication of the research society on marijuana 35 discussion links between cannabis consumption and spd appear in multiple studies, adding to concerns that the drug might contribute to the etiology of the diagnosis or exacerbate symptoms. but meta-analytic work reviewing 29 studies reveals that many of these studies focus on small samples of college students (11/29), adolescents (3/29) or samples of fewer than 300 participants (18/29; see szoke et al., 2014). over a decade ago, data suggested that the spq-b (raine & benishay, 1995) contained a potentially biased item that shows dif against cannabis users. this item made cannabis users appear more schizotypal than non-users who were equally schizotypal on all other items. removing the item eliminated group differences (earleywine, 2006), casting doubt on the link between cannabis consumption and spd. we sought to replicate the link between the spq-b and cannabis consumption in a large sample of community participants. group differences on the global spq-b and the original three subscales did not reach statistical significance; lifetime users and current users were as schizotypal as lifetime non-users and current non-users. this finding was somewhat surprising, as numerous studies highlight cannabis users outscoring non-users on measures of schizotypy, especially with regard to cognitive-perceptual symptoms (esterberg et al., 2009; fridberg et al., 2011; schiffman et al., 2005). these null results inspired an additional look at the factor structure. an exploratory factor analysis revealed a comparable three-factor model. the subscale we dubbed “odd and unusual behaviors” showed mean differences between lifetime users and nonusers, but one item (“i am an odd, unusual person”) showed dif. once other indices of schizotypy were covaried out, users were still more than 2.5 times as likely to endorse the item. the result suggests that some aspect of the item other than schizotypy is contributing to endorsement. item removal decreased lifetime group differences on the subscale to nonsignificance. participants might consider themselves odd and unusual in part because of their cannabis use or because of some correlate of use that other spq-b items do not address. the previous dif findings (earleywine, 2006) suggested a misinterpretation of a comparable item: “i use words in unusual ways.” although no single cross-sectional study can answer every question about schizotypy’s correlates, this second identification of a biased item against lifetime users might encourage careful use of the spq-b in future studies. future work could benefit from close examinations of dif among cannabis users and non-users. these results suggest that further work on cannabis and psychosis requires considerable cautions, particularly when research employs the spq-b. the current results suggest that in a large sample with unbiased subscales, cannabis users and nonusers rarely differ from each other on schizotypy or related subscales by more than 1/5 of a standard deviation and the effects disappear when biased items are removed. for a 22-item yes/no scale like the spq-b, this effect size arises from a bit more than one additional yes answer on average among cannabis users (the standard deviation for the whole scale is approximately 5.4). detecting effects of this size in future work is unlikely with samples of fewer than 600 participants (cohen, 2013). given an effect of 0.2, power of .80 with alpha of .05 for a one-tailed test requires 310 participants per group. in the future, those who identify cannabisrelated differences on the spq-b might provide additional analyses in the absence of items that have shown dif in previous work, including “i use words in unusual ways,” as well as “i am an odd, unusual person.” if cannabis-related differences disappear, conclusions about links to schizotypy should be tempered. changes to the presentation of these items might also prove illustrative. although the scale’s psychometric properties are clearly superb in many ways (raine & benishay, 1995), further work with cannabis users likely requires changes to instructions to avoid misinterpretation of items. measures of psychotic features frequently emphasize that drug-induced experiences do not qualify as signs or symptoms (apa, 2013). the instructions for the spq-b might also benefit from emphasizing that items do not refer to one’s identity. perhaps “i use words, other than cannabis slang, in unusual ways,” and “i am an odd, unusual person independent of my cannabis use” are a bit heavy-handed, but the spq-b’s initial instructions might benefit from emphasizing that participants should not endorse cannabis and schizotypy 36 items that are only true during intoxication or because of identification with a particular subgroup or culture. elevated schizotypy scores in those who do not share the most prevalent religion of their country might arise for comparable reasons (hancock & tiliopoulos, 2010; tiliopoulos & johnstone, 2008). if part of schizotypy selfreport measures include identifying deviance, the source of the deviance might matter. furthermore, our results highlighted significant positive correlations between cannabis use, cannabis-related problems, and both the original and new factors of the spq-b. these results were unsurprising, as prior work documents positive associations between cannabis use and self-reported schizotypy (williams et al., 1996). while those who use more cannabis, or endorse greater cannabis-related problems, might be more likely to endorse schizotypal characteristics, other variables might better account for these significant relations. for instance, as mentioned previously, individuals who use cannabis might have inadvertently misinterpreted instructions and reported on their schizotypal-like experiences during instances of cannabis intoxication. additionally, extraneous variables such as trauma exposure might help to explain positive links between cannabis use and schizotypy (airey et al., 2020; frydecka et al., 2020; houston et al., 2011; velikonja et al., 2015). future work might better assess for known correlates of both cannabis use and schizotypy to control for their influence. still, despite these significant associations, our work failed to find significant differences between cannabis users and non-users on the spq-b. like all correlational studies, this one has limitations related to sampling and assessment. the current sample had internet access and was primarily white and educated (see table 1). replication efforts are likely worthwhile, as this research question appears important. a huge sample with markedly more participants from understudied populations would undoubtedly strengthen generalization and provide added statistical power for estimating effects related to demographics. for example, only nine native americans, an ethnic group with varied but potentially dramatic mental health burden (asdigian et al., 2018), responded in the current data. oversampling from groups with less representation would strengthen conclusions considerably. moreover, given our large sample size, it is likely that a proportion of participants experienced some mental health concerns. although we did not specifically assess for histories of psychiatric diagnoses, such disorders might influence endorsements of schizotypy or cannabis use. for instance, data highlight associations between experiences of anxiety and depression and self-reported schizotypy (kemp et al., 2018; lewandowski et al., 2006). future work might assess for the presence of such symptoms and potentially control for these variables should they show significant correlations with schizotypy. additionally, the measures of both schizotypy and cannabis use were all self-report. although stigma around cannabis consumption might have decreased recently (carliner et al., 2017), biological confirmation of cannabis consumption might have advantages. future work might more thoroughly assess important aspects of cannabis use (e.g., type of products used, thc concentration), and attitudes regarding substance use more broadly, as they relate to schizotypy and cannabis problems. furthermore, the concept of socially desirable responding, especially as it relates to endorsements of cannabis-related problems, calls for careful interpretation of these findings, given the mild cannabis problems reported by this sample. nevertheless, the current results cast doubt on links between cannabis use and schizotypy, at least as measured by the spqb. future work might benefit from examinations of dif in other measures of schizotypy, such as the full-scale spq and the oxford-liverpool inventory of feelings and life (o-life; mason et al., 1995), as well as modest changes in assessment instructions. the presence of these measurement problems suggests that current estimates of links between cannabis use and schizotypy might be overestimates. a final limitation of this work relates to the dichotomous nature of the spq-b. the spq-b asks participants to endorse whether a symptom of spd applies to their experience on a “yes/no” scale. given these instructions, researchers are unable to ascertain whether an item currently applies to a participant or had previously applied. the approach also has the potential to neglect variation in symptom intensity. for instance, “people sometimes find me aloof and distant” might have applied to a person’s experience in the cannabis, a publication of the research society on marijuana 37 past, but not currently. this person might still endorse “yes” to this item, given the scale instructions. continued longitudinal work can disentangle relations between ongoing cannabis use and current presence of spd features. alternative response formats for the spq-b, such as that employed by the schizotypal personality questionnaire – brief revised (spq-br; 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(2013). new statistical procedures for the social sciences: modern solutions to basic problems. florence (ky): psychology press. funding and acknowledgements: the authors have no disclosures or conflicts of interest to report. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 64 ved abstract cannabis use and the prevalence of cannabis use disorder (cud) among emerging adults are on the rise. several indicators of cannabis use (e.g., quantity, frequency) as they relate to negative outcomes have been posited in the extant literature. despite research examining links between indicators and cannabis outcomes, few assessments of cannabis use indicators exist. the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu) was developed to assess cannabis use across a range of factors. however, the factor structure of the dfaq-cu has not been replicated. further, the dfaq-cu was modeled using reflective strategies despite formative strategies being conceptually appropriate. the present study utilized principal components analyses (pca) and principal axis factoring (paf) to evaluate the structure of the dfaq-cu. pca yielded a four-component solution; paf resulted in a five-factor solution. linear regression found significant relations between pca components and paf factors with cud symptoms and cannabis-related problems; however, effect sizes were larger for the paf suggesting possible misdisattenuation. the pca components demonstrated evidence of discriminant and convergent validity with measures of cannabis and alcohol behavior. the study informs research and clinical work through the refinement of cannabis use assessment and enhancing our understanding of the importance of model selection. key words: = cannabis; structural equation modeling; assessment; principle components analysis; emerging adults prevalence of cannabis use among collegeaged individuals is at a record high with 40.3% of emerging adults enrolled in college having used cannabis in the past year and 5.6% reporting daily use (patrick et al., 2022). previous work has demonstrated a host of deleterious cognitive (e.g., lovell et al., 2020), academic (e.g., meda et al., 2017; phillips et al., 2015), and health (e.g., russell et al., 2018) consequences associated with cannabis use. perhaps most importantly, prevalence of cannabis use disorder (cud) is rising. notably, in a sample of college students reporting past month use, 54% met criteria for cud (schultz et al., 2019). despite research noting a range of negative outcomes and increased rates of cud, cannabis use attitudes have become more favorable over time (gallup, 2021), particularly as cannabis becomes more widely available following shifts in policy over the last decade (carliner et al., 2017; roditis et al., 2016; jordan a. gette1, andrew k. littlefield2, sarah e. victor2, adam t. schmidt2, and sheila garos2 1the center of alcohol and substance use studies, rutgers university 2department of psychological sciences, texas tech university cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000161 evaluation of the daily sessions, frequency, age of onset, and quantity of cannabis use questionnaire and its relations to cannabisrelated problems corresponding author: jordan gette, ph.d., rutgers university, 607 allison road piscataway new jersey 08854. email: jordan.gette@rutgers.edu cannabis, a publication of the research society on marijuana 65 wall et al., 2016). thus, it is crucial to better understand which indicators of cannabis use most strongly relate to adverse outcomes among college students. indicators of cannabis problems and cannabis use disorder frequency. frequency of cannabis use is perhaps the most examined indicator of cannabis use problems (e.g., pearson, 2019). among those meeting criteria for cud, the mean number of use days in the past year was 225.3 (hasin et al., 2016), suggesting that those with cud use cannabis on more days than not. a systematic review found that cannabis use in adolescence increases the likelihood of developing cannabis dependence in adulthood and that as frequency of use increases, risk for cud development increases (levine et al., 2017). cannabis use frequency is significantly related to cannabis problems and cud and this relation holds when controlling for quantity of use and age of onset (callaghan et al., 2020; zeisser et al., 2012). although there is strong evidence to support the relation between cannabis use frequency and associated problems, there is still a significant portion of the variance in cud that is unaccounted for. for example, approximately 83% of weekly cannabis users do not meet criteria for a cud (cougle et al., 2016), suggesting that frequency alone is insufficient to explain cannabis problems. quantity. several studies have examined relations between quantity of cannabis used, cannabis-related problems, and cud. as quantity of use increases, the odds of having cud increase, even after controlling for frequency of use and age of onset (callaghan et al., 2020). further, past month quantity is significantly positively correlated with dependence symptoms (lopezpelayo et al., 2021). given difficulty in defining quantity, zeisser et al. (2012) attempted to create a “standard joint” (i.e., 10 puffs on a joint, 5 hits on a bong or pipe, or 0.5 grams of cannabis). using this means of assessment, increases in cannabis use quantity were significantly related to five cannabis use problem domains (social/financial/legal; failure to fulfill responsibilities; cannabis urge; concern by friends; and failure to reduce use). however, after controlling for frequency, quantity only remained a significant indicator of failure to fulfill responsibilities. although promising evidence exists that quantity of cannabis use predicts cannabis use problems and cud symptoms, more work is needed to understand the nuances of this relation, as single indicators of quantity are insufficient to fully capture the dynamic between quantity of use and associated problems. age of onset. another factor that may influence the experience of cannabis-related problems and cud is age of onset (i.e., age of first cannabis use). though recent work assessing age of onset is limited, several studies found that earlier age of onset (i.e., adolescence) is associated with increased odds of cannabis dependence (lopez-pelayo et al., 2021; richmond-rakerd, et al., 2016) and higher current frequency of use (azagba & asbridge, 2019). however, the relation between age of onset and cannabis-related problems may become non-significant when frequency is controlled for (rioux et al., 2018). as such, it may be that the relation between age of onset and cannabis-related problems is mediated by frequency of use. the daily sessions, frequency, age of onset, and quantity of cannabis use inventory the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaqcu; cuttler & spradlin, 2017) was developed to improve assessment of cannabis use. this selfreport measure is comprised of 24 core items and 17 screening items. screening items are used to establish that participants have used cannabis in their lifetime, assess for medical reasons of use, and measure estimated tetrahydrocannabinol (thc) levels. prior to factor analysis, only individuals that endorsed any lifetime cannabis use were retained. during reflective factor analysis (cuttler & spradlin, 2017), 22 of the 24 core items were retained across six factors: sessions per day, use frequency, age of use onset, quantity of loose-leaf cannabis use, quantity of cannabis concentrate use, and quantity of cannabis edible use (figure 1). in a sample of college students in washington state, these six factors accounted for 77% of available variance in cannabis use, with factor loadings ranging from .45 to .98. correlations between factors ranged from -.23 to .52. internal consistency estimates for the factors were as follows: frequency α = .95, the dfaq-cu and cannabis consequences 66 marijuana quantity α = .88, age of onset α = .81, cannabis concentrates α = .76, and daily sessions α = .69. the edible factor only contained one item, as such, internal consistency could not be calculated. strengths of the dfaq-cu include assessment of methods of cannabis administration (e.g., loose leaf, edibles, concentrates) and pictures to aid individuals in reporting quantity. though this is the first psychometrically robust self-report measure of cannabis quantity and frequency, it has yet to be evaluated outside of the original sample. further, the current factor structure warrants discussion. specifically, the quantity of edibles use factor is comprised of a single item, which can lead to difficulty specifying models and inability to assess reliability (e.g., bollen et al., 1998). additionally, the daily sessions factor is comprised of only two items and the internal consistency of this factor was in the “questionable” range (α = .69; kline, 2013), while only three of the six factors resulted in cronbach’s alpha values in the “good” or “excellent” range (kline, 2013). as such, it may be that the current factor structure of the dfaq-cu has psychometric limitations that may warrant improvement. dfaq-cu: a formative or reflective model? it is arguable that the modeling techniques used to develop the dfaq-cu were inappropriate. the dfaq-cu was developed by applying reflective latent variable modeling (principal axis factoring and maximum likelihood factor analyses; cuttler & spradlin, 2017). reflective models, such as exploratory and confirmatory factor analyses, assume that a latent construct exists, and items are developed to address the construct (borsboom et al., 2003). conversely, formative factor analyses, such as principle components analysis, are, in essence, data reduction techniques (borsboom, 2006) that posit that a collection of items can be reduced to create components. that is, the primary distinction is that formative models assume a latent variable is the outcome predicted by manifest indicators, whereas reflective models assume manifest indicators are the outcome predicted by the latent variable. in relation to the dfaq-cu, cannabis use frequency, quantity, and age of onset are not likely to be preexisting constructs observed by assessing how often or how much an individual uses cannabis. rather, it is more likely that items assessing these cannabis behaviors can be summarized as components in a meaningful way (borsboom et al., 2003). that is, a factor of quantity does not exist prior to items assessing quantity of use. as such, formative analytic strategies are arguably more appropriate for the dfaq-cu than reflective strategies (borsboom et al., 2004; coltman et al., 2007). beyond the above theoretical arguments against modeling the dfaq-cu as reflective would result in construct invalidity, rhemtulla et al. (2020) posit myriad problems that can occur when formative variables are modeled as reflective. of chief importance for the present analyses, these authors note that using latent factors as opposed to composites can result in overestimation of item correlations as well as both the overand under-estimation of model parameters (rhemtulla et al., 2020). this occurs because latent modeling assumes that all nonshared variance in the model is unrelated to the measured construct, which ultimately results in misdissattenuation (i.e., overcorrection of “false measurement error;” rhemtulla et al., 2020, p. 42) and bias due to overestimation of shared variance and the exclusion of unique variance across factors. importantly, if items are not modeled correctly, relations among factors and other outcomes (e.g., cannabis-related problems) may not be accurate. despite the original dfaq-cu resulting in good model fit via reflective indices, it may still be theoretically and mathematically inappropriate. the current study the purpose of this study is two-fold. first, the primary goal is to reevaluate the dfaq-cu to determine if its structure holds in an independent sample using formative analyses and how different modeling approaches relate to cannabis use outcomes. further, in addition to suboptimal modeling strategies, the dfaq-cu was assessed in a state that had already passed recreational and medicinal cannabis laws at the time of evaluation. evidence on the impacts of cannabis legalization is mixed, with studies of adolescent prevalence rates finding no difference (carliner et al., 2017; hasin et al., 2015; hunt & miles, 2015; imbens & wooldridge, 2009), but increases in cannabis, a publication of the research society on marijuana 67 cannabis prevalence in adults as a result of legality (carliner, et al., 2017; cerdá et al., 2012; wen et al., 2015). further, there is some evidence to suggest that different methods of use (e.g., wax, shatter, oils) may be more common in states in which cannabis is legal (daniulaityte et al., 2015). as such, the structure of the dfaq-cu may be different in states without legal cannabis, particularly the quantity of concentrates and quantity of edibles factors of the dfaq-cu. the second aim is to determine if the components derived from the pca demonstrate evidence of convergent and discriminant validity with existing measures of cannabis and alcohol behavior. the overarching goal of these aims is to discern the structure and utility of the dfaq-cu as a measure of cannabis use behavior. methods participants a total of 442 participants (mage = 19.37, 68.33% female, 60.64% white, 21.76% hispanic/latinx) from a large public university in texas were included in the present analysis. individuals had to be at least 18 years old to participate and received course credit for their participation. the present study utilized a subset of participants from a larger study that endorsed lifetime cannabis use collected prior to covid-19related campus closures. eligible participants were directed to an online survey database, qualtrics (qualtrics, 2015, provo, utah) to anonymously complete several measures regarding demographic information as well as measures assessing rates cannabis and alcohol use patterns. all procedures were approved by the university’s institutional review board. measures demographics. participants completed a baseline demographic measure assessing sex, gender, race, ethnicity, age, socioeconomic status, and other sociodemographic variables. the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaqcu; cuttler & spradlin, 2017). the dfaq-cu was used to assess cannabis use behaviors. as previously discussed, the dfaq-cu is a selfreport scale measuring frequency, quantity, and age of onset for cannabis use. the original scale, using reflective latent variable analyses, is comprised of 41 likert-like items (24 core items and 17 screening items) with 22 of the 24 core items loading onto six factors of cannabis use behaviors: daily sessions, frequency, age of onset, loose-leaf quantity, concentrate quantity, and edibles quantity (figure 1). cannabis timeline follow-back. a timeline follow-back of past-two-week cannabis quantity and frequency was included to compare to assess for evidence of convergent validity of the dfaqcu (pearson et al., 2017). participants reported whether they used cannabis on a given day, method of administration, and quantity in grams. three values were used in the present analyses: total use days, average weekend quantity, and average weekday quantity. cannabis consequences. the brief marijuana consequences questionnaire (b-macq; simons et al., 2012) was used to assess cannabis consequences. the b-macq is a self-report measure of cannabis-related problems experienced in the past six months developed from the 50-item marijuana consequence questionnaire. the 21 dichotomous (yes/no) bmacq items are summed to create a total problem score (range: 0 to 21) with higher values representing more cannabis-related problems. the b-macq demonstrates excellent internal consistency and does not exhibit differential item functioning across biological sex (simons et al., 2012). cannabis use disorder symptoms. to assess for cud symptomology, the symptoms of the dsm-5 cud were presented as 11 dichotomous (yes/no) items with higher sum scores representing greater cud symptoms in the past year. a similar approach has been used previously to assess cud symptoms (e.g., dierker et al., 2018). alcohol measures. alcohol frequency and binge drinking (4+/5+ drinks per occasion for women and men) were assessed using the niaaa binge drinking questionnaire (niaaa, 2004). this measure contains 10-items assessing past-year and past-two-week alcohol frequency, binge drinking, and quantity. to assess alcohol use disorder (aud) symptoms, the dsm-5 aud criteria were presented as 11 dichotomous (yes/no) items (american psychological association, 2013). items are summed to create a the dfaq-cu and cannabis consequences 68 total number of symptoms endorsed in the past 12 months. analytic approach pca and paf analyses were conducted in spss version 25.0 (ibm corp., armonk, ny, usa). confirmatory factor analyses and regressions were conducted in mplus version 7.31 (muthén & muthén, 1998-2015), and parallel analyses were conducted using r version 3.5.1 (r core team, 2018), consistent with our prior work using these techniques (gette et al., 2022). missing data patterns were analyzed using mplus software. of items that did not include skip logic, less than 1% of observations were missing. for pca and pfa, pairwise deletion was used (van ginkel et al., 2014). core dfaq-cu items were transformed into z-scores to account for variability in response options across items (i.e., some items begin with 0, some with 1, some are alphabetical, some free response) and to be consistent with the original scoring (cuttler & spradlin, 2017). prior to analyses, data were screened to assess distribution, skew, kurtosis, outliers, and missing data patterns. additionally, kaiser-meyer-olin (kmo) testing was conducted in spss to ensure that the sample was appropriate for component analyses with values of .60 or greater considered acceptable (kaiser, 1974). additionally, bartlett’s (1950) test of sphericity was used to examine redundancy among items to ensure that creation of components is appropriate. a significant pvalue (i.e., p < .05) indicates that variables are related and suitable for component analysis. horn’s (1965) parallel analysis was conducted to determine component and factor retention for both principal components analysis (pca) and principal axis factoring (paf; velicer et al., 2000; velicer & jackson, 1990) using the fa.parallel function under the psych package in r (revelle, 2020). this function was selected given its ability to handle missing data in its determination of the optimal number of components to retain. horn’s parallel analyses was conducted using a 95% confidence interval to avoid overfitting the data (glorfeld, 1995). prior to factor analyses, items were winsorized such that values exceeding 3.29 standard deviations above the mean were replaced to correspond to 3.29 standard deviations from the mean to minimize the influence of extreme values (e.g., consuming one ounce of cannabis per smoking session; tabachnick et al., 2007). a total of 125 observations (0.67%) were winsorized. next, pca and paf were used to determine the optimal structures of the dfaq-cu. pca is a data-reduction technique in which items are combined linearly to extract components in order to account for the maximum possible variance in a set of items. paf is a reflective modeling approach in which latent variables (or factors) are derived by determining the shared variance among a set of items to derive communalities and factor loadings, similar to exploratory factor analysis. paf is most useful for reflective modeling when there are few indicators per factor or variability among number of indicators per factor (de winter & dodou, 2012). the original factorization of the dfaq-cu resulted in six factors with one to nine items per factor, making paf an appropriate method from this perspective. both pca and paf models were conducted using a promax rotated oblique solution (dien, 2010) because it was expected that the factors and components would be correlated. for each component/factor, individual items with factor or component loadings greater than .45 were retained (kite & whitely, 2018). items were allowed to cross load if an item has a loading of .45 or greater on multiple factors. next, cronbach’s alpha and omega were calculated to assess factors and component reliability (mcdonald, 1999). alpha values of .90 and above indicate excellent consistency, values of .80 to .89 are good, and .70 to .79 is acceptable (kline, 2013). additionally, to test the replicability of the paf factors, h was calculated with values of .80 or greater indicating that the latent variable is welldefined (hancock & mueller, 2001; rodriguez et al., 2016). next, the models were compared to determine if these modeling techniques result in different structures and if so, which structure is most conceptually clear. to build evidence of convergent validity, the pca components were correlated with existing measures of cannabis use and to were also correlated with measures of alcohol use to assess discriminant validity. results table 1 presents sample characteristics and dfaq-cu item endorsements. kmo testing resulted in a value of .68 and a significant bartlett’s test of sphericity (p < .001), suggesting cannabis, a publication of the research society on marijuana 69 items were acceptable for components and factor analyses. principal components analysis as indicated by horn’s parallel analysis, the pca model was specified to include fourcomponents using a promax-rotated solution that accounted for 73.13% of the variance in cannabis use (see table 2 and figure 1). the frequency component (e.g., “how many days of the past week did you use cannabis?”) is comprised of 10 items with component loadings from .45 to .96 (see table 3) with an alpha of .94. the typicality of use component (e.g., “how many times a day, on a typical weekend, do you use cannabis?”) is comprised of nine items with component loadings from .45 to .93 and alpha of .91. the concentrates component (e.g., “how many hits of cannabis concentrates did you personally take yesterday?”) is comprised of four items with component loadings from .72 to .93 and an alpha of .76. lastly, the age of onset component (e.g., “how old were you when you first started using cannabis regularly [2 or more times/month]?”) is comprised of four items with component loadings from .76 to .89 and alpha of .87. of note, all crossloading of items were retained on the frequency figure 1. comparison of models derived from the daily sessions, frequency, age of onset, and quantity of cannabis inventory note. pca = principals components analysis, paf = principal axis factoring. colors correspond to factors and components with loadings ≥ .45. blue corresponds to frequency, green corresponds to age of onset, purple corresponds to quantity, yellow corresponds to typicality of use, pink corresponds to items included on two components or factors. the dfaq-cu and cannabis consequences 70 table 1. sample characteristics and descriptive responses of the core items of the daily sessions, frequency, age of onset and quantity use questionnaire prior to transformations. sample characteristics (n = 442) age 19.37 female 68.33% non-hispanic white 60.64% hispanic 21.76% cannabis consequences m (sd) 4.12 (4.46) cannabis use disorder symptoms m (sd) 1.91 (2.61) dfaq-cu multiple choice items and response options % endorsement (n) 2. which of the following best captures when you last used cannabis? over a year ago 16.5 (73) 9-12 months ago 5.4 (24) 6-9 months ago 5.0 (22) 3-6 months ago 9.3 (41) 1-3 months ago 12.7 (56) less than 1 month ago 13.1 (58) last week 10.2 (45) this week 7.7 (34) yesterday 12.2 (54) today 2.3 (25) i am currently high 5.7 (25) 3. which of the following best captures the average frequency you currently use cannabis? i do not use cannabis 0.0 (0) less than once a year 14.3 (63) once a year 12.9 (57) once every 2-6 months (2-4 times/yr) 4.5 (20) once every 2 months (6 times/yr) 18.3 (81) once a month (12 times/yr) 5.7 (25) 2-3 times a month 5.2 (23) once a week 10.0 (44) twice a week 5.2 (23) 3-4 times a week 9.5 (42) 5-6 times a week 4.5 (20) once a day 4.1 (18) more than once a day 5.9 (26) 6. how many days of the past week did you use cannabis? 0 days 56.1 (162) 1 day 9.7 (28) 2 days 6.6 (19) 3 days 6.9 (20) 4 days 3.1 (9) 5 days 3.5 (10) 6 days 2.8 (8) 7 days 11.3 (33) cannabis, a publication of the research society on marijuana 71 8. which of the following best captures the number of times you have used cannabis in your entire life? 1-5 times in my life 14.9 (43) 6-10 times in my life 9.0 (26) 11-50 times in my life 20.4 (59) 51-100 times in my life 11.4 (33) 101-500 times in my life 17.6 (51) 501-1000 times in my life 10.7 (31) 1001-2000 times in my life 6.6 (19) 2001-5000 times in my life 4.5 (13) 5001-10,000 times in my life 3.5 (10) more than 10,000 times in my life 1.4 (4) 9. which of the following best captures your pattern of cannabis use throughout the week? i do not use cannabis at all 41.3 (183) i only use cannabis on weekends 27.5 (122) i only use cannabis on weekdays 0.9 (4) i use cannabis on weekends and weekdays 30.2 (134) 10. how many hours after waking do you usually first use cannabis? i do not use cannabis at all 39.1 (173) 12-18 hours after waking up 17.6 (78) 9-12 hours after waking up 24.2 (107) 6-9 hours after waking up 7.9 (35) 3-6 hours after waking up 4.1 (18) 1-3 hours after waking up 3.4 (15) within 1 hour of waking up 1.4 (6) within ½ hour of waking up 1.4 (6) immediately upon waking up 1.1 (5) 32. which of the following best captures the average frequency that you used cannabis before the age of 16? more than once a day 0.7 (3) once a day 0.9 (4) 5-6 times a week 0.5 (2) 3-4 times a week 2.3 (10) twice a week 2.5 (11) once a week 1.1 (5) 2-3 times a month 4.5 (20) once a month 3.4 (15) once every 2 months (6 times/yr) 3.4 (15) once every 3-6 months (2-4 times/yr) 5.4 (24) once a year 3.2 (14) less than once a year 5.2 (23) never 66.9 (295) dfaq-cu free response items mean (range) 7. approximately how many days of the past month did you use cannabis? 7.16 (0.00 – 31.00) 11. how many times a day, on a typical weekday, do you use cannabis? 0.64 (0.00 – 10.00) the dfaq-cu and cannabis consequences 72 12. how many times a day, on a typical weekend, do you use cannabis? 1.13 (0.00 – 15.00) 17. in a typical session, how much marijuana do you personally use? (in grams) 0.69 (0.00 – 16.00) 18. on a typical day you use marijuana, how much do you personally use? (in grams) 0.66 (0.00 – 7.09) 19. in a typical week you use marijuana, how much marijuana do you personally use? (in grams) 2.33 (0.00 – 28.00) 20. on a typical day you use marijuana, how many sessions do you have? 1.18 (0.00 – 8.00) 22. in a typical session you use cannabis concentrates, how many hits do you personally take? 4.07 (0.00 – 30.00) 23. on a typical day you use cannabis concentrates, how many hits do you personally take? 5.20 (0.00 – 100.00) 24. how many hits of cannabis concentrates did you personally take yesterday? 1.65 (0.00 – 100.00) 25. on a typical day you use cannabis concentrates, how many sessions do you have? 1.55 (0.00 – 100.00) 27. when you eat edibles how many milligrams of thc do you personally ingest in a typical session? 75.15 (0.00 – 2000.00) 30. how old were you when you first tried cannabis? 16.25 (12.00 – 21.00) 31b. how old were you when you first started using cannabis regularly (2 or more times per month for 6 months or longer)? 17.29 (13.00 – 22.00) 31ci. how old were you when you first started using cannabis on a daily or near daily basis? 17.30 (14.00 – 21.00) note. for items presented as multiple choice items, the percent endorsement for each response is listed. for free response items, the mean and range of response is listed. table 2. component loadings of the daily sessions, frequency, age of onset, and quantity of cannabis use inventory using principal components analysis item principal component frequency age of onset concentrates typicality of use 2. which of the following best captures when you last used cannabis? .92 -.02 .23 .15 3. which of the following best captures the average frequency you currently use cannabis? .96 -.10 .12 .17 6. how many days of the past week did you use cannabis? .88 -.03 .24 .23 7. approximately how many days of the past month did you use cannabis? .92 -.02 .20 .24 8. which of the following best captures your pattern of cannabis use throughout the week? .39 -.34 -.13 .61 9. which of the following best captures the number of times you have used cannabis in your entire life? .88 -.10 .05 .07 cannabis, a publication of the research society on marijuana 73 10. how many hours after waking up do you typically first use cannabis? .61 -.29 .09 .70 11. how many times a day, on a typical weekday, do you use cannabis? .82 -.22 .09 .45 12. how many times a day, on a typical weekend, do you use cannabis? .81 -.15 .04 .47 17. in a typical session, how much marijuana do you personally use? .06 .04 .15 .61 18. on a typical day you use marijuana, how much do you personally use? .35 -.28 .15 .93 19. in a typical week you use marijuana, how much marijuana do you personally use? .45 -.23 .10 .82 20. on a typical day you use marijuana, how many sessions do you have? .49 -.37 -.00 .80 22. in a typical session you use cannabis concentrates, how many hits do you personally take? .11 -.09 .93 .06 23. on a typical day you use cannabis concentrates, how many hits do you personally take? .05 -.06 .84 .12 24. how many hits of cannabis concentrates did you personally take yesterday? .31 -.06 .78 .10 25. on a typical day you use cannabis concentrates, how many sessions do you have? .11 -.02 .72 .15 27. when you eat edibles how many milligrams of thc do you personally ingest in a typical session? -.25 -.17 .13 .66 30. how old were you when you first tried cannabis? -.32 .76 -.10 -.24 31b. how old were you when you first started using cannabis regularly (2 or more times/month)? -.05 .89 -.02 -.33 31ci. how old were you when you first started using cannabis on a daily or near daily basis? .18 .80 -.12 -.08 32. which of the following best captures the average frequency that you used cannabis before the age of 16? -.07 .85 -.10 -.06 note. bold text indicates that the item is included in the component as determined by component loadings ≥ .45. the dfaq-cu and cannabis consequences 74 and typicality of use components, suggesting overlap in these constructs. correlations between components ranged from -.25 (frequency and age of onset) to .90 (frequency and typicality of use; see table 3). items were included in any component in which the item exhibited a component loading of .45 or greater. as such, items 10 (typical hours awake before first use), 11 (typical sessions per weekday), 12 (typical sessions per weekend), 19 (typical weekly quantity), and 20 (typical daily sessions) were included on both the frequency and typicality of use components. although the present study applied names to the components, it should be highlighted that pca components are not latent variables, and component naming in this context was used to facilitate discussion of outcomes, not to imply causality of manifest items and creation of latent variables (borsboom, 2006; fried, 2020). comparing dfaq-cu components to a timeline follow-back measure of past month cannabis use, the frequency, concentrates, and typicality of use components yielded significant correlations with past month use days, average weekday quantity, average weekend quantity, cannabis consequences, and cud symptoms with the largest correlations observed for the frequency component followed by typicality of use (see table 6). interestingly, age of onset only resulted in a small, significant correlations with consequences and cud symptoms, but not measures of quantity or frequency. relations between dfaq-cu components and measures of alcohol frequency, and alcohol binge frequency yielded small-to-negligible correlations with all components. there were no significant correlations between dfaq-cu components and alcohol use disorder symptoms. principal axis factoring 1 using a promax-rotated solution with five factors specified per parallel analysis, the paf model resulted in solution accounting for 75.60% of the total variance (see table 4). the frequency factor (e.g., “how many days of the past week did you use cannabis?”) is comprised of eight items with loadings from .51 to .97. the typicality of use factor (e.g., “on a typical day you use marijuana, how many sessions do you have?”) is comprised of 10 items with loadings from .47 to .92. the concentrates factor (e.g., “how many hits of cannabis concentrates did you personally take yesterday?”) is comprised of four items with loadings from .65 to .92. the age of onset factor (e.g., “how old were you when you first started using cannabis regularly [2 or more times/month]?”) is comprised of four items with loadings from .72 to .88. finally, the quantity factor (e.g., “in a typical session, how much marijuana do you personally use?”) is comprised of four items with loadings from .58 to .85. correlations between factors ranged from -.21 (age of onset and concentrates) to .95 (frequency and typicality of use; see table 3). the paf model resulted in a high degree of cross-loading with 8 of 22 items loading onto two factors, primarily for frequency and typicality of use factors (six items), followed by the typicality of use and quantity factors (two items). notably, all items that cross-loaded loaded onto the typicality of use factor and one other factor, suggesting that this factor may not be distinct when modeling the dfaq-cu as reflective. this is further demonstrated by a correlation of .95 between the frequency and typicality of use factors. only the concentrates and the age of onset factors did not demonstrate any crossloading. the frequency (α = .94, ω = .95) and typicality of use (α = .94, ω = .93) factors evinced excellent internal consistency. the age of onset factor (α = .86, ω = .88), and quantity factor (α = .86) demonstrated good consistency and the concentrates factor (α = .75, ω = .84) was acceptable-to-good. h values for the factors ranged from .86 (concentrates) to .98 (quantity), suggesting that all paf factors demonstrate replicability and are considered well-defined latent variables. to assess the fit of the paf model, a confirmatory factor analysis (cfa) was conducted for the solution, resulting in an rmsea of .09 and a cfi of .86, suggesting suboptimal fit (hu & bentler, 1999). when the model was constrained such that items only loaded on to one component, 1 maximum likelihood factor analysis (mlfa) was also used as a reflective technique for the dfaq-cu as mlfa tends to outperform paf for models with unequal factor loadings (de winter & dodou, 2012). mlfa resulted in a similar factor structure as paf, similar fit to the data per cfi and rmsea, and similar relations with outcomes. however, mlfa had a greater number of items that cross-loaded (12 v. 8), accounted for less of the total variance for the dfaq-cu, and had higher correlations between factors compared to paf. as such, paf was selected for comparison to the pca. cannabis, a publication of the research society on marijuana 75 model fit worsened (rmsea = .10, cfi = .80). additionally, a cfa was conducted with the present data using the solution generated in the original dfaq-cu (cuttler & spradlin, 2017). this model resulted in an rmsea of .10 and a cfi of .83, again suggesting poor fit to the data. model comparisons and relations with outcomes mean scores for each participant on each component derived from the transformed data were used in the correlation analysis due to missing data attributable to dfaq-cu skip logic on items related to age of onset and concentrate use. examination of the relations among the pca components and paf factors found correlations ranging from -.27 to 1.00 (see table 3). pca components and paf factors that tapped similar constructs (age of onset and concentrates) showed correlations ranging from .92 to 1.00. though the paf model had similar factors as compared to the pca component solution, the amount of cross-loading in the paf model suggests differing outcomes as a result of modeling techniques with regard to simple structure (see figure 1). ordinal linear regressions were conducted to determine relations between pca components and cannabis-related consequences and use disorder symptoms (see table 5). examining cannabis consequences, the frequency and the typicality of use components evinced medium, positive relations with cannabis consequences such that as frequency and typical levels of use (e.g., quantity in a typical day) increase, the number of consequences incurred increases. the concentrates component evinced a small, positive relation cannabis consequences. age of onset evinced a small, negative relation with consequences such that earlier onsets of cannabis use was associated with greater number of consequences. effect sizes (r2) for these models ranged from .03 to .23. to determine if reflective modeling of formative variables results in overestimation of effects, univariate analyses were conducted to examine relations between paf factors as they relate to cannabis consequences with paf factors generally showing slightly larger effect sizes (see table 5). in particular, the age of onset factor exhibited the largest differences: the pca age of onset component resulted in an r2 of .07 with consequences compared to an r2 of .14 for paf age of onset factor with consequences. similar patterns between pca components and cud symptoms emerged. the frequency and the typicality of use components evinced medium, positive relations and the concentrates component evinced small, positive relations with cud symptoms. as with consequences, age of onset evinced a small, negative relation with cud symptoms. effect sizes (r2) for these models ranged from .03 to .18 for cud symptoms. again, the paf factors broadly showed larger effect sizes for relationships to both consequences and cud symptoms (see table 5). this difference was again most pronounced for the age of onset component with r2s of .03 and .07 respectively. table 3. correlations between principal components analysis mean values and principal axis factoring factor scores. component or factor 1 2 3 4 5 6 7 8 9 1. paf frequency 2. paf age of onset -.15 3. paf concentrates .36 -.21 4. paf typicality of use .95 -.20 .39 5. paf quantity .57 -.27 .52 .71 6. pca frequency .99 -.16 .38 .96 .63 7. pca age of onset -.15 1.00 -.21 -.20 -.27 -.16 8. pca concentrates .36 -.21 1.00 .39 .52 .38 -.21 9. pca typicality of use .85 -.25 .40 .92 .84 .90 -.25 .40 note. paf = principal axis factoring, pca = principal components analysis. all correlations are significant at p < .05. the dfaq-cu and cannabis consequences 76 table 4. item loadings of the daily sessions, frequency, age of onset, and quantity of cannabis use inventory using principal axis factoring item factor frequency typicality of use age of onset concentrates quantity 2. which of the following best captures when you last used cannabis? .93 .44 .03 .28 .07 3. which of the following best captures the average frequency you currently use cannabis? .97 .50 -.05 .18 .04 6. how many days of the past week did you use cannabis? .89 .47 .01 .29 .15 7. approximately how many days of the past month did you use cannabis? .93 .52 .04 .26 .12 8. which of the following best captures the number of times you have used cannabis in your entire life? .27 .70 -.27 -.01 .26 9. which of the following best captures your pattern of cannabis use throughout the week? .90 .35 -.07 .07 .07 10. how many hours after waking up do you typically first use cannabis? .51 .83 -.23 .19 .38 11. how many times a day, on a typical weekday, do you use cannabis? .72 .79 -.18 .21 .06 12. how many times a day, on a typical weekend, do you use cannabis? .71 .77 -.05 .16 .09 17. in a typical session, how much marijuana do you personally use .09 .26 -.05 .13 .81 18. on a typical day you use marijuana, how much do you personally use? .28 .79 -.28 .22 .85 19. in a typical week you use marijuana, how much marijuana do you personally use? .36 .80 -.20 .18 .62 cannabis, a publication of the research society on marijuana 77 20. on a typical day you use marijuana, how many sessions do you have? .34 .92 -.29 .13 .38 22. in a typical session you use cannabis concentrates, how many hits do you personally take? .16 .05 -.10 .92 .11 23. on a typical day you use cannabis concentrates, how many hits do you personally take? .07 .12 -.10 .85 .10 24. how many hits of cannabis concentrates did you personally take yesterday? .36 .10 -.09 .72 .21 25. on a typical day you use cannabis concentrates, how many sessions do you have? .13 .12 -.04 .65 .13 27. when you eat edibles how many milligrams of thc do you personally ingest in a typical session? -.27 .34 -.21 .14 .58 30. how old were you when you first tried cannabis? -.29 -.35 .72 -.14 -.23 31b. how old were you when you first started using cannabis regularly (2 or more times/month)? .03 -.42 .88 -.09 -.19 31ci. how old were you when you first started using cannabis on a daily or near daily basis? .23 -.13 .79 -.05 -.01 32. which of the following best captures the average frequency that you used cannabis before the age of 16? -.05 -.14 .84 -.12 -.12 note. bold text indicates that the item loads onto that factor. factor loadings ≥ .45 loaded onto the factor. the dfaq-cu and cannabis consequences 78 table 5. univariate linear regression of dsm-5 cannabis use disorder symptoms on the daily sessions, frequency, age of onset, and quantity of cannabis use inventory principal components and principal axis factoring factors cannabis consequences cannabis use disorder symptoms β r2 p β r2 p pca component frequency .38 .14 <.001 .39 .15 <.001 typicality of use .42 .17 <.001 .43 .18 <.001 concentrates .18 .03 .001 .16 .03 .003 age of onset -.26 .07 <.001 -.16 .03 < .001 paf factor frequency .39 .16 <.001 .40 .16 <.001 typicality of use .44 .20 <.001 .45 .20 <.001 concentrates .20 .04 .002 .17 .03 .01 age of onset -.37 .14 <.001 -.27 .07 <.001 quantity .48 .23 <.001 .52 .27 <.001 note. pca = principal components analysis, paf = principal axis factoring. table 6. correlations between dfaq-cu components and measures of alcohol and cannabis 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 1. dfaq-cu frequency 2. dfaq-cu age of onset -.16 3. dfaq-cu concentrates .38 -.21 4. dfaq-cu typicality of use .90 -.25 .40 5. past month cannabis frequency .83 -.11 .37 .67 6. average weekday cannabis quantity .33 -.06 .17 .37 .24 7. average weekend cannabis quantity .36 .00 .33 .51 .29 .75 8. cannabis consequences .34 -.07 .13 .37 .36 .04 .11 9. cud symptoms .34 -.10 .15 .37 .34 .12 .23 .67 10. past-year alcohol frequency .02 .04 .06 .00 .03 .04 .09 -.19 .15 11. past-year alcohol binges -.11 .07 -.11 -.14 -.07 .00 -.07 -.21 .20 .60 12. past-two week alcohol frequency -.09 -.02 -.01 -.12 -.04 -.04 -.02 -.16 .19 .60 .50 13. past-two week alcohol binges -.15 .10 -.09 -.19 -.07 -.13 -.13 -.16 .23 .40 .55 .60 14. aud symptoms .01 -.01 .07 .05 -.02 -.07 .14 .32 .39 .31 .30 .29 .28 note. dfaq-cu = daily sessions, frequency, age of onset, and cannabis use quantity questionnaire; cud = cannabis use disorder; aud = alcohol use disorder; weekday = monday – thursday; weekend = friday – sunday. bold indicates significance at p < .05. cannabis, a publication of the research society on marijuana 79 discussion the present study aimed to evaluate the structure of the dfaq-cu using reflective and formative modeling approaches. results of the current analyses suggest that 1) reflective and formative modeling result in different structures, highlighting the importance of selecting theoretically appropriate modeling techniques (e.g., borsboom et al., 2003; rhemtulla et al., 2020); 2) modeling formative items as reflective can result in overestimations of relations between constructs and outcomes; and 3) components of the dfaq-cu demonstrate evidence of convergent and discriminant validity with existing measures of cannabis and alcohol use. use of pca resulted in four components. the typicality of use component assesses an individual’s regular patterns of use; the frequency component assesses the number of uses in a given time frame; the age of onset component characterizes age of first use and first regular use; and the concentrates component measures the use of cannabis concentrates. conceptually, these components capture different facets of cannabis use and use patterns. the age of onset and concentrate components are comparable to cuttler and spradlin’s (2017) solution. however, the remaining components, though similar in name (e.g., frequency), are comprised of different core items. in the pca solution, the typicality of use component accounts for an individual’s typical pattern of use while the frequency component accounts for frequency in a given timeframe. these two components are distinct in that the frequency component could capture differences in recent use (e.g., decreased use in the past week due to studying for an exam). further, items of the frequency component are primarily likert-like items while the typicality of use component is comprised primarily of open-response items, which could partially explain relations between items of these components. of note, the typicality of use and frequency components have a correlation of .90, demonstrating a meaningful amount of overlap. overall, modeling the core items as formative resulted in a structure unique from the original reflective solution (cuttler & spradlin, 2017). this finding corroborates extant literature highlighting the importance of selecting theoretically appropriate models for evaluating the structure of assessment tools (e.g., borsboom et al., 2003; rhemtulla et al., 2020) and the development of practical constructs for outcome studies. though conceptual arguments suggest that the dfaq-cu should be modeled as formative, the present study also aimed to replicate the original factor structure of the dfaq-cu using reflective modeling (i.e., paf) which resulted in a five-factor solution with a high degree of crossloading, (i.e., 8 of 22 items) suggesting that reflective strategies does not result in simple structure and that there may be multicollinearity between factors. only the concentrates and age of onset factors resulted in items with no crossloading. ultimately, this pattern of findings suggests that when modeled as reflective, there may be limited distinguishability between items targeting frequency, quantity, and typical patterns of use. notably, the original dfaq-cu found correlations between factors ranging from .16 to .52 (cuttler & spradlin, 2017 p. 8), whereas we found much higher correlations among factors, up to .95. high correlations between factors further suggest that the factors originating from paf may not be capturing distinct facets of use. though some factors from cuttler and spradlin’s work have similar names and are comprised of identical manifest variables compared to the factors and components of the current study (e.g., age of onset), these factors resulted in different relations with other factors and cannabis use outcomes. this is consistent with extant literature highlighting that latent variables thought to be similar across studies can result in discrepant relations with outcomes (e.g., levin-aspenson et al., 2020). notably, fit indices derived using cfas of the present paf model and using cuttler and spradlin’s original structure resulted in poor fit to the data, further highlighting that reflective models may not be appropriate for this measure. it is worth noting here that pcas are data transformations and are not subject to fit indices such as cfi and rmsea. the poor fit of the cfa models add support to the need to reevaluate the dfaq-cu, but do not suggest that the pca “fits” the data better; rather, the data is more appropriate for formative models. using pca, the typicality of use and frequency components yielded medium size associations with cannabis use consequences and cud symptoms. the concentrates and age of the dfaq-cu and cannabis consequences 80 onset components yielded small effects. overall, findings suggest that regularity of use and typical use behaviors are the strongest indicators of both cannabis-related consequences and cud symptoms. this finding mirrors extant literature that reports strong relations between frequency of use and cannabis problems (e.g., pearson, 2019), which may be because more frequent/regular use likely results in more opportunities to incur negative consequences because of use. importantly, in line with rhemtulla et al. (2020), there were higher correlations among paf factors compared to pca components, and regressions between paf factors and outcomes resulted in larger effect sizes than models examining pca components and outcomes. with the rationale described by rhemtulla et al. (2020) in mind, these results indicate inflated estimates when using reflective modeling with formative variables. said another way, using reflective models when formative models are more conceptually appropriate may significantly bias findings by over-estimating the relations between variables and outcomes of interest. this risk of estimate inflation has important clinical implications for cannabis use and psychopathology more broadly. if clinical decision making is partially grounded on self-report assessment responses that were modeled incorrectly, we may be making evaluations of risk or treatment selection based on inflated effect sizes. for example, using the dfaq-cu modeled as reflective, concentrates and age of onset resulted in doubling of their effect sizes compared to the pca. if this effect were multiplied over several studies (e.g., using meta-analysis), researchers and clinicians may conclude that age of first use is a strong indicator of risk for cud and this could result in potentially inappropriate treatment referrals based on an early age of first use regardless of current pattern or use of resources being used for intervention development specifically for those with earlier age of onset. broadly, the components of the dfaq-cu demonstrated evidence of convergent and discriminant validity with measures of cannabis and alcohol use. the dfaq-cu components correlated most highly with other measures of cannabis frequency and cannabis outcomes as compared to alcohol use and symptoms. in particular, the frequency and typicality of use components evinced moderate-to-large correlations with cannabis use measures but negligible-to-small correlations with alcohol measures. the concentrates component had small-to-moderate correlations with cannabis outcomes and negligible relations to alcohol measures. the exception was the age of onset component which elicited small correlations with cannabis consequences and cud symptoms as well as alcohol binge frequency. it is likely that this pattern occurred as individuals with an earlier age of cannabis use onset are also at increased risk of heavy alcohol consumption (nelson et al., 2015; schauer et al., 2020). additionally, all four components were moderately-to-highly correlated with measures of cannabis consequences and cud symptoms, suggesting predictive utility of the dfaq-cu. overall, findings of the present study indicate that modeling strategies result in differing structures. the present sample was comprised of college students in a location without legalized cannabis, whereas cuttler and spradlin’s sample was assessed in a state with legalized medicinal and recreational cannabis. although both samples were predominately white and female, the present sample had more hispanic/latinx students whereas the cuttler & spradlin sample had more asian and black participants. these contextual and demographic factors may have played a role in differences in factor/component structures and correlations between studies. however, given the arguments in favor of formative modeling strategies for the type of constructs most relevant to cannabis use, measures aiming to understand cannabis use behaviors should carefully consider modeling approaches during measure development. limitations and future directions several limitations of the proposed study warrant discussion. the dfaq-cu asks participants about their primary form and forms used at least 25% of the time, however, it may be important to assess any lifetime use of cannabis forms in addition to regularly used forms. additionally, although the dfaq-cu aimed to mitigate several issues with earlier cannabis assessments, it still lacks core items assessing potency and other facets of use. further, the use of skip logic contributed to missing data related to cannabis, a publication of the research society on marijuana 81 concentrates and age of onset, which necessitated the use of component means when examining correlations and outcomes. however, in pca modeling, components scores are typically derived by multiplying an individual’s score on each item by the corresponding eigenvector and summing these values to create a singular score for each component, which was not possible in this case. globally, this points to a larger weakness in the dfaq-cu as a whole. namely, as a result, true component scores for the dfaq-cu cannot be calculated without bias, necessitating that “components” be calculated as the means of the individual items within a component. additionally, the 95% confidence interval was used for parallel analysis to determine factor and component retention. though this approach is considered strong, it should be noted that using the mean eigenvalue as opposed to the 95% confidence interval is best for highly correlated factors whereas the 95% confidence interval is best for factors and components with 6 or more items (crawford et al., 2010). the present structure resulted in moderate-to-high correlations between components and factors and 4 to 10 items per component or factor. lastly, despite anonymity of participant responses cannabis possession was illegal in texas at the time of data collection, so participants may have underreported their use. in response to the outcomes of this study and considering the limitations, several future directions for research are offered. first, the dfaq-cu will require further replication of its formative structure and, ideally, modification of skip logic to allow for more appropriate calculation of pca component scores. importantly, the present work offers a theoretical argument for use of a formative approach. however, there are analytic techniques such as tetrad confirmatory analyses (bollen & ting, 1993) that could empirically indicate model selection. presently, packages for use of these methods are not widely available but as access to this methodology increases, empirical selection of formative compared to reflective modeling is needed. second, the dfaq-cu assesses several methods of administration (e.g., loose leaf, concentrates, edibles). it is relevant to consider method of administration as quantity estimates also differ as a function of method (e.g., mariani et al., 2011), and even moderate-to-heavy users of cannabis have difficulty estimating the quantity of their use (prince et al., 2018). as such, work relying on self-reported cannabis quantity should be replicated using alternative measurement techniques (e.g., weighing individuals’ self-made cannabis products; prince et al., 2018) before drawing conclusions on relations between quantity of use and outcomes. third, understanding how the components of the dfaq-cu relate to outcomes (e.g., consequences, cud symptoms) across different timeframes and contexts would yield interesting findings. for example, future works should assess if strength of relations between components and outcomes differ by college attendance status. additionally, item response analyses to understand which items in particular are most apt at predicting risk could help to create a brief screening measure that could be applied in various settings (e.g., primary care) and reduce potential redundancy in items. future work should also consider not only the number of use sessions per day, but the timing of these sessions, which can impact cannabis-related problems (e.g., babson et al., 2017, bolla et al., 2008; drazdowski et al., 2019; earleywine et al., 2016). finally, measurement of cannabis use is lacking in its ability to assess potency of cannabis products, which is hampered due to wide variability across measurement methods, strains, and product stability (jikomes & zoob, 2018). recent innovations such as the purpl pro have increased ability to assess thc content (trull et al., 2022) and could improve our understanding of the role of thc concentration in predicting subsequent outcomes. more broadly, the present findings lend support to the importance of model selection and the potential risks of misdisattenuation. these issues reach beyond the dfaq-cu and may impact any survey-based research. careful evaluation of existing measures is warranted to determine if the model structure and scoring is appropriate for items and if not, replication of existing research is needed to determine if there is evidence of inflated estimates across measures and associated outcomes. conclusions overall, this work suggests that disparate modeling techniques can result in different the dfaq-cu and cannabis consequences 82 solutions. these discrepancies may have substantial implications for the constructs being evaluated and the relevance of these constructs for outcomes of societal and clinical interest. as such, model selection should be carefully considered during measure development and in outcome studies. regarding the dfaq-cu, the two modeling approaches failed to yield simple structure using two modeling approaches. replications of the dfaq-cu may want to considering reducing potentially redundant items to minimize overlap between components. further, the use of skip logic, particularly in relation to concentrate use and age of onset, necessitated the use of averages to create component scores as opposed to use of eigenvector multiplication. presently, the flaws inherent in the assessment (e.g., skip logic) in addition to a potential lack of simple structure for both modeling approaches suggests that the dfaq-cu may not be suitable for use in its current form. however, if the dfaq-cu were modified to eliminate skip logic and potentially redundant items, use of formative modeling on an updated version of the measure could be appropriate and useful. references american psychiatric association. 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(2012). a ‘standard joint’? the role of quantity in predicting cannabis-related problems. addiction research & theory, 20(1), 82-92. https://doi.org/10.3109/16066359.2011.569101 funding and acknowledgements: the submitted manuscript was not funded by any internal or external funding sources. the authors have no conflicts of interest to report. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://doi.org/10.1046/j.1360-0443.2000.951116697.x https://doi.org/10.1046/j.1360-0443.2000.951116697.x https://doi.org/10.1016/j.drugalcdep.2017.09.035 https://doi.org/10.1016/j.drugalcdep.2017.09.035 https://doi.org/10.1111/add.15872 https://doi.org/10.1016/j.drugpo.2016.01.015 https://doi.org/10.1016/j.jhealeco.2015.03.007 https://creativecommons.org/licenses/by/4.0/ 2022 rsmj abstracts for publication special section conference abstracts 85 special section editor benjamin o. ladd, ph.d. keynote addresses cannabis research at nida: implications for public health marsha lopez nih/national institute on drug abuse advances in adolescent cannabis use disorder: bridging science and practice robert miranda jr. brown university poster presentations all poster presentations and symposia were peerreviewed by the 2022 conference program committee of the research society on marijuana (rsmj) (bradley t. conner, colorado state university, benjamin o. ladd, washington state university vancouver, kristina t. phillips, kaiser permanante, verlin joseph, university of new mexico, kirstyn smith-lecavalier, university of washington). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. the power of placebo: does cannabidiol (cbd) expectancy alone impact acute stress and anxiety? toni c. spinella, sherry h. stewart, julia naugler, igor yakovenko, sean p. barrett (dalhousie university) background. there have been notable increases in the use of cannabidiol (cbd) for therapeutic purposes, such as in the treatment of stressand anxietyrelated disorders. preliminary research has demonstrated that cbd decreases indices of stress and anxiety. however, drug effects in humans are thought to be comprised of both pharmacological properties as well as a placebo response. little is known about the extent to which the purported therapeutic effects of cbd result from pharmacological versus expectancy factors. aims. the aim of this study was to evaluate whether (i) cbd expectancy alone could influence stress, anxiety, and mood, and (ii) the extent to which beliefs regarding cbd effects predicted these responses. generalized estimating equations (gee) were used to evaluate the research questions of interest. methods. in this randomized crossover study, 43 health adults (23 women) attended three laboratory sessions. during the first session, they were oriented to the study and rated the extent to which they believed that cbd helped with stress, anxiety, and mood. they then participated in two identical experimental laboratory sessions, where they self-administered cbd-free hempseed oil sublingually. during one session, they were (incorrectly) informed that the oil contained cbd and in the other session, that the oil was cbdfree. following administration, participants engaged in the maastricht acute stress test (mast) to induce moderate levels of stress and anxiety. heart rate variability (hrv) was assessed continuously, and subjective state (i.e., stress, anxiety, mood, other subjective states) was assessed at baseline, 90-min following oil administration, immediately following the mast, and after a 10-min recovery period. results. the cbd expectancy condition was associated with increased sedation as well as significant fluctuations in hrv that could indicate heightened anticipatory stress regulation. overall, there were no observed changes in subjective stress, or anxiety, according to expectancy condition. however, participants abstracts from the 2022 scientific meeting of the research society on marijuana july 22nd-24th, 2022 cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.000 conference abstracts 86 who endorsed the strongest a priori beliefs about cbd possessing anxiolytic properties reported significantly lower anxiety in the cbd expectancy condition and higher anxiety the cbd-free expectancy condition. conclusions. results from this study indicated that cbd expectancy alone impacted several subjective and physiological responses. additionally, expectancy-related factors were implicated in anxiolytic effects of cbd for those who strongly believed it was helpful for such purposes, suggesting that expectation plays some role in the purported stressand anxietyreducing effects of cbd. findings from this study emphasize the need to measure and control for cbd-related expectancies in clinical research that involves the administration of cbd. future investigations would benefit from replicating these findings and using a full balanced-placebo research design to elucidate the relative contributions of pharmacology and expectancy. effects of cannabidiol with and without other cannabinoids and terpenes on short-term and long-term stress-related behaviors mariam melkumyan, nicole lookfong, wesley raup-konsavage, kent vrana, yuval silberman (penn state college of medicine) introduction: stress-related disorders, such as anxiety and post-traumatic stress disorder, are a primary reason for treatment (and selfmedication) with medical cannabis products. research suggests endocannabinoids regulate neurotransmitters involved in stress but whether phytocannabinoids such as cannabidiol (cbd) reduce stress behaviors is not fully established. to that end, we sought to examine how cbd with and without other cannabinoids or terpenes might alter behavior in mouse models of short-term and long-term responses to acute stressors. methods: for short-term stress responses, adult male c57bl/6j mice received a 30-60-minute restraint stress followed by testing with open field and light-dark box tests. mice were treated with vehicle, cbd (10mg/kg), or cbd with low dose delta-9-tetrahydrocanabinol (thc, 2.5mg/kg and 7.5 mg/kg cbd for 10mg/kg total cannabinoid content) 45-60 minutes prior to stress exposure. for long-term stress behavior, mice underwent conditioned place avoidance to restraint plus predator odor contexts, with controls receiving individual stressors or no stress. avoidance to the stress paired context was examined 1, 7, and 28 days later. groups received vehicle, cbd (3.07 mg/ml cbd, 3mg/kg cannabigerol, low terpenes), cbd+thclo-terp (3.07 mg/ml cbd, 3mg/kg cannabigerol, 0.76 mg/ml thc, low terpenes), or cbd+thchi-terp (3.29 mg/ml cbd, 3mg/kg cannabigerol, 0.76 mg/ml thc, high terpenes) 3045 minutes after stress exposure. researchers were blinded to treatment conditions during all analyses. results: in the short-term experiments, mice treated with cbd trended towards an increase in the time spent and decreased latency to enter the light side of the light-dark box compared to vehicle, suggesting reduced anxiety-like behaviors. additionally, cbd treated mice showed reductions in freezing, immobility time, and latency to enter the center of the open field compared to vehicle treated mice, with no differences in the time spent in the center of the field. cbd+thc treatment showed no significant differences compared to vehicle. in the long-term experiments, mice exposed to restraint plus predator odor showed reduced time spent in the stress paired chamber on days 1, 7, and 28 poststress, although there did appear to be stress susceptible and resilient mice in this paradigm. avoidance behaviors were not seen when stressors were presented individually or if no stress was used. in this paradigm, cbd+thcloterp was the only treatment to reduce avoidance behavior at the post-stress time points tested. conclusions: these results suggest that cbd has a differential effect on anxiety-like behaviors based on type of stress, post-stress timing of behavioral testing, and cbd/thc/cannabigerol/terpene content. further studies are needed to uncover the effect of phytocannabinoids on short-term and long-term stress responses as well as related neurotransmitters and circuitries driving these effects. “i just smoke marijuana, which is not a drug, and cigarettes, which is a drug”: health perceptions of cannabis use among african american tobacco smokers cherell cottrell-daniels, bethany shorey fennell (moffitt cancer center) conference abstracts 87 cannabis and tobacco co-use has increased in recent years, including co-administration, in which tobacco and cannabis are consumed simultaneously. one common method of coadministration is the use of blunts, in which cigars or little cigars and cigarillos (lccs) are combined with cannabis. lcc use is associated with negative health outcomes and is elevated among black/african american populations and lower income adults. little is known about health perceptions of lccs among these populations, particularly as it relates to cannabis use. we report results from a mixed-methods study examining multiple tobacco use among african american adults. participants (n=22) were largely single (81.8%), male (59.1%), and had an annual household income of less than $30,000 (72.7%). all participants used combustible cigarettes in the past month (m days=26.23, sd=7.38) and the majority (91.0%) used lccs in the past month (m days=14.24, sd= 0.67). of these, 50.0% reported using lccs with cannabis all or some of the time. participants who reported co-use smoked lccs marginally more days (m=18.45, sd=11.88) than those who used lccs alone (m=9.60, sd=7.12, t(19)=-2.04, p = .055, d=.89). perceptions of the health risks of lccs compared to combustible cigarettes were variable among those who reported co-use and those who did not. for example, 45.5% of co-users vs. 20.0% lcc only users said they “don’t know” if lccs are more or less harmful than cigarettes, whereas 27.3% of co-users and 10.0% lcc only users thought lccs were “more harmful.” there was no difference between the groups on overall relative risk perceptions (χ2(3)=4.25, p=.24). semistructured interviews assessed tobacco use motives, including cannabis consumption, risk perceptions, and stress. similar to quantitative indices, participants reported variable perceptions of the health risks associated with couse of cannabis and tobacco. for example, a number of participants indicated that smoking lccs with cannabis may be healthier than smoking them with the original tobacco inside. many reported different motives for seeking out cannabis vs. nicotine (e.g., coping with stress, social situations). quotations from qualitative interviews will be included on the poster. in conclusion, health risk perceptions among this sample demonstrate the need for clearer public health messaging regarding tobacco products and co-use with cannabis. cannabis nomenclature: perceptions and preferences among women of reproductive age kara skelton, erin donahue (towson university) background: cannabis use among women of reproductive age has been rapidly increasing over the past decade in the united states (us). effective communication about risks of cannabis use is essential for preventing adverse health effects. however, prevention efforts, including public health messaging and clinician-directed communication often interchange the terms marijuana and cannabis. few studies have examined how women perceive cannabis terminology to guide the development of cannabis prevention efforts. methods: in april of 2021, we recruited women of reproductive age (18-40 years) for an online survey. we collected sociodemographic information and asked women about their knowledge of and attitudes towards cannabis, including perceptions of cannabis terminology. we used descriptive statistics and chi-squared tests to examine variations in cannabis terminology perceptions and preferences across sociodemographic characteristics and state-level cannabis policies. results: our sample (n=166) consisted of predominantly low-income (52.63%), white (77.19%) women, of whom 58.9% were currently pregnant or pregnant within the last 2 years. about 23.49% of women perceived the word marijuana to reference the smoked form of the plant only (e.g., joint). although not statistically significant, more women residing in states where recreational cannabis was legal were more likely to report this perception (26.56%) compared to women residing in states yet to legalize cannabis (21.57%). overall, most women (62.42%) preferred that the term, cannabis should be used when referencing thc-containing products. conclusions: future cannabis prevention efforts should consider these findings when designing interventions and public health campaigns to address cannabis use among women of reproductive age, including pregnant women. conference abstracts 88 the impact of cannabis edible packaging elements on appeal, harm perceptions and knowledge: an experimental study among a national convenience sample of adults in the united states beth a. reboussin, kimberly g. wagoner, erin l. sutfin, jennifer cornacchione ross, cynthia k. suerken, edgar alfonso romero-sandoval (wake forest school of medicine) allison j. lazard (university of north carolina at chapel hill) the state-legalized cannabis industry is rapidly evolving, and regulators lack scientific data as to how product packaging should be regulated to protect public health. cannabis edibles in particular pose unique public health and regulatory challenges. while smoking cannabis results in an immediate high, intoxication from consuming edibles can be delayed up to 2 hours or more which can lead to overconsumption of thc, particularly by naïve users. the packaging of edibles as appealing food products may also reduce harm perceptions. the goal of this pilot study was to examine the impact of flavor imagery and a cannabis warning on product appeal, harm perceptions, knowledge, and willingness to try edibles. we recruited a convenience sample of 700 adults ages 19-79 (mean age 38), 52% female, 77% white, 14% hispanic, 59% college-educated from amazon mechanical turk (mturk). participants were randomized to one of four experimental conditions to view a cannabis edible package that varied by presence of fruit imagery (yes/no) and type of warning (washington state cannabis warning; control warning). more than half of our sample had tried edibles and 36% were current users. participants viewing packages with fruit imagery were significantly more likely (p&lt;0.05) than participants viewing packages without fruit imagery to think the product was appealing (69% vs 39%) and safe to consume (69% vs 52%) and were more likely to want to try the product (58% vs 39%). among participants exposed to the cannabis warning, only 42% believed the package clearly indicated how to safely consume it and fewer than half knew the correct serving size, which was not significantly different than those not viewing the warning. only 17% of those viewing the warning knew the effects could be delayed by more than two hours. these results provide preliminary evidence of the impact of product packaging on appeal, knowledge, harm perceptions and willingness to try cannabis edibles and demonstrate the need for improved, edible-specific warnings to educate consumers about safe use. are cannabis use motives and consequences stronger by gender? katie r. moskal, jenni b. teeters (western kentucky university) background: cannabis is the most commonly used federally illicit substance among emerging adults (18-25). as cannabis use rates increase it is important to further understand reasons why individuals use cannabis and the problematic consequences of cannabis use. previous research has shown a variety of gender differences in recreational use vs. medical use, methods of cannabis use, and consequences related to cannabis use. however, little is known about gender differences in cannabis use motives and consequences related to cannabis use. to further understand the differential impact of cannabis use motives on problematic cannabis use, the present study examined whether gender moderated the connection between cannabis use motives and cannabis-related problems. it is hypothesized that gender will moderate the connection between cannabis use motives and cannabis-related consequences. method: 401 emerging adults (51.9% female; 59.1% caucasian) completed an online survey assessing gender, frequency of cannabis use, cannabis use motives, and cannabis related problems. motives for cannabis use were measured using the comprehensive marijuana motives questionnaire (cmmq) and problems related to cannabis use was measured using the marijuana problems scale (mps). the cmmq consists of 36 items that assess 11 subtypes of cannabis use motives including alcohol, celebration, relative low risk, conformity, boredom, altered perception, sleep, availability, social anxiety, coping, and enjoyment. bivariate correlations were used to examine the association between cannabis use motives, consequences related to cannabis use, and gender. moderation analyses were then conducted to assess whether gender moderated the relationship between each cannabis use motive and consequences related to cannabis use. conference abstracts 89 results: bivariate correlations revealed significant positive correlations for each cannabis use motive and consequences related to cannabis use (alcohol r = .28, p < .001 , celebration r = .20, p =.01, relative low risk r = .29, p < .001, conformity r = .23, p = .003, boredom r = .49, p < .001, altered perception r = .47, p < .001, sleep r = .30, p < .001, availability r = .29, p < .001, social anxiety r = .41, p < .001 , coping r = .45, p < .001 , and enjoyment r = .31, p < .001). several moderation analyses revealed gender moderated the relationship for cannabis use motives and cannabis related consequences, but only for boredom motives (95% ci [-.75, -.26]), altered perception motives (95% ci [-.52, -.03]), availability motives (95% ci [-.85, -.28]), coping motives (95% ci [-.72, -.21]), and sleep motives (95% ci [-.67, -.18]). the connection between each of these motives and cannabis-related problems was significantly stronger for males vs. females. conclusions: the results indicate that gender moderated the relationship between boredom motives, altered perception motives, availability motives, coping motives, and sleep motives and cannabis-related problems. the connection between these motives and cannabis-related problems was significantly stronger for males, suggesting that males who use cannabis for these reasons may be at elevated risk for experiencing cannabis-related problems relative to females who use cannabis for these reasons. interventions that target cannabis-related problems may benefit from tailoring intervention elements based on gender. motives and consequences associated with solitary alcohol and cannabis use among cousers during the covid-19 pandemic ayla sadeghi, kyra farrelly, jeffrey d. wardell (york university) background: the covid-19 pandemic resulted in lockdowns that had an impact on alcohol and cannabis use behavior. during the height of the early lockdowns, many individuals shifted to using alcohol and cannabis in solitary contexts (e.g., wardell et al., 2020). solitary drinking is a non-normative behaviour that can predict severe alcohol problems and is associated with copingmotivated drinking (keough et al. 2018; skrzynski & creswell, 2020). similarly, solitary cannabis use is associated with cannabis use disorder and using cannabis to cope (spinella et al., 2019). further, co-use of alcohol and cannabis is related to negative consequences such as alcohol use disorder, depressive symptoms, and impaired driving (yurasek et al., 2017). as there has been limited research on solitary alcohol and cannabis co-use, this study examined substance use motives and consequences associated with solitary use of both alcohol and cannabis among co-users during the pandemic. methods: canadians (n=149; 46% female; mean age = 31 years old) who reported co-use of alcohol and cannabis completed an online survey approximately 6-8 weeks into the first covid-19 lockdown. participants reported on past 30-day alcohol and cannabis use, solitary use, motives, and problems (i.e., short inventory of problems and marijuana problems scale). participants were divided into two groups: those reporting predominantly solitary use of both alcohol and cannabis during the lockdown (solitary co-users; n=61) and those reporting predominantly social use of one or both substances during the lockdown (social co-users; n=88). logistic regression was used to examine the unique associations of drinking motives and cannabis motives with couse group (solitary vs. social), and to examine if the solitary co-use group was more likely to report alcohol and cannabis problems (controlling for alcohol and cannabis use). results: coping motives for drinking were associated with greater likelihood of being in the solitary vs. social co-use group after controlling for other drinking motives and alcohol use (or=2.02, p=.023). conversely, none of the cannabis use motives were significantly associated with membership in the solitary vs. social co-use group. additionally, compared to social co-users, solitary co-users had higher odds of reporting alcohol problems, including one or more physical problems (or=2.37, p=.033), intrapersonal problems (or=3.95, p=.002), and social problems (or=2.79, p=.022), after controlling for alcohol use. cannabis-related problems did not differ between solitary and social co-users. conclusions: findings provide insight into the motives and consequences of solitary alcohol and cannabis use among co-users during the early stages of the covid-19 pandemic. these findings suggest that interventions should target co-users who are using both alcohol and cannabis in a solitary context during the pandemic as they conference abstracts 90 appear to be at higher risk for alcohol-related problems. future research should examine the long-term outcomes of solitary co-use throughout the covid-19 pandemic. given that it is not known if the solitary co-users in this study were engaging in simultaneous use of cannabis and alcohol (i.e., using both substances on the same occasion), future ecological momentary assessment (ema) studies should focus on understanding solitary simultaneous use during the pandemic. medicinal versus recreational cannabis use among youth: a systematic review nicolle fox, olivia canella, jeffrey d. wardell (york university) background: adolescents and young adults have high rates of cannabis use. although a sizeable portion of youth report that they use cannabis for medicinal reasons (wardell et al., 2020; wardell, in press), most research on youth cannabis use tends to focus on recreational use. it is important to understand how youth who use cannabis for medicinal reasons differ from those who use for recreational reasons. we aimed to review the limited research comparing youth engaging in medicinal cannabis use to those engaging in recreational cannabis use. methods: a systematic literature search of three databases (psychinfo, pubmed, medline) was conducted to identify studies that compared adolescents and/or young adults who engage in medicinal cannabis to those who engage in recreational cannabis use. studies that defined medicinal cannabis use either as self-reported use of cannabis for therapeutic reasons or as obtaining authorization/prescription for medical cannabis from a healthcare provider were included. only quantitative research studies published in a peerreviewed journal were included. after conducting the initial search and removing duplicates, 748 abstracts were reviewed independently by two researchers. any discrepancies were resolved by consensus in consultation with a third researcher. results: a total of 13 articles met inclusion criteria. outcome variables reported in the literature included cannabis use (frequency and amount), cannabis-related problems, use of other substances including illicit drug use or prescription medication misuse, and healthrelated variables such as mental health symptoms or physical pain. overall, the literature suggests that youth who use cannabis medicinally are more likely to use greater amounts of cannabis, to use more frequently, and to use a variety of different forms of cannabis, relative to youth who use cannabis recreationally. further, several studies reported that medicinal cannabis use among youth was associated with problems related to cannabis use, such as the risk for cannabis use disorder and problematic behaviour (e.g., driving under the influence). several studies also found that medicinal (vs. recreational) cannabis use was related to poorer mental or physical health, although a couple of studies did not support this finding. however, the results were mixed regarding the associations between medicinal cannabis use and the likelihood of using other drugs. conclusion: there is evidence that using cannabis for medicinal reasons is associated with greater cannabis consumption, cannabis-related problems, and negative health-related correlates among youth. although there was some consistency in findings across studies, the limited number of studies make it difficult to draw firm conclusions. causal inferences are difficult to make owing to the frequent reliance on crosssectional designs. the findings are further complicated by the heterogeneous definition of medicinal cannabis use (i.e., self-report vs. medically authorized). given that many young people engage in both medicinal and recreational cannabis use, it is difficult to fully disentangle the differences. additional research is needed for a complete understanding of the unique outcomes associated with medical cannabis use among youth. differences in alcohol and cannabis motives among simultaneous, concurrent, alcohol-only, and cannabis-only users katherine a. berry, alison looby (university of wyoming) stimulant norms and prevalence (snap) study team substance use motives are strong predictors of alcohol and cannabis use and consequences among college students. both simultaneous alcohol and cannabis (i.e., marijuana; sam) and concurrent alcohol and cannabis (i.e., marijuana; cam) use are associated with higher endorsement conference abstracts 91 of certain types of motives compared to single drug-only use, which may explain heightened risks for experiencing negative consequences evidenced by co-users. understanding whether motives differ according to type of use could provide an important avenue for intervention efforts; however, research has not yet examined if motives differ between sam and cam users. thus, the purpose of this study was to examine how sam, cam, and single drug-only users differ on alcohol and cannabis motives. participants were 2295 college students (72.4% female, 50.6% white) from seven us universities who reported past-month alcohol and/or cannabis use (41.2% sam, 12.4% cam, 39.1% alcohol-only, 7.3% cannabis-only). participants completed measures of alcohol and cannabis motives and past-month substance use frequency via online survey. two multivariate analyses of covariance (mancova) models were conducted to examine differences on cannabis motives (i.e., enjoyment, celebration, conformity, and coping) and alcohol motives (i.e., social, coping, enhancement, and conformity) separately by past-month user status, controlling for sex and frequency of use. the overall cannabis model was significant, with between-group effects on conformity (f(2,1398)=3.90, p=.02), coping (f(2,1398)=6.96, p=.005), and celebration (f(2,1398)=5.83, p=.015) motives. pairwise comparisons utilizing a bonferonni-corrected alpha (p<.017) indicated that sam users endorsed greater coping (p=.002) and celebration (p=.004) motives than cam users. moreover, cannabisonly users held greater coping motives than cam users (p=.009). sam and cannabis-only users did not differ on any motives. the overall alcohol model was also significant, with between-group effects on all four alcohol motives. pairwise comparisons indicated that sam users endorsed greater social (p=.012), coping (p=.003), and enhancement (p<.001) motives than cam users. moreover, sam users were higher on all four motives (all ps<.01) than alcohol-only users, and cam users were higher on social motives (p=.013) than alcohol-only users. results indicate that sam and cam users can be importantly differentiated by alcohol and cannabis motives, with sam users reporting greater motives for use related to coping with negative mood and enhancing positive mood/celebrating for both substances. interestingly, sam users did not differ from single drug-only users on cannabis motives, though they uniformly reported greater alcohol motives. given that sam users reported stronger enhancement and coping motives than cam users across both drugs, it is possible that college students may opt to combine their substances when they are predominantly motivated to use for mood-related reasons. considering that sam users only differed from single-drug users with regard to alcohol, but not cannabis motives, it may be that simultaneous use particularly enhances alcohol-related desirable outcomes, though not necessarily desirable cannabis outcomes. as such, intervention efforts designed to reduce sam use may benefit from specifically targeting alcohol and mood-related motives. moreover, research is needed to examine the within-person effects that motives may have on type of use. marijuana beliefs andrew p. weinstein, clayton neighbors (university of houston) cannabis has routinely been identified as one of the most frequently used illicit substances among adolescents, young adults, and the general adult population in the united states by epidemiological studies. recent policy changes in legal status have inspired calls for replication and further research on the biopsychosocial relationships between cannabis use and related outcomes. theoretical psychological perspectives of behavior, such as outcome expectancies, social norms, and motivation, have found success in explaining aspects of why substance use occurs. previous studies suggest that there are also underlying motivations, expectancies, and social norms for discontinuing use and maintaining abstinence-oriented behaviors. the present study sought to identify beliefs about cannabis as a substance in the process of constructing a measure of cannabis-related beliefs able to evaluate populations of cannabis users and nonusers. we will examine two important types of validity for new measures in unique content areas; distinguishing them from existing measures, (i.e. construct validity) and evaluating the ability to predict meaningful scores on other measures (i.e. predictive validity). we will examine the relationships among cannabisrelated beliefs in the context of social norms, expectancies, and motivation as well as the conference abstracts 92 associations with indicators of psychosocial wellbeing and cannabis-related consequences. thus, results will indicate if the proposed cannabis beliefs scale possesses validity as another approach to evaluating this area of substancerelated perceptions among more general populations than substance users alone. the influence of anxiety and avoidant coping style on probable cud madison stout, juan barrera-barker, alexis blessing, patricia d. russell, sandra b. morissette (university of texas at san antonio) introduction: cannabis is frequently used to cope with anxiety symptoms (sexton et al., 2016). unfortunately, individuals with anxiety are also at greater risk for developing probable cannabis use disorder (cud; marel et al., 2019), although mechanisms are not well understood. previous literature suggests avoidant coping styles (avc) are associated with higher anxiety levels, whereas action oriented coping styles (aoc) are associated with lower anxiety levels (ribadier & varescon, 2019). while cannabis coping motives are a significant predictor of probable cud for those with anxiety (buckner & zvolensky, 2014), no research has identified how anxiety and specific coping styles predict probable cud. the aim of the present study was to determine how avc and aoc interact with anxiety to predict the presence of probable cud. it was hypothesized that overall individuals with high anxiety would be more likely to endorse probable cud than low anxiety. among both anxiety levels, avc would be more likely to have probable cud than those with low avc. furthermore, individuals with high anxiety and high aoc would be less likely to have probable cud, compared with those with low aoc, even when anxiety is high. methods: college students (n = 371; 72.2% female) who used cannabis in the past six months were recruited as part of a study examining the influence of cannabis use on academic success. participants completed self-report measures to assess anxiety (dass-21), coping (b-cope), and probable cud (cudit-r). a confirmatory factor analysis was used to derive coping subscales using items from the b-cope (grosso et al., 2014). results: the data was analyzed through a logistic regression conducted in hayes process macro. even after controlling for gender, anxiety (b = .032, se = .016, p = .046) was a positive significant predictor of probable cud, however neither aoc (b = .030, se = .025, p = .221) or avc (b = .048, se = .056, p = .392) were significant predictors of probable cud. the interaction between anxiety x avc on probable cud was significant (b = -.011, se = .005, p = .026), indicating that those with low anxiety and high avc were more likely to have probable cud than those with low anxiety and low avc; however, this interaction did not apply when anxiety levels were high. the interaction between aoc and anxiety was not significant (b = .004, se = .003, p = .134), which did not support our initial hypothesis. discussion: even when anxiety levels are low, individuals with higher avc are more likely to endorse probable cud. in contrast, individuals with higher anxiety are more likely to exhibit probable cud, regardless of avc levels. interestingly, anxiety and aoc did not interact to predict probable cud, suggesting that risk for cud may be more about what people avoid than what they do to actively cope. these findings emphasize the importance of targeting both anxiety and avc when considering risk for probable cud. longitudinal data are needed to examine how anxiety and avc contribute to the development of cud over time. changes in mental health as a predictor of marijuana coping motives and consequences: examining the impact of covid-19 on college students rebecca j. dunaief, adrian j. bravo, elefteherios m. hetelekides, victoria o. chentsova (william & mary) cody raeder, james m. henson (old dominion university) background: the spread of covid-19 has increased anxiety and depression (khan et al., 2020), especially among college students (wang et al., 2020). several theoretical models focus on the impact of poor mental health on marijuana outcomes, largely via coping motives (cooper et al., 2016). college students may be turning to marijuana to cope with the mental health problems that covid-19 has exacerbated. the present study compared students who reported increases in anxiety and depression since covidconference abstracts 93 19 stay-at-home orders to those who reported no change in anxiety and depression on marijuana coping motives, use frequency, and negative consequences. specifically, we examined whether self-reported changes (i.e., group that indicated increases) in poor mental health during covid19 were associated with problematic marijuana use via higher marijuana coping motives. method: students were recruited to participate in an online study examining the effects of covid19 on mental health and substance use between fall 2020 spring 2021. given aims of the present study, our analytic sample was limited to 300 students that reported past-month marijuana use and completed measures of changes in mental health due to covid-19 (single item each for depression and anxiety), measure of general depression/anxiety, and measures of marijuana use, motives, and negative consequences. among our analytic sample, a majority of participants identified as being white (61.0%), female (71.3%), college freshman (46.8%), and reported a mean age of 20.36 (median = 19.00; sd = 3.78) years. to test study aims, we conducted two mediation models (changes in depression [model 1] or anxiety [model 2] due to covid-19→marijuana coping motives→ marijuana consequences) using the process macro (hayes, 2013) in spss. results: within our analytic sample, we found that 58% of students reported increases in depression since covid-19 stay-at-home orders, with the remainder (42%) reporting no change. for anxiety, trends were similar, with 63.6% indicating increases in anxiety due to covid-19, with the remainder (36.4%) reporting no change. within both of our mediational models, we found support for coping motives mediating the effects of changes in mental health on marijuana problems (depression model: indirect effect = 0.65, 95% cis = 0.29, 1.08; anxiety model: indirect effect = 0.57, 95% cis = 0.22, 0.98). specifically, we found that students reporting an increase in anxiety/depression (compared to those that indicated their mental health remained the same) reported more marijuana problems via higher marijuana use coping motives. it is important to note that we found these effects even when controlling for past month marijuana use frequency and past 2-week depression/anxiety levels (assessed via dass-21). conclusions: we found that in young adults, increases in levels of anxiety and depression due to covid-19 were associated with higher problematic marijuana use through higher motivation to use marijuana to cope. future prevention/interventions efforts targeting problematic marijuana use may benefit from considering changes to mental health before or during major events like covid-19. from adverse childhood experiences to problematic marijuana use: examining the role of distress tolerance and coping motives on negative marijuana use consequences victoria o. chentsova, adrian j. bravo, emily o. norton (william & mary) cross cultural addiction studies team background: problematic marijuana use is highly prevalent globally, particularly in young adults, with marijuana use disorder affecting 5.8%, or 2.0 million, of young adults (ages 18 – 25) in the united states alone (samhsa, 2020). previous research has reported a significant association between adverse childhood experiences (aces) and later marijuana use (scheidell et al., 2018). though existing research reports an association between exposure to aces and marijuana use outcomes, the underlying mechanisms that could explain these associations are unclear. in previous research, general drug use coping motives have been shown to significantly mediate the relationship between childhood emotional, physical, and sexual abuse and later drug use problems (hogarth et al., 2019). other research has suggested that the factors like distress tolerance, typically negatively associated with childhood trauma (robinson et al., 2021) and maladaptive coping strategies (zvolensky et al., 2010), can also play a role in specifically predicting future problematic marijuana use (buckner et al., 2018). objective: the present study aimed to probe this relationship by exploring the associations between aces, distress tolerance, marijuana use coping motives, and negative marijuana-related consequences. specifically, we hypothesized that greater experiences of aces would relate to more negative marijuana-related consequences via lower distress tolerance and higher coping motives. method: participants were 752 marijuana-using (i.e., used marijuana in the past month) u.s. conference abstracts 94 college students (66.0% female) who completed an online survey including measures of basic marijuana use patterns, marijuana use consequences (brief marijuana consequences questionnaire (macq); simons et al., 2012), marijuana use motivations (marijuana motives questionnaire (mmq); simons et al., 1998), aces (adverse childhood experiences international questionnaire (ace-iq); who, 2018), and distress tolerance (distress tolerance scale, simons et al., 2005). to address study aims, path analysis was performed within the whole sample to test the serial unique associations between aces → distress tolerance → using marijuana to cope → negative marijuana-related consequences. results: within our analytic sample, we found that only marijuana coping motives uniquely indirectly influenced the relationship between aces and negative marijuana-related consequences (indirect β = .079, 99% cis = .042, .121). distress tolerance did not significantly uniquely indirectly influence the relationship between aces and negative marijuana-related consequences. however, a significant doublemediation effect was found illustrating that a higher endorsement of aces was associated with lower distress tolerance, which in turn was associated with higher using marijuana to cope motives, which in turn was associated with more negative marijuana-related consequences (indirect β = .011, 99% cis = .002, .026). conclusions: these findings provide support for the relevance of distress tolerance and coping motives as potential factors in linking aces to problematic marijuana use among college students. our preliminary findings encourage further exploration of these associations in longitudinal or experimental studies. further these results lend support to the therapeutic targeting of distress tolerance and using marijuana to cope to mitigate harms stemming from aces and its impact on problematic marijuana use. the role of impulsivity on cannabis and alcohol use frequency and problems among frequent cannabis users rishika v. shah, sarah a. okey, william r. corbin (arizona state university) background: although the relation between impulsivity and substance use outcomes is welldocumented (jones et al., 2014; stautz et al., 2017), less is known about individual facets of impulsivity among individuals who use cannabis. there is some research suggesting that positive urgency, sensation seeking, and lack of premeditation are associated with greater cannabis use problems, but much of this research has been conducted in normative adolescent or young adult samples (vanderveen et al., 2016). given that more than 11% of legal cannabis users currently use daily/near daily (goodman et al., 2020), this study examined relations between individual facets of impulsivity and cannabis use, alcohol use, simultaneous cannabis and alcohol use, and problem use within a sample of frequent, adult cannabis users. methods: individuals (n=167) with a mean age of 34.89 (sd=11.19) who reported using cannabis on average once per day completed measures of individual facets of impulsivity (positive urgency, negative urgency, lack of premeditation, lack of perseverance, and sensation seeking; upps-p), cannabis use frequency, alcohol use frequency, simultaneous cannabis and alcohol use frequency, cannabis use problems, cannabis use disorder, and alcohol use disorder. path models were used to predict frequency of use (cannabis, alcohol, and simultaneous cannabis/alcohol) and problem use (cannabis consequences, cannabis use disorder, and alcohol use disorder) from each facet of impulsivity. models were first run using sex, age, and race as covariates, and subsequently run after adding depressive and anxiety symptoms as covariates. results: after controlling for sex, age, and race, positive urgency was associated with less frequent cannabis use (b=-0.28, s.e.=0.13, p=0.03), more frequent simultaneous cannabis and alcohol use (b= 0.24, s.e.=0.11, p=.04), and greater cannabis consequences (b=0.30, s.e.=0.10, p=0.002). negative urgency was associated with greater cannabis consequences (b=0.31, s.e.=0.09, p<0.001), cannabis use disorder (b=0.27, s.e.=0.09, p=0.002), and alcohol use disorder (b=0.27, s.e.=0.10, p=0.01). after including depressive and anxiety symptoms as covariates, relations with positive urgency, but not negative urgency, remained significant. conclusions: the findings of the current study suggest that positive urgency may be uniquely conference abstracts 95 linked to riskier behavior in frequent cannabis users given that no other facet of impulsivity was significantly associated with cannabis use outcomes after all covariates were included in the model. although not directly assessed in the current study, the findings suggest that relations between negative urgency and cannabis use frequency and cannabis and alcohol use disorder may be mediated by depressive and anxiety symptoms. this possibility should be explicitly examined in future studies. the lack of relations between other facets of impulsivity and alcohol and cannabis use outcomes in the current study suggest that effects of impulsivity among daily users may be restricted to urgency, in contrast to studies in normative adolescent and young adult samples (vanderveen et al., 2016). does anxiety mediate the relationship between cannabis use and psychotic-like experiences in emerging adults? investigating a conditional process model in a multi-site university sample haley c. r bernusky, phil g. tibbo, fakir m. yunus (dalhousie university) patricia j. conrod (universite de montreal) matthew t. keough (york university) kara d. thompson (st. francis xavier university) marvin d. krank (university of british columbia okanagan) sherry h. stewart (dalhousie university) background/aim: cannabis is commonly used by canadian emerging adults (ages 18-25 years), many of whom attend post-secondary institutions. frequent cannabis use has been linked with psychotic-like experiences (ples); however, the exact nature of this complex relationship remains to be fully understood. anxiety is a prevalent mental health concern in emerging adults and university students, and anxiety has been independently linked with both cannabis use and ples. males and females use cannabis and experience mental health differently: females tend to be more anxious while males tend to use more cannabis and are at higher risk for psychotic-like experiences. in this first of two studies for my masters, i evaluated whether anxiety mediated the relationship between cannabis use frequency and ples in emerging adult undergraduates. i then tested the impact of moderation by biological sex by assessing if the mediation model held statistical significance across sexes. hypotheses: h1) consuming cannabis more frequently will be associated with more anxiety which, in turn, will be associated with greater ples in emerging adults, h2) the anxiety mediation pathway will be statistically stronger for females; and h3) males will have a stronger direct association between cannabis use and ples. method: a sample of 1,507 firstand second-year emerging adult university students (mean [sd] age = 19.2 [1.52] years; 67% female) were recruited. cross-sectional, self-report survey data were collected throughout fall 2021 from five canadian universities as part of the univenture substance misuse prevention trial. validated measures capturing demographics, cannabis use frequency, anxiety, and ples were administered. results: the mediation model with cannabis use frequency as the predictor, ples as the outcome, and anxiety as the mediator was tested, followed by testing a moderated mediation (conditional process) model with biological sex moderating the paths from cannabis use frequency to anxiety and from cannabis use frequency to ples using the process macro for spss. bootstrapped 95% confidence intervals showed evidence of a significant indirect effect of cannabis use on ples through anxiety for emerging adults (a-path p < .001; b-path p < .001; 95% ci [.016, .048]), supporting h1. no direct effect was found (c’-path p = .946) suggesting that the relationship between frequent cannabis use and ples may be fully mediated by anxiety. in the second model, significant moderated mediation was found (95% ci [.005, .060]). more frequent cannabis use was associated with increased anxiety among females only. conditional indirect effects showed significant mediation through anxiety for females (95% ci [.020, .056]), but not males (95% ci [-.015, .028]), consistent with h2. no significant sex moderation was found for conditional direct effects of cannabis on ples for either males (p = .667) or females (p = .907), contrary to h3. conclusion: assuming replication in prospective research, results highlight anxiety as an important intervention target in frequent female conference abstracts 96 cannabis users to potentially prevent the development or worsening of ples. understanding differential trajectories from frequent cannabis use to ples is important for informing individualized prevention and programming and encouraging health equity. feasibility and utility of a structured guide for cannabis tolerance breaks in young adults thomas fontana, jonathan a. schulz (university of vermont) alan j. budney (dartmouth college) andrea c. villanti (university of vermont, rutgers university) objective: to explore the feasibility and utility of a tolerance break (t-break) guide on young adults' cannabis use. participants: young adults aged 18-29 (n=125) who were current cannabis users. methods: participants recruited through posters and listservs at various universities were offered the t-break guide to help complete a 21-day cannabis break. bivariate analyses examined associations between guide use and follow-up measures. intervention: the t-break guide was designed to help people complete a 21-day break from cannabis. for each day of the break, the guide offers inspiration in the form of a quote, reflections based on likely experiences occurring at that point during the break, advice on ways to overcome challenges, alternative activities in which to engage, and encouragement. the first week focuses on physical symptoms of cannabis withdrawal (e.g., sleep, appetite); the second week focuses on the emotional experience (e.g., anxiety, boredom); and the third week focuses on behavioral aspects (e.g., examining patterns, connections). the t-break guide follows the motivational interviewing principles of affirmation and autonomy. results: compared to non-guide users, participants who used the guide “a lot” were more likely to complete the 21-day abstinence break (84% vs. 57%), revise their personal definition of balance to mean less cannabis (84% vs. 62%), and plan a future break (32% vs. 11%). conclusion: use of this self-directed guide may help young adults take a break from cannabis use and reduce future use, and offers a novel approach to cannabis harm reduction. further research to test the guide’s longer-term efficacy is needed. associations of momentary mindfulness with affect and cannabis desire in a trial of cannabis use interventions with and without momentary assessment lydia a. shrier, sion k. harris (boston children's hospital, harvard medical school) background. mindfulness, a state of awareness that results from intentionally attending to the present moment without judgment, has been associated with improved health. in substance use treatment, mindfulness-based interventions (mbis) improve mood and emotional regulation, possibly through increased positive affect and effective coping with negative affect. mbis may also decrease substance cravings and use. because affect, substance desire, and mindfulness vary moment-to-moment in daily life contexts, examining their associations may improve understanding of how mbis reduce substance use. momentary effects of mindfulness also have implications for ecological momentary assessment (ema) and interventions (emis) for substance use. ema samples momentary experience and emis administer treatment in real-time, real-life contexts. in bringing attention to thoughts and feelings at the time of the report, ema can raise self-awareness. emis can provide content tailored to time or situation. ema studies have shown that increased momentary negative affect predicts momentary cannabis desire and use events. if mindfulness decreases momentary negative affect, then ema to raise awareness of momentary states and emis to prompt mindfulness practice in daily life may be effective cannabis use treatment. we examined whether momentary mindfulness changed after cannabis use interventions that included ema, and explored associations with momentary negative affect, positive affect, and cannabis desire. methods. hospital clinic outpatients 15-24 years using cannabis ≥3 times per week were randomized to one of three interventions to reduce cannabis use. all interventions included two weekly 1-hour motivational enhancement therapy (met) sessions. in two interventions, participants also received two weeks of ema with or without supportive messages following report of contexts conference abstracts 97 personally triggering for cannabis use. we used ema to measure cannabis-related momentary states, contexts, and behavior 4-6x/day for one week at baseline and three months postintervention. of 70 participants enrolled, 68 (met+ema, n=40; met-only, n=28) contributed momentary data (n=1,971 reports) to these analyses. we calculated individual-level mean scores for the continuous momentary variables and normalized them using z-score or blom transformation, as appropriate. using generalized linear mixed effects models, we examined momentary mindfulness trends from baseline to 3-month follow-up, and whether changes differed by study group (met+ema vs. met-only) via phase-by-group interaction. we then examined associations of momentary mindfulness with negative affect, positive affect, and cannabis desire in separate models. we ran models unadjusted and adjusted for momentary contexts, group, phase, and mean reports/day in phase. results. mean momentary mindfulness was significantly higher at follow-up, compared to baseline (adjusted βdifference=0.146, se=0.034, p<.0005). momentary mindfulness increased from baseline to follow-up in the met+ema group, but did not change significantly in the met-only group (βema_difference=0.237, se=0.045, p<.0005; βmet-only_difference=0.055, se=0.050, p=0.269; βphase_x_group =0.182, se=0.066, p=.006). higher momentary mindfulness was associated with lower negative affect (adjusted βmindfulness=-0.526, se=0.045, p<.0005) and with lower cannabis desire (adjusted βmindfulness=-0.521, se=0.044, p<.0005). momentary mindfulness was not significantly associated with momentary positive affect (adjusted βmindfulness =0.013, se=0.035, p=.712). conclusions. among youth using cannabis frequently, momentary mindfulness increased following interventions with ema after counseling, and was inversely associated with negative affect and cannabis desire. mindfulness may be a useful target for momentary intervention. are parents who use cannabis receptive to safe storage interventions and point-of-sale education? beatriz h. carlini, sharon b. garrett, lexi nims (university of washington) purpose: the provision of cannabis storage devices paired with consumer prevention messages at point-of-sale has been considered by local health agencies to reduce youth access to cannabis in homes with adult cannabis consumers. this project sought to learn about current storage practices, interest in safe storage devices, and acceptability of youth prevention messages among adult consumers with youth at home. methods: potential participants responded to a facebook advertisement and then completed an online survey which identified those who were over 21, used cannabis at least six times in the past six months, had children at home, lived in a target wa state county, and made at least one purchase from a cannabis store. semi-structured interviews were conducted over zoom, in mayjune 2021. participants responded to open-ended questions and reacted to existing prevention messages. thematic analysis was performed by the three authors in two iterations; first initial themes were identified, and a coding framework was developed, then focused coding was conducted using this framework. results: sixteen parents ranging in age from 21-50 were interviewed. most were women (14; 88%), 10 (63%) were white/caucasian, 3 (19%) black/african american, and 1 (1%) each pacific islander and white/caucasian, native american/american indian, and black/african american and white/caucasian. eleven had children between 210 y.o. and six between 11-17 y.o. in the home. thirteen (81%) used cannabis daily, many for medicinal reasons. parents described a wide range of storage practices and were supportive of receiving storage devices from retail stores. health messages were well received when they were simple, depicted parents in a positive light, included relatable images, and emphasized edibles and that children may not know that products contain cannabis. parents saw the importance of messages focused on brain development and the social consequences of teen use but were wary of messages that encouraged adult cannabis use to be hidden, that suggested that adults should communicate their disapproval of cannabis, or that described cannabis as addictive. conclusions: parents who use cannabis expressed concern for their kids and understood that cannabis use can negatively affect child conference abstracts 98 development. while most were willing to store their cannabis out of reach of their children, cannabis was not viewed as being as harmful as other products that they consider a priority to store out of reach of children, such as opioids, alcohol, and guns. content of health messages can easily be rejected if perceived as judgmental, stigmatizing, or untrue. most parents trusted that open dialogues with their kids was the most effective prevention, and most were not willing to hide their own use. responsible vendor training as a macro-level prevention tool– a case study of the massachusetts cannabis industry olivia laramie, alexander colby, hailey pensky (cannabis control commission, commonwealth of massachusetts) samantha m. doonan (nyu grossman school of medicine, vilcek institute of graduate biomedical sciences) julie johnson (cannabis control commission, commonwealth of massachusetts) as of march 2022, adult-use cannabis is legal in 18 states and medical-use is legal for certain patients in 37 states. unlike the illicit market(s), legal market(s) present new opportunities to embed public health strategies in varying levels of policy and regulation, such as public awareness campaigns or responsible vendor training (rvt). using the social ecological model (sem) as a guiding framework, we conceptualize stateimplemented public health strategies as operating at the macro-level through public policy or regulations, and interacting within and across varying social environments to impact individual behaviors. macro-level prevention and intervention tools that aim to reduce and prevent adverse cannabis outcomes, such as developing cannabis use disorder and cannabis impaired driving, are imperative to more safely implement cannabis legalization. rvt programs are an under-studied, yet critical macrolevel intervention, in many new cannabis industries that sell varying cannabis products with both known and unknown effects on the human body. rvt programs, operated by varying education providers and curriculums, are trainings provided to cannabis industry employees (“agents”) involved in the handling and sale of cannabis. training may include, but is not limited to, learning the law and regulations, identifying fake identification cards (ids), health effects of cannabis, and other public health and safety practices. at the implementation level, rvt training may affect individual change by shaping industry employees’ perceptions of their role in order to better support public health, clarifying the latest research on health effects, and roleplaying judgement-free strategies to provide public health education. currently, 31 states have rvt programs, however, massachusetts is currently the only state with both legalized adultuse and medical markets that mandates an rvt program by regulation [935 cmr 500 and 935 cmr 501]. as of february 2022, massachusetts certified 22 rvt program vendors and trained 10,142 out of 23,772 (42.7%) agents in the medical and adult-use workforce. rvt programs have the potential to counteract potential unsafe cannabis use behaviors following cannabis legalization implementation. however, the effectiveness of rvt programs is largely unknown. guided by the sem, this presentation will take a holistic view of the overlapping social environments surrounding an individual, to assess the potential of rvt programs operating at the macro-level to interact across social levels, including mesoand individual-levels, in order to prevent adverse outcomes (bronfenbrenner, 1977). this presentation provides a theoretical model and potential quantifiable metrics of study for researchers to better assess rvt program effectiveness. to reduce potential health and safety risks of cannabis legalization, policymakers and regulators can embed varying public health strategies in legal cannabis markets, including rvt programs. it is imperative that research assist policymakers and regulators to assess the effectiveness of current rvt programs to ensure rvt program(s) have the intended public health outcomes, in order to facilitate evidence-based cannabis policy in these new and emerging cannabis markets. identifying cannabis use patterns via latent profile analysis bethany gray, mark prince (colorado state university) reagan fitzke, eric pedersen (keck school of medicine of the university of southern california) conference abstracts 99 epidemiological surveys consistently report that cannabis use prevalence peaks during the college years. college students who use cannabis do so in a variety of contexts (e.g., at a party, when experiencing craving, for physical pain). cannabis use is associated with risk for experiencing undesirable consequences. protective behavioral strategies (pbs) are behaviors one can engage in to reduce use or to mitigate the risk of experiencing unwanted consequences. however, research has yet to explore which strategies are most effective in which specific contexts of use. it is likely that a strategy that works well to reduce the risk of consequences in one context may not work well in another context. we aimed to identify unobserved patterns of cannabis use contexts in a sample of college students, and examined whether these patterns of cannabis use contexts differed in cannabis use frequency, cannabis-related negative consequences (both at the item level and the cumulative number of consequences), and pbs use (also examined at the item and cumulative levels). using latent profile analysis of self-reported data, we identified three latent profiles of cannabis users. profile 1 (social use profile; n =100) reported use cannabis in predominantly social or uplifting contexts, profile 2 (physical & emotional pain profile; n =109) reported use primarily in the contexts of relieving physical and emotional pain, and profile 3 (all contexts profile, n =56) reported frequent use in all contexts assessed. the social use profile was associated with the least frequent cannabis use, the most pbs use, and fewest consequences compared to the other profiles. the physical and emotional pain profile was associated with moderate levels of cannabis use, consequences, and pbs use. the all contexts profile was associated with the most frequent cannabis use in all contexts. this included the contexts that were least associated with the social use profile and the physical & emotional pain profile, which were related to a craving to use cannabis and using cannabis in response to a fight with friends, family members, or partners. the all contexts profile was also associated with the most cannabis-related consequences, and the lowest level of pbs use. beyond the examination of overall indices of cannabis use, consequences, and pbs use, our data indicated that each profile was associated with the experience of specific consequences of use in differing frequencies and the use of certain pbs to a differing degree across profiles. this study provides preliminary evidence that the contexts in which people use cannabis may be associated with use level, number of consequences experienced, and pbs use. future prevention and intervention efforts may consider identifying those whose use pattern is consistent with profiles identified in this study that carry greater risk of cannabis-related consequences. this would include screening for use in many different contexts (all contexts use pattern) or for use primarily when in physical or emotional pain (physical & emotional pain use pattern), as these use profiles carry greater risk for frequent use, experiencing more consequences, and engaging in fewer protective strategies. time trajectories of medical cannabis purchases by patients with medical cannabis prescriptions alexandra f. kritikos (university of southern california) dominic hodgkin (brandeis university) rosalie liccardo pacula (university of southern california) background: medical cannabis (mc) use is rising with limited clinical data to support products and dosing for specific conditions. this study relies on observational data to examine mc purchases across time, and to assess dosing trajectories for different conditions. methods: a retrospective study of mc patients of dispensaries located in new york (ny). this study relies on secondary analysis of point-of-sale (pos) invoice data from 16,727 unique patients with 79,885 purchases between 2016-2019. groupbased-trajectory modeling (gbtm) was used to identify clusters of mc patients following similar progressions in potency utilization (e.g., thc and cbd) over time. multinomial logit models were estimated to identify group membership based on patient level characteristics and qualifying medical conditions. results: six distinct trajectory groups were identified. four of the groups compromised (75%), (39.9%), (8.2%), and (8.5%) of the population and purchased a steady dosage (ranging from low to high) of thc over time. the fifth (14.9%) and conference abstracts 100 sixth group (10.1%) demonstrated mc patients who gradually increased their thc dosage across time. patient characteristics and qualifying medical conditions for mc use were strong predictors of group membership. men, older individuals, and those with a qualifying pain condition were more likely to be part of a group that consumed higher doses of thc across time, compared to other reference groups. conclusion: this study identified distinctive trajectories of monthly thc and cbd potency levels purchased, and factors associated with these trajectories. examining mc purchasing patterns over time may help understand whether mc treatment works, subgroups of mc patients, and risk factors. this study pioneer’s analysis of pos data, which could help guide policy decisions to effectively monitor mc use, aid in the design of future mc programs and target prevention efforts. this study provides a strong foundation upon which that research can build by utilizing new-technologically advanced sales data sets. gender by ethnicity differences in trajectory of cannabis use among cannabis-using young adults during preand post-recreational cannabis legalization (rcl) in los angeles wong, cf (children's hospital los angeles/usc keck school of medicine) odejimi, o. (children's hospital los angeles chla) conn, bm (children's hospital los angeles/usc keck school of medicine) davis, j (usc) ataiants, j, fedorova, ev (drexel university) suen, m, lee, sj, osornio, a (chla) lankenau, se (drexel university) introduction: by the end of 2022, most states across the us except for three would have enacted some form of legalized cannabis policy. support for the legalization of cannabis for recreational purposes are particularly high among young adults. given the rapidly changing policy landscape, understanding how these policies may have impacted cannabis use among different groups of young people can help inform current and future policy decisions and programs/intervention to curb problematic use. there is evidence to suggest significant and meaningful differences in use behaviors among individuals from different racial/ethnic backgrounds and gender identities. however, limited research has examined how these groups based on the intersection of these identities might differ in their cannabis use prior to and after recreational cannabis legalization (rcl). method: 366 cannabis-using young adults (aged 18-26) comprising 210 medical cannabis patients and 156 non-patients were surveyed annually between 2014-2020 in los angeles culminating into 6 waves of data. bilinear spline growth curve models examined changes in cannabis use trajectory, with three waves pre-rcl and three waves post-rcl after accounting for patient status and age. multi-group analyses investigated differences between six genderxrace/ethnicity subgroups: 1) african american females (aaf); 2) caucasian/white females (wf); 3) hispanic females/latina (hf); 4) african american males (aam); 5) caucasian/white males (wm); and 6) hispanic males/latino (hm). omnibus tests investigated homogeneity in the latent growth constructs across the 6 groups. we tested equality of covariances (correlations) and means across groups (p < .05). if inequality was shown, further tests were conducted. results: overall, significant group differences were observed in cannabis use trajectories and the correlations between intercepts and growth factors. specifically, hf, hm, aam and wm reported moderate level of cannabis use (between 50 to 56 days of use) compared to aaf and wf at baseline, whereby aaf reported significantly higher use (70.72 days) relative to all other groups. in contrast, wf reported significantly lower use (35.42 days). there were different patterns in pre-rcl growth parameters. whereas aaf and hf had relatively flat rate of change, wf, wm, and hm had relatively similar significant decrease in use pre-rcl. interestingly, during the period post-rcl, aaf, wm, and hm all showed significant decline in use, but wf was the only group with a significant increase in use while hf and aam had modest increases in use. while baseline use generally predicted pre-rcl use within each subgroup (for some, baseline use led to more rapid increase while for others, it led to more rapid decrease in conference abstracts 101 use), this is less true for post-rcl use. significant effects associated with age and patient status were also observed. conclusions: these are among the first findings to show how cannabis policy has differentially impacted cannabis use behaviors prior to and after rcl among a diverse population of cannabis-using young adults. additional research should investigate potential mechanisms of these difference and longer-term health impacts. medical cannabis use among adults who report non-medical use of prescription opioids for pain relief catalina lopez-quintero, alyssa m. falise, james d. cury, vinita sharma, ellen l. terry, yan wang, robert cook (university of florida) objectives: this study uses a nationally representative sample of adults to investigate racial-ethnic differences in reasons for cannabis use among those reporting past 12-month misuse of prescription opioids for pain relief. methods: data from the 2015-2019 national surveys on drug use and health were used to study 3,093 adults 18 to 49 years old reporting past 12-month pain-related prescription pain reliever (opioid) misuse. logistic regressions assessed the association between past 12-month cannabis use – (non medical vs. any medical) – and multiple socio-demographic, psycho-social and drug use correlates. nsduh analysis weights were applied to accommodate for the sampling design. results: half of individuals who reported misuse of prescription opioids for pain relief used cannabis in the past 12-months. in this sample of cannabis users, 87.6% (95%ci = 86.1, 88.9) used non-medically, and 12.4 (95%ci = 11.1, 13.9) used for both medical and recreational reasons. individuals with past 12 months diagnosis of opioid use disorder were 1.8 (95%ci = 1.29, 2.63) times as likely to be medical cannabis users compared to those without a disorder. conclusions: the findings indicate that medical cannabis might be an alternative for nearly one in eight individuals misusing pain relievers to alleviate their pain, primarily those with an opioid use disorder. despite increased rates of cannabis use among males and non-hispanic whites in the general population, no gender or racial-ethnic differences were found in the selected sample. future studies should investigate simultaneous use and the analgesic effects of co-use in this sample. changes in marijuana use frequency among people with hiv during the covid-19 pandemic: a multi-methods exploration christina parisi, yan wang, deepthi s. varma, krishna vaddiparti (university of florida) gladys e. ibañez, liset cruz carrillo (florida international university) robert l. cook (university of florida) background: people with hiv (pwh) report unique reasons for using marijuana. similarly, they report unique concerns resulting from marijuana use. assessing and understanding the reasons driving marijuana use among pwh could provide critical insights into how to help maximize the therapeutic benefits and minimize potential harms of marijuana use. the covid-19 pandemic has impacted the access and use of substances globally. this study describes changes in patterns of marijuana use and reasons for those changes among pwh during the pandemic and implications for these findings in the future. the objectives of this study are to: 1) describe selfreported changes in marijuana use frequency during the covid-19 pandemic among a cohort of pwh in florida and 2) understand the reasons behind these changes through an analysis of openended qualitative questions. methods: data are cross-sectional and come from questions in a follow-up phone survey administered to a prospective cohort of pwh (75% current marijuana use) in florida between may 2020-march 2021. participants who used marijuana were asked about changes in their frequency of marijuana use due to the pandemic using a closed-ended quantitative survey and reasons for any reported changes in a qualitative open-ended question. descriptive statistics and significance testing were completed in sas 9.4. qualitative data were analyzed using thematic analysis. results: among the total sample of 227 pwh (mean age 50, 50% men, 69% black/african american, 14% hispanic/latino); 15% reported a decreased frequency of marijuana, 9% reported conference abstracts 102 increased frequency, and 76% reported no change. the most common reason for increasing the frequency of marijuana use was to reduce the increased anxiety or stress experienced during the covid-19 pandemic. participants also reported that marijuana helped them cope with selfreported depression and other negative life events and helped reduce boredom while their regular activities were restricted. concerns about the impacts of marijuana on covid-19 risk, using the pandemic as an opportunity to reduce or quit marijuana use, and issues with obtaining marijuana were common reasons for decreased use. additionally, some participants reported that a primary reason for using marijuana was the social aspect of using in a group, and without being able to gather they were less motivated to use, contributing to decreased use. conclusions: nearly one-quarter of the participants had changes in their marijuana use frequency during the pandemic, and most of the participants with a change decreased their frequency of use. the changes in the frequency of marijuana use experienced by pwh during the pandemic might continue and prevent a return to “normal,” so it is important to understand how to best address the new needs of pwh who use marijuana. understanding the reasons behind changes in marijuana use patterns in this population—and what demographics, attitudes, and beliefs might differentiate those with increases, decreases, or no change in marijuana use—can allow researchers and providers to make greater connections between hiv-specific health outcomes and marijuana use. these findings provide specific targets for interventions to maintain or even improve health among pwh during public health emergencies and beyond. medical marijuana & me (m3): designing measures of medical marijuana dose in an observational study hannah fechtel, ruba sajdeya, yan wang, gabriel spandau, amie goodin, almut winterstein, robert cook (university of florida) measuring marijuana exposure represents one of the biggest challenges in marijuana-related outcomes research. the challenge mainly emerges from the significant variability in medical marijuana (mmj) use characteristics on both the product level, including inter-product and intraproduct composition variability and possibility of using multiple consumption modes, and the patient level, including variations in use patterns, frequency and intensity of use, and routes of administration. while mmj-related observational research still mainly relies on self-reported mmj exposure, there remains a lack of validated and reliable exposure measures and a lack of standardized dose units, necessitating the development of such measures. in the medical marijuana & me (m3) study, a new combined cohort and cross-sectional study aiming to assess a multitude of mmj-related outcomes among mmj patients in florida, we developed a set of new comprehensive measures to quantify mmj use by assessing the specific modes of consumption, doses, frequency, and patterns of mmj use. after reviewing the literature for existing mmj measures, a multidisciplinary team of mmj certifying physicians, pharmacists, researchers, mmj patients, and dispensary personnel designed and developed a questionnaire covering a wide range of mmj products, including flower, vape cartridges, concentrates for smoking, topical products, tinctures, oral concentrates, edible products, and others. mmj dose and use are assessed via a nine-item mmj use measure for each mmj product participants use that gauges modes and routes of administration, frequency of use (per day, per week, per month), amount of consumed products, tetrahydrocannabinol and cannabidiol concentrations and ratios, and potency. for specific consumption modes (e.g., smoking and vaping), additional questions (e.g., number of inhalation seconds) were included to ensure a comprehensive approach of exposure measurement. visual prompts such as product example photos were also included to enhance participant engagement and ease. we pilot-tested the questionnaires on twenty current mmj patients in florida, who provided feedback to improve the measures’ relatability and enhance accuracy in capturing their mmj exposure. some of the key challenges we encountered were measuring the “amount” of solid and liquid concentrates, and difficulty in determining dose of vape cartridges due to inconsistencies in thc concentration between nearly identical cartridges. the nine-item mmj use questionnaire developed for m3 offers a framework for mmj exposure quantification in current and future observational conference abstracts 103 mmj-outcomes research. analyses resulting from m3 data will add to the sparse literature on mmj dose measures and assist in validating measures similar to the measure developed for m3. acute cannabis-related alterations in an fmri time estimation task krishna t. patel, michael c. stevens, suyash adhikari, greg book, muhammad mubeen (olin neuropsychiatry research center, institute of living at hartford hospital) godfrey s. pearlson (olin neuropsychiatry research center, institute of living at hartford hospital, depts. of psychiatry & neurobiology, yale university school of medicine) introduction: cannabis is widely popular recreational drug of choice in the us. the drug is known to alter the subjective experience of time. however, its effects on time estimation at a brain level are still largely unexplored. our goal was to investigate acute effects of cannabis on an fmri time estimation task by evaluating brain activation differences between cannabis and placebo conditions. we hypothesized that participants’ time estimation accuracy and corresponding bold response would be altered during the cannabis condition in a dose-related manner, compared to placebo. methods: in this placebo-controlled, double-blind randomized trial, a total of n=44 participants had 3 dose visits, at each of which they received either high-dose cannabis (0.5 gm of ~12.5% thc flower), low dose cannabis (0.5 gm of ~5.7% flower) or 0.5 gm placebo, using paced inhalation from a volcano via vaporizer. drug material was supplied by nida/rti. for the current study we analyzed fmri data from the first of placebo and high dose fmri sessions throughout each dosing day in which participants performed a time estimation task. participants were asked to respond with a mouse click as to which box of two boxes displayed for different intervals was displayed on the screen longer. both sub-second and supra-second temporal intervals were tested, with a range of easy to hard discriminations. we used the human connectome project processing pipeline to prepare fmri data for glm modeling of activation using the fsl feat toolbox. this model estimated the unique effect sub-second (short) and supra-second (long) interval discrimination, their average effect, and their difference. from these contrasts, the mean activation amplitudes within 387 brain parcels from the human connectome cortical atlas were extracted. robust statistics in r software estimated a paired t test equivalent using the bootdpci function to assess the difference between placebo and the high dose drug conditions for each contrast. results: only premotor cortex survived false discovery rate corrections for searching all 387 parcels across the entire brain for the average of short and long temporal estimation conditions. numerous other brain regions differed between placebo and high doses at p<.05 uncorrected for various task contrasts: short duration stimuli: premotor cortex, posterior cingulate cortex, medial temporal cortex, visual area, somatosensory cortex, anterior cingulate and medial prefrontal cortex, paracentral and mid-cingular cortex, inferior frontal cortex. long duration stimuli: premotor cortex, visual areas, somatosensory motor cortex, paracentral and midcingulate cortex, the tempo-parieto-occipital junction, dorsolateral-prefrontal cortex, posterior opercular cortex, medial temporal cortex, posterior cingulate cortex, orbito-frontal cortex. average of short and long duration stimuli: premotor cortex, somatosensory and motor cortex, posterior cingulate cortex, visual are, medial temporal cortex, paracentral and midcingulate cortex, anterior cingulate and medial prefrontal cortex, inferior frontal cortex, tempo-parieto-occipital junction, premotor cortex, somatosensory motor cortex, posterior cingulate cortex, medial temporal cortex, orbital and polar frontal cortex, hippocampus. difference of short and long duration stimuli: anterior cingulate and medial prefrontal cortex, ventral stream visual cortex, dorsal stream visual cortex, early visual cortex. conclusions: the current study elicited multiple brain activation differences for the initial, acute high-dose cannabis vs. placebo condition, but only premotor cortex region survived as significant following multiple comparison correction for short and long duration stimuli contrast. a post hoc power analysis showed that adding 10 additional subjects to this sample would achieve significance with multiple comparison correction for medium effect sizes at alpha=0.05. future studies on a larger sample can help identify such significant activation differences, and examining all doses and tasks would elucidate unfolding of effects conference abstracts 104 longitudinally post-dose, and dose-dependence of effects. effect of acute stress induction on cannabis demand yi-chun chang, benjamin o. ladd (washington state university vancouver) objective: substance demand, defined as the persistently high valuation of a reinforcer, is a critical factor that contributes to initiating and maintaining substance use. this study examined how cannabis demand was affected by an acute stress induction. here we focused on the most commonly used demand indices: intensity (i.e., the amount of drug consumed at zero cost) and omax(maximum expenditure). method: 33 young adults (66.67% female, 54.55% white, mean age = 22.88 years) reporting cannabis use at least 5 days per week in the past month and at least weekly use in the past 6 months were recruited from the community and a northwest college campus. after confirming eligibility, each participant was scheduled for an online zoom appointment with an experimenter. during this appointment, participants completed a pre-test stress assessment and marijuana purchase task (mpt). following, they completed the trier mental challenge test (tmct) for stress induction, during which they were asked to work four trials of arithmetic problems while being observed by the experimenter. finally, they completed the post-test stress assessment and mpt, as well as a cannabis use survey. results: stress (d = .58, p = .002) and intensity (d = .46, p = .014) significantly increased as a result of the stress induction. however, there was no significant difference between the pre-test and post-test in terms of omax (d = .21, p = .25). conclusion: this study demonstrates the effectiveness of administering stress induction (i.e., tmct) online among cannabis users. the study results also suggest heightened cannabis demand in young adult highfrequency cannabis users after experiencing acute stress, suggesting interventions on how to manage stress in the moment may provide valuable techniques for individuals trying to moderate or cut down on their cannabis use. ecological momentary assessment of cannabis use contexts rebecca k. denson, robin j. mermelstein (university of illinois at chicago) background: as recreational cannabis use increases, it is important to document the context in which use occurs. cannabis use contexts may relate to safety and daily functioning (e.g., if cannabis is used while driving or at work/school) as well as motives for use (e.g., if cannabis is used in social environments). the present study used ecological momentary assessment (ema) to examine the context surrounding cannabis use in adults’ natural environments. methods: participants were recruited for a longitudinal study of dual use of cigarette and ecigarettes. data were collected in illinois prior to legalization of recreational cannabis use. participants completed baseline questionnaires and two seven-day waves of ema; the current study included those who reported cannabis use on ema interviews. participants completed ema when randomly prompted (5-6 times/day) and when using tobacco products. ema reports measured past-hour substance use and current location, behavior, and social environment. descriptive analyses evaluated relative frequencies of ema events when cannabis use was reported (cannabis use events) and not reported (non-use events). cannabis use and nonuse event frequencies were examined by social environment (alone; with a partner/spouse, family, friends, children, coworkers, other), location (home, school/work, coffee shop/restaurant, sport/entertainment venue, car, other transit, bar/club), and behavior (hanging out, socializing, transit/driving, relaxing, texting/talking on phone, using a computer/app, nothing, other). participants chose one location and could select all items that applied for social environment and behavior. event frequencies were also examined by day of the week and time of day (4:00-8:59 am, 9:00 am-1:59 pm, 2:00-5:59 pm, 6:00-9:59 pm, and 10:00 pm-3:50 am). results: data come from 200 participants (35.5% female; mean age = 30; 11.5% hispanic/latino; 44.5% non-hispanic white; 29.5% non-hispanic black; 10.0% asian/pacific islander; 4.5% other race/ethnicity). past 6-month cannabis use frequency was reported at baseline: 12.5% no use, 10.5% monthly or less, 14% 2-4 times/month, 15% 2-3 times/week, 48% 4+ times/week. the average baseline score on the cannabis use disorders identification testconference abstracts 105 revised was 9.90 (sd = 6.57). overall, 14,160 ema events were captured with 2,672 cannabis use events and 11,488 non-use events. most cannabis use (77.2%) occurred at home. 9.1% of cannabis use occurred when driving/in transit. at cannabis use times, participants reported hanging out (41.5%), relaxing (35.0%), watching tv/movies (29.2%), and socializing (24.4%). participants were alone in 41.0% of cannabis use events; when not alone during cannabis use, participants were most often with friends (48.0% of social cannabis use events), a partner/spouse (43.1%), or a family member (24.1%). cannabis use was relatively consistent across days of the week, with slight increases on thursday (15.9%) and friday (16.4%). most cannabis use (34.5%) occurred between 6:00-9:59 pm. conclusions: these findings characterize the naturalistic context of cannabis use among a community sample of adults. most cannabis use occurred at home and when engaging in leisure activities (e.g., relaxing, hanging out). cannabis use did not appear to be very common in hazardous situations (e.g., while driving). as cannabis use continues to increase, the naturalistic context of cannabis use has implications for safety, motives, and cannabis use disorder. variations in likelihood to use protective behavioral strategies for marijuana across physical and social contexts of use kathleen l. egan (east carolina university) melissa j. cox (university of north carolina at chapel hill) protective behavioral strategies for marijuana (pbsm) are intended to reduce harms associated with use of marijuana. harms may vary based on the physical and social contexts in which individuals use marijuana resulting in people employing pbsm differentially across contexts. we examined where and with whom young adults are likely to employ pbsm when using marijuana. in fall 2021, we conducted an online survey with 506 young adults who were current users of marijuana and lived in the u.s. (n=506; 55.6% female, 62.6% white). participants were evenly distributed across states according to marijuana policy (33% each in recreational, medicinal, or neither). participants rated their likelihood (‘not at all,’ ‘somewhat,’ or ‘extremely/very likely’) to engage in 8 strategies derived from the pbsm scale that focused on using marijuana only with trusted peers, minimizing intoxication, and driving a vehicle after using marijuana. participants indicated their likelihood to use each strategy in 4 physical contexts (own home, friend’s home, someone else’s home, public location) and 3 social contexts (alone, one or few closest friends, large group). we conducted generalized logit mixed models with a multinomial dependent variable, treating the respondent as a random effect, to assess differences in likelihood to use pbsm across physical and social contexts. separate models were run for each pbsm by physical (referent: at own home) and social (referent: alone) context. physical context: odds of being ‘somewhat likely’ or ‘extremely likely’ (referent: ‘not at all likely’) to ‘use marijuana only among trusted peers’ were lower when using marijuana at someone else’s home or in a public location compared to their own home. odds of being ‘somewhat likely’ or ‘extremely likely’ (referent: ‘not at all likely’) to ‘use a little marijuana and then wait to see how you feel before using more,’ ‘avoid mixing marijuana with other drugs,’ and ‘avoid driving a car after using marijuana’ were lower when using marijuana in public settings compared to their own home. odds of being ‘somewhat likely’ (referent: ‘not at all likely’) to ‘limit the amount of marijuana they use in one setting’ were lower when using marijuana in public settings compared to their own home. social context: odds of being ‘somewhat likely’ (referent: ‘not at all likely’) to ‘avoid mixing marijuana with other alcohol’ were greater when using marijuana with a few close friends than alone. odds of being ‘extremely likely’ (referent: ‘not at all likely’) to ‘use a little marijuana and then wait to see how you feel before using more’ and ‘avoid driving a car after using marijuana’ were lower when using marijuana at an event with a large number of people compared to alone. our findings suggest that people differentially utilize pbsm based on the physical and social contexts in which they are using marijuana. people may be less likely to engage in pbsm in public locations and large groups of people compared to when they use marijuana at their home or alone. interventions for young adult marijuana use should consider the context of use conference abstracts 106 when providing behavioral intervention strategies. cannabis craving in response to alcohol cues in the laboratory and in daily life andrea m. wycoff, hayley treloar padovano, robert miranda, jr. (brown university) background: cannabis use is prevalent among adolescents and young adults who drink alcohol. compared to individuals who only drink alcohol, those who (co-)use both alcohol and cannabis are at greater risk of experiencing substance-related problems. one factor that could maintain patterns of co-use is the potential for one substance to elicit craving for another. this idea has been studied extensively in the alcohol and tobacco co-use literature but has yet to be applied to alcohol and cannabis co-use. thus, the present study examined whether alcohol cues elicit cannabis craving in the lab and in daily life. method: participants were 54 adolescents and young adults ages 15 to 24 (m age = 19.69, sd = 2.04) who were enrolled in one of two medication trials targeting alcohol use and endorsed lifetime cannabis use. participants were 51.9% female, 75.9% white, and 87.0% not hispanic or latino. average age at first alcohol use was 15.28 (sd = 2.07), and average age at first cannabis use was 15.91 (sd = 2.37). participants reported cannabis use on an average of 22.4% of the last 90 days via timeline follow-back. participants also completed a lab cue-reactivity task where they rated cannabis craving when presented with alcohol and control cues. finally, participants completed one week of ecological momentary assessment in their daily lives, reporting multiple times per day on their cannabis craving and the presence of alcohol cues in their surroundings. the data used in the present analyses were collected prior to randomization into medication condition and prior to taking any medications for the larger pharmacotherapy trials. results: results from mixed models demonstrated that baseline cannabis use frequency was positively related to lab cannabis craving, regardless of cue type, although this association was larger for control cues than for alcohol cues (b = -0.01, se = 0.00, p = .004). in daily life, the presence of alcohol cues was associated with greater momentary cannabis craving (b = 0.57, se = 0.25, p = .029). finally, greater lab cannabis craving in response to alcohol cues predicted greater momentary cannabis craving across all moments in daily life (not solely when alcohol cues were present; b = 0.61, se = 0.11, p < .001). discussion: results suggest that cannabis craving in the lab translates to daily-life cannabis craving across contexts, and that daily-life cannabis craving may be heightened in the presence of alcohol cues in individuals’ natural environments. collectively, these findings support the idea that alcohol cues may elicit cannabis craving among adolescents and young adults who report a history of alcohol-cannabis co-use. our findings may inform future work seeking to tailor cannabis use interventions among individuals who co-use cannabis with alcohol. concurrent alcohol and cannabis use influences eeg processing of alcohol cues eleftherios hetelekides, cheryl dickter, adrian j. bravo (william & mary) background. concurrent use of alcohol and cannabis (cam) has been shown to be common among college students (bravo et al., 2021), and is associated with more alcohol use and related negative consequences (cummings et al., 2019). there is evidence that both alcohol and cannabis use may be associated with changes in brain functioning and cognition (oomen et al., 2018), including differences on tasks related to cognitive inhibition/inhibitory control (i.e., go/nogo tasks; lopez-caneda et al., 2014). a promising method for assessing potential neurocognitive changes associated with alcohol and cannabis use is by examining substance-associated event-related potentials (erps) using electroencephalography (eeg; zhang et al., 2021). the present study aimed to examine differences in p300 erps associated with alcohol cues between binge drinking alcohol only students and binge drinking students who also consumed cannabis in the past 30-days (i.e., cam use). method. fifty binge drinking college students (26 of whom also reported using cannabis over the past 30 days) were recruited from a psychology department research pool to participate in an alcohol-related cued go/nogo task while their brainwaves were measured. the task was characterized by within-subjects factors block conference abstracts 107 (indicating probability of go/nogo task cue-target combinations), cue (alcohol vs. neutral), and target (go vs. nogo). participants identified as mostly white (78%), female (72%), were freshman (64%), and reported a mean age of 18.86 (sd=0.90). to test study aims, at electrode cz, we conducted a 2x2x2x2 mixed anova with all within-subjects factors (block, cue, target), and between-subjects factor cam over the past 30 days (cam use vs. no cam use). results. we observed a significant block*target*cam interaction with a medium effect size (richardson, 2011), f(1,47)=4.09, p=.049, η2=.08. cue was retained as a factor in subsequent analyses in order to effectively evaluate the hypothesis. in block 2, we found a non-significant cue*cam interaction, f(1,47)=3.10, p=.085, η2=.06, with a medium effect size. paired-samples t-tests revealed that individuals who used cannabis did not display a significant difference between alcohol and neutral cues, t(25)=0.243, p=.81, while individuals who did not use cannabis showed significantly greater alcohol vs. neutral cues, t(23)=2.34, p=.025. conclusions. while preliminary, we observed a significant difference in p300 erps for alcohol vs. neutral cues, only in individuals who did not report using cannabis over the past 30-days. in other words, we found that cam using individuals display similar neural reactivity to alcohol compared to neutral cues, while an alcohol vs. neutral difference was observed for alcohol-only individuals. it may be that by using another substance, alcohol stimuli lose salience, and evaluative processing indexed by the p300 is reduced. these are interesting results to be observed within a non-clinical sample of mostlyfreshman college students, and provides rationale for examining neuropsychological differences between individuals who use multiple substances versus one substance in populations with more severe levels of dependence. brain-behavior relationships of simulated naturalistic automobile driving under the influence of acute cannabis intoxication: a double-blind, placebo-controlled study shashwath a. meda, mike c. stevens (hartford hospital/yale university) erwin boer (entropy control inc.) catherine boyle, greg book (hartford hospital) nicolas ward (montana state university) godfrey d. pearlson (hartford hospital/yale university) background: driving is a complex everyday activity that requires the use and integration of different cognitive and psychomotor functions, many of which are known to be affected when under the influence of cannabis (cnb). given legal implications of drugged-driving and rapidly increasing use of cnb nationwide, there is an urgent need to better understand the effects of cnb on such functions in the context of driving. this longitudinal, double-blind placebo-controlled study investigated the effects of cnb on driving brain-behavior relationships in a controlled simulated environment using functional mri (fmri). methods: n=26 frequent cannabis users were administered 0.5 grams of 13% thc or placebo flower cannabis via a stortz+bickel ‘volcano’ vaporizer using paced inhalation, on separate days at least 1 week apart. on each study day, participants drove a virtual driving simulator (steering wheel, brake, gas pedal) inside an mri scanner approximately 40 minutes post-dosing. each fmri driving session presented a naturalistic simulated environment that unobtrusively engaged drivers with scenarios that tested specific driving skills and response. there were three, approximately 10 min epochs where drivers engaged in task of lane keeping/weaving (lk), lead car following (cf), and safe overtaking (ot). fmri data were prepared for analyses using the human connectome project pipeline, then subjected to group independent component analysis (ica) to isolate 50 spatially independent networks. 40 ica networks were deemed valid and non-noisy. network regions in these components were identified using 387 parcel locations, incorporating a cortical parcellation atlas (glasser et al 2016) and detailed subcortical labels. a placebo minus high difference connectivity map was generated for each subject. a similar placebo minus high behavioral score was generated for each subject and then subjected to a principal component analysis (pca) to reduce it to 8 orthogonal behavioral factors. of the 8 driving behavior factors, two represented cf conference abstracts 108 events (f1 and f5), three lk (f3, f4, and f8), and three ot (f2, f6, and f7). driving behavior factors were evaluated for linear association with connectivity maps via fsl’s randomize (p<0.01 fwe-corrected significance). results:across all components examined, we found connectivity differences between placebo v high thc within right motion-sensitive visual cortex (parcel fst) (visual) and right superior temporal gyrus (social cognition) to positively correlate with lk driving performance. the strongest brain-behavior relationships were found for ot-related behavioral factors. connectivity in left dorsolateral parcel a9-46v (cognitive flexibility) and right motor cortex parcel 3b (somatosensory) correlated negatively with f6 (ot). a left superior frontal parcel (higher order cognition/working memory) correlated negatively with f7 (ot) and finally r inferior frontal gyrus (response inhibition and reward deduction) correlated positively with f7 (ot). conclusion: our preliminary analyses yield a complex yet informative picture of key brain areas sensitive to acute cnb exposure on different driving behaviors using a simulated environment, further underscoring the impact of substance use on driving as a potential public safety issue. day-level associations of craving and anxiety with self-reported attention and concentration problems in young adults who use cannabis: a key role for anxiety tammy chung, brett millar, marie sizemore, yanping jiang, ashley grosso, zeeshan ahmed (rutgers university) aim: acute effects of cannabis use on cognitive functions such as attention and concentration are well studied. less is known about how subjective states such as craving and anxiety, both of which can occur during cannabis withdrawal, impact cognitive functioning in daily life. this smartphone survey study examined the extent to which day-level cannabis craving and anxiety were associated with self-reported attention and concentration problems, accounting for trait anxiety and cannabis withdrawal. study findings have implications for understanding how cannabis-related subjective states impact aspects of cognitive functioning in daily life. methods: young adults (ages 18-25), who reported using cannabis at least twice per week, were recruited (2017-2019) using craigslist and research registry to participate in a smartphone daily survey study for up to 30 days in pittsburgh, pa. participants completed a baseline lab assessment (cannabis withdrawal scale, statetrait anxiety inventory). phone surveys were delivered 3 times/day: morning, afternoon, evening. participants also self-initiated reports of cannabis use. phone survey items (rated: 0none to 10a lot) queried cannabis craving, “how are you feeling now?” (e.g., anxious), and in the evening: “today, how much difficulty did you have with…” “keeping your attention on an activity for long”; and “concentrating and thinking clearly”. on days with a completed evening survey, cannabis use was coded 0=none and 1=any use. multilevel models tested associations of day-level attention and concentration (separate outcomes) with daily cannabis craving and anxiety, accounting for day-level cannabis use, and baseline trait anxiety and cannabis withdrawal. results: young adults (n=57; 60% female; mean age=19.8 [sd=1.7]; 78.9% white, 10.5% black, 10.6% other race/ethnicity) reported cannabis use on 390 out of 558 days. at baseline, average trait anxiety was 20.6 (sd=5.9, range=11-33/40 maximum) and withdrawal severity was 6.3 (sd=6.6, range=0-29/68 maximum). average daily craving was 3.3 (sd=3.0) and momentary anxiety was 2.0 (sd=2.6). participants reported low average daily attention (2.5+2.5) and concentration (2.3+2.4) problems. in a multilevel model using trait anxiety, craving, state anxiety, and day-level cannabis use to predict daily attention problems, craving and state anxiety were significant predictors (p<.05). in predicting daily concentration problems using the same set of variables, craving, state and trait anxiety were unique predictors (p<.05). using withdrawal severity at baseline (instead of trait anxiety), and the same set of variables to predict daily attention and concentration problems (separate models), craving and state anxiety were statistically significant (p<.05). in a final model including both withdrawal and trait anxiety, with craving, state anxiety, and day-level cannabis use to predict daily attention and concentration problems (separate models), only state anxiety was significant (p<.05). notably, day-level cannabis use was not uniquely associated with self-reported attention or concentration problems. conference abstracts 109 conclusion: results suggest the unique contribution of momentary anxiety, over and above trait anxiety, cannabis withdrawal, momentary craving, and day-level cannabis use, on self-reported daily mild attention and concentration problems. the temporal ordering of anxiety in relation to cannabis use and its effects on attention and concentration remain unclear, but suggest the potential for mindfulness training to reduce anxiety and increase attentional focus. cannabis use disorder uniquely predicts educational impairment in college students over and above other mental health disorders alexis blessing, patricia d. russell, willie hale, sandra b. morissette (the university of texas at san antonio) background: approximately 40% of college students report using cannabis in the past year (scholenberg et al., 2020) and nearly 1 in 10 (9.4%) first-year college students meet criteria for a cannabis use disorder (cud; caldiera et al., 2008). the prevalence cud is concerning as it is linked to greater number of skipped classes and failure to graduate from college (arria et al., 2015; hunt et al., 2010). in addition, cud is often comorbid with other substance use and mental health symptoms that impact educational outcomes, including post-traumatic stress disorder (ptsd; morissette et al., 2020), major depressive disorder (de roma et al., 2009), and alcohol use disorder (aud; meda et al., 2017), yet the impact of cud has not been examined within the larger context of these mental health problems. the aim of the current study was to examine the impact of cud on education functioning and gpa within the context of cooccurring ptsd, mdd, and aud. it was predicted that cud, measured both continuously (cud symptom severity) and dichotomously (presence/absence), would predict greater educational impairment and lower current overall gpa, even after taking into account age, gender, and presence of probable ptsd, mdd, and aud. method: college students (n = 210) who reported using cannabis within the past six months completed self-report questionnaires assessing trauma exposure (lec-5), educational impairment (ipf-es), cud (cudit-r), ptsd (pcl-5), depression (phq-9), and aud (auditr). overall gpa was retrieved from college transcripts. results: a series of hierarchical multiple regression analyses were conducted in spss version 25. in the continuous model, younger age (β = -.13, p < .05), presence of probable ptsd (β = .26, p < .01), and cud symptom severity (β = .20, p < .01) significantly predicted educational impairment, with cud symptom severity significantly improving model fit (r2 =.20; f(1, 203) = 10.13, p <.01). in the dichotomous model, younger age (β = -.13, p < .05), male gender (β = .16, p < .05), presence of probable mdd (β = .17, p < .05), probable ptsd (β = .26, p < .01), significantly predicted educational impairment, however probable cud did not ((β = .01, p = .151). similar models for gpa indicated cud symptom severity was the only significant predictor of low gpa (β = -.15, p < .01), yet presence of probable cud was not significant (β = -.09, p = .183). model fit was poor for both measurement types (continuous model: r2 =.01; f(1, 203) = 4.09, p <.05; dichotomous model: r2 = .00, f(1, 203) = 1.78, p = .183). conclusion: cud symptom severity negatively predicted both educational impairment and gpa, whereas probable cud did not predict either outcome. importantly, cud symptom severity predicted over and above other common mental health conditions among college students. in the context of rapid legalization of cannabis, these data suggest that university counseling centers may need to incorporate cud into treatment planning, particularly when students are experiencing educational challenges. investigating predictors of problematic cannabis use in polysubstance users aaron shephard, şimal dölek, sherry h. stewart, sean p. barrett (dalhousie university) introduction: since its legalization in 2018, cannabis use has substantially increased in canada. this increased use is concerning, as one in every eleven cannabis users will go on to develop a cannabis use disorder. further, problematic cannabis use is often related to the use of additional substances, particularly nicotine and alcohol, and there is evidence to suggest that the degree of harms associated with cannabis use increases when cannabis is used in conjunction conference abstracts 110 with other substances. additionally, personality is a known risk factor for problematic substance use, although to date problematic cannabis use has not been consistently linked to any specific personality trait. this study aimed to investigate the relationship between substance use, personality, and problematic cannabis use in a sample of cannabis using polysubstance users. method: a sample of 521 polysubstance users (past 30-day users of cannabis, alcohol, and nicotine) completed an online survey measuring their substance use, dependence, and personality. levels of substance specific dependence was measured using the cannabis use disorder identification test – revised, the alcohol use disorders identification test, and the fagerström tests for cigarette and e-cigarette dependence, while personality was measured using the substance use risk profile scale (surps). results: regression analyses showed that the top predictors for problematic cannabis use levels were levels of alcohol dependence, cigarette/ecigarette dependence, impulsivity, and sensation seeking. further analyses compared those who met the criteria for problematic cannabis use to those who did not; problematic cannabis users had significantly higher levels of alcohol and nicotine dependence, as well as higher levels of impulsivity and sensation seeking (all p’s <.001). discussion: this study identified strong relationships of problematic cannabis use with problematic alcohol and cigarette/e-cigarette use, and with sensation seeking and impulsivity. the findings have implications for screening, intervention, and policy. for example, the strong relations of problematic cannabis use with problematic alcohol use speak to the inadvisability of the co-location of cannabis and alcohol sales, as is the case in several jurisdictions. associations between number of standard doses of tetrahydrocannabinol, cannabis use motives and cannabis-related negative consequences alexander j. tyskiewicz, bradley t. conner, mark a. prince, nathaniel r. riggs (colorado state university) intro: recently, the national institutes of health published a notice of information regarding the establishment of a standard unit of tetrahydrocannabinol (thc) to be used in research. to address this notice, the current study examined if associations would differ when using standard dose as a measure of cannabis use compared to cannabis use frequency. we hypothesized that there would be a positive significant relation between cannabis use motives and cannabis-related consequences. we also hypothesized a significant positive relation between motives and cannabis use as measured by standard dose. finally, we hypothesized that the positive relation between motives and cannabis-related consequences would be partially mediated by cannabis use as measured by standard dose but not cannabis use frequency. method: we conducted five path analyses to test study hypotheses in a sample of individuals (n=84) who reported regular to heavy cannabis use. results: coping motives significantly positively predicted cannabis-related consequences (b=0.376, se=0.136, p=0.006), such that a one-unit increase in coping motives was expected to increase cannabis-related consequences by a factor of 1.45 (45%). number of standard doses significantly positively predicted cannabis-related consequences (b=0.24, se=0.122, p=0.046) such that a one-unit increase in number of standard doses was expected to increase cannabis-related negative consequences by a factor of 1.27. (27%). in the social motives model, social motives significantly positively predicted cannabis-related negative consequences (b =.358, se=.133, p=.007) such that a one-unit increase in social motives was expected to increase cannabis related consequences by a factor of 1.43 (43%). also, social motives significantly positively predicted number of standard doses (b=0.3, se=0.097, p=0.002) such that a one-unit increase in sense social motives was expected to increase the number of standard doses by a factor of 1.349 (35%). enhancement motives significantly positively predicted cannabis-related consequences (b=0.406, se=0.161, p=0.012) and number of standard doses consumed (b=0.2, se=0.1, p=0.014). further, irrs revealed that one unit increases in number of standard doses ingested predicted larger increases in cannabis-related negative consequences than did one unit increases in cannabis use frequency across all models with significant results. all indirect effects were not significant. discussion: previous research has reported mixed findings on the relations between conference abstracts 111 cannabis use and motives and cannabis use and consequences. this is likely due to how cannabis was being measured, by frequency. our results suggest that relations between cannabis use frequency or standard doses have with motives and cannabis-related consequences differ in significant ways and that, when measured in standard dose or cannabis use frequency, cannabis use is not a significant mediator of the relation between motives and consequences. development and validation of the cannabisdependent appetite measure brooklyn m. deming (knox college) the present study was a two-part investigation into the concept of, risk markers for, and original measure of cannabis-dependent appetite (cda). cannabis-dependent appetite is a condition in which some prolonged heavy cannabis users develop disordered eating habits, marked by the increasing need for cannabis ingestion to stimulate appetite. current literature is mainly focused on changes in appetite post-ingestion. however, it is imperative to differentiate changes in appetite solely after use and changes in appetite both during sober and intoxicated periods. this distinction targets the disordered eating habits characteristic of cda. participants (n = 60) were 18 years or older and were cannabis users. in the first portion of the study, 11 risk markers (family and personal history of mental health disorders, number of daily sessions, frequency, form quantity, anxiety, depression, anxiety sensitivity, affectivity, difficulty in emotion regulation, and age of onset) were analyzed as potential predictors of the development of cda, which is measured using the cannabis-dependent appetite measure (cdam). in the second portion, participants (n = 40) from the first portion who were daily cannabis users, had a smartphone, had access to reliable internet or data, and were willing to receive text messages from the research team were included in the daily collection of self-reported eating and cannabis use habits. within-subject correlations between times when eating and cannabis use occurred were calculated and correlated with scores on the cdam as a way to validate that the cdam measures the behaviors aimed at assessing. it was hypothesized that individuals who use cannabis more frequently (vs. less frequently) are more likely to develop cannabis-dependent appetite (cda) as potential risk markers (family and personal history of mental health disorder, number of daily sessions, frequency, form quantity, anxiety, depression, anxiety sensitivity, negative affectivity, and difficulty in emotion regulation) increase and others (age of onset and positive affectivity) decrease. frequency (r(55) = .49, p < .001, r2 = .24), average number of daily sessions (r(55) = .45, p < .001, r2= .20), and quantity of cannabis concentrates (r(29) = .41, p = .024, r2= .16) were significantly positively associated with cannabis-dependent appetite. both age of onset (r(57) = -.29, p = .031, r2 = .08) and positive affectivity (r(60) = -.44, p < .001, r2 = .19) were significantly negatively correlated with cda. a significant positive correlation was found between being high and eating (r(38) = .37, p = .018, r2 = .14). data show the behavioral trends assessed using ecological momentary assessment add validity to the cdam. cannabis smoking and storage within the home: a cross-sectional survey of families with children kara skelton (towson university) sara benjamin-neelon (johns hopkins bloomberg school of public health) introduction: child cannabis exposure has increased in recent years – a trend that parallels changes to cannabis legality. yet, little is known about household cannabis practices in the us. to address this gap, this study aims to examine household cannabis practices among a geographically diverse sample of us women of reproductive age. we also examine variations in household cannabis practices across states with varying cannabis policies. methods: the study sample (n=114) included pregnant women and women with children in their home. in spring of 2021, participants completed a single crosssectional online survey that included demographic information and asked about cannabis use, household cannabis practices (e.g., indoor smoking, cannabis storage), and cannabis use risk perceptions. we analyzed data in march 2022 using descriptive statistics. results: a total of 69.23% and 42.98% of participants reported cannabis products were allowed in their home and conference abstracts 112 that smoking cannabis was permitted in one or more rooms of their home, respectively. although not statistically significant, more women residing in states with recreational cannabis more frequently reported that smoking cannabis was allowed in one or more rooms of their home than women residing in states yet to legalize (47.73% vs. 40.00%, respectively). conclusions: amid rapidly shifting cannabis policies, further examination of household cannabis practices is needed. public heath efforts should focus on reducing in-home cannabis exposure and promote safe storage and smoking practices for families with children in the home. association between cannabis use and suicidal ideation as moderated by gender identity kassidy a. robertson, patrice a. arkfeld, mark a. prince, bradley t. conner (colorado state university) cannabis is the most commonly used substance that remains federally illegal in the united states. with its rising legality in many states across the nation, it is important to understand the influence that cannabis can have on a user's physical and mental well-being. according to the centers for disease control and prevention (2022), suicide is among the top nine leading causes of death in the united states for individuals aged 10 to 64. research suggests that individuals diagnosed with depression who experience suicidal ideation, plans, and attempts is positively correlated with both daily cannabis use and non-daily cannabis use and that this correlation is more significant in women than in men (han et al., 2021). this study seeks to generalize this finding by investigating both the prevalence and intensity of 30-day cannabis use amongst individuals who endorse suicidal thoughts in the last 12 months and the moderating effect of gender identity on the relationship between 30-day cannabis use and suicidal thoughts in the last 12 months. this study will utilize a sample of college students who completed the american college health association-national college health assessment survey sometime between the fall academic semester of 2019 to the spring academic semester of 2021. the survey was completed on campuses across the united states with data collected on students’ health habits, behaviors, and perceptions. this data set consists of 198,848 participants aged 18 to 98 years of age (mage = 23.16), with 66.27% of participants identifying as cisgender women and 30.83% identified as cisgender men. within the dataset, 40.30% of participants endorsed thinking about or planning suicide in the last 12 months and 19.34% of participants reported using cannabis in the last 30 days. we anticipate that individuals who reported cannabis use in the last 30 days will show an increase in suicidal ideation in the last 12 months compared to individuals who reported never using cannabis. similarly, we anticipate that gender identity will moderate and strengthen the relation between cannabis use and suicidal ideation in such that individual who identify as women will have a stronger and more significant correlation between cannabis use and suicidal ideations compared to individuals who identify as men. if these results are supported, future research will be warranted to further investigate how the nuanced interaction between gender identity and cannabis use increases our understanding of the upward trend in suicidality among individuals with and without mental health diagnoses. examining the effects of cannabis use on sleep using daily diary data neel muzumdar, jennifer f. buckman (rutgers university) alexander sokolovsky (brown university) anthony p. pawlak, andrea m. spaeth (rutgers university) kristina m. jackson (brown university) helene r. white (rutgers university) background: college students in the united states widely report using alcohol and cannabis as a sleep aid. given the prevalence of sleep problems and insufficient sleep in this population, the high incidence in use and co-use of cannabis and alcohol is unsurprising. current evidence does not support alcohol as an effective sleep aid and research on the relationship of cannabis to sleep is limited and inconsistent. furthermore, the majority of current cannabis and sleep studies are limited to retrospective, person-level analyses even though there is a wide range of individual conference abstracts 113 and day-level differences in reactivity to intoxication. purpose: the aim of this study is to examine cannabis and alcohol use and their associations with sleep at both the between-person level (i.e., between-subjects comparison of chronic use behaviors) and within-person level (i.e., day-level comparison of use behaviors). method: this study is a secondary analysis of longitudinal data obtained from a study characterizing the effects of simultaneous alcohol and cannabis use. participants (n=341) completed surveys up to five times per day during two bursts of 4 weeks (54 days total) that occurred during two consecutive college semesters. self-reported quantities of cannabis use (as number of uses) and alcohol use (as number of drinks), as well as bedtimes (night) and wake times (morning) were reported. linear mixed models were conducted in sas 9.4 to characterize between-person and within-person (person-mean centered) correlations of cannabis or alcohol use and sleep duration. results: significant main effects of withinperson cannabis (estimate: 0.019, se: 0.007, t=2.86, p=0.004) and alcohol (estimate: -0.0402, se: 0.0076, t=-5.28, p<0.001) use were found, as was a between-person main effect of average cannabis use (estimate: 0.038, se: 0.012, t=3.28, p=0.001) across the full study period. the between-person main effect of average alcohol use was not significant. conclusions: the results suggested that generally heavier cannabis users sleep more than their non-using/generally light using counterparts and that they sleep more on nights following heavier use days. interestingly, the relationship between alcohol and sleep differed between the between-person and within-person levels: alcohol use was dose-dependently associated with reduced sleep duration; however, in this sample, generally heavier alcohol users did not appear to differ in overall sleep duration compared to generally lighter alcohol users. importantly, this sample included a wide range of substance users, none of whom were in treatment for a cannabis use disorder (cud) or alcohol use disorder (aud). whether these patterns of dose-dependence would be observed over longer time periods or in individuals who meet criteria for cud or aud remains to be studied. future studies will assess the effects of alcohol and cannabis co-use patterns as well as timing of consumption. adolescent-onset cannabis use disorder is associated with greater self-reported apathy among adults living with hiv in florida mark k. britton, eric porges, ronald cohen, yan wang (university of florida) gladys ibanez (florida international university) charurut somboonwit (university of south florida) robert cook (university of florida) introduction heavy cannabis use has been associated with increased self-reported apathy, or the reduction in motivation and goal-oriented behavior. apathy is also prevalent in people living with hiv (plwh). cannabis use is prevalent among plwh and has been associated with alterations in brain areas linked to motivation and reward. however, there is a paucity of studies directly examining heavy cannabis use as a predictor of apathy in this population. the current study focuses on age of initiating heavy use, as the neurobehavioral effects of chronic cannabis use may be intensified by early heavy use. we hypothesized that adolescent-onset heavy users would show greater apathy than adult-onset heavy users and that both groups would show greater apathy than never-heavy users and neverusers. methods baseline data were taken from a larger study of marijuana use, cognition, and health in adults living with hiv; included participants had complete marijuana use data (n = 236). the marin apathy evaluation scale – self (aes-s) was used to measure self-reported apathy. the marijuana section of the substance abuse module (sam-5) was administered. participants were divided, based on age of first meeting criteria for cannabis use disorder, into early-onset (<18) cud, late-onset cud, nevercud, and never-user groups. to account for variations in cell size and outliers, a robust oneway anova was conducted using the wrs2 r package, with age of onset of cud as a predictor and aes-s total score as dependent variable; results were submitted to hochberg post-hoc tests. conference abstracts 114 results the mean age of included participants was 49.81 years. 73% of participants identified as black/african american, and 54% were assigned male at birth. 8% of included participants had early-onset cud; 29% had late-onset cud; 43% never met criteria for cud; and 20% never used marijuana. 71.6% of participants currently used marijuana at least once a week. the mean aes-s score was 29.81. age of cud onset predicted aess score, f(3,48.5)=5.84, p = 0.002. post hoc tests revealed that the early-onset group (mean = 33.4) was significantly more apathetic than the neveruser group (mean = 28.5) (ψ = 5.95, ci=1.7310.16, p = 0.002) and the never-cud group (mean = 29.9) (ψ = 4.02, ci = 0.60-7.43, p = 0.013). no difference was detected between late-onset (mean = 30.1), never-cud, and never-user groups (p >.05). discussion we observed that age of cannabis use disorder onset is associated with aes-s score among adults living with hiv, such that adolescent-onset cannabis use disorder predicted higher levels of apathy relative to groups with no history of cannabis use disorder or cannabis use. two interpretations of this finding may be advanced: first, that individuals predisposed to apathy are more likely to engage in heavy substance use; second, that early-onset substance use alters behavior and perhaps underlying reward circuitry. limitations of this study include the absence of a control group without hiv and the cross-sectional nature of our data. future directions include assessing the roles of current age, depression, and hiv viral suppression as potential covariates. do cannabis pdmps change physician prescribing behavior? shelby steuart (university of georgia) as legal medical cannabis has become widespread in the united states, cannabis-related emergency department visits have increased. one reason for this increase is that physicians cannot prescribe medical cannabis, leading to a situation where physicians must rely on their patients to tell them whether they use medical cannabis. patients may withhold their use of cannabis from their physician out of fear of judgment or fear of changes to their prescriptions. at the same time, almost 400 medications have moderate or severe contraindications for use with cannabis, any of which could cause a poisoning severe enough to warrant hospitalization. to combat this problem of information asymmetry in patient cannabis use, about one-third of states with medical cannabis programs have added cannabis to their state prescription drug monitoring program (pdmp) over the past few years. this could lead to changes in the physician prescribing behavior, which may result in fewer accidental cannabisrelated poisonings. i will explore this question through the application of robust difference-indifference models to private and public insurance claims data as well as data from electronic medical records. using retailer data and subjective resident experience to assess legal cannabis access in massachusetts alexander m. colby, hailey pensky, marianne sarkis, julie k. johnson (massachusetts cannabis control commission) adult-use cannabis retail storefronts first opened in massachusetts in november 2018. forty months later, there are 366 cannabis retailers across the commonwealth, but it remains unclear which areas have adequate access to safe, regulated (“legal”) cannabis products, and which areas are underserved. in this study, we use open census and retailer data and self-report surveys from massachusetts residents to estimate access to legal cannabis across massachusetts. we used populations from the 2020 census and the cannabis control commission’s licensing data to approximate the cannabis retailer density per 100,000 people in each of massachusetts’ fourteen counties. counties were collapsed by region to provide trend estimates by general geographic location. cannabis retailer density were highest in berkshire, franklin, and hampshire counties (western), and lowest in norfolk (southeast), with less than one retailer (0.7) per 100,000 people, followed by barnstable (southeast) and suffolk (northeast) counties. massachusetts resident data from the international cannabis policy study (icps) for 2019 (n = 2,476) and 2020 (n = 2,207) were used to determine whether the subjective experiences and purchasing behaviors of residents support the results of our objective measure. binomial regressions were run at the region-level to lower conference abstracts 115 the risk of type i error. participants were first asked why they bought from an illegal rather than legal source, and comparisons were made between regions based on the amount of individuals answering “legal sources were too far away.” the southeast region served as reference group, as it had the lowest retail density and was believed to have more people reporting dispensaries were too far away. results show that only residents of the central region [rr .52, ci(.28, .91), p = .031] were less likely to report that legal sources were too far away than southeast residents. all other regions did not reach significance. we asked participants where they were purchasing their cannabis products and compared the number of residents of each region that reported purchasing from a “licensed recreational store.” we included western as the reference group for this model as it was the region with the highest retail density and was likely home to many residents buying from stores. residents of western massachusetts were significantly more likely to purchase their products from legal stores than residents of the central [.72, ci(.6, .87), p <.001], northeast [.74, ci(.64, .86), p<.001], or southeast [.81, ci(.7,.94), p=.005] massachusetts. it has been six years since massachusetts legalized cannabis, yet notable inequities still exist in residents’ access to legal, nonmedical, adult-use cannabis products. western massachusetts was the best-served region for cannabis consumers by our estimates, where southeast massachusetts remained largely underserved through 2020. these inequities may have implications for cannabis law enforcement in the state, as illicit sources of cannabis could flourish in the absence of easily accessible legal dispensaries. future work should consider the scope of the illicit market(s) and whether individuals in underserved areas are at higher risk of committing cannabis-related offenses either at the state (distribution) or federal level (trafficking cannabis across state lines). absence of age verification for delivery of online purchases of cbd and delta-8: implications for youth access to cbd and delta-8 products kathleen l. egan, sophia villani, eric k. soule (east carolina university) while marijuana is currently illegal in the united states (us) at the federal level and is a schedule i drug under the controlled substances act of 1970, the 2018 farm bill exempted some products containing cannabinoids from the drug enforcement agency’s controlled substance list. under the 2018 farm bill, products containing &lt;0.3% tetrahydrocannabinol (thc) content, such as cannabidiol (cbd) and delta-8 thc, would not be considered schedule i controlled substances. dependent on state law, individuals must be either 18+ or 21+ to purchase cbd and 21+ to purchase delta-8. the proliferation of online cbd/delta-8 shops and the shipment of these products from brick-and-mortar locations may contribute to youth access and use of these products in the absence of age verification checks. as part of a pilot study, we aimed to purchase a variety of cbd and delta-8 product types (e.g., edible, flower, vape, etc.) from cbd shops located in 18 unique states throughout the us. we identified 18 states based on those that permitted the sale of cbd and delta-8 products and represented all four census regions of the us (i.e., west, northeast, midwest, and south). we searched for the top-rated cbd shops in the largest city in the selected state using yelp. we selected the highest rated cbd/delta-8 product available of the identified product type. if we were not able to purchase the product at the shop, we would search the next shop that was in the yelp review. all products were ordered by someone over 21 years of age and were shipped to a residential address. we documented ability to purchase the product online, online age verification, and whether or not identification or a signature was required at the time of delivery. we had to visit different 26 cbd store websites to reach our goal of purchasing 20 cbd and delta-8 products from 20 unique states across all four census regions of the us. of the websites we visited to purchase cbd products, 37.5% required the customer to verify their age prior to viewing products, and 70.0% of the websites we visited to purchase delta-8 products required age verification. there were 6 shops that we were unable to purchase a product from. in most cases, this was due to a lack of shipping options, and one store required that the credit card used matched a valid id which was not possible given our use of an university credit card. at the time of delivery, none of the products required an age identification check or contact with the customer. all deliveries were either left in the mailbox or on the porch. the conference abstracts 116 findings of our pilot study suggest that youth can obtain cbd and delta-8 products from online sources without age verification. efforts are needed to increase the utilization of age verification at the point of delivery by stores that ship cbd and delta-8 products. the good, the bad, and the uncertain: a systematic review of the impacts of recreational cannabis legalization kyra n. farrelly (york university & peter boris centre for addictions research) jasmine turna (peter boris centre for addictions research & michael g. degroote centre for medicinal cannabis research) emma marsden, molly scarfe, peter najdzionek (peter boris centre for addictions research) jeffrey d. wardell (york university, center for addiction and mental health, & university of toronto) james mackillop (peter boris centre for addictions research, michael g. degroote centre for medicinal cannabis research, & homewood research institute) background: recreational cannabis legalization has become more prevalent over the past decade, with recreational cannabis now legal in 13 u.s. states and nationally in uruguay, canada, and malta. at the same time, there is evidence for increasing rates of cannabis use and consequences from use (i.e., crime and motor vehicle accidents) among some age groups, particularly in north america. thus, it is crucial to understand the role of recreational legalization on person-level outcomes, such as cannabis consumption and health-outcomes. previous reviews have focused on outcomes in the u.s., but there remains a need for a broader international evaluation of the effect of legalization. additionally, there is a dearth of reviews examining recreational cannabis legalization as past literature has focused more attention on medical cannabis legalization. the current review examined the role of recreational cannabis legalization on a variety of personcentered outcomes to understand if the consequences of legalization. method: a comprehensive systematic review was conducted in accordance with prisma guidelines. inclusion criteria involved: empirical quantitative research, article available in english, a research design evaluating the impact of recreational cannabis legalization (e.g., pre vs. post), and person-level cannabis use, and/or clinical outcomes included as dependent variables (opposed to outcomes such as changes in the price or potency of cannabis). two individuals independently coded studies for eligibility and extracted information. the search revealed 69 studies that met criteria for inclusion. results: our search revealed five main categories of outcomes associated with recreational cannabis legalization: cannabis and substance use behaviors, health-care impacts, attitudes surrounding cannabis, crime-related outcomes, and driving-related outcomes. the studies were predominantly cross-sectional designs and most took place within the u.s. the extant literature revealed inconsistencies surrounding the role of recreational legalization. in the case of cannabis use behaviours, there was mixed evidence for different subpopulations. for example, legalization was associated with increased cannabis use for college samples, but there were inconsistent findings for adolescents. additionally, some studies pointed towards negative consequences associated with legalization, such as increased cannabis use in clinical populations and increased cannabisrelated healthcare visits. other studies suggested no impact of legalization through either no change in examined outcomes or heterogenous conclusions (e.g., cannabis-related attitudes). finally, there was also evidence of positive consequences for recreational legalization, such as decreased drug-related arrests and cigarette use. conclusions: overall, the balance of research suggests there is no clear support for any large magnitude person-level impact of recreational cannabis legalization. this review indicates that more conclusive evidence regarding the impact of recreational legalization is still required and reveals a need for more longitudinal study designs with longer-term follow-ups as well as studies from a broader range of geographic jurisdictions. as recreational cannabis legalization becomes implemented globally, a systematic evaluation of the outcomes associated with enactment is of increasing relevance. conference abstracts 117 "you still have that fear": policy constraints on informed decision making about legalized cannabis use during pregnancy and lactation faith english (university of massachusetts, amherst) devon greyson (the university of british columbia) background: cannabis is the most commonly used drug during pregnancy in the united states and use during pregnancy is increasing along with greater legal and social acceptance. methods: we conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in massachusetts, a state that legalized cannabis for adult use in 2016. our aim was to explore how policy constrains or facilitates people’s ability to make informed decisions about cannabis use during pregnancy and lactation. our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences. results: findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of cannabis users and inhibit their ability to obtain expert advice from healthcare providers. conclusion: decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population. impact of recreational cannabis legalization on cannabis use patterns in the ny metropolitan area: a longitudinal survey rina goldstein, sean madden, allegra nevins (northwell feinstein institutes for medical research) monica tomlinson (northwell addiction recovery services) diana martins-welch (northwell health center for advanced medicine, zucker school of medicine at hofstra/northwell) nehal p. vadhan (northwell feinstein institutes for medical research, zucker school of medicine at hofstra/northwell) introduction. in march of 2021, limited recreational cannabis use was legalized in new york (ny) state. the effects of this legalization on cannabis use patterns remain unclear. this study aims to assess changes in cannabis use patterns and the reasons behind those changes following legalization. methods. 646 cannabis users from the ny metropolitan area who completed a baseline online survey in 2018 on cannabis use patterns and related variables were contacted via email to complete a follow-up survey that included additional items related to legalization. 135 adults (f=56, m=75, t/o=4) have completed the survey in a 6-week recruitment period thus far. respondents’ mean age at the time of the current survey was 36.1 (sd=8.5). most respondents reported being college-educated (68.1%) and employed (81.0%), and the racial/ethnic breakdown was as follows: white=53.3%; hispanic=18.5%; mixed/other=17.4%; black=7.4%; asian=2.2%. results. respondents reported using cannabis more for recreational than for medicinal purposes (48.46% vs 51.28% on a scale of 0 (fully recreational) -100 (fully medicinal); p=0.011) and reported spending $10.96 more as a minimum (p=0.031) and $49.61 more as a maximum (p=0.008) dollar amount, on average, on cannabis per week after legalization (relative to before legalization). fewer participants reported vaping as a route of administration following legalization (48.9%) compared to pre-legalization (65.9%; p=0.002). the primary type of cannabis use differed from preto post-legalization (p=0.020), with primarily thc-composed cannabis seemingly increasing (73.3% vs 84.4%) relative to other cannabinoids following legalization. finally, more participants reported hallucinogen use after conference abstracts 118 legalization relative to before legalization (p=0.013). conclusions. these data suggested that in a sample of regular cannabis users, some selfreported cannabis use patterns changed after legalization of recreational cannabis use in the ny metropolitan area. cannabis use for recreational purposes increased relative to medicinal purposes, as did certain cannabis spend parameters, proportional thc use, and hallucinogen use. reported vaping of cannabis decreased, which speculatively could be related to respiratory concerns associated with vaping interacting with the ongoing covid-19 pandemic, rather than legalization per se. these results may inform policy and treatment initiatives regarding cannabis. responses to recreational cannabis legalization among non-users, cannabis users without a license and cannabis users with a license delaney s. dunn (oklahoma state university and tset health promotion research center) sarah j. ehlke, michael a. smith (tset health promotion research center) darla kendzor, amy m. cohn (tset health promotion research center and university of oklahoma health sciences center) significance: with the changing cannabis legalization landscape, it is important to assess how people may respond to new cannabis legalization policies to inform the effectiveness of such policies that balance public health with consumer needs and interests. recent research compared intentions to use legalized cannabis among young adult never and ever cannabis users (leung et al., 2020) and found 59% of never users and 41% of ever users intended to try cannabis if it were legal. however, past research has not examined differences in cannabis use intentions among different groups who report using cannabis for medical reasons versus non-medical reasons, even though past research has demonstrated the importance of differentiating the two groups (roybyrne et al., 2015). as such, the present study aims to assess the unique correlates of responses to cannabis legalization across non-users, cannabis users without a license and cannabis users with a license. method: participants were adults living in oklahoma (verified by self-reported zip code of residence) who participated in one wave of a 3wave cross-sectional online survey (n = 5,248; 63.7%, non-past 30-day users, 15.8%, past 30-day cannabis users without a medical cannabis license, 17.8%, past 30-day cannabis users with a license) with an average age of 40.35 years. participants were female (56.8%) and nonhispanic white (70.3%). participants completed measures related to past 30-day cannabis use, procession of a cannabis license, and were asked to “select all that apply” to a single item with 8 response options about how they would respond if recreational cannabis was legalized in their state. results: multivariable logistic regression models revealed significant differences in all 7 of the response options analyzed among non-users, cannabis users without a license and cannabis users with a license controlling for demographic characteristics (ps < .05; the 8th item “would use it less” was not assessed among non-users). next, logistic regression models were examined in all 8 of the response options to compare cannabis users with a license and cannabis users without a license. cannabis users with a license were more likely to report they would recommend cannabis to a friend or family member (aor = 1.32, 95%ci: 1.04, 1.68), and they would use cannabis the same as they do now (aor = 1.75, 95%ci: 1.43, 2.15). in contrast, cannabis users without a license were more likely to report they would use cannabis more than they do now (aor = .44, 95%ci: 0.34, 0.57), they would use other types of cannabis (aor = .62, 95%ci: 0.47, 0.80), and they would use cannabis more often to help treat their symptoms (aor = .60, 95%ci: 0.47, 0.77). conclusion: findings support evidence of differences in how groups would respond to nonmedical cannabis legalization with cannabis users without a license intending to use more cannabis. this greater use could become problematic as cannabis strands become more potent with nonmedical legalization (shover & humphreys, 2019). future research should continue to examine responses to non-medical cannabis legalization to inform cannabis harm prevention and policy changes related to legalizing nonmedical cannabis. state marijuana and alcohol policies and co-use among adolescents conference abstracts 119 grisel garcía-ramírez, m.j. paschall, joel grube (prevention research center) introduction. liberalization of marijuana laws raises concerns regarding greater availability, more favorable norms, and increased use by adolescents. previous studies have examined associations of marijuana laws with marijuana use by youth with mixed results, but few studies have investigated the effects of marijuana and alcohol laws on marijuana and alcohol co-use. a study in oregon found an increase in marijuana and alcohol co-use among adolescents after recreational marijuana legalization in 2015, particularly in counties with greater retail marijuana and alcohol availability. no studies, however, have investigated the combined effects of state marijuana and alcohol policies on co-use. objective. the goal was to examine associations between variations of state-level marijuana and alcohol policies restrictiveness and marijuana and alcohol co-use among adolescents. we hypothesized that youth living in states with more liberal policies will have higher rates of marijuana and alcohol co-use and that marijuana and alcohol policies will interact such that co-use would be significantly higher when both were less restrictive. method. we analyzed data from 13,702 students living in 25 states who participated in the 2019 youth risk behavior survey (yrbs). students were asked about marijuana and alcohol use frequency in the past 30-days. those who engaged in marijuana and alcohol use at least once in the past 30-days were classified as marijuana and alcohol co-users (1=yes, 0=no). we assessed the restrictiveness of state-level alcohol regulatory policy environments using the 2018 alcohol policy scale (aps) and created an overall marijuana policy score (mps) for each state for 2018 with higher scores representing a more liberal marijuana policy environment. policy domains in the mps included recreational legalization (0=no, 4=yes), medical legalization (0=no, 1=cbd only, 2=no restriction), minimum legal age for medical marijuana use (0=21 years old, 2=18 years old), decriminalization (0=no, 2=yes), retail sales (0=no, 1=off-premise, 2=on/off-premise) and home deliveries (0=not allowed 1=with restrictions, 2=no restrictions). we performed multilevel mixed logistic regression analyses using stata version 17, accounting for nesting of schools within states and students within schools. covariates included age, sex, ethnicity, and race. results. less restrictive policy environments were associated with a greater likelihood of marijuana and alcohol co-use (mps or=1.50, 95% ci: 1.21, 1.87; aps or=1.03, 95% ci: 1.01, 1.05). the interaction of the state marijuana and alcohol policies showed that the least restrictive combination of these policies was marginally associated with lower odds of marijuana and alcohol co-use (or=.99, 95% ci: 0.99, 1.00), but this association was not substantively meaningful beyond the independent effects of the two policy measures. conclusion. our findings show that less restrictive state-level marijuana and alcohol policy environments, especially for marijuana policies, are associated with increased prevalence of marijuana and alcohol co-use among adolescents. these findings suggest that additional prevention efforts are needed as more states liberalize their marijuana laws. future studies should consider other negative consequences associated with less restrictive policies and resulting from co-use, and changes in marijuana and alcohol co-use among adolescents over time. pharmacy students’ knowledge, attitudes, and awareness toward marijuana use khaled m. hasan, olufisayo oluwafemi, wilde ketchatang (university of maryland eastern shore) introduction: this study aimed to assess the knowledge, attitudes, and awareness of pharmacy students toward marijuana use. methods: pharmacy students were asked to complete a survey that assessed students’ knowledge, attitudes, and awareness toward marijuana use. this study compared students’ awareness about the harmful effects of marijuana in comparison with alcohol and smoking tobacco. participants were asked about the possibilities of marijuana-induced cancer and addiction. results: twenty-three percent of pharmacy students reported having used marijuana at some point in their lives. in comparison with tobacco and alcohol, most of the students agreed that tobacco (49%) and alcohol (42%) are more harmful than marijuana (p <0.0001). more than sixty conference abstracts 120 percent of students considered marijuana as an addictive substance (p <0.02). a 45% of students opposed the possibility of marijuana-induced cancer. thirty-six percent of the students agreed that marijuana should be legalized for both medical and recreational use with a similar percentage of the students (30 – 32%) believing that marijuana should be legalized for medical use only. conclusion: pharmacy schools need to consider coverage of marijuana use in different sections of their curriculum. this will allow pharmacy students to be better prepared for current and future practice regarding the increased prevalence of marijuana use. medicinal cannabis prescribing guidance documents: an evidence-based, best-practice framework based on the new south wales experience myfanwy graham, elianne renaud, catherine j lucas, jennifer schneider, jennifer h martin (australian centre for cannabinoid clinical and research excellence, university of newcastle, centre for drug repurposing and medicines research, university of newcastle, hunter medical research institute) introduction: in 2018, the australian centre for cannabinoid clinical and research excellence (acre), a national health and medical research council (nhmrc) centre of research excellence was funded to develop a suite of state-wide medicinal cannabis prescribing guidance documents. at this time, regulatory changes in australia were enabling broader access to medicinal cannabis in a medical model. the initiative funded through the new south wales (nsw) government’s clinical cannabis medicines program enabled the development of practical resources to support nsw medical practitioners in prescribing medicinal cannabis to patients for conditions where cannabinoids are perceived to have some benefit. aim: to provide interim guidance to support medical practitioners in the prescription of medicinal cannabis where they are perceived to have potential benefit. methods: a team of clinical pharmacologists, pharmacists and clinicians collaborated in the development of the first tranche of prescribing guidance documents. the suite of six medicinal cannabis prescribing guidance documents covered the most common indications for which prescriptions for medicinal cannabis were being sought by nsw patients: dementia; anorexia and cachexia; nausea; chemotherapy-induced nausea and vomiting; spasticity; and chronic non-cancer pain. in 2019, the draft guidance documents underwent a comprehensive review and consultation process involving fifty key stakeholders before publication. results: the acre medicinal cannabis prescribing guidance documents have been widely adopted, both in nsw and around the world. the prescribing guidance documents are now recommended as a health professional educational resource by the australian national medicines regulator the therapeutic goods administration and state health departments. the prescribing guidance on epilepsy from the second tranche of guidance documents has recently been published in the british journal of clinical pharmacology. national medicinal cannabis prescribing pattern data and enquiries to the first-of-kind, stategovernment funded medicinal cannabis advisory service for medical practitioners informed the themes of the second tranche of six medicinal cannabis prescribing guidance documents being developed in 2022. conclusions: acre medicinal cannabis prescribing guidance documents delivered interim guidance to australian medical practitioners on the evidence-based and best-practice prescription of medicinal cannabis. prescribing guidance document themes align with australian medicinal cannabis prescribing patterns and areas where medical practitioners are seeking further information and advice. it is anticipated that the prescribing guidance documents will be updated periodically as further evidence becomes available. acknowledgements: nsw government through the nsw clinical cannabis medicines program supported development of the nsw cannabis medicines prescribing guidance. acre was established and is funded through the national health and medical research council centres of research excellence scheme. new kinds of [hash]tags: an interdisciplinary examination of semi-synthetic cannabinoid products conference abstracts 121 carlton bone, charles klein, robert strongin, kaelas munger (portland state university) the rise of distinct subcultures of cannabinoid users and the proliferation of new psychoactive substances derived from the hemp plant reflects a dynamic relationship between the development of new cannabis products and the growth of the markets for these goods. this research combines social science and analytical chemistry framework to explore the historical, linguistic, and chemical developments of cannabis acetates and related products over time. understanding the multiplicity of contexts that have influenced the trajectory of moieties like thc-o-acetate is an attempt at detecting and identifying other new psychoactive substances with structural or functional similarities to δ⁹-thc through an interdisciplinary lens. prevalence and predictors of simultaneous cannabis and alcohol use among medical cannabis patients— is one metric enough? alexandra f. kritikos, rosalie liccardo pacula (university of southern california) dominic hodgkin (brandeis university) julie k. johnson (massachusetts cannabis control commission) background: during the past two decades of cannabis legalization, the prevalence of medical cannabis (mc) use has increased and there has also been an upward trend in alcohol consumption. as less restricted cannabis laws generate more adult cannabis users, there is concern that more individuals may be simultaneously using medical cannabis with alcohol. a few studies have examined simultaneous use of medical cannabis with alcohol, but none of those studies also assessed patients’ current or previous non-medical cannabis use. this paper explores simultaneous alcohol and medical cannabis use among medical cannabis patients with a specific focus on previous history of cannabis use and current non-medical cannabis use. methods: a retrospective cohort study of mc patients (n=631) from four dispensaries located in new york state. bivariate chi-square tests and multivariable logistic regression are used to estimate the extent to which sociodemographic and other factors were associated with simultaneous use. results: approximately 29% of the sample engaged in simultaneous use and a large share of these users report previous (44%) or current (66%) use of cannabis for non-medical purposes. mc patients who either previously or currently use cannabis non-medicinally, men, and patients using mc to treat a pain-related condition, were significantly more likely to report simultaneous alcohol/mc use. conclusions: results suggest that cannabis use does not fit into two mutually exclusive typologies, medical and non-medical (“recreational”), but exists along a continuum where patients’ use and purposes shift to match their health and daily lives. findings indicate that there may be differential risks related to alcohol/mc use prevalence, which should be considered by cannabis regulatory policies and prevention/treatment programs. if patients are using cannabis and/or alcohol to manage pain, clinicians should screen for both alcohol and cannabis use risk factors. copyright: © 2022 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i1a4_authors_final_p research article 34 ved abstract objective: alcohol and cannabis use motives are often studied as contributors to risky substance use patterns. while various measures for capturing such motives exist, most contain 20+ items, which render their inclusion in certain research designs (e.g., daily diary) or with certain populations (e.g., polysubstance users) unfeasible. we sought to generate and validate six-item measures of cannabis and alcohol motives from existing measures, the marijuana motives measure (mmm) and the modified drinking motives questionnaire-revised (mdmq-r). methods: in study 1, items were generated, feedback from 33 contentdomain experts was obtained, and item revisions were made. in study 2, the finalized brief cannabis and alcohol motives measures, along with the mmm, mdmq-r, and substance-related measures, were administered to 176 emerging adult cannabis and alcohol users (71.6% female) at two timepoints, two months apart. participants were recruited through a participant pool. results: study 1 experts indicated satisfactory ratings of face and content validity. expert feedback was used to revise three items. study 2 results suggest test-retest reliabilities for the single-item forms (r = .34 to .60) were similar to those obtained with full motives measures (r = .39 to .67). validity was acceptable-to-excellent in that brief and full-length measures were significantly intercorrelated (r = .40 to .83). the brief and full-length measures had similar concurrent and predictive relationships for cannabis and alcohol quantity x frequency (copingwith-anxiety for cannabis and enhancement for alcohol) and problems (coping-with-depression), respectively. conclusions: the brief measures represent psychometrically-sound measures of cannabis and alcohol use motives with substantially less participant burden than the mmm and mdmq-r. key words: = cannabis motives; alcohol motives; test development; young adults individuals are motivated to engage in cannabis and alcohol use to achieve a variety of effects (i.e., substance use motives). theory suggests motivations for cannabis and alcohol use exist on positive vs negative reinforcement and internal vs external dimensions (cooper et al., 2016). these two dimensions interact to create four categories of motives for cannabis and alcohol use (cooper et al., 2016): 1) internal positive reinforcement motives, involving substance use to increase positive emotions (i.e., enhancement motives); 2) internal negative reinforcement motives, involving substance use to reduce negative emotions (i.e., coping motives); 3) external positive reinforcement motives, involving substance use to enhance or improve social events or relationships (i.e., social motives); and 4) external negative reinforcement motives, involving substance use to avoid ostracism (i.e., conformity motives). sara bartel1, simon sherry1, ioan mahu1, sherry stewart1,2 1department of psychology and neuroscience, dalhousie university 2department of psychiatry, dalhousie university cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.004 development of brief alcohol and cannabis motives measures: psychometric evaluation using expert feedback and longitudinal methods sherry h. stewart, ph.d., department of psychology and neuroscience, dalhousie university, life sciences centre, 1355 oxford street, po box 15000, halifax, ns, canada, b3h 4r2. email: sstewart@dal.ca cannabis, a publication of the research society on marijuana 35 research supports the validity of the above model for both cannabis and alcohol (see cooper et al., 2016 for review). as a result, various measures of cannabis and alcohol motives were based on this theory, beginning with cooper’s foundational measures (cooper, 1992; cooper, 1994). in recent years, iterations of cooper’s scales were developed and expanded upon. currently, two commonly used and well-validated iterations are the marijuana motives measure (mmm; simons et al. 1998) and the modified drinking motives questionnaire-revised (mdmq-r; grant, et al. 2007). both include cooper’s (1994) items assessing enhancement, social, coping and conformity motives. each also adds items either allowing for the separation of the internal, negative reinforcement motive into separate coping-withanxiety and coping-with-depression scales (mdmq-r) or the separation of the internal, positive reinforcement motive into separate enhancement and expansion motives scales (expansion motives include using to enhance experience and creativity; mmm). in line with motivational theory, the motives measured by the mmm and the mdmq-r are linked to cannabisand alcohol-related outcomes. coping, enhancement, and expansion motives have been shown to predict frequency and/or quantity of cannabis and alcohol use (bonar et al., 2017; cooper et al., 2016). coping motives have also been found to predict cannabisand alcohol-related problems cross-sectionally and longitudinally (cooper et al., 2016; patrick et al., 2016). with respect to alcohol coping motive subtypes, copingwith-depression appears to be particularly predictive of alcohol-related problems (e.g., loose & acier, 2017). other motives such as conformity and enhancement motives have also demonstrated weak positive (conformity) or indirect (enhancement – via consumption) relationships with cannabisand alcohol-related problems (cooper et al., 2016; simons et al., 1998). notably, social motives appear to be less of a risk factor, as they are related to typical patterns of consumption, but not consistently related to problematic use (cooper et al., 2016; kuntsche et al., 2005). limitations of current measures while both the mmm and the mdmq-r have strong psychometric properties (e.g., grant et al., 2007; simons et al., 1998), their use in certain study designs is not feasible due to their length (25+ items each). for example, the length of the mmm and the mdmq-r can pose a problem for polysubstance use studies or egocentric social network studies, as asking participants to complete these scales for multiple substances or multiple network members is burdensome. longer measures are also unsuitable for ecological momentary assessment studies where people may complete measures several times per day for multiple weeks. given research suggests questionnaire length and participant burden may be associated with careless participant responding, the length of the existing motives questionnaires may impact data validity (e.g., gibson & bowling, 2019). while a 12-item short form of cooper’s (1994) measure has been developed and validated for alcohol (kuntsche & kuntsche, 2009), it remains too long for research using the designs outlined above and does not separate the coping motive into coping-with-depression and copingwith-anxiety, distinguishable motives which are associated with different alcohol outcomes (e.g., grant et al., 2007; loose & acier, 2017). a short form of the mmm has yet to be developed. considering the above measurement issues, many researchers are forced to take non-ideal approaches when studying cannabis and alcohol motives. some researchers select and use a subset of items from existing subscales, which introduces limitations, as it cannot be assumed the chosen items represent each motive in a reliable and valid fashion (e.g., bonar et al., 2017; joyce et al. 2018; joyce et al., 2021; o’donnell et al., 2019; o’hara et al., 2015; pearson et al., 2020; stevenson et al., 2019). to overcome limitations of this approach, other researchers have been forced to choose to study only certain motives that are of highest interest (i.e., include only certain subscales), rather than study all possible relevant motives (e.g., dvorak et al., 2014). our goal was to develop and validate brief versions of the mmm and the mdmq-r so researchers no longer need sacrifice reliability or validity when studying substance motives. methods to develop and validate our measures, we conducted two studies. study 1 was a measure development study, consisting of item generation, expert feedback, and item revision. study 2 was a development of brief alcohol and cannabis use motives 36 validation study where the psychometric properties of the revised versions of our brief measures were tested in a longitudinal design in comparison with the original long forms. study 1: item development item generation. we followed the short-form test development methods employed by breslin et al. (2000) and smith et al. (2011). for both cannabis and alcohol, we created one item for each of the following six motives: enhancement, expansion, social, coping-with-anxiety, copingwith-depression, and conformity. each item consisted of a general statement representing the general concept of the motive, followed by two items from the mmm or the mdmq-r in brackets (e.g., “in the past 30 days, i’ve used cannabis because it’s a good way to socialize with others [e.g., because it makes social gatherings more enjoyable, or to be sociable].”). items were generated using the following guidelines: the general statement must be face-valid and reflect the main aspects of the motive, and the two examples that follow must, if possible 1) have high factor loadings onto the construct; 2) be face-valid; and 3) cover core aspects of the motive, as well as the breadth of content included in the motive items. when developing preliminary versions of these measures, we aimed to balance these guidelines; however, because we wanted to make uniform cannabis and alcohol scales to enable cross-substance comparisons, this was not always possible. for example, while the expansion motive items on the mmm have been studied in relation to alcohol1, factor loadings for these items are not published, and expansion motives are not included in the mdmq-r. as such, the developed expansion item relied upon factor loadings of the expansion items in the mmm. as we sought to measure each motive with one item, capturing variation in participant response was essential. as such, we chose a visual analog scale (vas) response format, which offers more nuanced response options than traditional likerttype scales (kuhlmann et al., 2017). vas response formats also have several advantages, including being quick, avoiding systematic bias from limited scale responses, and providing interval-scaled data (aguinis et al., 2009; klimek et al., 2017). item responses range from “never” (0) to “always” (100). expert opinion. we identified 72 experts from whom we sought feedback on our developed items2, consistent with best-practice recommendations for test development (boateng et al., 2018). while typically 5-7 experts are used, we wanted to receive as much expert feedback as possible (boeateng et al., 2018). an expert was defined as first or senior authors of at least one publication about cannabis or alcohol motives in the past 15 years and was identified through a psychinfo search on “cannabis motives” or “alcohol motives”. the experts were emailed a copy of our measures and an online questionnaire which asked them to provide feedback on our approach to test construction, and on the validity and wording of our draft items (see supplemental materials c for copy of this questionnaire). responses were anonymous. prior to reviewing expert feedback, we decided to change an item for both substances (see above) if >10% of experts disagreed on one of the questions related to that item or if >10% raised the same criticism regarding an item. expert responses. we received 33 responses to our survey (45.8% response rate). 95.2% and 92.3% of experts reported they would use the brief cannabis and alcohol motives measures, respectively; and 87.5% agreed we had taken an acceptable approach to brief-form test development; the remaining 12.5% neither agreed nor disagreed. the vast majority agreed the items had faceand content-validity (i.e., were fully representative; see table 1). given our >10% rule mentioned above, enhancement, coping-withdepression, and conformity items were altered for both substances. see supplementary materials a for a list of specific alterations to these three items. see supplementary materials b for the final versions of the brief cannabis motives measure (bcamm) and the brief alcohol motives measure (bamm). 1despite not being commonly mentioned in relation to alcohol, alcohol expansion motives have been shown to be endorsed more highly than alcohol conformity motives (simons, et al., 2000). thus, the expansion motive is likely relevant to alcohol and warranted inclusion in our alcohol measure. 2based on publication history, 27 experts were considered to have expertise in both alcohol and cannabis motives; 21 were considered to have expertise in cannabis motives only; and 25 were considered to have expertise in alcohol motives only. cannabis, a publication of the research society on marijuana 37 table 1. results from experts regarding face and content validity motive substance face validity core aspects all aspects (i.e., breadth) enhancement alcohol 90.62% (6.25%) 96.67% (3.33%) 80.64% (6.45%) cannabis 95.24% (4.76%) 95.24% (4.76%) 90.47% (9.52%) social alcohol 96.55% (3.45%) 100.00% (0.00%) 82.73% (10.34%) cannabis 100.00% (0.00%) 100.00% (0.00%) 85.71% (9.52%) coping-with-anxiety alcohol 100.00% (0.00%) 96.55% (3.45%) 86.21% (3.45%) cannabis 100.00% (0.00%) 100.00% (0.00%) 90.48% (4.76%) coping-with-depression alcohol 83.71% (3.57%) 92.85% (3.57%) 81.12% (3.57%) cannabis 95.00% (5.00%) 100.00% (0.00%) 80.95% (14.29%) conformity alcohol 92.00% (0.00%) 96.00% (0.00%) 82.61% (17.39%) cannabis 95.00% (5.00%) 90.00% (10.00%) 82.61% (17.39%) expansion alcohol 83.34% (16.67%) 80.00% (20.00%) 72.00% (20.00%) cannabis 100.00% (0.00%) 100.00% (0.00%) 95.24% (4.76%) note. the percentage before the brackets indicates the percentage of experts that agreed or strongly agreed that the item either was face-valid, represented all aspects of the motive (i.e., full coverage of the motive concept), and reflected the core aspects of the motive, respectively. the number within brackets represents the percentage of experts that neither agreed nor disagreed. study 2: measure evaluation we then sought to evaluate the reliability and further evaluate the validity of the bcamm and bamm. given many motives studies are conducted with emerging adults, a high substance using population (canadian centre on substance use and addiction, 2017), we chose to conduct the initial validation of the bcamm and bamm in this population. moreover, we chose to conduct study 2 in a sample of individuals who use both cannabis and alcohol, as research suggests 54% of young adults in canada use both alcohol and cannabis (13% concurrently and 41% simultaneously) and only 1% of young adult cannabis users use cannabis, but not alcohol (thompson et al., 2021). we hypothesized: h1) brief and full-length measures would have similar reliability, as indicated by relative consistency; h2) brief and full-length subscales would be at least moderately concurrently correlated; h3) brief and full-length subscales would remain significantly concurrently correlated after removing shared items between the brief and fulllength measures; h4) given theoretical links of internal motives with substance use quantity/frequency (cooper et al., 2016), for both substances, enhancement, coping-with-anxiety, and coping-with-depression (plus expansion for cannabis) would predict substance use quantity x frequency (qxf) concurrently for brief and fulllength scales; h5) given theoretical links of negative reinforcement motives with problems (cooper et al., 2016), for both substances, baseline quantity, conformity motives, and coping-withdepression motives would prospectively predict follow-up substance-related problems for the brief and full-length scales.3 participants. one hundred and seventy-six university students between 17-30 years old (m=20.15, sd = 3.15) were recruited (male = 50, female =126)4. on average, participants began 3while developing the mmm and the mdmq-r, the authors included all motives in regression analyses for exploratory purposes. as established relationships between the mmm and the mdmq-r with substance use outcomes now exist, that are consistent with theory (cooper et al., 2016), we only included specific theoretically derived motives in our hypotheses/analyses. development of brief alcohol and cannabis use motives 38 using alcohol at age 15.70 (sd = 1.97) and cannabis at age 16.88 (sd = 1.62) and had completed 1.6 full years of university (sd = 1.29; range 0-6). eighteen participants were lost to attrition at wave two (89.8% retention). to ensure participants could be considered “users”, they had to have used alcohol >four times, and cannabis recreationally >two times, in the past month at baseline (see cougle et al., 2015). an a-priori power analysis was conducted with g*power (faul et al., 2007), which allows for estimation of f2 through the imputation of predictor correlations. this analysis indicated a sample size of 166 to reach a power of .8. this analysis was based on grant et al. (2007) and simons et al. (1998), accounting for the slightly lower variance in outcomes predicted by single-item measures. measures bcamm and baamm. the bamm and bcamm each include an item to assess enhancement, expansion, social, coping-withanxiety, coping-with-depression, and conformity motives. instructions for measures are in supplementary materials b. a time frame of 30 days was used5. each item was answered using a vas from never (0) to always (100). items are scored individually (i.e., there is no total bcamm or bamm score). marijuana motives measure + (mmm+). the mmm (simons, et al., 1998) is a 25-item measure assessing enhancement, expansion, social, coping, and conformity motives for cannabis use. the mmm+ includes the following instructions: “listed below are 33 reasons people might be inclined to use cannabis. using the five-point scale below, decide how frequently your own cannabis use is motivated by each of the reasons listed.” a time frame of 30 days was used. response options ranged from almost “never/never” (1) to “almost always/always” (5). the original measure has good internal consistency (subscale a’s=.86 to .92), concurrent, and predictive validity (e.g., cannabis-related problems; simons et al., 1998). to compare the coping-with-anxiety and coping-with-depression items on the bcamm to full-length subscales, the coping-with-anxiety and coping-with-depression items from the mdmq-r were added to the mmm substituting “cannabis” for “alcohol”. the items replaced the original four mmm coping items. this modified version of the mmm had similar internal consistency to the mmm (a = .76-.94) on all comparable subscales other than social, which was lower than the mmm+. modified drinking motives questionnaire – revised + (mdmq-r+). the mdmq-r (grant et al., 2007) is a 28-item measure assessing enhancement, social, coping-with-anxiety, copingwith-depression, and conformity motives. the instructions for the mdmq-r+ were identical to the mmm+, substituting “cannabis” with “alcohol.” response options and time frame match that of the mmm+. this measure has good testretest reliability (icc = .65 to 78), concurrent validity for drinking quantity, and predictive validity for alcohol-related problems (grant et al., 2007). as previously done by simons et al. (1998), we added the expansion items from the mmm, substituting “alcohol” for “marijuana” to compare the expansion item on the bamm to a full-length subscale. each subscale of the mdmq-r+ had similar internal consistency (a = .67 to .93) to the corresponding subscale of the mdmq-r reported in grant et al. (2007). the expansion subscale had similar internal consistency to the alcohol expansion subscale reported by simons et al. (1998; a = .79). substance use questionnaire. this measure assessed alcohol and cannabis quantity and frequency using items recommended by the national institute of health (2003) for alcohol, and items from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017) for cannabis. each question referred to the past 30 days. alcohol questions included a depiction and description of a typical drink. ten response options were given for alcohol quantity within a typical drinking day, ranging from 0-25+ drinks. seven response options were given for past month alcohol frequency ranging from “once” to “every day”. an image with a canadian 5-dollar bill (as size referent) and various amounts of cannabis (1/8th -1 gram), adapted from the dfaq-cu was 4note that one additional participant aged 52 participated; however, as we sought to study emerging adults, this participant was excluded from the analysis. 5suggested instructions for daily, ecological momentary assessment and weekly time frames can also be found in supplementary materials b. cannabis, a publication of the research society on marijuana 39 given to assist in reporting on cannabis quantity. participants were asked to indicate number of grams used in a single session of use. responses were entered into a textbox and could include up to three decimal places. the dfaq-cu frequency question was altered to reflect the past 30 days (i.e., only response options referencing past 30 days use were included) and additional responses options were added to capture the nuance of high frequency use more accurately; sixteen response options were given for past month cannabis frequency ranging from “i did not use cannabis” to “15+ times a day.” similar approaches to measuring cannabis frequency were taken by other researchers (sofis et al., 2021). a qxf variable was created for both alcohol and cannabis by multiplying responses to quantity and frequency items (grant et al., 2007). we chose to combine quantity and frequency, as their combination together is arguably a more meaningful estimate of use than either alone (e.g., fischer et al., 2017; prince et al., 2019). rutgers alcohol problem index. the rapi (white & labouvie, 1989) is a 23-item measure assessing alcohol-related problems. the time frame was 30 days and items were scored dichotomously (i.e., “never” = 0; “1-2” “10+” times = 1) and then summed (martens et al., 2007). this method of scoring has been shown to have adequate convergent validity (e.g., r = .44 with drinking frequency; martens et al., 2007) and had excellent internal consistency in our sample [α = .91 (baseline) to .94 (follow-up)]. rutgers marijuana problem index (rmpi). the rmpi (simons et al., 2000) is a 23-item measure assessing common cannabis-related problems. the rmpi modifies rapi items to assess cannabis. the time frame was 30 days and items were scored dichotomously and then summed for consistency with the rapi scoring (i.e., “never” = 0; “1-2” “10+” times = 1). the rmpi demonstrates expected relationships with cannabis use (simons et al., 2005) and had goodto-excellent internal consistency in our sample [α = .87 (baseline) to .95 (follow-up)]. procedure. participants were recruited through a psychology participant pool at an eastern canadian university6. participants completed measures online in the lab at baseline and again two months later online at home. questionnaire order was randomized. participants were compensated with psychology credits or a $10 cdn amazon gift card after each wave. results analytic strategy. we planned to use pearson correlation coefficients to test h1-3, and multiple regression to test h4-5. assumptions of multivariate normality for pearson correlation coefficients were violated, so spearman’s rankorder correlations were used. assumptions of multivariate normality were also violated for the planned regressions to test h4 with cannabis variables and h5 with both alcohol and cannabis variables. as recommended (neal & simons, 2007), generalized linear modelling (glim) was chosen. robust estimates of standard errors were used to handle heterogenous variance. for each analysis, we ran models with various distributions and links, comparing averaged bic across 40 imputations to determine best fit. see supplementary materials e for model comparisons. we calculated mcfadden’s pseudo-r2 (mcfadden, 1973) to compare the predictive ability of brief and full measures. sex and age were examined as covariates, and sex was found to have a significant relationship with cannabis-related problems (i.e., greater in males). as a result, sex was included as a covariate in our predictive validity analyses for the bcamm. descriptive statistics eighteen participants demonstrated monotone missing data. there was no statistically significant difference in those who dropped out from those who were retained on baseline alcohol (t = -.45, p = .66) or cannabis quantity (t = .185, p = .85), or alcohol (t = -.18, p = .86) or cannabis frequency (t = .98, p = .33). little’s mcar test was non-significant (x2 = 1121.96; df = 1072; p = .14). multiple imputation in spss was used to handle missing data (40 imputations as recommended by graham et al., 6regarding ineligibility: the psychology participant pool indicates the inclusion criteria for the study on the study sign up page (i.e., potential participants read these criteria before signing up for a study participation timeslot). it is unclear how many people clicked on the study advertisement, but later realized they were ineligible. screening was formally done with participants that signed up for the study and attended the baseline assessment. only one participant was turned away due to not meeting the substance use criteria. all participants who consented participated. development of brief alcohol and cannabis use motives 40 2007). all variables in the analyses were used as potential predictors and imputed variables. no auxiliary variables were added. means, standard deviations and bivariate spearman’s rank-order correlations for brief and full measures appear in supplementary tables 2 and 3. at time 1 (t1), the mean numb er of drinks per occasion was 3.60 (sd = 1.4) and frequency of use was 3.59 (sd = 1.02; corresponds to “once per week”). the mean grams of cannabis used per occasion of use was .59 (sd = .75)7 and frequency of cannabis use was 4.01 (sd = 1.02; corresponds to “twice per week”). at time 2 (t2), the mean dichotomized and summed rapi score was 6.60 (sd = 5.80) and mean dichotomized and summed rmpi score was 4.89 (sd = 4.30), meaning participants experienced an average of seven alcohol-related problems and five cannabis-related problems in the past month. test-retest reliability to test h1, test-retest reliability was examined using spearman’s rank correlations (lexell & downham, 2005). as shown in table 2, brief measures were significantly correlated at t1 to t2 (cannabis, r=.33 to .60; alcohol, r=.34-.59). the mmm+ (r=.46-.67) and the mdmq-r+ (r=.39 to .63) were significantly correlated at t1 to t2. the strength of test-retest correlations between each item of the brief measures and the corresponding full-length subscale (e.g., bamm social item vs. mdmq-r+ social subscale) were compared (lee & preacher, 2013) and were not statistically different (see table 2 for specific p-values). convergent validity spearman’s rank correlations were run to test h2 and h3. convergent validity correlations were interpreted as moderate (r = .40 to .59), strong (r =. 60 to .79), and very strong (r = .80 to 1.00; evans, 1996). convergent validity between the bcamm and mmm+ subscales at t1 and t2 ranged from moderate (r = .56) to very strong (r = .83), with the majority (5/6) of subscales demonstrating strong or very strong convergent validity at t1 and t2. convergent validity between the bamm and mdmq-r+ subscales at t1 and t2 ranged from moderate (r = .40) to strong (r = .73), with the majority (4/6) of subscales demonstrating strong convergent validity at t1 and moderate convergent validity at t2 (4/6). see table 3 for convergent validity results. to examine whether correlations between brief and full measures were primarily due to the two shared items between the brief and full-length measures (i.e., two items within brackets in the bcamm and bamm), subscale scores of the mmm+ and the mdmq-r+ were re-calculated without shared items (see table 4). convergent validity remained moderate to very strong for all motives, except social motives for alcohol. further examination indicated the bamm social item was significantly correlated with the mdmq-r+ social motive items that have high face validity (e.g., “to be sociable”), but not with items with lower face validity (i.e., “as a way to celebrate”, “because it is customary on special occasions”). this pattern also existed for the bcamm and the mmm+, although correlations were stronger. see supplementary materials d tables 3-14 for correlations between the bcamm and bamm and individual subscale items from the mmm+ and mdmq-r+. concurrent and predictive validity our first set of concurrent validity analyses included alcohol qxf at t1 as predicted by t1 bamm or mdmq-r+ coping-with-anxiety, copingwith-depression, and enhancement motives (see table 5). partially consistent with h4, there was a significant effect of t1 bamm and mdmq-r+ enhancement. there were no significant effects of bamm or mdmq-r+ coping-with-anxiety or coping-with-depression. vif (bamm = 1.13 to 1.83; mdmq-r+ = .48 to 2.29) and tolerance values (bamm = .55 to .89; mdmq-r+ = .44 to .87) were acceptable. our second set of concurrent validity analyses included t1 cannabis qxf predicted by t1 bcamm or mmm+ enhancement, coping-with-anxiety, coping-with-depression, and expansion motives (see table 6). partially consistent with h4, there was a significant effect of bcamm coping-with-anxiety and mmm+ coping-with-anxiety, coping-withdepression, and expansion (inverse relationship) motives. no significant effects of bcamm or mmm+ 7an examination of the cannabis quantity variable indicated some participants had entered unrealistic values in answer to the question, “in a typical session of use (i.e., one sitting) over the last 30 days, how many grams of cannabis did you personally use?” (e.g., 100 grams). as such, 8 participants who entered >5 grams were removed from the analyses. cannabis, a publication of the research society on marijuana 41 table 2. test-retest correlations between t1 and t2 motive bamm mdmq-r+ difference between bamm & mdmq-r+ subscale bcamm mmm+ difference between bcamm & mmm+ subscale enhancement .53** .63** p = .10 .49** .61** p = .07 social .43** .49** p = .60 .47** .57** p = .11 coping with anxiety .54** .54** p = .91 .60** .67** p = .16 coping with depression .52** .59** p = .30 .60** .64** p = .32 conformity .55** .48** p = .37 .33** .46** p = .08 expansion .34** .39** p = .54 .50** .56** p = .29 note. correlations represent pooled spearman’s rank order correlations. correlations reflect items/subscales at t1 correlated with same items/subscales at t2. bamm = brief alcohol motives measure; mdmq-r+ = modified drinking motives questionnaire revised +; bcamm = brief cannabis motives measure; mmm+ = marijuana motives measure.* p < .05; ** p < .01. table 3. convergent validity between the bamm/mdmq-r and bcamm/mmm+ at t1 and t2 motive t1 alcohol t2 alcohol t1 cannabis t2 cannabis enhancement .63** .60** .62** .62** social .47** .40** .65** .62** coping with anxiety .70** .58** .81** .75** coping with depression .73** .62** .83** .74** conformity .61** .60** .59** .56** expansion .49** .57** .79** .73** note. correlations represent pooled spearman’s rank order correlations. t1 alcohol = correlations between t1 brief alcohol motives measure item and corresponding t1 modified drinking motives questionnaire revised + subscale; t2 alcohol = correlations between t2 brief alcohol motives measure item and corresponding t2 modified drinking motives questionnaire revised + subscale; t1 cannabis = correlations between t1 brief cannabis motives measures item and corresponding t1 marijuana motives measure + subscale; t2 cannabis = correlations between t2 brief cannabis motives measure item and corresponding t2 marijuana motives measure + subscale. * p < .05; ** p < .01. table 4. t1 concurrent correlation between the bamm/mdmq-r+ and bcamm/mmm+ excluding shared items motive alcohol cannabis enhancement .61** .63** social .19** .45** coping-with-anxiety .51** .70** coping-with-depression .70** .83** conformity .56** .61** expansion .45** .76** note. correlations represent spearman’s rank order correlations. due to shared items between the bamm and bcamm items and the mdmq-r+ and the mmm+ subscales, the subscale scores of the mdmq-r+ and the mmm+ were re-calculated without the shared items and correlated with the relevant bamm and bcamm items. ** p < .01. development of brief alcohol and cannabis use motives 42 table 5. regression coefficients in multiple regressions for alcohol qxf predicted by the bamm and the mdmq-r+ coping-with-anxiety, coping-with-depression, and enhancement motives t1 alcohol qxf measure bamm mdmq-r+ variables b se b t p r2 b se b t p r2 intercept 10.64 1.08 9.84 .00 .04 6.46 1.87 3.47 .00 .08 coping-with-anxiety t1 .01 .02 .27 .79 .09 .22 .42 .68 coping-with-depression t1 .00 .03 -.08 .94 .00 .10 .03 .97 enhancement t1 .04 .02 2.38 .02 .39 .12 3.26 .00 note. bamm = brief alcohol motive measures; mdmq-r+ = modified drinking motives questionnaire revised +. r2 represents average of r2 values across 40 imputations. b = unstandardized betas. table 6. generalized linear model for cannabis qxf predicted by bcamm and mmm+ coping-withanxiety, coping-with-depression, enhancement, and expansion motives t1 cannabis qxf measure bcamm mmm+ variable b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 intercept .80 .28 .24 1.35 .01 .14 1.01 .71 -.38 2.40 .15 .02 coping-withanxiety t1 .03 .01 .01 .04 .00 .14 .07 .01 .27 .04 coping-withdepression t1 .01 .01 -.01 .03 .40 .08 .03 .02 .14 .01 enhancement t1 .00 .01 -.01 .01 .93 -.05 .05 -.14 .05 .35 expansion t1 .00 .01 -.02 .01 .57 -.08 .03 -.15 -.01 .02 note. statistics represent pooled effects. generalized linear models utilized the gamma distribution with log link. bcamm = brief cannabis motives measure; mmm+ = marijuana motives measure+. r2 = mcfadden’s pseudo r2. enhancement motives were found. vif and tolerance statics are not available in glim models. see the supplementary materials f for an additional comparison of the effect sizes for the bcamm and the mmm+. our first set of predictive validity analyses included alcohol-related problems at t2 as predicted by t1 alcohol quantity, and bamm or mdmq-r+ conformity and coping-with-depression motives (see table 7). partially consistent with h5, there were significant effects of t1 bamm and mdmq-r+ coping-with-depression. there was no significant effect of t1 alcohol quantity or t1 bamm or mdmq-r conformity. see supplementary materials f for an additional comparison of the effect sizes for the bamm and the mdmq-r+. we then ran the same predictive validity models, substituting cannabis variables for alcohol variables and adding in sex as a covariate. partially consistent with h5, there was a significant effect of t1 cannabis quantity and t1 bcamm and mmm+ coping-with-depression in predicting t2 cannabis-related problems. there was a significant effect of sex for the bcamm (greater in males), with the effect of sex for the mmm+ marginal at p = .05. there were no significant effects of t1 bcamm or mmm+ conformity items (see table 8). see supplementary materials f for an additional comparison of the effect sizes for the bcamm and the mmm+. cannabis, a publication of the research society on marijuana 43 table 7. generalized linear model for time 2 alcohol-related problems predicted by time 1 alcohol quantity and enhancement and copingwith-depression motives t2 alcohol-related problems measure bamm mdmq-r+ variables b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 intercept 1.02 .29 .46 1.58 .00 .02 .42 .28 -.33 1.16 .27 .03 alcohol quantity t1 .12 .06 -.00 2.48 .05 .11 .06 -.01 .24 .08 conformity t1 .01 .00 -.00 .01 .10 .05 .03 -.01 .11 .09 coping-withdepression t1 .01 .00 .00 .01 .00 .04 .01 .02 .06 .00 note. statistics represent pooled effects. generalized linear models utilized the negative binomial distribution with log link. bamm = brief alcohol motive measures; mdmq-r+ = modified drinking motives questionnaire revised+. r2 = mcfadden’s pseudo r2. table 8. generalized linear model for time 2 cannabis-related problems predicted by time 1 cannabis quantity and conformity and copingwith-depression motives t2 cannabis-related problems measure bcamm mmm+ variables b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 b se wald 𝜒2 95% ci lower wald 𝜒2 95% ci higher p r2 intercept 1.85 .19 1.48 2.22 .00 .02 1.26 .38 .53 2.00 .00 .03 sex -.42 .19 -.78 .06 .02 -.38 .19 -.76 -.01 .05 cannabis quantity t1 .01 .00 .00 .02 .00 .01 .00 .00 .02 .01 conformity t1 -.01 .00 -.01 .00 .27 .00 .40 -.08 .08 1.00 coping-withdepression t1 .01 .00 .00 .01 .00 .04 .01 .02 .06 .00 note. statistics represent pooled effects. generalized linear models utilized the negative binomial distribution with log link. sex is coded as 0 = male and 1 = female. bcamm = brief cannabis motives measure; mmm+ = marijuana motives measure+. r2 = mcfadden’s pseudo r2. development of brief alcohol and cannabis use motives 44 discussion we developed and examined the psychometrics of the bcamm and the bamm, brief cannabis and alcohol motive measures based on the mmm and the mdmq-r, respectively. we began by creating two six-item measures and incorporating feedback from 33 experts in cannabis and/or alcohol motives. expert responses in study 1 suggest the bcamm and bamm have excellent faceand content-validity. results from study 2 suggest the brief and fulllength measures have similar test-retest reliability, supporting h1. note the reliability ranged from r = .34 to .67. this does not reflect poor psychometric properties, but rather the nature of motives, which are thought to be trait-states (i.e., demonstrating general stability, while also indicating some occasionspecific variability; windle & windle, 2018). while further research examining the use of our scales in daily diary contexts is needed, our test-retest reliability results suggest our measures, like the full measures, may capture sufficient change for such a design. in terms of convergent validity, the majority of concurrent correlations between the brief and fulllength measures were strong, supporting h2 and suggesting good convergent validity between the bamm, bcamm, and corresponding full measures. after removing shared items from the mmm+ and the mdmq-r+, the revised correlations remained similar, with the single exception of the social motive for alcohol. this may be explained by the facts that two of the three unshared items of the mdmq-r+ and the mmm+ social subscales do not include the word “social” and the social subscale of the mdmqr+ has lower internal consistency than other motives (a = .58; grant et al., 2007). given this, our bamm social item appears to capture the core components of the social motive well and may represent a more face valid social motive than that of the mdmq-r given the bamm’s focus on sample items that include the term “social”. of note, an examination of the relationship between bcamm and bamm items with corresponding mmm+ and mdmq-r+ subscales, respectively, suggests the bcamm and bamm appear to capture the breadth and depth of all other motives. thus, our results suggest the good convergent validity between brief and full-length measures is not simply due to shared items and largely support h3. study 2 also suggests our brief measures predict substance use outcomes in a similar fashion to the mmm+ and mdmq-r+. in line with h4 and research with the mdmq-r (e.g., grant et al., 2007), enhancement motives on both brief and full-length measures predicted concurrent alcohol qxf. similarly, coping-with-depression motives on both brief and full-length measures prospectively predicted both alcoholand cannabis-related problems, after controlling t1 quantity. this result aligns with research with the mdmq-r, as well as research indicating that mmm coping motives predict cannabis dependence (benschop et al., 2015), despite slight changes to the original measures in our study. thus, brief measures generally demonstrated the same concurrent and predictive relationships as the full measures. there were two notable exceptions to this, however. first, while mmm+ coping-withanxiety, coping-with-depression, and expansion motives were significant predictors of cannabis qxf8, only bcamm coping-with-anxiety was significant. this difference may be a result of power. in the mmm+ model, coping-with-anxiety was the strongest effect (b = .14), while the effects of copingwith-depression and expansion were weaker (b = .08); it is possible the bcamm model did not have enough power to detect these smaller effects due to the increased error associated with single-item measures and/or the highly correlated coping items (note, while vif and tolerance statistics are not available for bcamm analyses, bamm analyses suggested acceptable levels of multicollinearity). while our power analysis suggested we had a sufficient sample size, we may have underestimated the effect of increased error and including highly correlated predictors within the same model. despite this, it appears that coping-with-anxiety motives may have a stronger relationship with cannabis qxf than coping-with-depression for both the mmm+ and the bcamm, suggesting there may be utility in separating the two subscales. the bamm and the bcamm offer researchers the choice to study these two distinct coping motives or to combine them together into a global factor, as was done with the bamm elsewhere (e.g., deacon et al., 2021). second, bic comparisons often suggested models including full measures were a better fit. given the full scales have higher content validity simply by virtue of having more items (baumgartner & homburg, 1996), this was to be expected regardless of the 8note expansion motives had an inverse relationship with cannabis qxf. cannabis, a publication of the research society on marijuana 45 quality of our brief items. despite this, r2 and mcfadden’s r2 values for brief and full measures were similar, suggesting only a slight loss of predictive power when using the brief scales. in situations where the full-length measures cannot be used without significant participant burden, this slightly lower predictive power is likely worth the trade-off in increased feasibility. it is worth noting that study 2 results deviated from aspects of h4 and h5. first, despite hypothesizing enhancement, coping-with-anxiety, and coping-with-depression motives would predict alcohol qxf, only enhancement was a significant predictor for the bamm and mdmq-r+. this aligns with research indicating enhancement is a notably stronger predictor of both alcohol quantity and frequency than coping motives (e.g., cooper et al., 2016). additionally, with respect to coping motives not predicting alcohol qxf, this result may be expected given our non-clinical emerging adult sample; coping motives tend to be more prevalent in clinical populations (molnar et al., 2010) and were not endorsed highly by our participants. second, conformity motives were not a significant predictor of alcoholor cannabis-related problems for the brief or full measures. extant research suggests the relationship between conformity motives and alcohol-related problems is not always present (β = .02 to .12; cooper et al., 2016), and the relationship between conformity motives and cannabis-related problems is inconsistent (e.g., buckner et al., 2007; buckner et al., 2016; fox et al., 2011). thus, our lack of findings between conformity motives and substance-related problems may also reflect this complicated relationship. limitations and future directions our results are limited by our sample, which was predominantly female and recruited from a participant pool at a single university. it is not clear whether these measures are appropriate for other samples. relatedly, our sample was composed of emerging adults; while motives measures are often found to be valid in age groups other than those of the initial validation sample (e.g., crutzen & kuntsche, 2013; gilson et al., 2013; martens et al., 2008), this should be confirmed for the bcamm and bamm. moreover, our sample was composed of dual-alcohol and cannabis users. while we consider this to be a strength of our study, given the common cooccurrence of cannabis and alcohol use (thompson et al., 2021), the bcamm and bamm should be validated in single use samples. additionally, while we examined the bamm and the bcamm in a dualuse sample, the utility of the bamm and bcamm for predicting simultaneous cannabis and alcohol use relative to measures designed to tap specific motives for simultaneous use of these substances (e.g., patrick et al., 2018) remains to be determined. should researchers be interested in creating a version of the sam motives questionnaire developed by patrick et al. (2018) that includes one item per subscale, the bamm and the bcamm may provide a blueprint for the shortening of this measure. our results are also limited by our methodological decisions; as we sought to create brief versions of the established mmm and the mdmq-r, we did not add any additional motives that might be relevant for cannabis (e.g., sleep). while this allowed for comparison between the bcamm and the mmm, the bcamm might be limited by the exclusion of additional motives. moreover, as we sought to include expansion motives for alcohol, and copingwith-anxiety and coping-with depression motives for cannabis, we modified the mmm and the mdmq-r, creating the mmm+ and the mdmq-r+. while all original items of the mdmq-r+ were included, some original items of the mmm were changed (i.e., coping items were added or altered), limiting validity comparisons. furthermore, we did not have a second round of feedback with experts after changing the wording of three items. while our changes were carefully considered, an additional round of expert feedback would have provided further confirmation of face and content validity. finally, we chose to study the reliability and validity of the bcamm and the bamm in a longitudinal design. the validity of these measures in a daily diary/ecological momentary assessment context should be ascertained as a next step. conclusions our findings support the reliability and the validity of the bcamm and the bamm. in situations where the mmm or the mdmq-r cannot be feasibly used due to excessive participant burden, the bcamm and the bamm offer a psychometrically sound alternative. our measures open the door for motives to be included in various research designs where their use was previously considered impractical, thereby solving a problem in our research field. development of brief alcohol and cannabis use motives 46 references aguinis, h., pierce, c. a., & culpepper, s. a. 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(1989). towards the assessment of adolescent problem drinking. journal of studies on alcohol, 50(1), 30-37. https://doi.org/10.15288/jsa.1989.50.30 cannabis, a publication of the research society on marijuana 49 funding and acknowledgements: funding for this study was provided by a sshrc grant 8952019-1021. sshrc had no role in the study design; collection, analysis, or interpretation of the data; writing the manuscript; or the decision to submit the paper for publication. dr. stewart is supported through a tier 1 canada research chair in addictions and mental health. sara bartel, simon sherry, ioan mahu, and sherry stewart all report no conflict of interest. all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2000. research ethics board approval was obtained prior to data collection by the dalhousie health sciences research ethics board. informed consent was obtained from all patients for being included in the study. sara bartel, simon sherry and sherry stewart contributed to the study conception and design. material preparation, data collection and analysis was performed by sara bartel. the first draft of the manuscript was written by sara bartel and all authors commented on this first draft, as well as all subsequent drafts of this manuscript. all authors approved of the final manuscript. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i1a8_authors_final_p research article 99 ved abstract background: cannabis dispensaries have proliferated exponentially in oklahoma since the state legalized medical cannabis in 2018. oklahoma is unique from many other legalized states given its high number of lower income, rural, and uninsured residents, who may seek medical cannabis as an alternative to traditional medical treatment. methods: this study examined demographic and neighborhood characteristics associated with dispensary density (n = 1,046 census tracts) in oklahoma. results: compared to census tracts with no dispensaries, those with at least one dispensary had a higher proportion of uninsured individuals living below the poverty level and a greater number of hospitals and pharmacies. almost half (42.35%) of census tracts with at least one dispensary were classified as a rural locale. in fully adjusted models, percent uninsured, percent of household rentals, and the number of schools and pharmacies were positively associated with greater number of cannabis dispensaries, while the number of hospitals was negatively associated. in the best fitting interaction models, dispensaries were predominant in areas with a higher percentage of uninsured residents and no pharmacies, suggesting that cannabis retailers may capitalize on the health needs of communities with limited healthcare outlets or access to medical treatment. conclusions: policies and regulatory actions that seek to decrease disparities in dispensary locations should be considered. future studies should examine whether people living in communities with a scarcity of health resources are more likely to associate cannabis with medical uses than those living in communities with more resources. key words: = cannabis; dispensaries; census; location; demographics; poverty; oklahoma; medical as of october 2022, the majority (37) of states in the u.s. and the district of columbia have legalized medical cannabis, resulting in a proliferation of medical cannabis dispensaries. the medical cannabis market is expected to raise billions of dollars to improve infrastructure, fund education, and provide jobs for hundreds of thousands of individuals (decort et al 2020). despite noted benefits to the economy, studies show that medical cannabis dispensaries cluster in disadvantaged neighborhoods that have higher rates of crime and lower income residents (morrison et al. 2014; unger et al. 2020). even historically “conservative” leaning states amy m. cohn1,2, ami sedani3, taylor niznik1, adam alexander2,4, bryce lowery5, julia mcquoid2,4, janis campbell3 1department of pediatrics, college of medicine, university of oklahoma health sciences center 2 tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center 3 department of biostatistics and epidemiology, hudson college of public health, university of oklahoma health sciences center 4 department of family and preventive medicine, university of oklahoma health sciences center 5 regional + city planning, christopher c. gibbs college of architecture, university of oklahoma cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.008 population and neighborhood correlates of cannabis dispensary locations in oklahoma corresponding author: amy cohn, 655 research parkway, suite 400, oklahoma city, ok 73104. email: amy-cohn@ouhsc.edu demographic correlates of cannabis dispensary density 100 that have traditionally had a zero-tolerance policy about drug use have legalized medical cannabis. oklahoma is one such conservative-leaning state that legalized medical cannabis in 2018, and has a relatively unique policy environment. first, oklahoma is one of the few medical cannabis states that does not require a qualifying condition to obtain a medical cannabis license, and minors, in restricted cases, can obtain a license. easy access to a medical cannabis license in oklahoma is reflected by the number and proportion of oklahomans that have been issued a medical cannabis license. as of march 2022, the oklahoma medical marijuana authority (omma) has issued 384,974 patient medical cannabis licenses, reflecting approximately 10% of the population of oklahoma (butcher, 2019). second, the number of dispensaries has grown exponentially in oklahoma, surpassing that in geographically larger states, like colorado or california, which have allowed legal medical and recreational cannabis use for years (keating, 2019). this is likely because, from 2018 to 2022, there was no limit on the number of dispensary licenses issued by the omma, [a two-year moratorium on new business licenses was issued in august 2022 (oklahoma medical marijuana authority, 2022b)] and costs associated with obtaining a dispensary license have been less expensive compared to other states (americans for safe access, 2021). for example, dispensaries in oklahoma pay between $2,500 and $10,000 in licensing fees (oklahoma medical marijuana authority, 2022a), based on annual sales; whereas in california, licensing fees can reach up to $96,000 annually (california department of cannabis control, 2022). in colorado, fees and permits for a medical cannabis store license can be close to $20,000 (colorado department of revenue, 2022). there are also few regulations on where dispensaries can be located in oklahoma, although sales are prohibited within 1,000 feet of a school (oklahoma state department of health, 2020; schroyer, 2021). the number of dispensaries in oklahoma is greater than in any of the other 37 states that allow legal medical cannabis (2,378) and ranks second-highest in the u.s. for dispensaries per capita (15.6/100,000 residents) (hutchinson and ray, 2020). oklahoma has a high proportion of lowincome, rural, uninsured, and medically vulnerable residents. nearly 15% of oklahoma’s population is not covered by public or private health insurance, compared to 9.2% nationally (united health foundation, 2021). moreover, a third of oklahomans live in a rural area, twice as high as the national average (rural health information hub, 2021). oklahoma has few rural health clinics and federally qualified health centers outside of urbanized areas compared to other states (rural health information hub, 2021). limited access to medical treatment in rural areas could mean that rural oklahomans seek medical cannabis as an alternative to conventional treatment. given their high number per capita, dispensaries may be more widely available than traditional medical treatment outlets (e.g., pharmacies, physicians). it may also be possible that those who are uninsured seek out medical cannabis as a form of treatment, as a dispensary visit is a lower-cost alternative to a physician or hospital visit. cannabis dispensary density has been associated with several health and safety outcomes in previous work (boggess et al. 2014; everson et al. 2019; hust et al 2020; liang and shi, 2019; shi et al. 2018). studies show greater density and availability of medical cannabis dispensaries and recreational stores in areas with lower household incomes (morrison et al., 2014l shi et al., 2016), greater percent of racial/ethnic minorities (hughes et al. 2020; shi et al., 2016; thomas and freisthler, 2016a), and greater overall area deprivation (e.g., lower percent owner-occupied housing, higher percent living below poverty level, etc.) (amiri et al. 2019). cannabis retailer density has also been associated with increased risk of cannabis-related hospitalizations (mair et al 2015; 2021), greater alcohol outlet density (mair et al 2021; subica et al. 2018) and alcohol use (garcia et al. 2020), increases in dui arrests (hunt et al., 2018), and greater cannabis use frequency (freisthler & gruenewald, 2014). however, while some studies have shown increases in crime rate in the block and surrounding areas following the placement of cannabis dispensaries (hughes et al., 2020; subica et al., 2018), others have found decreases or no change in crime following the opening of a medical cannabis dispensary in that area (zakrzewski et al 2020). further, while most evidence suggests a positive impact of medical cannabis laws on reduction in opioid-related health consequences, some research shows an cannabis, a publication of the research society on marijuana 101 increase in opioid use disorder and overdose in areas that have a greater density of dispensaries (freisthler et al. 2020; liang and shi, 2019). the links between medical cannabis outlet density and adverse health and safety outcomes remain unclear, and may differ by state. despite oklahoma’s rapid proliferation of cannabis dispensary openings since 2018 (butler, 2019; cooper, 2020; hutchinson & ray, 2020), and the relatively robust associations between dispensary density and poor health and safety outcomes, questions remain as to whether there is an inequitable distribution of dispensaries across neighborhoods in oklahoma, as has been demonstrated in other states (amiri et al 2019; freisthler et al. 2017; galea et al. 2007; kepple and freisthler, 2012; morrison et al. 2014; shi et al. 2016; subica et al., 2018; thomas and freisthler, 2016b). from previous work, dispensaries may be perceived as undesirable establishments that contribute to higher crime, greater health harms, and lower property values (boggess et al., 2014; contreras, 2017), but this may not be the case for oklahoma, given the extremely high number of dispensaries across the state. this exploratory study examined factors associated with the number of cannabis dispensaries per census tract in oklahoma. factors included demographics capturing social vulnerability like lower socioeconomic status (ses), racial/ethnic minority status, lack of health insurance coverage, urbanicity, and neighborhood indicators of health (e.g., physician, pharmacy and hospital density, crime). we hypothesized positive associations between the number of cannabis dispensaries and lower ses, rurality, racial/ethnic minority status, lack of health insurance, and greater crime, as well as negative associations between the number of cannabis dispensaries and indicators of health. we also investigated whether associations between lower ses, racial/ethnic minority status, and lack of health insurance coverage with dispensaries would be more pronounced in rural than in urban locations and in areas with fewer healthcare outlets (e.g., pharmacies, hospitals, physicians). methods the unit of analysis was census tracts, and all census tracts in oklahoma (n = 1,046) were included. the population size of a census tract ranged between 4 and 15,702, with a mean of 3,746 (sd 1,914) (united states census bureau, 2020). the outcome variable of interest was cannabis dispensary counts in each census tract. data sources and preparation the list of licensed cannabis dispensary retailers was obtained online from omma on february 9, 2021 (oklahoma medical marijuana authority). an online search was performed for each dispensary to determine address (city, county, and zip code were provided on the licensing list) and whether they were open for business. locations were de-duplicated using microsoft excel® de-duplication tool with address, city, and zip. there were 1,844 dispensaries listed in the database, 7.9% (n=146) were unable to be geolocated and were not included in our analysis, and 4.9% (n=90) were found to be duplicates. this produced a final list of 1,608 unique licensed cannabis dispensaries with identifiable locations throughout oklahoma (figure 1). dispensaries were geocoded using arcgis (arcmap, version 10.8.1; esri inc., redlands, ca). data were spatially joined with census tracts to identify the census tracts with and without cannabis dispensaries, as well as population and neighborhood characteristics for each census tract. population characteristics the u.s. census bureau’s 2014-2018 american community survey (acs) was used for demographic characteristics estimates. the following variables were included: total population, percent under age 18, race/ethnicity (percent hispanic, non-hispanic [nh] white, nh black, nh asian american, and nh american indian/alaska native), percent living below the federal poverty level, percent unemployed, and percent uninsured. all data were analyzed using the percent of total collected for that variable. the percent of residents below the poverty is based on household income and the number of residents in the household. u.s. employment status includes those employed among the civilian population ages 16 and older. insurance status included the whole population. acs asked about private insurance (employer-based, direct-purchase, own employmentbased, and tricare) and public coverage (medicare), and means-tested health care (medicaid, children’s health insurance, state demographic correlates of cannabis dispensary density 102 figure 1. cannabis dispensary count per census tracts in oklahoma, 2021 (n=1,046) (panel a); oklahoma city (panel b), and tulsa (panel c). specific plans, and va health care and champva). indian health services (ihs) coverage is not health insurance, and thus those with only ihs were considered uninsured. each dispensary was joined to its census tract level u.s. census acs survey data, so that census tract was the unit of analysis. neighborhood characteristics neighborhood characteristics included: location (e.g., city, suburb, town, rural), percent of vacant units, percent of household rentals, healthcare availability (i.e., number of hospitals, number of physicians, number of pharmacies), education availability (i.e., number of schools), and crime index. we used the national center for education statistics (nces) education demographic and geographic estimates program (edge) locale boundaries to categorize geographic areas based on u.s. census bureau designations (geverdt, 2015). the nces locale boundaries were used because they are updated annually and because, in addition to urban and rural, suburbs and rural towns were included as both are unique populations and geographic locations in oklahoma. nces edge locales includes the following four location categories: (1) panel a panel b panel c panel a cannabis, a publication of the research society on marijuana 103 city, located within a principal city or the largest city in a metropolitan (50,000 or more inhabitants) or a micropolitan (10,000 to 50,000 inhabitants) area; (2) suburb, located outside a principal city but inside a metropolitan or micropolitan area; (3) town, located inside an urban cluster (area of at least 2,500 and less than 50,000 inhabitants); and (4) rural, located outside an urban area, urban cluster, and principal city (geverdt, 2015). vacant unit estimates were based on all households (rentals and owned). the acs also includes information about homeownership status (rent or own) of each household, only for those occupied; for this study, we used the percent of households who rent. the number of hospitals in each census tract was determined using esri arcgis online data (arcgis, 2020). hospitals locations were based on the homeland infrastructure foundation-level data (hifld) database downloaded from arcgis online (homeland infrastructure foundationlevel data et al., 2020). physician count was determined by using the esri arcgis online data as well (arcgis provider practice locations, american association of family practitioners). for physician density, we included only allopathic and osteopathic physicians (family medicine, general practice, internal medicine, and pediatrics) but excluded emergency medicine, respiratory specialists, nurse practitioners, and physicians’ assistants. these data were based on the center for medicaid and medicare services (cms) national provider identification (npi) by health landscape from november 2020 and available on esri arcgis online. pharmacy count was determined using the healthcare ready’s rx open data from april 2020 and downloaded from arcgis online (ready, 2020). each facility was summed and analyzed by census tracts. the number of schools for each census tract was determined by using the arcgis map service. education data originated from the national center for education statistics (nces) (arcgis & edge, 2020). to calculate the rate, we determined the count by summing all public schools (elementary, middle/junior high school, and high schools) by census tract. schools were included in this study because dispensaries must be at least 1,000 feet from a school, and thus they play an important role in the determining the geography and neighborhood landscape of dispensaries. lastly, we used the crime index developed by applied geographic solutions (ags), which is based on fbi uniform crime reports. these data use several years of crime reports from law enforcement jurisdictions across the u.s. we used the total crime rate for 2020 due to unstable numbers in many rural census tracts. these data have been shown to be a reliable choice for use in public health analysis (nau et al., 2020). statistical analysis geographic analyses were conducted in arcmap 10.8 (esri, redlands, ca), and all statistical analyses were conducted using sas v. 9.4 (sas institute, cary, nc). descriptive statistics were first used to examine the distribution of population and neighborhood characteristics for all census tracts and by the presence/absence of at least one dispensary in a census tract. statistical differences were evaluated using logistic regression. collinearity among all study variables was assessed (r2≥.80) during this stage. to assess spatial autocorrelation and test for residual spatial dependence, we performed a test for spatial autocorrelation (moran’s i) on the residuals and they were not clustered (p = 0.91) (waller and gotway, 2004). using proc genmod procedure, poisson regression models were conducted to determine which population and neighborhood characteristics had a statistically significant effect on the outcome variable (number of cannabis dispensaries per census tract). to obtain the final model of the most significant explanatory variables, we used manual stepwise selection; a semi-automated process. goodness-of-fit measures (e.g., pearson statistic and deviance statistic) were used to compare model and to determine the best fitting model. covariates that were statistically significant in the bivariate analysis (p≤0.1) using crude (unadjusted) risk ratios (rrs) were included in the model building. next, two-way interaction terms of sociodemographic and neighborhood characteristics, specified a priori, were examined independently. if an interaction emerged, analyses were repeated with stratification, in order to explicate the interaction. if present among a continuous variable, sensitivity analyses were conducted to determine optimal categorization to simplify interpretation and, subsequently, practical public health implications. demographic correlates of cannabis dispensary density 104 adjusted and unadjusted rrs and corresponding 95% confidence intervals (cis) were calculated. a two-sided p-value of <0.05 was considered statistically significant. given the exploratory nature of the study, adjustment for multiple comparisons was not made, as there was concern this may unduly increase type ii error relative to type i error (rothman, 1990). results our study included 1,608 licensed cannabis dispensaries as of february 9, 2021. the number of dispensaries per census tract ranged from 0-11, with an average of 1.54 (sd 1.78) per tract. descriptive statistics of population and neighborhood characteristics for all census tracts and by presence/absence of at least one dispensary are presented in table 1. the majority (65.0%, n=680) of census tracts in oklahoma had at least one dispensary, with more than half of the state’s population (68.9%, n= 2,700,187 individuals) living in those census tracts. logistic regression models showed a higher percentage of individuals living below poverty (18.3% vs. 16.0%) and uninsured individuals (18.2% vs. 16.1%) residing in census tracts with at least one dispensary compared to those census tracts without a dispensary (p’s <0.05). there were significant differences among census tracts with and without a dispensary by location type (p=0.01). compared to census tracts with no dispensaries, census tracts with at least one dispensary were more likely to be in a suburban area (15.6% vs. 13.9%), a town (11.5% vs. 7.1%), or a city (30.6% vs. 29.0%), and less likely to be in rural areas (42.4% vs. 50.0%). notably, nearly half (42.4%) of census tracts with a dispensary were rural. the average number of hospitals (0.12 vs. 0.18), pharmacies (0.43 vs. 0.97), and schools (1.60 vs. 1.83) was higher in census tracts with at least one cannabis dispensary compared to census tracts with no dispensaries (p’s <0.05). step 1 of poisson regression models (table 2) shows the associations of population characteristics with census tracts with and without cannabis dispensaries and step 2 shows the association of population characteristics that were significant in step 1 and neighborhood characteristics of census tracts with and without dispensaries. the following variables were statistically significant in the bivariate analyses (crude rrs) and considered in step 1: percentage under 18 years of age (p=0.03), percentage hispanic (p=0.02), percentage living below poverty (p<.01), and percentage uninsured (p<.01). percentage hispanic was not significant after adjusting for these factors. the following variables were statistically significant in the bivariate analyses and were considered in step 2: location type (p<.01), percentage of rental households (p<.01), hospital count (p <.01), school count (p=0.01), and pharmacy count (p<.01). only percent uninsured remained significant (p<0.01) when including significant neighborhood characteristics with the population factors that emerged significant from step 1. statistical interactions (table 3) were found between: percentage hispanic and percentage living below poverty (pinteraction<0.01); percentage uninsured and percentage living below poverty (pinteraction=0.01); physician count and location type (pinteraction<.01); pharmacy count and location type (pinteraction<.01); and pharmacy count and percentage of rental households (pinteraction<.01). due to significant evidence of effect modification on a multiplicative scale for pharmacy count, the final model was repeated with stratification on the presence/absence of pharmacies in the census tract (table 4) (knol & vanderweel, 2012). there were an average of 1.02 (sd 1.38) dispensaries in census tracts with no pharmacies, and an average of 2.11 (sd 2.00) dispensaries in census tracts with at least one pharmacy. stratification by the presence of pharmacies revealed that the positive association between percent uninsured and census tracts with cannabis dispensaries was restricted to only census tracts without pharmacies (arr: 7.81, 95% ci: 3.10, 19.64, p<.01). the positive association between location type and census tracks with a cannabis dispensary was restricted to only census tracts with at least one pharmacy (rural arr: 1.17, 95% ci: 0.98, 1.39; town arr: 1.27, 95% ci: 1.04, 1.55; arr: 0.71, 95% ci: 0.59, 0.86; all p’s<.01). a post-hoc analysis showed that census tracts with no pharmacies had a higher percentage of uninsured residents (18.04% vs. 16.85%) and percentage of individuals living below the poverty level (18.14 vs. 16.80) compared to census tracts with at least one pharmacy. census tracts with at least one pharmacy also had a higher number of hospitals (0.28 vs. 0.05), schools (1.96 vs. 1.60), and dispensaries (2.11 vs. 1.04). cannabis, a publication of the research society on marijuana 105 table 1. population and neighborhood-level characteristics of census tracts with and without at least one cannabis dispensary in oklahoma (n=1,046 census tracts) total census tracts with no dispensaries census tracts with ≥1 dispensary mean ±sd mean ±sd mean ±sd p-value census tracts, n (%) 1046 366 34.99% 680 65.00%) population, n (%) 3,918,137 1,217,950 31.08% 2,700,187 (68.92%) <.0001 population characteristics (%) under 18 years of age 23.87% 5.87% 23.76% 5.88% 23.93% 5.88% 0.304 white, nh 71.47% 15.43% 71.36% 16.89% 71.53% 14.59% 0.499 black, nh 8.62% 14.16% 9.20% 16.39% 8.32% 12.81% 0.251 ai/an, nh 7.33% 7.23% 7.34% 7.21% 7.33% 7.26% 0.850 asian, nh 1.92% 3.21% 1.95% 3.36% 1.91% 3.13% 0.339 hispanic 10.88% 13.05% 9.68% 11.66% 11.52% 13.70% 0.613 below poverty 17.52% 11.42% 16.01% 11.22% 18.33% 11.46% 0.028 unemployed 19.35% 25.26% 19.42% 26.00% 19.31% 24.89% 0.637 uninsured 17.49% 08.29% 16.12% 8.14% 18.22% 8.27% <.0001 neighborhood characteristics location type, n (%) 0.012 rural 471 45.03% 183 50.00% 288 42.35% suburban 157 15.01% 51 13.93% 106 15.59% town 104 9.94% 26 7.10% 78 11.47% city 314 30.02% 106 28.96% 208 30.59% percent vacant units 14.78% 9.02% 14.73% 9.91% 14.80% 8.51% 0.901 percent household rentals 35.58% 20.38% 30.98% 21.15% 38.05% 19.53% <.0001 no. hospitals (n=163) 0.16 0.43 0.12 0.39 0.18 0.45 0.033 no. physicians (n=4148) 3.97 16.47 4.48 24.65 3.69 9.52 0.382 no. pharmacies (n=813) 0.78 1.08 0.43 0.75 0.97 1.18 <.0001 no. schools (n=1827) 1.75 1.71 1.60 1.68 1.83 1.72 0.093 total crime rate 0.153 0.5676 0.1850 0.9257 0.1358 0.1853 0.183 note. sd= standard deviation; nh= non-hispanic; ai/an= american indian/alaskan native; no.= number. demographic correlates of cannabis dispensary density 106 table 2. risk ratios (rr) from poisson regression models predicting cannabis dispensary count per census tracts (n = 1,046) step 1, population characteristics a step 2 neighborhood characteristics b crude rr (95% ci) p-value arr (95% ci) p-value arr (95% ci) p-value population characteristics (%) under 18 years of age 0.41 (0.18, 0.94) 0.03 0.35 (0.15, 0.83) 0.02 0.66 (0.29, 1.51) 0.32 white, nh 0.95 (0.70, 1.31) 0.77 black, nh 0.78 (0.54, 1.12) 0.17 ai/an, nh 1.55 (0.80, 2.97) 0.20 asian, nh 0.67 (0.14, 3.19) 0.62 hispanic 1.52 (1.08, 2.15) 0.02 1.14 (0.74, 1.76) 0.54 living below poverty 3.97 (2.72, 5.80) <.01 2.77 (1.72, 4.48) <.01 1.19 (0.65, 2.18) 0.57 unemployed 0.96 (0.78, 1.18) 0.69 uninsured 5.26 (3.01, 9.17) <.01 2.11 (1.03, 4.29) 0.04 3.41 (1.66, 7.01) <.01 neighborhood characteristics location type, (%) <.01 <.01 rural 0.76 (0.66, 0.87) 0.90 (0.76, 1.05) suburban ref ref town 1.28 (1.07, 1.52) 1.03 (0.86, 1.23) city 0.81 (0.70, 0.94) 0.79 (0.68, 0.92) percent vacant units 1.27 (0.75, 2.17) 0.38 percent rental households 3.25 (2.61, 4.04) <.01 2.64 (1.85, 3.77) <.01 no. hospital 1.32 (1.20, 1.45) <.01 0.89 (0.80, 1.00) 0.04 no. physician 1.00 (1.00, 1.00) 0.35 no. school 1.04 (1.01, 1.06) 0.02 1.05 (1.02, 1.08) <.01 no. pharmacy 1.32 (1.27, 1.36) <.01 1.29 (1.24, 1.35) <.01 total crime rate 0.97 (0.88, 1.08) 0.55 note. rr= risk ratio; arr=adjusted risk ratio; nh= non-hispanic; no. = number. a controlled for: under 18, hispanic, living below poverty, and uninsured. b controlled for: under 18, uninsured, location type, household renters, hospital count, physician count, and pharmacy count. cannabis, a publication of the research society on marijuana 107 table 3. interactions of population and neighborhood factors on cannabis dispensary count per census tracts variable 1: main effect variable 2: main effect joint effects predictors estimate p-value estimate p-value estimate p-value location type x per. below poverty location coeffs= city: -0.21 rural: -0.42 town: -0.01 <.01 poverty coeff= 1.23 <.01 city: -0.37 rural: 0.76 town: 0.65 0.13 hispanic x per. below poverty hispanic coeff = 1.26 <.01 poverty coeff= 1.83 <.01 -4.35 <.01 per. uninsured x per. below poverty uninsured coeff = 1.70 <.01 poverty coeff = 1.77 <.01 -3.56 0.01 no. pharmacies x per. below poverty pharmacy coeff = 0.24 <.01 poverty coeff = 1.39 <.01 0.21 0.18 location type x no. physician location coeff = city: -0.18 rural: -0.38 town: 0.24 <.01 physician coeff = 0.00 <.01 city: -0.01 rural: 0.04 town: 0.00 <.01 location type x per. uninsured location coeff= city: -0.29 rural:-0.28 town: -0.12 0.18 uninsured coeff = 1.87 <.01 city: -0.10 rural: -0.38 town: 1.29 0.56 location type x no. pharmacies location coeff = city: -0.11 rural:-0.51 town: 0.09 <.01 pharmacy coeff = 0.14 <.01 city: -0.04 rural:0.31 town: 0.07 <.01 no. pharmacies x per. rentals pharmacy coeff = 0.43 <.01 rentals coeff = 1.37 <.01 -0.39 <.01 note. no.= number; per = percent; coeffs = coefficients. reference group for location type = suburban. demographic correlates of cannabis dispensary density 108 table 4. adjusted risk ratio (arr) of cannabis dispensary count per census tracts stratified by presence/absence of a pharmacy total (n=1,046 census tracts) stratum 1: no pharmacies (n=560 census tracts) stratum 2: ≥1 pharmacies (n=486 census tracts) arr (95% ci) p-value arr (95% ci) p-value arr (95% ci) p-value per. uninsured 2.85 (1.57, 5.17) <.01 7.81 (3.10, 19.64) <.01 1.63 (0.71, 3.74) 0.24 per. rentals 3.32 (2.54, 4.33) <.01 2.54 (1.65, 3.90) <.01 3.16 (2.16, 4.63) <.01 location type <.01 0.06 <.01 rural 0.87 (0.75, 1.01) 0.70 (0.53, 0.93) 1.17 (0.98, 1.39) suburban ref ref ref town 1.13 (0.95, 1.35) 0.93 (0.65, 1.34) 1.27 (1.04, 1.55) city 0.68 (0.58, 0.79) 0.78 (0.58, 1.05) 0.71 (0.59, 0.86) note. arr = adjusted risk ratio; per.= percent. cannabis, a publication of the research society on marijuana 109 discussion our study found that most census tracts in oklahoma had at least one licensed dispensary. from bivariate models, census tracts with at least one dispensary had a significantly greater percentage of residents who were hispanic, living below the poverty level, and uninsured, consistent with previous work published on data from other states (morrison et al., 2014; novak et al., 2020; shi et al., 2016). in these bivariate models, the likelihood of living in a census tract with a dispensary was 52% higher among hispanic than non-hispanic residents, and 3-5 times higher among uninsured and low ses individuals. race was unrelated to dispensary density. it could be that the associations among sociodemographics, census tracts, and dispensaries are better accounted for by lower income and lack of health insurance rather than race, as these factors emerged as significant correlates of census tracts with and without dispensaries in adjusted risk ratio models. at the neighborhood level, bivariate analysis showed that nearly half of the census tracts with cannabis dispensaries were in rural areas. notably, just over a third of oklahomans live in a rural area (rural health information hub, 2021). the availability of dispensaries in rural areas suggests that many oklahomans have easy access to medical cannabis. valencia and colleagues (2017) conducted a systematic review of the structural barriers to accessing medical cannabis, but urbanicity was not examined, thus our findings add to the literature. finally, in both crude and adjusted models, results showed that hospitals, pharmacies, schools, and rental units were more prevalent in census tracts with at least one dispensary than among those without a dispensary. this may be because of the high concentration of dispensaries in cities and suburban areas, or higher population density in these areas that creates greater demand. crime was unrelated to dispensary density, inconsistent with previous research (boggess et al., 2014; contreras, 2017; freisthler et al., 2017). the association of certain sociodemographic factors with cannabis dispensaries differed by the presence or absence of pharmacies in those census tracts, in fully adjusted interaction models. to our knowledge, this is the first study to examine the relationship between cannabis dispensary location and healthcare availability (e.g., pharmacies, hospitals, physicians). our findings are consistent with a recent systematic review of correlates of geographical accessibility of pharmacies, which found lower pharmacy accessibility in low-income populations and rural areas (jagadeesan and wirtz, 2021). other work has found that dispensaries are spatially related to market potential (morrison et al 2014). as such, our results suggest that, in oklahoma, dispensaries may be situated in areas where there are limited healthcare outlets, and in doing so, allow residents to access dispensaries as alternatives to conventional medical treatment. this partially supports our hypothesis that census tracts with lower income and rural locales would be more likely to have a dispensary, as retailers may benefit from the demand for accessible and affordable alternatives to medical treatment in these remote, and, in some cases, under-served locations. the hypothesis that dispensaries might serve as an alternate point for healthcare access should be explored in future research. other reasons that may drive dispensaries to certain locations were not examined in the study but should be in future studies, include rent/real estate costs, zoning, and social acceptability of cannabis use. further research is needed to examine the complex relationships among cannabis dispensary density, pharmacy availability, housing tenure and costs, resident insurance coverage, and attitudes about cannabis use. qualitative studies could examine how residents of areas with high dispensary density perceive and interact with cannabis retail outlets, whether or not residents are using cannabis as an alternative to conventional health care services, and why. this study had several limitations. first, conclusions cannot be drawn regarding causation, as we did not investigate change over time. given that the medical cannabis industry in oklahoma is relatively new, there may be a lag-time associated with the passing of policies, their implementation, and an assessment of the impact. (hudson et al., 2019). second, while census tracts are often used as a proxy for neighborhoods in public health research, these areas are not homogeneous, and relationships observed at one level of aggregation may not persist using different spatial units, such as zip codes or u.s. census block groups. third, while data were not demographic correlates of cannabis dispensary density 110 temporally homogenous, they were assessed close in time and we do not believe this significantly impacted the outcomes. fourth, policy changes in oklahoma may impact these associations over time. oklahoma issued up to a two year moratorium on new business licenses, which could impact density. finally, we did not adjust for multiple comparisons, following recommendations by rothman. while type i error rate is possible, such adjustments also increase the likelihood of type ii error rate and thus spurious results (rothman, 1990). conclusions results confirm an inequitable distribution of cannabis dispensaries by population and neighborhood demographics in oklahoma. higher dispensary density was associated with a greater proportion of uninsured and low income individuals in those areas, which suggests that dispensaries could serve as an alternative access point for healthcare needs for individuals who may have other barriers to accessing traditional healthcare. even if dispensaries may partially address health needs of individuals living in these areas, disparities in dispensary location could lead to greater social and economic consequences (kong et al., 2019, 2020; loomis et al., 2013; rodriguez et al., 2013). understanding how oklahoma’s dispensary distribution is related to population demographics provides valuable information for other states looking to legalize cannabis in the future. references americans for safe access. 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(2020). cannabis in the capital: exploring the spatial association between medical marijuana dispensaries and crime. journal of crime and justice, 43(1), 115. funding and acknowledgements: amc was supported in part by the university of oklahoma health sciences center, oklahoma tobacco settlement endowment trust (tset) contract # r22-02 and nci grant p30ca2255520 awarded to the stephenson cancer center. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. jc was partially funded by national institute of general medical sciences, grant/award number: u5gm104938 and in part by the national cancer institute cancer center support grant p30ca225520 awarded to the university of oklahoma stephenson cancer center for use of the biostatistics and research design shared resources. all data used in this study are publicly available. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 89 ved abstract models of personality suggest that adolescent substance use may be associated with adolescent impulsive traits as well as changes in impulsive traits from adolescence into emerging adulthood. however, little research has focused on how adolescent alcohol and cannabis co-use, an increasingly popular and risky substance use pattern, may relate to adolescent impulsive traits as well as changes in impulsive traits from adolescence to emerging adulthood. therefore, the current study tested patterns of adolescent co-use and their links with adolescent impulsive traits and changes in impulsive traits into emerging adulthood. data come from the add health study and encompassed two timepoints spanning adolescence (age 13-18) and emerging adulthood (age 19-25). a combination of latent profile analysis, mean comparisons, and latent difference scores were estimated. results suggested that four profiles of co-users and alcohol-only users emerged, and profiles differed in levels of adolescent personality and prospective personality change. importantly, frequent adolescent co-users had higher levels of adolescent sensation seeking and impulsivity, but also reported the steepest decline in both traits into emerging adulthood. findings are discussed in terms of personality theory and public health implications. key words: = impulsivity; sensation seeking; personality change; co-use; alcohol use; cannabis alcohol and cannabis are the most frequently used psychotropic drugs in the u.s. (nida, 2020), and remain significant public health concerns. rates are on the rise (grant et al., 2017; hasin, 2018; meich et al., 2023; nida, 2020), and each are associated with adolescent and young adult negative consequences such as cognitive decline, impaired driving, and medical/mental health comorbidities (cole & saitz, 2020; perkins et al., 2002; meier et al., 2012; volkow et al., 2014). nevertheless, the co-use of alcohol and cannabis, defined as using both alcohol and cannabis at the same time [simultaneous use] or using both separately within a given time period [concurrent use]; gunn et al., 2018; gunn et al., 2022; yurasek et al., 2017), confers risk for negative consequences (e.g., green et al., 2019; wardell et al., 2020; waddell et al., 2021a; 2021b) and development of alcohol use disorder (aud; e.g., midanik et al., 2007; waddell, 2021) above and beyond levels of drinking and demographic (age, sex) and psychosocial factors (e.g., family history of aud, expectancies; waddell, blake, & chassin, 2021; waddell, jager, & chassin, 2022). furthermore, rates of alcohol and cannabis co-use continue to rise in adolescents/young adults (e.g., mccabe et al., 2021), and thus it is vital to understand predictors and consequences of co-use to target via early age prevention efforts. jack t. waddell1 & lindy k. howe2 1department of psychology, arizona state university 2department of psychological sciences, indiana university cannabis 2023 © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000162 relations among adolescent alcohol and cannabis co-use, adolescent impulsive traits, and prospective change in impulsive traits into emerging adulthood corresponding author: jack t. waddell, m.a., arizona state university, department of psychology, 900 s mcallister, tempe, az 85281. phone: 480-965-1616. fax: 480-965-8544. e-mail: jtwaddell@asu.edu mailto:jtwaddell@asu.edu adolescent alcohol/cannabis co-use and impulsive traits 90 substance use and impulsive personality traits decades of research suggests that generalized impulsivity, defined as rash action with little regard for future consequences (moeller et al., 2001), is cross-sectionally and prospectively associated with heavier alcohol and cannabis consumption in adolescents, young adults, and adults (e.g., dick et al., 2010; henges & marczinkski, 2012; stautz & cooper, 2013; waddell et al., 2021c; wiers et al., 2010). similarly, sensation seeking, defined as thrill and/or rewarding seeking (zuckerman, 2007), is associated with substance use across developmental stages (e.g., andrew & cronin, 1997; donohew et al., 1999; kaynak et al., 2013; magid et al., 2007; waddell, elam, & chassin, 2022). meta-analyses in adults and adolescents for both substances suggest that generalized impulsivity facets (e.g., a lack of premeditation and perseverance) were strongly associated with heavier alcohol and cannabis use, whereas sensation seeking was strongly associated with use frequency and any use (e.g., coskunpinar et al., 2013; vanderveen et al., 2016). despite robust literature on associations between impulsive personality traits and single substance use, relations between impulsive personality traits and alcohol and cannabis co-use are less often studied. some studies suggest that adult and adolescent dualand poly-substance users report higher levels of generalized impulsivity (hammers & suhr, 2010; veredgogarcia et al., 2010), and some suggest that alcohol and cannabis co-users report higher levels of sensation seeking (linden-carmichael et al., 2019a; koller et al., 2015). however, a recent study tested both late adolescent generalized impulsivity and sensation seeking as competing correlates of alcohol and cannabis co-use, which previous studies had not, and found that sensation seeking (but not impulsivity) was crosssectionally related to adolescent alcohol and cannabis co-use (waddell et al., 2021a). put together, these studies indicate that adolescent heavier single substance use may be associated with generalized impulsivity, whereas frequency of use and/or co-using alcohol and cannabis together may be associated with adolescent sensation seeking. however, no studies to date have tested whether there are differences in impulsive personality in certain alcohol and cannabis cousers from alcohol-only users during adolescence, as well as whether higher-risk co-using adolescents differ from other adolescent alcohol and cannabis co-users who have differing levels of use. one possibility is that adolescents who co-use alcohol and cannabis, regardless of frequency, may report higher sensation seeking, as the act of using two substances, even infrequently or rarely, may be perceived as thrilling and exciting. it is also possible, though, that more frequent adolescent use of alcohol and cannabis may be related to sensation seeking, considering strong links between frequency of single substance use and sensation seeking in adolescent and adult studies (coskunpinar et al., 2013; vanderveen et al., 2016). substance use and impulsive personality change furthermore, links between substance use and impulsive personality traits are more complex than a one-to-one directional effect. although personality is thought to be a relatively stable construct, modern models of personality suggest shifts in personality across the lifespan, particularly during adolescence and emerging adulthood (mccrae & costa, 1994; mccrae et al., 1999). neurodevelopmental imbalance and dual systems theories purport that adolescence is a time of peak levels of sensation seeking and impulsivity, due to increased reward-seeking in adolescence and later, more slowly developing topdown cognitive control (e.g., defoe et al, 2019; steinberg et al., 2010; wasserman et al., 2020). these theories suggest normative declines in sensation seeking and impulsivity after adolescence, however there are several factors that may influence personality change over time, such as substance use. one model of change proposed by caspi et al. (2005) highlights the corresponsive principle, which asserts that personality traits that drive specific behaviors are strengthened and reinforced by engaging in the target behavior (i.e., substance use). indeed, several studies have found that substance use, particularly alcohol, is a strong predictor of personality change into adulthood, particularly impulsivity (e.g., ashenhurst et al., 2015; littlefield et al., 2009; 2010; hakulinen & jokela, 2019). however, developmental timing plays an important role in cannabis, a publication of the research society on marijuana 91 the prediction of personality change from substance use. for instance, quinn & harden (2013) found that age 15 heavier drinking was associated with less of a decrease in impulsivity and sensation seeking from age 15 to age 26. in addition, quinn et al. (2012) found that age 17-19 heavier drinking was associated with increases in sensation seeking and impulsivity 4 years later. nevertheless, it remains unclear whether the couse of alcohol and cannabis in adolescence predicts personality change into emerging adulthood above and beyond levels of alcohol use. considering undoubted links between adolescent sensation seeking and alcohol and cannabis co-use (e.g., linden-carmichael et al., 2019a; waddell et al., 2021a), theory may suggest that higher risk alcohol and cannabis co-use in adolescence, characterized by frequent alcohol and cannabis use together either concurrently or simultaneously, may predict increased levels of sensation seeking into emerging adulthood. the current study therefore, the current study tested whether alcohol and cannabis co-use (compared to alcoholonly use) was associated with higher levels of impulsivity and sensation seeking during adolescence, and whether adolescent alcohol and cannabis co-use was related to changes in personality from adolescence into emerging adulthood. the current study used two timepoints spanning adolescence (13-18 years old) and emerging adulthood (19-25 years old). theory suggests that adolescence is a critical period to study the development and stability of personality traits (e.g., defoe et al., 2019; steinberg et al., 2010), and that personality traits become stable during adulthood (roberts et al., 2006). thus, the current study tested effects during the transition from adolescence into emerging adulthood, a time of potentially rapid personality and behavior change. furthermore, the current study used mixture modeling to obtain profiles of adolescent alcohol and cannabis co-users rather than using a dichotomy of any alcohol and cannabis co-use like previous studies have (e.g., linden-carmichael et al., 2019a; waddell et al., 2021a). investigating data-driven profiles of alcohol and cannabis co-use allows for a better test of the corresponsive principle (e.g., caspi et al., 2005), as this allowed the current study to 1) differentiate adolescent alcohol and cannabis co-users along a continuum rather than creating a dichotomy, 2) differentiate adolescent alcohol and cannabis co-users and alcohol-only users based upon their frequency of both alcohol use, binge drinking, and cannabis use as well as whether participants used both simultaneously (i.e., at the same time), and 3) use several variables to create categories of adolescent alcohol and cannabis co-use and alcohol-ony use rather than creating categories from a singular variable (i.e., cannabis use in alcohol users; see lanza et al., 2022 for more details on mixture modeling of alcohol and cannabis co-use). it was hypothesized that 4+ classes of substance users would emerge from analyses, representing lower risk alcohol-only users, higher risk alcohol-only users, lower risk alcohol and cannabis co-users, and higher risk co-users in adolescence (e.g., waddell, 2022). second, assuming these profiles were found, it was hypothesized that both classes of adolescent alcohol and cannabis co-users would report higher sensation seeking cross-sectionally, whereas higher risk adolescent alcohol-only users would report higher generalized impulsivity crosssectionally. finally, it was hypothesized that the higher-risk adolescent alcohol and cannabis cousers (i.e., more frequent, heavier use) would report increases in sensation seeking from adolescence to emerging adulthood. methods participants the current study used publicly available data from the national longitudinal study on adolescent to adult health (add health). add health is a longitudinal survey that followed a representative cohort of united stated high schoolers across four waves of data collection into adulthood. at wave 1 (1994-1995), high schools around the u.s. were contacted about participation, and students within schools that consented answered a variety of questionnaires related to development, health, and wellbeing. participants were followed up approximately one year later (wave 2; 1996), and then again approximately five (wave 3; 2001-2002) and ten (wave 4; 2007-2008) years later. the current study used data from waves 2 and 3 to test changes in personality from adolescence into adolescent alcohol/cannabis co-use and impulsive traits 92 emerging adulthood. retention was 74.3% from wave 1 to wave 2, and 75.1% from wave 1 to wave 3. participants who were age 13-18 at wave 2 and 19-25 at wave 3 were included. furthermore, considering the current study focused on alcohol use, alcohol and cannabis co-use, and personality, participants for the current study were only included if they endorsed drinking alcohol. participants (n=3,277) were a mean age of 16.43 (sd= 1.40) in adolescence and 21.34 (sd = 1.45) in emerging adulthood, were 52.9% female, and 32.5% reported being an ethnic/racial minority. measures demographics. participants’ age during adolescence (13-18) and sex (male vs. female) were assessed and included as covariates. alcohol use. the current study assessed pastyear alcohol use frequency and binge drinking frequency during adolescence. participants were asked, “during the past 12 months, on how many days did you drink alcohol?” and “over the past 12 months, on how many days did you drink five or more drinks in a row” on a scale of 1 (every day or almost every day) to 7 (never). items were reversescored so that higher scores indicated heavier drinking, and rescored on a scale of 0 (never) to 6 (every day or almost every day). cannabis use. adolescent cannabis use frequency was assessed by asking participants, “during the past 30 days, how many times have you used marijuana?” with responses ranging from 0 to 500 times; all values 30+ were coded as 30, such that a times per month cannabis was used (0 to 30+) variable was created. this variable has been used in other add health studies (e.g., deutsch et al., 2020). simultaneous alcohol and cannabis use. adolescent simultaneous alcohol and cannabis use was assessed by asking participants, “since [the last assessment one year ago], have you drunk alcohol when you were using drugs?”, and “the most recent time you drank alcohol when you were using drugs, what kind of drugs were you using?”, with marijuana as the first option. impulsive personality traits. three items were used to measure impulsive personality traits. in adolescence, participants were asked to respond to the following items: “when making decisions, you usually go with your ‘gut feeling’ without thinking too much about the consequences of each alternative”, “you live your life without much thought for the future”, and “you like to take risks” on a scale of (1) strongly agree to (5) strongly disagree. in emerging adulthood, participants were asked to respond to the following items: “you go with your “gut feeling” and don’t think much about the consequences of each alternative”, “you live your life without much thought for the future”, and “you like to take risks” on a scale of (1) strongly agree to (5) strongly disagree. thus, the wording for the “gut feeling” item slightly changed from adolescence to emerging adulthood, however measured the same construct on the same scale; this item has been used in other add health longitudinal research (e.g., converse et al., 2018). items were reverse scored so that higher levels were indicative of more impulsivity. several measurement models of personality with these items were considered. first, an overarching ‘behavioral undercontrol” model (e.g., sher et al., 1991) was considered where all three items loaded onto one latent factor. to test the structure and fit of this model, a measurement model was estimated where each item was specified onto a latent factor during adolescence and emerging adulthood, and latent factors across time points were allowed to freely covary. in addition, each of the three items were allowed to freely covary within timepoint. this model fit the data well (x2 (5) = 14.45, p = .01, rmsea = .024, cfi = .99, tli = .97, srmr = .014). however, the factor loadings for “gut feeling” (adolescent b = .67, p < .001; emerging adult b = .60, p < .001) and “little thought for the future” (adolescent b = .50, p < .001; emerging adult b = .54, p < .001) were substantially higher than risk taking/sensation seeking (adolescent b = .39, p < .001, emerging adult b = .41, p < .001). a second model was considered where (1) “gut feeling” and (2) “little thought for the future” were specified as indicators of a latent variable, whereas risk taking/sensation seeking was a single item. this model fits more in line with the dual systems model (steinberg et al., 2008) and upps-p (whiteside & lynam, 2001), suggesting that sensation seeking/risk taking is a separate, yet correlated, personality construct. for the second model, since there were only two indicators of the latent variable, model constraints were used to extract the commonality between the two items. furthermore, sensation seeking was cannabis, a publication of the research society on marijuana 93 allowed to freely covary with the latent variable at the cross-sectional time point, and each of the three items were allowed to freely covary within timepoint. this model also fit the data well (x2 (7) = 64.74, p < .001, rmsea = .05, cfi = .95, tli = .90, srmr = .047). the factor loadings for “gut feeling” and “little thought for the future” were high during adolescence (b = .58, p < .001) and emerging adulthood (b = .56, p < .001), and the latent factor was moderately correlated with sensation seeking in adolescence (r = .31, p < .001) and emerging adulthood (r = .34, p < .001). ultimately, the second model had higher factor loadings and was more in line with contemporary theory (steinberg et al., 2008; whiteside & lynam, 2001) and past add health studies (peach & gaultnety, 2013; lydon-staley & geier, 2018). thus, impulsivity and sensation seeking/risk taking were treated as separate constructs1. the two-item combination will be referred to as impulsivity and sensation seeking/risk taking will be referred to as sensation seeking. data analytic plan the current study used a combination of mixture modeling and structural equation modeling to test 1) patterns of alcohol and cannabis use during adolescence, 2) whether adolescent patterns of alcohol and cannabis use differentiate adolescent levels of impulsive traits, 3) the directionality of change in impulsive personality traits from adolescence to emerging adulthood, and 4) whether patterns of alcohol and cannabis use during adolescence are associated with prospective changes in personality from adolescence into emerging adulthood. across all aims, full information maximum likelihood (fiml) was used to estimate missing data. aim 1: first, a latent profile analysis of adolescent alcohol and cannabis use was estimated. latent profiles were comprised of four variables representing one’s alcohol use frequency (continuous), binge drinking frequency (continuous), cannabis use frequency (continuous), and simultaneous use of alcohol and cannabis (binary; yes/no). thus, the latent profiles consisted of average means of continuous variables and likelihood of endorsing simultaneous use since it was a binary variable; likelihood above 50% was considered higher likelihood of reporting a 1 (i.e., simultaneous use) compared to 0 (i.e., no simultaneous use). all models were run with 50 random starts, and solutions with 1-6 profiles were considered. latent profile enumeration was decided based upon both statistical and theoretical fit of latent profiles. aikake information criteria (aic) values, bayesian information criteria (bic) values, entropy values, the lo-mendell rubin adjusted likelihood ratio (llr) test (nylund et al., 2007) were used as indices of model fit. smaller aic/bic values and higher entropy values are indicative of better model fit, and entropy values greater than .80 indicate adequate class separation (bolck et al., 2004). a significant llr test also suggests better fit than the previous solution (nylund et al., 2007). aim 2: once the optimal profile solution was decided upon, we tested cross-sectional relations among profiles of alcohol and cannabis use and impulsive personality traits. we used the manual 3-step bolck, croon, and hagenaars (bch; bolck et al., 2004) approach to examine profile differences in cross-sectional impulsive personality traits reported during adolescence. the bch method provides estimates of mean differences in variables of interest (i.e., impulsive personality traits) by estimating singular pairwise differences among distal means within each profile. the bch method takes into account classification error by assigning individuals to their most likely latent profile while also accounting for posterior probabilities. to execute pairwise comparisons, the model constraint command in mplus was used 1although model fit comparisons are the typical way of comparing two models statistically, model fit comparisons were not appropriate for these models. considering the complexity of modeling a latent variable with 2 indicators, several constraints were required to accurately parse out the commonality of the two items, and these constraints were not present in the 3-indicator latent variable model. in addition, a correlation between sensation seeking and the latent factor for each variable was specified in the 2-indicator latent variable model, which also was not present in the 3-indicator latent variable model. thus, the two models were not fully nested, and the additional constraints of the 2-indicator model naturally would have led to a decrement in model fit. rather, the current study used factor loadings and theoretical fit to decide on the optimal modeling approach for personality items. adolescent alcohol/cannabis co-use and impulsive traits 94 to test whether the means of each impulsive personality trait within profiles differed from one another. aim 3: latent difference scores were estimated to test the directionality of change in impulsive personality traits. latent difference scores were estimated in the following fashion: 1) the factor loading of the emerging adult value onto the difference score was set to one, 2) the regression of the emerging adult value on the adolescent value was set to one, 3) the correlation between the young adult value and the adolescent value was set to zero, 4) the variance of the emerging adult value was set to zero, 5) the intercept of the emerging adult value was set to zero while the intercept of the adolescent value was allowed to freely covary, and 6) the latent change score was correlated with the adolescent value. this approach effectively tests change from adolescence to young adulthood, which diverges from basic computed change scores in that the model-based error component is separate from the latent change parameter (mcardle & grimm, 2010). standardized betas are reported for univariate latent difference scores. aim 4: finally, we used a combination of the manual bch method and latent difference scores to estimate whether adolescent alcohol and cannabis use profiles predicted personality change from adolescence into emerging adulthood. thus, each profile vs. one another was estimated as a predictor of change in personality traits. in these models, adolescent age and sex were covaried and allowed to freely covary. in line with other models of alcohol use and personality change (luchetti et al., 2018; stephan et al., 2018), predictors of latent change scores will be interpreted in the direction of change. thus, if a construct increases over time, a positive coefficient will be interpreted as an “more of an increase”, whereas a negative coefficient will be interpreted as a “less of an increase”. however, if a construct decreases over time, a positive coefficient will be interpreted as “less of a decrease”, whereas a negative coefficient will be interpreted as “more a decrease”. results aim 1: characterizing patterns of alcohol and cannabis co-use latent profile solutions were fit starting with a 1-profile model through a 6-profile model (see table 1). aic and bic values declined from the 1profile through 6-profile solutions, and δbic appeared to level off after the 4-profile solution. entropy values remained high across all solutions (entropy>.948), and the llr test was significant for the 2-profile (p<.001), 3-profile solutions (p<.001), and 4-profile solutions (p=.005). the 1 through 4-profile solutions all had >100 participants per profile, whereas the 5and 6profile solutions had profiles with as low as 2% of the sample. in addition, the 4-profile solution showed a substantial drop in aic and bic values, entropy, suggesting better fit than the 3-profile solution. thus, we deemed the 4-profile solution to be the optimal fit to the data. profiles are described as follows: low-risk alcohol-only users (i.e., “alcohol only users”; n=2459, 75%), higher-risk alcohol users who experiment with cannabis (i.e., “experimental cousers”; n=581, 18%), higher-risk alcohol users who regularly use cannabis (i.e., “regular cousers”; n=116, 4%), and higher-risk alcohol users who very frequently use cannabis (i.e., “frequent co-users”; n=121, 4%). alcohol-only users used alcohol occasionally (m=.84, se=.05), but not did not use cannabis (m=.19, se=.02) nor binge drink (m=.26, se=.02). experimental co-users reported monthly-to-weekly alcohol use (m=3.57, se=.07) and binge drinking (m=3.31, se=.14), but reported very infrequent cannabis use (m=.95, se=.10) that had a low likelihood of being simultaneous with alcohol (28.3% likelihood). regular co-users reported monthly-to-weekly alcohol use (m=3.30, se=.16) and binge drinking (m=2.73, se=.20), however reported using cannabis on average about 13.7 (se=.54) times monthly and a high likelihood of using both simultaneously (67.2% likelihood). frequent cousers reported monthly-to-weekly alcohol use (m=3.27, se=.15) and binge drinking (m=2.80, se=.19) and reported using cannabis on average 28.69 (se= .32) times monthly and a high likelihood of using both simultaneously (64.8% likelihood; see figure 1). cannabis, a publication of the research society on marijuana 95 table 1. model fit statistics for latent profile analysis aic bic δbic entropy class size (%) lmr 1-class 47387.50 47430.16 --1.000 100 -- 2-class 41334.93 41408.07 6,022.09 .991 94, 6 < .001 3-class 37827.70 37931.31 3,477.39 .948 75, 19, 6 < .001 4-class 35446.89 35580.97 2,350.34 .954 75, 18, 4, 4 .005 5-class 34116.83 34281.39 1,299.58 .955 74, 16, 4, 4, 2 .29 6-class 32888.28 33.083.31 1,198.08 .960 73, 15, 5, 3, 3, 2 .13 note. lmr = lo-mendell rubin loglikelihood ratio test; the 4-class solution was deemed to have the best statistical and theoretical fit. figure 1. latent profile analysis of adolescent alcohol and cannabis use note. profiles were named the following: alcohol-only users (profile 1; 75% of sample), experimental co-users (profile 2; 18% of sample), regular co-users (profile 3; 4% of sample), and frequent co-users (profile 4; 4% of sample); n=2459 alcohol-only use, n=581 experimental co-use, n=116 regular co-use, n=121 frequent co-use. aim 2: mean differences in impulsive personality traits during adolescence frequent adolescent co-users (class 4) had higher levels of adolescent sensation seeking and impulsivity compared to alcohol-only users and experimental co-users, but did not differ in levels of adolescent sensation seeking nor impulsivity from regular co-users. regular adolescent cousers reported higher levels of adolescent sensation seeking and impulsivity compared to alcohol-only users but did not differ in adolescent sensation seeking nor impulsivity from experimental co-users. finally, experimental adolescent co-users reported significantly higher levels of adolescent sensation seeking and impulsivity compared to alcohol-only users (see tables 2 and 3). 0 0.5 1 1.5 2 2.5 3 3.5 4 profile 1 profile 2 profile 3 profile 4 drinking and binge drinking frequency drinking frequency binge drinking frequeny 0 5 10 15 20 25 30 profile 1 profile 2 profile 3 profile 4 cannabis use frequency 0 10 20 30 40 50 60 70 80 90 100 profile 1 profile 2 profile 3 profile 4 likelihood of simultaneous use adolescent alcohol/cannabis co-use and impulsive traits 96 table 2. mean values for adolescent and emerging adult sensation seeking and impulsivity among profiles sensation seeking impulsivity adolescent mean emerging adult mean adolescent mean emerging adult mean alcohol-only 3.541 3.465 2.597 2.461 experimental co-use 3.804 3.633 2.883 2.613 regular co-use 3.946 3.418 3.078 2.679 frequent co-use 4.08 3.568 3.150 2.858 note. sensation seeking was measured on a scale of (1) strongly disagree to (5) strongly agree; alcohol use frequency and binge frequency were largely identical across the three classes of co-users, with the main differentiating variable being cannabis frequency (see figure 1); n=2459 alcohol-only use, n=581 experimental co-use, n=116 regular co-use, n=121 frequent co-use. table 3. mean differences in adolescent sensation seeking and impulsivity among profiles sensation seeking mean diff. se p-value alcohol-only vs. experimental co-use .257 .060 < .001 alcohol-only vs. regular co-use .404 .101 < .001 alcohol-only vs. frequent co-use .558 .087 < .001 experimental co-use vs. regular co-use .147 .124 .263 experimental co-use vs. frequent co-use .301 .086 < .001 regular co-use vs. frequent co-use .154 .137 .263 impulsivity mean diff. p-value alcohol-only vs. experimental co-use .289 .050 < .001 alcohol-only vs. regular co-use .470 .087 < .001 alcohol-only vs. frequent co-use .569 .091 < .001 experimental co-use vs. regular co-use .181 .098 .065 experimental co-use vs. frequent co-use .280 .094 .003 regular co-use vs. frequent co-use .099 .115 .388 note. models controlled for age and sex in the prediction of latent difference scores; n=2459 alcohol-only use, n=581 experimental co-use, n=116 regular co-use, n=121 frequent co-use. table 4. mean differences in latent change of sensation seeking and impulsivity among profiles sensation seeking mean diff. se p-value alcohol-only vs. experimental co-use .135 .066 .041 alcohol-only vs. regular co-use .373 .125 .003 alcohol-only vs. frequent co-use .465 .111 < .001 experimental co-use vs. regular co-use .238 .146 .104 experimental co-use vs. frequent co-use .330 .114 .004 regular co-use vs. frequent co-use .092 .153 .546 impulsivity mean diff. se p-value alcohol-only vs. experimental co-use .151 .047 .002 alcohol-only vs. regular co-use .208 .115 .071 alcohol-only vs. frequent co-use .248 .099 .012 experimental co-use vs. regular co-use .057 .130 .659 experimental co-use vs. frequent co-use .098 .100 .327 regular co-use vs. frequent co-use .041 .145 .778 note. models controlled for age and sex in the prediction of latent difference scores; n=2459 alcohol-only use, n=581 experimental co-use, n=116 regular co-use, n=121 frequent co-use. aim 3: change in personality from adolescence to emerging adulthood latent change scores for sensation seeking and impulsivity were estimated alongside one another. both latent change parameters showed significant change from adolescence to emerging adulthood, such that levels of sensation seeking (b = -.13, se = .03, p < .001) and impulsivity (b = .17, se = .02, p < .001) decreased from adolescence to emerging adulthood. aim 4: co-use profiles as predictors of personality change the rate of decrease in sensation seeking from adolescence to emerging adulthood was higher for frequent adolescent co-users compared to alcoholonly and experimental co-users but not regular cousers. similarly, the rate of decrease in sensation cannabis, a publication of the research society on marijuana 97 seeking from adolescence to emerging adulthood was higher for regular adolescent co-users compared to alcohol-only but not experimental cousers, and the rate of decrease in sensation seeking from adolescence to emerging adulthood was higher for experimental co-users compared to alcohol-only users. the rate of decrease in impulsivity from adolescence to emerging adulthood was higher for frequent adolescent co-users and experimental cousers compared to alcohol-only users. however, no other pairwise comparisons were statistically significant (see table 4). discussion the current study aimed to examine whether adolescent alcohol and cannabis co-use was crosssectionally and prospectively associated with impulsive personality traits, namely impulsivity and sensation seeking. the current study also sought to use a finite mixture modeling approach to differentiate adolescent co-users, which previous research has largely considered a dichotomy (0=non-co-user, 1=co-user). there were several major findings. first, the mixture model suggested that a four-profile solution fit the data best: profiles were indicative of adolescent lower-risk alcohol-only use (i.e., alcohol-only use), higher-risk alcohol use with experimental cannabis use (i.e., experimental cousers), higher-risk alcohol use with regular cannabis use (i.e., regular co-users), and higherrisk alcohol use with frequent cannabis use (i.e., frequent co-users). second, pairwise comparisons suggested that frequent adolescent co-users and regular co-users had the highest cross-sectional levels of sensation seeking and impulsivity. furthermore, frequent adolescent co-users had significantly higher cross-sectional levels of sensation seeking and impulsivity than all adolescent groups except regular co-users, and both regular and experimental co-users had higher levels of adolescent sensation seeking and impulsivity than alcohol-only users. lastly, and surprisingly, frequent adolescent co-users reported steeper declines in sensation seeking from adolescence into emerging adulthood compared to all profiles except regular co-users, and both regular and experimental adolescent cousers reported steeper declines in sensation seeking from adolescence into emerging adulthood compared to alcohol-only users. frequent co-users and experimental co-users also declined in impulsivity from adolescence into emerging adulthood at higher rates than alcoholonly users. findings related to the mixture model were largely in line with hypotheses. however, rather than a higher-risk adolescent alcohol-only profile emerging, a higher-risk adolescent alcohol use profile who experimentally used cannabis emerged. all adolescent co-user profiles examined had relatively similar rates of alcohol use and binge drinking, and thus the primary differentiating variable was cannabis use. furthermore, experimental adolescent co-users reported using cannabis an average about 1 time over the past month, regular co-users reported using cannabis an average of about 13.7 times over the past month, and frequent co-users reported using cannabis an average of 28.7 times over the past month. expectedly, both the adolescent regular (i.e., 14 times a month) and frequent (i.e., 28 times a month) profiles reported a higher probability of using alcohol and cannabis simultaneously. thus, we believe this mixture model represents stronger measurement of adolescent co-use compared to some past studies, as experimental, regular, and frequent co-users would have all been treated the same in an analysis dichotomizing co-use as 0 = no co-use, 1 = co-use. cross-sectionally, hypotheses related to personality differences in adolescence were largely supported. thus, regular and frequent adolescent co-users reported higher levels of adolescent sensation seeking and impulsivity during adolescence compared to experimental cousers and alcohol-only users. in addition, experimental adolescent co-users reported higher levels of adolescent sensation seeking and impulsivity compared to alcohol-only users. there were no pairwise differences between regular and frequent adolescent co-users, nor between regular and experimental co-users, though, in adolescent sensation seeking nor impulsivity. findings replicate previous research suggesting that adolescent co-users have higher adolescent levels of sensation seeking and generalized impulsivity compared to alcohol-only users (e.g., hammers & suhr, 2010; koller et al., 2015; waddell et al., 2021a). thus, adolescent co-users, from the continuum of experimental to frequent co-use, had adolescent alcohol/cannabis co-use and impulsive traits 98 higher levels of both traits in adolescence compared to alcohol-only users. however, frequent adolescent co-users also had higher levels of both traits in adolescence compared to experimental co-users. on the contrary, both regular and frequent adolescent co-users did not differ in levels of either trait in adolescence. this is likely because both groups reported higher likelihood of simultaneous use in adolescence, which past research has suggested is related to heightened sensation seeking (lindencarmichael et al., 2019a). put together, findings point to a complex mix of betweenand withingroup findings, as frequent adolescent co-users had higher levels of adolescent sensation seeking and impulsivity compared to both alcohol-only users (i.e., between-group) and experimental cousers (i.e., within-group). previous research found between-group and within-group variability in relations between co-use (i.e., co-users vs. alcohol user, within co-users) and aud (waddell, 2021; waddell, 2022) as well, and thus the current study points to personality as an important variable to target in mechanistic studies. in addition, providers may consider attending to sensation seeking and impulsive tendencies when working with adolescent co-users in a clinical setting when evaluating potential risk factors and intervention targets. prospectively, the current study found the opposite effect as hypothesized related to changes in personality traits. all three profiles of adolescent co-users reported steeper declines in sensation seeking into emerging adulthood compared to alcohol-only users, and frequent adolescent co-users also reported steeper declines into emerging adulthood compared to experimental co-users. considering caspi (2005)’s model of personality would suggest that adolescent co-use should increase one’s sensation seeking, these findings were a bit surprising. there are several explanations, however, for these surprising yet important finding. first, considering adolescence is a time of peak sensation seeking (e.g., defoe et al., 2019; steinberg et al., 2010), it is not uncommon to observe a general trend in which sensation seeking levels decline over time. furthermore, considering co-use is cross-sectionally related to sensation seeking, both in the current study and in past studies (e.g., linden-carmichael et al., 2019a; waddell et al., 2021a), one interpretation of findings may be that adolescent co-users already have such high levels of sensation seeking in adolescence that there is much more room to decline over time. this is supported by the crosssectional analyses, showing that all adolescent cousers had higher levels of sensation seeking and impulsivity, and that frequent adolescent co-users also had higher levels of adolescent sensation seeking compared to experimental co-users and alcohol-only users. second, it is possible that the measurement focus on risk taking within trait sensation seeking lead to high reporting endorsement of sensation seeking in this sample. specifically, adolescents in the co-use profile may have been more likely to endorse high levels of risk taking that is captured in our measurement of sensation seeking, contributing to the ultimate finding. although risk taking is a predominant theme in the construct of sensation seeking, changes in other aspects of sensation seeking, such as thrill/reward seeking, may be more related to co-use. thus, adolescent past-year cousers may already have peak levels of risk taking, but they have more room to increase/grow in thrill/reward seeking behaviors that are less proximal during adolescence (e.g., parachute jumping, flying an airplane). therefore, future research is needed to test study findings with larger measures of sensation seeking that consider multiple domains of the construct. similar to co-use and changes in sensation seeking, profiles indicative of frequent adolescent co-use and experimental co-use were associated with a steeper decline in impulsivity into emerging adulthood. thus, findings were largely in line with sensation seeking findings, except that there were no pairwise differences between regular adolescent co-users and alcohol-only users in their rate of decline in impulsivity into emerging adulthood. nonetheless, a similar explanation may be present as above, such that adolescents in profiles 2 and 4 reported higher levels of impulsivity in adolescence compared to alcohol-only users, leaving more room to decline into emerging adulthood. importantly, it is surprising, though, that the regular adolescent couse profile did not follow a similar pattern of analyses. although the magnitude of mean differences was similar to that of experimental adolescent co-use, there was more error around this estimate worthy of further replication and extension. thus, future research is needed to cannabis, a publication of the research society on marijuana 99 affirm this pattern of findings. clinically, the findings related to both sensation seeking and impulsivity changes from adolescents to emerging adulthood point to potentially important targets for interventions, especially adolescents engaging in frequent co-use. clinicians should consider evaluating these traits in addition to substance use behavior at the beginning of treatment. while the current study represents the first to examine relations among patterns of alcohol and cannabis use and cross-sectional impulsive traits as well as prospective change in impulsive traits, it is not without its limitations. one limitation to consider is the use of only three items to evaluate impulsive personality traits, as opposed to a full measure or screener. while single items or short form measures can be useful (stephenson et al., 2003), particularly in large national datasets, future research should examine these effects using a more robust measure of impulsive traits. second, it is possible that there is significant within-person variation when it comes to changes in personality across the lifespan and in certain situations (fleeson, 2004); however, the current approach did not disaggregate between-person vs within-person change since two timepoints were used (curran et al., 2012). although we considered using three time points, the current study’s focus was on the early transition to adulthood; in addition, several variables changed or removed in the prior and subsequent wave of add health data (particularly cannabis use and simultaneous use). thus, future research should consider using random intercept cross-lagged panel modeling to evaluating how these variables vary withinand between-individuals into later timepoints of adulthood as well as their reciprocal relations. similarly, the current study was unable to capture dynamic changes (e.g., assessments 6 months to a year a part; e.g., wasserman et al., 2020) in personality during adolescence. third, the current study’s measures of cannabis use frequency were past-month whereas measures of alcohol frequency were past-year; however, we believe that estimating density/frequency of cannabis use, compared to other studies that test “any” cannabis use (e.g., haas et al., 2015; patrick et al., 2018; waddell et al., 2021a), was a strength despite non-ideal measurement. in addition, the item about simultaneous alcohol and cannabis use asked about the most recent time drugs were used with alcohol and could have been subject to measurement error. thus, future research with more comprehensive, matched measures of alcohol and cannabis use are needed. the current study also did not consider cannabis-only, as it was focused on alcohol and cannabis co-use; incorporating co-use vs. cannabis-only would require a separate set of analyses (with cannabis use being an inclusion criterion rather than alcohol use), which would have substantially limited the sample and required double the analyses. thus, future research on co-use vs. cannabis-only relations with personality is needed. finally, the current study did not incorporate nicotine or other drugs into analyses, and future research should consider how additional polysubstance use patterns may affect impulsive personality traits. despite these limitations, the current study provides important information for models of substance use and personality as well as personality change. findings evinced that all adolescent co-users had higher cross-sectional levels of adolescent sensation seeking and impulsivity compared to alcohol-only users that frequent adolescent co-users also had higher levels of adolescent sensation seeking and impulsivity compared to experimental co-users, potentially suggesting adolescent sensation seeking and impulsivity as a risk factor and intervention target for co-use. and. furthermore, adolescent co-users reported a steeper decline in impulsive traits from adolescence into emerging adulthood, and there was some evidence to suggest that frequent adolescent co-users decrease in sensation seeking from adolescence into emerging adulthood at higher rates compared to experimental adolescent co-users, pointing to a likely complex relationship between rates of adolescent co-use and personality changes between adolescence and emerging adulthood. overall, findings have implications for developmental models of personality change (e.g., caspi et al., 2005), suggesting that growth/increases in personality traits could be blunted if 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184-193. zuckerman, m. (2007). sensation seeking and risky behavior. american psychological association. funding and acknowledgements: this study was supported by grant f31-aa030167 (pi: jack t. waddell) from the national institute on alcohol abuse and alcoholism. the authors report no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ brief report 15 ved abstract abstract objective: individuals with anxiety frequently use cannabis to cope and are at greater risk for developing probable cannabis use disorder (cud). previous literature suggests avoidant coping styles are associated with higher anxiety levels and risk for problematic cannabis use, while action-oriented coping is associated with lower anxiety and problematic cannabis use. no studies have examined whether anxiety and actionoriented coping or avoidant coping interact to influence risk for cud, which was the aim of the present study. method: college students were recruited as part of a cross-sectional study on cannabis use. participants (n = 371; 72.2% female) completed the depression anxiety and stress subscale (dass-21), cannabis use disorder identification test-revised (cudit-r), and the brief-cope (b-cope). results: the data were analyzed using logistic moderation analysis. after controlling for gender, anxiety was a positive significant predictor of probable cud, but action-oriented coping and avoidant coping were not. the interaction between anxiety and avoidant coping on probable cud was significant, indicating that participants with high avoidant coping (regardless of high or low anxiety) and those with high anxiety (even with low avoidant coping) were more likely to have probable cud than those with both low anxiety and low avoidant coping. no significant interaction was observed with action-oriented coping. conclusions: results suggest that avoidant coping, but not action-oriented coping, influences the relationship between anxiety and risk for probable cud. findings emphasize the importance of targeting both anxiety and avoidant coping when considering risk for probable cud. key words: = cannabis use disorder; anxiety; avoidant coping; action-oriented coping; college students despite being illegal for recreational use in many states, cannabis is one of the most frequently used drugs in the united states (samhsa, 2019), and its prevalence has been especially increasing among college students (schulenberg et al., 2019). in addition, college students who endorse greater anxiety levels are more likely to use cannabis frequently (teeters et al., 2021), and adults with anxiety are also at greater risk for developing cannabis use disorder (cud; marel et al., 2019).the association between anxiety and cud could in part be linked to selfmedication, given evidence in the literature that individuals with anxiety are more likely to use cannabis to cope with anxiety symptoms (i.e., substance-related coping; crippa et al., 2009). emerging adults who use cannabis to cope with social anxiety are more likely to endorse problematic cannabis use, regardless of social anxiety levels (walukevich-dienst et al., 2022), indicating that coping with anxiety is likely to predict cannabis problems. coping motives for cannabis use have also been associated with more severe anxiety disorder symptoms among individuals who used cannabis within the past 30 days (bonn-miller et al., 2008). further, coping motives serve as a mediator of the positive relationship between mental health symptoms, such as anxiety and depression, and problematic cannabis use (metrik et al., 2016; scarfe et al., 2022), and are a significant predictor of cud (moitra et al., 2015). alexis blessing1, patricia d. russell2, madison s. stout1, juan barerra-barker1, sandra b. morissette1 1department of psychology, the university of texas at san antonio, san antonio, tx 2rocky mountain mirecc for suicide prevention, aurora, co cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000192 the influence of anxiety and avoidant coping on probable cannabis use disorder corresponding author: alexis blessing, ph.d., the university of texas at san antonio, one utsa circle. san antonio, texas, 78249. email: alexis.blessing@utsa.edu. cannabis, a publication of the research society on marijuana 16 although these data suggest that coping motives for anxiety may contribute to cud, more research on specific non-substance related coping strategies moderating the relationship between anxiety and cud is needed, particularly among college students. given these findings, and the strong relationship between anxiety and cannabis use, it is reasonable to question whether use of specific types of coping strategies interacts with anxiety to predict probable cud, particularly given that coping strategies are a modifiable treatment target for cannabis use reduction (litt et al., 2021). although coping can be defined in many ways, action-oriented coping and avoidant coping have been among the most well studied relevant to substance use literature (ahsan et al., 2021; buckner et al., 2014; grosso et al., 2014; mueller et al., 2021; litt et al., 2021; ribadier & varescon, 2019). action-oriented coping, also known as adaptive coping, is characterized by the features of active coping, such as using informational support and positive reframing. avoidant coping, also known as maladaptive coping, is characterized by physical or cognitive efforts to avoid confronting the stressor through such strategies as self-distraction and denial. although research on the role of action-oriented coping within the context of anxiety and cud is limited, adaptive coping strategies have been associated with improvement of symptoms in the treatment of cud (litt et al., 2021), and are negatively associated with anxiety levels (lopes & nihei, 2021). by contrast, high avoidant coping is frequently endorsed among individuals with cud (ahsan et al., 2021), and avoidant coping is positively associated with problematic cannabis use among individuals with social anxiety (mueller et al., 2021). avoidance also plays a role in the relationship between anxiety and coping motives for cannabis use (buckner et al., 2014), and predicts greater cannabis use problems. researchers suggest that people with anxiety may use cannabis to avoid unpleasant situations associated with anxiety (walukevich-dienst et al., 2019). importantly, much of the previous literature on the influence of avoidant coping on anxiety and cannabis has mostly focused on social anxiety, rather than anxiety symptoms more broadly (buckner et al., 2014; mueller et al., 2021; walukevich-dienst et al., 2022). further, no research has examined how avoidant coping and action-oriented coping might interact with general anxiety levels to predict probable cud among college students. turning to the alcohol literature, low action-oriented coping coupled with high avoidant coping among individuals with posttraumatic stress disorder (ptsd) predicted worse alcohol outcomes and greater likelihood of meeting criteria for alcohol use disorder (grosso et al., 2014). whether or not similar patterns would be observed with respect to action-oriented coping and avoidant coping in relation to probable cud warrants investigation. the aim of the present study was to investigate the influence of action-oriented coping and avoidant coping styles (assessed via the briefcope [b-cope]; carver, 1997) on the relationship between anxiety levels (assessed depression, anxiety and stress scale-21 [dass21] anxiety subscale; sinclair et al., 2012) and probable cud diagnosis (assessed by the cannabis use disorder identification test – revised [cudit-r]; adamson et al., 2010) in college students. it was hypothesized that high anxiety would be associated with greater risk for probable cud. furthermore, an interaction effect was predicted between anxiety and avoidant coping such that those with both high anxiety levels and high avoidant coping would be more likely to endorse probable cud compared to those with low avoidant coping and high anxiety levels. by contrast, individuals with high action-oriented coping were predicted to be less likely to have probable cud, even in the presence of high anxiety (i.e., protective effect). gender was included in current analyses as a covariate, as male college students are at greater risk for cud via engagement in problematic cannabis use, and greater levels of addiction and dependence (phillips et al., 2018; villanueva-blasco et al., 2022). methods participants & procedures participants were undergraduate college students (n = 1,100) enrolled at the university of texas at san antonio (utsa) who participated in a cross-sectional online survey examining the influence of cannabis use on academic functioning. students were recruited from one of three sources: introduction to psychology avoidant coping and cannabis use disorder 17 research subject pool, other psychology courses, or via advertisement flyers and student emails. students were compensated with either extra credit if recruited through organized courses or a $10 amazon gift card if recruited outside courses. eligibility criteria included students who were 18 years or older, currently enrolled at utsa, and agreed to grant access to academic transcripts (due to the focus of the parent study). for the current study, the sample was limited to participants who reported past 6-month cannabis use (n = 395). due to insufficient sample size to run comparisons based on gender, students who identified as non-binary were excluded from analyses (n = 5). after accounting for these criteria, there were an additional 15 participants who were excluded from analyses due to missing data, and 4 participants for not following survey instructions. the final sample included 371 college students. measures the cannabis use disorder identification test – revised (cudit-r; adamson et al., 2010) is an 8-item measure used to assess probable cud. items were rated using a 5-point likert scale ranging from 0 (never) to 4 (daily or almost daily). higher scores on this measure indicate greater cannabis symptom severity. relevant to the current study, a score of 10 or higher was used to determine probable cud (bonn-miller et al., 2016). while a lower cut-off score of 6 has been found to discern cud in college students (schultz et al., 2019), the cut-off score of 10 was utilized, given that it was derived from outpatient and community samples via diagnostic interview and self-report assessments of cud symptoms (bonnmiller et al., 2016), and the former was derived via self-report (schultz et al., 2019). for the current study, the cudit-r measure had acceptable internal consistency (α = .78). the depression anxiety and stress scales (dass-21; sinclair et al., 2012) is a 21-item selfreport instrument designed to measure depression, anxiety, and stress levels. relevant to this study, only the seven items from the anxiety subscale were used. items were rated using a 4point likert scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). scores on this scale range from 0 to 21, with higher scores indicating greater levels of anxiety. for the current study, this measure had good internal consistency (α = .85). the brief-cope (b-cope) is a 28-item questionnaire designed to measure adaptive and maladaptive methods of coping with stressful life events (carver, 1997). items were rated using a 4point likert scale ranging from 0 (i usually don’t do this at all) to 3 (i usually do this a lot). this questionnaire is comprised of 14 subscales to assess different forms of coping: denial, venting, behavioral disengagement, self-blame, active coping, planning, positive reframing, acceptance, religion, emotional support, instrumental support, self-distraction, substance use, and humor. higher scores on this measure indicated higher endorsement of a particular coping style. a confirmatory factor analysis was used to derive action-oriented coping and avoidant coping subscales using items from the b-cope (grosso et al., 2014). through this factor analysis, active coping (.84), planning (.81), positive reframing (.79), acceptance (.71), religion (.41), emotional support (.60), instrumental support (.57), and selfdistraction (.57) subscales comprised the actionoriented coping factor. for avoidant coping, denial (.74), venting (.60), behavioral disengagement (.83), and self-blame (.77) subscales were used. the humor subscale was excluded from this analysis, as it did not factor into either actionoriented coping or avoidant coping. the substance use subscale was excluded to examine nonsubstance use-related coping (i.e., coping related specifically to cannabis use) and to reduce conceptual overlap with cannabis use on the cudit-r. results sample characteristics this sample consisted of 371 students with a mean age of 20.30 years (sd = 4.38). most students identified as female for gender (n = 268; 72.2%) and hispanic for ethnicity (n = 244; 65.8%). in terms of race, 74.1% of participants were white (n = 275), 9.4% were black (n = 35), 5.4% were asian (n = 20), 2.7% were american indian/alaskan native (n = 10), 0.5% were native hawaiian/pacific islander (n = 2), and 7.8% identified as other (n = 29; self-reported responses included “belizean” [n = 1], “middle eastern” [n = 2], “mexican/latinx/hispanic” [n = 10], cannabis, a publication of the research society on marijuana 18 “mixed/biracial” [n = 5], and unsure [n = 1]). regarding their college classification, 47.7% were freshman (n = 177), 25.6% were sophomores (n = 95), 12.9% were juniors (n = 48), and 13.7% were seniors (n = 51). approximately 35.6% (n = 132) met criteria for probable cud. in addition, the average dass-21 anxiety subscale score was 10.09 (sd = 9.45), suggestive of moderate anxiety. table 1 displays correlations between predictor and outcome variables. table 1. bivariate correlations m sd 1 2 3 4 1. gender 2. anxiety levels 10.09 9.45 .19** 3. action-oriented coping 13.87 4.67 .00 .03 4. avoidant coping 3.66 2.58 .13* .63** .11* 5. probable cud diagnosis -.14* .09 .07 .08 note. gender coded as 1 = male; 2 = female. *p < .05, **p < .001 the data were analyzed through a logistic moderation analysis conducted in hayes process macro in ibm spss statistics (version 25). after controlling for gender, anxiety (b = .032, se = .016, p = .046) was a positive significant predictor of probable cud. in contrast, neither actionoriented coping (b = .030, se = .025, p = .221) nor avoidant coping (b = .048, se = .056, p = .392) were significant predictors of probable cud. the interaction between action-oriented coping and anxiety was not significant (b = .004, se = .003, p = .134). however, as seen in figure 1, the interaction between anxiety and avoidant coping on probable cud was significant (b = -.011, se = .005, p = .026). participants with high avoidant coping (regardless of whether anxiety was high or low; probability of cud diagnosis = .41 and .42, respectively) and those with high anxiety (even when avoidant coping was low; probability of cud diagnosis = .49) were more likely to have probable cud than those with both low anxiety and low avoidant coping (probability of cud diagnosis = .24). the final model had significantly better fit than the constant model, χ2(df = 6) = 20.93, p = .002 figure 1. interaction between anxiety levels and avoidant coping style on probable cud diagnosis note. plot depicting anxiety by avoidant coping style (avc) levels interaction predicting probable cud diagnosis among college students. 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 1 sd below dass-21 anxiety score mean 1 sd above dass-21 anxiety score mean pr ob ab ili ty o f p ro ba bl e cu d di ag no si s 1 sd above mean of avc 1 sd below mean of avc avoidant coping and cannabis use disorder 19 discussion the present study indicated that individuals with high avoidant coping, regardless of whether anxiety was high or low, were more likely to endorse probable cud. although initially these results imply that avoidant coping amplifies risk for probable cud, interestingly, it was also observed within the interaction that those with high anxiety, regardless of whether avoidant coping was high or low, had similarly high risk for probable cud. however, contrary to hypotheses, avoidant coping was not associated with a greater likelihood for probable cud diagnosis as there was with anxiety, as avoidant coping only predicted risk for probable cud among individuals with low anxiety. in the context of the current study model, anxiety had a conditional effect according to the level of avoidant coping, and vice versa (e.g., avoidant coping’s effect is conditional on the level of anxiety). in addition, there was not a synergistic effect between high avoidant coping and high anxiety to intensify risk for probable cud; rather the findings suggested that both avoidant coping and anxiety constructs are important, even in the absence of the other. importantly, both anxiety (buckner & carroll, 2010) and coping styles (litt et al., 2021) are malleable treatment targets for cud. specifically, cognitive behavioral therapy in combination with motivational enhancement therapy significantly reduced anxiety levels from preto post-treatment, which in turn resulted in greater reduction in cannabis use (buckner & carroll, 2010). with regards to coping styles, the individualized assessment and treatment program (iatp; litt et al., 2020) was created to specifically treat cud, and provides training in coping skills specific to the individual. notably, while increases in active coping styles were associated with reductions in cannabis use, changes in engagement in avoidant coping strategies were not assessed (litt et al., 2021). it is possible that increased training in active or action-oriented coping is associated with lower engagement in avoidant coping styles, thus resulting in lower cannabis use. given the results of the current study, future research should assess how avoidant coping interacts with anxiety to influence treatment outcomes. in contrast to hypotheses, action-oriented coping did not interact with anxiety in predicting the presence of a probable cud diagnosis, suggesting that there was not a protective effect of adaptive coping. although we anticipated a positive influence on action-oriented coping, these results were similar with findings observed in alcohol literature. specifically, grosso et al. (2014) found that action-oriented coping did not have a significant interaction with ptsd symptoms in influencing heavy drinking or alcohol-related problems. collectively, these findings suggest that it may be more useful for clinicians to target avoidant coping in the context of cannabis use and cud than action-oriented coping. strengths, limitations, and future directions key strengths of the study include the use of psychometrically established measures and a sample of college students with strong representation of hispanic ethnicity. however, there are several limitations to consider that influence interpretation of the results. first, the current study only included college students and was largely female, which limits generalizability. second, cud was not diagnosed, rather the cudit-r was used to ascertain probable cud due to its low burden and scalability within university settings. further, other co-occurring diagnoses were not assessed, and it was not known whether any students were seeking mental health treatment. lastly, the cross-sectional study design cannot speak to direction of the relationships among variables. longitudinal data are needed to examine how anxiety and avoidant coping contribute to the development of cud over time, including how changes in one variable influence changes in the other, and whether addressing these factors in the treatment of cud could be beneficial. overall, these findings emphasize the potential benefit of targeting both anxiety and avoidant coping among cannabis users when considering risk factors for probable cud. more research examining how these variables interact for individuals who receive treatment for clinically diagnosed cud is needed (roos et al., 2020). in addition, it may be beneficial to examine whether certain avoidant coping strategies have a stronger negative impact than others to devise more targeted interventions. cannabis, a publication of the research society on marijuana 20 references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2019). cannabis and anxiety: a biopsychosocial model. current addiction reports, 6; 456–465. https://doi.org/10.1007/s40429-019-00284-w funding and acknowledgements: this project was funded by the university of texas at san antonio (utsa), office of the vice president for research, economic development, and knowledge enterprise through the utsa internal research award (intra), awarded to sandra morissette, ph.d. the authors have no conflicts of interest to disclose. cannabis, a publication of the research society on marijuana 22 copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 93 ved abstract introduction: increasing reinforcement received from cannabis-free activities, relative to reinforcement from cannabis-related activities, is one way to reduce harmful cannabis use. thus, accurate measurement of cannabis reinforcement is important. using convergent mixed methods, we developed the adolescent reinforcement survey schedule-cannabis use version (arss-cuv). arss-cuv, adapted from the alcohol use version, measures cannabis reinforcement by asking individuals how frequently they engaged in, and how much they enjoyed, different activities when using and not using cannabis. method: young adults (n = 65; mage = 20.4 years [sd = 1.8]) completed measures of cannabis use, the arss-cuv, and provided feedback on included activities, via focus groups. following standards for educational and psychological testing framework, this study examined evidence of measurement validity based on item content. results: quantitative findings revealed that peer interactions were the most reinforcing activities, whereas activities related to family were least reinforcing. qualitative findings indicated some confusion with question wording. participants also indicated the importance of environmental context when using cannabis and noted who they use cannabis with may be more important than the activity they are doing. changes were made to survey flow and response choices after participant feedback. conclusions: arsscuv includes revisions in activities solicited and response format. the revised arss-cuv provides opportunities to advance measurement of an important construct (i.e., reinforcement) in the study of cannabis use. psychometric properties of the arss-cuv across different populations and contexts of use (e.g., polysubstance use) should be examined. key words: = marijuana; behavioral economics; college students; substance-free reinforcement; qualitative cannabis use is most prevalent among young adults between 18 and 25 years of age (34.5%) (substance abuse and mental health services administration, 2021). past year cannabis use is reported by 44% of college students, and by 43% of young adults who are not in college (schulenberg et al., 2021). heavy cannabis use is a critical public health concern as it is associated with numerous deleterious outcomes, including increased risk for cannabis use disorder (cud) (cerdá et al., 2020), negative effects on individuals’ cardiovascular health (cohen et al., 2019), and motor vehicle crashes (rogeberg & elvik, 2016). with the rapid increase in legalization of medical and recreational cannabis in concordance with shifting normative nioud m. gebru1, tyler g. james2, ricarda foxx3, michelle castro3, ali m. yurasek3 1center for alcohol and addiction studies, department of behavioral and social sciences, brown university school of public health, providence, ri, usa 2 department of family medicine & center for disability health and wellness, university of michigan medical school, ann arbor, mi, usa. 3 department of health education & behavior; center for behavioral economic health research; university of florida, gainesville, fl, usa cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000185 measuring cannabis reinforcement among young adults: a mixed methods examination corresponding author: nioud (neo) gebru, ph.d., brown university, 121 s. main st., box g-s121-3, providence, ri 02912 usa, phone: 401-863-1000, email: neo_gebru@brown.edu cannabis, a publication of the research society on marijuana 94 perceptions (wallace et al., 2020), there is a need to identify factors associated with, and intervene upon, harmful cannabis use among young adults. behavioral economic evidence suggests increasing reinforcement received from drug-free activities, relative to reinforcement from drug-related activities, is one way to reduce harmful cannabis use (leventhal et al., 2015). thus, accurately quantifying reinforcement gained from cannabis use is of critical importance, yet measurement of cannabis reinforcement remains understudied. behavioral economic theory posits that cannabis use is most likely to occur when it is readily available, inexpensive, and when there are few cannabis-free alternative reinforcers to compete with its use (higgins et al., 2004). cannabis use generally provides an immediate reinforcement (e.g., anxiety reduction, euphoria), whereas many cannabis-free activities (e.g., school or work attendance, chores) provide delayed reinforcement (e.g., graduation, promotion) (bickel et al., 2014). individuals who use cannabis heavily may under engage in activities with the potential to compete with cannabis use (such as exercising, studying, or working) as the benefits of these activities are often delayed. previously, the adolescent reinforcement survey schedule – substance use version (arsssuv) has been used to reliably capture reinforcement from substance-related activities (murphy et al., 2005). the arss-suv seeks to measure the two core components of reinforcement – strength of the reinforcer (i.e., magnitude) and rate of reinforcement (i.e., frequency) (acuff et al., 2019). specifically, the arss-suv asks participants to indicate the frequency with which they engage in a variety of different activities (e.g., go to parties with friends) with and without using alcohol or drugs and how much they enjoyed each activity with and without using alcohol or drugs. frequency and enjoyment ratings are multiplied to compute substancerelated and substance-free reinforcement, from which a reinforcement ratio can also be calculated (acuff et al., 2019). in addition to a total score of reinforcement, the arss-suv can also be broken down into sub-scales of activities, including peerrelated activities, dating, and chores. reinforcement ratios from arss-suv have been related to several substance use outcomes (acuff et al., 2019) including past year alcohol use and alcohol-related negative consequences (hallgren et al., 2016). the arss-suv allows for a broad assessment of activity engagement and enjoyment for nonspecified substance use (i.e., use of alcohol or drugs) to produce a substance-involved versus substance-free reinforcement ratio. therefore, it does not allow for the identification of substancespecific substance-involved and substance-free activities, making it difficult to isolate what activities (and in turn, reinforcement) are related to a specific drug (e.g., cannabis) use. hallgren and colleagues (2016) adapted the arss to assess alcohol-only reinforcement (arss-auv), which revealed a unique factor structure compared to the arss-suv. their study also found that the nature of the activity is less predictive of frequency of alcohol use than with whom the activity is performed (i.e., context), highlighting the importance of examining context and substance-specific reinforcement (hallgren et al., 2016). a cannabis adaptation of the arss-suv is also needed to improve cannabis intervention efforts. for instance, dennhart and colleagues (2015) tested a brief intervention to reduce substance use and found that reinforcement ratio at baseline was predictive of changes in cannabis use at 6-month follow-up. specifically, alcohol using college students who also used cannabis and had high reinforcement from substances were more likely to reduce their substance use and were more responsive to the intervention (dennhardt et al., 2015). however, because reinforcement was measured via the arss-suv, it is challenging to disaggregate whether reported substance-related reinforcement at baseline was from alcohol, cannabis, or use of some other substance. adapting the arss-suv to cannabis by only changing substances (i.e., replacing “alcohol and drugs” with “cannabis” only) without further refinement may not be sufficient. compared to measuring alcohol, many aspects of cannabis complicate measurement of cannabis-specific reinforcement, including lack of standards (e.g., hits, joints, grams). for instance, one study found that the marijuana purchase task, which had been adapted from the alcohol purchase task, had differential latent factor structure when compared, in part due to such measurement issues (aston et al., 2017). measurement and measuring cannabis reinforcement 95 validity issues are further complicated by several possible routes of administration (e.g., vaping, edibles, spotting) and the illicit nature of cannabis at the federal level in the u.s. thus, a cannabis-specific reinforcement measure designed with such considerations for the contextual factors associated with cannabis and its use is needed. reinforcement gained from cannabis use may also vary from reinforcement from using other substances, due to differences in cannabis use contexts. for example, cannabis use may involve different types of social networks, be more or less available and accessible, and be used in different locations (meldrum & leimberg, 2018; phillips et al., 2020). hence, activities that young adults particularly engage in and enjoy (i.e., find reinforcing) with and without using cannabis might not be fully captured by current versions of the arss, limiting measurement of, and our understanding and ability to intervene on, cannabis reinforcement. further, it is important to examine the factor structure of the arss subscales, to ensure that each subscale is capturing relevant activities. enhancing measurement of cannabis reinforcement can help in developing and implementing more tailored interventions aimed at reducing harmful cannabis use. thus, we sought to develop the arss-cannabis use version (arss-cuv) using a convergent mixed methods approach. this mixed methods study was based on the standards for educational and psychological testing, which provides a framework for collecting evidence of validity (american educational research association et al., 2014). this study was focused primarily on evidence of validity based on content, including the wording and response format of items. one primary concern when measuring reinforcing activities is ensuring the activities are relevant to the intended population. failing to capture relevant activities leads to a phenomenon known as “construct underrepresentation,” which is one of the biggest threats to validity (american educational research association et al., 2014, p. 12). therefore, the purpose of this study was to begin the process of testing and revising a preliminary arss-cuv to be cannabis-use specific by aligning arss-suv content to activities of interest to young adults who use cannabis. methods study design this study used a convergent mixed methods design, in which qualitative and quantitative data were collected to gain a broader understanding of a specific phenomenon (figure 1). consistent with guidance in mixed methods research studies (fetters, 2020; fetters & molina-azorin, 2017), we integrated data on multiple dimensions. first, with the intention to merge the two databases to capture the reinforcing activities of young adults who use cannabis, we used the preliminary arsscuv to guide interviews and match constructs asked in both data collection segments (moseholm & fetters, 2017). secondly, we used an identical sample where the participants were in both the quantitative and qualitative aims (fetters, 2020). recruitment and screening procedures participants were 65 young adults between ages of 18 and 26 years old who reported using cannabis at least 3 times in the past month. participants were recruited through printed flyers posted at public locations (e.g., restaurants, stores) near a large university in north central florida. interested participants contacted the research team via phone or email and were provided with an overview of study procedures and a link to the screening survey. the online screening survey included an informed consent form followed by questions to determine eligibility. eligible participants were then scheduled for a focus group session and were sent a link to an online survey to be completed before the focus group. this survey included the informed consent and collected data on drug use and related activities, including the preliminary arss-cuv. all participants completed the preliminary arsscuv before the focus group session. at the end of the focus group, participants were compensated with a $30 visatm card. all procedures were approved by the university’s institutional review board. cannabis, a publication of the research society on marijuana 96 figure 1. convergent mixed methods procedural diagram of the current study. quantitative measures screening survey. participants were presented with questions on age, gender, race, employment status, and income. participants were also asked to report how many days they had used cannabis in the past month. preliminary adult reinforcement survey schedule – cannabis use version (arss-cuv). a preliminary, modified version of a 26-item arsssuv (murphy et al., 2005) was used to determine past-month engagement and enjoyment from various cannabis-free and cannabis-related activities. modifications made to the arss-suv were minimal, primarily asking about participant engagement in activities with or without cannabis (instead of alcohol or drugs). activity frequency and enjoyment ratings were assessed using 5point likert scales ranging from 0-4. frequency ratings ranged from 0 (zero times per week) to 4 (more than once a day), and enjoyment ratings ranged from 0 (unpleasant or neutral) to 4 (extremely pleasant). a cross-product score, reflecting reinforcement derived from an activity with or without cannabis, is calculated by multiplying the frequency and enjoyment ratings for each activity (correia et al., 2003). the relative reinforcing value of cannabis use, or the reinforcement ratio (r-ratio) was then computed [(cannabis-related total)/(cannabis-free total + cannabis-related total)]. dsm-5 cannabis use disorder (cud) checklist. a categorical variable (i.e., none, mild, moderate, severe) was created indicating cud severity based on participant responses indicating experiencing any dsm-5 cud related symptoms in the past year (american psychiatric association, 2013). focus group procedures nine in person focus groups were conducted in a conference room located within a research space. there were 5-10 people per focus group (m = 7.2), and sessions lasted approximately 75 minutes. focus groups were moderated by the principal investigator and trained research assistants, and a trained note-taker was present during all sessions. data collection • survey of cannabis and other drug use, preliminary arsscannabis use version, and demographic measures. data collection • focus groups on preliminary arsscannabis use version revisions, and activities and social factors related cannabis use. data analysis • classical test theory statistics, including reinforcement ratio and cannabis-free crossproduct means and correlations. data analysis • conventional content analysis of reinforcing activities related to cannabis use and arss questionnaire format revisions. integrative data analysis • weaving. quantitative qualitative revised arsscannabis use version integration: • matching quantitative and qualitative data collection topics. • connecting samples across both quantitative and qualitative aims. integration: • merging quantitative and qualitative findings. • explaining quantitative results using qualitative findings. measuring cannabis reinforcement 97 at the start of the focus group, participants were instructed to refer to each other by the numbered name tags at their seats and that the session would be audio recorded. they were informed that the purpose of the focus group was to provide feedback about a questionnaire assessing cannabis use and activities young adults do while using cannabis. participants received a blank copy of the preliminary arss-cuv and the pleasant events schedule (pes; correia et al., 2002) which were used to stimulate discussion. in the first hour, participants were asked to look at the preliminary arss-cuv and circle activities people their age commonly engage in and cross out activities they thought people their age are less likely to engage in. they then provided feedback on how to adapt the measure to be more relevant to cannabis use. after a 5–10-minute break, the remaining 30 minutes were spent discussing how other drugs impact cannabis use, enjoyment of activities precannabis use versus post-cannabis use, and any other relevant activities that may not have come up in the discussion. data analysis following the convergent mixed methods design, data analysis was conducted prior to merging results to develop mixed methods metainferences. quantitative analysis. arss-cuv indices were scored using r statistical software (version 4.2.2; r core team 2022). cannabis-related and cannabis-free reinforcement was calculated by multiplying frequency and enjoyment for each activity, from which reinforcement ratios were calculated. data were cleaned in ibm spss statistics (version 25) and analyzed in sas version 9.4 (sas institute inc). descriptive statistics of the cannabis reinforcement ratio were examined. as a test of internal structure, we originally intended to conduct an exploratory factor analysis (efa) to determine if the factor structure of the preliminary measure was similar to that reported by murphy and colleagues (2005). however, due to the small sample size, the efa solution did not converge. eigenvalue analysis indicated a five-factor solution may be appropriate for the data. given the five factors sub-scales identified for the arss-suv (murphy et al., 2005), the factor structure for the preliminary arss-cuv was expected to be similar. thus, internal consistency reliability estimates and correlations between factors are reported. arss-cuv factor scores were calculated based on the average response scores for non-missing data (i.e., if a factor consisted of 3 items but only 2 were completed, the demonimator would be a 2; holmes et al., 1987). qualitative analysis. transcripts of focus group recordings were managed and analyzed using maxqda (verbi software, berlin, germany). analysis focused on the addition or revision of items for content representation on the arss-cuv, and format considerations of the measure. the first two focus group transcripts were free coded by the second and last author. coding decisions were discussed to develop new codes and resolve discrepancies through consensus (saldaña, 2015). then, the two coders separately coded the remaining seven focus group transcripts, before the coded transcripts were merged in maxqda. lastly, the second author audited the transcripts to ensure the code scheme was applied consistently. mixed methods. mixed methods data analysis was facilitated by assessing quantitative and qualitative results that were matched on constructs. instead of reporting results separately, we report findings from both data sources based on the similarity of constructs in an integration process known as weaving (fetters et al., 2013). results sample characteristics participants were on average 20.4 years old (sd = 1.77), with the vast majority (96.9%) being college students (table 1). approximately half were white (49.2%), and slightly over half were women (55.4%). participants used cannabis an average of 19.9 days per month. of the participants who met the symptom count criteria for dsm-5 cud diagnosis (83.1%), almost half were classified as mild cud. evidence of validity based on internal structure estimates of mean item responses, internal consistency reliability, and r-ratio correlations are provided in table 2. cannabis, a publication of the research society on marijuana 98 table 1. demographic characteristics. characteristic % (n) age in years, m (sd), range 20.40 (1.77) 18 – 26 race white 49.23% (32) hispanic or latino 21.54% (14) asian 16.92% (11) black or african american 1.54% (1) other 1.54% (1) biracial or multiracial 9.23% (6) gender woman 55.38% (36) man 43.08% (28) non-binary 1.54% (1) attend college yes 96.92% (63) no 3.08% (2) cannabis use days, past month, m (sd), range 19.94 (8.81) 3 – 31 cud diagnostic criteria, dsm-5 none (0 – 1 symptom) 16.92% (11) mild (2 – 3 symptoms) 38.46% (25) moderate (4 – 5 symptoms) 24.62% (16) severe (6+ symptoms) 20.00% (13) table 2. internal structure based on assumed factors of scores on the preliminary arss-cuv. factor reinforcement ratio score (sd) internal consistency (unstandardized ⍺) reinforcement ratio correlations cannabis -related cross product cannabisfree cross product dating activity peer interaction sibling & family interaction sexual activity chores dating activity 0.31 (0.20) [n=31] 0.86 0.92 peer interaction 0.37 (0.19) [n=53] 0.88 0.92 0.70*** [n=29] sibling & family interaction 0.16 (0.19) [n=51] 0.77 0.89 0.76*** [n=29] 0.63*** [n=50] sexual activity 0.28 (0.25) [n=59] 0.88 0.91 0.59** [n=30] 0.47** [n=53] 0.58*** [n=51] chores 0.29 (0.24) [n=56] 0.67 0.84 0.48** [n=29] 0.45** [n=53] 0.36** [n=50] 0.28* [n=56] total 0.31 (0.17) [n=28] 0.90 0.94 0.89*** [n=28] 0.89*** [n=28] 0.88*** [n=28] 0.63** [n=28] 0.68*** [n=28] note. reinforcement ratio correlations present p-values that are not corrected for multiple comparisons. interpret with caution. * p < .05, ** p < .01, *** p < .001. measuring cannabis reinforcement 99 unstandardized cronbach’s alpha for both the cannabis use and cannabis-free measures were high (⍺s = 0.90 and 0.94, respectively). mean rratio was highest for the peer interaction factor (r-ratio mean = 0.359), and lowest for sibling and family interaction (r-ratio mean = 0.141). internal consistency reliability was high for both the cannabis-related and cannabis-free cross products for all factors except for the cannabisrelated cross product for chores. r-ratio correlations were significant for all factors, and ranged in strength from weak to strong effect (pearson rs 0.297-0.897). evidence of validity based on content and response processes evidence of validity based on content and response processes were identified based on itemlevel statistics and focus group responses to prompts about the activities that were and were not included in the preliminary arss-cuv (which are the same activities from the arsssuv). this section first provides an overview of the activities included on the survey, and activities that the participants indicated were relevant to them, followed by information about the response formats of the survey. item content. descriptive, item-level statistics are shown in table 3. items (i.e., activities) with r-ratio approaching 1.0 are more reinforcing when using cannabis; items with higher cannabisfree reinforcement values indicate the activities were more reinforcing without cannabis. table 3. descriptive item-level statistics original arss-suv factor item reinforcement ratio cannabis-free reinforcement value n mean (sd) range n mean (sd) range dating_1 go places with dates or potential romantic partners 60 0.28 (0.29) 0 to 1 63 3.54 (4.24) 0 to 16 dating_2 talk with dates or potential romantic partners 58 0.29 (0.25) 0 to 1 62 6.68 (6.37) 0 to 16 dating_3 go out to eat with dates or potential romantic partners 39 0.28 (0.28) 0 to 1 62 3.24 (4.06) 0 to 16 dating_4 flirt with dates or potential romantic partners 58 0.35 (0.31) 0 to 1 62 5.42 (5.56) 0 to 16 dating_5 get compliments from dates or potential romantic partners 49 0.33 (0.24) 0 to 0.86 61 6.41 (5.78) 0 to 16 dating_6 go on dates 37 0.30 (0.31) 0 to 1 62 3.05 (3.73) 0 to 16 dating_7 kiss dates or potential romantic partners 47 0.34 (0.29) 0 to 1 63 5.34 (5.79) 0 to 16 leisure_1 exercise or participate in sports 58 0.16 (0.23) 0 to 0.80 62 6.53 (5.52) 0 to 16 peer_1 go out to eat with friends 59 0.44 (0.28) 0 to 1 63 6.25 (4.39) 0 to 16 peer_2 talk with same sex friends 58 0.44 (0.27) 0 to 1 62 11.31 (5.03) 0 to 16 peer_3 go places with friends 58 0.40 (0.24) 0 to 1 62 8.92 (5.42) 0 to 16 peer_4 go for a walk with friends 60 0.25 (0.31) 0 to 1 63 3.51 (4.48) 0 to 16 peer_5 talk on the phone with friends 60 0.29 (0.29) 0 to 1 63 5.68 (5.62) 0 to 16 peer_6 go to parties with friends 56 0.52 (0.36) 0 to 1 62 3.68 (4.46) 0 to 16 cannabis, a publication of the research society on marijuana 100 peer_7 talk with friends about day’s activities 58 0.36 (0.22) 0 to 1 62 10.21 (5.41) 0 to 16 peer_8 get compliments from friends 58 0.33 (0.24) 0 to 0.82 62 6.89 (5.38) 0 to 16 peer_9 meet new people my age 60 0.28 (0.27) 0 to 1 63 5.19 (4.87) 0 to 16 peer_10 go hang out where friends meet 55 0.31 (0.27) 0 to 1 62 5.89 (5.27) 0 to 16 peer_11 interact with people of own age and sex 58 0.36 (0.23) 0 to 1 61 9.80 (5.27) 0 to 16 peer_12 write email, text messages, or letters to friends 57 0.38 (0.23) 0 to 1 60 10.43 (5.03) 0 to 16 family_1 go places with siblings or family members 52 0.19 (0.29) 0 to 1 61 3.33 (4.23) 0 to 16 family_2 talk with siblings or family members 57 0.19 (0.24) 0 to 0.67 60 7.83 (5.18) 0 to 16 family_3 go out to eat with siblings or family members 59 0.12 (0.23) 0 to 1 62 3.57 (4.56) 0 to 16 family_4 tell secrets to siblings or family members 59 0.10 (0.25) 0 to 1 62 1.92 (3.77) 0 to 16 family_5 spend weekends or vacations with siblings/family 59 0.12 (0.24) 0 to 1 62 3.69 (4.65) 0 to 16 sex_1 caressing with a date/romantic partner 59 0.32 (0.29) 0 to 1 62 5.48 (5.23) 0 to 16 sex_2 oral sex with a date/romantic partner 59 0.28 (0.29) 0 to 1 62 4.07 (4.45) 0 to 16 sex_3 sexual intercourse with a date/romantic partner 59 0.29 (0.29) 0 to 1 62 4.69 (4.93) 0 to 16 sex_4 weekends/vacations with romantic partner 59 0.21 (0.32) 0 to 1 62 2.1 (3.57) 0 to 16 chores_1 going to school 56 0.17 (0.25) 0 to 1 60 7.28 (4.78) 0 to 16 chores_2 studying 56 0.22 (0.33) 0 to 1 60 5.28 (4.83) 0 to 16 chores_3 doing chores at home 58 0.47 (0.34) 0 to 1 61 4.48 (4.29) 0 to 16 note. items with reinforcement ratios closer to 1.000 indicate activities that were more reinforcing when using cannabis than when not using cannabis. dating. dating or activities with potential romantic partners were relatively less reinforcing when engaged in after cannabis use (r-ratio range: 0.208-0.351). the dating item with the highest cannabis-free reinforcement value was flirt with dates or potential romantic partners. focus groups indicated multiple opportunities to revise the content of items. first, participants indicated confusion on what ‘romantic partners’ meant. this difference in understanding the item wording reportedly influenced their item response, and how researchers may interpret the response data. “the other thing was that i put four [on the likert-type survey, which is the highest score for frequency and enjoyment of each activity] for everything where romantic partners were concerned, but i am in a relationship. i think that blurred the lines – it may if i’m in a relationship, but if i’m not, it seemed like i just go on a lot of dates and with different people…i don’t think that when under the influence of drugs, i would go on a date with a stranger.” (focus group [fg] 1; participant [p]3) in addition, some highlighted concerns with understanding the items. as some items related to measuring cannabis reinforcement 101 hanging out with friends indicate hanging out with same sex friends, it led to confusion with interpreting the flirting items. “yeah, it seems inherently heteronormative. what does that mean if i’m bi? then, it goes into all of the flirting questions. i’m like, ‘i don’t get it.’” (fg 6; p1) leisure. there was only one item related to leisure: exercising or participating in sports. this was associated with low cannabis reinforcement (r-ratio = 0.16). in focus groups, participants indicated that there should be a distinction between solo-exercising (e.g., weightlifting) and playing recreational sports which have a social component. participants encouraged a number of new activities to be added to the measure including: sleep, listening to music, watching tv, movies, or youtube, exercising, arts and crafts, shopping, playing video games, scrolling through social media, and relaxing through meditation or yoga. these activities were indicated as being differentially reinforcing depending on cannabis use. “a lotta stuff you do normally would just be heightened by smoking, listening to music, just eating anything, going out and shopping, getting groceries. [smoking cannabis] just makes it better.” (fg 6; p6) peer. items within the peer factor had the highest reinforcement ratios and cannabis-free reinforcement values on the scale. going to parties with friends had the highest cannabis reinforcement of all items (r-ratio=0.516). however, participants indicated confusion with this item, and that the item may not have been accurately measuring the intended construct. from focus group 6: “also, maybe going out is different than going to a party ‘cause you’re at a public bar versus a house or something. going out versus a party…” (p8) “there’s a difference between a house party and a bar scene.” (p3) from focus group 2: “honestly, partying, i stopped doing a lot. i know that’s maybe not directly the question you’re asking, but i definitely stopped partying a lot after i started smoking a lot.” (p2) “yeah, me too. i never really went to parties that much, and if i do now, they’re weed parties.” (p4) furthermore, participants indicated it was important to differentiate between scenes where drug use was more expected (e.g., concert) than going out to a nightclub, or if cannabis was being used with friends. highly reinforcing cannabis-free activities were related to communication with friends (cannabis-free reinforcement values > 10). however, participants indicated these items may be unnecessarily gender specific and outdated (e.g., writing letters). participants also wanted more clarity on the type of conversations that they were having. when high, ‘you can have really deep conversations’; participants distinguished this level of conversation from ‘chatting.’ participants indicated that items asking getting compliments from friends were irrelevant and should be removed from the survey. from focus group 4: “i don’t really understand ‘getting compliments’ [as an activity].” (p5) “it’s on there twice, too. get compliments from dates and get compliments from friends...” (p6) “that’s not an activity. i’m thinking of activities as something i go out of my way to do.” (p2) one item that was more controversial was walking with friends. some participants indicated that it was not a relevant activity for them to engage in; some participants, however, indicated that they routinely ‘explore all of campus high.’ this item had the lowest reinforcement ratio on the peer factor (r-ratio = 0.249). family. the items related to family had the lowest reinforcement ratios and cannabis-free reinforcement value ranges of the entire cannabis, a publication of the research society on marijuana 102 instrument. telling secrets to siblings or family members (r-ratio = 0.102) was perceived as an irrelevant activity by participants despite being sensitive to individual differences and contexts. “i also really liked the question about [telling] secrets because i feel like i can't tell my family stuff 'cause i know my sister will tell my mom right away. …. i really like that question 'cause it applies very differently to people.” (fg 2; p5) in general, however, participants felt that it was inappropriate to be using cannabis while around family (supporting the lower r-ratios). from focus group 8: “i feel like a lot of the family member [questions] may be a bit tricky ‘cause i’m not tryin’ to hang out with my mom while i’m blazed.” (p10) “i don’t wanna speak for everyone, but [smoking with family] is just not right. if you’re home with your family, then you walk out [to smoke] and come back in, unless it’s thanksgiving. that’s a different story.” (p9) sex. caressing romantic partners had the highest reinforcement ratio of the items related to sexual intimacy (r-ratio = 0.319); yet, this item was perceived to be ‘weird’ and redundant. “i’d also say joining caressing, oral sex and sexual intercourse [as a single activity] maybe. that’s physical touch with your romantic partner, unless there’s a reason to—why those need to be [asked separately]…” (fg 7; p8) in contrast, during focus groups, participants described a variety of sexually intimate behaviors they felt were applicable to the cannabisreinforcing activities including masturbation, sex with a partner who is also high, and sex with a partner who is not high. “personally, with my boyfriend, if he's high and i'm not, i don't enjoy it as much 'cause i feel like we're not in the same place, and then vice versa. also, if we're both high, it can be really, really enjoyable...” (fg 2; p2) chores. the chores domain had the second highest mean r-ratio score, which was driven by doing chores at home having the second highest item-level r-ratio of the entire questionnaire (rratio = 0.472). doing chores at home (e.g., laundry, cleaning dishes) was perceived as enjoyable when high. “yeah. i know there’s one question about doing chores at home. it’s definitely more enjoyable to do stuff like that when you’re high like cleaning. i feel like time is less important. it’s like, ‘oh, i have time to do things i need to do,’ so i’ll cook. i’ll do little stuff that i’ve been meaning to do.” (fg 3; p1) some participants, however, felt that the activities they were doing at home (e.g., organizing) would not be considered a chore. the items related to schoolwork and studying were perceived as relevant to participants, and may differentiate between participants’ usage patterns (e.g., some participants indicated they ‘definitely wouldn’t’ go to school or study high, while others go ‘to class high almost every single day’). similar to other activities, cannabis was a way to ‘enhance’ otherwise monotonous activities. participants also recommended adding working as an activity. other activities that were recommended in this domain were cooking and grocery shopping. item response format. focus groups provided several format considerations. there was substantial discussion regarding confusion given the format of the arss-suv and use of numerical values for ‘enjoyment’ and ‘frequency’ for activities when cannabis was and was not being used. “yeah, it was just a lot to think about, the difference and then how many times for each scenario if you were using [cannabis or not]. especially because it’s so repetitive, i was just like—i put this for this answer. i’m just gonna put the same [answer] cuz it’s the same question for me.”(fg3;p6) this is a major concern for reliability and validity of responses, as participants indicated that they ‘completely ignored the key’ for responses and used the actual frequency instead of the intended frequency measure. measuring cannabis reinforcement 103 this concern is also related to participant burden. in addition to the length of the survey, other considerations included the usability of the survey on mobile phones. lastly, participants were not sure what to include for ‘enjoyment’ when the ‘frequency’ was never (value of 0). this was particularly relevant for activities, such as vacations, which are infrequent. mixed methods findings we integrated findings from the quantitative and qualitative data sources to develop a revised version of the arss-cuv. the revised preliminary survey and scoring instructions is provided in supplemental file 1. discussion substance use is related to the availability and reinforcing aspect of substance-free and substance-involved activities (bickel et al., 2014). much of the evidence has utilized measures of reinforcement, such as the arss-suv which broadly assesses reinforcement from activities with and without using alcohol or drugs. this study was the first to attempt to adapt a reinforcement measure specifically for cannabis use by utilizing mixed-methods procedures to test a modified, cannabis version of the arss and collect formative data to guide measurement refinement. the preliminary arss-cuv had high internal consistency, and reinforcement ratios between each of the five factors were significantly correlated. the arss-cuv measures the relative reinforcing value of engaging in activities with cannabis compared to without cannabis. assessment of engagement in different activities via the arss-cuv allows for quantification of the relative enjoyment and frequency (i.e., magnitude and rate of reinforcement; r-ratio) of individuals’ behavioral allocation with and without cannabis. future studies will examine if cannabisreinforcement as measured by the revised arsscuv is associated to cannabis use and cud symptom severity. further, recent evidence indicates that behavioral economic interventions that promote cannabis-free activity engagement among adults with cud are promising in reducing cannabis use (coughlin et al., 2023). moreover, research shows that substance-free reinforcement moderates treatment response, such that those who reported low levels of substance-free reinforcement at baseline showed greater reductions in heavy drinking following brief intervention (murphy et al., 2012). future research may test whether cannabis-free reinforcement as measured by the arss-cuv is predictive of treatment response, and whether increasing cannabis-free reinforcement is a viable intervention target. the revised arss-cuv was tailored to a young adult population by ensuring that the survey items (i.e., activities) were relevant and salient. availability and access to potentially reinforcing activities is an important consideration when measuring reinforcement. future studies may need to test and adapt the arss-cuv if measuring cannabis reinforcement in samples that are considerably different (e.g., intreatment populations). further, given the length and structure of the arss-cuv, as highlighted by participants’ comments regarding its repetitive nature, future research should test and validate briefer versions to assess cannabis-related and cannabis-free reinforcement. the five-factor subscales of the arss-cuv was informed by the arss-suv (murphy et al., 2005). of the five subscales, the peer interaction factor had the highest reinforcement ratio, while the siblings and family factor had the lowest. overall, internal consistency was high for both cannabis-related and cannabis-free cross products across all factors (except for chores) and reinforcement ratio correlations were also significant for all factors. the findings related to internal structure, however, are secondary to the evidence related to the content of the measure. we identified specific activities young adults who use cannabis engage in and find reinforcing, which are discussed below. dating. within the dating subscale, activities involving romantic partners were less reinforcing when using cannabis. young adults may not be comfortable interacting with dates while under the influence of cannabis, which is consistent with their verbal responses, suggesting feelings of discomfort when using cannabis with individuals they do not know well. this may in part be due to confusion surrounding how “potential romantic partner” was defined. participants felt that their decision to use cannabis with romantic partners is dependent on length of time knowing the person cannabis, a publication of the research society on marijuana 104 (long-term relationship versus “hooking up”), which might influence reinforcement. hence, it may be important to assess and control for relationship status when measuring cannabis reinforcement in this population. leisure. participants strongly encouraged addition of leisure activities including playing video games, communicating via social media, arts and crafts, and separating exercise from sports, which were incorporated in the revised version. interestingly, many participants encouraged the addition of sleep as it was a commonly reported motive for using cannabis in this sample. yet, how to best assess cannabis-free vs. cannabis-involved reinforcement from sleep remains unclear. some participants recommended defining sleep as “downtime before bed” in which the frequency and enjoyment (perceived sleep quality) of using cannabis before bed would be assessed. the current arss-cuv does not include sleep, however, future research should examine how to properly define and assess sleep-related cannabis reinforcement. peer. reinforcement ratios and cannabis-free reinforcement values were highest among the peer factors. this is consistent with findings from the alcohol specific reinforcement literature which highlights that the social component of substance use may be more important from a reinforcement and risk aspect than the type or nature of the activity (hallgren et al., 2016). future studies could assess whether activities were conducted alone or with peers. type of peer-involved activity was also important from a reinforcement standpoint with parties providing more cannabisrelated reinforcement and communication with peers providing high levels of cannabis-free reinforcement. future research will examine relations between social groups and social network affiliations to better understand reinforcement from activities such as interacting with people of own age. the revised measure differentiates between house parties and going out to bars/clubs as this distinction may influence cannabis use and reinforcement. similarly, we eliminated the same-sex wording throughout. family. family related items had the lowest reinforcement ratios and cannabis-free reinforcement value ranges on the measure. most young adults were not comfortable using cannabis when with parents, whereas some were comfortable using around siblings or cousins. time spent with family, especially parents, may serve as a protective factor for risky cannabis use. this is consistent with evidence suggesting young adults adjust their substance use based on the environment, including parental influence (miller et al., 2016). future research could separately assess activity reinforcement with different types of family members (e.g., siblings; parents). further, because the sample was primarily college students, the frequency of engagement in family-related activities may be lower due to participants being away at school which may impact interpretation of reinforcement levels. hence clarifying or assessing opportunity to engage in family-related activities may be useful when assessing cannabis-free and involved reinforcement with this population. sex. although participants reported that sexual activity with cannabis was highly reinforcing during the qualitative focus group discussions, quantitavely, sexual activity had the second lowest raw reinforcement ratio score (only higher than sibling and family interactions). these contrasting findings may be explained in part by the phrasing of the question in survey which was perceived by particpants as ‘weird’ and redundant. based on participant recommendations, the sex-related questions were simplified and reduced to one question encompassing multiple sexual related behaviors for the main measure. sexual activities while under the influence of cannabis (i.e., high from cannabis use), and in situations where both the individual and the sexual partner are both “high” appear to be particularly enjoyable and may thus be differentially reinforcing. this increased reinforcement from “sex while high” may also increase odds of future cannabis use and higher consumption, which may increase odds of cud, and should be examined in future studies, using the sex-module to the arss-cuv. participants also acknowledged that sex is, in many ways, a unique activity compared to other activities included in the arss-cuv, suggesting it may warrant a separate, specific sex reinforcement module to be developed in the future. chores. the chores domain had the second highest mean reinforcement ratio score, indicating high levels of enjoyment when doing chores while using cannabis, especially homerelated chores. changes made to this section include adding examples of common chores measuring cannabis reinforcement 105 completed at home, adding a chore conducted outside of the home (e.g., grocery shopping), and adding cooking as its own question among other minor changes. academic-related activities like studying seemed to be a protective factor for some participants while others noted experiencing reinforcement from using cannabis when engaging in these activities. this is consistent with behavioral economic literature demonstrating that academic and career related next-day responsibilities (e.g., test) are related to reductions in substance use demand (ferguson et al., 2021; skidmore et al., 2011). those who verbally indicated enjoying using cannabis during academic activities may be less sensitive to environmental contingencies which places them at increased risk for cannabis related consequences. this study has limitations. the use of a small convenience sample in the quantitative aim led to the inability to explore the factor structure, even though the current sample (n = 65) is comparable to the arss-suv study (murphy et al., 2005; n = 54). however, in mixed methods studies, the alignment between samples across data sources (i.e., use of quantitative and qualitative data) is a relative strength, bolstering confidence in findings (perez et al., 2023). in addition, there were very few non-college students (n = 2); thus, generalizability to the broader young adult population may be limited. methods (e.g., use of self-report, focus groups) may introduce some bias (e.g., desirability) despite efforts to minimize their effects. conclusions this study is the first to adapt a reinforcement measure specifically for cannabis use using a mixed methods design. while our results provide some initial support for the validity of the arsscuv, there are several opportunities to improve the measurement of cannabis reinforcement. future research should test psychometric properties of this measure across different populations. references acuff, s. f., dennhardt, a. a., correia, c. j., & murphy, j. g. 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(2015). the coding manual for qualitative researchers. sage. schulenberg, j. e., patrick, m. e., johnston, l. d., o’malley, p. m., bachman, j. g., & miech, r. a. (2021). monitoring the future national survey results on drug use, 1975-2020. volume ii, college students & adults ages 1960. in institute for social research. institute for social research. https://eric.ed.gov/?id=ed615085 skidmore, j. r., & murphy, j. g. (2011). the effect of drink price and next-day responsibilities on college student drinking: a behavioral economic analysis. psychology of addictive behaviors : journal of the society of psychologists in addictive behaviors, 25(1), 57–68. https://doi.org/10.1037/a0021118 stoner, s. (2018). marijuana and sexual risk behavior among youth and emerging adults: what do we know? seattle: alcohol & drug abuse institute, university of washington. http://adai.uw.edu/pubs/pdf/2018marijuanar sb.pdf substance abuse and mental health services administration. (2021). key substance use and mental health indicators in the united states: results from the 2020 national survey on drug use and health. center for behavioral health statistics and quality, substance abuse and mental health services administration. https://www.samhsa.gov/data/ wallace, g. t., parnes, j. e., prince, m. a., conner, b. t., riggs, n. r., george, m. w., & shillington, a. m. (2020). associations between marijuana use patterns and recreational legislation changes in a large colorado college student sample. addiction research & theory, 28(3), 211–221. https://doi.org/10.1080/16066359.2019.162200 funding and acknowledgements: this research was supported by research funds from the department of health education and behavior at the university of florida. dr. gebru’s contribution to the manuscript was supported by niaaa t32 aa07459. dr. yurasek’s contribution to the manuscript was supported by national institute on drug abuse (nida) grant k23 da046565. all funding sources had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. all authors report no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v6i1a1_authors_final_p brief report 1 ved abstract wide variation exists in the possession limits of cannabis products sold for medical use in the u.s. as well as the tetrahydrocannabinol (thc) content of cannabis products. prior work has found that legal limits on recreational cannabis sold per transaction may promote moderate use and diversion. this paper finds similar results for monthly medical cannabis limits. in the present analyses, state limits on medical cannabis were aggregated and converted into 30-day limits and 5 milligram (mg) thc doses. grams of pure thc were calculated using plant weight limits and medical cannabis median thc potency aggregated from colorado and washington state medical cannabis retail sales data. weight in pure thc was then broken down into 5 mg doses. weight-based possession limits of cannabis for medical use varied widely across states (range: 1.5-762.05 grams pure thc per 30 days), with three states lacking a quantifiable weight limit (in which limits are not by weight but by physician’s recommendation). states generally do not impose limits on the potency of cannabis products, therefore small differences in weight limits can result in large differences in the amount of total thc allowed to be sold. assuming a typical medical dose of 5 mg and the median thc potency of 21%, current laws allow for sales of 300 (iowa) to 152,410 (maine) doses per month. current state statutes and methods of cannabis recommendation allow patients to increase therapeutic thc doses independently, and perhaps unknowingly. high thc content products combined with the higher purchase or possession limits allowed by medical cannabis laws may lead to an increased potential for overconsumption or diversion. key words: = cannabis; medical cannabis; cannabis policy there exists vast heterogeneity in state cannabis laws including qualifying medical conditions, approved cannabis products, and the allowance of home cultivation. as of june 3rd, 2022, 38 states and washington dc have legalized medical cannabis use, with all states except alabama having some form of medical thc-based treatment currently available (see supplemental table 1 for details and citations). within legalized states, patients purchasing cannabis for medical use must have a physician certify that they have a qualifying condition, pay a fee (which ranges from $1 to $300), and possess a license to purchase cannabis. cannabis purchase amounts are either capped by the state in the form of weight limits or by physicians in the form of “day” limits.1 a growing area of concern within medical cannabis policy is identifying dosage information. because cannabis is labeled as a schedule i drug at the federal level, physicians and nurse practitioners cannot prescribe medical cannabis and modern clinical studies of cannabis treatment are severely lacking, often leaving patients to determine their own doses (corroon et al., 2019; likhitsathian et al., 2021; morris, 2019; romerosandoval et al., 2018). while purchase caps, in theory, exist to prevent diversion to the illicit market (hall et al., 2019; pacula et al., 2021a), the present study sought to determine whether current state-established cannabis limits exceed recommended dosing for medical cannabis consumption. shelby r. steuart1 1department of public administration & policy, university of georgia cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.001 state variation in u.s. medical cannabis limits, restrictions, and therapeutic cannabis dosing corresponding author: shelby r. steuart, department of public administration & policy. university of georgia. e-mail: shelby.steuart@uga.edu 1 for example, a physician may recommend a “30-day limit” of one ounce, but the recommendation will vary by patient. state variation in u.s. medical cannabis limits 2 while numerous other cannabis compounds (such as cannabidiol (cbd) and cannabinol (cbn)) have shown therapeutic value, they are not the focus of this article because they do not possess psychoactive properties and are not scheduled at the federal level (u.s. department of justice, 2021). methods data on state medical cannabis limits were gathered from state legal statutes (see supplemental table 1). states were coded as currently having an operational medical cannabis program if they have open cannabis dispensaries that allow for the sale of cannabis products above 0.3% thc. state cannabis limits are described in terms of either a possession limit (the amount patients can legally possess on their person or at home), a purchase limit (the amount patients can legally purchase during a fixed period), or no limit. states were coded as having no limit if there is no explicit legal limit in the cited medical cannabis law, for the given consumption category in supplemental table 1. some states address this by allowing physicians to set the limits. states that have both plant weight limits and interdependent purchase limits often require dispensaries to calculate product equivalence so that purchases of all goods do not exceed the plant weight limit. thc product equivalencies are also included in table 1 and supplemental table 1. states where medical cannabis is currently illegal are omitted. often states have a whole plant weight limit in the text of their medical cannabis law and later issue subsequent administrative rules establishing thc product equivalency. in order to compare the whole plant limit to the product limit, it was necessary to use the whole plant weight limits to calculate the equivalent number of grams of pure thc. the median percent thc available for medical cannabis patients (21%) was calculated using a list of available strains of medical cannabis in colorado and washington state provided by cash et al (2020)2 and multiplied the number of grams of whole plant product permitted by the median percent thc to reach the equivalent number of pure thc grams. in the interest of improving the ease of comparison, weight limits were standardized to fit a 30-day period. this was done by multiplying the weight limit by the number that would make it equivalent to 30 days (for example, 10-day limits were multiplied by 3, 90-day limits were multiplied by 0.33). it is worth noting that the number of grams per ounce varies across states, with some states rounding “28.3495...” up to 28.5 or even 30. in the present analysis, an ounce was considered equivalent to 28.35 grams to be as accurate as possible. recent research suggests the standard dose of 5 milligram (mg) thc for researchers studying cannabis (filbey, 2020a; freeman & lorenzetti, 2020; hammond, 2020; volkow & weiss, 2020), regardless of route of administration. while some researchers recommend using 10 mg as the standard recreational dose due to state standards for edible product labeling (pacula et al., 2021b), numerous studies have shown 5 mg doses are recommended for medical administration, particularly in the treatment of pain where low doses are associated with decreasing perception of pain whereas higher doses are associated with higher perception of pain (filbey, 2020b; portenoy et al., 2012; wilsey et al., 2013). the number of pure thc grams derived from the monthly whole plant limit was multiplied by 1000 to convert to milligrams then divided by the dose in milligrams (pacula et al., 2021a), to calculate the number of doses in a monthly limit. three states pennsylvania, new york, and west virginia do not currently have weight-based possession or purchase limits because their limits are established for each patient by the recommending physician. these states were omitted from the analyses but their statutes and limitations are included in supplemental table 1. the weight limits in all states except oklahoma and north dakota are interdependent, meaning the entire purchase may not exceed the equivalence of the whole plant limit. if the state limit is interdependent, the higher of the two calculations (the equivalent grams of pure thc calculated using the flower weight limit or the state pure thc limit) is used. if the state limit is not interdependent, the equivalent grams of pure thc were calculated by adding together the equivalent pure thc grams of all applicable limits. 2 cash et al.’s s1 data supporting information xlsx file contains a dataset of available flower strains for medical cannabis patients in colorado and washington state, from dispensaries with established websites. while available strains may vary by state, it is likely many states have similar available strains, but this is included as a limitation. cannabis, a publication of the research society on marijuana 3 table 1. state medical cannabis limits expressed in grams pure thc, milligrams pure thc, and 5 milligram doses, over a 30-day period1 state 5 mg doses maximum thc per month (grams) monthly limit on whole plant, converted to thc (grams) monthly limit on thc in products (grams) al2 na na na na ak3 33,600 168 178.61 168 az 6,376 31.88 31.88 10.71 ar 2,976 14.88 14.88 na ca 9,526 47.63 47.63 na co 2,380 11.9 11.91 20 ct 4,168 20.84 20.84 1.75 de 34,020 170.1 35.72 170.1 dc 2,382 11.91 11.91 na fl 4,762 23.81 23.81 na hi 4,762 23.81 23.81 na ia4 300 1.5 na 1.5 il 6,376 31.88 31.88 2.68 la 6,376 31.88 31.88 na me 152,410 762.05 762.05 na md 7,200 36 25.18 36 ma 5,954 29.77 29.77 2.5 mi 11,908 59.54 59.54 na mn 6,376 31.88 31.88 na ms 4,120 20.6 20.60 2.8 mo 6,400 32 23.81 32 mt 5,954 29.77 29.77 4 nv 2,976 14.88 14.88 10 nh 7,144 35.72 35.72 42.6 nj 3,572 17.86 17.86 na nm 5,948 29.74 29.74 28.31 ny5 na na na na nd6 4,372 21.86 17.86 na oh 3,568 17.84 17.84 3.30 ok7 15,196 75.98 47.63 28.35 or 28,576 142.88 142.88 5 pa8 na na na na ri 2,976 14.88 14.88 1.25 sd 3,572 17.86 17.86 2.4 ut 4,738 23.69 23.69 20 vt 2,382 11.91 11.91 na va 4,762 23.81 23.81 na wa 4,200 21 17.8605 21 wv9 na na na na note. limits expressed in grams have been rounded to two decimal places, and 5 mg doses have been rounded to whole numbers when applicable for brevity. 1if the state has both a daily limit and a monthly or possession (at any given time) limit, the monthly/possession limit is reflected in the table. (table continues) state variation in u.s. medical cannabis limits 4 2not yet operational, see details in supplemental table 1. 3alaskan law stipulates that all flower and cannabis products may not exceed 5600 milligrams, this in effect caps the thc content of flower at 19.75%. this statutory limit is reflected in the calculated limits in this table. 4iowa state cannabis limit is in concentrate, purchase of flower is not allowed at this time. 5new york allows the purchase of flower and thc products but there is no statutory limit, limits are set by providers during initial consultation. 6north dakota’s limit is not interdependent; therefore, patients may possess the maximum amount of 100% thc in addition to the maximum amount of flower. 7oklahoma’s limit is not interdependent; therefore, patients may possess the maximum amount of 100% thc in addition to the maximum amount of flower. 8pennsylvania allows the purchase of flower and thc products but there is no statutory limit, limits are set by providers during initial consultation. 9west virginia allows the purchase of flower and thc products but there is no statutory limit, limits are set by providers during initial consultation. figure 1. the number of doses of medical cannabis per month allowed by each state’s medical cannabis limit. note. limits are calculated using the median thc percentage for the maximum thc allotted (whether flower or cannabis products) and a dose of 5mgs. maine has been excluded due to illegibility caused by the extremely high limit (equivalent to over 150,000 doses per month). states that have a physician-set limit are omitted from the figure since they do not have a statutory dose limit. ak ar az ca co ct dc de fl hi ia il la ma md mi mn mo ms mt nd nh nj nm nv oh ok or ri sd ut va vt wa st at e 0 10,000 20,000 30,000 40,000 5 mg doses per month cannabis, a publication of the research society on marijuana 5 results the median number of grams of thc per 30day period is 23.8 grams from whole plant cannabis and 10.4 from thc products. because of the influence of maine, which with a medical cannabis possession limit of 8 pounds (3628.8 grams) of plant material at any given time was a significant outlier (see table 1), the mean number of thc grams was 55.3 from whole plant cannabis and 27.9 from thc products. the number of 5 mg thc doses ranged from 300 in iowa to 152,410 in maine. the median number of 5 mg thc doses permitted per 30-day period was 4,763 doses and the mean number was 11,762 doses. over 75% of states currently permit fewer than 10,000 doses per 30-day period (see table 1 and figure 1). most state medical cannabis limits represent a combination of whole plant, thc products, and home cultivation. for several reasons, including the wide variation in the amount of cannabis that can be grown by home cultivators, this paper focused on purchasable cannabis only; home cultivation limits were not included in limit calculations. all states that currently have an operational medical cannabis program allow for some form of thc products and, except for iowa, allow patients to have access to whole plant cannabis. discussion our results present quantities of doses an order of magnitude greater than pacula et al (2021), who calculated the transaction limits of recreational cannabis. this is at least in part because recommended medical cannabis doses are lower than average recreational doses (5 mg as opposed to 10 mg) and limits are standardized to 30-day periods (not transactions). however, medical cannabis limits are higher than recreational cannabis limits for all states that have both medical and recreational cannabis access, except for michigan.3 this could be because the medical cannabis laws were written with the most severe patients in mind, because fewer people use medical cannabis than recreational, or potentially because medical users’ conditions require large amounts of cannabis to treat. additionally, while medical users have a lower recommended dose, they report using more cannabis and spending more money on cannabis than recreational users (pacula et al., 2016), perhaps because they consume more frequently and more regularly, and build up tolerance quicker than recreational users (haug et al., 2017; kim et al., 2019; salazar et al., 2019). regardless, the possession and purchase limits appear to be well above usage behavior in most states (grella et al., 2014; kepple & freisthler, 2018; kim et al., 2019). this begs the question, if registered medical cannabis users can purchase so much more than they require medically, could the limits be exploited to divert cannabis to the illicit market? or conversely, could such high limits encourage problematic overuse of cannabis? it is also worth noting the number of doses a patient can purchase varies based on the percent thc and the products they choose to purchase. while for most states purchasing cannabis flower at the median thc potency provides the patient with more total grams of thc than if the patient were to purchase other products, a few states either have product limits that provide the user with more thc than their flower limits using the median thc potency or have non-interdependent limits. this means the patient can purchase both the maximum amount of flower and the maximum amount of thc products per month. in the case, in our analyses, where state statutes or regulations included a pure thc limit, whichever product provided the highest number of doses of thc per month was used. limitations medical cannabis research is a field that is evolving rapidly but still has many gaps. while this paper attempts to fill some of those gaps, a few limitations must also be acknowledged. first, calculations on the median thc potency for flower products were determined from a database of available cannabis strains at dispensaries with established websites in colorado and washington state (cash et al., 2020) without knowledge of which strains are the most popular or how the potency varies across all medical cannabis states, over time. 3 from a comparison between pacula et al.’s recreational cannabis limits and supplemental table 1. state variation in u.s. medical cannabis limits 6 pacula et al. (2021) calculated the number of pure thc doses recreational users can purchase per transaction, but this study focuses on the number of pure thc doses medical cannabis users can purchase per 30-day period. the reasons for this are twofold: first, medical cannabis is recommended for long-term, chronic illnesses or symptoms (boehnke et al., 2019) and thus medical cannabis is used regularly (not “as needed”) and in consistent amounts (bonn-miller et al., 2014). therefore, it is reasonable to consider the amount these patients are able to access over a period of time rather than at a point of sale. second, because of their consistent use of cannabis, medical cannabis users can be assumed to have a regular purchasing pattern, the same way patients regularly pick up prescriptions. therefore, it makes more sense to think of a scenario where patients purchase the maximum amount of cannabis each time they visit a dispensary to evaluate how much unused cannabis could potentially be in their possession. this paper argues that high limits in medical cannabis states, especially where recreational cannabis is still illegal, could potentially lead to higher accidental diversion because high limits, regular purchase patterns, and regular cannabis use make it challenging for users to track the exact amount in their possession at a given time. however, the limitation in this approach is that information on how much medical cannabis users are using in each month is not available, therefore calculating an excess amount is not feasible. another limit in this approach is in the case of alaska, medical cannabis patients can purchase an ounce per day, but can only ever have an ounce in their possession. alaska is coded as a maximum of 30 ounces per month. while alaska’s code makes it consistent with the other states in the sample, it is very unlikely that patients are doing that in alaska. conclusions clinical research on appropriate medical cannabis dosing by condition is still developing; however, it is clear the current medical cannabis limits allow for very large cannabis purchases. since most states do not have thc potency limits or weight limits that take the thc potency into account, patients could increase the total number of doses they purchase by purchasing cannabis with very high potency. some states also allow for limits to be increased or waived based on patient cannabis need. in addition to providing the potential for overconsumption, high limits provide an opportunity for diversion to the illicit market. as research develops and physicians become more knowledgeable about cannabis, they could fill a role in helping patients determine ideal doses and thc potency for specific indications. this could also open the door to policymakers establishing weight limits that would be more aligned to the goal of providing relief to patients without the potential for overconsumption and diversion. references cash, m. c., cunnane, k., fan, c., & alfonso romero-sandoval, e. 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(2020). importance of a standard unit dose for cannabis research. addiction 115(7), 12191221. https://doi.org/10.1111/add.14984 wilsey, b., marcotte, t., deutsch, r., gouaux, b., sakai, s., & donaghe, h. (2013). low-dose vaporized cannabis significantly improves neuropathic pain. the journal of pain: official journal of the american pain society, 14(2), 136–148. funding and acknowledgements: the content of this study is solely the responsibility of the author and does not necessarily represent the official views of national institute on drug abuse (nida) state variation in u.s. medical cannabis limits 8 or nih. nida had no role in the study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. i gratefully acknowledge aaron ferguson’s contribution to an early version of this paper. this study was supported by award r01da047365-01 from nida. no financial disclosures were reported by the authors of this paper. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v6i1a3_authors_final_p_revapr5 research article 20 ved abstract introduction. as the covid-19 pandemic has caused historic morbidity and mortality and disrupted young people’s social relationships, little is known regarding change in young adults’ social cannabis use following social distancing orders, or other factors associated with such changes before and during the pandemic. methods. 108 young adult cannabis users in los angeles reported on their personal (egocentric) social network characteristics, cannabis use, and pandemic-related variables before (july 2019 – march 2020) and during the covid-19 pandemic (august 2020 – august 2021). multinomial logistic regression identified factors associated with increasing or maintaining the number of network members (alters) participants used cannabis with before and during the pandemic. multilevel modeling identified egoand alter-level factors associated with dyadic cannabis use between each ego and alter during the pandemic. results. most participants (61%) decreased the number of alters they used cannabis with, 14% maintained, and 25% increased. larger networks were associated with a lower risk of increasing (vs. decreasing); more supportive cannabis-using alters was associated with a lower risk of maintaining (vs. decreasing); relationship duration was associated with a greater risk of maintaining and increasing (vs. decreasing). during the covid-19 pandemic (august 2020 – august 2021), participants were more likely to use cannabis with alters they also used alcohol with and alters who were perceived to have more positive attitudes towards cannabis. conclusions. the present study identifies significant factors associated with changes in young adults’ social cannabis use following pandemic-related social distancing. these findings may inform social network interventions for young adults who use cannabis with their network members amid such social restrictions. key words: egocentric networks; social network analysis; social distancing; covid-19; young adults; cannabis the severe acute respiratory syndrome coronavirus (sars-cov-2) that causes the coronavirus disease 2019 (covid-19) is responsible for over 950,000 deaths in the united states to date (center for systems science and engineering, 2022). less known is the impact of social distancing and related mandates on individuals’ substance use behaviors at different points during the pandemic. this is especially true for young adults, some of whom continued socializing (e.g., attending parties or large gatherings) despite social distancing graham t. diguiseppi1, ekaterina v. fedorova2, bridgid conn3,4, stephen e. lankenau2, jordan p. davis1, janna ataiants2, carolyn f. wong3,4 1suzanne dworak-peck school of social work, university of southern california 2drexel university, dornsife school of public health, department of community health and prevention 3children’s hospital los angeles, division of adolescent and young adult medicine 4university of southern california, keck school of medicine, department of pediatrics cannabis 2023, volume 6 (1) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.01.003 understanding changes in social cannabis use among young adults during the covid-19 pandemic: a social network analysis corresponding author: graham t. diguiseppi, university of southern california suzanne dworak-peck school of social work, 669 w 34th st, los angeles, ca 90089. email: diguisep@usc.edu cannabis, a publication of the research society on marijuana 21 recommendations (park et al., 2020; suffoletto et al., 2020). throughout the pandemic, social alcohol use at bars and restaurants has been deemed a high-risk activity, as it may increase the risk of coronavirus transmission (fitzgerald et al., 2021). while the link between covid-related social stressors and increased cannabis use has been documented (bonar et al., 2021), social cannabis use before and during the pandemic has received less attention. research conducted prior to the pandemic supports that cannabis is often consumed by young adults amongst small groups of friends by sharing blunts, bongs, and other devices used to consume cannabis (dunlap et al., 2005; kelly, 2005). research with dutch young adults has found that solitary cannabis use most of the time was reported by 27% and 16% of users with and without cannabis dependence, respectively (van der pol et al., 2013). among young adult college student cannabis users, social cannabis use was reported almost twice as often (7 days per month) than solitary cannabis use (4 days per month) on average (buckner et al., 2016). given that the traditionally social nature of cannabis use— whether for recreational or medical purposes— may run counter to social distancing recommendations, particularly among young adults and, whose cannabis use during the pandemic appeared to have increased (boehnke et al., 2021; fedorova et al., 2021; graupensperger et al., 2021; schepis et al., 2021), additional research is needed to better understand how social isolation and restriction resulting from a pandemic could significantly alter social cannabis use for young adult users. the literature is presently unclear on the extent to which social distancing, a key measure to control the pandemic which has been found to increase one’s sense of social isolation and loneliness (czeisler et al., 2022; lee et al., 2020; weissbourd et al., 2021), has impacted the social use of cannabis among young adults. some evidence indicates that young adult cannabis users may have reduced their use with others (bonar et al., 2021). on the other hand, countervailing pressures may present barriers to adherence to social distancing and limiting using cannabis use with others. indeed, one study of canadian adolescents reported that almost a quarter (23.6%) were still practicing in-person cannabis use with friends in april 2020, directly after social distancing orders went into effect (dumas et al., 2020). given the continued protracted nature of the covid-19 pandemic and its deleterious impacts on young adult social interactions, a greater understanding of the individual and social network factors associated with continued social cannabis use during the pandemic is needed. while individual substance use behaviors have been associated with non-adherence to social distancing during the pandemic (fendrich et al., 2021; taylor et al., 2021), characteristics of one’s immediate social network members may offer important insights on understanding changes in the nature of social cannabis use among young adults. in social network terminology, egocentric social networks (or ego networks) are made up of network members (alters) who have direct ties to a focal individual (the ego) (perry et al., 2018). this allows egos to report on the characteristics of each alter and their relationship (e.g., used cannabis together). young adults with ego networks composed of a stronger core structure (borgatti & everett, 2000; wellman et al., 1997), characterized by greater level of trust in alters, may be more likely to maintain (rather than decrease) the number of alters they use cannabis with during the pandemic (völker, 2023). young adults may also be more likely to use cannabis with alters they consider to be close friends (mason et al., 2014) and alters they use other substances with, such as alcohol (meisel et al., 2021). propinquity, or close proximity to alters (cairns et al., 1995), may be a significant factor as well, possibly leading to a greater tendency for young adults to use cannabis with household members because of lower perceived risks and fewer opportunities to use substances with individuals outside of the household during a pandemic (jackson et al., 2021). finally, since social norms play a strong role in young adults’ cannabis use (arbour-nicitopoulos et al., 2011; neighbors et al., 2008) and intentions to practice social distancing (ang et al., 2021), young adults may be more likely to use cannabis with alters who they perceive to have more positive attitudes toward cannabis, and less likely to use cannabis with alters whom they perceive to have negative attitudes towards cannabis (labrie et al., 2011). the present study uses egocentric social network data to identify factors associated with changes in young adults’ social cannabis use during the covid-19 pandemic, a time of understanding changes in social cannabis use 22 increased stress and fluctuations in public health policies associated with prescribed social distancing that has been found to increase social isolation and loneliness (czeisler et al., 2022; lee et al., 2020; weissbourd et al., 2021). thus, we address three research questions: 1) to what extent did the number of alters young adults use cannabis with change from before to during the covid-19 pandemic? 2) what factors are associated with young adults’ tendency to increase or maintain the number of alters they use cannabis with from before to during the covid-19 pandemic? 3) what ego and alter-level characteristics are associated with using cannabis with a particular alter during the covid-19 pandemic? due to the novelty of this research topic, no a priori hypotheses are proposed. therefore, we use an inductive approach to select and determine which variables may be significantly associated with young adults’ cannabis use with their network members during the pandemic. methods participants were los-angeles-based young adult cannabis users participating in a longitudinal study about the impact california’s legalization of adult-use cannabis on cannabis use and health (lankenau et al., 2018). inclusion criteria were: either having a current valid doctor’s recommendation for medical cannabis issued in california or never having a recommendation for medical cannabis (40% of the sample were medical cannabis patients); using cannabis at least four times in the past 30 days; residing in the los angeles metro area; ability to read and speak english; 18 to 20 years old at the time of enrollment. additional participant characteristics are displayed in table 1. participants (n = 139) were enrolled via targeted and chain-referral sampling at medical and recreational cannabis dispensaries, college campuses, and craigslist, and completed a baseline survey between july 2019 and august 2020. follow-up surveys were completed one year later, from august 2020 through august 2021. participants were surveyed face-to-face in private (i.e., study office) and semi-private (e.g., coffeeshops, parks) locations up until the start of the covid-19 pandemic in march 2020, and via zoom or webex after march 2020 to reduce covid-19 transmission risks. to examine the potential impact of the covid-19 pandemic on young adults’ social cannabis use behaviors, 124 participants who completed their baseline survey prior to march 1, 2020 were selected for inclusion. of these, 16 participants with no follow-up data were excluded, resulting in an analytic sample of 108 participants with longitudinal data. a majority of participants (88%) completed their follow-up survey prior to april 15, 2021, before individuals aged 16 and older in los angeles were eligible to receive the covid-19 vaccine. data collection instruments and all study procedures were approved by the institutional review boards at children’s hospital los angeles and drexel university. measures demographics. participants self-reported their sex at birth, race/ethnicity, college student status, and relationship status (monogamous partner, open/non-monogamous partner, single). for regression analyses, relationship status was dummy coded with “single” as the reference group. egocentric network characteristics aggregate network variables (baseline). participants reported their egocentric network characteristics at each survey with the help of a trained interviewer. participants were asked to list up to 10 alters who a) provided social support, b) used cannabis with the ego, or c) served both roles in the past three months, and were then asked a series of questions about each alter (see diguiseppi et al. [in press] for more information). from this, total network size, number of alters who provide social support, number of alters who use cannabis with the ego, and number of alters who provide social support and use cannabis with the ego variables were calculated. egocentric network variables were also averaged across alters, generating unique values for each ego. these variables included frequency of communication with network (1 = “never communicate” to 6 = “communicate every day”), trust in network (1 = “don’t trust at all” to 10 = “trust with my life”), duration of relationship with network (1 = “known less than 1 year” to 8 = “known 31-35 years”), attitudes towards cannabis (range: 1 = “very negative” to 5 = “very positive”), and ego network density, a proportional measure of connectedness cannabis, a publication of the research society on marijuana 23 within a network, defined by the number of actual connections between alters divided by all possible connections between alters (perry et al., 2018, p. 175). alter-alter connections were determined from ego’s reports (1 = connection, 0 = no connection) after all alters were listed. alter-level variables (follow-up). a number of alter-level variables were calculated to describe characteristics of each alter and their relationship to the ego during the covid-19 pandemic at follow-up. these included relationship type (parent, other family member, boyfriend/girlfriend, friend, drug seller, casual acquaintance, other), gender (0 = male; 1 = female; due to low sample sizes, n = 7 alters identified as transgender were recoded as missing in regression models), and young adult age group (0 = 27 years or older; 1 = less than 27 years). in addition, duration of relationship, frequency of communication, and level of trust were examined at the alter-level, as well as cannabis, alcohol, and other drug use with each alter. variables measuring substance use with each alter were measured on a six-point scale (ranging from “never” to “everyday”), but were dichotomized such that 1 = monthly or more and 0 = less than monthly. this cutoff was chosen as a reasonable measure of high-risk substance use with each alter (given covid-19 risks) and because it corresponds with our dyadic cannabis use outcome in aim 3. alter attitudes towards cannabis, reported by the ego, were also examined. pandemic-related variables (follow-up). living situation during the pandemic was a multiplechoice item (i.e., lived with others related by marriage or birth, lived with partner, lived with roommates/friends) with categories dummy coded and “lived alone” used as the reference group in regression analyses. social distancing was assessed with the question, “to what extent did you practice social distancing (e.g., limiting inperson communication with family members/friends not living with you; limiting time outside; or limiting excursions except for essential activity, e.g., food, medicine)”. responses were on a five-point scale ranging from 1 = “no social distancing – behaved as usual” to 5 = “exclusive social distancing”. participants were also asked whether they experienced any of 14 mental health problems due to covid-19 (e.g., difficulty with sleep, anxiety, depressed mood or sadness, etc.; items developed by study authors). affirmative responses were summed to create a scale ranging from 0-14 which demonstrated good inter-item reliability (α = 0.88). ego’s cannabis use, cannabis patient status, and medicinal/recreational orientation (at baseline). medical cannabis patient was defined as having a current medical cannabis recommendation. past 90-day cannabis use was measured using number of cannabis use days (range: 0 to 90) and typical number of hits per day (“pull off of a pipe, joint, bong, etc.”) (range: 1 to “more than 100”). medicinal/recreational orientation towards cannabis was assessed by asking participants to classify their use as “medicinal” or “recreational” on a five-point scale ranging from 1 = “exclusively medical (no recreational use)” to 5 = “exclusively recreational (no medical use)”. dependent variables change in number of cannabis use alters (baseline and follow-up). for each alter, participants answered the question “does this person use cannabis with you?” (with six response options ranging from “never” to “everyday”). the number of alters egos used cannabis with “1 time a year or more”, “1 time a month or more”, “1 time a week or more”, and “everyday” were summed at the baseline and follow-up surveys. a threecategory variable was then created, first by calculating change scores, and then categorizing whether egos decreased (0), maintained (1), or increased (2) the number alters they used cannabis with from baseline to follow-up. dyadic cannabis use during the covid-19 pandemic (follow-up). a binary variable was created to indicate cannabis use with each alter (0 = ego did not use cannabis with the alter monthly or more; 1 = ego did use cannabis with the alter monthly or more often) at the follow-up survey. data analysis our first research question regarding the extent to which young adults changed the number of alters they used cannabis with from before to during the pandemic was addressed by presenting simple descriptive statistics. our second research question (what factors are associated with young adults’ tendency to increase or maintain the number of alters they used cannabis with, from before to during the covid-19 pandemic?) was understanding changes in social cannabis use 24 addressed using multinomial logistic regression. model results are expressed in terms of relative risk ratios (rrr), with egos who decreased the number of cannabis use alters as the reference group. model building was carried out in two steps. first, a series of bivariate multinomial logistic regression models were performed to model the association between each predictor and the outcome. as described above, we examined demographics, baseline cannabis use behaviors, baseline aggregate egocentric network characteristics, and pandemic related variables (e.g., social distancing, living situation) measured at follow-up as predictor variables. the outcome variable was change in the number of cannabis use alters from before to during the covid-19 pandemic. as a data reduction step, predictors that were significant at the bivariate level (p < 0.10) were included in a final multivariate model (hosmer & lemeshow, 2000). our third research question (what ego and alter-level characteristics are associated with using cannabis with a particular alter during the covid-19 pandemic?) was addressed with multilevel modeling (mlm). since alters are nested within egos, dyadic analysis using egocentric network data often violates the assumption of non-independence in ordinary least squares regression (perry et al., 2018). mlm is an appropriate analytical strategy to account for variance within and between each ego network by adding random or fixed effects for intercepts and slopes (raudenbush & bryk, 2002). dyadic cannabis use with a particular alter was modeled as a binary outcome using the melogit command in stata version 15.1 (statacorp, 2021). mlm model building was carried out in multiple steps outlined by perry, pescosolido and borgatti (2018). in step 1, we ran a null random intercept model with baseline intraclass correlations to determine if clustering is present. in step 2, conceptually important covariates were selected a priori (i.e., ego birth sex, recreational/medicinal orientation; and alter-level covariates) and added in a single step to the random intercept model. likelihood ratio tests were run to determine if adding covariates significantly improved model fit. in step 3, random coefficients were added for each significant covariate (p > 0.05) to determine if the relationship between the predictor and outcome varied significantly between egos. random coefficients were added one at a time, with likelihood ratio tests used to determine if they improved model fit until a final model was determined. results factors associated with change in the number of alters egos used cannabis with as shown in table 1, most participants (61.1%) decreased the number of alters they used cannabis with in the past year from before to during the covid-19 pandemic, while 13.9% maintained and 25.0% increased the number of cannabis use alters. it should also be noted that the overall number of alters decreased from 769 at baseline to 660 at follow-up, representing a decrease of about one alter named in each ego network, on average. this, as well as other descriptive social network characteristics, are displayed in table 2. in bivariate multinomial logistic regression models, recreational/medicinal cannabis use orientation, relationship status, ego network size, number of supportive cannabis-using alters, average length of time known alters, and living situation during the pandemic were associated with a maintaining or increasing (vs. decreasing) the number of alters egos used cannabis with (see supplemental table 1). demographics, ego’s pre-pandemic cannabis use, medical cannabis patient status, covid-19 related mental health problems, social distancing, and other aggregate network variables (i.e., frequency of communication, level of trust, network density, etc.) were not associated with changes in cannabis use with network members (p > 0.10), and therefore were not included in the multivariate model in the next step. in the final multivariate multinomial logistic regression model (table 3), number of supportive cannabis-using alters was associated with a lower risk of maintaining the number of alters ego use cannabis with (vs. decreasing; rrr = 0.55, 95% ci = [0.32, 0.93]), while total network size was associated with a lower risk of increasing the number of alters ego used cannabis with (vs. decreasing; rrr = 0.66, 95% ci = [0.47, 0.93]). cannabis, a publication of the research society on marijuana 25 table 1. participant (ego) characteristics (n = 108) variable n (%) m (sd) range demographics at baseline age (in years) 19.0 (0.8) 18 – 20 birth sex (male) 50 (46.7%) race/ethnicity non-hispanic black/african american 17 (15.9%) non-hispanic white/caucasian 27 (25.2%) non-hispanic multiracial 6 (5.6%) hispanic/latinx 46 (43.0%) non-hispanic asian 11 (10.3%) college student 79 (73.2%) relationship status monogamous partner 33 (30.6%) open/non-monogamous partner 11 (10.2%) single 63 (58.9%) pandemic related variables at follow-up living situation lived with others related by marriage/birth 76 (70.4%) lived with partner 18 (16.7%) lived with friends/roommates 24 (22.2%) lived alone 13 (12.0%) social distancing no social distancing behaved as usual 4 (3.7%) some social distancing but largely behaved as usual 8 (7.4%) social distancing in some situations and behaved as usual in other situations 18 (16.7%) social distancing in most situations 47 (43.5%) exclusive social distancing 31 (28.7%) num. of covid-19 mental health problems 5.5 (4.1) 0 – 14 cannabis use at baseline medical cannabis patient 43 (40.2%) medicinal/recreational orientation 3.6 (1.1) 1 5 number of cannabis use days (past 90) 61.6 (30.7) 2 90 typical number of cannabis hits per day 22.0 (30.6) 1 101 change in cannabis use alters (past year) decreased 66 (61.1%) maintained / stayed same 15 (13.9%) increased 27 (25.0%) note. living situation categories are not mutually exclusive understanding changes in social cannabis use 26 table 2. egocentric social network characteristics variable n (%) m (sd) range aggregate network variables at baseline (n = 108) number of alters (total n = 769): total 7.2 (2.7) 1 – 10 provide social support only 2.6 (1.9) 0 – 7 provide social support and use cannabis with ego 3.9 (2.2) 0 – 10 frequency of communication 5.2 (0.6) 1 – 6 level of trust 8.1 (1.4) 2.8 – 10 relationship duration 2.7 (0.8) 1.1 – 6.3 attitudes toward cannabis 4.1 (0.6) 2.6 – 5 ego network density 0.60 (0.34) 0.00 – 1.00 alter characteristics at follow-up (n = 660) alter gender male 336 (50.9%) female 316 (47.9%) transgender / non-binary / gender fluid 8 (1.2%) alter age <= 26 years 556 (84.2%) alter's attitude toward cannabis 4.0 (1.0) 1 – 5 dyadic characteristics at follow-up (n = 660) relationship type parent 51 (7.7%) other family member 84 (12.7%) boyfriend/girlfriend 49 (7.4%) friend 439 (66.5%) other relationship, drug seller, casual acquaintance 37 (5.6%) relationship duration 3.0 (1.4) 1 – 8 frequency of communication 1.9 (0.8) 1 – 5 level of trust 8.2 (2.1) 1 – 10 substance use with alter (monthly or more) used alcohol with alter? 266 (40.3%) used other drugs besides cannabis with alter? 105 (15.9%) used cannabis with alter? 349 (52.9%) cannabis, a publication of the research society on marijuana 27 table 3. multinomial logistic regression model of change in number of cannabis use alters from before to during covid-19 95% ci maintaining (vs. decreasing) rrr ll ul p pre-pandemic cannabis use recreational use (vs. medicinal use) 0.80 0.37 1.69 0.55 pre-pandemic ego network variables monogamous relationship status (single ref.) 4.68 0.85 25.92 0.08 "open" relationship status (single ref.) 0.39 0.02 7.14 0.53 total network size 0.83 0.57 1.22 0.35 num. supportive cannabis using alters 0.55 0.32 0.93 0.03 average time known alters 6.09 2.22 16.71 0.00 pandemic living situation (lived alone ref.) lived with family 4.39 0.34 56.92 0.26 lived with partner 4.40 0.33 58.26 0.26 live with friends/roommates 6.52 0.96 44.06 0.054 intercept 0.01 0.00 1.19 0.06 increasing (vs. decreasing) rrr ll ul p pre-pandemic cannabis use recreational use (vs. medicinal use) 1.84 1.00 3.36 0.048 pre-pandemic ego network variables monogamous relationship status (single ref.) 0.65 0.16 2.60 0.55 "open" relationship status (single ref.) 0.32 0.05 2.30 0.26 total network size 0.66 0.47 0.93 0.02 num. supportive cannabis using alters 1.03 0.69 1.53 0.90 average time known alters 4.87 2.03 11.67 <0.001 pandemic living situation (lived alone ref.) lived with family 0.24 0.06 1.03 0.06 lived with partner 0.75 0.11 4.93 0.76 live with friends/roommates 2.15 0.49 9.47 0.31 intercept 0.02 0.00 1.01 0.05 n = 104; likelihood ratio chi square = 59.4, df = 18, p < 0.001; psuedo r2 = 0.31 note. ci = confidence interval; rrr = relative risk ratio; ll = lower limit; ul = upper limit. significant associations are in bold. alternatively, average length of time known alters was associated with a higher risk of maintaining (vs. decreasing; rrr = 6.09, 95% ci = [2.22, 16.71]) and a higher risk of increasing (vs. decreasing; rrr = 4.87, 95% ci = [2.03, 11.67]). recreational use orientation (vs. medicinal use) was associated with a greater risk of increasing (vs. decreasing; rrr = 1.84, 95% ci = [1.00, 3.36]) as well. factors associated with dyadic cannabis use during covid-19 in step 1 of mlm building to predict dyadic cannabis use during the covid-19 pandemic, the null (intercept only) model estimated that egos had 12% higher odds of using cannabis with a particular alter than not using cannabis with a understanding changes in social cannabis use 28 particular alter (unadjusted or 1.12, 95% ci = [0.76, 1.67]). the null model produced an icc = 0.49, indicating 49% of the variance in using cannabis with particular alters was between egos. the likelihood ratio test was also significant (p < 0.001), indicating the need to use a random intercept to adjust for clustering within egos. in step 2 of model building, covariates were added to the random intercept model. egos had lower odds of using cannabis with female alters (compared to male alters). in addition, using alcohol and using drugs with a particular alter were strongly related to using cannabis with a particular alter. egos were also more likely to use cannabis with alters who were perceived to have more positive attitudes towards cannabis. in step 3 of model building, random coefficients for the significant covariates were added to determine if those improved model fit. separate models revealed that adding a random coefficient for alter gender (c2 [2] = 1.83, p = 0.40) and alter’s attitude toward cannabis (c2 [2] = 1.12, p = 0.57) did not result in better model fit. however, adding random coefficients for alcohol use with an alter (c2 [2] = 8.18, p = 0.02) and other drug use with an alter (c2 [2] = 9.59, p = 0.01) did result in improved model fit. confidence intervals for the dyadic drug use with an alter estimate were unacceptably wide, however (or = 26.05, 95% ci = [1.36, 499.45]). therefore, this variable was removed from the final model. in the final mlm model displayed in table 4, alcohol use with a particular alter (or = 24.64, 95% ci = [8.11, 74.89]) and alter’s positive attitudes towards cannabis (reported by ego; or = 9.30, 95% ci = [5.16, 16.78]) were significantly associated with greater odds of using cannabis with a particular alter during covid-19. discussion the present study used egocentric network analysis to describe important changes in young adults’ social cannabis use from before to during the earlier part of the covid-19 pandemic that prescribed social distancing and restrictions which are particularly challenging for young adults. although over half of young adults decreased the number of alters they used cannabis with, a quarter of the sample increased, and 14 percent maintained the number of cannabis use alters from before to during the pandemic. even as this is consistent with other recent studies reporting decreased in-person socialization during the pandemic among young adult cannabis users (bonar et al., 2021; fedorova et al., 2021), the proportion of young adults who reported increasing or maintaining the number of alters they used cannabis with is greater than in a recent report among canadian adolescents (dumas et al., 2020). this suggests a general tendency among young adults to decrease inperson social cannabis use, but also highlights that a significant proportion of may have continued to engage in social cannabis use with their personal network members during the pandemic. recent studies have reported that increases in cannabis use among young adults during the pandemic have been accompanied by greater feelings of loneliness, mental health problems, and loss of employment (bonar et al., 2021; fedorova et al., 2021; pocuca et al., 2022). although our study did not investigate changes in the amount or frequency of young adults’ cannabis consumption during the pandemic, our results do not support that covid-19 related mental health problems—or pre-pandemic cannabis consumption—are related to changes in the number of ego network members young adults’ used cannabis with. however, our results indicate that a greater orientation towards recreational use (vs. medicinal use) was associated with a greater risk of increasing (vs. decreasing) the number of people young adults’ used with. this is consistent with typical conceptualizations of recreational users as social cannabis users (fedorova et al., 2019; lankenau et al., 2018), but also may be indicative of greater precautions taken by medicinally oriented users, who may have perceived greater risks associated with covid-19 due to their medical conditions. our results also showed that the length of time young adults reported knowing their ego network members (on average) appeared to have the strongest associations with increasing or maintaining (relative to decreasing) the number of network members egos used cannabis with. this makes sense, as the duration of one’s relationships to their close network members may indicate a stronger core network structure, which may be associated with greater social pressures to use cannabis together (urberg et al., 2003). cannabis, a publication of the research society on marijuana 29 table 4. multilevel logistic regression model of dyadic cannabis use during covid-19 95% ci or ll ul p ego-level covariates female 0.44 0.15 1.29 0.13 recreational use (vs. medicinal use) 0.70 0.43 1.14 0.15 alter-level covariates female 0.53 0.27 1.04 0.07 young adult (older adult ref.) 2.93 0.74 11.64 0.13 parent (friend ref.) 2.21 0.31 15.54 0.43 other family member (friend ref.) 2.74 0.74 10.22 0.13 romantic partner (friend ref.) 0.81 0.26 2.54 0.72 other relationship (friend ref.) 0.64 0.11 3.94 0.63 time known 0.89 0.62 1.27 0.53 level of trust 1.04 0.85 1.27 0.71 alcohol use with alter 24.64 8.11 74.89 < 0.001 alter pos. attitude toward cannabis 9.30 5.16 16.78 < 0.001 intercept 0.001 < 0.001 0.04 < 0.001 variance (alcohol use with alter) 6.78 2.18 21.05 n/a variance (intercept) 6.48 3.21 13.08 n/a covariance (alcohol use with alter, intercept) -4.82 -9.65 -0.001 0.05 negos = 102 nalters = 596, m = 5.8 (minimum = 2, maximum = 10) wald c2 = 73.05, p = < 0.001 note. or = odds ratio; ci = confidence interval; ll = lower limit; ul = upper limit. significant associations are in bold. research with cannabis-using young adults shows that their positive attitudes toward cannabis generally match the attitudes of their close friends (labrie et al., 2011). since relationship duration is a measure of the strength of one’s relationships, young adults who knew their network members longer, on average, seemed to have been more likely to maintain or increase their cannabis use with these network members overall. in fact, recent research suggests that young adults may have been more likely to maintain their relationships with core network members (compared with more peripheral network members) in various ways during the pandemic (völker, 2023). on the other hand, a number of variables were associated with lower risk of increasing or maintaining the number of cannabis use alters during the pandemic. put another way, these variables were associated with a decrease in the number of alters young adults’ used cannabis with during the pandemic. such characteristics included having a greater number of supportive cannabis-using alters in one’s ego network and a larger ego network size prior to the pandemic. our results suggest that those with larger prepandemic ego networks may have been more likely to decrease the number of people they used cannabis with out of shared concern for each other’s health, as larger networks may indicate greater risk for covid-19. in addition to these aggregate network variables predicting change in the number alters egos used cannabis with before and during the pandemic, the present study identified significant correlates of cannabis use with a particular alter during the pandemic. using alcohol with a particular alter and perceiving that the alter had understanding changes in social cannabis use 30 a more positive attitude towards cannabis emerged as significant. while it is not clear whether cannabis and alcohol were used on the same occasion (meisel et al., 2021), this finding suggests that young adult dyads may be more likely to engage in cannabis and alcohol co-use during the pandemic than cannabis use alone. however, our model also suggests that significant variation in the tendency to engage in polysubstance use with one’s alters exists between young adults. results also highlight the importance of perceived norms within dyads. given broader societal norms of disapproving of in-person cannabis use during the pandemic (dumas et al., 2020), young adults may have only used cannabis with alters whom they perceived may be more approving of this practice. interestingly, relationship type (friend, family member, etc.), relationship duration, and other characteristics were not significantly associated with dyadic cannabis use during the pandemic. it appeared that young adults were more likely to use cannabis with female alters, but this relationship became non-significant in the final model. limitations results from this study should be considered in light of several limitations. despite the unique opportunity to collect egocentric social network data before and during the covid-19 pandemic, the present analyses are limited by the small sample size, possibly leading to type ii error and limiting our ability to detect significant associations between variables. the small sample size also limited the number of covariates we could select as predictors in multivariate models. in addition, the present study cannot account for the evolving social dynamics that have occurred throughout the pandemic, including changes to social distancing policies and widespread vaccine availability in april 2021 in los angeles county that may have affected participants’ behaviors. still, given that the covid-19 pandemic is an ongoing, chronic stressor, research that includes an ongoing assessment of young adults’ engagement with their network members is of value. finally, there were limitations on the number of alters egos could nominate (a maximum of 10), which could have excluded some important network members from our analysis. furthermore, we were not able to determine whether there was turnover in young adults’ ego networks, as our survey did not identify individual alters and whether they were lost, retained, added from the baseline to follow-up survey. conclusions the present study reflects a unique opportunity to observe changes in young adults’ social cannabis use with their egocentric network members before and during the covid-19 pandemic. these findings highlight that while a majority of young adults in los angeles county decreased their cannabis use with their close network members, a large minority may have continued to use cannabis socially with their ego network. young adults’ tendency to expand or contract their cannabis use network during a time of great uncertainty and mandate for social restrictions appears to be related to the strength of their core network (relationship duration), or possibly due to risk-mitigation (larger prepandemic network). during the pandemic, polysubstance use (i.e., alcohol and cannabis) and perceived positive attitudes toward cannabis appear to be catalysts for cannabis use among dyads. these factors should be considered when developing future risk-mitigation strategies when social distancing is warranted, or in other situations that may increase social isolation or abrupt changes to young adults’ social networks. for example, these results may be generalizable to young adults leaving home to attend college, military service, or who are socially isolated due to a medical condition. more research is needed to determine how these types of situations may differentially impact young adults’ decisions to use cannabis with their network members. in a pandemic context, decisions to use cannabis with close network members should be made by individuals in light of evidence-based public health recommendations, while also considering young adults’ need for socialization during a time of significant social distancing. references ang, t., wei, s., 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(1997). a decade of network change: turnover, persistence and stability in personal communities. social networks, 19(1), 27–50. https://doi.org/10.1016/s03788733(96)00289-4 funding and acknowledgements: this work was supported by national institute of drug abuse grants da034067 and f31da053779-01. the funding source did not have any role in the study design, collection, data analysis, or writing the report or submitting the article for publication. gd developed research questions, performed data analysis, and drafted the manuscript. ef developed research questions, assisted with data analysis and interpretation, and editing of the manuscript. bc developed research questions and contributed to the first draft of the manuscript. se developed research questions, reviewed and edited the manuscript. jd assisted with data analysis, interpretation, and edited the manuscript. ja reviewed and edited the manuscript. cw developed research questions, contributed to data analysis decisions, and reviewed and edited the manuscript. all authors approved of the final draft of the manuscript. we would like to thank and acknowledge ellen iverson, chaka dodson, ali johnson, alexander kecojevic, salini mohanty, avat kiomarsi, miles mcneely, megan reed, meghan treese, maral shahinian, meagan suen, mavis yeh, marina mill, ana francisco, and alisha osornio for their contribution to the data collection and various aspects of this study. we would also like to acknowledge the input provided by the project’s community advisory board. finally, we want to express our appreciation for the participants of this study who shared with us their life experiences and for their continued participation. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. microsoft word 2019 rsmj abstracts for publication_final.docx special section conference abstracts 64 special section editor benjamin o. ladd, ph.d. keynote address cognitive behavioural interventions for cannabis use disorder: timing, technologies, and the potential for adjunctive cannabinoid replacement? jan copeland university of new south wales contact: jan copeland profj@ciscopeland.com keynote address communicating about cannabis: safe, high risk, therapeutic, cannabinoids, evidence alan budney dartmouth college contact: alan budney alan.j.budney@dartmouth.edu poster presentations all poster presentations and symposia were peerreviewed by the 2019 conference program committee of the research society on marijuana (rsmj) (co-chairs: bradley t. conner, colorado state university, benjamin o. ladd, washington state university vancouver, kristina t. phillips, university of northern colorado). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. the alcohol policy information system (apis) as a tool for studying effects of cannabis policy elyse r. grossman & gregory bloss the cdm group, inc. & national institute on alcohol abuse and alcoholism as of january 1, 2018, eight states and the district of columbia (henceforth "states") had legalized recreational cannabis use for adults to varying degrees. although these states often get studied together, there are differences in their policy provisions, their processes for legalization, and their regulatory structures for the cannabis industry. these differences may lead to differences in health-related behaviors and outcomes related to cannabis. to better understand the effects of legalization and its variations, the national institute on alcohol abuse and alcoholism (niaaa) recently expanded the alcohol policy information system (apis) to include recreational cannabis laws for all states. this poster provides: 1) an overview of the cannabis laws and regulations covered by apis; 2) descriptions of analyses that can be performed and research questions that can be addressed using apis data; and 3) an example cannabis 2020, 3 (1), 64-138 © author(s) 2019 researchmj.org open access abstracts from the 2019 scientific meeting of the research society on marijuana july 26th-28th, 2019 vancouver, washington conference abstracts 65 analysis using apis data of the effects of policies toward home delivery of cannabis products on use of cannabis by youth. the apis database provides in-depth comparisons of state and federal laws on selected alcoholand cannabis-related topics with exact effective dates and supplemental information useful to researchers interested in alcohol and cannabis policy. data on recreational cannabis policies cover laws and regulations effective on or after january 1, 2012, encompassing 21 specific variables in four policy topic areas: 1) cannabis product control; 2) taxation, fees, and pricing; 3) advertising, marketing, and mass media; and 4) transportation, crime, and public safety. apis facilitates valid cross-sectional and longitudinal comparisons of state alcohol and recreational cannabis policies, providing researchers with the basis for a wide range of analyses of policy effects and effectiveness. researchers can conduct before-and-after studies of the impact of a specific law in one or more states; difference-in-difference analyses comparing the impact of a specific law enacted in some states to other states where the law was not enacted; or cross-sectional analyses comparing cannabis laws across all states or comparing policies addressing recreational cannabis to those pertaining to alcohol. this poster outlines the broad range of research opportunities available using apis data. to illustrate the kinds of research that apis data on recreational cannabis can support, we present a sample analysis exploring policy effects on youth cannabis use. apis documents whether states that have legalized recreational cannabis also permit or prohibit the delivery, after sale, of recreational cannabis products to customers who are not physically present at a retail outlet. like home delivery of alcohol, home delivery of cannabis may increase availability to youth by increasing opportunities to evade minimum age purchase requirements. we use data from the youth risk behavioral surveillance system (yrbss) in conjunction with policy information from apis to analyze the effects of home delivery policies on cannabis use by high school students. this poster will summarize the design, methods, and findings from that analysis to illustrate how apis can support studies of the effects of changing cannabis policies on behaviors and outcomes of public health importance. contact: elyse grossman elyse.grossman@cdmgroup.com factors related to increasing marijuana use in the us between 2008-2009 and 2016-2017 susan a. stoner university of washington marijuana use is on the rise in the us, but not uniformly so. to examine factors related to increasing marijuana use over the past decade, we examined state-level data from the national survey of drug use and health (nsduh) from the 2008-2009 and 2016-2017 biennia. derived from annual nsduh data, estimates of the percentage of the us population self-reporting any recent marijuana use were published by the substance abuse and mental health survey administration, stratified by biennium, state, age group (12-17, 18-25, or ≥26 years), and time frame (past 30 days, past year). additionally, we stratified the data according to state marijuana legalization status as of 2016 (legal medical and nonmedical use, legal medical use, legal noneuphoriant use, or no legal use). multivariate analysis of variance was conducted with the states and the district of columbia as subjects (n=51), legalization status and region as between-subjects factors, and time frame, age group, and biennium as within-subjects factors. a full factorial model was examined and estimated marginal means were examined. results indicated main effects for all factors except region. as hypothesized, all else being equal, the proportion of the population reporting recent marijuana use increased significantly from the 2008-2009 biennium (13.4%) to the 2016-2017 biennium (16.3%). also consistent with hypotheses, across biennia, rates of marijuana use were highest among those aged 18-25 years (26.2%) and in states with legal medical and nonmedical use (19.5%) and lowest among those aged ≥26 years (8.3%) and in states with no medical use (11.9% and 12.7%). these main effects were qualified by several twoand three-way and a four-way interaction between biennium age group, legalization status, and region. notably, no significant increases were observed among those aged 12-17, regardless of state legalization status. among 18-25 year-olds and those 26 and older, increases in marijuana use in states with legal nonmedical use outpaced conference abstracts 66 those in states without such use. this poster will fully present these interactions as well as differential individual-level data from the nsduh between the two biennia. contact: susan stoner sastoner@uw.edu age-related differences in cannabis product preference luna f. ueno, maha mian, brianna altman, eric giandelone, mike luce, mitch earleywine university at albany, suny & high yield insights examining age-related differences among cannabis users and their product choices could help target prevention and treatment efforts in specific populations. in the present study, we examined use and purchase habits of current cannabis users (n=1500; 70.3% female) residing in metro areas where recreational marijuana has been legalized. analyses showed significant differences in product preference depending on participants' age, which was split into 6 groups (18-24, 25-34, 35-44, 45-54, 55-65, 65+). all groups reported loose flower as their most commonly used product, with 62.7% of participants endorsing use, followed by edibles (55.6%) and pre-rolled joints (41.7%). the 18-24 age group was more likely to use prerolled joints (χ2 (5, n = 1500) = 89.6, p < .001), edibles (χ2 = 26.08, df = 5, p < .001), dry vaporizers (χ2 = 40.64, df = 5, p < .001), oil/wax vaporizers (x2 = 43.85, df = 5, p < .001), and dabbing (χ2 = 87.15, df = 5, p < .001); while the 25-24 age group had the highest use of loose flower (χ2=20.25, df = 5, p <.01). a majority of participants (over 50%) at every age group, with the exception of 65+ yearolds, used loose flower. both 25-34-year-olds and 18-24-year-olds were over twice as likely to use loose flower products than the 65+ age group (ors: 2.28, p < .001 and 2.01, p < .01, respectively). the 65+ year-olds also reported higher rates of use of loose flower than any other product (48.4%), despite having the lowest use rate of all age groups. a majority of participants in every age group also consumed edibles, except for those 55-65 and 65+, with the 18-24 age group 2.6 (p < .001) times more likely to currently use edibles than the 65+ group. younger participants were also more likely to use pre-rolls than the oldest participants, with the 18-24, 25-34, and 3544 age groups (ors: 5.98, 4.7, and 3.45, p < .001) showing the greatest difference. dabbing, or the flash vaporization of marijuana concentrates (i.e. wax, shatter, etc.), was unique in that this kind of use was more common (between 25-29%) among the youngest age groups (18-24, 25-34, and 35-44year-olds), but occurred in less than 10% of the older age groups (45-54, 55-65, and 65+). the youngest (18-24) age group was almost 17 times more likely to endorse dabbing than the oldest group (or:16.94, p < .001), while the 25-34 and 35-44 groups were almost 14 times more likely to do so (ors: 13.87 and 13.88, p < .001). tinctures (χ2 = 4.52, df = 5, p = .477), cannabis-infused topicals (χ2 = 7.42, df = 5, p = .191), and ingestible oils (χ2 = .95, df = 5, p = .967) did not vary with age, perhaps because they had the lowest overall rates. taken together, these findings suggest that younger and older cannabis users use different types of cannabis products. intervention efforts for higher risk populations might benefit from targeting the products most likely to be used among those groups. contact: luna ueno lueno@albany.edu cross-cultural examination of college marijuana culture in five countries melissa sotelo, matthew r. pearson, adrian j. bravo, angelina pilatti, laura mezquita, hendrik g. roozen university of new mexico, national university of cordova, argentina, & universitat jaume i de castellón, spain marijuana internalized norms have been found to be a more robust predictor of alcohol use/ outcomes in college students than either marijuana descriptive norms or marijuana injunctive norms. the perceived importance of marijuana to the college experience scale (pimces) has similarly found that marijuana internalized norms are a more robust predictor of marijuana related use/ outcomes among college students. these marijuana normative perceptions have not yet been assessed in countries outside of the us, which may vary based on marijuana legalization status and cultural differences. in the conference abstracts 67 present study, we sought to examine whether the pimces could be used to accurately assess marijuana internalized norms cross-culturally, across sex, and users/non-users looking at 5 different countries. we wanted to determine the degree to which college students perceive marijuana to be an important part of the college experience across these same variables. lastly, we wanted to examine the construct validity of the pimces to determine the degree to which the associations between marijuana internalized norms and marijuana-related outcomes are similar/different. we assessed (n=3,424; 68.0% female) college students from 8 different universities across 5 different countries (us, uruguay, argentina, spain, and netherlands). we found strong measurement invariance for the pimces across countries, across males and females, and across marijuana users and nonusers. compared to college students from all other countries, college students in the u.s. reported the highest levels of marijuana internalized norms. males and marijuana users showed significantly higher scores on the pimces than females and non-users, respectively. bivariate correlations between pimces scores and other marijuana-related variables were similar across males and females, though differences across countries warrant further exploration. contact: melissa sotelo sotelomelis@gmail.com marijuana use patterns among young adults devon alisa abdallah, christine m. lee, rose lyles-riebl university of washington purpose: marijuana use has been slowly, but steadily increasing, among young adults (mtf, 2018); with daily or near daily use, at an all-time high with 13.2% of young adults using regularly and perceptions of risk from regular marijuana use decreasing. while most epidemiological studies focus on prevalence of use, little is known about patterns or frequency of use within a day or week. increased knowledge of young adults’ frequency of marijuana use, including the days per week and number of times per day, and when they use (e.g., morning, afternoon, evening) will help guide intervention efforts. the present study assessed the current patterns of marijuana use (e.g., time(s) of day, day(s) of the week) of a sample of young adults who reported marijuana use in the past week. method: participants included a subsample of young adult drinkers and marijuana users (n=308; 48.4% female, mage=21.61, sd=2.14) who were part of a larger longitudinal daily study on health behaviors. participants reported drinking at least three times in the past month, simultaneous alcohol and marijuana use at least once in the past month, and marijuana use at least once in the past week. data for present analyses come from the baseline survey where participants were asked to think about their marijuana use each day in the past week and indicate for each day the time(s) of day they used marijuana. each day, participants endorsed three-hour time blocks (e.g., 6pm to 9pm, 9pm to midnight) for use. for the purposes of this analysis, the number of endorsed days was summed (0 to 7) and the number of time blocks on any given day was summed (0 to 8). results: frequencies were performed to determine the least and most popular days and time frames of marijuana use. marijuana use varied across the past week with monday the least popular day to use (59%) and friday the most with over 80% of the participants using marijuana. over 80% of participants used marijuana between 9pm and midnight on any given day with the second most popular time frame 6pm to 9pm. nearly 65% of participants used marijuana on fridays and saturdays between 6pm to 9pm. on average, participants used marijuana 4.76 (sd=2.27) days in the past week and 3.33 (sd=1.78) time blocks per day with 42.5% of participants using marijuana every day in the past week, 86% in more than one time block on any one day, and 41.2% using marijuana more than once every day in the past week. conclusions: with the increase of daily, or near daily, marijuana use improved understanding of marijuana use among young adults is beneficial for interventions and public health messaging. knowledge of marijuana use patterns, including day(s) of the week, time(s) of day, and frequency of use, can help discern if certain use patterns are more indicative of use disorders, health issues, and/or associated with negative consequences. with this in mind, future research should examine young adults’ marijuana conference abstracts 68 use patterns and potential associated consequences and health issues. contact: devon alisa abdallah abdallah@uw.edu an alternative option: cannabis substitution decreases other drug use following recreational legalization maha n. mian, brianna r. altman, luna ueno, eric giandelone, mike luce, mitch earleywine university at albany, suny & high yield insights previous research demonstrates that many medical cannabis users substitute cannabis for other drugs, emphasizing perceptions of the plant’s improved efficacy and side effect profile. in the present study, we examined cross-sectional, retrospective data from the spring 2018 high yields insight survey to determine if changes in cannabis legalization across states produced reported decreases in other drug use (n=1500, 70.33% female, mean age=35-44). specifically, we examined consumption differences in spirits, wine, beer, diet medication, over-the-counter (otc) sleep medication, otc pain medication, prescription sleep medication, prescription pain medication, prescription depression medication, and prescription anxiety medication. additionally, all changes in use were totaled for a single use index variable. our findings revealed that decreases in other drug use were associated with frequency of cannabis use (spearman’s rho=.119, p<.05), and positively covaried with support for legalization (spearman’s rho=.250, p<.01). a series of t-tests from 0, with an applied bonferroni correction, demonstrated use significantly decreased for each drug (t values ranged from -9.5 to -23.18, p<.001). effect sizes were moderate to large, ranging from -.31 to -.71. finally, decreases in the index of all other drug use were independent of gender, education, race, cannabis use, medical/recreational user status, and legalization attitudes (f(27, 273)=1.008, p>.05). taken together, these results suggest that cannabis legalization potentially decreases selfreported retrospective use of other drugs for a diverse range of users. these results justify continued research on cannabis substitution, including randomized controlled trials, given its potential to decrease consumption of more harmful and addictive drugs. contact: maha mian mmian@albany.edu marijuana and alcohol use patterns across education levels rose lyles-riebli, devon a. abdallah, anne m. fairlie, jennifer c. duckworth, christine m. lee university of washington marijuana and alcohol are the two most commonly used substances among young adults (18-25 years old) and are associated with acute negative consequences and risk for longer-term developmental and health effects (nida, 2018). with the majority of research and intervention efforts focusing on 4-year college students, much less is known about young adults who are (a) attending 2-year colleges, (b) not currently in school and have not earned a 2or 4-year degree, and (c) not currently in school but have earned a postsecondary degree. notably, 2017 monitoring the future data showed nearly three times as many non-students reported using marijuana on a daily basis than those attending a 2or 4-year college. the present study examines differences in weekly marijuana and alcohol use among young adults across different levels of education. participants included a subsample (n=720) from a larger study on health behaviors, aged 18 to 24 (mage=20.54, sd=1.690, 54.9% female). participants reported drinking at least once in the past year and were categorized into one of four education categories: 4-year students (n=354), 2year students (n=167), non-students without a 2 or 4-year degree (n=73), and non-students with a postsecondary degree (n=126). participants completed measures assessing typical weekly marijuana and alcohol use in the past month. analysis of covariance (ancova) was conducted separately for typical weekly marijuana and alcohol use, controlling for age and biological sex. over 77% of the sample reported lifetime use of marijuana. of the four groups, non-degreed nonstudents were at greatest risk of marijuana use. specifically, non-degreed non-students used marijuana more days in a typical week (m=2.90) and were high more hours in a typical week (m=17.68) than both 4-year students (m=1.41; conference abstracts 69 m=4.59) and degreed non-students (m=1.30; m=5.78); 2-year students were high more hours (m=10.33) than 4-year students. in addition, nondegreed non-students were high more hours per week (m=17.68) than 2-year students (m=10.33). non-degreed non-students reported being high for significantly more hours than all other groups every day of the week except for thursdays and fridays when they were high longer than 4-year and degreed non-students but not 2-year students. similarly, 2-year students reported being high significantly more hours than 4-year students every day of the week. for alcohol use, findings indicated 4-year students reported drinking significantly more drinks per week (m=7.27) than 2-year students (m=3.74). nondegreed non-students (m=1.93) and 4-year students (m=1.91) drank significantly more days per week than 2-year students (m=1.41). on thursdays, fridays, and saturdays, 4-year students reported consuming significantly more drinks than 2-year students and, on fridays, more than non-degreed non-students. however, nondegreed non-students drank more than 4-year students and degreed non-students on sundays. 2-year students and non-students, in particular non-students without a 2or 4-year degree, appear to be at high risk for marijuana use compared to 4-year students; though different patterns are found for alcohol. due to different substance use patterns, young adults across different education levels may warrant different interventions with specific efforts made to reach 2-year students and those not attending college. contact: rose lyles-riebli analyles@uw.edu marijuana content on twitter and marijuana use among teens yoonsang kim, hy tran, & sherry emery norc at the university of chicago background: digital media have become an important channel for marijuana marketing and consumer engagement. marijuana dispensaries and retail outlets advertise a broad range of products and devices on social media, employing marketing strategies that attract youth such as recruiting celebrity enthusiasts and musicians for product promotion. also regular people express behavioral intentions, opinions, and beliefs about marijuana on social media. many such messages portray positive sentiment and normalization of marijuana use, and youth culture with memes and cartoon images. while marijuana-related posts certainly reflect marketing and community norms, to date, there is scant evidence about whether the marijuana-related digital media environment is associated with marijuana use, especially among young people. we analyzed the association between marijuana-related posts on twitter and marijuana use among youth. method: marijuana-related tweets were geolocated at the state-level and linked with state-level prevalence of youth marijuana use. we obtained the statelevel prevalence of past 30-day marijuana use among 12-17 year olds, which were estimated using individual-level data from the 2015-2017 national survey on drug use and health (nsduh). tweets were collected using search queries that included language related to marijuana use, blunt smoking, and associated marketing accounts from gnip’s historical powertrack. about 35% of retrieved and relevant tweets were geolocated to u.s. states based on tagged locations and location information extracted from user profiles. sentiment of tweets was assessed using vader, giving a score between -1 (highly negative) and 1 (highly positive) for each tweets, and averaged within states. result: average sentiment scores of marijuana tweets ranged from -0.06 to 0.04 across states and were positively correlated with statelevel prevalence of youth marijuana use (r=0.61, p<.0001). average sentiment scores of bluntrelated tweets ranged from -0.025 to 0.075, indicating more positive sentiment toward blunt than marijuana, and were also positively correlated with prevalence of youth marijuana use (r=0.54, p<.0001). conclusion: the sentiment of marijuana-related posts at state level is significantly associated with marijuana use among teens. our findings suggest that the marijuana-related social media environment may reflect and/or influence youth marijuana use at community level. social media data may be used to supplement survey data or to understand marijuana use behavior measured by survey. our study is the first step to understand marijuanarelated communication environment and its influence on youth marijuana use. future research is needed to examine the relationship at conference abstracts 70 granular level, such as individual and smaller geographic units. contact: sherry emery emery-sherry@norc.org marijuana content on digital media and marijuana use among us young people yoonsang kim, sherry emery, jidong huang norc at the university of chicago & georgia state university background: digital media have become an important channel for marijuana marketing and consumer engagement. marijuana dispensaries advertise a broad range of products and devices on social media, employing marketing strategies that attract young people such as recruiting celebrity and musicians for product promotion. also regular people search for marijuana-related information online and express behavioral intentions, opinions, and beliefs about marijuana on social media. many such messages portray positive sentiment and normalization of marijuana use. the aggregation of these marijuana-related searches and posts reflect both community norms and marketing activities. however, to date, there is scant evidence about the relationship between marijuana-related digital media environment and actual marijuana use, especially among young people. we explored whether marijuana-related search volume on google trends and posts on twitter are associated with self-reported marijuana use and exposure to marijuana-related information online. method: a us representative sample of youth and young adults (13-24 years, n=3,884) were interviewed in march-april 2018. their responses were linked with google trends data for “marijuana” search and “cannabis” search for one year prior to the survey (mar 2017 -feb 2018) based on designated market area (dma) they resided in. marijuana-related tweets posted in jan -dec 2017 were collected using search queries that included language related to marijuana and associated marketing accounts. tweets were geolocated to dmas based on tagged locations and information extracted from user profiles. sentiment of tweets were assessed using the vader sentiment model giving a score between -100 (highly negative) and 100 (highly positive) for each tweets, averaged within dmas, and linked with survey data. result: youth and young adults living in the dmas with the highest quartile (top 25%) of “marijuana” or “cannabis” search volume and sentiment score of marijuanarelated tweets were more likely to have seen marijuana-related ads, pictures, or videos online or on social media than those living in other dmas (bottom 75%); 26.7% vs. 17.8% for marijuana search volume, 21.2% vs. 19.4% for marijuanarelated tweet sentiment. based on multivariate analyses, the odds of current marijuana use was 35% greater (or 1.35, ci 1.13 -1.62) as the search volume increases by one standard deviation (about 13.8 percentage points), controlling for age, sex, race/ethnicity, and household income. the “cannabis” search volume on google trends showed similar association with current marijuana use too. in addition, the odds of current marijuana use was 33% greater (or 1.33, ci 1.12 -1.57) as tweet sentiment score increases by one standard deviation (= 5.4), controlling for the same demographic characteristics. conclusion: marijuana-related information-searching and posting are associated with self-reported exposure to marijuana-related content online as well as offline marijuana use. our findings suggest that the marijuana-related digital media environment may reflect and/or influence exposure to marijuana-related content as well as youth marijuana use among youth and young adults. digital media data may be used to supplement survey data or to understand marijuana use behavior measured by survey. contact: sherry emery emery-sherry@norc.org state-by-state patterns of marijuana use incidence rates in the us from 2002-2017 karl c. alcover, abram j. lyons, morgan kelly, michael g. mcdonell washington state university introduction. the gradual liberalization of marijuana policies in the us increases access to marijuana, which might result in increased risk of first-time marijuana use. as of june 2019, 10 states including washington d.c. have legalized marijuana for recreational use. in this study, we aim to describe the patterns of marijuana use incidence in the us, state-by-state. we provide conference abstracts 71 state-specific incidence estimate from 2002-2017. methods. the study population involves us residents age 12 and older. included in this study are individuals from the annual cross-sectional national survey on drug use and health, 20022017. the participants were randomly selected to participate through multi-stage probability sampling. after consent, participants responded to audio computerized-assisted self-interviews on drug-related behaviors including the timing of their first-time marijuana use. we used the restricted-data analysis system (r-das), an online tool from substance abuse and mental health services administration, to estimate state-specific incidence rates by year-pairs (i.e., 2002-2003 through 2016-2017). we then used joinpoint regression analysis to determine significant change in the estimated incidence rates over the years. lastly, we then compared the estimates by aggregating nsduh data based on the year in which recreational marijuana was first legalized, that is, aggregating the 2002-2013 nsduh data and the 2014-2017 nsduh data. results. overall, the estimated incidence rate of marijuana use in the us increased from 1.5% (95% ci = 1.4%, 1.5%) in 2002-2003 to 1.8% (95% ci = 1.7%, 1.9%) in 2016-2017. of the 50 states and washington d.c., a steady increase in the incidence estimate was observed in 16 states from 2002-2003 to 2016-2017 (î²>0; p-value<0.050). a statistically significant decrease in incidence rate was observed in kentucky from 2002-2003 to 2006-2007 (î² = -0.12; p-value = 0.002) and increased from 2006-2008 to 2016-2017 (î² = 0.10 p-value < 0.001). a statistically significant increase in incidence rate was observed in new hampshire from 2002-2003 to 2010-2011 (î² = 0.13, p-value = 0.042), with the estimate stabilized from 2010-2011 to 2016-2017. when data were aggregated from 2002-2013, the overall incidence rate estimate was 1.5% (95% ci = 1.5%, 1.6%). ranked in order, the highest estimated incidence rates are from rhode island, washington d.c., colorado, vermont, and alaska. when data were aggregated from 2014-2017, the overall incidence rate estimate was 1.8% (95% ci = 1.7%, 1.8%). ranked in order, the highest estimated incidence rates are from washington d.c., colorado, oregon, washington, and alaska. discussion. our findings suggest an increasing incidence rate of marijuana use in the us. with increased rates of marijuana incidence among several of the 50 states and washington d.c. since 2002, we expect increased occurrence of consequences of marijuana use (e.g., marijuana-related accidents). general principles indicate close state-level surveillance, primary prevention, and outreach initiatives to reduce the risk of marijuana use and other marijuana-related consequences. contact: karl alcover k.alcover@wsu.edu survey, ingestion, or lab? examining differences among volunteers in cannabis research maha n. mian, brianna r. altman, luna ueno, rachel luba, mitch earleywine university at albany, suny despite efforts to recruit representative samples for research, the potential for bias remains a concern. while previous work demonstrates that volunteers differ from non-volunteers on substance use and sex, less is known about the personality factors and attitudes of participants who volunteer for studies on cannabis. in the present work, undergraduate students (n=308) could volunteer for one of three study options randomly ordered on the university research site: marijuana investigation (ingestion, survey, or laboratory). all participants then completed a purported prescreen survey, ostensibly to determine eligibility for the study option they selected. the survey addressed demographic information, cannabis use, sensation seeking (bsss-8), and research attitudes (raq). participants were also asked about participation in a follow-up study with three potential motivators (to contribute to science, for a prize, and for cash), which was totaled for a single measure of willingness to volunteer. participants varied in initial selection preference, with the majority choosing the survey option (63.3%), followed by the ingestion (24.7%), and then the laboratory option (12%). typical cannabis use per week was significantly higher for those who chose the ingestion option compared to the survey option, with the lab option between them but not significantly different from either (f(2, 293)=3.06, p<.05, eta squared=.02). men and women volunteered at comparable rates for each option. individuals higher in sensation-seeking and conference abstracts 72 higher in past month cannabis use were more likely to select the survey condition (ors: 1.05 and 1.91, respectively, p<.05), while those with positive research attitudes were only .94 (p<.05) times as likely to do so (χ2 (5, n=280)=14.5 p<.05). follow-up studies also appealed to different people. males and higher sensation seekers were more likely to participate in a follow-up study for science (ors: 2.56 and 1.1 times more likely, respectively), while those with more positive research attitudes were only .778 times as likely (χ2=65.77, df=6, p<.001). men were also more likely to participate in a follow-up study for a prize (or: 2.04). higher past week cannabis use and research attitudes were only .609 times and .904 times as likely to participate in this follow-up (χ2=22.05, df=6, p<.01). similarly, individuals with higher past week cannabis use and research attitudes were .50 times and .86 times as likely to participate in a follow-up for cash (χ2=24.44, df=6, p<.001). overall, males and higher sensation seekers were more likely to agree to any follow-up study, while those with higher typical weekly cannabis use (beta=-.16, p<.05) and positive research attitudes (beta=-.33, p<.01) were less likely to agree to a follow-up (f(7, 294)=8.11, p<.001). those who volunteer to ingest cannabis in the lab systematically differ from those who come in to complete a survey, and volunteers for cannabis research are more likely to be male and higher in sensation seeking. these data suggest that those who volunteer to ingest cannabis use are not representative of many cannabis users, impacting the generalizability of results. contact: maha mian mmian@albany.edu gender bias in the cannabis-associated problems questionnaire (capq): a replication and extension brianna r. altman, maha n. mian, luna ueno, eliza barach, mitch earleywine university at albany, suny research on gender differences in cannabisrelated problems not only continues to fascinate researchers but also requires an unbiased assessment of these problems. otherwise, gender differences might arise because of measurement problems rather than true differences. previous work suggests that the cannabis associated problems questionnaire (capq; stephens, roffman, & simpson, 1993) includes items biased by gender based on differential item function (dif; lavender et al., 2008). unfortunately, few dif analyses of any scale replicate. the present study sought to replicate the findings of lavender and colleagues (2008) in 4,053 cannabis users (mage = 32.77, 60% male) by examining gender differences across measures of cannabis use and related consequences. men endorsed greater monthly cannabis use (t=6.80, p<.001, cohen’s d=.22), greater daily use (t=8.07, p<.001, cohen’s d=.27), and a greater average high (t=5.89, p<.001, cohen’s d=.19) than women. men also scored higher than women on global capq scores (t = 6.292, p<.001, cohen’s d=.17, mmale = 27.42, sdmale = 8.64, mfemale = 25.99, sdfemale = 8.394). at the individual item level, eight items showed uniform differential item functioning (dif) after using a bonferroni-corrected p-value to account for inflations in type i error (χ2 ranged from 14.21 to 63.50, p< .001). specifically, four items that replicated in the lavender et al. (2008) study showed gender dif. items 1 (problems between you and your partner; t=5.79), 2 (problems in your family; t= 8.18), and 14 (legal problems; t=12.62) appeared biased against males based on elevated mean scores (p < .001). item 15 (decreased energy; t= -2.48, p<.05) yielded significantly higher scores for females than males. additionally, four new items emerged as problematic. items 3 (to neglect your family; t=4.70) and 6 (to lose a job; t=4.95) revealed higher average endorsements for males than females (p<.001). conversely, items 7 (to have lower productivity; t=-1.87, p=.062) and 8 (medical problems; t=-2.82, p<.01) showed gender bias toward women based on higher mean scores. removal of these eight items slightly reduced cronbach’s alpha for the scale from .849 to .807; however, gender differences still remained on the condensed version (t=3.77, p <.001, cohen’s d=.12). finally, correlations between both the full and short-form of the capq and measures of monthly cannabis use (r=.087 and .076, respectively), daily cannabis use (r=.098 and .097), and average high (r =.154 and .120) were slightly diminished but showed a similar pattern of significance. taken together, these results demonstrate that certain items of the capq may impose biased responses based on respondent conference abstracts 73 gender. items biased against men appeared to be related to family and relationship functioning, occupational impairment, and legal issues, while items biased against women involve behavioral and medical dysfunction. removal of these items yields a drastically shorter scale with similar psychometric properties and identical functioning. while true discrepancies may exist between males and females in their experience of cannabis-related consequences, a condensed form of the capq with biased items removed, may allow for a better understanding of this phenomenon. contact: brianna altman baltman@albany.edu from a (abstain) to z (zooted): qualitatively assessing marijuana-related terminology among late adolescents and young adults in washington state to inform development of implicit association tests elliot c. wallace, jason j. ramirez university of washington implicit association tests (iats) are computerized reaction time measures that aim to assess implicit associations between various constructs. iats include various stimuli presented as pictures or words on a computer screen to represent the constructs of interest for measurement. as more states continue to legalize the recreational use of marijuana, the culture surrounding marijuana is rapidly changing. in turn this has created a need to validate images and words that represent today's marijuana culture to be included in the development of iats. the aims of this study were to 1) improve our understanding of terminology currently used to describe marijuana and marijuana-related constructs in a state with legalized recreational use of marijuana, and 2) develop word-based stimuli for a novel iat that aims to measure associations between marijuana and one's identity. data come from focus groups for two studies; one with late adolescents (n = 30, ages 1518) and one with young adults (n = 22, ages 1825). participants in both sets of focus groups were asked to provide words commonly used to refer to the following categories: 1) marijuana itself, 2) people who use marijuana regularly, 3) people who abstain from marijuana use, 4) marijuana's effects, and 5) modes of marijuana use and associated paraphernalia. participants provided written lists of words referring to these categories and engaged in discussion on the use of these words in their day-to-day lives. stimuli chosen for the development of the iat include words that were endorsed as being most typically used in conversations among peers including "stoner," "high," and "smoke." discussion of marijuanarelated terminology revealed several important themes including context specificity of stigma regarding certain words (e.g., "stoner"); generational differences in terminology (e.g., "pot" vs. "dank"); and words reflecting modern modes of use that are increasing in popularity (e.g., "dabbing"). contact: elliot wallace elliotcw@uw.edu to bake or not to bake? individual differences in adverse reactions to cannabis emily lafrance, amanda stueber, nicholas glodosky, dakota mauzay, aria petrucci, carrie cuttler washington state university recent trends towards legalization of recreational cannabis in north america have increased access to, and social acceptance of recreational cannabis. these trends may increase experimentation with cannabis among novice users. acute cannabis use is known to be associated with a variety of common side effects including anxiety, paranoia, apathy, panic attacks, loss of motivation, altered sense of time, euphoria, and reduced stress. furthermore, it appears that some people are more likely to experience positive drug effects while others appear to be vulnerable to the negative effects of cannabis. however, we presently have little ability to predict who is at higher risk of experiencing negative effects of cannabis and who is more likely to perceive these effects as distressing. this study was designed to assess adverse reactions to cannabis and explore possible predictors of these effects. the adverse reactions scale (ars) was developed for the present study and comprised 28 adverse reactions to cannabis that were identified by compiling negative effects from previous empirical literature conference abstracts 74 and consulting with experienced cannabis users. the ars was administered to over 1000 undergraduate students in an online survey that also contained measures of cannabis consumption patterns (dfaq-cu), personality (neo-ffi), anxiety (bai), depression (bdi), cannabis use motives (mmm), and cannabis use disorder symptoms (cudit). results indicated that negative affect, personality traits, motives for cannabis use, and symptoms of cannabis use disorder predicted both the frequency of, and level of distress caused by, adverse reactions to cannabis. specifically, anxiety, depression, stress and neuroticism were positively correlated with number of adverse reactions to cannabis. enhancement, expansion, and conformity motives for cannabis use, and symptoms of cannabis use disorder were also positively correlated with number of adverse reactions experienced. additionally, conscientiousness was negatively related to number of adverse reactions experienced, and both conscientiousness and conformity motives were positively associated with level of distress associated with adverse reactions. furthermore, frequent cannabis users, individuals high in openness to experience, and those using cannabis for coping, enhancement, and social motives were less likely to experience distress from adverse reactions to cannabis. results of this study have implications for cannabis users who may be at increased risk for experiencing distressing negative effects of cannabis use based on personal characteristics, such as affect, personality, or cannabis use motives. contact: emily lafrance emily.lafrance@wsu.edu over baked: adverse reactions to cannabis amanda stueber, emily lafrance, nicholas glodosky, aria petrucci, dakota mauzay, carrie cuttler washington state university recent trends toward the legalization of cannabis in north america may increase experimentation with the drug among novice users. however, novice users may have limited knowledge of possible adverse reactions to cannabis. two of the most well-known adverse reactions are anxiety and paranoia, however, few studies have documented the prevalence of other possible adverse reactions. therefore, the present study was designed to determine the prevalence of various self-reported adverse reactions to cannabis as well as level of distress produced by each. to achieve this goal, a measure of adverse reactions to cannabis (adverse reactions scale [ars]) was created by consulting previous empirical literature, popular sources, and experienced users. the ars included a list of 28 reactions to cannabis as well as a free response option. for each, participants indicated whether or not they had ever experienced the reaction as well as the level of distress they experienced. a total of 732 cannabis-using students at washington state university completed the inventory as part of a larger online survey. results indicated that the most common adverse reactions reported were: anxiety (55.1% reported experiencing this reaction), paranoia (53.2%), feeling off balance (51.4%), light-headedness (48.6%), dissociation (43%), dizziness (42.3%), feeling of body humming or vibrating (39.5%), and feeling out of control (38.2%). participants reported experiencing the following reactions as most distressing: panic attack, fainting, vomiting, paranoia, anxiety, heart palpitations, and trouble breathing. results from the present study provide a more comprehensive account of the various adverse reactions to cannabis that individuals may experience, which may be used to educate novice users about potential unwanted side effects. contact: amanda stueber amanda.stueber@wsu.edu marijuana-related perceptions as mediators of the association between trait impulsivity and marijuana outcomes margot rheinhardt, mark prince, angelina pilatti, adrian j. bravo, cross-cultural addictions study team colorado state university, universidad nacional de cordoba, & university of new mexico background: previous research has found that normative perceptions (descriptive norms, injunctive norms, and college-related alcohol beliefs) mediate the association between more conference abstracts 75 distal antecedents (i.e., personality traits, including impulsivity) and alcohol outcomes. the purpose of this study is to examine these associations for marijuana outcomes through examining the effect of trait impulsivity on marijuana outcomes via descriptive norms, injunctive norms, and college-related marijuana beliefs. in addition, we sought to test the structural invariance of the model across countries and sex. method: college students from five countries (u.s., argentina, uruguay, spain, and the netherlands) completed an online survey as part of a broader study focused on mental health, personality traits, and marijuana use behaviors. only data from students that reported past month (i.e., past 30-day) marijuana use (n=1,175; 62.9% females) were included in the final analysis from each country (u.s., n=698; argentina, n=153; spain, n=178; uruguay, n=79; netherlands, n=67). a comprehensive saturated mediation path model was conducted such that double-mediated paths were examined for each impulsivity-related trait and perceived norms. we examined the total, indirect and direct effects of each predictor variable on marijuana outcomes using bias-corrected bootstrapped estimates. in order to test whether our mediation model was culturally-specific or culturally-universal, we conducted χ2 difference tests comparing a freely estimated multi-group model to a constrained multi-group model (i.e., constraining the paths of the mediation model) to determine whether constraining the paths to be equivalent across countries and sex resulted in a worse fitting model. results: the present results indicate that marijuana-related norms mediate impulsivitymarijuana outcomes associations. additionally, we found unique significant mediations, via particular perceived norms (specifically injunctive norms), involving specific impulsivity-facets and marijuana outcomes. further, our findings supported the robust role of college marijuana beliefs as a proximal mediator of personalitymarijuana outcomes associations and indicate that this role is still significant when examining the multifaceted nature of impulsivity. finally, this mediational model was found to be invariant across sex and across different countries/cultures. discussion: based on results from the path analysis, impulsivity-like traits, and normative perceptions work in concert to result in marijuana use, which in turn portends risk for marijuanarelated consequences. negative urgency had a robust positive association with marijuanarelated consequences, which suggests that intervention and prevention efforts should focus on targeting negative urgency specifically, regardless of cultural background. of all normative perceptions measured, the strongest and most robust effects were found for perceptions about marijuana use as being part of the college experience. college administrators and other stakeholders could work together with clinicians and public health experts to develop social norms campaigns targeting this perception. changing the perception that marijuana use is central to the college experience may be an efficient way to reduce marijuana use and related consequences on a large scale. contact: margot rheinhardt margotarheinhardt@gmail.com chronic marijuana use, inhibitory control, and processing speed in young adult college students jessica m. cavalli & anita cservenka oregon state university objective. marijuana is the most widely used illicit substance in the united states, and its use is especially prevalent among young adults. over the past two decades, there has been an overall decline in perceived harmfulness of marijuana use in young adults ages 18-30, despite growing evidence that chronic marijuana use may be associated with cognitive impairment. there have been mixed results regarding the effects of chronic marijuana use on inhibitory control. furthermore, previous literature has shown inconsistent results regarding processing speed in marijuana users. the current study examined inhibitory control and processing speed in chronic marijuana-using young adult college students and healthy controls ages 18-22. methods. 33 healthy controls (mean age: 19.18 ± 1.13; 18 male) and 28 chronic marijuana users (mean age: 20.25 ± 1.17; 19 male) were included in the study. chronic marijuana users had to have used marijuana ≥5 times/week over the past year to be eligible. participants were instructed to remain abstinent from marijuana use for 12 hours prior to the study visit. the 30-day timeline followback (tlfb) conference abstracts 76 was used to assess recent marijuana use and participants were asked to estimate age at first marijuana use and lifetime days of marijuana use. participants completed the stroop color word task (scwt), and the interference t-score was used as a measure of inhibitory control. furthermore, we examined marijuana use characteristics (i.e. age at first use, lifetime marijuana use, and past 30-day marijuana use) in relation to performance on the scwt. additionally, exploratory analyses investigated differences in the color and word conditions of the scwt between the two groups and as a function of marijuana use characteristics. results. results indicated no significant group differences on the interference, word, and color conditions of the scwt. furthermore, there were no significant correlations between age at first use, lifetime marijuana use, and past 30-day marijuana use with any conditions of the scwt, but, there was a trend for greater past 30-day marijuana use to be associated with poorer performance on the color condition (r(26) = -0.26, p = 0.09). conclusion. these findings indicate that chronic, heavy marijuana use may not be associated with impairments in inhibitory control or processing speed, which is consistent with other studies examining current use, heavy use, and chronic use in adolescents, young adults, and adults. further research is needed to determine whether chronic, heavy marijuana use during young adulthood affects higher-order cognitive functioning skills needed for success in college, starting a career, and transitioning into adulthood. contact: anita cservenka anita.cservenka@oregonstate.edu facets of impulsivity are differentially associated with marijuana use through expectancy effects: an expanded test of the acquired preparedness model caitlin a. falco, tess m. kilwein, kyle p. de young, lauren zimmerman, nick livingston, alison looby university of wyoming & denver health medical center, behavioral health services the acquired preparedness model (apm) posits that the relationship between impulsivity and substance use is mediated by drug effect expectancies. specific to marijuana, college students high in impulsivity hold weaker negative marijuana-related expectancies and subsequently use marijuana more often. however, research applying the apm to marijuana use has yet to examine how these relations may vary by specific facets of impulsivity, as there are differential associations between various impulsivity traits and certain aspects of substance use. therefore, the current study aimed to expand the apm as an explanatory model for marijuana use by examining the mediated effects of positive and negative expectancies on the relation between different facets of impulsivity and marijuana use. college students (n = 480, mage = 19.42, 63.2% female) completed an online survey assessing frequency of past-month marijuana use, five facets of impulsivity via the upps-p, and expectancies via the marijuana effect expectancy questionnaire. a bootstrapped path analysis was conducted, in which the upps-p subscales were modeled as predictors of past-month marijuana use via positive and negative expectancies. marijuana use was modeled using a zero-inflated poisson distribution, wherein presence of pastmonth marijuana use was examined independently of frequency of use. there was a significant indirect effect of sensation seeking on frequency of use through positive expectancies, such that higher sensation seeking was associated with stronger positive expectancies, which was associated with increased frequency of pastmonth use (î² = 0.10, 95% ci [0.02, 0.18]). there were two significant indirect effects of facets of impulsivity on presence of use through expectancies. higher negative urgency was associated with decreased likelihood of use through stronger negative expectancies (î² = -0.87, 95% ci [-1.08, -0.29]), and higher lack of premeditation was associated with increased likelihood of use through weaker negative expectancies (î² = 0.50, 95% ci [0.23, 0.84]). there were no significant indirect effects for positive urgency or lack of perseverance. these results expand previous literature on the apm and marijuana use by underscoring the importance of examining impulsivity as a multi-dimensional construct when trying to understand marijuana use. these findings are consistent with prior results if impulsivity is equated with lack of premeditation; however, they provide a more nuanced understanding of how other impulsivity conference abstracts 77 traits relate to marijuana use. importantly, thrillseeking is related to frequency of marijuana use through positive expectancies, and individuals high in negative urgency may actually be less likely to use marijuana through strengthened negative expectancies. knowledge that facets of impulsivity differentially relate to expectancies and marijuana use can better direct targeted and efficacious prevention or intervention efforts to reduce marijuana use. contact: caitlin falco cfalco@uwyo.edu measuring the gap: predictions from dualsystems theory shane d. kentopp, gereon fredrickson, bradley t. conner colorado state university the dual-systems model of behavior posits that spikes in deviant behavior in late adolescent and early adulthood arise from the differential development of two neurobiological systems: the cognitive control systems and socioemotional system. the cognitive control system directs executive functioning and impulse control. the socioemotional system processes emotions, social cues, and reward. there is evidence that the cognitive control system develops linearly and does not fully mature until adulthood. the socioemotional system develops curvilinearly, peaking in adolescence. this rapid development and early peak in the socioemotional system during adolescence, along with the linear development of cognitive control results in a developmental “gap” between the two systems. the gap produces an impulsive need for novel and exciting experiences with little ability to control those impulses. this results in a propensity to engage in deviant behavior. the current study utilized a novel approach to modeling the gap between the two elements of dual systems theory to test relations between the gap and deviant behavior. the divergence between the two systems was assessed in a sample of college undergraduates (n = 7,109) and associations with cannabis use were tested. the upps-p impulsive behavior scale (upps-p) was used to operationalize the cognitive control system and the sensation seeking personality type questionnaire (sspt) was used to operationalize the socioemotional system. two dual-system latent risk scores (dlrs) were created from the subscale scores of these measures. the experience seeking/ cognitive control dlrs represents the extent to which an individual's desire for novel experiences outweighed their ability to exert control over their behavior. the risk seeking/ cognitive control dlrs represents the extent to which an individual's desire for risky experiences outweighed their ability to exert control over their behavior. the experience seeking/ cognitive control dslr was significantly positively related to 30-day cannabis use (b = 0.29, se = 0.03, p < .001). the incident rate ratio (irr) for the effect of the experience seeking/ cognitive control dslr (e0.29 = 1.34) indicates that a one unit increase in the dslr results in a 34% increase in expected number of times during the last 30 days that cannabis was used. the risk seeking/ cognitive control dslr was also significantly positively related to 30-day cannabis use (b = 0.15, se = 0.03, p < .001). the irr (e0.15 = 1.16) indicates that a one unit increase in the dslr results in a 16% increase in expected number of times during the last 30 days that cannabis was used. these findings support the proposition of the dual systems model that deviant behavior arises from the divergence of the two component systems. clinicians can utilize these findings to inform efforts aimed at reducing cannabis use in adolescents and young adults. either increasing the influence of the cognitive control system or reducing the influence of the socioemotional system may serve to reduce cannabis use. numerous interventions already exist to foster emotion regulation. results of the current study suggest that these interventions may be effective in reducing cannabis use. contact: bradley conner brad.conner@colostate.edu effects of menstrual cycle phase on impulsivity and cannabis use in female cannabis users emma n. cleary, philip s. santangelo, julia e. hooker, emily b. ansell syracuse university menstrual cycle phase has been shown to impact inhibitory control, a mechanism underlying conference abstracts 78 impulsive behavior. specifically, women exhibit less efficient inhibitory control in the follicular phase compared to the menstrual and luteal phases. substance use has also been linked to deficits in inhibitory control. past findings have shown increased craving and self-administration of various substances in the follicular phase, but little research has been done on the effects of menstrual cycle phase on impulsivity in cannabis users. the present study examines the relationship between menstrual cycle phase, impulsivity and cannabis use in 67 young adult women using a behavioral paradigm and three ecological momentary assessment (ema) selfreport measures. participants were recruited as part of a larger longitudinal study on recreational cannabis use. the menstrual cycle questionnaire was used to determine menstrual cycle phase at the time of the assessment. participants also completed the stop signal task, which is a widely used assessment of response inhibition. they then completed three ema measures: the barret impulsivity scale-brief (bis-brief), a self-report measure of impulsivity, as well as two selfreported assessments of cannabis use: cannabis craving and total days of cannabis use during one week of ema. due to the skewness of the data, we used non-parametric statistical tests to examine our hypotheses. a mann-whitney test indicated that women in the menstrual and follicular phases exhibited more difficulty inhibiting responses on the stop signal task than women in the luteal phase (u = 326.000, p= 0.004). a kruskal-wallis h test showed no significant differences by phase in the ema measures: bisbrief (χ2(2) =2.818, p= .244), craving (χ2 (2) = 1.135, p = .567), and days of cannabis use (χ2 (2)= 1.733, p =. 420). higher medians were found in the follicular phase compared to the menstrual and luteal phases for all measures: bis (menstrual median = 26.813, follicular median = 34.875, luteal median = 30.750); craving (menstrual median = 3.500, follicular median = 15.000, luteal median = 9.500); days of cannabis use (menstrual median = 1.000, follicular median = 4.000, luteal median = 2.500). as has been demonstrated in past research on substance use and menstrual cycle phase, participants in the follicular phase exhibited higher impulsivity than participants in the luteal phase. increased difficulty inhibiting responses during the follicular phase could be a predictor of increased cannabis use. analyses of cannabis craving, frequency of cannabis use, and menstrual phase did not reach significance in this study. this result could be due to being underpowered for the effect, as descriptive statistics indicated increased craving and increased cannabis use in the follicular phase compared to the menstrual and luteal phases. these results demonstrate the need for further research on the role that impulsivity plays in the effect of menstrual cycle on cannabis use. contact: emma cleary encleary@syr.edu harassment and marijuana use among adolescents in oregon counties with retail availability of marijuana grisel garcia-ramirez, mallie j. paschall university of california, berkeley, & pacific institute for research and evaluation, prevention research center objective: research has suggested lower marijuana use by adolescent bullying victims due to difficult accessibility of marijuana mainly because of their limited association with peer groups. however, bullying and harassment has been associated with negative mental health outcomes, and the use of marijuana and other substance use to self-medicate for mental health issues and to cope with harassment. this study investigates whether easier accessibility of marijuana through legalization of recreational marijuana sales in oregon counties is associated with higher marijuana use for students who report harassment. method: data for 6th (n = 12,175), 8th (n = 12,937) and 11th graders (n = 8,516) from the 2018 student wellness survey in 35 oregon counties (n = 33,628) were analyzed using multi-level logistic regression models in hlm software to assess past 30-day marijuana use among students who did and did not experience past 30-day harassment in counties that have allowed recreational marijuana sales since 2015 compared to counties that do not. results: multi-level logistic regression models indicated that students who live in counties that allow recreational marijuana sales reported more past 30-day marijuana use (or = 1.26, p < .03; ci 95%: 1.03, 1.54) compared to students that live in counties where the sales are not allowed. a conference abstracts 79 greater likelihood of marijuana use was observed for students who reported harassment including discriminatory harassment over the past 30-days (or = 2.01, p < .001; ci 95%: 1.84, 2.20), compared to students who did not report harassment. discussion: as expected, students reported more past 30-day marijuana use in counties that allow recreational marijuana sales. although previous research has suggested lower levels of marijuana use for youth that report harassment, our results indicate that students who reported harassment were more likely to report past-30-day marijuana use than students who had not experienced harassment. contact: grisel garcia-ramirez garcia.griselm@gmail.com anti-marijuana motives: what do they tell us? andrew p. weinstein, clayton neighbors university of houston marijuana motives are typically considered in the context of why people choose to engage in marijuana use; as conceptualized by measures such as the marijuana motives measure (simons, correia, carey, & borsari, 1998). however, the opposite question is often overlooked, "why do people decline to use marijuana?" the present analysis utilized secondary data from 262 participants who provided their reasons for not using marijuana (reasons given = 1090). these participants responded negative to "in your lifetime, have you ever used marijuana (cannabis, pot, hash, hashish)?" these participants were then asked to freely respond to the question: "please list briefly, in rank order, the top five reasons for why you do not use marijuana." five raters assessed each response on an axis of 12 categories that the researcher believed would cover the breadth of the reasons provided by participants. the present analysis utilized krippendorf's alpha (α; hayes & krippendorf, 2017) as a measure of interrater reliability. examining overall reliability of the raters (î± = .53), we found that reliability was significantly improved by excluding the fifth rater (α = .69, δα = -.17, t = -50.48, p < .001) while excluding any of the other four raters worsened reliability significantly. following the example of hayes & krippendorf (2017), we found that among the remaining four raters there was modest or better reliability for legal (α = .87), availability (α = .87), social (α = .83), monetary (α = .88), smell (α = .90), interest (α = .75), and academics (α = .80) reasons. we found that 30.91% of participants reported legal reasons, 5.72% availability reasons, 39.69% social reasons, 16.79% monetary reasons, 21.37% smell reasons, 35.88% interest reasons, and 8.40% academic reasons. thus, in the final analysis we examined the relationship of these seven variables with cannabis refusal self-efficacy and demographic factors. contact: andrew weinstein aweinstein42@gmail.com personality, psychological well-being, negative affect, and marijuana consequences: a moderated-mediation model reagan e. fitzke, theodore j. fetterling, mark a. prince, adrian j. bravo, cross-cultural addictions study team colorado state university & university of new mexico marijuana consequences (macq) are negatively associated with psychological well-being (pwb). previous research has shown pwb and macq are both related to personality. several facets of personality (i.e., emotional regulation, openness, conscientiousness, extraversion, and agreeableness) have been shown to positively correlate with pwb, with extraversion, openness, and emotional regulation having comparatively stronger associations. furthermore, low levels of agreeableness, conscientiousness, and emotional regulation relate to higher endorsement of macqs. negative affect, related to both anxiety and depression symptoms, has also been shown to relate to greater endorsement of macqs. moreover, general negative affect is negatively related to pwb. individuals low in emotional regulation have shown predisposition to anxiety disorders and co-morbid anxiety and depression. whether an individual endorses anxiety and depression or not then may have an influence on one’s personality, pwb, and endorsement of macqs. thus, while examining the relationship between macq, personality, and pwb, it may be beneficial to consider the possible moderating effects of anxiety and depression. the current conference abstracts 80 study aims to examine the relationship between emotional regulation, pwb, and macq, in relation to anxiety and depression. specifically, we hypothesized higher emotional regulation would predict lower macq through decreased pwb, and that anxiety and depression would moderate these relationships. path analysis was used to assess these hypotheses using moderatedmediation models, with separate models for each of the six facets of pwb (autonomy, selfacceptance, purpose in life, environmental mastery, positive relationships, and personal growth). analyses indicated lower emotional regulation significantly predicted lower levels of autonomy and environmental mastery. the indirect effect of macq on these relationships were significant, with higher levels of macq also indicating lower levels of autonomy and environmental mastery. depression was a significant moderator only on the relationship between trait neuroticism and environmental mastery, among individuals who indicated lower levels of depression. anxiety was not found to be a significant moderator. findings suggest emotional regulation and well-being may play an important role in lowering the degree to which individuals experience consequences from marijuana use. further research is needed to assess the relationship of other personality characteristics and macq, in relation to wellbeing and negative affect, to develop a more comprehensive understanding of personality’s role in experiencing marijuana-related consequences. contact: reagan fitzke refitzke@rams.colostate.edu do attitudes about and injunctive norms for alcohol and marijuana predict simultaneous use? nicole fossos-wong, helene r. white, alexander w. sokolovsky, jason r. kilmer, ha-yoon lee, kristina m. jackson university of washington, rutgers university, & brown university background: simultaneous alcohol and marijuana (sam) use (i.e., using alcohol and marijuana together so that their effects overlap) is prevalent among college students and can result in more negative consequences than using either substance alone. it is well established that positive attitudes towards and injunctive norms regarding alcohol and marijuana use predict higher levels of use of each substance. nonetheless, we do not know how these attitudes and norms affect sam use. this study examined whether and how attitudes and close friend injunctive norms regarding daily alcohol and marijuana use were associated with sam use frequency in a sample of college students attending three state universities in states with different legal regulations regarding recreational marijuana use (one state where it was illegal, one where it was decriminalized, and one where it was legal for adults). we also examined whether sex moderated these associations. methods: data came from 1,390 students who were past-year alcohol and marijuana users. students completed online surveys in the fall of 2017 (wave 1) and 3 months later in the winter of 2018 (wave 2). negative binomial regression analyses were performed to evaluate whether one’s own attitudes toward, as well as perceived injunctive norms for close friends regarding daily alcohol and marijuana use at wave 1 predicted sam use frequency at wave 2. sex was evaluated as a moderator in the models and analyses controlled for school. results: in the first model evaluating the role of attitudes toward daily alcohol and marijuana use, there were significant main effects for sex, own approval for daily marijuana use and own approval for daily alcohol use predicting sam use frequency at wave 2. men engaged in sam use more frequently than women at wave 2. moreover, higher approval for daily marijuana and daily alcohol use at wave 1 was associated with greater sam use frequency at wave 2. there was a significant interaction between sex and selfapproval of daily marijuana use, suggesting that the relationship between one’s own approval for daily marijuana use and sam use frequency was stronger for women than men. a second model was run to evaluate whether perceived injunctive norms regarding daily alcohol and marijuana use for close friends assessed at wave 1 predicted sam use frequency at wave 2. there were significant main effects for sex and perceived close friend approval for daily marijuana use, revealing that the more students perceived their close friends approved of daily marijuana use at wave 1, the greater the frequency of their wave 2 sam conference abstracts 81 use. however, there were no significant interactions between sex and perceived friend approval for daily alcohol or daily marijuana use in predicting sam use frequency at wave 2. conclusions: positive attitudes and injunctive norms regarding daily alcohol, and especially marijuana use, are associated with higher frequency of sam use. moreover, the relationship between attitudes toward daily marijuana use and later sam use frequency was stronger for women than men in our sample. therefore, interventions that target attitudes and norms for alcohol and marijuana use can help reduce sam use among college students and may have particular relevance for women. contact: nicole fossos-wong nfj2@uw.edu cannabis expectancies and future time perspective mark j. crisafulli, kathleen m. palm reed, victoria ameral, michael e. dunn university of central florida & clark university purpose: cannabis is being used more frequently throughout the country, and with recent legalization in several states, this trend is likely to continue. understanding factors that impact initiation and maintenance of use is vital to preventing misuse and abuse of cannabis. cannabis expectancies predict cannabis use, but many questions remain regarding use patterns and expectancies. future time orientation has been found to have a negative relationship with substance use, and to impact the relationship between cognitions and cannabis use suggesting a potential moderation effect. the present study examined future time orientation, particularly the degree to which one thinks or plans ahead, and how it may interact with the relationship between expectancies and use. method/data: students at a small liberal arts college in the northeast (n=109) completed an anonymous online survey that assessed cannabis expectancies, future time perspective, and cannabis use. regression analyses were conducted to assess variance, and moderation analyses were conducted to assess future time perspective’s role, based on previous research. results: regression analyses indicated that cannabis expectancies accounted for a significant amount of variance in amount of cannabis smoked per occasion (r2 = 0.13, p < 0.01), past 30-day use (r2 = 0.25, p < 0.01), lifetime use (r2 = 0.10, p < 0.01), past week quantity smoked (r2 = 0.05, p = 0.04), and past week frequency of use (r2 = 0.18, p < 0.01). future time perspective did not significantly moderate any of these relationships, but there was a near significant interaction effect on amount smoked per occasion that was examined at high and low levels (+1 and -1 standard deviation) of future time perspective. simple slopes were graphed to better understand this potential relationship. conclusion: results suggest that future time perspective may moderate the relationship between cannabis expectancies and cannabis use. additionally, cannabis expectancies accounted for a significant amount of variance in several cannabis use measures, indicating that expectancies may play a role in use patterns. a large body of literature suggests that alcohol expectancies may be causal in determining alcohol use, and the same may be true for cannabis expectancies. there were limitations that may have impacted the results of this study. first, the sample may have been too small to detect hypothesized effects, and future studies should take this into account. second, data was collected from a single university limiting generalizability. contact: mark crisafulli markcrisafulli4@gmail.com marijuana use and perceived descriptive norms among 2-year and 4-year college students jennifer c. duckworth, christine m. lee center for the study of health and risk behaviors, department of psychiatry and behavioral sciences, university of washington significance: young adults (yas) are at increased risk for marijuana (mj) use and related harms. while nearly 40% of college students in the u.s. attend 2-year colleges, over half of whom are yas, we know very little about mj use and risk factors for use among 2-year students relative to traditional 4-year students. an important risk factor appears to be the extent yas overestimate peers’ substance use and correcting these misperceptions has been an effective strategy for conference abstracts 82 reducing substance use among 4-year students. the present study examines patterns of mj use and perceived norms among 2and 4-year students with an eye toward understanding how norms function among 2-year students to inform potential interventions aimed at decreasing highrisk use. methods: participants included 506 yas aged 18-24 (m=20.17, sd=1.58) participating in a longitudinal study examining substance use and social roles. participants reported educational status [2-year (n=167) or 4-year (n=339)], mj use in a typical week and mj-related consequences, both in the past month, and perceived peer mj use. independent sample t-tests were conducted to assess mean differences between norms and use, separately by college status. controlling for gender and age, negative binomial regression models were conducted examining if use and perceived norms differed for 2and 4-year students and also to examine associations between mj norms and actual use controlling for college status. tests of differences were conducted to examine if relationship between mj norms and use differed for 2and 4-year students. results: significant differences between norms and use were detected for 2and 4-year students (all ps<0.05). overall, 2-year students reported greater mj use than 4-year students including, more hours high per week (2-year: m=7.65, sd=14.98; 4-year: m=3.41, sd=8.43), days high per week (2-year: m=1.78, sd=13.39; 4-year: m=1.03, sd=1.93), and hours high per day (2year: m=1.09, sd=2.14; 4-year: m=0.49, sd=1.20). two year students reported more mjrelated consequences than 4-year students (2year: m=6.41, sd=11.02; 4-year: m=4.88, sd=8.72). two-year students thought that their peers were high more hours per week (m=13.51, sd=13.39), used marijuana more days per week (m=1.78, sd=2.69), and were high more hours per day (m=1.93, sd=1.91) than 4-year students (m=8.59, sd=7.66; m=1.03 sd=2.12; m=1.23 sd=1.09, respectively). in models including educational status and mj norms, both remained significant and positive suggesting that 2-year status and higher perceived norms are each uniquely associated with increased mj use (all ps<0.05). no differences in associations between use and norms by college status were observed. discussion: results suggest that relative to 4-year students, 2-year students are at higher-risk for mj use and have higher perceived norms about their peer use. both 2 and 4-year students thought that their peers used more mj than their peers actually used. there were no differences in associations between norms and use by college status suggesting that interventions aimed at correcting misperceived peer norms may be an effective strategy for decreasing use among 2-year students. future research could examine if adapting norms-based interventions to the 2-year college context is effective at reducing mj use and related consequences. contact: jennifer duckworth jencduck@gmail.com marijuana use in adolescence predicted alcohol and drug-related problems in young adulthood maria m. wong idaho state university we examined whether marijuana use in adolescence predicted substance use related problems in young adulthood. previous research indicated that marijuana use is associated with alcohol and other substance use (lee et al., 2019; roche et al., 2019). however, the long-term relations between marijuana use and problems of other substances is less clear. in this study, we examined the prospective relations between marijuana use and a number of substance use outcomes, including alcohol and drug-related problems. study participants were 6504 adolescents from the national longitudinal study of adolescent health (add health) (harris et al., 2009). data were collected from interviews and questionnaires. the current study analyzed data at times 2 and 3 (t2 & t3). the two waves of data collection were 5 years apart from one another. participants were approximately 16 years old at t2 (mean=16.02, sd=1.62). marijuana use in the last year was measured by the question, "in the past year, have you used marijuana?" alcohol-related interpersonal problems were measured by five items, asking whether the respondent had problems with their friends or family due to their drinking, e.g., "over the past 12 months, have you gotten into trouble with your parents because you had been drinking". additionally, we also examined other substance use problems such as going to work or school while drunk, driving while drunk, using conference abstracts 83 cocaine, getting into a sexual situation that one later regretted while on drugs. data were analyzed by logistic regression. all analyses controlled for demographic variables (i.e., sex, age, school grade, poverty, and chronic health problems) as well as depressive symptoms. these variables are either contemporaneously associated with or longitudinally predict substance use in previous research. we also controlled for the specific substance-related problems at the previous wave. t2 marijuana use significantly predicted t3 alcohol-related interpersonal problems (or = 1.37, p<.01), going to school or work while drunk (or = 2.03, p<.001), driving while drunk (or = 1.88, p<.001), ever using cocaine (or = 4.09, p<.001) and getting into a sexual situation that one later regretted while on drugs (or = 2.44, p<.001). marijuana use in adolescence appears to be a robust risk factor for alcoholand drug-related problems in adulthood. contact: maria wong wongmari@isu.edu individualized assessment and treatment program (iatp) for cannabis use disorder: randomized controlled trial with and without contingency management mark litt, phd uconn health this study tested a new approach to the treatment of cannabis use disorder (cud). cud is difficult to treat, and eliciting abstinence is particularly difficult. the individualized assessment and treatment program (iatp) was intended to address this problem by providing a highly individualized approach to the training of coping skills most relevant for each individual. to do this, an experience sampling procedure was employed prior to treatment to record patients' marijuana use behavior and associated thoughts, feelings, coping behaviors and situations. this information was used by therapists to plan treatment that would address the specific strengths and weaknesses of each patient in drug-use situations. the present study tested iatp against a conventional combined motivational enhancement-cognitive-behavioral treatment (met-cbt), with or without the addition of contingency management (cm) for abstinence. the patients were 198 men and women randomly assigned to one of four 9-session treatment conditions: met-cbt; met-cbt-cm; iatp; or iatp-cm. patients were assessed out to 14 months. planned contrasts indicated that the iatp conditions yielded greater levels of abstinence than the met-cbt conditions. the addition of contingency management did not bolster the performance of iatp, but did do so for met-cbt. as expected, iatp did lead to greater use of coping skills than the met-cbt conditions. however, coping skills use was not a significant predictor of outcome when other variables were in the same analyses. self-efficacy was a robust predictor, and mediator, of outcome. we suggest that the highly individualized iatp may act by enhancing self-efficacy. contact: mark litt litt@uchc.edu treating synthetic cannabinoid (“spice”) dependence with psychotherapy and cannabinoid replacement therapy: a case report tess m. kilwein, michelle gaffaney, jeremy kozak, thom dunn denver health medical center, university of wyoming, university of colorado, palo alto university, & university of northern colorado cannabis use disorders are the mostly commonly reported substance use disorder. even with best practice psychosocial interventions (e.g., cbt) and treatment of acute withdrawal, relapse rates are around 80%. accordingly, there is strong interest in the development of treatment approaches that combine psychosocial and pharmacological interventions to treat cannabis dependence. thus far, cannabinoid replacement therapy has demonstrated potential as an intervention, with one systematic review showing promising effects of dronabinol, nabilone, or nabiximols in reducing cannabis withdrawal symptoms. in addition, evidence suggests that combining psychosocial and pharmacological interventions produces the best outcomes. however, far less is known about synthetic cannabinoid dependence (e.g., spice®, k2®) and withdrawal. though synthetic cannabinoids are chemical relatives to substances found in cannabis, they have different chemical structures conference abstracts 84 and are full agonists at cannabinoid receptors, resulting in often different and more extreme side effects (e.g., anxiety, psychosis) than cannabis. to our knowledge, there is no existing research that has examined the potential benefits of psychosocial and agonist replacement interventions specifically for synthetic cannabinoid dependence. accordingly, we present the case of a 28-year-old african american male who presents with symptoms of depression, anxiety, agitation, and synthetic cannabinoid (“spice”) dependence secondary to stress associated with a gunshot wound and resulting paraplegia sustained in 2017. he had struggled with adherence to treatment with multiple discharges against medical advice (ama), inability to optimally attend to caring for his wounds, and lack of participation with necessary rehabilitation therapies (i.e., physical occupational). during a subsequent inpatient hospitalization in 2019, an addiction and psychiatry consult/liaison service at an urban hospital in the mountain west initiated a combination of psychosocial interventions focused on increasing motivation towards desired action (e.g., sobriety) and adherence to medical recommendations and cannabinoid replacement therapy (i.e., dronabinol 30 mg tid) for withdrawal symptoms. unfortunately, after stabilization and discharge, the medication was discontinued at a long-term acute care facility, resulting in leaving the facility, relapsing on spice, and attempting suicide. the medication was re-started in the hospital and only two months after first initiating the treatment, the patient endorsed improvements in mood, insight into the adverse effects of his substance use, and ability to tolerate medical treatment, as well as an overall reduction in withdrawal symptoms (e.g., agitation, mood swings). the patient's follow-up plan includes cannabinoid maintenance therapy while in outpatient psychotherapy and eventual taper upon mental health stabilization. this case provides further evidence for the benefits of combining psychosocial interventions with cannabinoid replacement therapy to patients with cannabis dependence, as alleviating withdrawal and reducing cravings may facilitate greater engagement in psychosocial interventions. in addition, we demonstrate a novel finding that this effect may extend to synthetic cannabinoid dependence, a substance use disorder that remains far less understood. future research, including randomized controlled trials on the treatment of synthetic cannabinoid dependence, is warranted. contact: tess kilwein tkilwein@uwyo.edu marijuana negatively impacts other health behavior change kirk von sternberg, liza barros lane, mary m. velasquez university of texas at austin & baylor college of medicine introduction: negative health behaviors rarely occur in isolation and research is moving to the study of interventions addressing multiple health behavior change in order to maximize impact. there is growing evidence that changes in one targeted health behavior increases the likelihood of changing other similar or related behaviors. the change of more than one targeted health behavior may be facilitated by common factors involved in a behavior change process (e.g., motivation to change, self-efficacy, and processes of change or action-steps). however, little is known about how the presence of an untargeted health risk behavior might impact the change of targeted behaviors. this study examined the impact of marijuana use (untargeted behavior) on reducing risk level alcohol consumption (>3 drinks/day and/or >7 drinks/week) and use of effective contraception (targeted behaviors) in women at risk of an alcohol-exposed pregnancy (aep). methods: this study used data from choices plus (n=261), a study to test a preconception intervention to reduce the risk of alcoholand tobacco-exposed pregnancy in women who were 18-44, drinking at risk levels, sexually active, fertile, and not using effective contraception. the choices plus intervention consists of two visits with a behavior health specialist trained in the transtheoretical model, motivational interviewing, and the choices plus intervention. women were recruited from 12 primary care clinics in a large texas public healthcare system and assessed at 3, 6, and 9 months post-intake. women receiving the choices plus intervention were more likely than those receiving brief advice to reduce risk of conference abstracts 85 aep (absolute risk reduction= -0.233 [95% ci= 0.239, -0.226]) at 9 months. results: 45% of the women at risk of aep reported marijuana use (untargeted) at intake to the study. of the women who received the choices plus intervention (n=105), those who continued to use marijuana at 9 months were less likely to reduce their risk of an aep (46.7% of the marijuana users versus 73.3% of the non-users were at reduced risk; or 3.143; p=.007), less likely to reduce risk level drinking (25.9% of the marijuana users versus 50.0% of the non-users; or 2.867; p=.013), and less likely to use effective contraception (33.3% of the marijuana users versus 60.0% of the non-users, or 3.000; p=.007) at 9 months. discussion: women who continued to use marijuana through the outcome period in choices plus had overall worse outcomes. the use of marijuana interfered with the effectiveness of the choices plus intervention to facilitate change in the targeted behaviors. marijuana users were less likely to reduce risk level drinking, increase effective contraception use, and reduce the risk of aep. we are currently testing the addition of marijuana as a target behavior and comparing the counselordelivered intervention to one delivered by a tablet (niaaa, 1r01aa022924). conclusion: behavioral health interventionists need to be aware of the negative influence that an untargeted risk heath behavior can have on the probability of positive change in targeted health risk behaviors, and studies addressing multiple risk behaviors simultaneously are needed, particularly when marijuana use is prevalent in the study population. contact: mary velasquez velasquez@mail.utexas.edu adaptation of marijuana and alcohol use among participants in a drunk driving intervention michael scherer, eduardo romano, tom nochajski, amy manning, robert voas, eileen taylor the chicago school for professional psychology, pacific institute for research and evaluation, & university at buffalo purpose: in clinical settings, alcohol interventions have been found to have the inadvertent adverse outcome of increasing non-alcohol-related substance use while the intervention was in effect, though this has not been examined in alcohol ignition interlock interventions. however, the role of other substance use among drivers receiving drunk driving interventions is relatively unknown. one objective of the managing heavy drinking (mhd) study is to examine whether the interlock experience non-alcohol substance use. though, no significant aggregate changes in alcohol consumption have been found while drivers are on alcohol ignition interlock, deviations within stratified groups is evident. in the current endeavor, we examined the differences in each of the three alcohol outcomes on patterns of marijuana consumption among interlock drivers in new york state (preliminary results). methods: participant alcohol use was measured using hair ethylglucuronide (hetg) at time 1 (during interlock installation) and again at time 2 (6-month follow-up while the interlock was installed on their vehicle). similarly, marijuana consumption was measured at the same time intervals using blood thc concentrations. the current preliminary study examined participants who provided both hair and blood samples for analysis at both time points (n = 74). due to a skewed distribution, blood thc levels and hetg alcohol levels were standardized through logadjustment. two-way mixed analyses of variance were conducted to examine changes in levels of ethanol in hetg and thc in blood within participants between time points as well as interaction effects. results: among the sample of 74 participants available at the time this application was submitted, drivers who exhibited a decrease in hetg levels from time 1 to time 2 (n = 26; 35%) showed a mean increase in thc concentrations in their blood (m = 0.24 in t1 to 0.49 in t2; î” = 0.25) which was significantly greater than that found in the other alcohol consumption conditions (m = 0.05 in t1 to 0.14 in t2; î” = 0.09). differences in blood thc concentrations pre-installation between conditions was not significant; however, changes in thc concentrations while the interlock was installed were significant (f = 272.89, p <.001; î·2 = .791). conclusions: comparison of blood thc concentrations and hetg levels at time 1 and time 2 suggests that though installing the ignition interlock device requires individuals to better manage their alcohol consumption, at least in some cases, it may also inadvertently increase the conference abstracts 86 appeal of other substance use (i.e., marijuana in the case of this study). the information from the current study is of particular interest as these drivers may present a risk that has been largely overlooked in prior research in this field. these changes in substance use patterns while on iid, may suggest that interlocks impact more than just alcohol use. this finding is consistent with previous research that has examined the role of other substance use in clinical treatment of alcohol-related disorders. future studies could determine if this change in substance use behaviors is maintained after the device is removed and how changes in other substance use impact lockouts. contact: eduardo romano romano@pire.org perceptions of cannabis in patients receiving treatment for substance use disorder allison engstrom, julia holloway, jennette lovejoy, jessica wyse, travis lovejoy va portland health care system background: as many as 50% of patients with substance use disorders experience chronic pain, and many patients with substance use disorders use alcohol and other drugs to manage pain. in general and patient populations, cannabis has been associated with reductions in pain and improvements in functioning. however, research on this association has been limited, and few studies have examined the pathways in which cannabis improves pain, particularly in patients receiving substance use disorder treatment. procedures: we conducted in-depth qualitative interviews with 34 patients diagnosed with chronic non-cancer pain who were actively engaged in specialty substance use disorder treatment in a program serving patients in oregon and washington states. the interviews elicited descriptions of patients’ use of cannabis for pain and the perceived pathway in which this pain relief occurs. the coding team consisted of 4 research personnel. codes were iteratively developed from the data following the guidelines of qualitative content analysis. coded data were sorted into categories and concepts using a thematic analysis of all 34 interviews. each transcript was coded by two members of the team and consensus was reached on codes through open discussion. when consensus was not met between the two primary coders, the code was discussed among the entire team until consensus was achieved. exemplar quotes of key themes were selected for inclusion. results: patients were predominantly male (88%) and white, nonhispanic (91%). most patients were in treatment for alcohol use disorder (68%) or opioid use disorder (18%). only one patient was attending treatment as a result of cannabis use disorder, though cannabis use was common in this sample. of those participants who endorsed the benefit of cannabis thc and/or cbd on chronic pain, two perceived pathways emerged. in the first, participants described a direct benefit of cannabis on physical pain. some patients cited a direct link between cannabis use and a decrease in muscle tension and stiffness. others detailed a reduction in the need for opioids, muscle relaxants and other previously utilized pharmacologic pain relievers. in the second pathway, participants described an indirect benefit of cannabis on chronic pain through improvements in mental health functioning. for these patients, cannabis distracted them from the pain, “took the edge off,” or reduced anxiety and depression, which subsequently resulted in less pain. conclusion: many patients receiving treatment for active noncannabis substance use disorders in this sample experienced reductions in pain and improvements in functioning with the use of cannabis, though benefits sometimes occurred indirectly through improvements in mental health. given widespread legalization of cannabis in the u.s. for medical and recreational purposes and the growing interest among patients to use cannabis as a primary or secondary pain treatment modality, additional well-controlled studies are needed that examine the benefits and harms of cannabis for chronic pain. contact: allison engstrom allie.engstrom77@gmail.com childhood emotional abuse and hazardous use of cannabis and alcohol: the mediating role of emotion dysregulation vanessa joseph, ruichen sun, amelia v. wedel, emily b. ansell syracuse university conference abstracts 87 purpose: adverse childhood experiences such as emotional abuse have been linked to maladaptive behaviors such as substance use. emotion dysregulation has been found to mediate the relationship between emotional abuse and hazardous opiate use (barahmand, khazaee, & hashjin, 2016). however, there is limited literature that focuses specifically on the role of emotion dysregulation in connecting childhood emotional abuse with cannabis and alcohol use in young adulthood. we hypothesized that a history of greater childhood emotional abuse predicts more hazardous cannabis and alcohol use in young adulthood. method: participants (n = 224; 56% female) who reported alcohol and cannabis use were pulled from a parent study of cannabis users. participants completed measures on history of childhood trauma (ctq), emotion dysregulation (ders), and hazardous cannabis and alcohol use (cudit-r; audit). simple mediation analyses were performed on cannabis and alcohol use separately. data and results: emotion dysregulation mediated the relationship between childhood emotional abuse and both hazardous cannabis use (p < .001, r-square = .11) and hazardous alcohol use (p < .001, r-square = .17), such that childhood emotional abuse predicted emotion dysregulation, which then predicted hazardous cannabis and alcohol use. the direct effect of childhood emotional abuse was non-significant in the cannabis model; however, it was significant and negative in the alcohol model. conclusion: emotion dysregulation helps to explain the mechanism by which childhood emotional abuse is associated with hazardous substance use. these findings expand on the previous literature in identifying this association with both cannabis and alcohol use contact: amelia wedel amelia.vw@gmail.com examining the relationships between anxiety sensitivity, interoceptive awareness, and cannabis use dakota mauzay, nicholas glodosky, amanda stueber, emily lafrance, carrie cuttler washington state university emerging research supports links between anxiety sensitivity, interoceptive awareness, and cannabis use. anxiety sensitivity refers to catastrophizing the meaning of anxiety-related bodily sensations (e.g., elevated heart rate), while interoceptive awareness refers to the tendency to focus on these bodily sensations. previous research indicates that individuals with cannabis use disorder (cud) are more sensitive to aversive interoceptive stimuli than those without cud. further, anxiety sensitivity has been linked to problematic cannabis use, frequency of use, as well as to both positive and negative effects of cannabis. nevertheless, previous research on these links has been rather sparse and findings are somewhat equivocal. moreover, no known research has examined the possibility that interoceptive awareness mediates the relationship between cannabis use and anxiety sensitivity. that is, no one has tested the notion that heightened interoceptive awareness might underlie the relationships between anxiety sensitivity and various aspects of cannabis use. therefore, the main objectives of the present study were to examine i) whether anxiety sensitivity and/or interoceptive awareness are significantly associated with cannabis use frequency, cud symptoms, and adverse reactions to cannabis and ii) whether interoceptive awareness mediates the putative relationships between anxiety sensitivity and cannabis use/misuse. a sample of 853 undergraduate students completed an online survey containing measures of anxiety sensitivity (anxiety sensitivity inventory), interoceptive awareness (multidimensional assessment of interoceptive awareness), cannabis use patterns (daily sessions, frequency, age of onset, and quantity of cannabis use inventory), cud (cannabis use disorders identification test), and adverse reactions to cannabis (adverse reactions scale). results revealed significant bivariate correlations between anxiety sensitivity and frequency of adverse reactions to cannabis as well as levels of distress associated with these reactions. anxiety sensitivity was not related to any other cannabisrelated outcomes. in contrast, interoceptive awareness was significantly, positively correlated with anxiety sensitivity, cannabis use frequency, cud, and frequency of adverse reactions to cannabis (but not level of distress associated with them). the mediation analysis further indicated conference abstracts 88 that interoceptive awareness does not mediate the relationship between anxiety sensitivity and frequency of experiencing adverse reactions to cannabis. these findings suggest that interoceptive awareness is related to various aspects of cannabis use, while anxiety sensitivity appears to be related more specifically to adverse reactions. therefore, anxiety sensitivity may increase the likelihood that people notice, report, and feel distressed by the acute effects of cannabis. in contrast, interoceptive awareness may increase the likelihood that people notice these effects without the associated feeling of distress. notably, these results also suggest that interoceptive awareness does not underlie the relationship between anxiety sensitivity and cannabis use. contact: dakota mauzay dakota.mauzay@wsu.edu changes in anxiety level are associated with changes in marijuana-related problems sarah n. elder, robert e. mcbride, shelby a. king, kathryn e. soltis, james g. murphy, jenni b. teeters western kentucky university & university of memphis background: the present study aimed to examine whether changes in anxiety over time impact marijuana use and problems in a sample of college marijuana users enrolled in a brief marijuana intervention trial. past research has shown that many individuals use marijuana in an attempt to self-medicate anxiety symptoms. however, little to no research has examined whether changes in anxiety level over the course of an intervention directly influence intervention outcomes. method: participants were 132 college students from a large public university in the united states who reported cannabis use on 4 or more days in the past month and were enrolled in a brief intervention trial. participants were randomly assigned to the following conditions: 1) marijuana brief intervention + a substance free activities session (sfas), 2) marijuana brief intervention + a relaxation session, or 3) assessment only. participants completed measures of anxiety level, past month marijuana use, and marijuana-related problems at baseline and at a 6-month follow-up. results: changes in days of marijuana use, number of marijuana-related problems, and anxiety were calculated by subtracting 6-month scores from baseline scores for each variable. pearson's correlations revealed that changes in anxiety level were associated with changes in the number of marijuana-related problems (r = .43) but not with changes in days of past month marijuana use (r = .04). additionally, a linear regression model that controlled for baseline number of marijuana problems, gender, ethnicity, and days of past month marijuana use revealed that changes in anxiety level were significantly associated with number of marijuana problems endorsed at 6-month follow-up (p<.01). discussion: results of the present study suggest that changes in level of anxiety over the course of time impact the endorsement of marijuanarelated problems. more specifically, marijuana users who experienced decreases in anxiety levels from baseline to 6-month follow-up experienced decreases in the number of marijuana problems endorsed (regardless of intervention condition). however, changes in anxiety level over time were not associated with days of past month marijuana use, suggesting that anxiety level may be more closely tied to experiencing marijuana-related problems rather than frequency of use. with the legalization of recreational and medical marijuana on the rise, there is an increased need for research on the differential effectiveness of interventions aimed at reducing marijuana use and related problems. these results indicate that specifically targeting anxiety may be worthwhile in future interventions aimed at reducing marijuana-related problems. contact: jenni teeters jenni.teeters@wku.edu examining trait mindfulness as a moderator of the mediating relationship between social anxiety, using cannabis to cope, and cannabisrelated consequences cody a. raeder, melissa r. colangelo, james m. henson old dominion university the present research examined the relationships among social anxiety, coping motives for cannabis use, trait mindfulness and cannabis-related conference abstracts 89 consequences. specifically, previous research has identified a positive relationship between social anxiety and cannabis-related consequences despite non-significant findings for cannabis use measured in terms of frequency. researchers have identified coping motives as a mediator of the relationship between social anxiety and cannabisrelated consequences. mindfulness-based interventions, such as mindfulness based stress reduction, have been shown to be effective in treating both social anxiety and reducing cannabis use in those with anxiety. further, trait mindfulness has been shown to have a negative relationship with both social anxiety and cannabis-related consequences. this study examined the potential moderating effects of the five trait mindfulness facets as measured by the five facet mindfulness questionnaire on the mediating relationship between social anxiety, coping motives for cannabis use, and cannabisrelated consequences. participants (n = 232) were undergraduate college students from a midsized university in the southeastern united states who completed an online survey, including the social interaction anxiety scale, the using marijuana to cope with social anxiety scale, the brief version of the marijuana consequences questionnaire, a single item measuring past 90-day cannabis use, and the five facet mindfulness questionnaire. the moderated mediation model was analyzed using process, an spss macro developed by hayes (2018). significance was determined using confidence intervals generated from 10,000 bootstrapped samples using the percentile method. results indicated the observe, describe, and nonreactivity facets of trait mindfulness showed significant moderated mediation, such that those with higher levels of these facets of trait mindfulness show a reduced relationship in the indirect effect between social anxiety, coping motives for cannabis use, and cannabis-related consequences. these findings may have important implications in the development of interventions that can be used to treat individuals who suffer from both social anxiety and cannabis-related problems. contact: cody raeder cody.a.raeder@gmail.com motives matter: marijuana use motives moderate the links between stress and negative affect nicholas glodosky, amanda stueber, emily lafrance, dakota mauzay, aria petrucci, carrie cuttler washington state university previous research has revealed relationships between stress, depression, anxiety, and cannabis use but the direction of these effects is still rather unclear. nevertheless, recent research from our lab indicates that acute cannabis intoxication temporarily relieves stress, anxiety, and depression. however, continued use of cannabis to manage these symptoms may exacerbate symptoms of depression and maintain symptoms of anxiety over time. regular cannabis users commonly report using cannabis to cope with stress. however, previous research indicates that coping motives are potentially associated with negative outcomes, such as problematic cannabis use and symptoms of cannabis use disorder. in the present study, we sought to further explore the nature of the relationships between stress, motives for cannabis use, anxiety, and depression. a sample of 628 cannabis using college students completed an online survey containing a demographics questionnaire, the depression, anxiety, stress scale, and the marijuana motives measure which measures coping, enhancement, expansion, social, and conformity motives for cannabis use. the results of correlation analyses revealed significant positive relationships between stress, depression, anxiety, and the various motives for using cannabis. subsequent moderation analyses using hay’s process macro for spss indicated that, after controlling for anxiety, coping motives moderated the relationship between stress and depression. after controlling for depression, conformity motives were found to moderate the relationship between stress and anxiety. no other motives for cannabis use were significant moderators of these relationships. these results suggest that using cannabis to cope with negative affect and other problems may potentiate the link between stress and depression; while using cannabis to fit in or conform with others may strengthen the link between stress and anxiety. therefore, while previous research indicates that cannabis conference abstracts 90 provides temporary relief from symptoms of stress, anxiety, and depression, findings from the present study indicate that using cannabis to cope may exacerbate, rather than ameliorate, the potential effects of stress on depression, while using cannabis for conformity motives may compound the effects of stress on anxiety. contact: nicholas glodosky nicholas.glodosky@wsu.edu an initial trial of a facebook intervention for depressed cannabis users suzette glasner, danielle ramo, frances kaylambkin, alan budney, helene chokron garneau, alfonso ang ucla, ucsf-hopelab, the university of newcastle, & dartmouth college cannabis use disorders (cud) are associated with four times the risk of developing depression; moreover, depression is one of the most commonly cited conditions for which cannabis is used medicinally. motivational enhancement therapy (met) combined with cognitive behavioral therapy (cbt) is the current state-of-the art intervention for cud; nevertheless, availability of this approach is limited. as such, approaches to facilitate dissemination and implementation of cbt/met via technology could broaden accessibility of increasingly needed treatment for cud. we developed and pilot tested an evidencebased, computer-assisted strategy combining met and cbt with a social media intervention delivered via facebook targeting cannabis use and depressive symptoms. a nonrandomized, 10week comparison study assigned 43 adults with major depression and cud in a primary psychiatric care setting to either a computerassisted cbt/met intervention, self-help for alcohol and drug use and depression (shade) (n=26), or to a social media-enhanced intervention, connected cannabis users’ network for enhancement of cognitive therapy (connect) (n=17). the connect intervention combines shade with a social media component to enhance social support and between-session practice of essential therapeutic skills, delivered via facebook. cannabis use frequency was assessed using the timeline follow back and depression symptoms were measured using the phq-9. connect participants evidenced greater reductions in cannabis use frequency in the past 30 days from baseline to treatment-end, relative to those in the shade condition, t(42)=1.8, p<0.05. likewise, larger improvements in depressive symptom severity among those in the connect group were observed from baseline to treatment-end, as compared to shade participants, t(42)=2.0, p<0.05. these preliminary findings suggest that use of a social media platform with secure privacy settings to deliver therapy skills training may improve outcomes over and above those resulting from computerized cbt/met, and provide an easily deployable strategy for the treatment of depressed cannabis users. contact: suzette glasner sglasner@ucla.edu sex differences in the association between depressive symptoms and marijuana use and related consequences among nonmedical prescription stimulant-using us college students ha-yoon lee, nicole fossos-wong, anne m. fairlie, jason r. kilmer, mary e. larimer, christine m. lee, kathryn b. vincent, amelia m. arria, m. dolores cimini, karen sokolowski, geetha subramaniam, david liu university of washington, university of maryland, university at albany-suny, national institute on drug abuse, nih marijuana is the second most common substance (following alcohol) used by us-attending college students. with recent legalization of personal/non-medical marijuana use for those 21 and older in states spanning the nation, research has found increased prevalence, frequency, and consequences of use as well as decreased perceptions of risk among college students in these states. depression is both a risk factor for and consequence of marijuana use among college students and rates of depression in this population appear to be on the rise. however, longitudinal studies regarding marijuana use and depression report mixed results and tend to focus on the transition between adolescence and young adulthood or have only looked at the impact of marijuana use on later depression. moreover, conference abstracts 91 most research has not evaluated whether there are sex differences in the association between depressive symptoms and later marijuana use in college students. the purpose of this study was to examine sex differences in the association between depressive symptoms and subsequent marijuana use and related consequences over time using a longitudinal sample of college students who were screened for past-year nonmedical use of prescription stimulants as a part of a larger web-based intervention study (n=5099). participants (n=254, 65.0% female) reported past-six-month frequency of marijuana use and related negative consequences and depressive symptoms at baseline and six months later. multiple linear regression analyses were performed controlling for study condition. consistent with past research, men used marijuana more frequently than women. results further revealed that participants who reported more depressive symptoms at baseline used marijuana more frequently six months later. a significant interaction between depressive symptoms and sex indicated that females who reported high depressive symptoms at baseline used marijuana more frequently six months later than females who reported low depressive symptoms at baseline. however, this pattern was not observed for males. regression analyses further revealed another significant main effect of depressive symptoms on marijuana consequences, indicating that participants with higher levels of depressive symptoms at baseline reported more negative consequences related to their marijuana use at follow-up, but no main effect for sex or significant interaction were found. this study builds on existing research showing a link between depressive symptoms and marijuana use. in particular, female college students struggling with depressive symptoms may be a group who are more prone to using marijuana to cope with their symptoms. in addition, students exhibiting symptoms of depression may be at increased risk for experiencing negative consequences related to their use. future studies should explore sex differences in the associations between cannabis use disorder/addiction and depression in college students and possible circular directionality of the relationship between use and depressive symptoms. contact: ha-yoon lee eeh95@uw.edu provider perspectives on mothers using marijuana during pregnancy and postpartum crystal lederhos smith, ekaterina burduli, olivia brooks, richa mehta, masha gartstein, celestina barbosa-leiker washington state university background: marijuana use during pregnancy has significantly amplified in the last two decades. stillbirth, low birth weight, and admission to neonatal intensive care units are linked to marijuana use during pregnancy. as the potency of δ-tetrahydrocannabinol (thc) has doubled in the past 10 years in the united states, previous studies may underestimate potential harms from current marijuana use. methods: healthcare providers in a state that legalized the sale of recreational marijuana in 2012 were interviewed to determine their perspectives about perceptions of risks and benefits of marijuana use during pregnancy and postpartum. we used qualitative description methodology to identify common themes in the data (transcripts) to provide definitions and details of the most prominent ideas provided by the participants’ responses. results: ten healthcare providers gave their perspectives. five themes emerged from the data: 1) prenatal risk, 2) current trends/normalization after legalization, 3) need for more research, 4) parenting and postpartum risk, and 5) personal beliefs vs. provider approach. conclusions: healthcare providers for pregnant and postpartum women who use marijuana may have a difficult time communicating with their patients about health risks due to perceived lack of definitive research on the topic. all the providers interviewed communicated that they felt that it was not safe for pregnant women to use marijuana, yet many of their patients tell them that they feel it is safe. many healthcare providers noted an increase in patient disclosure of use after legalization, which may present an opportunity to apply best practices for patient education. future work will offer healthcare providers a means of effective provision of this information to their patients. contact: crystal lederhos smith crystal.lederhos@wsu.edu conference abstracts 92 depressive symptoms, ruminative thinking, marijuana use motives, and marijuana outcomes melissa sotelo, adrian bravo, matthew r. pearson, cross-cultural addictions study team university of new mexico in previous studies, mediation models have shown that depressive symptoms and alcohol outcomes are mediated by rumination and drinking motives. the present study examined whether a similar mediation model could extend into marijuana using a cross-cultural sample. we examined distinct rumination facets (problemfocused thoughts, counterfactual thinking, repetitive thoughts, and anticipatory thoughts) and marijuana use motives (social, coping, expansion, conformity, enhancement) as doublemediators of the effects of depressive symptoms on marijuana use outcomes and consequences. using college student marijuana users (n=1,175) from 8 different universities in 5 countries (u.s., argentina, uruguay, spain, netherlands), we conducted a comprehensive mediation path model. multi-group models were tested to determine if the proposed mediational model was invariant across sex and different cultures/countries. the present study found that rumination and marijuana use motives mediated the associations of depressive symptoms with marijuana outcomes. participants who reported having higher depressive symptoms were found to have higher problem-focused thoughts; which in turn were associated with: a) higher endorsement of coping motives which in turn was associated with higher marijuana use and related consequences and b) lower endorsement of enhancement motives which in turn was associated with lower marijuana use and related consequences. the multi-group analyses showed that the model was invariant across sex and the five countries. while the present study found that marijuana use/misuse has a cross-culturally invariant negative affect regulation pathway similar to previous alcohol research, additional research is needed to confirm the role of enhancement motives in the associations of depression, rumination and marijuana outcomes. contact: melissa sotelo sotelomelis@gmail.com prevalence and correlates of medical cannabis patients' use of cannabis for recreational purposes meghan e. morean, izzy r. lederman oberlin college & yale school of medicine background. rates of legal medical cannabis (mc) use are increasing, but little is known about the prevalence and correlates of recreational cannabis (rc) use among medical users (mc/r). methods. 348 mc users who resided in a state in which mc is legal and had medical authorization to use mc legally completed an anonymous survey in spring 2017 (64.1% female, 82.8% white, mean age 33.03[±10.37] years). rates of endorsing mc/r and the following potential correlates of mc/r were examined: the legal status of rc in participants’ states of residence, sex, age, race, primary medical condition, mc product(s) used, mc expectancies, features of mc sought out (e.g., high tetrahydrocannabinol [thc] content), and negative cannabis use consequences. results. 55.5% of mc users engaged in mc/r. mc/r was associated with residing in a state in which rc is legal, being female, using mc for pain or mental health conditions, vaping mc concentrates, holding positive expectancies for combustible mc, and seeking out mc products with high thc concentrations. preferring mc products with high cannabidiol (cbd) concentrations protected against mc/r. conclusions. more than half of mc users endorsed mc/r, which is considerably higher than rates of misuse observed for other prescription medications. findings raise concerns about circumvention of rc laws in states where rc remains illegal and could be used to inform mc regulatory efforts (e.g., reducing thc content, increasing cbd content). findings also suggest that prevention/intervention efforts to reduce mc/r may be needed, especially among high-risk populations of mc users (e.g., women, patients using mc to treat the symptoms of chronic pain or mental health conditions). contact: meghan morean meghan.morean@gmail.com conference abstracts 93 examining marijuana use as a risk factor for discontinuity of care among persons living with hiv/aids bryan hartzler, beatriz h. carlini, jason r. williams, heidi m. crane, elvin h. geng, w. christopher mathews, kenneth h. mayer, richard d. moore, michael j. mugavero, sonia napravnik, benigno rodriguez, dennis m. donovan university of washington, university of california-san francisco, university of california-san diego, harvard university, johns hopkins university, university of alabamabirmingham, university of north carolinachapel hill, & case western reserve university background: marijuana use presents dilemmas for the clinical workforce that treats persons living with hiv/aids in the united states, among whom the estimated prevalence of marijuana use is more than triple that of the general population. while use of marijuana may be medically authorized to help manage aspects of the illness (i.e., nausea, neuropathy, pain, weight loss), patient susceptibility to develop marijuana use disorder (mud) is a concern for many clinicians. notably, mud is an established predictor of care discontinuity in the initial years following one's hiv diagnosis and linkage to care, though to what extent such risk extends to all marijuana-using hiv care recipients is unknown. methods: a comparative examination was undertaken in a multiregional center for aids research network of integrated clinical systems (cnics) cohort of 9153 americans linked to care at seven affiliated hiv settings. based on patient reporting on the alcohol, smoking, and substance involvement test and its established mud diagnostic threshold, this cnics cohort was trifurcated as: 1) marijuana abstainers (n=3376), marijuana users without mud (n=2932), and those with mud (n=2845). a binary, hrsa/hab-defined care continuity outcome (absent, present) was computed from visit data at cnics-affiliate settings for two years following patients' earliest recorded visit, with affirmative cases as those for whom records in both years documented attendance of two care visits separated by 90+ days. a generalized estimating equation (gee) tested a population-average model for this binary two-year care continuity outcome. the model: 1) included as potential effect modifiers four established mud predictors in this cohort (i.e., age-group, sex, care setting, assessment timing), 2) accounted for nonindependence of observations among patients at the seven cnics-affiliate settings, and 3) specified robust covariance structure due to the large cohort size. results: the multivariate gee model revealed a significant marijuana group effect, with lesser rate of care continuity among those with mud (68%) relative to that among marijuana abstainers (73%) and users without mud (72%). the gee model revealed effect modification by patient age-group, with larger discrepancies among young adults (aged 18-29 years) for whom 56% care continuity was evidenced among those with mud relative to 67-69% among same-age counterparts. in older age-groups, progressively higher care continuity rates were comparable across marijuana groups. the gee model also revealed effect modification by assessment timing, reflecting differential historical patterns of care continuity by marijuana group. whereas rates of care continuity among those with mud were stable across historical periods (66-72%), those rates evidenced somewhat greater historical variability among marijuana abstainers and users without mud (66-78%). conclusions: collective findings distinguish mudnot marijuana use per seas a risk factor for discontinuity in the initial years of hiv care, particularly among young adults. these and other at-risk patient groups continue to pose 'marijuana dilemmas' for the hiv workforce, thereby compromising domestic efforts to achieve the '90-90-90' public health goals. to mitigate marijuana-related risks for care discontinuity, hiv care settings may need to expand current surveillance practices to incorporate diagnostic assessment of mud. contact: bryan hartzler hartzb@u.washington.edu attitudes toward recreational versus medical marijuana among medical marijuana users, recreational marijuana users, and marijuana naïve individuals adams bellows, meghan morean oberlin college conference abstracts 94 background. medical marijuana (mm) and recreational marijuana (rm) are the same substance, but perceptions about the harms of use and support for legalization may differ based on the term that is used to describe the marijuana (i.e., mm or rm). methods. 617 adults completed an anonymous online survey in fall 2018 (76.8% female, 84.9% white, mean age 45.63[±15.29] years; 28.2% never marijuana users; 26.1% mm only users, 25.4% mm/rm users; 20.3% rm only users). for both mm and rm, participants reported on their perceptions of how high the typical user gets, negative consequences of use, driving impairment, addictive potential, and support for legalization for adults ages 21 and older. repeated measures general linear models were run to evaluate differences in perceptions based on the marijuana label specified (mm vs rm), marijuana use status, and their interaction. results. overall, participants thought that, compared to rm, mm is less likely to induce high, produces fewer negative consequences, impairs driving less, is less addictive, and should be legalized for adults ages 18 and older. for mm, interactions suggested that never users were less likely than mm/rm and rm users to think that mm get users high and more likely than all marijuana users to think that mm use has negative consequences, adversely impacts driving ability, and is addictive. mc only users were less likely than mm/rm and rm only users to believe that mm gets users high and less likely than rm only users to think that mm is addictive. regarding rm, never users were less likely than all marijuana users to think rm gets users high and to support legalization and were more likely to believe rc use has negative consequences, adversely impacts driving ability, and is addictive. mc only users were more likely than never users but less likely than mm/rm and rm only users to think that rm gets users high. mm only users also were more likely than mm/rm users to think that rm use leads to negative consequences and were less likely than rm only users to support legalized rm. conclusions. as mm continues to be legalized across the united states, marijuana use and perceptions of acceptability have increased while perceptions of marijuana-related harm have decreased. the current findings suggest shifting public opinion may be driven, in part, by the impact of referring to marijuana as “medical.” among all participants, referring to marijuana as medical versus recreational reduced all perceptions of harm and increased support for legalization. where differences in perceptions emerged based on marijuana use status, never users tended to have harsher attitudes toward both mm and rm than did marijuana users. mc only users tended to have more favorable attitudes toward mm and less favorable perceptions of rm. efforts are needed to educate the public that mm and rm are the same substance and share a profile of positive and negative effects. contact: meghan morean meghan.morean@gmail.com the benefits of using only medical cannabis to treat chronic pain compared to co-use with opiate and non-opiate pain medications izzy r. lederman, meghan e. morean oberlin college & yale school of medicine background: there is limited research on the positive and negative outcomes associated with solely using medical cannabis (mc) to treat the symptoms of pain conditions relative to co-use of mc with opioid and/or non-opioid medications. methods: an anonymous survey was completed in spring 2017 by 348 mc users who resided in a state in which mc is legal and had medical authorization to use mc legally. the analytic sample comprised 199 mc patients who reported using mc to treat the symptoms of a pain condition (58.8% female, 87.4% white, mean age 35.3[±10.23] years). medication use status (i.e., mc only, mc/opioids, mc/non-opioids, mc/opioids/non-opioids) was examined in relation to quality of life, current pain level, the frequency of using combustible mc, mc withdrawal symptoms, and negative consequences of mc use. results: patients reported using mc only (61.6%), mc/opioids (17.2%), mc/non-opioids (14.1%), and mc/opioids/non-opioids (7.1%). mc only users reported higher quality of life than the co-use groups with the exception of the small group of mc/opioid/ non-opioid users (n.s.). mc only users reported comparable levels of pain management compared to the co-use groups. no significant differences in the frequency of using combustible mc, the experience of withdrawal symptoms, or the experience of negative consequences of mc conference abstracts 95 use were observed. conclusions: pain patients who endorsed using only mc reported a higher quality of life than mc/opioid and mc/non-opioid users, comparable levels of pain management, and no evidence of increased negative outcomes of mc use (i.e., more frequent use, withdrawal, or negative consequences). these findings suggest that solely using mc to treat pain symptoms may produce comparable or, in some cases, better outcomes relative to co-using mc with traditional pain medications. these findings are particularly promising given the urgent need to reduce opioid pain medication use in light of the current opioid crisis. contact: meghan morean meghan.morean@gmail.com medical marijuana's impact on patients with chronic pain: looking beyond an individual's level of function nichole e. stetten, jamie pomeranz, michael moorhouse, ali yurasek, amy v. blue background. clinical trials examining the efficacy of medical marijuana show limited evidence of its therapeutic potential. the current field of research narrowly focuses on how medical marijuana improves level of functioning and ignores other key aspects of health-related quality of life (i.e. activities of daily living and participation in society). this focus stems from the standard medical approach that views disability as a condition or problem within an individual's body that needs treatment in order to "fix or cure the disability." the purpose of this study was to examine the effectiveness of medical marijuana beyond the level of functioning among individuals living with chronic pain in florida. methods. participants were recruited using convenience sampling from medical marijuana dispensaries, tobacco shops and online through florida specific facebook groups. interviews were conducted using the world health organization (who) disability assessment schedule (whodas 2.0) 12-item version. semi-structured interview questions were developed using the social ecological model. the whodas 2.0 was used to measure the range of disability caused by chronic pain in patients (i.e. level of functioning). the social ecological model was used to highlight the social determinants surrounding medical marijuana. a direct content analysis was used to analyze interviews. results. the overall whodas 2.0 scores show that most participants had a moderate impairment in functioning. within the six domains of functioning mobility had greatest level of impairment followed by life activities (i.e. domestic responsibilities, leisure, work and school) and participation (i.e. joining in community activities, participating in society). five separate themes were analyzed within the data: health impact of medical marijuana, cost, quality of life, social support, and accessibility. three subthemes emerged from the data that were not initially predicted in the direct content analysis: opioids and addiction, social media and travel. conclusions. results of the study show that participants report a significant improvement in functioning, specifically for levels of activity and participation. overall responses from participants show that medical marijuana may not cure them of their chronic pain, but it relieves symptoms enough for them to live again, thus improving their quality of life. participants also described using medical marijuana as a replacement for opioids in their treatment of chronic pain. these findings could show the potential for medical marijuana to serve as a harm-reduction approach for opioid addiction. contact: nichole stetten n.e.stetten@phhp.ufl.edu migraines and cannabis relief: online survey results from users in legal states hitchcock, ln, gibson, lp, yorkwilliams, s, mueller, r, bryan, ad, hutchison, k, bidwell, lc university of colorado, boulder background: as the legality of and cultural attitudes towards cannabis in the united states become more liberal, an increasing number of americans are turning to cannabis to selfmedicate a number of ailments, including migraines. both chronic and episodic migraines pose a major public health concern when left untreated by negatively impacting physical health, quality of life, interpersonal relationships, productivity, and financial security. as such, efforts must be made to understand the link conference abstracts 96 between cannabis consumption and migraine relief. methods: an anonymous “cannabis and health” online survey was advertised in 5 states with legal recreational cannabis to measure cannabis use and health profiles, including migraine prevalence. individuals (n=606) aged 21 and older living in states with legal recreational cannabis were compared for basic demographic information, cannabis use profiles, migraine prevalence and percent relief from cannabis and non-cannabis treatments. results: by examining data from an ongoing survey on cannabis use and health, data presented here provide compelling insights into the characteristics of those using legal market cannabis for migraines and the percent of relief that it provides. like controlled clinical trials and smaller case reports, our results support reports that migraine suffers (n=108 migraineurs, n=426 non-migraineurs) were primarily female (3:1 female to male) and aged 35±13 years and reported more edible use compared to non-migraineurs (ps < 0.05). importantly, cannabis reportedly provided 76±0.18% relief for migraines, significantly more than non-cannabis treatments by 30% (p < 0.05). this naturalistic report also demonstrated that non-migraine and migraine sufferers alike report: frequent use of flower and concentrates, cannabis use, with varying strengths of cannabinoids (much higher than previously researched in migraine suffers). conclusions: these preliminary report in cannabis use and effects on migraineurs lends strong support for further investigation, where blood cannabinoid levels, cognitive effects, and potential cannabis withdrawal could be tested before and after periods of cannabis use in relation to type, duration, and intensity of migraine relief. understanding how cannabis use may mitigate migraine symptoms is imperative to promoting the health and well-being of migraineurs and is an important first step in determining the potential for cannabis as an effective acute and prophylactic migraine treatment. contact: leah hitchcock leah.hitchcock@colorado.edu use of cannabis for pain in patients with active substance use disorders julia holloway, allison engstrom, jessica wyse, jennette lovejoy, travis lovejoy va portland health care system background: as many as 50% of patients with substance use disorders experience chronic pain, and many patients with substance use disorders use alcohol and other drugs to manage pain. in general and patient populations, cannabis has been associated with reductions in pain and improvements in functioning. however, research on this association has been limited, and few studies have examined the pathways in which cannabis improves pain, particularly in patients receiving substance use disorder treatment. procedures: we conducted in-depth qualitative interviews with 34 patients diagnosed with chronic non-cancer pain who were actively engaged in specialty substance use disorder treatment in a program serving patients in oregon and washington states. the interviews elicited descriptions of patients’ use of cannabis for pain and the perceived pathway in which this pain relief occurs. the coding team consisted of 4 research personnel. codes were iteratively developed from the data following the guidelines of qualitative content analysis. coded data were sorted into categories and concepts using a thematic analysis of all 34 interviews. each transcript was coded by two members of the team and consensus was reached on codes through open discussion. when consensus was not met between the two primary coders, the code was discussed among the entire team until consensus was achieved. exemplar quotes of key themes were selected for inclusion. results: patients were predominantly male (88%) and white, nonhispanic (91%). most patients were in treatment for alcohol use disorder (68%) or opioid use disorder (18%). only one patient was attending treatment as a result of cannabis use disorder, though cannabis use was common in this sample. of those participants who endorsed the benefit of cannabis thc and/or cbd on chronic pain, two perceived pathways emerged. in the first, participants described a direct benefit of cannabis on physical pain. some patients cited a direct link between cannabis use and a decrease in muscle tension and stiffness. others detailed a reduction in the need for opioids, muscle relaxants and other previously utilized pharmacologic pain relievers. in the second pathway, participants described an indirect benefit of cannabis on chronic pain through improvements in mental health conference abstracts 97 functioning. for these patients, cannabis distracted them from the pain, “took the edge off,” or reduced anxiety and depression, which subsequently resulted in less pain. conclusion: many patients receiving treatment for active noncannabis substance use disorders in this sample experienced reductions in pain and improvements in functioning with the use of cannabis, though benefits sometimes occurred indirectly through improvements in mental health. given widespread legalization of cannabis in the u.s. for medical and recreational purposes and the growing interest among patients to use cannabis as a primary or secondary pain treatment modality, additional well-controlled studies are needed that examine the benefits and harms of cannabis for chronic pain. contact: julia holloway juliaholloway821@gmail.com bidirectional relations between sleep problems and marijuana use in a nationally representative sample tess k. drazdowski oregon social learning center marijuana is a popular substance used among adults with over 48% reporting lifetime use in 2017. anecdotally and in emerging research, people report using marijuana to help with sleep and certain strains are marketed as sleep aids (e.g., "tahoe og kush"). in the united states more than a third of the adult population report not getting enough sleep, with estimated economic costs of $411 billion annually. prescription drugs are avoided because they are less effective over time and have unwanted side effects. however, people looking to use marijuana as a sleep aid contradicts research that using marijuana results in more sleep disturbances and reducing marijuana use improves sleep. while some work has looked at how sleep disturbances affect individuals' abilities to reduce their use, there is a dearth of research in this area; particularly how sleep problems and marijuana use may impact each other over time in generalizable samples. the present study addresses current research gaps by investigating the bidirectional relations between sleep problems and marijuana use in a longitudinal nationally representative sample of adults from the 2013-16 population assessment of tobacco and health (path) study. baseline data was collected from 32,320 adults (18 and older) via in-person computerized interviews who were followed annually for two years. sleep problems were assessed by self-reporting the, "last time you had significant problems with sleep trouble such as bad dreams, sleeping restlessly or falling asleep during the day." marijuana use was assessed by self-reporting the last time the participant, “used marijuana, hash, thc, grass, pot or weed.” all responses were recoded to: 0 = never, 1 = more than 1 year ago, 2 = in the past 2-12 months, and 3 = in the past 30 days. a path model focusing on within-person relations using maximum likelihood estimation for missing data was analyzed in mplus version 8 accounting for complex sampling and using replicate weights. results indicated that the data fit the model well (srmr = 0.003). after accounting for the correlations between the variables at each wave (e.g., wave 1 sleep problems with wave 1 marijuana use) and previous levels of each predictor (e.g., wave 1 sleep problems predicting wave 2 and wave 3 sleep problems), more recent sleep problems were significant predictors of more recent marijuana use over time. the reverse was also supported; more recent marijuana use predicted higher rates of sleep problems across all waves (betas = 0.01-0.06; all ps < .000). this study supports a bidirectional relationship between sleep problems and marijuana use, such that individuals who have more sleep problems report more marijuana use and those that use more marijuana, in turn, report more sleep problems. alternative evidence-based methods for improving sleep, such as cognitive-behavioral therapy for insomnia (cbt-i), may be more appropriate for reducing sleep problems and may result in reduced marijuana use over time. future work needs to investigate the use objective measures of sleep problems and get more detailed information about the strains and method of marijuana ingestion being used. contact: tess drazdowski tessd@oslc.org heavy marijuana use and risky decisionmaking in young adult college students jorie casey, anita cservenka conference abstracts 98 oregon state university objective: marijuana (mj) is the most widely used illicit substance, and its use is especially prevalent among adolescents and young adults. previous evidence suggests frequent mj use is associated with impairments in cognitive flexibility and inhibition, both of which play important roles in decision-making. however, the effects of chronic mj use on decision-making performance are mixed and not well understood. given the protracted development of the prefrontal cortex, young adulthood may be especially sensitive to the neurotoxic effects of mj use. the current study examined the influence of heavy mj use on risky decision-making in college students, 18-22 years old, who were recruited as part of a larger study on mj use and executive functioning. method: 33 healthy controls (hc) (mean age: 19.18 ± 1.13; 18 male, 15 female) and 27 heavy mj users (mj+) (mean age: 20.22 ± 1.19; 18 male, 9 female) reporting ≥5 episodes of mj use per week over the past year were included in the current study. participants were instructed to remain abstinent from mj use for 12 hours prior to their study visit to ensure they were not acutely intoxicated during testing. the 30-day timeline followback (tlfb) was used to assess recent mj use and participants were asked to estimate age at first mj use and lifetime days of mj use. participants completed the iowa gambling task (igt), a measure of risky decision-making, and net igt scores (advantageous-disadvantageous decisions) were used as a measure of optimal decision-making. analysis of covariance was used to examine group differences in decision-making performance while controlling for age and iq. furthermore, exploratory analyses investigated the effects of group, sex, and their interaction on decision-making performance. results: there was a trend for the effect of group on net igt scores (f(1,56) = 3.209, p = 0.079, partial eta squared = 0.054), such that mj+ made more disadvantageous decisions on the igt compared with hc. the exploratory analyses indicated a non-significant group-by-sex interaction on net igt scores. the final model with main effects of group and sex showed a significant effect of group on net igt scores (f(1,54) = 5.399, p = 0.024, partial eta squared = 0.091) and a trend for the main effect of sex (f(1,54) = 3.295, p = 0.075, partial eta squared = 0.058). mj+ had lower net igt scores than hc and female participants had a trend towards lower net igt scores than male participants. there were no significant relationships between age at first mj use, past 30day mj use occasions or lifetime days of mj use and net igt scores in mj+. conclusion: these findings suggest heavy mj use in young adults may impair adaptive decision-making. further research is needed to understand whether impairments in mj+ are a result of the neurotoxic effects of mj or if riskier decision-making may be present in mj+ prior to initiation of mj use, and whether these differences persist after abstinence. contact: anita cservenka anita.cservenka@oregonstate.edu cannabis use predicts indicators of academic problems regardless of academic self-efficacy samuel m. dicecco, bradley t. conner colorado state university college is a heightened time of risk for emerging adults for engagement in a host of health risk behaviors, chief among them the initiation and continuing use of cannabis. a large body of literature indicates that there are risks for negative academic outcomes resulting from cannabis use, including low grades, dropping classes, and eventually dropping out of college all together. however, research often fails to assess attitudes towards school, including whether a college student sees themselves as able to be successful in the college environment. there is also a large body of research that indicates that academic self-efficacy is a significant inverse predictor of negative academic outcomes. given the prevalence of cannabis use among college students and the costs associated with experiencing negative academic outcomes, it is important to understand whether cannabis use may moderate these relations. we hypothesized that 30-day cannabis use would moderate the relation between academic self-efficacy and indicators of academic problems such that as 30day use increased the relation between selfefficacy and problems would significantly weaken. data for this study come from a college undergraduate population attending college at a large public institution in the american west (n = conference abstracts 99 989, 73.4% female, mean age = 19.45, sd = 2.4, 75% white). we spss process v3.3 (hayes, 2019) was used to test whether past 30-day cannabis use moderated the relation between academic self-efficacy and indicators of academic problems. results indicated that academic selfefficacy significantly negatively predicted indicators of academic problems (b = -0.12, se = 0.01, p < 0.001). however, results revealed that the relation between academic self-efficacy and indicators of academic problems was not significantly moderated by 30-day cannabis use (p = 0.72). additional analyses revealed that, while 30-day cannabis use significantly predicted indicators of academic problems (b = 0.35, se = 0.09, p < 0.001), it did not predict nor was it predicted by academic self-efficacy (p = 0.13 and p = 0.13 respectively). that 30-day cannabis use did not impact the negative relation between academic self-efficacy and indicators of academic problems failed to support study hypotheses. this indicates that the relation between academic selfefficacy and indicators of academic problems is robust to cannabis use. however, cannabis use is predictive of increased indicators of academic problems regardless of level of academic selfefficacy. results indicate that reducing 30-day cannabis use may reduce experiencing negative academic outcomes. contact: samuel dicecco sam.dicecco@colostate.edu cannabisand alcohol-related protective behavioral strategies: evidence of crossover effects brittany e. blanchard, angela k. stevens, andrew k. littlefield texas tech university & alpert medical school of brown university over the past few decades, attention to substancerelated protective behavioral strategies ([pbs]; i.e., ways in which individuals reduce consumption and/or consequences associated with substance use) has increased exponentially. most evidence indicates naturalistic use of pbs is negatively associated with consumption and consequences for the respective substance. moreover, recent work demonstrated pbs crossover effects, such that use of one substancespecific pbs (i.e., alcohol) is associated with reduced consequences for another outcome (i.e., pathological gambling). original cannabis-related pbs work indicated a small-to-medium association with this construct and use of alcoholrelated pbs; however, no study, to our knowledge, has yet to examine potential crossover effects for alcoholand cannabis-related pbs. thus, the purpose of this study was to reexamine original pbs association findings and estimate the correlations between use of alcohol pbs on cannabis outcomes (i.e., consumption and use disorder criteria), and vice versa. participants consisted of college students from a large, hispanic-serving southwestern institution who endorsed lifetime cannabis use and past-year alcohol use (n = 501). the sample consisted of individuals self-identifying as 65% women, 67% white, non-latinx, 16% latinx, mean age = 19.22, sd = 2.41). participants completed a battery of self-report assessments, including the protective behavioral strategies for marijuana (pbsm), protective behavioral strategies scale-20 (pbss20), national institute of alcoholism and alcohol abuse recommended alcohol consumption questions, a modified daily drinking questionnaire to assess past-month cannabis use, and dsm-5 alcohol and cannabis use disorder criteria. first, a series of psychometric evaluations (i.e., exploratory factor analyses [efa], confirmatory factor analyses [cfa], graded response models, and measurement invariance testing across gender) were conducted. next, structural equation models were used to examine latent variable correlations among constructs of interest. results suggested a 44item, one-factor solution for the pbsm. the pbss-20 factor solution was not recovered from efa, though cfa indicated good fit. measurement invariance was not demonstrated when using multigroup cfa and difftest. neither scale exhibited partial scalar invariance, suggesting differential item functioning across at least 8 items per scale. significant associations suggested crossover effects. specifically, among women, use of all three types of alcohol-related pbs (i.e., stopping/limiting drinking, manner of drinking, and serious harm reduction) was negatively associated with past-month cannabis frequency (rs = -.13 to -.24) and cannabis use disorder criteria endorsement (rs = -.21 to -.37). for cannabis pbs use, a similar pattern emerged conference abstracts 100 with alcohol consumption (r = -.29) and alcohol use disorder criteria endorsement (r = -.17). among men, all three types of alcohol-related pbs were associated with cannabis use frequency (r = -.25 to -.43), while only serious harm reduction was significantly associated with cannabis use disorder criteria endorsement (r = -.32). cannabis pbs use was also significantly associated with alcohol consumption (r = -.29) and alcohol use disorder criteria endorsement (r = -.27) among men. although these crossover effects require replication in clinical samples, these preliminary findings suggest use of one type of pbs can have protective effects. contact: brittany blanchard brittanyblanchard96@gmail.com the effects of health beliefs on marijuana protective behavioral strategies olivia bolts, alex robredo, mark prince colorado state university greater use of protective behavioral strategies (pbs) is associated with lower frequency of problematic marijuana use, fewer experiences of negative marijuana related consequences, and fewer symptoms of cannabis use disorder among young adults. identifying person-specific characteristics related to pbs use is important because of the potential to help explain why some individuals engage in protective behaviors while others do not. the current study employed the health belief model (hbm) as a theoretical base to examine person-level characteristics. the hbm is an effective framework in substance use research for predicting and explaining engagement in preventive behaviors, including self-control strategies for limiting drinking. the goal of the current study was to discern latent profiles of hbm variables (i.e., susceptibility, severity, benefits, barriers, cues to action measured by consequences) and to test whether latent profiles were differentially associated with use of protective behaviors. to achieve this goal, we performed a latent profile analysis (lpa) to identify profiles of health beliefs and marijuana related consequences while controlling for gender and marijuana use frequency. we tested differences in pbs use frequency among the latent profiles using the bch method in mplus. the sample included 334 undergraduate students (mage = 18.8; 63.2% female; 78.7% white). following recommendations by nylund et al. (2007) for determining class structure, a 3-profile solution best fit the data. we identified three different health belief profiles, labeled as 1) adaptive beliefs/low consequences (ablc), 2) maladaptive beliefs/moderate consequences (mbmc), and 3) maladaptive beliefs/high consequences (mbhc). the ablc profile was associated with the greatest frequency of pbs use. the mbmc profile and mbhc profiles did not differ on pbs use, but the mbmc profile appears to be associated with more effective use of pbs as a harm reduction method compared to the mbhc profile. moreover, the mbmc profile was associated with experiencing a moderate amount of consequences despite using pbs, which is likely due to their demotivating belief system. taken together, these profiles suggest that individuals with adaptive beliefs may be more likely to recognize the severity of consequences and the benefit of protecting oneself through pbs, whereas individuals with maladaptive beliefs appear more likely to minimize the severity and susceptibility of consequences and have greater beliefs of barriers to using pbs. results of the present study demonstrate the importance of identifying person-specific variables that may facilitate with tailoring brief interventions for marijuana use. for example, individuals in the ablc profile would benefit from support to continue with their adaptive beliefs and engagement in protective behaviors. individuals in the mbmc profile would benefit from corrective beliefs to be more adaptive. lastly, individuals in the mbhc profile would benefit from learning to use more effective protective strategies. overall, interventions for marijuana use might be more effective by including a focus on beliefs associated with health, as well as helping individuals protect themselves through psychoeducation of pbs. contact: olivia bolts olivia.bolts@colostate.edu identifying classes of people who endorse marijuana-related health risks and benefits bethany r. shorey-fennell, renee e. magnan, benjamin o. ladd washington state university vancouver conference abstracts 101 with growing popularity of marijuana, a wide range of perceptions of both the health risks and benefits of its use abound. currently, many of these perceived effects are based on anecdotal evidence rather than rigorous empirical support. the goal of the current investigation is to explore if meaningful groups of individuals can be identified based on their endorsement of various health effects of marijuana. undergraduate students (n=398, 77.4% female, mage=21.21), both users and nonusers, indicated whether they believed 30 health risks (e.g., causes lung damage, worsens sleep quality) and benefits (e.g., relieves pain, protects against memory loss) to be true. a latent class analysis using sas proc lca, considering parsimony and interpretability, revealed a 2-class model best fit the data. class 1 (c1; 55.1%) reported perceiving few benefits and many risks regarding marijuana use. class 2 (c2; 44.9%) reported perceiving many benefits and moderate risk. for example, participants in c1 were more likely to endorse that marijuana use could be addictive (87.3%) than those in c2 (43.4%), and less likely to endorse that it could treat nausea and stomachache (55.4% c1 vs. 75.8% c2). additionally, participants in c2 were more likely than those in c1 to endorse that marijuana use can improve sleep (85.8% c2 vs 70.0% c1) or treat cancer (53.9% c2 vs 40.4% c1), and less likely to endorse some risks such as causing psychosis (23.0% c2 v 67.0% c1). although individuals in c2 endorsed more benefits to marijuana use, they did not perceive it as risk free. for example, over two-thirds of c2 (67.7%) indicated that marijuana could cause birth defects during pregnancy. there was also agreement between classes (i.e. less than 10% separation in endorsement rates) for 23% of the health risk and benefit items. this agreement included, generally high endorsement of some benefits (e.g. relieves pain; 94.1% c1, 96.6% c2) and generally low endorsement of some benefits (e.g. protects against memory loss; 7.8% c1, 7.2% c2). while there was some agreement across classes, these results may be indicative of the current polarization in attitudes toward marijuana use, with a little over half of individuals perceiving few benefits but many risks in engaging in this behavior, and a little under half endorsing many benefits but only moderate risks. follow-up analyses will explore if there are differences between these classes in marijuana use and marijuana-related problems. where these groups differ and agree may yield targets for future marijuana education interventions. contact: bethany shorey-fennell b.shoreyfennell@wsu.edu protective behavioral strategies mediate the relation of happiness, life satisfaction, psychological well-being on marijuana-related consequences kirstyn n. smith-lecavalier, mark a. prince, cross-cultural addictions study team colorado state university happiness has been characterized across 17 subjective domains including housing, vocation/education, alcohol/drug use, etc., life satisfaction is defined as a subjective-global assessment of one’s quality of life based on standards or expectation the individual has set for themselves, and psychological well-being (pwb) has been characterized across six domains, i.e., autonomy, environmental mastery, personal growth, positive relationships with others, purpose in life, and self-acceptance. there is a great amount of research showing that these constructs are negatively associated with higher levels of marijuana use, but little research has been done to explore the relation between these constructs and marijuana-related consequences (mrc). additionally, happiness, life satisfaction, and pwb have frequently been explored as outcomes of use and related constructs, but very few studies have examined these constructs as predictors. it has yet to be explored how happiness, life satisfaction, and pwb predict pbs use frequency. the use of protective behavioral strategies (i.e., strategies used to reduce use or harms associated with use) are robustly, negatively associated with mrc. it has yet to be established how differing levels of happiness, life satisfaction, and pwb predict pbs use frequency, and how happiness, life satisfaction, and pwb predict mrc via pbs use frequency. we hypothesized that individuals who report higher levels of happiness, life satisfaction, and pwb would also report using more pbs and therefore would experience less mrc. the present study used data collected from us college students as conference abstracts 102 part of a large multi-site sample (n = 698, 63.8% female). we used path analysis to examine the mediating power of pbs use frequency on the relations between happiness and mrc, life satisfaction and mrc, and the six individual facets of pwb and mrc, controlling for past 30day marijuana use. we used the product of coefficients method to determine the significance of the indirect effects. in assessing direct effects, pbs use frequency negatively predicted mrc in all models. additionally, happiness, life satisfaction, environmental mastery, positive relations with others, purpose in life, and selfacceptance were positively associated with pbs use frequency. the indirect effects from these 6 constructs to mrc via pbs use frequency were also significant and negatively associated. however, autonomy and personal growth did not predict pbs use and the associated indirect effects were not significant. this indicates that happiness, life satisfaction, and some facets of pwb predict mrc through their influence on pbs use frequency. our findings suggest that the relation between happiness, life satisfaction, and pwb and the experience of mrc may be closely linked to pbs use frequency, and that happiness, life satisfaction, and pwb may be a significant determinate in one’s willingness to use pbs. this suggests that happiness, life satisfaction, and pwb may be important factors to take into account when tailoring prevention and intervention efforts. more specifically, focusing these efforts towards individuals experiencing lower levels of happiness, life satisfaction, and pwb could mitigate harms associated with use via pbs. contact: kirstyn n. smith-lecavalier kirstynlecavalier@gmail.com runner's high...or high runners? exercise as a motive for marijuana use trevor j. levingston, luke m. walker, benjamin o. ladd washington state university vancouver since 2004, marijuana and cannabinoids have been listed as performance-enhancing drugs (ped; u.s. anti-doping agency, 2019). nevertheless, many professional and recreational athletes admit to using cannabinoids in training and/or competition with the intent of increasing performance (huestis et al., 2011; campian et al., 2018). in the current analysis, we aimed to evaluate the importance of exercise-related motives in predicting the frequency of adult marijuana use, in relation to already established marijuana-use motives. to assess marijuana motives, we used the 5-factor marijuana motives measure (mmm; simons et al., 1998), a validated measure used in predicting overall marijuana use and use-related problems, which assesses the relative importance of enhancement, conformity, expansion, coping, and social motives for marijuana use. additionally, we created a 5-item measure of exercise motives assessing participants' beliefs of marijuana's effects on the enjoyment, motivation, recovery, feelings of reward, and performance in relation to exercise on a likert scale similar to that used in the mmm. using cross-sectional data collected from marijuana-using adults in oregon and washington state, results of a linear regression revealed the 5-factor mmm was not a significant predictor of marijuana use. however, the addition of the exercise motives component resulted in a significant increase of variability explained (δr2 = .053, f(6,70) = 2.61, p = .024), such that the overall model with the 6-factor motivation construct significantly predicted marijuana use frequency. the simple effect of exercise motives was a unique and significant predictor (β = .238, p = .037). given that the mmm has been studied primarily within college students and younger adults, these results provide evidence that a 5factor model may not accurately capture the complexities of motivations for marijuana use among non-college aged adults. understanding the role of exercise-related marijuana use motives could help inform future research regarding the physical and mental health implications of using marijuana; for example to facilitate exercise in specific populations such as for individuals with chronic pain disorders or obesity. contact: benjamin ladd benjamin.ladd@wsu.edu conference abstracts 103 symposia symposium: promising (and not so promising) pharmacological treatments for cannabis use disorder chair: matthew r. pearson university of new mexico despite the relatively low addictive potential of cannabis relative to other substances used for their euphoria-inducing properties (e.g., alcohol, tobacco, cocaine, heroin), the high rates of cannabis relative to many of these substances (e.g., cocaine, heroin, etc.) results in cannabis use disorder (cud) being the third most prevalent substance use disorder (only behind alcohol and tobacco). to date, the u.s. food and drug administration has approved of three medications for treating alcohol use disorder (acamprosate, disulfiram, and naltrexone), three medications for treating opioid use disorder (buprenorphine, methadone, and naltrexone), and six medications for treating tobacco use disorder (buproprion, varenicline, nicotine inhaler, nicotine spray pump, nicotine gum/lozenge, and nicotine transdermal patch). however, no medication is currently fda-approved for treating cannabis use disorder (cud). thus, there is clearly a need to develop effective medications for treating cud, but there are a number of challenges, including some general challenges to drug discovery in general as well as some specific challenges for treating cud in particular. matthew pearson will present some perspective from systematic reviews and meta-analyses of pharmacotherapies for treating cud. kevin gray will review the evidence base for n-acetylcysteine (nac) as a treatment for cud, highlighting differences found with adolescent vs. adult populations. aimee mcrae-clark will review some new findings with oxytocin, progesterone, and varenicline as possible medications to treat cud. contact: matthew r. pearson mateo.pearson@gmail.com what we can learn from systematic reviews and meta-analyses of pharmacotherapies for cannabis use disorder matthew r. pearson, jon houck, kevin s. montes university of new mexico, california state university dominguez hills to date, no pharmacotherapy has been approved for treating cannabis use disorder (cud). in this systematic review, we characterize the heterogeneity in treatment outcomes as well as the inclusion/exclusion criteria across clinical trials examining pharmacotherapies for cannabis use disorder (cud). we consider how these methodological factors may contribute to the lack of discovering efficacious medications for cud. next, we use meta-analysis to develop the most precise effect size estimates for various pharmacotherapies for cud. the story of n-acetylcysteine as a pharmacotherapy for cannabis use disorder kevin m. gray medical university of south carolina the over-the-counter antioxidant nacetylcysteine (nac) reduces drug seeking and reinstatement in animal models via effects on glutamate in the nucleus accumbens. its potential application as a pharmacotherapy in clinical populations has been the focus of recent research, yielding an array of findings across substance use disorders. specific to cannabis use disorder (cud), a randomized controlled trial (rct) in adolescents yielded positive findings, while a subsequent rct in adults yielded null findings. these discrepant results will be presented and discussed in the context of platform treatments, participant characteristics, and developmental considerations. ongoing research involving nac for cud will be introduced, and the potential role of nac as an adjunctive pharmacotherapy in the clinical management of cud will be discussed. conference abstracts 104 novel pharmacotherapy targets for cannabis use disorder treatment aimee mcrae-clark medical university of south carolina previously explored pharmacotherapeutic agents for cannabis use disorder have targeted the serotonergic, dopaminergic, and noradrenergic neurotransmitter systems; however, positive results in clinical trials have been limited to date. this talk will focus on recent data involving novel pharmacologic targets and interventions for cannabis use disorder. oxytocin is a hypothalamic neuropeptide that has been shown to mediate behavioral responding to stress as well as play a role in neuroadaptations that occur as a consequence of long-term drug use, including modulation of cannabis craving. a growing literature suggests that ovarian hormones also play a key role in drug use, misuse and stress, and that exogenous progesterone may attenuate drug sensitivity and behavior as well as mitigate cannabis withdrawal-induced craving. finally, varenicline, a selective nicotinic acetylcholine receptor partial agonist of the α4β2 subtype and a full agonist of the α7 subtype, may improve cannabis use outcomes through multiple mechanisms, including interaction with the mesolimbic dopamine system and reduction in withdrawal associated negative affect. preliminary data on these agents and their potential utility in treatment of cannabis use disorder will be discussed. discussant: matthew r. pearson university of new mexico symposium: marijuana use and adolescents: epidemiology, policy, and longitudinal consequences chair: douglas c. smith university of illinois at urbana-champaign adolescence is thought to be a developmentallysensitive period, during which marijuana use may confer a heightened risk for consequences relative to use occurring later in development. this symposium addresses multiple topics related to marijuana use by adolescents, including: optimal screening procedures for heavy marijuana use among adolescents, developmental risk factors in adolescence that predict emerging adult co-use of marijuana and other substances, and whether adolescents residing near medical marijuana dispensaries use more marijuana than those living further away from them. because research on marijuana among teens is a national priority in our current policy environment, the research in this symposium is critical. these studies use rigorous methods and large datasets to make novel contributions, extending our understanding of screening, risk and protective factors, and the impact of medical marijuana policies on adolescents. contact: douglas c. smith smithdc@illinois.edu sensitivity and specificity of the crafft to identify heavy cannabis use: evidence from a large statewide adolescent sample douglas c. smith, kelly clary, carol lee, angus lanker university of illinois at urbana-champaign background: the crafft (car, relax, alone, forget, friends, trouble, 1999) is one of the most widely used screening instruments for adolescents to diagnose aud and sud. this study examined optimal cutoffs for the overall sample, examined subgroup differences, and tested whether using a modified version of the car item improved its performance. iys is a self-report survey administered in school settings and is designed to gather information about a variety of health and social indicators including substance use patterns and attitudes of illinois youth. methods: participants were youth who responded to the illinois youth survey (iys) in 2018. iys is a statewide survey representative of 6th, 8th, 10th, and 12th grade youth attending public schools in illinois. a total of 138,214 adolescents (age range, 13-19 years) were included in the analysis. the mean age of the sample was 16.18 (sd 1.205) years with more girls (n = 70,291; 50.9%) than boys (n=65,283; 47.2%). receiver operating characteristic (roc) curves were calculated to determine optimal crafft cutoff scores for identifying adolescents with heavy cannabis use (i.e., 10 occasions or more in past 30 days). optimal cutoffs were those with a conference abstracts 105 combination of the highest youden’s index alongside sensitivities larger than 0.8. results: the mean crafft score was 0.739 (sd 1.34), with 5.2% of participants reporting heavy cannabis use. the crafft performed best in the overall sample at a cut score of 2 (sensitivity, 81.17%; specificity, 83.96%) with area under the curve (auc) of 0.878; 95% confidence interval 0.873 0.882. sensitivity (81.31%), specificity (85.66%) and auc (0.896) were not substantially improved by replacing the car item. performance of the crafft did/did not differ by gender, race, free and reduced lunch status, or whether the participants lived in rural areas. conclusions: the crafft has excellent sensitivity and specificity for detecting heavy cannabis use among adolescents. this study is the largest study of the crafft ever conducted, and supports the cutoff of 2 established by other research. further, it appears that the performance of the crafft is not enhanced by requiring youth to specify if they personally were driving a car under the influence. subgroup analyses in this very large study generally support the use of the crafft among diverse populations of adolescents. adolescent risk factors for marijuana co-use with tobacco and alcohol during young adulthood: a 10-year longitudinal study elizabeth j. d’amico, anthony rodriguez, eric r. pedersen, joan s. tucker rand corporation given the changing legal landscape of marijuana, studies need to better understand the co-use of marijuana with other substances, including alcohol and tobacco, among young people. we analyzed data from a diverse sample of youth surveyed annually from ages 11 to 21 to assess trajectories of individual, peer, family, and neighborhood factors in middle and high school and the associations of these trajectories with concurrent and sequential co-use at age 21. concurrent co-use was defined as using both alcohol/marijuana (cam) or tobacco/marijuana (ctm) in the past month. sequential co-use was defined as using both alcohol/marijuana (sam) or tobacco/marijuana (stm) on the same occasion during the past month. parallel-process piecewise latent growth models evaluated how each developmental trajectory (i.e., middle vs. high school) across the four domains predicted four types of co-use at age 21. rates of co-use were 21% for sam, 10% for cam, 14% for stm, and 6% for ctm. increases in perceived peer use during both middle and high school predicted greater sam and cam, and for high school, also greater stm and ctm. increases in sibling use during middle school were associated with greater ctm. increases in positive expectancies during high school were associated with greater sam. greater resistance self-efficacy during middle and high school were associated with lower sam and stm, and in high school, also with cam. perceived peer use and resistance self-efficacy trajectories emerged as primary predictors of co-use across both developmental periods, highlighting the importance of prevention programming addressing peer influence throughout adolescence. proximity of medical marijuana dispensaries and adolescent marijuana use allison salisbury, douglas c. smith, shahana begum university of illinois at urbana-champaign in the united states, 19 states permit medical marijuana and nine states and the district of columbia permit fully legal recreational use of marijuana (marijuana policy project, 2019). a central concern that continues to emerge in debates about marijuana policy is whether liberalized marijuana policies will result in increased adolescent marijuana use. to date, there is no evidence that adolescents are increasing their use in states with liberalized policies (hasin et al., 2015), but these analyses were based on state prevalence estimates. this study extends this research by using a statewide representative epidemiological survey called the illinois youth survey to determine if dispensary location is associated with higher adolescent marijuana use. methods. dispensary locations (i.e., zip codes) and license dates were obtained by the illinois department of public health, which regulates dispensaries. participant zip codes on the iys were matched to dispensary location zip codes to determine if adolescents lived nearby a dispensary. we compared past 30 day and past year use of any marijuana. results. approximately 13% (n = 1348) of adolescents in conference abstracts 106 the weighted sample (n=11,259) resided in a zip code with a dispensary. the prevalence of marijuana use (30 day/past year) was 6.6%/9.7%, 10.6%/16.9%, and 20.1%/30.9% for 8th, 10th, and 12th graders in in dispensary zip codes, respectively. however it was 5.2%/8.4%, 13.7%/20.3%, and 26.4%/36.1% for 8th, 10th, and 12th graders youth not in dispensary zip codes, respectively. in sensitivity analyses, we analyzed the non-weighted dataset (n=231,000). findings diverged where 8th graders in zip codes dispensaries no longer had higher past 30 day and past year prevalence. however, 10th and twelfth graders in this analysis living in dispensary zip codes did. conclusion/discussion. although this study was cross-sectional and used a crude measure of proximity to marijuana dispensaries, findings raise some concerns about the association between the influence of medical marijuana on adolescent marijuana use prevalence. this was especially problematic for 8th graders in our weighted sample, who had higher past month and past year marijuana use if they lived in dispensary zip codes. these findings should be replicated in longitudinal designs with better distance measures. symposium: current issues in the measurement of cannabis use chair: bradley t. conner colorado state university while highly controlled lab studies provide exact information regarding cannabis administration, there are a limited number of researchers who are allowed to conduct cannabis administration research. field research on cannabis use, while more common, is typically limited to self-report on established scales that may be missing key information. the first talk in this symposium will present data collected from regular-to-heavy cannabis users who provided quantity and potency information about their most recent retail cannabis purchase to assess links between cannabis potency and mental and physical health outcomes. the second talk provides data on a feasibility trial of a new smart vaporizer that provides automatic real-time data collection of quantity, potency, and frequency of cannabis concentrate use and allows for survey data collection that is prompted by cannabis use. the third talk in this symposium will present data comparing measures of cannabis use disorder and cannabis use motives across a sample comprised of both college students and veterans to determine if measures are invariant across samples. the goal of this research is to test whether construct definitions are the same across these two populations. the final study will present a qualitative analysis of data on patterns of cannabis use from a sample of regular-to-heavy recreational cannabis users to elucidate complex patterns of cannabis use across method of administration, time of day, and other key variables. contact: bradley t. conner brad.conner@colostate.edu the relation between cannabis potency and mental and physical health outcomes bradley t. conner, mark a. prince colorado state university cannabis use is associated with unwanted health outcomes, including anxiety, depression, poor sleep hygiene, and disrupted cognitive functioning. however, research to date has not been able to disentangle the complexities of these relations, leaving behavioral health service providers lacking clear direction for treatment. a limiting factor may be the common practices for cannabis use assessment. cannabis use is typically assessed by frequency, even though to estimate the amount of psychoactive compounds ingested potency, quantity, and route of administration should also be assessed. this study, one of the first of its kind, takes an important step in assessing cannabis use by studying the link between cannabis potency and behavioral health (i.e., physical and mental health) outcomes. data from two studies will be presented. the first study used facebook recruiting to gather data from 156 regular to heavy cannabis users (44.7% female). in the first study, self-reported data were analyzed using the new statistics, which focuses on effect sizes and confidence intervals, rather than null hypothesis significance testing. findings were inconsistent, with some positive, some negative, and some trivial associations across four domains (i.e., demographic variables, cannabis use variables, conference abstracts 107 mental health, and physical health). the most valuable discovery was the importance of method of administration in understanding the link between potency and health. we observed a “potency valley” (i.e., a range of potencies for which products were not available) between flower potencies and concentrate potencies. further, collapsing potency data across flower and concentrated cannabis obscured important relations between cannabis potency and behavioral health outcomes. the second study is currently gathering data from customers at retail cannabis locations in denver, co. participants are asked to provide an email address and to allow researchers to photographically record the product information off the labels of the products they had just purchased. the goal of the second study is to replicate findings from the first study while improving on study design issues noted in the initial data collection. we hypothesize that we will replicate findings of links between cannabis potency and mental and physical health outcomes. findings from both studies suggest that to more fully understand the relation between cannabis potency and behavioral health outcomes, researchers should examine potency separately across routes of administration. automatic realtime data collection of cannabis use mark a. prince, bradley t. conner colorado state university cannabis use is defined by at least four indicators, i.e., frequency, quantity, potency, and route of administration. it is imperative that variables that define cannabis use be distinct from those that define problematic cannabis use to be able to predict beneficial and adverse physical and mental health outcomes resulting from cannabis use. the national academies of sciences, engineering, and medicine (nas) reviewed over 10,000 research reports on the health effects of cannabis and concluded that, to date, there is “insufficient evidence to support or refute” (pg. 120) conclusions regarding cannabis’ effects on a host of physical and mental health outcomes. one limiting factor in building an evidence base linking cannabis use to health outcomes is the difficulty collecting accurate cannabis use data. even utilizing the current best practice of ecological momentary assessment relies on selfreported cannabis use information. importantly, previous research has shown that participants are unable to accurately report on cannabis quantity and may not know the potency of the products they are consuming. the state-of-the-science today is the gofire bluetooth enabled vaporizer, which, for the first time, allows for automatic collection of cannabis use data (i.e., frequency, quantity, potency, and standardized route of administration) without the need for self-report. the gofire device delivers metered doses of cannabis with known chemical profiles that are tracked in a database linked to an interactive smartphone application (app) where participants can provide information on personal reasons for use (e.g., anxiety, sleep, pain) and efficacy of use for the selected reason. automatically collecting lab quality dose and schedule data maximizes internal validity, while simultaneously maximizing ecological validity by allowing participants to purchase their own cannabis product to use as they typically would. additionally, using the gofire device and app results in the collection of big data that is wellsuited for predictive analytics. the present study reports on preliminary data from a pilot study of 20 regular cannabis users from a state with legal recreational cannabis. we will compare cannabis use data to timeline followback data and discuss participants’ experiences related to using the device (i.e., satisfaction, reasons for use, effectiveness). the gofire device has the potential to be a useful tool for cannabis researchers interested in collecting precise cannabis use data without the need for self-report. assessing invariance of marijuana motives and cannabis use disorder assessments in veterans versus college students morgan l. sneed, samuel r. davis, theodore j. fetterling, mark a. prince, bradley t. conner colorado state university as legislative changes have increased access cannabis for recreational and medicinal purposes, use and the prevalence of cannabis use disorder among veterans have also increased. research shows that marijuana motives are a predictor of both cannabis use and consequences from cannabis use, including the development of conference abstracts 108 cannabis use disorder. research has led to the development of commonly used measures of marijuana motives and cannabis use disorder. typically, these measures are deployed in research on different samples of the overall population without testing whether the construct definitions underlying these assessments are valid. in other words, researchers assume that different segments of the population (i.e., veterans, civilians, college students) all define marijuana motives the same way, however, very little research has examined the validity of this statement in samples of veterans. additionally, even within special populations, such as veterans, some research has shown that variations in construct definitions may exist. for instance, research has shown that construct definitions of alcohol use motives differ among veterans based on whether they were deployed (mansfield et al., 2010). research has also indicated that factor structures of motives measures may be unstable for both alcohol and cannabis use motives (o’hara). the current research attempts to determine whether construct definitions are the same across populations and to clarify factor structure stability in a veteran sample. more specifically, we plan to assess invariance of a brief version of the marijuana motives questionnaire (simons et al., 1998) and the shortened version of the cudit-sf (bonn-miller et al., 2016) between a sample of 689 of veterans and a sample of 1074 college undergraduates (data are collected and analyses are ongoing). it was hypothesized that measures would, at least, indicate factorial invariance across samples, in accordance with previous findings in the alcohol literature. however, specific hypotheses were not made regarding metric and configural invariance of these measures between these samples as this is the first study we aware of to assess invariance of cannabis measures in these populations and similar findings in the alcohol literature are, at best, mixed. findings and implications of the results will be discussed. a descriptive study of cannabis use patterns among adult users in colorado elizabeth ballinger-dix, jamie e. parnes, alexander tyskiewicz, bradley t. conner colorado state university historically, research on cannabis use has mostly focused on risk factors, dependency issues, and negative consequences among adolescent or college aged users. legalization of medical and/or recreational cannabis in several states, including colorado, has led to a growing interest in expanding research to include motives, use patterns, consequences and characteristics of adult recreational cannabis users. while there has been a recent increase in research on differences in use patterns between cannabis users, the majority of published studies have focused on identifying between-group differences between medical marijuana users and recreational marijuana users. one facet of cannabis use that remains understudied is within-group differences in use patterns, particularly among adult recreational users. for example, little is known about how adult recreational users vary in their selection of different products, concentrations, and dosage across different times of day and contexts. the proposed study will use a qualitative approach toward understanding how adult recreational cannabis users differ in their description of frequency, quantity, potency, type of product, and context for use. in order to identify themes in how individuals describe their cannabis use patterns, we will conduct a qualitative analysis of 73 short interviews that were conducted at two live cannabis use events in denver, colorado. our data will be analyzed with atlas.ti, a software program that facilitates qualitative data analysis. the first round of coding will be conducted with attribute coding, followed by a second round of magnitude coding, and a third round of descriptive coding. attribute coding will allow us to identify how demographic characteristics vary across use patterns. magnitude coding will allow us to identify how users communicate the frequency, potency and dosage of their use. then, descriptive coding will enable us to identify how users communicate the contextual factors of their use. after each round of coding, codes will be categorized using the organizational features of atlas.ti. a final analysis will be conducted to identify themes that illustrate distinct cannabis use patterns across recreational cannabis users. we believe that the results of this study will help to highlight characteristic and use pattern differences across cannabis users. identifying distinct patterns across adult users may also help conference abstracts 109 medical professionals and clinicians to differentiate in their approach toward working with clients who engage in cannabis use. discussant: matthew r. pearson university of new mexico symposium: washington state marijuana law: in the forefront of change chair: louise kaplan washington state university washington state has both legalized medical and recreational marijuana and is the only state with the legally authorized role of medical marijuana consultant. this regulatory landscape presents an opportunity to explore a changing culture. this proposed symposium will provide a brief overview of the evolution of washington state’s marijuana laws since medical marijuana was first authorized in 1998, and subsequent implications for healthcare providers and patients. the role of health care professionals who authorize medical marijuana and the role of the medical marijuana consultant will be explained. the results of a statewide research study conducted in 2018 to determine the knowledge, attitudes and practices of health care professionals and medical marijuana consultants will be discussed. a portion of the symposium will describe key findings from this study regarding the sources of information used by health care professionals and medical marijuana consultants to advise patients and make decisions. the final component of the symposium will explore implications of legal access to marijuana for health care professionals and their patients, including those who suffer from chronic pain and use opioids. washington state’s unique medical and recreational marijuana laws louise kaplan washington state university washington’s original medical marijuana law, created by an initiative of the people in 1998, allowed physicians to authorize medical marijuana use for qualifying patients with valid documentation. in 2007, legislation required the washington department of health to develop rules to define the law’s provision to allow a patient to have a 60-day supply of marijuana. in 2010, the washington state legislature expanded the health care professionals who could provide authorizations for medical marijuana use to include advanced registered nurse practitioners, physician assistants, and naturopathic physicians. a 2011 law required a health care professional who provides an authorization to examine a patient, document the debilitating or terminal condition, inform patients of and document other options to treat the condition. washington state legalized recreational marijuana in 2012 and merged the medical and recreational systems in 2015, at which time the first and only medical marijuana consultant role was created. in this talk, details of this history and an overview of washington state’s current marijuana laws will be described. this includes the state’s qualifying conditions, laws which govern health care professionals’ decisions to provide an authorization, requirements to become a medical marijuana consultant, and the services a medical marijuana consultant is authorized to provide. the washington state health care professional and medical marijuana study louise kaplan, janessa graves washington state university this talk will summarize findings from a 2018 study, entitled “knowledge, practices and attitudes regarding marijuana for medical conditions among washington state healthcare providers and certified marijuana consultants.” the study consists of two cross-sectional, mixed mode surveys examining the knowledge, attitudes and practices of key players in the authorization and distribution of medical marijuana in washington state: medical marijuana consultants and healthcare providers. medical marijuana consultant survey: this crosssectional, mixed mode survey was administered to a random sample of 360 medical marijuana consultants (32% response rate). most respondents (84%-100%) correctly identified conditions that qualify a patient to receive a medical marijuana authorization with fewer (8%31%) accurately identifying conditions that do not qualify for an authorization such as depression conference abstracts 110 and anxiety. three-quarters or more correctly identified the amount a patient could possess, that health plans are not liable for claims for reimbursement, all children under age 18 must be in the database, and employers are not required to make an accommodation for medical marijuana use. almost all identified the aspects of the consultant role they are legally authorized to perform and those they are not. almost onequarter, however, did not know they may provide instruction and demonstration of proper use of marijuana products. attitudes strongly supported dea reclassification of marijuana to no longer be a schedule i drug, medical marijuana should be incorporated into healthcare provider education, marijuana helps patient with chronic debilitating conditions, and that it provides significant physical and mental health benefits. health care professional survey: this cross-sectional, mixed mode survey was administered to a random stratified sample of 1800 medical doctors, nurse practitioners, physician assistants (27.7% response rate). depending on the condition, 29% to 93% of health care professionals correctly identified whether or not the condition qualified a patient to receive a medical marijuana authorization. a narrower range (21%-51%) accurately identified conditions that do not qualify for an authorization, such as anxiety and depression. depending on the condition, 4% to 45% of respondents indicated they “did not know” whether a condition qualified. only 57 participants (13.6%) had ever issued an authorization for medical marijuana. over half (58%) who had not issued authorizations felt they lacked skills and knowledge to provide them. more than one-third (38%) reported their practice had a policy prohibiting medical marijuana authorizations. attitudes varied widely although 75% somewhat or strongly agreed marijuana helps patients who suffer chronic, debilitating medical conditions. over half (62%) strongly or somewhat agreed the drug enforcement agency should reschedule marijuana to make it legal at the federal level. policy recommendations include evaluation of the medical marijuana consultant role to determine if the role fulfills its intended purpose or if revision is needed; if the consultants adhere to the law; consultant satisfaction with the role; and customer satisfaction with the services. regulators should consider a requirement for health professional education to incorporate evidence-based information into curricula. another proposed change would be to develop requirements specific to authorizations for special populations such as pregnant women and children. sources of information used by washington state health care professionals and medical marijuana consultants: has science gone up in smoke? tracy klein washington state university the 2018 study that will be discussed in talk 2 of the symposium included a series of questions regarding the sources of information the medical marijuana consultants and health care professionals utilize to evaluate the risks and benefits of medical marijuana. medical marijuana consultants reported their top three sources of information as their certification training course (85%), other consultants (72%), patients (68%), and websites (55%). scientific journals were identified as sources of information for marijuana risks and benefits by only 14% of consultants. in contrast, health care professionals reported other licensed health care professionals (64%) and continuing education (47%) were the most frequently reported sources of information. reports from patients and scientific journals each were utilized by 31% of the respondents, and websites by 22%. this talk will summarize findings of information preferences from these surveys and outline recommendations for improving the quality of and access to evidencebased materials for medical marijuana consultants and health care providers. work groups can be formed to critique and update sources of evidence to provide health care professionals and medical marijuana consultants. implications of washington state’s marijuana laws for health care professionals and patients marian wilson, tracy klein washington state university this presentation compares the perspectives of patients, providers, and marijuana consultants regarding cannabis use for symptom management, and provides a framework for conference abstracts 111 patient-centered shared decision-making regarding cannabis use. results from the 2018 study described in this symposium will be compared with data from a 2016-2017 survey of marijuana use among adult patients in washington state receiving opioids for chronic pain or opioid use disorder. a conceptual framework will be presented to depict commonalities and differences between the three populations examined. the 2016-2017 survey of washington state adults included 300 patients, 388 providers, and 118 marijuana consultants. pain was the symptom most commonly targeted by patients, followed by sleep, anxiety, and drug withdrawal. most providers (85%) reported never authorizing cannabis for medical use, citing multiple factors including lack of knowledge and skill. common themes from the data sets included cannabis benefits, adverse effects, and knowledge gaps. benefits and harms of cannabis were mentioned in all groups. medical marijuana consultants endorsed few risks; 28% of consultants believed cannabis can be addictive, compared to 69% of providers. significant knowledge gaps involved identifying mental health conditions that do not qualify for cannabis authorizations (e.g. depression and anxiety). all groups mentioned cannabis should be more accessible. implications include that understanding perspectives of stakeholders can assist in patient-centered shared decision making for treatment planning regarding cannabis use. discussion of the meaning of the data will conclude the symposium. for example, what does it mean for patient care when providers do not believe cannabis helps pain or that cannabis can be addictive? how should clinicians manage conflicting viewpoints? how should patients share their preferences? discussant: louise kaplan washington state university symposium: what people think about the effects of cannabis: a balanced view of perceived risks and benefits chair: benjamin ladd washington state university perceptions of risks and benefits of cannabis abound; many lay claims have mixed empirical support or lack support altogether. these perceptions have important implications in terms of cannabis use and health. furthermore, research on the effects of cannabis often is onesided and emphasizes only the negative consequences of cannabis use. this likely contributes to an incomplete picture of the factors related to cannabis use decision-making. this set of talks describe recent efforts to improve understanding of perceptions of cannabis health effects by taking a balanced approach to studying perceived risks as well as benefits in a range of populations. dr. fales will examine the perceived benefit of cannabis to manage pain in young adults with and without chronic pain. dr. teeters will explore the role of positive and negative expectancies of cannabis use on decisions to drive after having used. ms. pritschmann will look at cannabis and cannabis-free reinforcement and cannabis outcomes from a behavioral economic perspective. finally, dr. magnan will examine prevalence and endorsement of users’ and nonusers’ beliefs around various positive and negative health consequences of cannabis. the goal of this symposium is to improve understanding of current perceptions of risks and benefits related to cannabis use and relative ratios of these two aspects in order to identify areas for future research inquiry (e.g., common anecdotal claims lacking scientific study) as well as establish potentially useful targets for intervention and prevention (e.g., correcting inaccurate beliefs, associations between motivations for use and cannabis-related harm). contact: benjamin ladd benjamin.ladd@wsu.edu young adults are using recreational cannabis products to manage their pain: it might not be helping them jessica fales washington state university as estimated 100 million americans experience chronic pain each year at an annual cost exceeding $600 billion. defined as physical pain that persists or recurs past the time of expected healing, chronic pain is associated with a wide range of negative sequelae including disruptions in mood, sleep problems, limitations in physical conference abstracts 112 activities, and impairment in interpersonal relationships. although the past decade has seen a tremendous increase in evidence-based treatment options for chronic pain, few have access to specialty pain care. this is especially true for young people, whose pain has historically been under-recognized and undertreated. cannabis is commonly used recreationally among adolescents and young adults (ayas) and due to widespread beliefs about its pain relieving properties it may be a drug of choice for ayas experiencing chronic pain. the present study determines whether pain relief is an important motivation for use among aya recreational users and compares depressive symptoms, sleep problems, and health related quality of life in users with and without persistent pain. aya recreational cannabis users (n = 202; 18-29 years of age; m = 24.22, sd = 2.71; 43% female; 73% caucasian) were recruited from communities in the pacific northwest to participate in a study investigating their cannabis use and health. all were weekly or more frequent users (74% reported daily or multiple times daily use). all completed a set of questionnaires assessing their cannabis use and pain history (including pain-related interference; promis-pi), motivations for cannabis use, depressive symptoms (ces-d), sleep problems (psqi) and health-related quality of life (sf-36). pain problems were surprisingly common in our sample. approximately half reported a weekly pain problem of at least 3 months duration (51%; m usual pain intensity = 5.67, sd = 1.82; 0-10 numerical rating scale) and a quarter (27.2%) reported chronic pain accompanied by clinically significant pain-related interference. among all users, pain relief was rated as a somewhat important motivation for use; however, it was the primary motivation for use among users with chronic pain [f(1,200) = 119.58, p< .001]. compared to users without pain, users with chronic pain reported more clinically significant sleep problems (77% vs. 29%; χ2 = 45.60, p < .001) and depressive symptoms (67% vs. 26%; χ2 = 34.48, p< .001). they also reported worse health-related quality of life across nearly all domains, including poorer physical functioning [f(1, 200) = 30.96, p<.001] and social functioning [f(1,200)=23.82, p<.001]. while users with disabling chronic pain reported the highest symptoms and worst quality of life, users with non-disabling chronic pain were also significantly distinguishable from aya without pain on nearly all assessed outcomes. findings highlight that a number of young adult recreational users may be using cannabis products for the express purpose of relieving pain. despite frequent cannabis use, many aya report experiencing significant pain and pain-related interference alongside elevated depressive symptoms, poor sleep quality, and poor health-related quality of life. clinical implications and study limitations will be discussed. negative marijuana expectancies are associated with driving after marijuana use jenni b. teeters, matthew j. woodward, shelby king western kentucky university background: marijuana is the most prevalent illicit substance detected among drug-impaired drivers and the most frequently used illicit drug on college campuses. though years of epidemiological and experimental research has demonstrated that marijuana use impairs driving ability and increases risk for traffic accidents, college students perceive driving after marijuana use as more acceptable and less dangerous than driving after drinking. additionally, a subset of marijuana users perceive that using marijuana actually improves their driving and other abilities. thus, a potential explanation for the perceptions of decreased risk associated with driving after marijuana use is an individual's expectancies about the effects of marijuana use, which may in turn influence the decision about whether to drive after use. consequently, the aim of the present study is to determine whether marijuana expectancies are associated with driving after marijuana use. method: participants were 94 college student marijuana users enrolled in a pilot trial of a mobile-phone based intervention aimed at reducing driving after substance use. all participants completed measures of marijuana use frequency, driving after substance use, and the marijuana expectancies questionnaire-brief (meeq-b). the meeq-b consists of 6-items that measure participants’ level of agreement with assertations about marijuana's effects and has two subscales: positive expectancies and negative expectancies. pearson's correlations were used to examine the associations between marijuana expectancies and conference abstracts 113 driving after marijuana use. negative binomial regressions were then utilized to assess whether positive and negative expectancies were associated with the number of times driving after marijuana use after accounting for control variables. results: pearson’s correlations revealed that stronger endorsement of the expectancies “marijuana makes it harder to think and do things” and “marijuana generally has bad effects on a person” showed significant negative correlations with the number of times driving after marijuana use (r = -.34 and -.23, respectively). additionally, the negative expectancies subscale demonstrated a significant negative correlation with the number of times driving after marijuana use (r = -.35). notably, positive expectancies of marijuana use were not significantly correlated with driving after marijuana use. results of a negative binomial regression controlling for age, gender, ethnicity, and the number of days using marijuana in the past month revealed that the negative expectancies subscale, but not the positive expectancies subscale, was significantly associated with likelihood of driving after marijuana use (irr: .664, p<.01). conclusions: past research has indicated that positive marijuana expectancies are related to greater frequency of use and problems while negative marijuana expectancies are related to non-use and lower endorsement of negative consequences. results of the present study add to this growing body of literature by demonstrating that marijuana use expectancies play a role in the decision to drive after using marijuana, arguably the most immediately dangerous consequence associated with marijuana use. with increased legalization of recreational and medical marijuana, it is becoming increasingly important to understand factors related to driving after marijuana use. our findings suggest that negative expectancies related to marijuana use may be an important prevention and intervention target. associations between behavioral economic reward value, expectancies and cannabis use outcomes ricarda pritschmann, ali yurasek university of florida cannabis is one of the most widely used drugs on college campuses and is associated with cannabis use disorders (cuds), poor academic achievement and other consequences. however, students often report cannabis as beneficial for sleep, anxiety and stress. students who anticipate more positive outcomes from cannabis use often use more, have difficulty cutting down, and show higher rates of cuds, compared to those who expect more negative outcomes. behavioral economic theory is often used to identify predictors of substance use and may help disentangle the relationship between cannabis use and its perceived benefits and risks. the behavioral economic concept of reward value captures the degree of preference for a reinforcer like cannabis and suggests that use is influenced by 1) its relative availability and price and 2) alternative cannabis-free sources of reinforcement. reinforcement ratio (rr) is one measure of reward value that assesses relative levels of substance-free and substance-involved activity participation and enjoyment; whereas demand curve measures of reward value assess consumption levels across a range of prices. in general, higher levels of reward value are related to greater cannabis use, problems, and cud severity. some research has also linked reward value, specifically cannabis demand, to negative and positive perceptions of cannabis use outcomes suggesting elevated demand is associated with lower negative expectancies (ne) and higher positive expectancies (pe) of cannabis use outcomes in adults. despite these associations, it remains unclear whether reward value, including rr, influences cannabis expectancies among college students and whether these variables jointly predict cannabis related outcomes (i.e., consequences). purpose. the purpose of this study was to investigate whether cannabis reward value is related to positive and negative cannabis expectancies, and the influence of these variables on cannabis-related problems and cud symptoms in a college student sample. methods. eligible students (n = 221) were between the ages of 18-25 (mage = 19.9; sd = 1.36) and reported using cannabis at least 3 times in the past month (mdays = 10.65; sd = 8.3). participants completed a series of questionnaires related to their use including the marijuana effect expectancy questionnaire-brief (meeq-b), the marijuana purchase task (mpt), the adolescent conference abstracts 114 reinforcement survey schedule (arss), a dsm-5 cud symptom checklist, and the kilmer-lee marijuana consequences scale (klmc). a series of hierarchical regressions controlling for marijuana use days, age and sex were conducted. results. analyses indicated that higher elasticity of demand (less consumption as price increases) predicted greater ne, and lower elasticity predicted greater pe. greater rr predicted lower ne, but was not significantly related to pe. finally, greater ne and rr predicted more consequences and cud symptoms. conclusion. findings suggest that students who more highly value cannabis also report more positive expectancies and fewer negative expectancies associated with their cannabis use. furthermore, higher ne and rr was related to greater problem use. this may suggest that students with more severe cannabis use may be more likely to expect negative consequences but have fewer alternatives to using. prospective studies are needed to better understand the temporal order of these variables however. identifying perceptions of risks and benefits of cannabis use: associations with cannabis use and related problems renee e. magnan, eric malain, benjamin ladd washington state university perceived risk of behavior is commonly studied in health-decision making, but far less is understood about the role of perceived benefits. cannabis use might be a particularly important target for investigating the competing roles of perceptions of risks and benefits given recent dramatic shifts in public acceptability, accessibility, and common misinformation about its use. moreover, cannabis use is an ambiguous health behavior which could result in benefits (e.g., pain modulation) in addition to harms (e.g., addiction). a clearer, balanced understanding of perceived risks and benefits of cannabis use will provide targets for intervention development to increase accuracy of cannabis risk estimates, inform cannabis decision-making, and prevent cannabis-related problems. across two studies, we identified perceptions of risks and benefits of cannabis use and examined the association of these perceptions with cannabis use frequency and related problems. in study 1, adult cannabis users (n = 96) who used at least twice a week, indicated their cannabis use and related problems, and then evaluated their perceptions of risks and benefits related to personal harms/benefits, negative/positive health outcomes, negative/positive mental health outcomes, and harming/benefitting others. perceptions of personal risks were low while perceptions of benefits were relatively high. perceptions of risks, but not benefits, were associated with problem severity (r = .44, p < .001). neither were associated with use. in study 2, college students (n = 399) viewed 21 possible positive and 28 possible negative consequences of cannabis use and indicated if they thought each consequence was true. on average, participants thought 48% of the positive consequences and 65% of the negative consequences were true. the most and least endorsed negative consequences were its cost (92.5%) and cause of seizures (21.1%), respectively. the most and least endorsed positive consequence was relieving pain (94.7%) and protecting against memory loss (7.5%), respectively. frequency of use and marijuana problems were negatively associated with the number of negative consequences endorsed (r = .21, -.31, ps < .001, respectively) and positively associated with number of benefits endorsed (r = .37, .29, ps < .001, respectively). moreover, those who used more frequently were more confident in the benefits of use (r = .13, p = .01). taken together, these findings suggest that people are aware of potential risks of use but may not perceive these as personally relevant. we will discuss the implications of these findings in terms of public education and highlight specific areas upon which such communications could focus to correct misperceptions. discussant: benjamin ladd washington state university symposium: changing marijuana policy and its potential impact on unintentional injury chair: renee m. johnson johns hopkins university unintentional injuries are the leading cause of death for people aged 1-44 in the us. this symposium will provide a forum to examine the conference abstracts 115 potential impacts of changing marijuana laws in the us on unintentional injury. the chair will introduce the symposium and give an overview of the epidemiology of marijuana-associated injury, with a focus on traffic safety and poisoning (i.e., unintentional ingestion or overingestion of cannabis). the first presentation will address adolescent use of emerging modes of marijuana in colorado. high levels of edible use, dabbing, and smoking may increase risk for overingestion and burns. the second presentation is a study of colorado adults and describes their driving after having consumed marijuana. the third presentation builds on findings that pediatric healthcare contacts resulting from marijuana exposure increased in colorado and washington state following passage of recreational marijuana laws (rmls); it presents an investigation of marijuana-related poison center calls among 0-24 year olds in massachusetts. storing poisonous substances in a manner that prevents child access has been an important strategy for poisoning prevention and is well-integrated into physicianbased education for parents. the fourth presentation focuses on how colorado parents store marijuana to gauge risk for childhood poisoning in the state. the discussant will highlight key themes across the presentations and will discuss policy implications, present recommendations for injury prevention, describe key sources of data, and highlight gaps in knowledge. contact: renee m. johnson rjohnson@jhu.edu modes of marijuana consumption among colorado high school students renee m. johnson, ashley brooks-russell johns hopkins university, university of colorado denver the purpose of this presentation is to characterize colorado adolescents’ modes of marijuana consumption. data are from the 2017 healthy kids colorado survey (hkcs), a state adolescent health surveillance system. among youth who report past 30-day marijuana use, we describe modes of marijuana consumption and examine variation by grade, race/ethnicity, sex, sexual minority status, and frequency of use. more than three-quarters (77.8%) reported that smoking was how they usually consumed marijuana, whereas 9.8% reporting vaping and 4% reporting edibles as their usual modes. the prevalence of smoking as a usual mode of use was lowest among 9th graders (87.3%) and highest among 12th graders (94.6%). sixty percent reported use of just one mode in the past 30 days; 40% used 2 or more modes, usually smoking along with another mode. more than onethird reported any past 30-day consumption of edibles (35.6%) and dabbing (34.4%), and 20.3% reported vaping. findings suggests that colorado high school students who have used marijuana in the past 30 days use a variety of modes of consumption. driving after cannabis use and perceived impairment among colorado adults ashley brooks-russell university of colorado denver in the context of a state with legal recreational cannabis use, we surveyed a large number of current and frequent cannabis users about their driving after cannabis use. data are from an online survey conducted between july, 2018 and april, 2019 with the primary goal of screening participants for a larger study on cannabisimpaired driving. participants were asked if the research team could retain their survey responses regardless of eligibility for the larger study. of 3,282 surveys initiated, 1,568 did not finish the survey, which included extensive inclusion and exclusion criteria for the larger study, or declined their responses be retained. of the 1,714 surveys with complete data, 82.6% (1,415) reported past 30-day cannabis use, 77.1% of whom reported near daily or daily use (i.e., use of >20 days in the past month). among those who used cannabis 110 days in the past month, 26.6% reporting driving after using cannabis on 1-10 days. among those who reported cannabis use on >20 days in the past month, 36.8% reporting driving after using cannabis on 20 or more days in the past month. a majority of respondents reported that cannabis use “did not affect their driving” and between >15% said that cannabis use made them drive better. more than one-third said they would use less cannabis if they knew they would be driving within two hours. there was wide endorsement of compensatory driving behaviors, including: “try to pay more attention to my speed,” conference abstracts 116 endorsed by 87.5% to 93.8%; “increase the distance from the vehicle in front of me,” endorsed by 79.1% to 89.6%; and “drive slower,” endorsed by between 69.7% and 83.3%, depending on cannabis use frequency. in summary, respondents reported driving after cannabis use and indicated that they did not perceive that cannabis use impaired driving ability. however, respondents also reported moderating cannabis use before driving and engaging in compensatory driving behaviors when driving after cannabis use, which suggests an implicit acknowledgement that cannabis use does impair driving ability. further exploration of the discrepancies of these behaviors can information prevention messages and intervention strategies to prevent impaired driving. marijuana-related poison center calls among 024 year olds in massachusetts before and after medical marijuana legalization jennifer m. whitehill, calla harrington, cheryl lang, michael chary, waqaas a. bhutta, michele m. burns university of massachusetts amherst, boston children's hospital, brigham and women's hospital pediatric healthcare contacts resulting from marijuana exposure increased in colorado and washington state following changes in marijuana policy; data on whether this was the case in other states is limited. the purpose of this study is to document child and adolescent marijuana exposures reported to the regional poison control center (pcc) before and after the 2012 passage of a medical marijuana law (mml) in massachusetts. we conducted a pre-post comparison of marijuana-involved pcc cases for 0-24 year olds, examining four years before and after mml. from 2009-2016, there were 311 calls to the pcc involving cannabis (n=118 single substance; n=193 polysubstance). the average annual prevalence of single-substance cannabis calls increased 150%, from 0.4 per 100,000 before to 1.0 per 100,000 after. there was an increase for all age subgroups, and 15-19 year olds had the highest rate of pcc-reported marijuana exposures. the proportion of all pcc calls that were due to single-substance marijuana exposure increased. exposures related to edible marijuana products increased after mml for most age groups. child and adolescent cannabis exposures increased in massachusetts after medical marijuana was legalized, despite childproof packaging and warning labels to keep the products away from youth. mmls are associated with increases in cannabis-related poisoning among very young children and overingestion by adolescents. our findings extend prior work by demonstrating that youth are also experiencing increased cannabis-related health system contacts via poison control centers. given the growth of retail cannabis sales, including edibles and potables, additional efforts are needed to prevent poisonings among children and youth. storage of marijuana in the home and unintentional ingestion among children janessa m. graves, ashley brooks-russell washington state university, university of colorado denver within the context of a legal recreational cannabis state, we examined the prevalence of cannabis products in homes with children to estimate the potential exposure in the population. we also investigated temporal trends in storage practices among caregivers and storage practices by caregiver characteristics. data are from a population-based telephone survey of caregivers of children aged 1-14 years in colorado, administered annually from 2014 to 2017. reponses are weighted to the population of colorado. representing 79,805 households in colorado with children aged 1 to 14 years, 8.6% (95% ci: 7.3-10.0) of caregivers reported cannabis stored in the home. overall, 3.8% (95% ci: 2.9-4.6) of caregivers reported cannabis was used in the home; there was minimal variation by demographic factors. from 2014 to 2017, the prevalence of caregivers reporting cannabis in or around the home increased significantly from 6.9% (95% ci 4.9-8.9) to 11.2% (95% ci: 8.2-14.5) (p=.02); however, caregivers-reported cannabis use remained unchanged. among caregivers who reported cannabis in the home, 91.4%, (95% ci 87.4-95.4) reported storage locations inaccessible to children, such as “out of reach.” two-thirds (67.0%, 95% ci: 59.6-74.4) reported storage in a locked container, such as a cabinet, drawer, or safe. in a us state with legalized recreational conference abstracts 117 marijuana for adults, an increasing number of children live in homes where cannabis is present; leaving children at risk for unintentional ingestion. clinicians should promote messages to caregivers about safe cannabis storage practices to prevent unintentional ingestion. discussant: ashley brooks-russell university of colorado denver symposium: ecological momentary assessment of cannabis: lessons learned from microlongitudinal studies chair: noah n. emery brown university ecological momentary assessment (ema; shiffman, 2009) leverages intensive repeated measures to capture moment-to-moment fluctuations in emotional, cognitive, and behavioral experiences in near real-time while participants are in their natural environment. this allows researchers to establish temporal precedence between variables of interest and to model differences between closely spaced successive time points across a single day or a series of days. as such, these microlongitudinal designs are uniquely suited to rapidly address key gaps in the literature. in the current symposium, we review cutting edge ema research on how systematic changes in advance of quitting cannabis contribute to improved success rates during a quit attempt (shrier et al.); we examine the effects cannabis use on sleep and social activity in older persons living with hiv (henry et al.); we investigate the effects of cannabis use on the time course of positive and negative affect (emery et al.); we examine how context of use moderates the relationship between use frequency and hazardous use (wedel & ansell); and review ema data can be used to individualize treatment of cannabis use disorder (litt). finally, given her extensive experience using ema to study the etiology and treatment of cannabis use, our discussant will provide a unique synthesis of these talks (collins). taken together, our symposium presents a wide range of ema research on cannabis use, highlighting the diversity of research questions that can be answered using microlongitudinal designs. contact: noah emery peos129@hotmail.com changes in cannabis use-related factors prior to a self-quit attempt lydia a. shrier, ziming xuan, sion kim harris boston university, boston children’s hospital/harvard medical school young adults who use cannabis heavily often attempt to quit on their own and may try several times before achieving cessation. preparing to quit may increase the likelihood that abstinence will be achieved. however, little is known about the process of preparing to quit in this population and how that process relates to patterns of use during the quit attempt. using ecological momentary assessment (ema; shiffman, 2009), we examined cannabis use and use-related factors for two weeks before and two weeks during a selfquit attempt in a community sample of 18-25 year olds reporting daily/near-daily cannabis use and planning to quit. we instructed participants to use cannabis as they usually do during the prequit period (“usual use”). during both the pre-quit and quit attempt periods, we assessed momentary positive and negative affect, craving, availability, situational permissibility, confidence to not use, and characteristics of cannabis use events (social and temporal contexts, reason, feelings about use) in response to 6 prompts at random times each day, as well as a scheduled diary of symptoms of cannabis withdrawal and cannabis use in the past 24 hours. we had previously identified that situational permissibility in the two weeks before trying to quit was the only averaged ema variable that contributed to a model predicting lapse during the attempted abstinence period (shrier et al., 2018). additionally, we had observed that cannabis use frequency declined over the two weeks before the quit date. to better understand the process of preparing to quit, we sought to determine whether participants (n=34) experienced changes in cannabis use-related factors during the pre-quit period, and whether these changes predicted time to lapse and cannabis use frequency during the quit attempt period. we found that several ema variables changed from the first week to the second week prior to the quit attempt, including decreases in positive affect, frequency of cannabis craving, conference abstracts 118 cannabis availability, situational permissibility, cannabis use since last report, bad feeling following use, and cannabis withdrawal symptoms, and increase in confidence to not use cannabis (all ps<0.05). on linear regression modeling, decline in use days from the first to the second week of the pre-quit period was associated with fewer use days during the quit attempt period (beta=5.90, p=0.04), adjusting for pre-quit change in confidence. pre-quit changes did not predict time to lapse or cannabis use frequency during the 2-week quit attempt period for any other cannabis use-related ema variables. the study was limited by its small sample size and prescribed quit date. in summary, young adults preparing to quit cannabis in the context of a research study demonstrated changes in advance of quitting that may reflect preparatory actions. only the often-recommended strategy of reducing use of a substance prior to attempting cessation was associated with improved success with trying not to use cannabis following a quit date. further ema research on changes in anticipation of cannabis cessation will be important for developing effective pre-quit tools and strategies to aid young adults using cannabis heavily to successfully abstain. ecological momentary assessment of cannabis use in older persons living with hiv: relationships with sleep and social activity brook l. henry, laura m. campbell, jessica l. montoya, emily w. paolillo, bin tang, caitlin wei-ming watson, raeanne c. moore university of california san diego background: substance use, including cannabis, is elevated in persons living with hiv (plhiv). older plhiv also have impaired sleep and reduced social activity when compared to demographically-matched older persons without hiv (hiv-). smartphone-based ecological momentary assessment (ema) can help elucidate the real-time associates between cannabis use and other behaviors, such as sleep and social activity, among plhiv. this report includes two studies. study 1 explored the association between cannabis use reported via ema and objective measures of sleep. study 2 explored the concurrent association between substance use and social activity. methods: fifty-nine older plhiv and 35 hiv-negative adults (50-74 years) completed up to four ema surveys per day for 14 days. via ema surveys, participants reported substance use, current social activity (alone vs being with others), ratings around social interactions (perceptions of satisfaction, success, and feeling liked), and mood ratings. participants also wore actigraphy watches to objectively assess sleep quality (i.e., total sleep time, efficiency, fragmentation, movement, wake after sleep onset, and number of awakenings). study 1 included a subset of study participants (11 plhiv, 6 hiv-) who had actigraphy data and reported cannabis use at least once during the ema study period. linear mixed-effects models were used to examine the association between cannabis use and subsequent sleep. study 2 included participants who endorsed using cannabis more than once during the 14-day ema period (11 plhiv, 4 hiv). ratings of social interactions were averaged and a dichotomous variable was created indicating lower vs higher social interaction ratings. separate mixed-effects logistic regression models were tested to evaluate whether cannabis use predicted current (within-survey associations) social activity and ratings of social interactions. random intercepts were specified for participants; covariates included time of day, hiv status, and mood ratings. results: in study 1, selfreported cannabis use via ema was significantly associated with greater total sleep time (p=0.02) in models adjusting for day of the study and alcohol use. however, cannabis use was also associated with greater number of awakenings at trend-level (p=0.07). study 2 indicated that cannabis use was associated with an increased likelihood of being with others at a trend-level of significance (or=1.43, p=.06) and with a higher likelihood of having higher ratings of social interactions (or=2.68, p=.01). the effect of hiv serostatus was non-significant in all models. conclusions: these preliminary results indicate cannabis use may have both positive and negative effects on sleep and a positive effect on social activity. future studies with larger sample sizes that also assess cannabis use in more detail (e.g., quantity, route of administration, reason for use) are needed to further understand these dynamic relationships. the effect of marijuana use on the time course of positive and negative affect in daily life conference abstracts 119 noah n. emery, ryan w. carpenter, robert miranda, jr brown university theoretical accounts of the relationship between affect and substance use suggest that marijuana is often consumed as a form of affect regulation due to its positive or negative reinforcing qualities (cooper & haney, 2008; simons et al., 1998). however, ecological momentary assessment (ema) research on associations between affect and marijuana use in daily life has predominantly focused on whether positive and negative affect serve as stimuli for increased use (wycoff et al., 2018). fewer studies have tested whether marijuana use is associated with subsequent reductions in negative affect (na) or increases in positive affect (pa). while there is strong theoretical rationale for these affective alterations, results from (ema) research in this area are mixed, with studies reporting decreased na, no effect on either na or pa, or even increased na after use (buckner et al., 2015, 2012; ross et al., 2018). this suggests that there are unanswered questions regarding the emotional payoff of marijuana use. in the present research, we used ema data from 85 treatment seeking youth age 15-24 to model the time course of affect and tested withinand betweenperson factors that could moderate associations between successive assessments of negative and positive affect. our objectives were to: 1) test if marijuana use attenuates associations between successive assessments of negative affect; 2) test if marijuana use potentiates associations between successive assessments of positive affect; and 3) to investigate if the above within-person effects vary across gender, to advance understanding of gender differences in vulnerability for and maintenance of cannabis use disorder. we estimated two multilevel models (three-levels; moments, days, persons) for positive and negative affect, respectively. the core of each model was an autoregression of affect regressed on lagged affect. each included a random slope of lagged affect at the person-level and random intercepts at person and day-levels. residuals followed an ar-1 autoregressive structure. use was a dichotomous lagged predictor. we included a quadratic effect for lagged affect in each model because the persistence of affective states over time may vary by intensity. for the na model, there was a significant quadratic interaction between lagged na and lagged use, such that use at the previous moment was associated with decreased levels of na at the next moment and this effect became increasing pronounced as lagged na increased. similarly, the pa model had a significant quadratic interaction between lagged pa and lagged use, such that use at the previous moment was associated with increased levels of pa at the next moment and this effect became increasing pronounced as lagged pa increased. gender did not exhibit significant effects in either model. these findings are consistent with affective models of substance use. marijuana use had inverse associations with next-moment na and positive associations with next-moment pa. in each case, these effects increased in magnitude at higher levels of affective arousal during the previous moment. the results add to the literature on associations between affect and use by examining the often-overlooked part of reinforcement models (i.e. changes in affect following use). solitary cannabis use moderates the relationship between use frequency and hazardous cannabis use amelia v. wedel, emily b. ansell syracuse university individualized assessment and treatment program (iatp) for cannabis use disorder: randomized controlled trial with and without contingency management mark litt university of connecticut discussant: r. lorraine collins university at buffalo symposium: medical and recreational marijuana laws in adolescents and young adults: where do we go from here? chair: silvia martins columbia university our symposium will present some of the latest findings of epidemiologic studies to identify conference abstracts 120 changes in marijuana use and marijuana use disorder following marijuana policy changes in the united states. first, our symposium will address consequences of marijuana medical and recreational legalization in the us. dr. martins’ study will present on data on marijuana use and opioid use after medical legalization using data obtained from the national survey on drug use and health (nsduh) restricted use files, to examine these relationships across the 50 states from 2004-2016. she will also show changes in the prevalence, incidence and frequency of marijuana use and prevalence of marijuana use disorder changed following legalization of recreational marijuana use in colorado, washington, alaska and oregon from 2011 to 2016. dr. dilley’s study will report on findings about adolescent groups who are relatively more at-risk following legalization. she will present on data from a study of the role of community policies on cannabis use and related public health outcomes following legalization in the pacific northwest (oregon and washington state). dr. johnson’s study will characterize adolescents’ reports of the modes of marijuana consumption in the early years of retail marijuana sales in colorado, washington, and oregon. data are from large, state-representative adolescent health surveillance systems, i.e., the healthy kids colorado surveys (hkcs), the washington healthy youth survey (hys), and the oregon healthy teens survey (ohts). finally, dr. mauro will present associations between medical marijuana law (mml) status and screening/discussing marijuana or illegal drug use with health care providers in a nationally representative sample. contact: silvia martins ssm2183@cumc.columbia.edu medical and recreational marijuana laws: effects on marijuana and opioid outcomes in adolescents and young adults silvia martins, pia mauro, christine mauro, luis segura, magdalena cerda, katherine keyes, morgan philbin, natalie levy, ava hamilton, melanie wall, deborah hasin columbia university, new york university getting into the weeds: identification of youth at-risk following retail cannabis legalization in the pacific northwest julia dilley oregon health authority modes of marijuana consumption among high school students in colorado, washington, and oregon renee johnson, julia dilley, johannes thrul, kayla n. tormohlen, kristin e. schneider, ming ma, arnold levinson, ashley brooks-russell johns hopkins university, oregon health authority, university of colorado denver medical marijuana laws are associated with screening and discussing marijuana use with health care providers: findings among adolescents and young adults in 2015-2017 pia mauro, melanie askari, silvia martins columbia university discussant: jan copeland university of new south wales symposium: concurrent and simultaneous use of marijuana and other drugs: current research on patterns of use and associated consequences chair: adrian j. bravo university of new mexico concurrent polysubstance use can be defined as the use of two or more substances within a given time period (e.g., over the past month or year) and can lead to dramatic health consequences due to the additive or interactive psychosocial or health effects of combining substances. within the present symposium, we feature four presentations examining diverse research questions on the initiation and consequences of concurrent use (including simultaneous use) of marijuana and other drugs (e.g., alcohol, tobacco, cocaine) across various populations and methodologies. first, using population-based data, dr. cohn will present on findings on the relative proportion and correlates of youth and young adults who report trying alcohol vs tobacco vs marijuana first, and conference abstracts 121 whether trying marijuana first (vs alcohol or tobacco first) increases risk for poly-substance use. second, using population-based data, dr. lopez-quintero will present data exploring the patterns and outcomes (including past-year substance use disorders) of drug co-use among subgroups of marijuana users (i.e., medical-only users, recreational-only users, or combined medical and recreational users). third, mr. voss will present on findings examining correlates and potential functional impairment associated with alcohol and cannabis co-use in a diverse sample of young adult heavy drinkers. fourth, dr. fairlie, will present on findings using ecological momentary assessment to examine day-to-day fluctuations in motives for using alcohol and/or marijuana among young adult substance users, and the extent to which motives predict the likelihood of simultaneous use. finally, dr. bravo will discuss the clinical and research implications from these studies. contact: adrian j. bravo ajbravo@wm.edu sequencing of onset of alcohol, tobacco, and marijuana use and implications for single and poly-substance use in youth and young adults amy m. cohn, amanda l. johnson university of oklahoma background: more than half of us states allow for recreational, medical, or decriminalized use of cannabis. concerns have been raised that increased availability and/or exposure to marijuana could lead to greater curiosity to use and lower age of onset for marijuana, as well as be a “gateway” drug to other substances, like alcohol or tobacco. to address these concerns, this study used population-based data to examine the relative proportion of youth and young adults (yas; ages 18-24) who reported ever trying alcohol vs tobacco vs marijuana first; as well as the mean age of onset for each product across those who ever tried one, two, or three of these products. analyses also examined the extent to which trying marijuana first (vs alcohol or tobacco first) increases risk for poly-substance use. method: data were from youth (n = 5,904) and yas (n = 8,339) in wave 1 of the population assessment of tobacco and health (path) study (2013-2014) who reported ever using alcohol, marijuana, and/or tobacco. results: the majority of youth had tried only a single substance (56.9%), while almost half of yas had tried all three substance categories (44.6%), followed by two categories (28.7%), and then a single category (26.6%). among each trier subgroup, the majority of respondents reported trying alcohol first or trying alcohol with either tobacco or marijuana first. in both youth and yas, trial of tobacco alone or with other substances was the second most common product that was tried first. in each trier group, the proportion of respondents who tried marijuana first (alone or with alcohol or tobacco) was lower than the proportion of respondents who had ever tried alcohol or tobacco first. among youth, the average age of trial for marijuana did not differ significantly across the trier subgroups (p =.102), but did for yas (p = .002). specifically, the average age of onset for marijuana trial was significantly lower for yas who had tried two (m = 16.7) or three substance categories (m = 16.2) vs one substance category (mage = 17.2). finally, in multivariable models that adjusted for demographics and mental health variables, trying marijuana first (vs alcohol or tobacco first) was associated with increased the odds of past 30-day poly-substance use vs single substance use (aor = 1.43; 95% ci:1.20, 1.71). conclusions: recent population-based data suggest that marijuana trial is not more popular than trial with either alcohol or tobacco. however, among those who do use marijuana first, the odds of engaging in polysubstance use are increased by 43%, even after controlling for a variety of factors that could be correlated with marijuana and substance use behavior. this latter finding suggests that prevention efforts focused on deterring initiation of marijuana could have secondary public health benefits by reducing other substance use behavior. patterns of drug co-use and drug use outcomes among medical and/or recreational marijuana users catalina lopez-quintero university of florida aim: cannabis-only users have an exceptionally low risk of becoming drug dependent (<2%), in contrast with the risk of those who use cannabis conference abstracts 122 with other drugs (>16%). while the number of medical marijuana users is growing, little is known about the patterns and consequences of drug co-use in this population. this information is essential to reduce potential negative consequences associated with medical marijuana use, particularly when marijuana is recommended within a clinical encounter. this study aims to fill this knowledge gap by assessing the patterns and outcomes of drug co-use among subgroups of marijuana users (i.e., medical-only users, recreational-only users, or combined medical and recreational users). methods: data was derived from the 2015-2017 national survey on drug use and health (nsduh) involving a sample of 25,689 adults (18+ years old), who used marijuana in the past year. mean number of days of tobacco use, binge drinking, cocaine use, and analgesic, stimulants or tranquilizers misuse in the past-month and the prevalence of past-year use disorders occurrence were estimated across subgroups of marijuana users. multiple negative binomial and multivariable logistic regression models examined the association between marijuana use subgroup and days of use in the past-month and drug use disorder occurrence. analysis weights with taylor series linearization were applied to accommodate for the complex sampling design. results: rates of past-year cannabis use disorder (cud) were higher among combined medical and recreational marijuana users (16.1%) than among medical-only (9.9%) or recreational-only (9.4%) marijuana users (p<0.01). among any medical marijuana users, any additional drug co-used increased the likelihood of cud occurrence by almost 70% (aor: 1.7; 95% c.i.: 1.4;1.9). compared to medical-only marijuana users, combined medical and recreational marijuana users reported more days of tobacco use (irr: 1.4; 95% c.i.: 1.2, 1.6), binge drinking (irr: 1.4; 95% c.i.: 1.1, 1.7), cocaine use (irr: 3.3; 95% c.i.: 1.5, 7.1) and prescription pain reliever misuse (irr: 2.7; 95% c.i.: 1.5, 5.0). relative to medical-only users, combined medical and recreational users were more likely to report past-year nicotine dependence (aor: 1.8; 95% c.i.: 1.3;2.4), a past-year cocaine use disorder (aor: 2.6; 95% c.i.: 1.2;5.3), and a past-year prescription pain reliever use disorder (aor: 2.5; 95% c.i.: 1.4;4.6). conclusions: after accounting for important potential confounders, such as age or health status, those who used marijuana for both medical and recreational reasons showed higher levels of drug co-use and drug use disorders occurrence, including cud, than medical-only users. among medical users, the number of drugs co-used was positively associated with cud occurrence. combined medical and recreational marijuana users also showed higher levels of tobacco use and nicotine dependence than recreational-only users. the findings underscore the need to incorporate drug use prevention interventions during clinical encounters where marijuana is recommended. study results should be interpreted in light of misclassification, socialdesirability and other bias. future studies need to investigate in depth the factors associated with increased drug co-use and adverse outcomes among combined medical and recreational marijuana users. characteristics of alcohol and cannabis co-use in a diverse sample of emerging adult heavy drinkers andrew t. voss, ashley a. dennhardt, james mackillop, james g. murphy university of memphis, mcmaster university objective: data from the most recent monitoring the future study suggests that cannabis use among emerging adults is more common than in any other age group, while perceptions of the risks associated with cannabis among this group are at an all-time low. in addition, cannabis is the most common type of illicit drug used concurrently with alcohol, with some studies estimating co-use rates of 20-30% among young adult heavy drinkers. despite the high prevalence of co-use, the literature on correlates and potential functional impairment associated with alcohol and cannabis co-use is mixed, with some studies finding worse alcohol-related (e.g., drinking and driving, alcohol use disorder), and other psychosocial (e.g., anxiety and depressive symptoms) outcomes among cousers, and others with null findings. further, it is important to extend the existing literature by examining co-use and associated outcomes among diverse young adult populations, including african-americans, and young adults who have not attended college. considering the mixed results and low perceived risk of cannabis use, it is especially important to identify outcomes of couse among young adult populations. the current conference abstracts 123 study seeks to replicate and extend the current literature on correlates of co-use in a diverse sample of young adult heavy drinkers. method: data were from a sample of young adults age 2125 who endorsed past-month heavy drinking (n = 604). the majority of participants had some college experience (60%) with 56.7% identifying as female, 46.9% who identified as white and 41.6% who identified as black or african-american. participants reported consuming on average 17.4 (sd = 15.2) drinks per week; 33.3% reported using cannabis at least once in the past month, and 20.2% reported daily use of cannabis. results: participants without college experience were almost twice as likely to endorse co-use as their college peers and a greater percentage of co-users were unemployed (25%), compared to alcohol-only users (18%). participants who identified as black, endorsed co-use at higher rates (27%) than any other racial group. pertaining to alcohol-related outcomes, 32% of daily co-users reported at least one recent alcohol-induced blackout, compared to only 21% of alcohol-only users. after controlling for college status and employment, daily cannabis use was associated with greater depressive and anxiety symptoms, a greater number of environmental suppressors of reward, more alcohol use disorder symptoms, less perceived risk of drinking after driving (dd), and greater number of dd episodes. however, these associations varied significantly across racial groups. namely, environmental suppressors of reward was highly associated with co-use among african-american participants, while other variables were non-significant. conclusions: the current results suggest that daily use of cannabis among heavy drinking young adults is associated with unique risk for specific severe alcohol-related consequences including alcohol-induced blackouts, and drinking and driving. further, findings suggest a novel correlate of co-use (i.e., environmental suppression of reward) that could shed light on the higher rates of anxiety and depressive symptoms among this group. finally, the current study contributes to the literature by identifying important differences in incremental functional impairment of co-use across racial groups. daily motives for alcohol and marijuana use as predictors of simultaneous use among young adults anne m. fairlie, megan e. patrick, jennifer m. cadigan, devon alisa abdallah, mary e. larimer, christine m. lee university of washington, university of minnesota objective. most research has examined motives for alcohol or for marijuana separately, although young adults may be using either substance separately or both substances together for similar reasons. simultaneous alcohol and marijuana (sam) use, “using alcohol and marijuana at the same time so that their effects overlap,” is common among young adults. in order to understand when sam use is most likely to occur, it is important to understand reasons across substances, including the motivational context in which young adults choose to use alcohol and/or marijuana. this study examines day-to-day fluctuations in motives for using alcohol and/or marijuana among young adult substance users. aims were to determine: (1) the extent to which coping, enhancement, social, and conformity motives predict heavy episodic drinking (hed; 4+/5+ for women/men), alcohol use, and marijuana use on days young adults used either alcohol and/or marijuana, (2) the extent to which motives predict sam use on days young adults used alcohol, and (2) the extent to which motives predict sam use on days young adults used marijuana. method. data were from a community sample of young adults who were 18-25 years old, reported sam use 1+ times in past month, reported drinking alcohol 3+ in past month (analytic sample: n=399, mean age=21.63 [sd=2.17]; 50.9% women). participants reported alcohol use, marijuana use, sam use, and also coping, enhancement, social, and conformity motives “for alcohol and/or marijuana use” for 14 consecutive days. multilevel models (mlms) were estimated to test the extent to which motives for alcohol and/or marijuana use were associated with alcohol, marijuana, and sam use. hed and sam use were each modeled with a logit function, while number of drinks and hours high were each modeled using a poisson distribution. results. across the 14 days, most participants reported alcohol use (95.4%; 1,917 days) and also marijuana use (81.70%; 2,166 days). sam use (599 days) was reported by 21.30% of participants on one day, 15.04% on two days, 21.05% on 3-11 conference abstracts 124 days, and the remaining 42.61% on zero days. multilevel models showed that motives on a given day were associated with substance use that day. elevated enhancement motives on a given day were associated with hed, drinking more, and more hours high from marijuana. elevated social motives were associated with engaging in hed and drinking more and also with fewer hours high. elevated conformity motives were associated with drinking more. sam use was more likely on alcohol days and on marijuana days with elevated enhancement and conformity motives. sam use was also more likely on alcohol days with elevated coping motives and on marijuana days with elevated social motives. conclusions. sam use on a given day was primarily associated with enhancement and conformity motives. social motives were more strongly linked to alcohol use, and to some extent coping motives were linked to marijuana use in this sample of young adult users. further examination of situation-specific motives and contexts of use is needed to inform development of real-time interventions for sam use and consequences. discussant: adrian j. bravo university of new mexico symposium: customers, retail staff and “stoners”: young adults’ new roles and identities in a legal marijuana state chair: beatriz carlini university of washington before 2012, adult marijuana consumers in wa state relied on a black/gray market to sustain their use, and risked incarceration when engaging in commercial transactions to acquire or sell cannabis. since legalization, young adult consumers have come “out of the shadows” and can now openly engage in the marijuana market landscape as consumers and cannabis industry professionals. they also have the opportunity to discuss their identity, practices and perspectives as marijuana consumers more openly, creating a window of opportunity for research. this symposium will present studies conducted by three university of washington researchers, bringing a diverse perspective of how young adults navigate the legal marijuana landscape in washington. implications of these findings for prevention and treatment will be discussed. contact: beatriz carlini bia@uw.edu marijuana customers: product preferences amongst different types of young adult consumers devon alisa abdallah, christine m. lee, rose lyles-riebli, megan patrick university of washington, university of minnesota purpose: marijuana is the most commonly used psychoactive substance, after alcohol, amongst young adults, with 53% reporting lifetime use and 22% past month use (nida, 2018). despite popularity and increasing legalization, important knowledge gaps exist, such as why marijuana users prefer certain modes of use and what characteristics they look for when choosing products. the present study examines differences between self-identified light, moderate, and heavy marijuana users in terms of 1) preferred mode of use (e.g., smoking, eating, drinking, vaping, and other), 2) why they prefer a given mode, and 3) to what extent they pay attention to certain properties when choosing marijuana (e.g., thc content, cost, strain). answers to these questions will inform development of targeted messaging. method: participants included a subsample of young adults who self-identified as marijuana users (n=218; 54.6% female, m age=21.88, sd=1.78) who were part of a larger study on health behaviors in washington state. participants completed measures about their marijuana use, preferred mode of use, and reasons for mode preference. participants indicated the extent to which they pay attention to thc content, strain, quality of marijuana, and cost when choosing marijuana (from 0=not at all to 4=very much). data analyses included one-way anovas to compare three types of self-described marijuana users (i.e., light users [n=108, 49.5%], moderate users [n=71, 32.6%], and heavy users [n=39, 17.9%]) on their marijuana use, modes of use, and preferences when choosing marijuana. open-ended responses on the reasons for mode preference were coded for themes, including better or different high (than other modes), conference abstracts 125 convenient or easy to use, and healthier than smoking marijuana. results: in the past 30 days, 90.4% of participants reported marijuana use. overall, heavy marijuana users reported being high from marijuana more hours in a typical week (m=31.38, sd=20.73) than either moderate or light users, with moderate users (m=16.18, sd=10.95) reporting being high more hours than light users (m=3.38, sd=5.61). when participants were asked their preferred mode of use, light marijuana users were more likely to prefer edibles, while heavy users are more likely to prefer “other” (e.g., dabs) modes. qualitative analyses revealed the majority of participants who preferred edibles (n=34) or vaping (n=39) used these modes because they believed they were healthier than smoking. participants (n=109) who preferred smoking cited their top reason as convenience. regarding attention paid to other characteristics, light users paid significantly less attention to thc content, strain, quality, or cost when choosing marijuana (ps<.001). conclusions: taking into consideration changing marijuana policies, understanding the decision making processes among different user types is critical for public health messaging. for example, participants in this sample who cited vaping as their preferred mode reported choosing this method because it was “healthier than smoking marijuana”, but may be unfamiliar with the risks associated with vaping. similarly, different types of marijuana users may warrant different messaging. for example, light marijuana users are more likely to use edibles and less likely to pay attention to thc content, which may put them at greater risk for overdose. cannabis retail workers: exploring the potential of budtenders as harm reduction agents beatriz h. carlini, caislin firth, sharon garrett, robin harwick university of washington we will present the results of a just concluded project exploring the potential for cannabis retail staff (budtenders) to educate their customers on practical strategies aimed at reducing negative consequences associated with cannabis use. a harm reduction framework and qualitative methods was utilized. participants who report working in washington (wa) cannabis retail stores for at least six months and interacting directly with the public were recruited for four focus groups. a total of 18 participants, median age of 27 years, fourteen women and four men, shared their perspectives about their professional role in, experiences with and motivations for conveying information to customers on minimizing risks associated with cannabis use. group discussions were recorded and transcribed verbatim for analysis. topics explored included budtenders’ perspectives on issues of public health significance such as cannabis dosing and potency, cannabis use during pregnancy, acute cannabis intoxication, driving under the influence, cannabis storage and second hand exposure. results are under analysis and will be presented in the symposium. results will be used to inform recommendations for developing training resources for this growing and important segment of the cannabis industry workforce. marijuana identities: developing and examining implicit association tests that measure associations between marijuana and the self among wa state young adults jason j. ramirez, christine m. lee, kristen p. lindgren university of washington introduction/objective: it has now been over six years since the approval of i-502 to legalize recreational marijuana use in washington state. considering this timeframe, many young adults’ experiences with marijuana in wa have taken place in a social climate that is vastly different compared to older generations' social climates. as more states seek to legalize recreational use, it is becoming increasingly important to understand how younger generations think about marijuana and how they conceptualize their own identities in relation to marijuana use in this social climate. this presentation will discuss qualitative and quantitative findings from a project that developed marijuana identity implicit association tests (mi-iats), which are computerized measures that aim to assess the strength of associations between marijuana and one’s identity among young adults (ages 18-25). methods: the current project included 150 young adults (18-25 years old, 48.2% female) recruited from washington state who reported using conference abstracts 126 marijuana at least once per week in the past month. twenty-two participants in the sample participated in focus groups to discuss perceptions of marijuana identification and to inform the development of mi-iats. the remaining 128 participants completed an online assessment that included self-report measures of marijuana use and related consequences and two versions of miiats; one of which used words to represent marijuana, the other used images to represent marijuana. a two-week follow-up assessment, to assess test-retest reliabilities of the mi-iats, was also completed by 65 of the participants. results: young adults in focus groups noted that increased identification with marijuana could occur via several mechanisms including 1) increased frequency and quantity of use, 2) involvement in a marijuana-using peer group, 3) engaging in specific modes of use, and 4) selling and/or growing marijuana. based on feedback from focus groups, two mi-iats were developed. the imagebased mi-iat had test-retest reliability of r = 0.37 and split-half internal consistency of r = 0.62, whereas the word-based mi-iat had test-retest reliability of r = 0.45 and split-half internal consistency of r = 0.40. regression models that controlled for age and sex found significant, positive associations between word-based mi-iat scores and typical hours high per week in the past month (b = 0.56, p = .03) and marijuana-related consequences (b = 13.16, p = .01), whereas imagebased mi-iat scores were not significantly associated with hours high or consequences (ps > .05). conclusions: overall, results provide partial support for associations between marijuana and identity as risk factors for marijuana misuse. however, only scores on the word-based mi-iat were uniquely associated with young adults’ marijuana use and related consequences. one possible explanation for the findings is that young adults’ identities may be largely social constructs during this period of development. to this end, some of the stimuli in the word-based mi-iat were thought to represent social groups (e.g., the words “stoner, user”), whereas stimuli in the image-based mi-iat were limited to images of marijuana and related paraphernalia itself which may be less tied to one’s social identity. discussant: susan stoner university of washington symposium: marijuana use among older adolescents and young adults: measurement, rates, and types of use among diverse groups in the united states and abroad chair: eric pedersen rand corporation older adolescents and young adults continue to be important groups to examine in marijuana studies given their higher rates of use compared to other age groups. using large and diverse samples of adolescents and young adults, we present a series of talks increasing in global diversity, beginning with college students from one state and ending with college students from five different countries. first, we present on college student marijuana use in colorado, a state where marijuana is legal for sale and possession, and describe a novel method for collecting detailed information regarding frequency and quantity of marijuana use across a variety of different products, potencies, and doses. next, we present data from a large national epidemiological study on use among american indians living on or near reservations, which is a population at risk for heavy and problematic substance use, but for which little is known about risk factors. third, we present data from a large scale study of american college students studying abroad in foreign countries. we present prevalence rates of use abroad by gender and by country, and describe risk factors for heavier use abroad. lastly, we present data from a large multinational study of college students in the united states, argentina, spain, uruguay, and the netherlands. findings presented will describe high rates of use across countries with multiple cross-national differences on consumption patterns and contexts of use. overall, our findings have important implications for assessment, prevention, and treatment of heavy marijuana use among young adults in the united states and abroad. contact: eric pedersen ericrpedersen@gmail.com a modified timeline followback for marijuana: a simple comprehensive marijuana use assessment mark a. prince conference abstracts 127 colorado state university marijuana use is best described across four domains: quantity consumed, frequency consumed, potency of the product (i.e., the amount of psychoactive compounds per unit), and route of administration. however, the majority of studies rely on marijuana use frequency alone. the reliance on marijuana use frequency is in part due to the ease of collecting frequency data using established self-report measures. while easy to collect, frequency data alone does not allow for rank ordering of participants based on the amount of psychoactive compounds consumed. further, there is a growing literature on the heterogeneity in pharmacokinetics of marijuana across routes of administration. thus, two people consuming the same quantity and potency of marijuana products using different routes of administration may experience different effects. there is a need for an easy to use comprehensive marijuana assessment that will collect adequate information to achieve the goal of establishing links between marijuana use and a variety of outcomes. the present study combined a number of often used substance use assessments (e.g., the timeline followback, the modified daily drinking questionnaire broken into 4-hour blocks) with knowledge about the nuances of marijuana use. the final assessment tool allows participants to report quantity, potency, and route of administration information in each 4-hour block across the past two weeks (though it could easily be extended to longer time frames). frequency data is gathered by aggregating across blocks and days. the range of possible variables that can be calculated from this assessment tool is immense. some examples include: percent time using marijuana flower, concentrate, edibles, or topicals; typical potency of products across a range of routes of administration; typical quantity consumed; maximum quantity consumed; typical marijuana dose (i.e., quantity x potency); percent days abstinent, and so on. each of these metrics may have differential predictive power for a host of outcomes. the present study reports on pilot data from 512 marijuana using college students (72% female) in a state with legal recreational marijuana. dr. prince examined a range of marijuana use indicators' associations with marijuana use consequences. participants reported selecting concentrated marijuana products that contained on average twice the potency of thc compared to the potency of marijuana flower products; however, on average they reported similar levels of cbd levels across flower and concentrated marijuana products. spearman's correlations were calculated due to the non-normality of most indices of marijuana use and of the marijuana problems total score. correlations ranged from trivial to large, with the largest associations between marijuana use and consequences coming from the following indices: percent time using marijuana flower, percent days abstinent, maximum quantity of concentrated marijuana, and concentrated marijuana dose of thc and cbd (as separate variables). this measure is easy to use, quick to administer, and has the quality of providing data towards a range of indices that can capture the nuances of marijuana use. marijuana use patterns among american indian youth olivia bolts, mark a. prince, linda stanley, randall swaim colorado state university american indian (ai) youth are more likely to endorse past 30-day marijuana use compared with non-ai youth who attend the same schools located on or near reservations. however, there is limited research describing marijuana use patterns among ai youth. an increased understanding of marijuana use patterns and behaviors of ai youth can help inform prevention efforts for ai youth. the present study is a large epidemiological study of 7th-12th grade selfidentified ai students who reside in different regions of the united states (i.e., north east, north west, northern plains, south east, south west, upper great lakes). ai youth in the upper great lakes region report the highest frequency of marijuana use, while ai youth in the north east region report the lowest frequency of use. across all regions, risk factors for increased marijuana use include common reasons for using (i.e., to feel good or get high, to find deeper insights and understanding, to get through the day, because i have to have it). in addition, feeling discriminated against because of race or ethnicity appears as a prominent risk factor among all regions excluding the south east. also, greater perceived risk of harm from using marijuana conference abstracts 128 regularly serves as a protective factor associated with less use among ai youth in all regions. moreover, an increased importance of religion in one's life and attendance of religious services function as protective factors for ai youth in the northern plains, south east, and south west regions. excluding the north east region, attitudes toward school (e.g., enjoyment of school, endorsement of greater likelihood for attending college) are associated with less marijuana use, as well. risk and protective factors related to identifying with ai culture vary across regions. among ai youth in the north east, endorsement of future success in the white-american culture appears as a specific risk factor for increased marijuana use. for ai youth in the north west, following another way of life different from ai and white-american culture may serve as a risk factor for greater use. ai youth from the south west and upper great lakes regions might be at heightened risk for increased marijuana use if their family follows ai culture and they intend to incorporate ai culture as an adult, whereas these characteristics might function as protective factors against greater use for ai youth in the northern plains region. lastly, protective factors for ai youth in the south east include living in line with white-american or non-ai culture. overall, risk and protective factors observed across distinctive regions of ai youth provide a glimpse into the potential differences of marijuana use patterns among ai youth, and thus suggest the importance of continuing to identify within-group differences and considering such differences when implementing interventions on ai reservations. college student marijuana use during study abroad experiences eric r. pedersen, sarika bharil, david klein, elizabeth d'amico, beth ann griffin rand corporation college students who are completing study abroad experiences have recently been identified as a group at-risk for increased heavy drinking, with levels of alcohol use more than doubling during the one to three-month time periods while students are abroad. however, very little is known about the drug use of american college students abroad. as part of a larger study examining the drinking behaviors of college students abroad, we assessed marijuana use among 2,245 american college students (mean age = 20, 77% women, 69% white) completing study abroad programs in 12 different countries in europe, australia, asia, latin america, and africa. marijuana use was assessed by a single item for frequency via online self-report surveys regarding the month immediately prior to the trip, during the first month of the trip, and during the last month of the trip. during each time point, participants also indicated their perceptions of the marijuana use of their country-specific study abroad peers. among the entire sample, 24% reported marijuana use in the month prior to the study abroad trip, with 19% reporting use in the first month of their trip and 23% reporting use during the last month of their trip. at all timepoints, men were significantly more likely to report marijuana use than women. students in specific countries (e.g., germany, costa rica, south africa, spain) reported higher rates of use abroad than students in other countries (e.g., china, japan, mexico). participants perceived that other students in their host country were using marijuana abroad at rates much higher than actual: they believed that 72% and 69% of their peers were using marijuana during their first and last months abroad, respectively. in addition, participants believed that local people in their host countries were using at higher rates than estimated as actual in each country, with participants believing that 66% and 64% of local people were using marijuana during their first and last months abroad, respectively. these findings demonstrated that about 1 in 5 college students abroad report marijuana use during their trip, with differences in rates of use by gender and by host country. as perceptions of prevalence of use by other study abroad students and by local people were drastically overestimated, it may be important to develop programs that correct normative misperceptions of marijuana use abroad, particularly for students studying in countries where recreational marijuana is illegal, in an effort to prevent students from experiencing negative consequences from drug use during the trip. examining marijuana use prevalence and context of use in five countries: findings from the cross-cultural marijuana study conference abstracts 129 adrian j. bravo, cross-cultural addictions study team university of new mexico marijuana (or cannabis) is the most widely used illicit drug in the world. rates of marijuana use and cannabis use disorder peak in young adulthood and among young adults, college students are at a significantly higher risk for marijuana use initiation compared to same-aged individuals not enrolled in college. globally, marijuana use among college students is prevalent and heavy marijuana use is associated with increased negative consequences. despite the high prevalence of marijuana use in college students around the world, alongside recent increments in the medicalization and legalization of marijuana use, there is a paucity of crosscultural studies fully examining differences in patterns of use across countries with different cultural backgrounds and marijuana policies. in this presentation, dr. bravo will present on work examining prevalence, patterns (i.e., product use, consumption location, and consumption context), and cross-national differences of marijuana use among college students (total sample: n=3,482, 68.1% females) from five countries (u.s.: n=1,918, 67.3% females; argentina: n=375, 66.7% females; spain: n=754, 66.4% females; uruguay: n=133, 80.5% females; and netherlands: n=302, 70.4% females). cross-tab calculations were conducted to examine differences across countries on proportion of students that reported lifetime and last 30-day use (significant differences were determined by using a z-test with a bonferroni correction). significant mean differences on continuous marijuana use variables were determined via post-hoc comparisons using a bonferroni correction within an anova framework. among all marijuana users, students consumed marijuana on about 10 days in the past 30 days (m=9.80), reported using about 6 grams of marijuana (m=6.12) across 6-7 time periods during a typical week (m=6.10). on a 0 (not at all) to 100 (completely) scale, participants reported typical subjective intoxication to be above the midpoint (m=55.36) and reported being intoxicated for a 3 hours on a typical use day (m=3.00). for consumption patterns, most students reported consuming "plant" as their primary product (77.11%). for location, the majority of participants consumed marijuana either a home or a friend's home (63.82%). for context, most participants consumed marijuana with friends (76.07%). there was a plethora of cross-national differences on consumption patterns, location of use, and context of use that will be discussed in the presentation. our findings supported marijuana use as a highly prevalent behavior in college students from different countries/cultures, particularly in uruguay, a south-american country that recently endorsed the legalization of marijuana production, possession and use (all these regulated by the federal government). moreover, cross-national analyses revealed distinct routes of ingestion, context of use, and type of products used among college student marijuana users from 5 countries. these distinct patterns in use of marijuana across european and american countries have particular implications for prevention and treatment. symposium: methodological challenges in cannabis research chair: robert cook university of florida as state policies have begun to change and cannabis products have become more readily available to consumers, the opportunities to research health harms and benefits of cannabis have also increased. despite an increase in research opportunities, cannabis research still faces significant barriers and challenges. as cannabis itself is a complex substance that cannot be reduced into a single pharmacological agent it poses significant methodological challenges. this symposium will examine and discuss methodological challenges in cannabis research specifically in recruitment, measurement of marijuana use, and issues determining the efficacy of marijuana for a therapeutic use. the first presentation will examine the barriers to recruiting hard-to-reach, hidden, or vulnerable populations in cannabis studies. the second presentation will discuss challenges and strengths of using the marijuana timeline follow back measurement in a multi-site research setting. the third presentation will explore the feasibility of using an ecological momentary assessment to determine real-time medical conference abstracts 130 marijuana use among older adults with chronic pain. the final presentation will examine results from a scoping review to show common methodological challenges among medical marijuana efficacy studies. contact: robert cook cookrl@ufl.edu recruitment and retention of hard-to-reach, hidden and vulnerable populations in cannabis research shantrel canidate university of florida objective. despite regulatory efforts set forth by the national institute of health (nih) to increase the representation of women and minorities in clinical research, recruitment and retention of these groups including hard-to-reach, hidden, or vulnerable populations in clinical research is relatively low. factors influencing low participation among these groups include the social or physical location of the group, vulnerability, as well as the hidden nature of the group. with regard to cannabis research, researchers have been unsuccessful in recruiting and retaining non-injecting drug users as well as recreational drug users in clinical research. though cannabis use is highly common in many western countries and its prevalence rate exceed that of many illicit drugs. this presentation attempts to discuss the importance of recruiting and retaining hard-to-reach, hidden, or vulnerable populations in clinical research specifically, cannabis research. as well as factors contributing to barriers and challenges, as well as solutions to overcome these challenges. methods. the marijuana and potential long-term effects (maple) study seeks to explore the influence of marijuana on key health outcomes and behaviors among persons living with hiv (plwh). to date, the study has recruited 79 individuals from various settings (i.e., public health clinics, patient registries, and patient referrals from the community) with the goal of 480 study participants. findings. while determining the most effective recruitment strategy takes significant planning and execution, working around the unforeseen factors which may negatively impact recruitment is imperative. moreover, challenges associated with hard-toreach, hidden, as well as vulnerable population are primarily contingent upon two factors: individual barriers to study participation (i.e. labeling the population, mistrust of researchers, risks associated with participating in clinical research, lack of resources) and sampling issues (i.e. snowball and respondent-driven sampling and derived rapport). among the hard-to-reach, hidden, and vulnerable populations such as cannabis users, studies examining barriers and challenges to recruitment and retention among these populations reported solutions which include developing a well-thought out study design which includes multiple sampling strategies, expanding eligibility criteria, disseminating study findings to garner to dispel mistrust, as well as building rapport with potential participants and key community members. strengths and challenges of using the marijuana timeline follow back for a multi-site research setting verlin joseph, paige rickett, robert cook university of florida, florida department of health objective. as attitudes and policies regarding marijuana use continue to shift, developing selfreported measurement tools have become a leading concern in the field. in clinical and research settings, the gold-standard of selfreported substance use is the timeline followback (tlfb). previously, the tlfb has been shown to be both valid and reliable for measuring alcohol, marijuana, and illicit drug use. traditionally, marijuana is more difficult to quantify due to having several routes of administration when smoking (i.e. joints, blunts, pipes, bongs, and vaporizers) and unique dosing per individual. further complicating self-reported marijuana is recall bias. in order to overcome these limitations, we have adapted the alcohol timeline tlfb in order to develop a common metric of cannabis use. the primary goal of the marijuana tlfb is develop a standardized unit of measurement to compare marijuana use across mode of administration, quantity/frequency of use, and thc/cbd concentration. here, we discuss the strengths and challenges of using the conference abstracts 131 tlfb to measure marijuana use. methods. in order to overcome these challenges, we have adapted the tlfb for alcohol use to address these limitations. our tlfb instructs participants to recall the past 30 days of marijuana use. we are especially interested in mode of administration, number of grams, and number of hits. to date, we have recorded (n= 70) responses, there were slightly more women than men (50.8% vs 47.5%). most participants were non-hispanic black (75.4%) compared to non-hispanic white (16.4%) and other (8.2%). findings. strengths of tlfb include: identifying distinct patterns of marijuana use, capturing detailed use across varying modes of administration, and time efficiency. overall, participants enjoy this section as it offers a change of pace from longer study visits and they enjoy talking about their marijuana use. challenges of tlfb include: recall bias as many participants, do not know the amount they are using, developing a standardized score to successfully describe the quantity/frequency of marijuana use. additionally, several participants do not have a distinct pattern of use do to only using when it is available. lastly, several participants struggle to remember the precise number of hits which may introduce bias when creating a standardized use score. measuring medical marijuana use in older adults: feasibility and preliminary findings from a study using ecological momentary assessment (ema) yan wang, robert cook university of florida objective. older adults, a population with high chronic pain burden, have become the fastest growing group of medical marijuana consumers in the context of the opioid crisis. there is an urgent need to investigate whether medical marijuana can help people reduce/quit opioids and improve pain management. however, it's challenging to accurately measure medical marijuana use given the widely varied products (e.g., different thc:cbd ratios and routes of administration) available at different dispensaries and the fact that people are self-dosing with minimal monitoring. this pilot study aims to investigate the feasibility of using ecological momentary assessment (ema) to determine real-time medical marijuana use and pain relief among older adults with chronic pain. methods. older adults with chronic pain seeking to start medical marijuana were recruited from two medical marijuana clinics in florida. using smartphone based ema, participants (50+ years old) rated their momentary pain approximately 1-week pre and up to 3 weeks post initiation of medical marijuana treatment. specifically, participants were asked to complete three random assessments on their medical marijuana treatment and outcomes (e.g., product composition, dosage, administration route, time since last dose, real-time pain level, side effects) and one daily assessment (e.g., past 24-hour medication and substance use, sleep quality) every day for up to 4 weeks. participants were also asked to take pictures of the labels on their medical marijuana products for validation of their self-reported information. findings. data from the first 11 participants (mean age = 57.2, sd = 2.1) included a total of 640 random and 224 daily ema assessments (ongoing data collection). ten out of 11 participants successfully complied with ema procedures, and all 10 participants reported ema procedures as acceptable and easy to follow. results showed a wide range of products have been used by these participants. most of them were using at least two different products at the same time with 1 vape product and 1 sublingual drop being the most common pattern of use. the composition ranged from pure cbd to pure thc with a variety of combination ratios in between (e.g., 1:1, 20:1, 40:1, 60:1). participants reported positive effects of medical marijuana included improving sleep and helping with withdrawal/side effects from opioids, and side effects included dry mouth, nausea, and feeling sedated/sleepy/depressed. these preliminary findings suggest that ema is a feasible and valid method for collecting data on the complex patterns of medical marijuana use and also for investigating the real-time health and side effects of medical marijuana on older adults with chronic pain. methodological limitations and barriers when measuring the efficacy of medical marijuana nichole e. stetten, jamie pomeranz, michael moorhouse, ali yurasek, amy v. blue university of florida conference abstracts 132 objective. as states continue to legalize medical marijuana, it is crucial that we examine the empirical evidence of the safety and efficacy of cannabis for therapeutic purposes. a scoping review was conducted to examine the levels of evidence currently available on medical marijuana's efficacy in the treatment across a large range of disabilities. results from the scoping reviewed mirrored that of the national academy of science report but noted how quantitative and qualitative studies contradict each other on marijuana's efficacy in treatment of specific disabilities. the purpose of this presentation is to expand further on the published results of the scoping review and highlight common methodological limitations and barriers among the studies examined. methods. the search strategy was developed to represent the four broad categories of disability: (1) physical (e.g. mobility, neurologic, traumatic brain injury, musculoskeletal), (2) intellectual (e.g. mental, down's syndrome, autism), (3) cognitive (e.g. learning, attention deficit disorder) and (4) psychiatric (e.g. anxiety, depression, bipolar, schizophrenia). the search was completed using the following online databases: pubmed, proquest and ebsco (academic search premier, cinahl, psychinfo). findings. the majority of studies examined did not report what type of marijuana was used, how marijuana was being delivered, and dosage levels. when studies did report the strain, dosage and delivery method, they were usually significantly different across studies making it difficult to compare results of efficacy across studies. these results highlight the methodological challenge of drug delivery and standardized dosing procedures in cannabis research. the stark contrast in quantitative and qualitative research on the effectiveness of medical marijuana highlight another methodological issue in how efficacy is reported in the treatment of specific disabilities. another explanation is that quantitative and qualitative are measuring two different types of outcomes. looking at the canonical framework in disability research, international classification of functioning, disability and health (icf) model, quantitative studies are measuring body function and structure, one of the three levels of functioning. whereas qualitative studies are typically assessing the other two levels of functioning (i.e. activity and participation). discussant: robert cook university of florida symposium: risk, resilience, reasons, and reduction: factors related to marijuana outcomes chair: kirstyn n. smith-lecavalier colorado state university the present symposium explores multiply determined marijuana-related outcomes (i.e., marijuana use and consequences) and elucidates factors that increase risk or protect against these outcomes. more specifically, four symposium talks will address the associations between childhood factors, psychological well-being and happiness, potency of the product being used, frequency of use, and a brief intervention have on marijuanarelated outcomes. the first talk will discuss how an increase in experienced adverse childhood experiences predicts an increased likelihood of trying marijuana, and at a younger age, while childhood resiliency predicts the frequency at which one later uses. the second talk explores how varying levels of happiness and the six facets of psychological well-being are closely related to one's motives, specifically for individuals who use for coping and conformity motives. the third talk focuses on how both the frequency at which one uses cannabis and the potency of the cannabis being used influences the effect of motives on marijuana-related consequences. the fourth talk will describe the development of a single-session, harm reduction intervention designed to reduce marijuana-related problems. more specifically, this study assesses the differences in marijuanarelated outcomes between two interventions using motivational interviewing and psychoeducation that differ in content. the four talks will provide greater understanding of how adverse childhood experiences, resiliency, happiness, psychological well-being, the types of products being used, and a harm-reduction intervention contribute to the experience of marijuana-related outcomes which may inform future prevention and intervention efforts. contact: kirstyn n. smith-lecavalier kirstynlecavalier@gmail.com conference abstracts 133 childhood factors predict later marijuana initiation and use jamie parnes, bradley conner colorado state university initiation of marijuana use in adolescence is known to predict greater shortand long-term negative consequences associated with use, including increased rates of dependence. frequent marijuana use, particularly as an adolescent, may also lead to greater experienced harms from use. when examining distal factors that predict initiation of use, adverse childhood experiences are an influential component. adverse childhood experiences have been previously linked to increased substance use, including marijuana use. childhood resiliency, or the protective factors individuals have during their upbringing, serve to reduce rates of substance use initiation and use frequency. however, it has yet to be examined how adverse childhood experiences and childhood resiliency may interact to alter marijuana-related outcomes. based on past literature, we hypothesized that increases in adverse childhood experiences would predict increased likelihood of marijuana initiation, earlier age of initiation, and increased frequency of use as a young adult we also hypothesized that childhood resiliency would moderate these relations, such that increased resiliency would mitigate the influence of adverse childhood experiences on marijuana outcomes. participants (n = 826) were university students (m age 20.17, sd = 2.26; 55.7% female, 77.5% white, and 80.6% non-hispanic). participants completed several measures, including the adverse childhood experiences questionnaire (aces) and the child and youth resilience measure (cyrm). measured marijuana-related behaviors included having ever used, age of initiation, and past 30-day use frequency. moderation analyses were conducted in spss version 25.0, using aces, cyrm (mean centered), an interaction term (aces*cyrm), boostrapping to stabilize parameter estimates, and alpha set to .05. binary logistic regression was used to examine the outcome of having ever used marijuana. as age of initiation approximated a normal distribution, linear regression was conducted to test this outcome. finally, negative binomial regression was used to examine past 30day use frequency. results indicated increases in reported aces related to an increased likelihood of endorsing having tried marijuana (b = .21, or = 1.23, se = .05, p <.01), however neither cyrm nor the interaction term were significant. similarly, greater reported aces were related to a younger age of initiation (b = -.16, se = .05, p < .01). however, neither cyrm nor the interaction term significantly predicted age of initiation. finally, past 30-day use frequency was significantly predicted by cyrm (b = -0.3, irr = 0.97, se = 0.004, p < .001), however neither aces nor the interaction term were significant. while study hypotheses were not upheld, the results may still be meaningful. combined, increases in experienced aces predicted increased likelihood of trying marijuana, and at a younger age, while childhood resiliency predicted the frequency at which one later uses. therefore, interventions focused to reduce adverse childhood experiences may help reduce later marijuana use. as younger age of initiation predicts greater experienced negative consequences of use, interventions delaying initiation through reduced aces may also be effective harm reduction strategies. for adolescents already using, promoting resiliency factors may reduce frequency of use and related harms. an examination of the influence of happiness and psychological well-being on marijuana use motives and marijuana-related consequences kirstyn n. smith-lecavalier, theodore j. fetterling, mark a. prince, cross-cultural addictions study team colorado state university marijuana use motives (mum) are uniquely associated with marijuana use and marijuanarelated consequences (mrc). psychological wellbeing (pwb) has been characterized across six domains: autonomy, environmental mastery, personal growth, positive relationships with others, purpose in life, and self-acceptance. happiness has been characterized across 17 subjective domains including housing, vocation/education, alcohol/drug use, etc. some studies have examined pwb and happiness as outcomes of marijuana use and mrc. however, it is possible that pwb and happiness levels portend risk for marijuana use and consequences, and that conference abstracts 134 those with higher or lower levels of pwb and happiness will be motived to use for different reasons. the extant literature on pwb, happiness, and marijuana outcomes provides an inconsistent picture with some studies concluding that marijuana use and dependence are associated with lower general happiness and lower levels of pwb, and others finding no relation. researchers have yet to examine whether varying levels of pwb and happiness are differentially associated with mums, which are, in turn, differentially associated with marijuana outcomes. we hypothesized that a sequential pathway from pwb and happiness to marijuana outcomes mediated by mums. the present study used data collected from college students in the us as a part of a multi-site international study (n = 698, 63.8% female). path analysis was used to assess indirect effect from happiness through each of the five mum to mrc, and the indirect effect from each of the six facets of pwb through each of the five mum to mrc, controlling for past 30-day use. we used the product of coefficients method to determine significance of indirect effects. in assessing direct effects of happiness and pwb to mums, happiness and all six facets of pwb negatively predicted coping motives. all six facets of pwb also predicted conformity motives. in addition, social motives were negatively associated with three facets of pwb (i.e., autonomy, personal growth, purpose in life), and enhancement motives were positively associated with three facets of pwb (i.e., autonomy, personal growth, positive relationships with others). in assessing direct effects of mums on mrc, coping motives were positively associated with mrc in all models, and conformity motives were positively associated with mrc in three of the pwb models (i.e., personal growth, positive relationships, self-acceptance). happiness was negatively associated with mrc. in assessing indirect effects, coping motives mediated the sequential path from happiness and all six facets of pwb to mrc. additionally, conformity motives mediated the path from personal growth and positive relationships with others to mrc. our findings suggest that happiness and the six facets of pwb are closely related to one's motives, specifically for individuals who use for coping and conformity motives. this suggests that pwb and happiness measures may be useful in screening and brief interventions to identify those at greater risk for using for maladaptive motives and subsequently for greater risk of negative marijuana-related outcomes. for example, tailoring prevention and intervention efforts towards those experiencing lower levels of happiness and pwb may mitigate the harms associated with use via coping and conformity motives. marijuana use motives predict marijuanarelated consequences via marijuana use frequency and potency alexander j. tyskiewicz, shane d. kentopp, gemma wallace, bradley t. conner, mark a. prince colorado state university marijuana use motives have been shown to have a unique effect on marijuana use and the likelihood of experiencing marijuana related consequences (mrc). marijuana use frequency directly predicts mrc, as do marijuana use motives. however, it is unknown the extent to which marijuana potency influences these relations. limited research has demonstrated that the use of marijuana concentrates predicts greater mrc than flower marijuana use. based on past research, we hypothesize that marijuana use motives will have positive relations with mrc. further, marijuana use frequency and product potency will moderate the effect of marijuana use motives on mrc. the current study is a secondary data analysis of research conducted as part of a larger study. participants were recruited at marijuana dispensaries in colorado. researchers photographed the marijuana products that the participants bought in order to record the potency of the products. participants then completed a survey online at their convenience in the next week. participants completed the marijuana motives measure, the marijuana consequences questionnaire, and a survey intended to assess participants' marijuana product information and typical use patterns. as prior research has found there to be a large gap between the potency of flower and concentrates, the two types of products will be analyzed separately. the sample will be split into two groups based on the type of product participants purchased. individuals who purchased flower will be assigned to one group and participants who purchased flower will be conference abstracts 135 assigned to the other. to test the study hypotheses, a series of 10 negative binomial regressions with interaction terms will be estimated in each group using mplus version 8.0 (muthen & muthen, 1998; 2012). individual models will test the effect of one of the five marijuana use motives on mrc, moderated by use. use will be operationalized as the potency of the product purchased multiplied by frequency of marijuana use, as this is a better assessment of thc intake than frequency or potency alone. since multiple models will be run, an alpha of .01 will be used to correct for potential type 1 errors. assuming study hypotheses are upheld, multiple conclusions can be made. first, the effect of motives on mrc is dependent on both the frequency at which one uses marijuana and the potency of the marijuana. people who use marijuana as a result of enhancement, conformity, expansion, coping, and social motives will report more consequences if they use marijuana frequently and use potent marijuana products. if the frequency of use and potency of the product are cumulatively high, motives will have a positive relation with mrc. if the frequency and potency concerning one's use are not cumulatively high, marijuana use motives will not predict more mrc. treating marijuana-related problems: a brief intervention theodore j. fetterling, mark a. prince colorado state university national survey data on drug use has shown that young adults (i.e., 19-30 years old) report consistently elevated levels of daily and past 30day marijuana use. higher rates of marijuana use have been linked with higher endorsement of negative marijuana-related outcomes. one approach designed to mitigate negative outcomes is through harm reduction (hr) interventions. researchers have consistently demonstrated the effectiveness of hr approaches for the treatment of substance use. in fact, empirical evidence suggests that hr treatments are equally effective as the more common abstinence-based treatments. despite these findings, hr remains relatively underutilized in marijuana treatment. the current study describes the development and evaluates the efficacy of a single-session, hr intervention designed to reduce marijuanarelated problems. participants will be randomly assigned to a marijuana specific treatment (mst) experimental or healthy stress management (hsm) control condition. both conditions incorporate motivational interviewing (mi) style and psychoeducation but differ in content. the mst condition is composed of assessment feedback, a biopsychosocial model, decisional balance, and goal setting specific to marijuana use. comparatively, the hsm condition provides general stress reduction techniques and coping strategies with no marijuana focus. we hypothesize that the mst condition will reduce significantly more marijuana-related problems than the hsm condition. the primary outcome of interest, marijuana-related problems, will be assessed using the cannabis problems questionnaire (cpq). an online survey including the cpq will be administered via qualtrics at baseline and approximately one-month post-treatment. this talk will focus on the development of the cannabis intervention based on previous studies shown to be effective in reducing cannabis related consequences (e.g., candis), highlighting the modules selected and the rationale behind the selected components. in addition, preliminary analyses for the first few participants will compare treatment and control conditions for changes in cpq scores, distress ratings for marijuana-related outcomes, and marijuana use. additionally, we will discuss how a brief hr intervention can be used to facilitate treatment among problematic marijuana users. discussant: mark a. prince colorado state university symposium: the future of cannabis research: promising directions from early career investigators chair: matthew r. pearson university of new mexico in the present context of legalization and medicalization of cannabis, applied cannabis research has reached an all-time high. the future of cannabis research will be greatly impacted by individuals who are presently choosing to focus their careers on cannabis. there are always conference abstracts 136 significant time lags between the generation of a research question, conducting the study to answer the research question, and the dissemination of such findings to the field. the goal of this symposium is to highlight the ongoing and future research efforts by early career investigators. each early career presenter will provide brief talks about an ongoing or future study, focusing on the importance of their study to the field. we anticipate that most of these researchers will present findings from these projects in the next few years. after each individual talk, all presenters will be invited to discuss critical research questions to the field that cross specific disciplines and research interests. contact: matthew r. pearson mateo.pearson@gmail.com social weedia: social media research on cannabis use latrice montgomery university of cincinnati as of february 2019, the total population of the world exceeded 7.7 billion people. approximately 3.4 billion of those individuals are active social media users. social media represents a potentially inexpensive and powerful tool for gaining insights into cannabis-related issues (e.g., impact of policies, emerging trends) in real time and with large population-level datasets of diverse cannabis users. this presentation will briefly cover how social media can be and has been leveraged to study recreational and medical cannabis use, as well as to deliver treatment interventions for individuals with cannabis use disorders. the presentation will also briefly cover opportunities for growth in social media research on cannabis and highlight future directions. acute stress modulation of the cannabis cueelicited late positive potential: a biomarker of cannabis use disorder risk among emotionally vulnerable cannabis users richard j. macatee auburn university the prevalence of regular cannabis use and cannabis use disorder (cud) has increased in the united states over the past two decades, but the majority of regular users do not develop cud. however, given the high disability associated with cud, it is imperative that regular users at highest risk for severe and persistent cud are identified for the purposes of early identification and targeted intervention. co-occurring internalizing psychopathology is associated with greater cud severity among regular users, but little is known about the neural mechanisms underlying increased cud vulnerability among this group of cannabis users. identification of underlying neural mechanisms could lead to the development of a neurobehavioral profile with greater predictive power in estimating cud risk and guide the development of novel interventions that can target these neural mechanisms directly. preliminary electroencephalography (eeg) data has revealed that acute stress-elicited motivated attentional processing of cannabis-related cues (i.e., the late positive potential [lpp], a positive slow wave evoked by motivationally-salient stimuli) is enhanced in regular cannabis users with high relative to low internalizing vulnerability. further, cannabis cue-elicited lpp amplitude in the context of acute stress was positively associated with cud severity and trajectory in the high internalizing vulnerability group. acute stress modulation of the cannabis cue-elicited lpp may be a valuable neurobiological signature of cud risk in regular cannabis users with co-occurring internalizing psychopathology; theoretical and clinical implications will be discussed. marijuana and me: adapting the implicit association test to measure associations between marijuana and the self among late adolescents jason j. ramirez university of washington the use of implicit measures of substance-related associations stems from dual process models of substance misuse that distinguish two classes of cognitive processes: implicit (i.e., relatively fast, automatic, reflexive) cognitions and explicit (i.e., relatively slow, controlled, reflective) cognitions. one crucial measure to the field has been the implicit association test (iat), a computerized reaction time task intended to measure the conference abstracts 137 strength of associations between constructs held in memory. among marijuana research, iats have been developed to measure associations between marijuana and 1) positive arousal words, 2) negatively valenced words, and 3) sedation words. however, studies examining the predictive validity of these iats have found conflicting findings to date. one adaptation of the iat that is consistently associated with drinking outcomes is an iat measuring associations between drinking and one’s self-concept. this presentation will discuss a mixed-methods approach to develop marijuana-identity iats (mi-iats) that assess the strength of associations between marijuana and the self among late adolescents (ages 15-18). to inform task development, focus groups with late adolescents will be conducted to improve our understanding of marijuana-related terminology and imagery described as typical among this age group. using this feedback to select relevant words and images, mi-iats will be developed and completed online by late adolescents ranging from lifetime non-users to current daily users. mi-iats will be evaluated on the basis of psychometric properties (e.g., split-half internal consistency) and validity in predicting marijuana use and related consequences both concurrently and longitudinally. elucidating the complex interactions between socio-cultural, neurocognitive and drug-userelated factors on drug-use trajectories catalina lopez-quintero university of florida despite a growing body of research documenting that the social environment shapes neural structures and processes and vice versa, there is currently only a limited number of studies employing an integrated approach for exploring how these factors interact. the few studies available suggest that early, severe, and chronic exposure to adversity moderates the association between neurocognitive processes and adoption of risky behaviors. my current research aims to develop a transdisciplinary research program aimed at reducing drug-use disparities across and within minority populations by investigating the mutual back-and-forth influences between neurocognitive and social-cultural factors. currently, i am exploring whether neurocognitive factors such as decision-making mediate the associations between socio-cultural factors (e.g. poverty) and drug-use outcomes (e.g., cannabisuse trajectories) among a sample of young latino adults. i am also studying whether socio-cultural factors (e.g., acculturative stress) moderate the associations between drug-use behaviors (e.g., cannabis use patterns) and neurocognitive processes (e.g., episodic memory). i believe collaborative interdisciplinary work integrating cognitive neuroscience and sociocultural research promises to significantly advance our understanding of the etiological mechanisms leading to drug-use disparities. i foresee that the adolescent brain cognitive development study (abcd study) or the healthy brain and child development study (hbcd study), will allow us to investigate in depth these interactions within a life course health development framework. this will enhance our understanding of the dynamic and multilevel processes contributing to drug-use disparities. at the same time, this research will inform the development of developmentally and socio-culturally appropriate preventive interventions. using a system science approach to understand the dynamic social context of adolescent and young adult marijuana use pamela a. matson, sarah flessa, leah frerichs, maria trent, kristen hassmiller lich johns hopkins university, university of north carolina at chapel hill aims: group model building, a system science approach, was used to understand from youth how social complexities influence uptake, continuation and escalation of marijuana use. methods: two groups of marijuana exposed youth, aged 15-20, recruited from adolescent clinic, emergency department and the community participated in four, 2-hour workshops. through structured activities (i.e. behavior over time graphs), participants generated a system dynamics model representing critical features of the complex and dynamic social system impacting marijuana use for youth in their community. results: youth (n=19) were african american, 42% male, mean age 17 yrs. participants produced a causal loop diagram, including balancing and reinforcing loops, reflecting how interpersonal interactions conference abstracts 138 contribute to a high prevalence of marijuana use at the community level. the model illustrates how marijuana is used to cope with both life and romantic relationship stressors and to facilitate positive interactions with both partners and nonromantic peers. while adolescents identified how supportive behaviors in romantic relationships could be protective against substance use, issues with trust and vulnerability dominate so when conflicts arise, they increasingly resort to cycles of negative behaviors adding to increasing relationship stress and ultimately more marijuana use. both groups generated the same system diagram. conclusions: youth articulated connections between multilevel factors, which feedback to maintain a high prevalence of marijuana use. rather than influence initiation as hypothesized, romantic relationships impact continuation and escalation of marijuana use. understanding how factors function as a system provides important information toward testing dynamic hypotheses and ultimately designing more impactful and synergistic interventions. medical marijuana laws and substance use disorder treatment: thinking beyond marijuana use pia mauro columbia university since 1996, 33 states have enacted medical marijuana laws (mmls) and 10 states and dc also have legalized recreational marijuana use. mmls can vary widely across states, particularly in terms of marijuana dispensary access and other provisions. studies aiming to understand the effects of mmls have primarily focused on proximal substance use outcomes, such as marijuana use prevalence across populations of interest. however, evidence suggests that mmls may affect more distal outcomes, such as treatment for substance use disorders (suds). the mechanisms through which mmls could affect sud treatment utilization are complex and multi-layered. these mechanisms incorporate multiple systems, such as the specialty sud treatment and criminal justice systems. in this presentation, we will discuss the challenges and opportunities of studying the effects of mmls on sud treatment, including leveraging strengths of different data sources to better understand mechanisms of action. data from the national survey on drug use and health will be used to highlight measurement issues related to the operationalization of mml policy exposure, as well as how to estimate associations before and after mml enactment while controlling for secular changes in the outcomes of interest. the presentation will conclude with a discussion of planned research aims and steps to study recreational marijuana laws. examining the therapeutic and adverse effects of diverse cannabis-based products using realtime data kevin s. montes california state university dominguez hills discussant: matthew r. pearson university of new mexico copyright: © 2019 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 76 ved abstract objectives. states that are legalizing cannabis for adult use are increasingly focused on equity, with the goal of repairing some of the harm caused by the war on drugs. this study explains and describes the emphasis states are placing on equity and assesses whether public education can be used to increase public support for equity-focused cannabis policies. methods. we conducted an online survey of 893 new jersey adults in august and september of 2021, just as state’s cannabis regulatory commission was publishing the first set of regulations for the legal sale and use of cannabis for adults age 21 and older. the study included an experimental design, in which half of respondents viewed an educational message about equityfocused cannabis policies before answering survey questions, and the other half did not. results. few participants (24.9%) were familiar with the concept of equity in cannabis policy, and a substantial proportion—from about 20% to 35%—provided a “neutral” or “don’t know” response when asked about support for specific policies. exposure to an educational message was associated with greater perceived importance of equity in cannabis policy (p < 0.05) and greater support for equity-focused policies. specifically, participants who saw an educational message had greater agreement that new jersey should provide priority licensing (p < 0.01) and grants (p < 0.001) to people who have been arrested for cannabis, and who now want to participate in the legal cannabis industry. conclusions. cannabis regulators, public health professionals, and people working to advance racial justice may be able to advance state equity goals and remedy some of the harm from the war on drugs by expanding public education campaigns to include equity messages. key words: = cannabis; marijuana; equity; systemic racism; war on drugs; media; public education states that are legalizing cannabis for adult use are increasingly focused on equity, with the goal of repairing some of the harm caused by the war on drugs (title, 2021). this study (1) explains why states are emphasizing equity in cannabis policy; (2) shows how states are acknowledging the harm of the war on drugs by calling for social equity programs, community reinvestment, and expungement of cannabis records within cannabis legislation; and (3) examines whether public education can be used to increase public support for equity-focused cannabis policies. why states are emphasizing equity in cannabis policy the war on drugs is an example of systemic racism (alexander, 2012). systematically, over decades, black and latine people in the united states have been arrested for cannabis possession at higher rates than white people, although white people are more likely than black people to report using cannabis at least once in their lives (american civil liberties union, 2013; edwards et al., 2020; substance abuse and mental health services administration, 2014, 2020a). today, black people are arrested for cannabis possession at nearly four times the rate of white people (edwards et al., 2020). racial inequities in cannabis law enforcement are not limited to arrests. in new york city from 1980 to 2003, black and latine people were not only more likely jane appleyard allen1, youn ok lee1, robyn woodlea1, vincenzo f. malo1, lauren v. zitney1 1rti international, research triangle park, nc cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023/000146 public education can be used to increase support for equity in cannabis policy corresponding author: jane appleyard allen, rti international. 307 waverley oaks rd #101, waltham, ma 02452. email: janeallen@rti.org cannabis, a publication of the research society on marijuana 77 than white people to be arrested for using cannabis in public view, they were also more likely to be detained prior to arraignment, convicted, and sentenced to jail (golub et al., 2007). these cannabis-related interactions with the criminal legal system contribute to the mass incarceration of black and latine people in the united states. numerous studies document the harm of incarceration, not only to individuals who are incarcerated, but to their families and communities. people who are incarcerated have increased exposure to violence, including sexual assault (acker et al., 2019); higher rates of communicable disease, such as covid-19 (natoli et al., 2021); higher rates of chronic health conditions (massoglia & remster, 2019); and are likelier to have access to only nutritionally inadequate food, and live in dehumanizing conditions (acker et al., 2019). children of incarcerated parents experience the loss of a parent’s care; loss of stability; increased likelihood of poverty and homelessness; increased likelihood of entering foster care; and increased risk of physical and mental health conditions such as asthma and depression (acker et al., 2019). at the community level, incarceration manifests as the erasure of young black men. a 2016 study found that so many young black men are incarcerated in the united states that national surveillance systems— which exclude institutionalized populations —underestimate health outcomes for black men aged 18 to 25 (kennedy et al., 2016). because these systems are used to identify needs and allocate funding for programs (centers for disease control and prevention, 2018), reduced representation may lead to reduced federal funding for public health issues facing black communities. at the individual, family, and societal level, the effects of incarceration reverberate long after imprisonment has ended, contributing to unstable housing, reduced job opportunities, lower-paying jobs, and worse longterm physical and mental health outcomes (acker et al., 2019; massoglia & remster, 2019). in the words of a boston leader whose mother was incarcerated during his childhood: “removing my mother from my home didn’t make me safe. didn’t make my siblings safe; didn’t make my community safe. it made us less safe. it destabilized us. it created trauma.” (martinez, 2022). legal scholar michelle alexander concludes that any involvement with the criminal legal system, including fines, stops, detainments, probations, and arrests, can produce outcomes similar to incarceration (and can lead to incarceration itself) (alexander, 2012). for example, because of the long history of criminalizing poverty in the united states, the inability to pay small legal fines and fees can lead to arrest and incarceration (jahangeer, 2019). encounters with the police—ranging from “stop and frisk” to police brutality—cause psychological and physical harm even when they don’t result in arrest (alang et al., 2017; cooper, 2015). black and latine men—especially those who identify as members of the lgbtqia+ community—are at greater risk than white, straight, cisgender men of being stopped and frisked in new york city, regardless of their cannabis use (khan et al., 2021). even programs intended to reduce the harm of incarceration can be counterproductive. an evaluation of a cannabis criminal justice diversion program in harris county, tx, found that black men are overrepresented in the program, and that black and latine men are less likely than white men to finish the program—an outcome that is associated with increased subsequent involvement in the legal system (sanchez et al., 2020). the movement to legalize cannabis for adult use is in part a response to the racist policies of and harm caused by the war on drugs. although ballot language in the first states to legalize — colorado, washington, alaska, oregon—did not explicitly reference the war on drugs, news reports suggest it was a theme of public discussion (martin & seattle times, 2012). within several years of the first states legalizing cannabis, however, it became clear that legalization had not eliminated racial inequities in cannabis arrest rates. although the total number of cannabis arrests declined in states that legalized cannabis, racial inequities worsened (edwards et al., 2020; firth et al., 2019; gunadi & shi, 2022; sheehan et al., 2021). of the eight states that legalized cannabis before 2018, racial inequities in arrest rates increased in two states and remained unchanged in one (edwards et al., 2020). although racial inequities in arrest rates declined slightly in massachusetts after its 2016 cannabis legalization— which had an emphasis on equity — they were still higher than the national average public education can support equity in cannabis policy 78 in 2018 (edwards et al., 2020). despite cannabis being decriminalized statewide in new york in 2019 leading to substantial declines in the total number of cannabis arrests in new york city, a 2020 study concluded that people from black and latine communities represented 95% of all cannabis arrests and 96% of all criminal court summons for cannabis in new york city (the legal aid society, 2021). developing cannabis policy to reduce some of the harm of the war on drugs having seen that greater support is needed for equity to become a reality, states that legalized cannabis more recently — massachusetts, illinois, new jersey, new york—explicitly named the harms of the war on drugs and proposed social equity provisions in their legislative texts (sinha, 2021). the following excerpts from state acts legalizing cannabis for adult use illustrate the acknowledgment of harm caused by past enforcement of cannabis laws. the general assembly … finds and declares that individuals who have been arrested or incarcerated due to drug laws suffer longlasting negative consequences, including impacts to employment, business ownership, housing, health, and long-term financial wellbeing. the general assembly also finds and declares that family members, especially children, and communities of those who have been arrested or incarcerated due to drug laws, suffer from emotional, psychological, and financial harms as a result of such arrests or incarcerations. –cannabis regulation and tax act, illinois (the state of illinois, 2019) existing laws have been ineffective in reducing or curbing marihuana [sic] use and have instead resulted in devastating collateral consequences including mass incarceration and other complex generational trauma. –the marihuana [sic] regulation and taxation act, new york (the state of new york, 2021) black new jerseyans are nearly three times more likely to be arrested for marijuana possession than white new jerseyans, despite similar usage rates. a marijuana arrest in new jersey can have a debilitating impact on a person’s future, including consequences for one’s job prospects, housing access, financial health, familial integrity, immigration status, and educational opportunities. … new jersey cannot afford to sacrifice public safety and individuals’ civil rights by continuing its ineffective and wasteful past marijuana enforcement policies. –an act concerning the regulation and use of cannabis, new jersey (the state of new jersey, 2021) the following excerpts illustrate approaches states are taking to create opportunities for those who have been harmed by the war on drugs to participate in the new legal industry. the regulations shall include…. procedures and policies to promote and encourage full participation in the regulated marijuana industry by people from communities that have previously been disproportionately harmed by marijuana prohibition and enforcement and to positively impact those communities. –the regulation and taxation of marijuana act, commonwealth of massachusetts (commonwealth of massachusetts, 2016) [i]n the interest of remedying the harms resulting from the disproportionate enforcement of cannabis-related laws, the general assembly finds and declares that a social equity program should offer, among other things, financial assistance and license application benefits to individuals most directly and adversely impacted by the enforcement of cannabis-related laws. –cannabis regulation and tax act, illinois (the state of illinois, 2019) “a goal shall be established to award fifty percent of adult-use cannabis licenses to social and economic equity applicants and ensure inclusion of: (a) individuals from communities cannabis, a publication of the research society on marijuana 79 disproportionately impacted by the enforcement of cannabis prohibition…” –the marijuana regulation and taxation act, new york (the state of new york, 2021) using public education to increase support for equity in cannabis policy with equity now an explicit cannabis policy goal for some states, cannabis regulators, public health professionals, and people working to advance racial justice may be reflecting on how they can support the development and successful implementation of equity-focused cannabis policies. we consider public education a promising approach for two reasons. first, public education is a powerful tool that has been used successfully in public health for decades, including to increase support for policy (allen et al., 2015; centers for disease control and prevention, 2007; niederdeppe et al., 2008; tobacco free nys, 2018). second, states that are legalizing cannabis for adult use are already using public education campaigns to inform people about the new law, prevent accidental ingestion and overconsumption of edibles, discourage driving under the influence, and discourage use among people who are pregnant, breastfeeding, or under 21 years of age (colorado department of public health and environment (cdphe), 2019; doonan sm. et al., 2020). expanding public education campaigns to include equity messaging could promote public support for specific equity-focused cannabis policies and help states achieve their equity goals. at least one state is already taking this approach. in june 2022, the new york state office of cannabis management released the first broadcast tv ad in the united states to address the issue of equity in cannabis as part of its cannabis conversations campaign. the ad highlights “how decades of cannabis overpolicing harmed black and latino new yorkers, and the work [the new york state office of cannabis management is] doing to address these devastating wrongs,” (new york state office of cannabis management, 2022). this study describes public support for equityfocused cannabis policies among new jersey adults and assesses whether public education can be used to increase awareness of and support for equity-focused cannabis policies. to our knowledge, this is the first study to explore the use of public education to increase support for equity in cannabis policy. methods study design and implementation we conducted an online survey with an embedded experimental design to (1) assess public support for equity-focused cannabis policy among new jersey adults and (2) determine whether a simple, educational message can increase support for equity-focused cannabis policy. from august 23 through september 15, 2021, we recruited 893 new jersey adults aged 21 and older through advertisements on twitter and facebook (hereafter referred to as “social media”). the people depicted in the social media advertisements were racially diverse. the study protocol, social media advertisements, consenting documents, survey, and educational messages were approved by rti’s irb. the 15-minute survey was optimized for use on mobile devices. people who clicked on the social media advertisements were asked to provide informed consent before taking the study screener. the screener included multiple checks to verify that respondents were residents of new jersey aged 21 or older. specifically, we began the screener by asking people “how old are you?” and “what state do you live in?” later in the screener, we asked people their date of birth and 5-digit zip code. we screened people out of the survey if their age and location data did not align. we asked about race and cannabis use in the screener to intentionally create a nonprobability sample that was racially diverse and had good variation across cannabis use status, with a specific goal to oversample black and latine people. we consider it a priority to emphasize the perspectives of black and latine people in research about possible reparative actions relating to the war on drugs, because black and latine people have been, and still are, disproportionately harmed by the war on drugs. another goal was to ensure that we developed a sample with a range of cannabis use experiences. because people who use cannabis continue to be stigmatized and criminalized as a result of cannabis policy, we believe it is important to emphasize their perspectives in research that may shape future policy. although data are weighted to public education can support equity in cannabis policy 80 the population of new jersey, oversampling specific populations leads to greater precision of estimates for these populations. we monitored screener data daily during data collection and closed the survey to specific populations as they became sufficiently represented in the sample for the purposes of our study. to protect cannabis consumers, who were reporting on cannabis use and purchasing behaviors that were legal in new jersey at the time of the survey but illegal at the federal level, we advised respondents to take care to protect their survey responses. we also programmed the survey so that one question appeared on each screen, and it was not possible to move backward within the survey. this practice protects respondent privacy by locking each survey response immediately upon entry. figure 1. messages viewed by study participants we asked eligible respondents to provide informed consent a second time to take the main survey. after providing consent, respondents were randomly assigned to a control or experimental condition. we asked all respondents whether they had ever heard of the concept of equity in relation to cannabis legalization. after measuring unaided awareness of equity, all participants swiped through three screens that defined equity (figure 1). participants in the control condition then went on to the rest of the survey. participants in the experimental condition had to swipe or click through seven screens with equity-focused messaging (figure 1) before proceeding to the remainder of the survey. all questions in the main survey were skippable. we implemented fraud prevention and detection measures developed by our organization’s social media data collection team to ensure that respondents were humans (not bots), were located in new jersey, were age 21 or older, and each took the survey only once. we screened out respondents who failed either of two midsurvey attention checks. we sent all respondents who completed the survey a $15 digital gift card. measures key study measures were (1) awareness of the concept of equity in cannabis policy; (2) perceived importance of equity in cannabis policy; and (3) agreement with specific equity-focused cannabis policies. we measured awareness of the concept of equity by asking, “have you heard the term ‘equity’ used in the context of marijuana legalization before?” response options were “yes,” “no,” “i don’t know,” and “prefer not to answer.” we measured perceived importance of equity by asking, “overall, how important is equity in cannabis to you?” response options took the form of a 5-point scale ranging from “very important” to “not at all important,” including a neutral response. we measured agreement with specific equity-focused policies by stating, “new jersey should provide the following types of support to people who have been arrested for marijuana, and who now want to participate in the legal cannabis industry…(1) priority in licensing (have your cannabis business license application reviewed before other people); (2) license application assistance (help getting together everything needed to apply for a cannabis business license); (3) technical assistance (help getting together everything needed to start a cannabis business); (4) low-interest loans (loans that don’t cost much to pay back); (5) grants (funding that doesn’t need to be paid back).” response options took the form of a 5-point likert scale ranging from “strongly agree” to “strongly disagree,” including a neutral response and the response “i don’t know.” measures in this section were randomized to preclude order effects. cannabis, a publication of the research society on marijuana 81 figure 2. importance of equity in cannabis analysis we used weighted data to produce estimates for unaided awareness of equity, importance of equity, and support for specific equity-focused policies, because we wanted these estimates to reflect the population of new jersey. sampling weights were created to remove bias, making the data more representative of the new jersey population of adults 21 years of age and older. the steps for calculating weights were to (1) calculate the base weight; (2) calibrate to known population totals; and (3) evaluate the unequal weight effect (uwe). we adjusted the weights to sum to the population totals for demographic categories that are correlated with study outcomes to reduce bias stemming from oversampling of cannabis consumers, coverage error, differential nonresponse, and different selection probabilities. the five distributions used in the calibration adjustment were gender, age category, race/ethnicity, educational attainment, and age category by marijuana use. data were weighted using the u.s. census national characteristics vintage 2021 file, the 2020 american community survey (asc) 5-year summary file, and the 2018– 2019 national survey on drug use and health. a hot deck imputation procedure was used to replace 18 missing values for variables used in the calibration weighting. to simplify our reporting of unaided awareness of equity, importance of equity, and support for specific equity-focused policies, we combined “strongly agree” and “agree” response options and “strongly disagree” and “disagree” response options. we also combined “neutral” and “i don’t know” responses on the principle that both types of responses represent an opportunity for public education. we used unweighted data to test whether outcomes were statistically significantly different by study condition. it is not necessary to weight experimental data in which participants are randomly assigned to a condition; weighting can reduce the precision of estimates (miratrix et al., 2018). given that the purpose of significance testing was to compare differences across study conditions rather than to describe a population, we opted to use unweighted data for this component of the study. to increase the variation for each outcome variable, we used means (rather than proportions) for these analyses. we calculated mean perceived importance and mean agreement for each outcome based on a 5-point scale, using unweighted data and t-tests. we conducted a sensitivity analysis using welch’s t-tests and wilcoxon rank-sum tests to confirm that results were stable and consistent across these tests and their assumptions. in the results section of this paper, we report results from the t-tests. analyses were conducted using stata version 16. results sample characteristics approximately half of the study participants (n = 429) were assigned to the control condition and the other half (n = 434) to the experimental condition. the study sample’s racial makeup was 44% white, 23% asian, 18% black, 12% multiracial or another race, and 2% american indian, alaska public education can support equity in cannabis policy 82 native, native hawaiian, or pacific islander. census data for new jersey indicate that in 2020 the state was 71% white, 15% black, 10% asian, 2% multiracial, and 1% american indian, alaska native, native hawaiian, or pacific islander (united states census bureau, 2021). in terms of ethnicity, the study sample was 25% latine, compared to 19% in the state of new jersey (united states census bureau, 2021). the study sample consisted of current (past 30-day) cannabis consumers (33%), people who have used cannabis but not in the past 30 days (32%), and people who have never used cannabis (35%). monitoring the future survey data from 2020 indicate that, among young adults aged 19 to 30, 27% were past 30-day cannabis consumers, 37% have used cannabis, but not in the past 30 days, and 36% have never used cannabis (schulenberg et al., 2020). however, these national estimates are likely greater than the prevalence of cannabis use in new jersey, because we know that young adults use cannabis at higher rates than older people and the mean age of our study participants is 39 (substance abuse and mental health services administration, 2020b). data from the national survey on drug use and health indicate that just under 10% of new jerseyans 18 and older report being a past 30 day cannabis consumer (substance abuse and mental health services administration, 2021). thus, our study sample has greater representation of black and latine individuals and includes a greater proportion of cannabis consumers than the population of new jersey. detailed, unweighted sample characteristics overall and by study condition are shown in table 1. table 1. unweighted study sample, overall and by condition overall experimental control p-value age 38.8 39.4 38.3 0.28 gender identity female 56.1% 54.8% 57.3% 0.46 male 41.8% 43.3% 40.3% 0.37 genderqueer/other 2.1% 1.8% 2.3% 0.62 are you hispanic or latino? (yes) 24.9% 25.1% 24.7% 0.89 race american indian/alaska native 1.6% 1.8% 1.4% 0.61 asian 23.4% 22.8% 24.0% 0.68 black 18.3% 18.7% 17.9% 0.79 native hawaiian 0.7% 0.5% 0.9% 0.41 white 43.7% 44.0% 43.4% 0.85 other/multiracial 12.3% 12.2% 12.4% 0.95 have you ever used mj in any form? (yes) 65.1% 65.2% 65.0% 0.96 have you used mj in the past 30 days? (yes) 33.3% 32.3 % 34.3% 0.53 highest grade or level of school completed? high school, ged, or less * 21.3% 24.2% 18.4% 0.04* some college or bachelor’s degree 59.4% 56.5% 62.5% 0.07 master's degree or higher 19.2% 19.4% 19.1% 0.93 how would you describe your overall political philosophy? very or somewhat conservative 20.5% 22.4% 18.6% 0.18 moderate 36.2% 36.4% 35.9% 0.88 very or somewhat liberal 37.7% 36.6% 38.7% 0.53 none of the above 5.7% 4.6% 6.8% 0.17 note. mj = marijuana; * = p < .05; ** = p < .01; *** = p < .001 cannabis, a publication of the research society on marijuana 83 unaided awareness of the concept of equity in cannabis policy more than half of participants (58.7%) had not heard of equity in the context of cannabis policy, and another 16.5% said they did not know or preferred not to answer. thus, only about onequarter of participants (24.9%) had heard of equity in regard to cannabis policy. we asked this question before participants were routed to a study condition, and there was not a statistically significant difference in responses by condition (24.9% experimental condition; 24.8% control condition). importance of equity in cannabis policy among participants in the experimental condition (indicated as “saw message” in the figure) 64.6% perceived equity in cannabis to be important, compared with 55.7% of those in the control condition (“did not see message”) (figure 2). more than 20% of participants in both conditions endorsed a “neutral” or “don’t know” response. to express the data in a way that better facilitates significance testing, mean perceived importance was 4.06 in the experimental condition and 3.87 in the control condition (t = 2.41, p < 0.05) (data not shown in figure). means are based on a 5point scale. figure 3. agreement with specific equity-focused cannabis policies public education can support equity in cannabis policy 84 support for specific equity-focused policies for each of the six equity-focused policies we studied, a greater proportion of participants in the experimental condition agreed with the policy relative to those in the control condition. across the six policies, agreement in the experimental condition (“saw message”) ranged from 39.7% to 56.7%, compared to a range of 26.4% to 45.4% in the control condition (“did not see message”) (figure 3). approximately 20% to 35% of participants in both conditions endorsed a “neutral” or “don’t know” response. we calculated mean agreement with each policy approach (not shown in the figure) to conduct significance testing. for two of the six policies, mean agreement between experimental and control conditions was statistically significant. the policies for which we observed statistically significant differences by condition related to state support for people who have been arrested for cannabis, and now want to participate in the legal cannabis industry. mean agreement that the state should provide priority licensing to this population was 3.26 in the experimental condition and 3.04 in the control condition (t = 2.73, p < 0.01). mean agreement that the state should provide grants was 3.42 in the experimental condition and 3.12 in the control condition (t = 3.68, p < 0.001). means are based on a 5-point scale. discussion this study provides preliminary support that states that are prioritizing equity in cannabis policy may be able to use public education to educate the public about the rationale for an equity focus and increase support for specific equity-focused policies. two aspects of the data presented here suggest that this topic area is one in which public education could have a substantial impact. first, a very small proportion of new jersey adults (25%) had heard of the concept of equity in cannabis policy. when a concept is relatively new, it is easier for public messaging to have a large impact on beliefs about and perceptions of that concept (davis et al., 2016). second, a substantial proportion of study participants endorsed a “neutral” or “don’t know” response when asked about their support for specific equity-focused policies. we have found that it is easier to shift beliefs and perceptions when they are not strongly held (davis et al., 2016). these two findings—low unaided awareness of the concept and substantial neutral/don’t know responses—reflect the novelty of the concept of equity in cannabis policy and an opportunity for public education. cannabis regulators, public health professionals, and people working to advance racial justice may be able to advance state equity goals and remedy some of the harm from the war on drugs by expanding existing or planned public education campaigns to include equity messages. one unpublished study provides context for our findings. a 2020 survey of 240 new jerseyans aged 18 and older found that 60% of respondents agreed that new jersey should implement a loan or grant fund to support those negatively impacted by the war on drugs; 78% agreed that new jersey should prioritize expungement of prior cannabis records (azad et al., 2020). these estimates are higher than our control condition results, in which 45% supported expungement, 39% supported loans, and 26% supported grants for those harmed by past enforcement of marijuana policy. the difference in results may be explained by different study methodologies. this study has a number of limitations. first, we used social media recruitment to invite participants to this study. a limitation of this recruitment method is that it produces a nonprobability sample; in this case, a study sample that is not representative of the people of the state of new jersey. furthermore, social media recruitment may systematically exclude people living in communities that were formerly redlined due to differential broadband access (armstrong-brown et al., 2021). in this way, social media recruitment (and online data collection) can exacerbate systemic racism. however, a benefit of this method is that it makes it easier to include specific populations of interest (guillory et al., 2016; guillory et al., 2018). probability samples often do not produce a sufficient sample of black and latine participants, which historically has translated into a lack of evidence about the effects of public health interventions for these populations (allen et al., 2011). by their nature, state-level probability samples require investigators to spend the majority of their data collection budget collecting data from white people. thus, we believe it is important to cannabis, a publication of the research society on marijuana 85 embrace emerging data collection methods like social media recruitment when engaged in research designed to dismantle systemic racism. second, the study was conducted with new jersey adults; findings may not be generalizable to other states. third, we measured message effects immediately following message exposure, and therefore do not know whether effects are enduring. fourth, we forced message exposure to participants in the experimental condition, achieving a level of exposure that no real-world campaign could replicate (hornik, 2002). fifth, because our measure of unaided awareness of the concept of equity did not specify “social equity” it is possible that some participants interpreted our question as relating to stocks or shares in cannabis companies. sixth, the equity message conveyed to participants in the experimental condition represented multiple ideas, including three equity-focused policy approaches, and required study participants to read quite a bit of text. a public education campaign that focused on a primary message and made use of effective message characteristics may be able to produce stronger effects (niederdeppe et al., 2008). seventh, public education campaigns that seek to change knowledge and beliefs in novel topic areas tend to have a greater influence than those that seek to create change in topic areas that are more well-known (davis et al., 2016). thus, the effects of equity-focused messaging may be greater in states that implement them first, and effects may diminish as public knowledge about equity in cannabis becomes more widespread. a great deal more research is needed to understand public perceptions of and support for equity-focused policy, as well as whether equityfocused cannabis policies can mitigate some of the harms caused by the war on drugs. an important area for future research will be identifying effective message characteristics for this policy area. as equity-focused cannabis policies are implemented, we will be better-positioned to evaluate the effects of those policies on individuals and communities that have been harmed by the war on drugs. references acker, j., arkin, e., leviton, l., parsons, j., & hobor, g. 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(2021). quickfacts new jersey retrieved december 1 from https://www.census.gov/quickfacts/nj funding and acknowledgements: this paper was funded by rti international. this study was created and conducted with support from andrew freeman, jessica speer, allie rothschild, jessica sobolewski, kim hayes, dr. matthew farrelly, dr. james nonnemaker, burton levine, anna macmonegle, dr. jennifer duke, dr. barrett montgomery, and dr. gary zarkin. thank you to shaleen title, esq., for reviewing our survey instrument; to tauhid chappell and reverend charles boyer for talking with us about this idea; and to shellery ebron and the innovation team at rti international for support of this project. thank you to dr. stephanie hawkins and dr. megan comfort of rti’s transformative research unit for equity (true) for reviewing this concept and manuscript with an equity lens. thank you to teyonna downing and virginia ferguson for helping to prepare this manuscript, and to our editor, christina rodriguez. we are grateful to two anonymous reviewers; their thoughtful comments improved this manuscript. the authors have no conflicts of interest to report. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 81 ved abstract objective: cannabis is being used as a therapeutic option by patients around the globe, and older patients represent a rapidly growing subset of this population. this study aims to assess the patterns of medical cannabis use in patients over 50 years of age and its effect on health outcomes such as pain, sleep, quality of life, and co-medication. method: the medical cannabis in older patients study (mcops) is a multi-site, prospective observational study examining the real-world impact of medical cannabis use on patients over age 50 under the guidance of a health care provider. the study included validated instruments, with treating physicians collecting detailed data on participant characteristics, medical cannabis and comedication use, and associated impacts on pain, sleep, quality of life, as well as adverse events. results: inclusion criteria were met by 299 participants. average age of participants was 66.7 years, and 66.2% of respondents identified as female. approximately 90% of patients used medical cannabis to treat painrelated conditions such as chronic pain and arthritis. almost all patients reported a preference for oral cannabis products (e.g., extracts, edibles) rather than inhalation products (e.g., flower, vapes), and most preferred oral formulations high in cannabidiol and low in tetrahydrocannabinol. over the six-month study period, significant improvements were noted in pain, sleep, and quality of life measures, with 45% experiencing a clinically meaningful improvement in pain interference and in sleep quality scores. additionally, nearly 50% of patients taking co-medications at baseline had reduced their use by the end of the study period, and quality of life improved significantly from baseline to m3 and from baseline to m6, with an incremental cost per quality-adjusted life-year (qaly) of $25,357.20. no serious adverse events (saes) were reported. conclusions: in this cohort of older patients, most of whom suffered from pain-related conditions, medical cannabis seemed to be a safe and effective treatment. most patients experienced clinically significant improvements in pain, sleep, and quality of life and reductions in co-medication. the cost per qaly was well below the standard for traditional pharmaceuticals, and no saes were reported, suggesting that cannabis is a relatively safe and cost-effective therapeutic option for adults dealing with age-related health conditions. key words: = cannabis; cannabidiol; tetrahydrocannabinol; pain; older persons; geriatric in canada, a growing number of adults aged 50 and older are turning to cannabis for treatment of age-related ailments (ahamed et al., 2020; brown et al., 2020; lloyd & striley, 2018). older patients tend to present with potentially confounding factors, such as polypharmacy, pharmacokinetic changes, and complex medical profiles. the many health conditions for which blake pearson1, mariah walker2, josé tempero3, kaye ong4, & philippe lucas4,5 1greenly medical consulting 2tilray canada leamington, ontario 3tilray deutschland gmbh cologne, germany 4tilray canada nanaimo, british columbia 5social dimensions of health, university of victoria cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000239 volume 8, issue 1 medical cannabis for patients over age 50: a multi-site, prospective study of patterns of use and health outcomes corresponding author: josé tempero, pharmd, msc, tilray deutschland gmbh, cologne, 50668, germany. email: jose.tempero@tilray.com. cannabis, a publication of the research society on marijuana 82 older patients are using medical cannabis have been documented via patient surveys and cross-sectional studies. while a large online survey of cannabis consumers in canada and the us stemming from wave 1 of the international cannabis policy study (icps) conducted in 2018 found a higher prevalence of self-reported medical use in respondents <56 years old, a focus in the treatment of chronic pain conditions was found across the age spectrum (leung et al., 2022). however, a study of invoice data tracking dispensary purchases in new york state found that patients ≥65 older (n = 2991) were more likely to use cannabis for cancer and parkinson’s disease, to use sublingual tinctures, and to start treatment with lower thc/higher cbd products (kaufmann et al., 2022. ). moreover, a large clinicbased study of older patients in canada (n = 9766) that gathered data from 2014-2020 found chronic pain was the most cited primary indication, and that older patients had a preference for high cbd orallyingested cannabis oil. the majority reported improvements in pain, sleep and mood (p < 0.0001), and 35.6% reduced their use of opioids, and 19.9% reduced the use of benzodiazepines. the study concludes by citing the need for additional research to better determine indications, dosages and associated patient outcomes (tumati et al., 2022). comprehensive clinical evidence for the effectiveness of cannabis-based products is limited to a few indications, such as pediatric epilepsy (bialer & perucca, 2020), chronic pain (häuser et al., 2018), spasticity associated with multiple sclerosis (the health effects of cannabis and cannabinoids, 2017), and chemotherapy-induced nausea and vomiting (gottschling et al., 2020; grimison et al., 2020; maida & daeninck, 2016; sarris et al., 2020; smith et al., 2015). additionally, numerous observational studies have reported significant reductions in symptoms and high satisfaction levels with cannabis-based products (cahill et al., 2021; schilling et al., 2021; sexton et al., 2016; tumati et al., 2022; yang et al., 2021). furthermore, recent studies have hypothesized that cannabis can function as a substitute for many traditional pharmaceutical medications such as opioids, benzodiazepines, and anti-depressants (corroon et al., 2017; kvamme, pedersen, alagem-iversen, et al., 2021; lucas et al., 2021), which may prove especially pertinent for older patients, who are more likely to hold multiple prescriptions that include drugs with potentially serious adverse effects. of particular relevance, patient surveys show that reduction of pharmaceutical medications is a motivating factor for initiating medical cannabis treatment (adams et al., 2021; lucas et al., 2021; lucas & walsh, 2017), and us states where cannabis has been legalised have seen reductions in the use of many pharmaceuticals (raman & bradford, 2022a), including opioids (bradford et al., 2018; shi et al., 2019). in order to increase the state of knowledge regarding the use of cannabis-based products by older patients, we have conducted a multi-site, longitudinal, observational study to examine the real-world effects of medical cannabis on the health and well-being of patients over 50 years of age who are receiving cannabis treatment under the guidance of a physician in a naturalistic setting. the primary objectives of the medical cannabis in older patients study (mcops) were to assess safety and patterns of use; to evaluate the impact of medical cannabis on health outcomes, with a focus on pain, sleep and quality of life; and to explore changes in comedication use and the associated pharmacoeconomics of medical cannabis use in this older patient population. methods recruitment medical clinics across canada that were identified as having a high percentage of older patients were contacted about the study. all participating sites went through ethics review and approval by advarra, an independent service provider, prior to launch (protocol #pro00059863). lead physicians were required to provide proof of completion of tri-council policy statement 2 course on research ethics training prior to ethics review and launch of the study site. physicians were compensated for unbillable time and resources needed to administer the study at a rate of $50 for each completed set of surveys. inclusion criteria were patients who had a permanent fixed address, had no previous recommendation/prescription from a physician for the use of medical cannabis, were over 50 years old, had the capacity to consent for themselves, could read, write, and speak english, and had chosen to initiate the use of tilray medical cannabis products in their course of treatment. patients were offered a 15% discount on all cannabis products purchased medical cannabis for patients over age 50 83 from tilray for the duration of the study, as confirmed by follow-up visits and completion of survey measures at those time points. instruments the survey included seven instruments, four of which were self-administered by patients: a demographic survey, the pittsburgh sleep quality index (psqi) (buysse et al., 1989), the euroqol 5dimension 5-levels questionnaire (eq-5d-5l) (herdman et al., 2011), and the cannabis use survey (baron et al., 2018; lucas & walsh, 2017). the other three instruments were administered by physicians: the brief pain inventory (bpi) (cleeland & ryan, 1994), the medical cannabis and prescription drug questionnaire (mcpdq), and the adverse events survey (aes). the mcpdq and the aes were developed specifically for this study. the mcpdq provides a detailed inventory of medical cannabis and prescription drug use at all timepoints via multiple choice options inquiring about the methods of use tried as well as preferred primary method of use (e.g,. joint, waterpipe/bong, oil/edible, vaporizer for flower, vape pen, topical); type of cannabis currently used (indica, sativa, hybrid); use of extracts (yes/no), and if yes, preferred type of extract (2:100 thc/cbd, 1:25 thc/cbd; 5:20 thc/cbd; 10:10 thc/cbd and 25:0 thc/cbd), along with associated average dosing for both flower (in grams per day), and/or extracts (times used per day). in addition, the mcpdq gathered retrospective information on daily and nondaily prescription drug use in milligrams per dose and doses per day or week (where applicable) at each medical visit, and has an autofill function connected to the national drug data file (nddf), a us-based national prescription drug database, to ensure that consistent generic prescription drug names were used in order to facilitate final longitudinal analysis. the adverse event survey was administered at each follow up visit, starting with the following question: “have you experienced any adverse events since the previous study visit?” if the response was “yes”, a drop-down menu of common aes reported in other medical cannabis studies presented a series of options to chose from (confusion/disorientation, depression, dizziness/lightheaded/faint, drowsiness, feeling too high, nausea/vomiting). a catch-all of “other” enabled a textual response for aes not listed in the drop-down menu. if an ae was reported, a severity scale of 1-10 was provided for each event, followed by a question assessing the relationship between the ae and medical cannabis use (did the event begin within 1 hour of medical cannabis use?; more than 1 hour before or after use?; or cannot recall). this was followed by a question regarding what action was taken by the patient and physician (none; medical cannabis use was temporarily disrupted; medical cannabis use stopped until today; patient was hospitalized), and finally, what was the outcome of the ae (patient recovered; patient did not recover). data was collected at three timepoints: baseline, 2–3 months post-baseline (m3), and 6 months post-baseline (m6). baseline data was collected between 2018 and 2020, with a final cutoff of 15 august 2020 to allow time for follow-up to m6. the demographic survey was completed at baseline, the adverse events survey at m3 and m6, and the remaining measures at all three time points, except for the bpi. only patients that reported chronic pain or an associated pain disorder such as arthritis or headaches/migraines as a primary condition at baseline and subsequent timepoints completed the bpi at baseline and the ensuing timepoints. due to public health measures related to covid-19, which encouraged social distancing and use of telemedicine, the majority of m3 and m6 surveys were conducted via telemedicine or telephone. statistical analysis mixed effects linear regression modelling was used to assess differences between baseline versus m3 or m6 for bpi pain severity, bpi pain interference, psqi, euroqol-5d-5l utility score, and co-medication costs. proportional analysis using the chi-square test (for categorical variables with all expected cell counts ≥ 5) or fischer’s exact test (for categorical variables with any expected cell count < 5) was employed to identify significant differences in medication use. based on thresholds identified in the literature, minimal clinically important difference (mcid) scores were estimated for the bpi and psqi (buysse et al., 2011; mathias et al., 2011): bpi: a decrease of at least -2; psqi: a decrease of at least -3. analysis of bpi and psqi scores included all patients for whom data was available, irrespective cannabis, a publication of the research society on marijuana 84 of the primary condition treated with medicinal cannabis. analysis of co-medication use included all patients for whom data was available, with pain medications sub-categorized as opioid medications, non-opioid pain medications (e.g., nsaids, non-opioid analgesics), as well as “any pain medication” that also included anti-seizure medications often used to treat chronic pain. for the pharmacoeconomic analyses, medication costs were acquired through searches of the bc and ontario drug formularies as well as a national commercial pharmacy. using this information and qaly results from the eq-5d5l, incremental cost-utility ratios were calculated for medical cannabis use. due to the single-arm nature of the study, it was not possible to assess incremental cost-utility ratios against a comparable population that did not use medical cannabis. accordingly, a counterfactual scenario was employed with the assumption that, in the absence of medical cannabis treatment, participant baseline values would remain constant over the six-month follow-up period. results nine clinics in british columbia and ontario participated in the study, recruiting a total of 417 patients. of these, 299 met the inclusion criteria, which included a baseline visit prior to august 15, 2020 and at least one follow-up visit at m3 or m6. data was available for 299 patients at baseline, 240 patients at m3, and 225 patients at m6. participant characteristics and primary medical condition participant characteristics and primary medical condition are shown in table 1. this population was mostly female (66.2%), with a mean age of 66.7 years old. thirty-three point eight percent report having a college degree or higher, 25.1% report working full or part time, 62.5% were retired, and 10.4% were unable to work due to a disability. annual household income was quite low, with 47.8% reporting annual household incomes of less than $40,000. in terms of ethnicity, we saw an over-representation of white participants (87.6%), and an under-representation of all other ethnicities. self-reported knowledge and experience with cannabis at baseline was low, with a mean rating of 30.4 on a scale of 1 (no knowledge and experience) to 100 (very knowledgeable and experienced). chronic pain (60.5%), arthritis (20.5%), and insomnia (11.9%) were the most common primary conditions cited by participants, with 1.6% citing use for anxiety disorder. table 1. participant characteristics and primary medical condition associated with medical cannabis use variable results for n = 299 (n, %) gender male 101 (33.8%) female 198 (66.2%) age mean (sd) 66.7 (9.5) median (q1, q3) 66.0 (59.0, 73.0) range 51.0 – 92.0 highest degree completed high school or lower 198 (66.2%) college or higher 101 (33.8%) employment status working full time 50 (16.7%) working part time 25 (8.4%) unemployed but not looking for work 6 (2.0%) retired 187 (62.5%) unable to work (disabled) 31 (10.4%) annual household income less than $40,000 143 (47.8%) $40,000 $69,000 82 (27.4%) $70,000 $99,000 38 (12.7%) $100,000 $129,000 23 (7.7%) $130,000 or more 13 (4.3%) ethnicity caucasian (white) 262 (87.6%) hispanic (e.g., mexican, central american, south america, etc.) 9 (3.0%) asian (e.g., chinese, japanese, korean, vietnamese, etc.) 7 (2.3%) south asian (e.g., east indian, pakistani, sri lankan, etc.) 11 (3.7%) black (e.g., african, caribbean, etc.) 5 (1.7%) aboriginal/first nation 4 (1.3%) metis 1 (0.3%) other 4 (1.3%) results for n = 185 (n, %)* primary condition chronic pain 112 (60.5%) arthritis 38 (20.5%) insomnia 22 (11.9%) anxiety disorder 3 (1.6%) others 10 (5.4%) note. *since patients were cannabis-naïve at baseline, the data on primary condition for which they actually used medical cannabis was collected at m3. medical cannabis for patients over age 50 85 patterns of use at baseline, 27 patients (9.0%) reported they had used cannabis in the previous 4 weeks, and their primary methods of use included oral products (n = 11), vaporizers (n = 7), joints (n = 7), water bongs (n = 1), and topical products (n = 1). of those 27 patients, 12 (44.4%) reported that their cannabis use was recreational, and 15 (55.6%) were self-medicating prior to gaining the support of their physician for medical use. of the 223 participants that remained in the study at m6, 100 reported not using medical cannabis in the past 4 weeks but continued to participate in the study nonetheless. of the remaining 123 patients that did continue to use cannabis, 95.9% (n = 119) reported using orally administered products as their primary method of use, 4 (3.3%) reported using joints, and 1 (0.8%) reported using a vaporizer. during the treatment period, patients used cannabis twice a day on average (mean ± sd = 2.1 ± 1.0 and 1.8 ± 0.9 times per day at m3 and m6, respectively) and 7 days per week on average (mean ± sd = 6.8 ± 1.0 and 6.7 ± 1.2 days at m3 and m6, respectively). among patients who reported using inhalational products, all preferred formulations were high in 9tetrahydrocannabinol (thc). among patients who reported using orally administered products, most preferred formulations were cannabidiol (cbd) dominant (m3 = 78.9% and m6 = 72.6%), followed by balanced thc/cbd products (m3 = 20.6% and m6 = 21.6%) and thc dominant products (m3 = 0.6% and m6 = 6.0%). impact of medical cannabis on pain of the patients that reported chronic pain or an associated pain disorder such as arthritis or headaches/migraines as a primary condition at baseline and subsequent timepoints and that used medical cannabis in the previous four weeks, bpi scores for pain severity and pain interference decreased significantly at both m3 and m6 compared to baseline. baseline scores for pain severity were a mean of 5.89 and median of 5.75 (n = 179), decreasing to 4.92 and 5.0 respectively at m3 (n = 144) and 4.96 and 5.0 at m6 (n = 136). bpi scores for pain interference saw an even greater decline, from a mean of 5.81/median of 6.0 at baseline, to 4.03/3.79 at m3, and 3.87/3.64 at m6 (table 2). of the 131 participants with chronic pain for whom a difference between baseline and m6 could be calculated, 31% (n = 40) saw clinically meaningful improvements in pain severity, and 45% (n = 59) saw clinically meaningful improvements in pain interference. table 2. changes in bpi scores from baseline to m3 and m6 characteristics baseline (n = 299) m3 (n = 240) m6 (n = 225) bpi severity scale n 179 144 136 mean (sd) 5.89 (1.82) 4.92 (2.08) 4.96 (2.19) median (q1, q3) 5.75 (4.75, 7.00) 5.00 (3.50, 6.31) 5.00 (3.25, 6.50) range 1.00 10.00 0.00 10.00 0.00 10.00 bpi interference scale n 179 144 136 mean (sd) 5.81 (2.29) 4.03 (2.54) 3.87 (2.63) median (q1, q3) 6.00 (4.29, 7.64) 3.79 (1.86, 6.14) 3.64 (1.57, 5.86) range 0.00 10.00 0.00 10.00 0.00 10.00 impact of medical cannabis on sleep quality sleep quality saw statistically significant improvements at both m3 and m6. baseline psqi mean/median scores were 10.86/11 respectively (n = 299), decreasing to 8.55/8.0 at m3 (n = 238), and 8.51/8.0 at 6 months (n = 224) (table 3). of the 224 participants for whom a difference between baseline and m6 could be calculated, 100 (45%) showed a clinically meaningful improvement in sleep quality. cannabis, a publication of the research society on marijuana 86 table 3. changes in psqi scores between baseline, m3 and m6 baseline (n = 299) m3 (n = 240) m6 (n = 225) global scale n 299 238 224 mean (sd) 10.86 (4.39) 8.55 (3.91) 8.51 (4.01) median (q1, q3) 11.00 (7.50, 14.00) 8.00 (6.00, 12.00) 8.00 (6.00, 12.00) range 1.00 20.00 0.00 19.00 0.00 19.00 impact of medical cannabis on quality of life figure 1 highlights improvements in quality of life. results from eq-5d-5l show statistically significant improvements in quality of life from baseline to m3 and m6. the most notable improvements over study visits were observed in the domains of ability to complete usual activities, pain/discomfort, and anxiety/depression over the course of the study, characterized by increasing proportions of individuals in the least severe category (level 1). additionally, visual analogue scale (vas) scores increased from a mean of 61.81 at baseline, to 67.54 at m3, and 68.52 at m6. figure 1. eq-5d-5l categories over time, stratified by the five domains medical cannabis for patients over age 50 87 changes in co-medication following medical cannabis initiation table 4 shows changes in prescription drug use between baseline (pre-medical cannabis initiation), m3, and m6 by drug category. percentages are based on the total number of patients with data at that time point (n). almost half of all patients were using some kind of pain medication at baseline (47.2%; n = 299). for each medication category, the percentage of all patients using that type of medication decreased from baseline to m3, with further decreases at m6 for all medications except for benzodiazepines and antiseizure medications. when considering only patients who were using pain medications at baseline (47.2%; n = 141), the proportion of those still using pain medications decreased significantly at m3 and m6 (p < 0.05). table 4. changes in prescription drug use between baseline, m3 and m6 medication class baseline (n = 299) m3 (n = 240) m6 (n = 225) opioids 74 (24.7%) 46 (19.2%) 41 (18.2%) non-opioid pain/anti-inflammatory 86 (28.8%) 55 (22.9%) 48 (21.3%) stimulants 0 (%) 0 (%) 0 (%) benzodiazepines 10 (3.3%) 5 (2.1%) 7 (3.1%) muscle relaxants/sleep aids 18 (6.0%) 1 (0.4%) 5 (2.2%) antidepressants 31 (10.4%) 13 (5.4%) 8 (3.6%) antiemetics 2 (0.7%) 0 (0.0%) 0 (0.0%) antipsychotics 1 (0.3%) 0 (0.0%) 0 (0.0%) antiseizure 40 (13.4%) 16 (6.7%) 16 (7.1%) diabetes medications 28 (9.4%) 14 (5.8%) 10 (4.4%) blood pressure medications 31 (10.4%) 10 (4.2%) 8 (3.6%) any pain-related medication 142 (47.5%) 84 (35.0%) 70 (31.1%) figure 2 highlights the percentage of patients at each time point who were still using opioids, non-opioids, or any type of pain medication relative to the number of patients at that timepoint who reported using pain medication at baseline. we saw statistically significant declines in all three pain medication categories, with most of the declines in use taking place between baseline and m3 (p < 0.05). figure 2. use of pain medication among patients using those medications at baseline note. * p < .05 (change compared to baseline). 40 60 80 100 baseline m3 m6 p er ce n ta ge o f p at ie n ts (r el at iv e to t h o se u si n g at b as el in e) patients using pain related co-medication opioids (n=74) non-opioids (n=86) any pain meds (n=141) * * cannabis, a publication of the research society on marijuana 88 pharmacoeconomic analysis as shown in table 5, there was a significant decrease in mean 30-day co-medication costs over time, both as a percentage of all patients and as a percentage of only those patients with co-medication costs at baseline. among ‘all patients’ the decrease was from a mean of $42.60 per month at baseline (sd = $150.80) down to $17.90 (sd = $46.30) at m3, and $17.10 at m6 (sd = $53.80), representing a mean monthly savings of $25.50, and a 59.9% decline in monthly costs between baseline and m6. table 5. 30-day medication costs over time baseline m3 m6 costs among all patients n 209 192 180 mean (sd) $42.6 (150.8) $17.9 (46.3)* $17.1 (53.8)* median (q1, q3) 5.0 (0.0, 35.4) 0.0 (0.0, 9.8)* 0.0 (0.0, 5.2)* costs among those with baseline costs n 120 76 75 mean (sd) $74.1 (193.3) $26.1 (55.4)* $28.7 (69.5)* median (q1, q3) 27.7 (7.6, 71.0) 0.0 (0.0, 19.0)* 0.0 (0.0, 14.9)* note. * p < 0.05 (change compared to baseline) among patients with medication costs at baseline, mean monthly medication costs dropped from $74.10 at baseline (sd = $193.30) down to $28.70 at m6 (sd = $69.50), representing a $45.40 mean monthly savings, and a 61.3% decline in prescription medication costs. with respect to medical cannabis costs, the three most popular formulations for orally administered medical cannabis products were considered, based on percentage of patients at m6, their estimated cost per use (based on an average of 1.5 ml per use), and their estimated cost per month (based on mean self-reported cannabis use per day and 30.5 days per month). table 6 shows medical cannabis costs over the six-month study period, qalys, and incremental cost-effectiveness ratios for all patients and for patients who were using prescription medications at baseline. for both populations, the incremental cost-utility ratio, which was $25,357 and $18,522 canadian dollars respectively, was well below the standard threshold of $50,000usd per qaly. table 6. incremental cost-utility analysis for medical cannabis treatment all patients patients with medication use at baseline observed counter factual difference observed counter factual difference medical cannabis costs $1,174.80 $255.60 $919.20 $1,231.80 $444.60 $787.20 qaly 0.331 0.295 0.036 0.333 0.29 0.043 incremental cost per qaly $25,357.20 $18,522.30 adverse events as table 7 illustrates, a total of 13 adverse events were reported during the study, none of which were considered serious adverse events (saes). out of the 13 reports of adverse events, one patient reported such events at both m3 and m6, and four patients who reported adverse events during baseline-m3 did not experience any events during m3-m6. additionally, two patients who did not report any events during baseline-m3 reported events during m3-m6. out of participants who reported adverse events at m3 follow up, the majority experienced dizziness, drowsiness, and nausea, typically within 1 hour of using medical cannabis. at both timeframes, most participants did not take any specific action related to the adverse event, and subsequently recovered. however, three participants stopped using medical cannabis following the adverse event they experienced. medical cannabis for patients over age 50 89 table 7. adverse event characteristics, context, and outcomes m3 (n = 240) m6 (n = 225) describe the adverse event that you experienced confusion/ disorientation 1 (0.4%) 0 (0.0%) depression 0 (0.0%) 1 (0.4%) dizziness/ lightheaded/ faint 2 (0.8%) 1 (0.4%) drowsiness 1 (0.4%) 0 (0.0%) feeling too high 2 (0.8%) 0 (0.0%) nausea and/or vomiting 4 (1.7%) 0 (0.0%) other 0 (0.0%) 1 (0.4%) amongst individuals with any adverse event n = 10 n = 3 self-rated symptom severity on a scale of 1 to 10 mean (sd) 6.1 (1.9) 6.3 (4.0) median (q1, q3) 6.0 (4.2, 7.8) 7.0 (4.5, 8.5) range 4.0 9.0 2.0 10.0 what was the adverse events relationship to your medical cannabis use? event began within 1 hour of medical cannabis use 7 (70.0%) 1 (33.3%) event began more than 1 hour before or after medical cannabis use 2 (20.0%) 0 (0.0%) cannot recall 1 (10.0%) 2 (66.7%) what action did you take? none 5 (50.0%) 2 (66.7%) medical cannabis use interrupted temporarily 2 (20.0%) 1 (33.3%) medical cannabis use stopped completely (until today) 3 (30.0%) 0 (0.0%) what was the outcome? recovered 8 (80.0%) 2 (66.7%) discussion adults over age 50 represent a rapidly growing segment of patients seeking cannabis-based products to treat a variety of health conditions, many of which are related to aging. in the present observational study, adults over 50 years of age (mean age 66.7) were treated with medical cannabis for six months under the guidance of a physician, and validated instruments for measuring pain, sleep, and quality of life were employed to evaluate patient outcomes. among study participants, the most common primary conditions for initiating medical cannabis treatment were chronic pain, arthritis, and insomnia, which is consistent with several previous studies (cahill et al., 2021; kvamme, pedersen, alagem-iversen, et al., 2021; leung et al., 2022; lucas & walsh, 2017), including those focusing on medical cannabis use by older patients (brown et al., 2020; kaufmann et al., 2022; lum et al., 2019). mcops used a number of validated instruments to assess these health outcomes, and scores for pain severity/pain interference (bpi), and sleep quality (psqi) saw statistically significant improvements over the 6 months of the study. reductions in the use of traditional prescription medications following the initiation of medical cannabis under guidance of a health care practitioner can also be viewed as further evidence of treatment tolerability and effectiveness. mcops saw a statistically significant reduction in the ratio of patients taking any type of prescription medication, as well as pain medications, antidepressants, and sleep aids. these results are consistent with previous findings from past patient surveys (corroon et al., cannabis, a publication of the research society on marijuana 90 2017; kvamme, pedersen, rømer thomsen, et al., 2021; lucas & walsh, 2017; takakuwa & sulak, 2020), prospective studies (lucas et al., 2021), and population-level studies monitoring prescription drug use following cannabis legalization in specific jurisdictions (bradford et al., 2018; bradford & bradford, 2017; liang et al., 2018; raman & bradford, 2022b; shi et al., 2019). the substitution of traditional prescription pain medication with cannabis-based products – particularly opioids – may be an effective harm reduction strategy and result in public health benefits, especially in the context of the current opioid overdose crisis (livingston et al., 2017). additionally, our results showed a significant improvement in quality-of-life scores during cannabis-based treatment, which is consistent with findings of several previous studies (cahill et al., 2021; doeve et al., 2020; meng et al., 1903; naftali et al., 2021; peterson et al., 2021; schlienz et al., 2021). moreover, using eq-5d-5l to track the impacts of medical cannabis on the quality of life of participants also presented an opportunity to assess the incremental cost per qaly for cannabis treatment (reported in canadian dollars). our analysis suggests that the qaly costs associated with the medical use of cannabis, which ranged from $18-25,000cdn were well below the standard of $50,000usd (neumann et al., 2014), suggesting that cannabis is a costeffective treatment in this population of older medical cannabis users. finally, fewer than 5% of patients reported adverse effects, the most common of which were nausea/vomiting and feeling “too high”, which is lower than those reported in most previous studies of medical cannabis in older populations. the lower rate of adverse events in the present study might reflect access to and use of qualitycontrolled cannabis products within the canadian federally-regulated medical cannabis system, as well as the availability of standardized high cbd/low thc cannabis products preferred by this patient population, the latter of which are associated with fewer side-effects and adverse events than high thc/low cbd cannabis products. this study has some limitations. while this is the largest longitudinal study of older medical cannabis patients that we’re aware of, the participating clinics were from ontario and bc, therefore the sample may not be representative of the broader population of older cannabis patients in canada or otherwise. furthermore, at baseline, 9% of patients reported they had used cannabis in the four weeks prior to joining the study, which may suggest they had already been benefitting from its use, resulting in a potential recruitment bias. additionally, while the loss-to-follow-up (ltfu) rate at m6 was relatively low (13.29%) for a longitudinal study of this kind, a large ratio of patients (n=100 of 223) reported not using medical cannabis in the 4 weeks leading up to m6. the reasons for this discontinuation of use remain unknown, as there were no measures in the study that anticipated and/or assessed this particular outcome, and could have resulted in selection bias. in considering potential explanations, it seems unlikely the participants ceased use due to adverse events in light of the low rate of aes reported in the study, which a subsequent sensitivity analysis did not associate with the population reporting no use in the 4 weeks prior to m6 (lange et al., 2010; lucas et al., 2021b). it is certainly possible that that some patients stopped using medical cannabis because of improvements in their overall condition (which is consistent with many of the outcomes reported in the study), or because they found it ineffective, or quite simply that their patterns of use were more occasional and did not coincide with the 4 weeks prior to m6. it may also be that the cost of medical cannabis – which is not covered by public payers, and which has been shown to be an obstacle to access in previous studies – also played a role (lucas & walsh, 2017; lucas et al., 2021b). however, in light of the time period of this study, it may also be that their supply and subsequent patterns of use were interrupted by the covid-19 pandemic, particularly closer to the end of the study (which would coincide with m6 for many participants) during the summer of 2020. to reduce any bias arising from these and other factors, all data was collected by physicians and clinic staff, and health outcomes were measured using validated instruments which were subsequently coded and analyzed by a third-party health economics outcome research organization (broadstreet heor, vancouver bc). additionally, the large sample size and prospective design of this medical cannabis for patients over age 50 91 study offsets some of these potential limitations. conclusion to the best of our knowledge, the present report describes one of the largest longitudinal study of authorized older medical cannabis patients to date. given current population trends suggesting significant growth in aging populations and longer lifespans overall, finding safe, efficacious, and cost-effective treatments for geriatric care is a priority. the results of this multi-site, prospective, longitudinal study of medical cannabis patients age 50 years and older indicate that cannabis may be a relatively safe and effective treatment for chronic pain, sleep disturbances, and other conditions associated with aging, leading to subsequent reductions in prescription drug use and healthcare costs, as well as significant improvements in quality of life. as the use of cannabis for medical purposes by older 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(2021). cannabis: an emerging treatment for common symptoms in older adults. journal of the american geriatrics society, 69(1), 91–97. https://doi.org/10.1111/jgs.16833 funding and acknowledgements: tilray canada inc. is the sponsor of this study and has provided funding for this study, including study design, data collection, analysis, and interpretation of data, and writing the manuscript. mw, pl, and jt own stock in tilra y brands inc., of which tilray canada and tilray deutschland are subsidiaries, which may serve to gain financially, now or in the future, from publication of the manuscript. bp performed services as a consultant for tilray brands, of which tilray canada and tilray deutschland are subsidiaries. jt receives and mw received salary from tilray brands inc., of which tilray canada and tilray deutschland are subsidiaries, which may serve to gain financially, now or in the future, from publication of the manuscript. pl and bp designed the study, and jt contributed to its conception and implementation. mw wrote the first draft of the manuscript and contributed to the statistical analysis. pl and jt wrote sections of the manuscript. ko organized the database and liaised with clinic sites. all authors contributed to manuscript revision, read, and approved the submitted version. the authors would like to thank all the patients that shared their experiences by participating in this study, the many clinics that helped recruit and gather data from their patients, and tilray for sponsoring this research. we’d also like to thank broadstreet heor for their assistance in coding, cleaning, and conducting the primary analysis of this data. additionally, we would like to dedicate this publication to co-author mariah walker, who unfortunately did not live to see this data published, but whose lifelong dedication to academic inquiry continues to bear fruit. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: pearson, b., walker, m., tempero, j., ong, k., & lucas, p. (2025). medical cannabis for patients over age 50: a multi-site, prospective study of patterns of use and health outcomes. cannabis, 8(1), 81-94. https://doi.org/10.26828/cannabis/2024/000239 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ brief report 1 ved abstract background: cannabis use among college students represents a continued public health issue. the objective was to assess risk factors and reasons for cannabis use among students who violated their university’s drug use policy, and whether risk factors influenced cannabis use quantity. methods: this cross-sectional survey study included 99 college students enrolled at a large u.s. public university. descriptive statistics were calculated, and an ordinary least squares regression analysis was conducted. results: students reported using cannabis an average of 7.4 (sd = 10.2) days in the past month, with 8% reporting daily use. on average, students consumed slightly over 0.25 (sd = 0.25) grams per day, with 40% reporting greater than one gram per day. the average age of onset of cannabis use was 16.8 (sd = 1.8) years old. the top reasons for cannabis use were to: relax or relieve tension (75.8%), feel good or get high (62.6%), and have a good time with friends (60.6%). students perceived an average of 47% of their peers engaged in past-month cannabis use and only slight risk was associated with regular use. students perceived their loved ones would mostly approve of a reduction in their cannabis use. regression results indicated pastmonth cannabis frequency (p = .002) and being of racial/ethnic minority descent (p = .05) were positively associated with quantity of cannabis per day, while perceived risk of regular cannabis use (b = -0.21) was negatively associated. conclusion: evidence-based cannabis interventions for students who violate their university’s drug use policies are critically needed that aim to reduce cannabis use and mitigate its associated negative consequences. key words: = cannabis; risk factors; interventions; college students; policy violators cannabis use among college students represents a continued public health issue throughout the u.s. (gunn et al., 2021; hammond et al., 2020; office of disease prevention and health promotion, odphp, 2021; sznitman et al., 2022; welsh et al., 2019). data from the monitoring the future study (2023) indicated that 24% of college students engaged in pastmonth cannabis use (patrick et al., 2023). this represents a significant 10-year increase in students’ cannabis use prevalence, likely influenced by the declines in the perceived risk of harm associated with cannabis use (carliner et al., 2017; hammond et al., 2020), and the ongoing decriminalization and legalization of cannabis throughout the united states (u.s.; hall & lynskey, 2020; zellers et al., 2022). traditionally, substance use-related behaviors pose unique challenges among college students and are often associated with poor academic performance and potential substance use disorders (suds; welsh et al., 2019). additionally, the use of cannabis and alcohol together is prevalent among college students with nearly one-third reporting benjamin n. montemayor1, anas k. nabil1, ashley l. merianos2 1department of health behavior, texas a&m university school of public health, college station, tx 2school of human services, university of cincinnati, cincinnati, oh cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000191 risk factors for quantity of cannabis use per day among college students who violated their university drug use policy corresponding author: benjamin n. montemayor, ph.d., texas a&m university, school of public health, 212 adriance lab rd, sph-a room 319, college station, texas 77843. phone: (979) 436-9770. email: bnmontemayor@tamu.edu. cannabis, a publication of the research society on marijuana 2 concurrent (ingestion in the same time period) polysubstance use, thus increasing their vulnerability to negative consequences such as vomiting, blackouts, driving under the influence, and suds (haas et al., 2015; subbaraman & kerr, 2015). a particularly important high-risk subpopulation known to engage in substance use more often are students who violate their university’s drug use policy, and as a result, receive disciplinary referrals to intervention programs (terlecki et al., 2015). most universities require students to adhere to specific drug use policies while on campus. regarding cannabis, university regulations largely prohibit the use of cannabis on campus regardless of age or the state policy surrounding cannabis. this is particularly true for public universities that receive federal funds and are obligated to adhere to the federal cannabis use policy, which involves the prohibition of the use of cannabis containing over 0.3% of the cannabinoid tetrahydrocannabinol (thc; caulkins & kilborn, 2019). those found in violation of campus policies are typically adjudicated to some form of education or intervention programming. compared to nonpolicy violators, students who have violated their university’s policy engage in drug use more frequently, experience more negative consequences, are at an increased risk of being diagnosed with a sud or a cannabis use disorder (cud; buckner et al., 2018), and are often more reticent to seek help or express they are ready for a change (palmer et al., 2010; terlecki et al., 2015). however, few evidence-based prevention intervention programs exist aimed at reducing cannabis use and associated consequences that complement the ever-changing landscape (montemayor et al., 2022b). although many universities purchase online education programs or adapt alcohol programming to inform cannabis prevention/intervention programs, these approaches have limitations. for example, most of the programs included in montemayor et al.’s (2022b) cannabis systematic review, which explored cannabis use outcomes among substance use policy violators, were alcohol-centered programs. due to the different physiological interactions of alcohol and cannabis within individuals, curriculum not tailored to cannabis use motives, education, and consequences likely overlook key risk-factors of cannabis use (haas et al., 2015). additionally, while programs like the cannabis echeckup to go are easily accessible and provide important information such as immediate personalized feedback of cannabis use, the financial burden of cannabis use, and consequences of use, the content included in these programs does not always account for various potential factors (san diego state research foundation, 2014). this includes current information on the diverse ingestion methods in which students are experimenting with cannabis use (e.g., dabbing, gravity bong, etc.) and the associated hazards, sociocultural factors impacting cannabis use (e.g., culture, religion, values), or the state cannabis policy where the user resides and its potential influence in generating permissive norms that cannabis use is allowed (carliner et al., 2017; daniulaityte et al., 2017; schauer et al., 2016). thus, some institution’s cannabis prevention and intervention programming potentially fail to address the complicated nature of cannabis in our society. various risk factors for increased levels of cannabis use among young adults have been identified. adults who reported an initiation of cannabis use as young teenagers reported increases in use of cannabis as adults (griffin et al., 2010). for college students who began using cannabis prior to college, the college environment can potentially act as a facilitator for further increases in cannabis use (wetherill et al., 2016). furthermore, early initiation of substance use increases the likelihood of engagement in other risky behaviors (barry et al., 2016). for example, montemayor et al. (2022a) revealed among highrisk college students who were active drinkers, an early initiation of alcohol use significantly predicted participation in recent cannabis use. studies commonly report around a quarter of young alcohol users also engaging in cannabis polysubstance use (bravo et al., 2021; montemayor et al., 2022a; terry-mcelrath & patrick 2023). intra-individual reasons and beliefs are also positively associated with cannabis use. for example, reasons or motives for cannabis use have been associated with higher frequency of cannabis use among college students (buckner, 2013; glodosky & cuttler, 2020). regarding mental health, a common conception for cannabis use cannabis use risk factors among college student policy violators 3 motives among young adults, reasons for cannabis use were highly correlated with stress, depression, and anxiety, and significantly moderated the relationship between stress and depression (glodosky & cuttler, 2020). additionally, an individual’s perceived injunctive and descriptive norms regarding cannabis use are considered predictors of increases in use. more specifically, those who possess greater descriptive norms of cannabis use or who perceive more permissive injunctive norms from those they love and respect have been shown to result in higher use of cannabis (ecker et al., 2017; napper et al., 2015). relatedly, perceived risk associated with cannabis use has declined in the u.s. (han et al., 2021). among a representative national sample of u.s. adults, significant decreases in perceived risk surrounding cannabis use was associated with increases in occasional and regular cannabis use (okaneku et al., 2015). campuses report university substance use policy violations as the most frequent reason students receive disciplinary referrals every year (suffoletto et al., 2016). despite the understandings of the associations between cannabis use and various risk factors among young adults, there remains a significant gap regarding the investigation of reasons and risk factors for cannabis use among college students who violated their universities drug use policy. among college students who violated their university’s cannabis use policy, we hypothesize quantity of cannabis use per day will be associated with past-month cannabis frequency and polysubstance use with alcohol. additionally, we hypothesize quantity of cannabis use per day will be associated with injunctive and descriptive norms. finally, we hypothesize an association between quantity of cannabis use per day and age-of-onset of cannabis use and perceived risks related to cannabis use. it is important to inform future programming for policy violators by investigating reasons and risk factors of cannabis use among students adjudicated to a drug use course for violating their university’s policy (buckner et al., 2018). methods participants and procedures this cross-sectional survey study was conducted at a large, u.s. southeastern public university with >30,000 enrolled students that has a zero-tolerance drug use campus policy. this includes the prohibition (e.g., possession, use, distribution, serving, using) of all federally illicit substances, including cannabis, by adults and students. state policies also prohibited any possession or use (i.e., medicinally, or recreationally) of cannabis prior to and during the time period in which the data were collected (october 2019 and july 2021). despite health and safety covid-19 protocols for the 2020 academic year instituted by the university, students were still allowed to reside and take part in on-campus events, places where policy violations occur most often. after receiving a referral from an authority figure (e.g., campus police, residence hall directors) for violating the campus drug use policy, students were required to enroll in the face-to-face group adjudicated drug course offered by the university’s department of campus recreation and wellness (dcrw). students were included for this study if they were registered in a mandated course due to solely getting caught using cannabis and no other drugs (e.g., alcohol) on campus. the course curriculum focused on the education of the consequences of cannabis use (e.g., personal, academic), risk factors for cannabis use (e.g., peer norms), and risks of polysubstance use. courses were taught on a rolling basis once a month. a total of 111 students were adjudicated to programming for cannabis use exclusively during this time and of those, 99 students volunteered to participate in this study, a response rate of 89%. per dcrw requirements, all students were asked to complete a baseline assessment designed to ascertain their current beliefs and behaviors surrounding cannabis use (i.e., frequency, quantity, norms, risks) prior to attending their mandated course. in conjunction with the baseline assessment, students were provided with a cover letter describing information about this current study. the cover letter provided to all potential participants provided important study details, served as their notice of the nature of the study, assured their anonymity, and asked the participants if they were willing to share their data with the researcher. all procedures were vetted and approved by the university’s institutional review board (irb). cannabis, a publication of the research society on marijuana 4 measures past-month cannabis use frequency and quantity per day students reported on their past-month cannabis frequency and quantity of cannabis use per day using two items from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaqcu) (α = .95; cuttler & spradlin, 2017). participants reported the frequency of their past-month cannabis use (an independent variable) by answering the following question, “approximately how many days of the past month did you use cannabis?” response options ranged from 0-31 days. although all students included in this study were enrolled in the course due to their cannabis use, they may have completed the course over one month later and therefore did not use cannabis in the past 31 days prior to survey completion. students’ quantity of cannabis use per day, the outcome variable, was measured on a scale ranging from 0 = 0 grams to 11 = more than 1 ounce. reasons for cannabis use students were asked to report their reasons for using cannabis by answering the following question that was adapted from prior research (cooper et al., 2016), “thinking back to occasions in which you have ever used cannabis, what has been the most important reasons for your cannabis use?...(click yes or no for each item).” reasons included: “to relax or relieve tension; to feel good or get high; to have a good time with friends; as a sleeping aid; to experiment; because of boredom or nothing else to do; to seek deeper insights or understanding about a subject; to escape from problems; due to anger or frustration; to make it through the day; to fit in with a group; because they feel “hooked” or dependent on cannabis; other.” due to the multicollinearity associated with reasons for cannabis use, these variables were only assessed descriptively among participants. other risk factors for cannabis use students were asked to report about several risk factors for cannabis use, which were all independent variables of interest. students descriptive peer norms was assessed utilizing the following question, "within the last 30 days what percent of the typical student at your university do you think used cannabis,” with response options ranging from 0-100%. additionally, injunctive norms of their friends and family were measured with two semantic differential scales (e.g., “my [friends, family] thinks it [-3=would not/+3=would] be a good idea to decrease my cannabis use”). the two items were added together, and an average score was computed for subjective norms, a methodology used in previous studies (a = .72; buckner et al., 2018; cooke et al., 2016; norman et al., 2011). another risk factor assessed was students’ perceived risk of regular cannabis use, which was assessed via the following item from the substance abuse and mental health services administration national survey on drug use and health (substance abuse and mental health services adminstration, 2020), “how much do you think people risk harming themselves (physically or in other ways) if they use cannabis regularly (once or twice a week)?” response options included (1) no risk, (2) slight risk, (3) moderate risk, and (4) great risk. another risk factor assessed was past-month alcohol use. in order to determine potential concurrent use with cannabis, students were asked to respond to the following question adapted from the american college health association national college health assessment (american college health association, 2013), “within the last 30 days, how often did you use alcohol?” five-point likert scale response options ranged from never to always. for the purpose of this study, responses were dichotomized as no past-month alcohol use (“never”) and past-month alcohol use (“rarely”, “sometimes”, “often”, and “always”). another risk factor assessed was age of first regular cannabis use (age of onset; gruber et al., 2012), and students reported at which age they first started to regularly use cannabis by answering the following item, “how old were you the first time you started to regularly use cannabis, beyond just a one-time puff or experimentation,” with participants asking to choose a year between a range <14 years old to >21 years. cannabis use risk factors among college student policy violators 5 demographic characteristics the survey asked respondents to voluntarily provide demographic characteristic information including: biological sex (male, female); race/ethnicity (non-hispanic white, non-hispanic black, non-hispanic asian/pacific islander, nonhispanic other, hispanic); age in years; year in school; and fraternity/sorority membership (no, yes). demographic variables were utilized as indicator variables to act as controls when assessing the relationship between the cannabis use risk-factors and quantity of cannabis use per day. data has previously identified certain demographic populations as being at high-risk of cannabis use among the college student population. accordingly, the following indicator variables were utilized: male sex (cotto et al., 2010), racial and/or ethnic minoritized descent (wu et al., 2016), fraternity/sorority membership (welsh et al., 2019), and 1st year in school (suerken et al., 2014). based on the small group sizes outlined in table 1, race/ethnicity was assessed as non-hispanic white versus racial and/or ethnic minoritized identity in the analysis. similarly, year in school was assessed as 1st year versus ≥2nd year. table 1. demographic characteristics and quantity of cannabis use per day among college students enrolled in their university’s adjudicated drug course for cannabis use on campus (n = 99) variable n %a sex male 66 66.7 female 33 33.3 race/ethnicity non-hispanic white 65 65.6 non-hispanic black 20 20.2 non-hispanic asian/pacific islander 3 3.0 non-hispanic other 6 6.1 hispanic 5 5.1 age in years, m (sd) 19.2 (1.5) year in school 1st 54 54.5 2nd 34 34.3 3rd 8 8.1 ≥4th 3 3.1 fraternity/sorority membership no 66 66.7 yes 33 33.3 grams of cannabis used per day, m (sd) 0.25 (0.25) note. apercentage, unless noted otherwise. bbased on a scale ranging from 0 = 0 grams to 11 = more than 1 ounce. analysis data analyses were conducted using spss (version 28.0). descriptive statistics were calculated for all variables of interest. distributions of outcome variable (quantity per day) was assessed for nonnormality issues. outliers that fell above or below three standard deviations from the mean were re-coded into the highest nonoutlying value plus one to account for any nonnormality concerns (tabachnick & fidell, 2001). first, the relationship between the two past-month cannabis use behaviors (i.e., cannabis frequency and cannabis quantity per day) was analyzed utilizing a pearson product-moment correlation. then, an ordinary least squares (ols) regression model was fitted to assess whether risk factors for cannabis use (i.e., cannabis frequency, descriptive peer norms, injunctive norms, perceived risk of regular cannabis use, alcohol use, age-of-onset) predicted quantity of cannabis use per day among students cannabis, a publication of the research society on marijuana 6 enrolled in the university’s adjudicated drug use course for cannabis use, controlling for important demographics (i.e., sex, race/ethnicity, age, year in school, fraternity/sorority membership). results results table 1 displays demographic characteristics and quantity of cannabis use per day over the past month among students enrolled in the university’s adjudicated drug course for cannabis use. the majority of the students in the sample were male (m = 66.7%) and non-hispanic white (m = 65.6%); the average age of students was 19.2 (sd = 1.5) years with an age range between 17 – 24. over half (54.5%) were enrolled in their first year of school and 33.3% were fraternity/sorority members. the average quantity of cannabis use per day was 0.25 (sd = 0.25) grams per day. reasons for cannabis use the three top reasons for cannabis use reported by students were to: relax or relieve tension (75.8%), feel good or get high (62.6%), and have a good time with friends (60.6%; table 2). the least common reason for use reported by students was because they feel “hooked” or dependent on cannabis (5.1%). table 2. reasons for cannabis use among college students enrolled in the university’s adjudicated drug course for cannabis use on campus (n=99) variable n % to relax or relieve tension 75 75.8 to feel good or get high 62 62.6 to have a good time with friends 60 60.6 as a sleeping aid 49 49.5 to experiment 45 45.5 because of boredom or nothing else to do 38 38.4 to seek deeper insights or understanding about a subject 32 32.3 to escape from problems 29 29.3 due to anger or frustration 19 19.2 to make it through the day 19 19.2 to fit in with a group 10 10.1 other (common reasons listed: anxiety; celebration; depressed; parties; recreation; sports) 10 10.1 because they feel “hooked” or dependent on cannabis 5 5.1 risk factors for cannabis use concerning descriptive peer norms of cannabis use, students perceived that an average of 47.4% (sd = 29.3%) of their fellow students engaged in past-month cannabis use. students also perceived their friends and family would mostly approve (m = 1.7) of a reduction in their cannabis use (injunctive norms). students reported an average perceived risk of regular cannabis use of 1.8 (sd = 1.0), indicative of slight risk; interestingly 53.5% of students reported there was no risk associated with regular cannabis use. over 6-in-10 (63.6%) were past-month alcohol users. the average age of first regular cannabis use was 16.8 (sd = 1.8) years old, and about two-thirds (64%) reported regular use before the age of 18. participants reported using cannabis an average of 7.4 (sd = 10.2) days in the past month, with 8% of participants reporting daily cannabis use (table 3). cannabis use risk factors among college student policy violators 7 table 3. risk factors for cannabis use among college students enrolled in the university’s adjudicated drug course for cannabis use on campus (n=99) variable m (sd)a perceived descriptive norms of cannabis use 47.4 (29.3) perceived injunctive normsb 1.27 (1.4) perceived risk of regular cannabis usec 1.8 (1.0) past-month cannabis use in days 7.4 (10.2) past-month alcohol user, n (%) 63 (63.6) age of first regular cannabis use 16.8 (1.8) note. amean (standard deviation), unless noted otherwise. b based on a 7-point semantic scale ranging from -3 to +3 cperceived risk ranged from 1-4 with higher scores indicative of greater risk. risk factors predicting quantity of cannabis use per day the average quantity of cannabis used per day was a little over 0.25 grams, however, 40% of those who reported past-month cannabis use reported consuming ³ one gram of cannabis per day on days they used. the coefficient between frequency and quantity of cannabis use per day indicated there was a moderate-positive relationship between the variables, r(99) = .49, p < .001. the ols regression results indicated significant model fit, and explained 32% of the variance in quantity of cannabis per day (r2 = .32, f(11,87) = 3.72, p < .001) (table 4). concerning significant predictor variables, past-month cannabis frequency (b = .33, p = .002) and being of racial/ethnic minority descent (b = .19, p = .05) were positively associated with quantity of cannabis use per day among students, while perceived risk of regular cannabis use (b = -.21, p = .04) was negatively associated with the outcome variable. multicollinearity diagnostics revealed no variables had tolerance levels lower than .30, which is above the threshold minimum level of .20 that would indicate an issue with tolerance (tabachnick & fidell, 2001). additionally, all variance inflation factors (vif) values were between one and five, which are the suggested lower and upper threshold vif values, indicating that multicollinearity was not an issue (hair et al., 1998). a normal p-p plot revealed the data followed the normality line. finally, a scatterplot of the residuals versus predicted values was used to test for heteroskedasticity (glejser, 1969). the scatterplot depicted that a majority of the values below e = zero were clustered together on lower predicted values of x as well as for higher predicted values of x, indicating that heteroscedasticity was not an issue. table 4. ordinary least squares regression model results of risk factors for cannabis use predicting quantity of cannabis use per day among college students enrolled in the university’s adjudicated drug course for cannabis use on campus (n=99) variable b se b t p-valuea perceived descriptive norms 0.01 0.01 0.1 0.95 0.34 perceived injunctive norms 0.11 0.15 0.1 0.7 0.49 perceived risk of regular cannabis use -0.47 0.22 -0.21 -2.12 0.04 past-month cannabis frequency 0.07 0.02 0.33 3.27 0.00* past-month alcohol user 0.44 0.42 0.1 1.03 0.31 age of first regular cannabis use -0.16 0.12 -0.13 -1.34 0.18 male sex (versus female) 0.29 0.42 0.06 0.68 0.5 cannabis, a publication of the research society on marijuana 8 racial and/or ethnic minoritized identity (versus nonhispanic white) 0.89 0.45 0.19 2 0.05 age in years -0.23 0.17 -0.15 -1.32 0.19 1st year in school (versus ≥2nd year) -0.37 0.49 -0.08 -0.75 0.45 fraternity/sorority member -0.15 0.45 -0.03 -0.34 0.73 note. abold font indicates statistical significance. *p < .01 discussion substance use-related behaviors pose unique challenges among college students, and is often associated with adverse academic (e.g., poorer performances) and personal (e.g., sud) outcomes (welsh et al., 2019). among college students, a particular high-risk subpopulation known to engage in substance use more often are students who violate their university’s drug use policy (terlecki et al., 2015). this study found that among students who violated their university’s zero-tolerance drug use campus policy by using cannabis, there was an association between quantity of cannabis use per day and those who (a) had a higher frequency of cannabis use, (b) had a lower perceived risk of regular cannabis use, and (c) who were of racial/ethnic descent. to our knowledge, this is the first study to evaluate reasons for, and risk factors of, cannabis use among students who violated their university’s drug policy. the exploration of risk factors of cannabis use in this population is timely due to the rising prevalence of cannabis use among college students (patrick et al., 2023), the ongoing decriminalization and legalization of cannabis throughout the u.s. (hall & lynskey, 2020; zellers et al., 2022), and the increased susceptibility of this at-risk group to substance use consequences (terlecki et al., 2015). we hypothesized past-month cannabis frequency would be associated with quantity of cannabis use per day. the study found that on average the students used cannabis 7 days out of the past 30 days. although this is half as often as college student policy violators in buckner et al.’s. (2002) study, 8% of the students in our study reported using cannabis daily, double the prevalence reported in the most recent monitoring the future national report for college students (patrick et al., 2023). additionally, despite a relatively low average quantity of cannabis use per day (0.25 grams), 40% of the students reported consuming ³ one gram of cannabis per day on days they used. the correlation between cannabis frequency and quantity per day revealed a moderate-positive, r(99) = .49, association, such that the greater number of days reported engaging in cannabis use was associated with more cannabis use per day. after accounting for important covariates, an ols regression revealed that the frequency at which students engage in cannabis use was positively associated with the quantity of cannabis used per day (b = .33). the findings from this study suggest that individuals who engage in cannabis more frequently are also using more per day. common explanations for increases in cannabis use among active users could be due to a development of tolerance to cannabis use (i.e., diminished effect of drug use of the same dose), more cravings to use cannabis (i.e., a strong desire or urge to use cannabis), and a feeling of withdrawal, all conditions consistent with the diagnostic and statistical manual of mental disorders (dsm)-5 criteria for a cud (american psychiatric association, 2013). although not assessed in the current study, a previous study characterized symptoms of cud among a sample of college students who violated their university drug policy by using cannabis and found as much as 43% met the dsm-5 criteria for moderate or severe cud (buckner et al., 2018). among the study’s sample, tolerance to cannabis and engaging in larger amounts of cannabis use over a longer period of time were among the top symptoms endorsed by participants (buckner et al., 2018). efforts at the university level should be made to effectively intervene with policy violators to reduce or halt the negative outcomes associated with high cannabis use, including the development of a cud. we also hypothesized quantity of cannabis use per day would be associated with perceived risk cannabis use risk factors among college student policy violators 9 related to cannabis use. this study observed an average “slight risk” perceived risk level of engaging in regular cannabis use. descriptive analysis revealed over half (53.5%) of the students reported they believed there was no risk associated with regular cannabis use. findings from this study revealed perceived risk of regular cannabis use was negatively associated with the quantity of use per day (b = -.21), further substantiating previous research which links a decrease in perceived risk with an increase in cannabis use (okaneku et al., 2015). however, this study is the first to our knowledge to explore quantity of daily cannabis use and perceptions of risk of cannabis use among students who violated their university’s drug use policy and were adjudicated to educational programming. this finding carries practical implications for tailoring cannabis education programming to effectively address this significant risk-factor for this high-risk population. finally, although not a tested hypothesis, an indicator demographic variable (racial/ethnic minority) was significantly associated with the outcome variable. despite accounting for only onethird of the population, students who identified as a racial/ethnic minority (b = .19, p = .05) were positively associated with an increase in quantity of cannabis use per day. studies have demonstrated this previously across racial and ethnic groups. for example, higher likelihood of cannabis frequency and cud was discovered among young adults who identified as black, native-american, and mixedrace (wu et al., 2016), and among hispanic college students in their first year of college (suerken et al., 2014). additionally, among a group of students who violated their university’s alcohol policy, belonging to racial/ethnic minority population significantly predicted past-month alcohol frequency (montemayor et al., 2022a). the finding in the current study substantiates the need to tailor interventions to target racial, ethnic, and cultural factors associated with cannabis use during the design and implementation phase of interventions for this high-risk population. although a non-significant finding, we also found that nearly two-thirds (63.6%) of students reported past-month alcohol use, which is disproportionately higher when compared to prior studies that report approximately one-third of alcohol users concurrently used cannabis (haas et al., 2015; subbaraman & kerr, 2015). literature suggests the combination of using alcohol and cannabis is associated with additive impairment effects and could increase the likelihood of experiencing comorbid mental health disorders and suds (yurasek, et al., 2017). additionally, age of onset of cannabis use was not statistically significant in our study. it is important to note though that the average age of first regular cannabis use was 17 years old. this is concerning, since early use increases the likelihood of future use and experiencing delays in developing selfregulation skills and susceptibility of being diagnosed with a future cud (gruber et al., 2012; wetherill et al., 2016). descriptive norm was also not significantly associated with cannabis use. however, students in our study perceived 47% of other students at their university used cannabis in the last 30 days, nearly double the prevalence of actual past 30-day cannabis use in college students (patrick et al., 2023). research has shown the association between inflated rates of descriptive norms and an increase in the likelihood of engaging in cannabis use (napper et al., 2015). finally, despite injunctive norms failing to reach statistical significance, the students perceived their friends and family would mostly approve of a reduction in their cannabis use. the theoretical basis of injunctive norms and substance use behavior is based on a perception that those close to the individual would approve or disprove of a reduction in cannabis use and have been proven to positively influence reductions in substance use (ajzen, 1991; buckner et al., 2018; ecker et al., 2017). understanding key reasons for cannabis use can aid in the development of prevention intervention programming. in this sample, the top reported reasons for cannabis use were to relax or relieve tension, to feel good or get high, and to have a good time with friends. other studies report similar reasons for cannabis use among general college students (i.e., enhancement, relaxing; buckner, 2013; dennhardt & murphy, 2013). a noteworthy finding is that the least common reason for use was because they felt “hooked” or dependent on cannabis use. this is concerning since a longitudinal study indicated that nearly half of general college students met the criteria for a sud within the first three years of college (caldeira et al., 2009). additionally, other studies have reported as much as 70% of college students who actively use cannabis met the dsm-5 criteria for a cud (pellegrino et al., 2020), as well as 43% of policy violators (buckner et cannabis, a publication of the research society on marijuana 10 al., 2018). future program curricula should focus on providing alternative stress management and recreational strategies and consider implementing education on recognizing signs of a cud by implementing standardized screening tools related to cannabis use, such as the cannabis abuse screening test (cast) or the cannabis use disorder identification test (cudit; adamson & sellman. 2003; buckner et al., 2018). students who violate their university’s policy and are at risk for a cud should be referred to campus counseling services for individualized treatment, a setting which has been shown to reduce problematic substance use among college students (denering & spear, 2012). researchers have noted the dearth of evidence available that evaluates the effectiveness of interventions in reducing cannabis use among students who violated their university’s drug use policy (buckner et al., 2018; montemayor et al., 2022b). given our findings, colleges should seek to establish evidence-based cannabis prevention and intervention programs leveraging key cannabis use risk factors and correcting misperceived social norms and risk perceptions. health and wellness programmers and university administrators could focus their attention on developing programs tailored to the behaviors, beliefs, and needs of their students and addressing the complex nature of cannabis in our society. policies regarding cannabis use in the u.s. are constantly changing, and yet despite sweeping changes at the national level, cannabis is still illegal on public college campuses per the drug-free schools and communities act (1989). for students who attend public universities in a state with legal cannabis medicinal or recreational policies, these policies might allow students to generate permissive norms that cannabis use is allowed and accepted, despite any use being a violation of university and federal policy. the long-term evaluation on the impact of these strategies on cannabis use could provide important insight for ongoing cannabis prevention and intervention efforts within universities. limitations researchers should consider the results within the context of the following limitations. first, the sample was predominantly white nonhispanic, and the study was conducted at one university. while reflective of overall demographics of the university, the results are not generalizable to all u.s. students, including those from various racial and ethnic backgrounds. second, data were self-reported in a state where cannabis use was illegal at the time of data collection, so some reported answers could be overor underreported. it is important to note, however, self-report data can accurately reflect behaviors when reporting conditions are designed to maximize response accuracy (e.g., anonymity), such as those used in this study (del boca & darkes, 2003). third, the quantity of cannabis use was limited to assessing cannabis utilized in the flower form, thus concentrates (i.e., edibles, wax, vapes, etc.) were not directly measured. though, the items used to assess cannabis quantity in this study have helped facilitate research on quantity of cannabis use in the past and is a psychometrically sound assessment (cuttler & spradlin, 2017). finally, the data analyzed were cross-sectional and we were unable to draw any casual inferences. conclusion the current study highlights reasons for cannabis use and associated risk factors among a sample of college students enrolled in an adjudicated drug course for violating the university’s policy for using cannabis on campus. the most prevalent reasons for cannabis use cited by students were for relaxation, to feel good, and have a good time. higher frequency of cannabis use, lower perceived risk of regular cannabis use, and identifying as a racial/ethnic minority were associated with students’ engaging in higher quantities of cannabis use per day. universitybased cannabis prevention interventions for students who violate their university’s drug use policies are critically needed to reduce and mitigate use and its associated negative consequences. these programs should consider educating students about actual risks associated with regular cannabis use, including cud, investigating key reasons associated with cannabis use, and collaborating with other university programs to ensure tailored and comprehensive care for students in this population. cannabis use risk factors among college student policy violators 11 references adamson, s. j., & sellman, j. d. 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(2023). impacts of recreational cannabis legalization on cannabis use: a longitudinal discordant twin study. addiction, 118(1), 110-118. https://doi.org/10.1111/add.16016 funding and acknowledgements: the author(s) received no financial support for the research, authorship, and/or publication of this article. the authors have no potential conflicts of interest to disclose. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 141 ved abstract objective: the diagnostic and statistical manual of mental disorders version 5 (dsm-5) defines cannabis use disorder as a polythetic unidimensional diagnosis (>2 symptoms from up to 11), but few studies have empirically evaluated the latent structure of cud. rasch analysis is a psychometric technique that has previously been used to validate unidimensional scales, like dsm-5 cud. method: in this study, the rasch model was used to evaluate the dsm-5 cud criteria in a clinical sample of adults receiving inpatient treatment for substance use disorder (n = 249) reporting active cannabis use at admission. the unidimensionality of the criteria was evaluated using the martin-löf test and the nonparametric –t2 test of ponocny. model fit was assessed using the χ2 goodness of fit test for individual items. results: results supported the unidimensional structure of the criteria. symptom # 3 was the least endorsed, highest severity item. conversely, symptom #9 was the most endorsed and had the lowest severity estimate. overall, the data fit the rasch model well, although misfit was observed for symptom # 8. conclusions: rasch's analysis of cud symptoms in an inpatient sample broadly supports the dsm-5 cud syndrome. further examination is needed to determine if removing or revising the hazardous use symptom criterion in future dsm revisions would improve diagnostic measurement. key words: = cannabis; rasch; cud; addiction; psychometric analysis cannabis is the third most-used psychoactive drug globally after alcohol and tobacco (connor et al., 2021). cannabis use directly affects vital areas of the brain, especially those responsible for memory, learning, emotion, decision-making, attention, coordination, and reaction time (filbey et al., 2014). there is also a risk of developing psychosis and bronchitis with continuous use (mattick, 2017; meier et al., 2012). approximately 3 in 10 people who use cannabis regularly will develop a cannabis use disorder (cud; hasin et al., 2015), the clinical diagnosis for clinically significant cannabis misuse. globally, 22.1 million people met the diagnostic criteria for cud in 2016 (degenhardt et al., 2018). according to the most recent version of the diagnostic and statistical manual of mental disorders, version 5 (i.e., dsm-5), cud is diagnosed when a person endorses at least 2 out of the 11 symptoms (hasin et al., 2013; lago et al., 2016). in other words, dsm-5 defines cud as a polythetic unidimensional diagnosis (>2 marie n. s. gendy1, 2, 3, radia taisir3, emily britton3, jean costello3, james mackillop1, 2, 3, 4, 5 1peter boris centre for addictions research, mcmaster university & st. joseph's healthcare hamilton 2department of psychiatry and behavioral neurosciences, mcmaster university 3homewood research institute 4michael g. degroote centre for medicinal cannabis research, mcmaster university & st. joseph's healthcare hamilton 5department of psychology, neuroscience, and behavior, mcmaster university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000229 volume 8, issue 2 rasch analysis of cannabis use disorder in an adult inpatient sample corresponding author: marie gendy, md, msc, phd. peter boris centre for addiction research the michael g. degroote centre for medicinal cannabis research, department of psychiatry and behavioral neurosciences mcmaster university/st. joseph's healthcare hospital, hamilton, ontario, canada, l9c 0e3. phone: (905) 5221155email: gendym1@mcmaster.ca cannabis, a publication of the research society on marijuana 142 symptoms from up to 11; bartolucci et al., 2015). in addition, the severity of the disorder is based on the number of endorsed criteria: 2–3 = mild, 4– 5 = moderate, ⩾ 6 = severe condition (murphy & hallahan, 2016). the fifth edition of the dsm addressed issues concerning substance use disorder (sud) diagnostic criteria (including cud) that were identified with prior versions to enhance diagnostic specificity and increase clinical utility (murphy & hallahan, 2016). the main differences from the previous version were combining abuse and dependence into a single diagnosis, adding withdrawal and craving criteria, and removing the legal criterion (fink et al., 2022). several studies have suggested that the abuse and dependence criteria do not consistently capture the mildest or most severe use conditions and instead represent a single continuum of severity rather than two separate disorders (saha et al., 2006; sellman et al., 2014). sophisticated statistical techniques, such as item response theory modeling, have been used to guide decisions about which criteria to include and exclude in new dsm versions (saha et al., 2012). further, due to insufficient evidence, cannabis withdrawal was not included in earlier dsm versions; it was added in dsm-5 based on studies conducted after the publication of dsm-iv (budney et al., 2004). the continuous evaluation of the latent structure of cud or suds, in general, can help refine the criteria that are used for diagnosis and classification for better accuracy and improved estimates of the sensitivity and specificity of each diagnostic sign or symptom (ruscio & ruscio, 2008). for instance, the psychometric properties of cannabis abuse and dependence (dsm-iv) have been explored before using nesarc data (lynskey & agrawal, 2007). results from this research suggested the inclusion of a severity spectrum to describe cud. regression analyses also validated cud criteria and severity in the dsm-5 (fink et al., 2022). further, factor analysis was used to assess dimensionality, and the results showed unidimensionality of the 11 criteria of dsm-5 (shmulewitz et al., 2023). nevertheless, the rasch model has not been used before to evaluate the latent structure of the 11 criteria of dsm5 cud. the rasch model is a statistical technique that is well-suited for evaluating unidimensional latent diagnoses. introduced by georg rasch (rasch, 1960), it is a one-parameter logistic item response model in which both the item difficulty and the person's ability are scaled independently along an underlying latent continuum using an equal interval log odds scale (kahler & strong, 2006) the rasch model uses the logit of the probability of a person endorsing an item to model the difference between a person's cud severity level and the item's severity level. if the item severity level is greater than the person's severity level, the probability of endorsement will be low. like the deterministic guttmann scaling method (stouffer et al., 1950), the rasch model assumes that endorsing a severe item means that the person also endorsed all less severe items in the index; the only difference is that the rasch model allows for probabilistic ordering of item severities (kahler & strong, 2006). thus, the rasch model can be used to find the most likely pattern of responses for each possible total score, evaluate the relative severity of each item, and compare sub-groups through item severity estimates from independent analyses (as the estimation of item characteristics does not depend on the distribution of the latent construct; strong et al., 2003). the rasch model has been used in prior research to validate measures of psychiatric disorders, including motivation for treatment of drug disorders (martinez-gonzalez et al., 2020), nicotine dependence symptoms (strong et al., 2003), gambling problems (strong & kahler, 2007), food addiction (saffari et al., 2022), internet addiction (lu et al., 2022), and dsm-5 items for alcohol use disorder (aud; ingesson et al., 2022). however, the rasch model has not been previously used to evaluate dsm-5 cud criteria. the present study extends previous psychometric evaluations of the dsm-5 by evaluating cud criteria using rasch analysis in a clinical sample of adults receiving inpatient treatment for sud. more specifically, we aimed to (1) assess the fit of the criteria to the rasch model and (2) examine the severity and range of the criteria. we hypothesized that the dsm 5 criteria would be a good fit for the rasch model. moreover, if the current data fit the model well, the probability of endorsing a particular criterion will increase as the individual's cud severity exceeds the severity expressed by the criterion (bond & fox, 2007; kahler & strong, 2006). this means that those with more severe cud are more likely rasch for cud 143 to endorse all symptoms, and less severe items are more likely to be endorsed by all subjects (bond & fox, 2007). more broadly, support for a unidimensional construct of cud would support the contemporary dsm-5 conceptualization. methods participants and procedure participants in this study were adults who voluntarily entered a large inpatient sud treatment program located in guelph, ontario, between april 26, 2018, and february 28, 2020. the program consisted of 35 – 42 days of abstinence-based treatment for adults aged 19+ with various suds. data was collected using electronic, self-administered assessments as part of routine clinical assessment upon admission to the program. the assessment consisted of psychometrically validated scales that measured a variety of clinically relevant domains, including the dsm-5 sud symptom checklist for each endorsed substance (e.g., cannabis, alcohol, cocaine, etc.). this research protocol received ethical approval from the regional centre for excellence, research ethics board in guelph, ontario, canada (protocol #19-8). during the study, 1639 patients entered the treatment program and completed the clinical assessment. the responses from the first treatment episode were retained for those patients who were admitted more than once over the study period (n = 83). the principal eligibility criteria were: 1) cannabis use, 2) no missing responses for the dsm-5 cud checklist items, 3) positive for cud (i.e., endorsed at least two symptoms from the dsm-5 checklist), 4) reported only recreational cannabis use, and 5) were discharged from the addiction program, leaving a final sample of 249 patients for the analysis. among these 249 patients, 90.4% endorsed alcohol use, and 65.1% endorsed multiple substance use (cocaine, alcohol, and cannabis) by examining the severity of each endorsed substance, cannabis was showed the highest severity of use by 18.5%. the average age of the sample was 33.9 years; 78.3% self-reported as male, 70.7 % as employed, and 89.6 % as white (see table 1). table 1. socio-demographic and clinical characteristics demographics % or mean (sd) n = 249 sex (%) males 78.3 % age mean (sd) years 33.9 (9.9) education (%) some college/ university 54.6% employment (%) employed 70.7% marital status (%) married or partnered 31.3% race (%) caucasians first nation, inuit, or metis asian african, caribbean, black latin american multiple or mixed 89.6% 2.4% 0.8% 1.2% 0.4% 4.4% measures symptoms of cud. symptoms of cud were assessed using the 11 items of the dsm-5 sud checklist (hasin et al., 2013). response options were dichotomous (yes or no), indicating whether the individual had experienced each symptom over the past 90 days. items are presented in table 2, ordered by their endorsement frequency. based on the dsm-5 guidelines, individuals who endorsed two or more symptoms would meet the criteria for diagnosis of cud. data analysis the measurement properties of the 11 items of the dsm-5 cud checklist were examined by evaluating the fit of the data to the rasch model. the primary assumption of the rasch model is unidimensionality (i.e., that the dsm-5 cud items measure only a single construct). an exploratory common factor analysis of the interitem tetrachoric correlations was performed to test this assumption. both eigenvalues and factor loadings were examined. it was concluded that the measure was unidimensional if a single factor accounted for a large proportion of the variance in responses and if all items loaded strongly (> .30) on the single factor (ponocny, 2001). to assess unidimensionality, the following tests were applied: the martin-löf test that uses the likelihood ratio test (christensen et al., 2002) and the nonparametric t2 test of ponocny (ponocny, cannabis, a publication of the research society on marijuana 144 2001) that checks for multidimensionality within model-deviating subscales via decreased dispersion (variance was used) of subscale person raw scores (mair et al., 2022). another assumption of the rasch model is local independence (i.e., the item responses are independent of one another). to test this, the standardized residual correlations of the items after fitting the rasch model were first examined. a principal components analysis (pca) of the residuals was also conducted. the assumption was considered violated if an inter-item residual correlation was more than 0.2 greater than the average correlation (christensen et al., 2017) and/or if components extracted from the pca accounted for greater than 1.5 units of variance (linacre, 1998). the item parameters of the rasch model were computed using conditional maximum likelihood (cml) estimation with the sum of the item parameters fixed to zero. item and person severity estimates are expressed in equal interval log odds units (logits). the rasch model fit was assessed using the infit (inlier-sensitive or informationweighted fit) and outfit (outlier-sensitive fit) statistics based on the mean-square residuals. the acceptable range for model fit is 0.6 to 1.4 (wright & linacre, 1994). lower values indicate an overfit to the model (i.e., responses are too predictable), whereas higher values indicate an underfit to the model (i.e., data are too noisy; kahler & strong, 2006). the χ2 goodness of fit test for individual symptoms (tennant & conaghan, 2007) is a significant test that indicates an item misfit with the model. finally, the symptom-total correlations were computed, the point biserial correlations between a given item, and the sum of the remaining items. more significant correlations indicate that the item has a stronger association with the latent construct and is more efficient in predicting responses (kahler & strong, 2006). the person separation reliability, which indicates the measure’s ability to reliably order persons along the latent continuum and discriminate the sample into levels, was also estimated. the person separation reliability is similar in interpretation to cronbanch’s α. however, it is more conservative and less misleading as it adjusts for the fact that data are never a perfect fit to the rasch model (linacre, 1997). all analyses were performed using r version 4.2.0 (r core team, 2022). results unidimensionality and local independence the principal iterated common factor analysis of the tetrachoric correlations supported a onefactor solution. the first eigenvalue of the common factor solution was 4.91, which was almost six times larger than the second eigenvalue of 0.81. loadings on the first factor ranged from 0.41 to 0.81, except for “recurrent cannabis use in physically unsafe environments (symptom 8)” (0.29), and the first factor accounted for 45% of the common variance among the cud items. the martin-löf test (with the mean as the subgroup criteria) failed to reject the null hypothesis of unidimensionality (lr = 29.22, p = 0.454), and the nonparametric t2 test suggested no evidence of multidimensionality (p = 1). overall, for the single factor solution, all the item loadings were > .30, with one exception (symptom 8, “recurrent cannabis use in physically unsafe environments,” which was .29 ~ .30), and both the martin-löf test and nonparametric t2 test supported unidimensionality, it was concluded that the syndrome was unidimensional. all inter-item (symptom) standardized residual correlations after fitting the rasch model were less than 0.2 larger than the absolute value of the average correlation (0.09), except for the correlation between symptom 6 (continued cannabis use despite it causing significant social or interpersonal problems) and item 10 (tolerance: individual requires increasingly higher doses of the substance to achieve the desired effect, or the usual dose has a reduced effect; -0.34). since symptom responses should not influence one another after accounting for the underlying construct (wright & linacre, 1994), this suggests that the local independence assumption was violated for that pair of symptoms. principal components analysis of the standardized residuals further supported the unidimensionality of the items. however, it also indicated that the local independence assumption was violated as the eigenvalue of the first contrast was 1.84 (which is above the suggested cutoff value of 1.50 but still <2). symptom 4 (experiencing craving, a pressing desire to use cannabis, 0.49), symptom 5 (cannabis use impairs the ability to fulfill major obligations at work, rasch for cud 145 school, or home, -0.48), item 6 (continued use of the substance despite it causing significant social or interpersonal problems, -0.71), symptom 7 (reduction or discontinuation of recreational, social, or occupational activities because of substance use, -0.45), item 10 (tolerance, 0.53), and item 11 (withdrawal, 0.46) all had high loadings (>0.4) on the first component. there was not enough evidence of local independence of symptom item responses. local dependency always exists in empirical data, but it only affects the spacing, not the ordering of measures. model fit table 2 presents each item's percentage endorsement, difficulty estimates with standard errors, item-total correlations, and infit and outfit statistics. the range of infit values was 0.749 to 1.290, and the range of outfit values was 0.719 to 1.632. the infit values for all the 11 items were within the acceptable range of 0.6 to 1.4. for (symptom 8) “recurrent cannabis use in physically unsafe environments,” the outfit value was above the acceptable range and can be considered to have relatively less predictable responses. the symptom-level chi-square goodness of fit tests indicated that two symptoms, (symptom 2), “persistent desire to cut down or regulate use. the individual may have unsuccessfully attempted to stop in the past” (p = 0.001) and (symptom 8; p < 0.001), had a suboptimal model fit (see table 3). the range of the total correlations between the symptoms was 0.196 (symptom 8) to 0.593 (symptom 1: consuming the substance in larger amounts and for a longer amount of time than intended). finally, the estimated person separation reliability was 0.660, which suggests that the symptoms did not reliably order participants in the sample. a misfit was observed for symptom # 8, "recurrent cannabis use in physically unsafe environments". table 2. items, endorsement, and the rasch model estimates criteria symptom % endorsed item total correlation item difficulty parameter se infit outfit 1 consuming cannabis in larger amounts and for a longer amount of time than intended 53.4 0.59 -0.27 0.14 0.75 0.72 2 persistent desire to cut down or regulate use 49.4 0.28 -0.05 0.14 1.27 1.33 3 spending a great deal of time obtaining, using, or recovering from the effects of cannabis 28.9 0.56 1.26 0.17 0.90 0.81 4 experiencing craving, a pressing desire to use cannabis 51.4 0.55 -0.16 0.14 0.83 0.78 5 cannabis use impairs the ability to fulfill major obligations at work, school, or home 32.1 0.53 1.02 0.16 0.94 0.87 6 continued use of cannabis despite it causing significant social or interpersonal problems 36.9 0.51 0.69 0.15 0.96 0.88 7 reduction or discontinuation of recreational, social, or occupational activities because of cannabis use 37.8 0.59 0.64 0.15 0.84 0.81 8 recurrent cannabis use in physically unsafe environments 60.2 0.19 -0.63 0.14 1.29 1.63 cannabis, a publication of the research society on marijuana 146 9 persistent cannabis use despite knowledge that it may cause or exacerbate physical or psychological 81.1 0.23 -1.82 0.16 0.97 0.94 10 tolerance: individual requires increasingly higher doses of cannabis to achieve the desired effect, or the usual dose has a reduced effect 74.3 0.29 -1.39 0.15 0.95 0.94 11 withdrawal: a collection of signs and symptoms that occurs when blood and tissue levels of the substance decrease. individuals are likely to seek the substance to relieve symptoms. 36.9 0.586 0.69 0.15 0.85 0.79 table 3. a chi-square test for individual cud criteria: a significant test indicates an item misfit to the model number symptom χ2 p value 1 consuming cannabis in larger amounts and for a longer amount of time than intended 164.64 .99 2 persistent desire to cut down or regulate use 304.43 .001 3 spending a great deal of time obtaining, using, or recovering from the effects of cannabis 185.78 .98 4 experiencing craving, a pressing desire to use cannabis 177.97 .99 5 cannabis use impairs the ability to fulfill major obligations at work, school, or home 199.27 .91 6 continued use of cannabis despite it causing significant social or interpersonal problems 202.61 .89 7 reduction or discontinuation of recreational, social, or occupational activities because of cannabis use 186.63 .98 8 recurrent cannabis use in physically unsafe environments 373.71 < .001 9 persistent cannabis use despite knowledge that it may cause or exacerbate physical or psychological problems 216.51 .69 10 tolerance: an individual requires increasingly higher doses of cannabis to achieve the desired effect, or the usual dose has a reduced effect 214.44 .73 11 withdrawal: a collection of signs and symptoms that occurs when blood and tissue levels of the substance decrease. individuals are likely to seek the substance to relieve symptoms. . individuals are likely to seek cannabis to relieve the symptoms 181.74 .99 rasch for cud 147 item (symptom) difficulty estimates and personitem map the item severity, [the symptoms that are least likely (severe) or more likely (easy) to be endorsed], estimates ranged from -1.822 to 1.260, related to the endorsement percentage (table 2). symptom 3, “spending a great deal of time obtaining, using, or recovering from the effects of cannabis use,” was the most difficult (severe) symptom with the lowest endorsement (28.9%), and symptom 9 (persistent use despite the knowledge that it may cause or exacerbate physical or psychological problems) was the least difficult symptom with the highest endorsement (81.1%). the distance between the easiest item (symptom 9) and the next easiest item, “tolerance” (symptom 10), was 0.429 logits. the distance between the most difficult item (symptom 3) and the next most difficult (symptom 5), “cannabis use impairs the ability to fulfill major obligations at work, school, or home”, was 0.237 logits. figure 1 presents the person-item map where the symptoms are sorted in increasing order according to their location on the latent cud severity dimension. all person and symptom locations are expressed in logits. from the upper panel, the person parameter distribution is slightly positively skewed. patients with the lowest severity estimates answered ‘no’ to almost every symptom, and those with the highest severity estimates answered ‘yes’ to almost every symptom. from the lower panel of the personitem map (symptom 9), “persistent use despite the knowledge that it may cause or exacerbate physical or psychological problems.” was the least severe symptom (i.e., easiest) and (symptom 3), “spending a great deal of time obtaining, using, or recovering from the effects of cannabis,” was the most severe symptom (i.e., hardest); as symptoms fall higher on the latent continuum they are less likely to be endorsed. the following symptoms: [(symptom 7), “reduction or discontinuation of recreational, social, or occupational activities because of cannabis use,” (symptom 11), “experiencing withdrawal symptoms, which can be relieved by taking more cannabis,” and (symptom 6), “continued use of cannabis despite it causing significant social or interpersonal problems”], exhibited very similar levels of severity. cannabis, a publication of the research society on marijuana 148 figure 1. person-item map sorting cud symptoms by latent severity dimension* note. *all person and item locations are expressed in logits. patients with the lowest severity estimates answered ‘no’ to almost every cud symptom, and those with the highest severity estimates answered ‘yes’ to almost every symptom. discussion the present study evaluated the dsm-5 cud criteria using rasch analysis in a sample of patients receiving inpatient treatment for sud. previous research has debated whether suds are a unidimensional or a multidimensional diagnostic phenomenon and whether the importance of criteria differs by severity (boness et al., 2021), broadly supporting the unidimensionality of the 11 dsm-5 sud criteria (kervran et al., 2020), but few studies have examined the construct validity of the dsm-5cud diagnosis. the present study's findings extend this previous work by showing that rasch's analysis supports the dsm-5 conceptualization of cud as a polythetic unidimensional syndrome. our results showed that the data fit the rasch model well in terms of the overall model fit. however, misfit was observed for symptom # 8, "recurrent cannabis use in physically unsafe environments," where the outfit value was above the acceptable range and had a significant χ2 test. a high outfit mean square value indicates that this symptom may be more sensitive to extreme rasch for cud 149 responses. this is consistent with a previous study assessing the properties of the dsm-5 cud criteria in a sample of individuals in addiction treatment (kervran et al., 2020). in that study, the results of a factor analysis indicated that the hazardous use criterion had the lowest factor loading of all the criteria. another study applying a 2-parameter irm to the dsm-5-aud criteria also found that symptom # 8 had the lowest discrimination parameter of all the criteria, which could explain its poor fit to the rasch model, which assumes equal discrimination across symptoms (saha et al., 2020). on the other hand, a large study of a nationally representative sample of adult australians identifying use disorders among people who use cannabis or alcohol found an excellent fit for a unifactorial model for dsm-5 (lago et al., 2016). however, there are few cud studies, making contextualizing these findings regarding cud criteria difficult. the short form of the cud identification test-revised (cudit-r), based on dsm-5-cud criteria, has been evaluated using rasch analysis, characteristic test curve, logistic regression, and discriminant function analysis in two community samples of cannabis users from two countries. the four-item (symptom)-selection methods were implemented to identify the optimal three-item shortened version. results from the rasch analysis revealed that items 4 (fail to do what was usually expected because of cannabis), 5 (spending more time getting, using, or recovering from cannabis), and 6 (problem with your memory or concentration after using cannabis) were the best-fitting items that also differentiated between participants with different levels of cannabis use problems in both samples (bonn-miller et al., 2016). regarding item severity, which indicates how difficult it is to endorse each of the cud criteria, symptom # 3 (spending a great deal of time obtaining, using, or recovering from the effects of substance use) was the most severe symptom and the least endorsed. conversely, symptom # 9 (persistent substance use despite the knowledge that it may cause or exacerbate physical or psychological problems) had the lowest severity estimate and was the most endorsed item. on the other hand, previous studies on dsm-5-aud criteria found that symptom 8 is the most severe item (hallgren et al., 2022). further investigations are necessary to reassess which symptoms are most likely to be endorsed and which are less likely to be endorsed in order to provide improved recommendations for future versions of the dsm. strengths and limitations the present study's findings should be interpreted considering certain strengths and limitations. however, a limitation of the study is that all data were collected from a single addiction treatment program where the patients were predominantly males, caucasian, educated, and employed. as a result, the sample may only partially represent the diverse characteristics found in many other treatment settings and may not represent patients in primary care or the general population. further, the lack of demographic variability limited our ability to test for differential symptoms functioning across subgroups. future research should replicate these findings across various treatment settings and with a more demographically diverse sample. finally, as with all patient-reported information, responses are vulnerable to self-report bias that could have affected the results. conclusion the present study extends previous evaluations of the dsm-5 e cud syndrome using rasch analysis in a clinical sample of adults receiving inpatient treatment for sud (dawson et al., 2010; hagman & 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(1994). reasonable mean-square fit values. rasch measurement transactions, 8, 370–371. funding and acknowledgements: this work was supported by charitable donations to homewood research institute, a registered charity in canada, and the peter boris chair in addictions research. jm is a principal and senior scientist in beam diagnostics, inc. and a consultant to clairvoyant therapeutics. all the other authors have no disclosures. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: gendy, m. n. s., taisir, r., britton, e., costello, j., & mackillop, j. (2025). rasch analysis of cannabis use disorder in an adult inpatient sample. cannabis, 8(2), 141 152. https://doi.org10.26828/cannabis/2025/000229 issue date: july 15, 2025 research article 167 ved abstract objective: people living with chronic pain increasingly use medical cannabis for symptom relief. we conducted a retrospective cohort study examining cannabis for chronic pain relief using anonymous archival data obtained from the medicinal cannabis tracking app, strainprint®. method: we acquired cannabis utilization data from 741 adults with chronic pain and used multilevel modeling to examine the association of age, sex, type of pain (muscle, joint or nerve pain), cannabis formulation (high cbd, balanced cbd:thc, or high thc), route of administration (inhaled or ingested), cannabis use before vs. during the covid-19 pandemic, and duration of cannabis use, with pain relief. results: most patients were female (n = 464; 63%), with a mean age of 39 (sd = 11), and our cohort had completed a total of 83,622 tracked cannabis sessions through strainprint. the majority of sessions reported use of inhaled cannabis products (78%), typically with high tetrahydrocannabinol (thc; 64%) versus high cannabidiol (cbd; 15%) or balanced thc:cbd (21%) products. the median change in pain scores across sessions was -3.0 points on a 10-point numeric rating scale (nrs; iqr -4.5 to -2.0). in our adjusted model, greater pain relief was associated with male vs. female sex (-0.69 points on a 10-point nrs; 95%ci -0.46 to -0.91). we found statistically significant, but trivial associations with joint pain (-0.05 points), balanced thc:cbd products in the long term (-0.003 points), and cannabis use during the pandemic (0.18 points). conclusions: we found that people living with chronic pain report important pain relief when using cannabis for medical purposes, and that men may achieve greater pain relief than women. key words: = cannabis; marijuana; chronic pain; mobile application; cohort; strainprint approximately one in five adults suffer from chronic pain globally (goldberg & mcgee, 2011). the severity of symptoms and functional limitations are variable and have been associated with underlying pathology, age, sex, and mental health status (reyes velez et al., 2021; treede et al., 2015). medical cannabis is an increasingly popular treatment for chronic pain, however, clinical trials typically evaluate a narrow range of products consumed through one route of administration (ingestion; busse et al., 2021) which has uncertain generalizability to the wide range of products available to patients. aidan giangregorio,1 li wang,2,3 sheila sprague,3,4 michelle arbus,5 jason w. busse2,3,6 1the michael g. degroote school of business, mcmaster university 2department of anesthesia, mcmaster university 3department of health research methods, evidence, and impact, mcmaster university 4department of surgery, mcmaster university 5strainprint (arbus) 6the michael g. degroote centre for medicinal cannabis research, mcmaster university cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000259 volume 7, special issue 3 predictors of response to medical cannabis for chronic pain: a retrospective review of real-time observational data corresponding author: jason w. busse, ph.d., department of anesthesia, michael g. degroote school of medicine, mcmaster university, hsc-2v9, 1280 main st. west, hamilton, canada, l8s 4k1 phone: (905) 5259140. email: bussejw@mcmaster.ca cannabis, a publication of the research society on marijuana 168 although medical cannabis has been found to provide modest relief from chronic pain, pooled estimates across trials show substantial unexplained heterogeneity (wang et al., 2021), suggesting the possibility that effectiveness may vary depending on patient or product characteristics. for example, a prospective cohort study of 551 people living with chronic pain and using cannabis for medical purposes found that achieving ≥30% reduction in pain at 1-year was positively associated with lower body mass index, long to normal sleep duration, and lower depression scores at baseline, and negatively associated with neuropathic pain (aviram et al., 2021). another cohort study of 2,987 individuals using cannabis products to manage chronic pain found that higher tetrahydrocannabinol (thc) products were associated with both greater pain relief and increased risk of side effects (li et al., 2019). clinical trials typically randomize patients to a single type of cannabis product that they adhere to for the duration of the study, whereas in practice patients may alter their method or frequency of consumption, or change products based on response. although observational data is unable to establish causality, patient data in naturalistic conditions can help inform practical patterns of use that may identify promising interventions for clinical trials (united states food and drug administration (fda), 2018). we conducted a retrospective study of medical cannabis use among people living with chronic pain to evaluate the different types of products in use, associations with pain relief, and factors that may influence treatment effects. methods we conducted a retrospective cohort study examining cannabis use for chronic pain with anonymous archival data obtained from the medicinal cannabis tracking app, strainprint (https://strainprint.ca/). strainprint is compliant with the health insurance portability and accountability act (hipaa), the personal information protection and electronic documents act (pipeda), and the personal health information protection act (phipa), and individuals who register on the app sign a consent to collection and use of data form for research purposes. we adhered to the strengthening the reporting of observational studies in epidemiology (strobe) guideline (vandenbroucke et al., 2007) for our study, which was approved by the hamilton health sciencesmcmaster research ethics board (project no. 10562). upon initial use of the strainprint app (strainprint technologies inc., 2020), individuals are prompted to enter demographic information, such as date of birth and sex, plus the conditions and symptoms on a pulldown menu that they hope to address with cannabis. users are then prompted to rate the severity of each symptom on a 0 to 10point numeric rating scale (nrs) prior to cannabis use. higher scores indicate greater pain on the 10point nrs, and the minimally important difference is -1.5 points (wang et al., 2023). next, they select the cannabis product they are using (i.e., flower, oil, capsule, edible, vape pen cartridge, concentrate), route of administration (i.e., vape, oil, smoke, edible, pill, tincture, spray, concentrate, dab bubble, dab portable, topical), and dose (i.e., mgs for soft gel, mls for oils, puffs for inhaled products) for each session. strainprint records the cannabis product used, linked to a certificate of analysis confirming the levels of thc and cannabidiol (cbd). after an onset period that is defined by the chosen route of administration (e.g., 10 minutes for inhalation, 60 minutes for ingestion), users are prompted with a push notification to complete their session by rating their post-use symptom severity on the same 10-point numeric scale. for each session, a change score is generated by subtracting the initial symptom severity from the symptom severity after cannabis use. since some users have multiple sessions per day, we used the average change score for each day of cannabis use to calculate the daily average change score for all users. inclusion criteria all individuals (canadian adults ≥18 years of age) who entered session data into strainprint regarding use of cannabis for relief from muscle, joint or nerve pain, from february 2017 to november 2020, were included in our study. we only included data from individuals that inhaled or ingested medical cannabis, as other methods (e.g., topical) were rarely endorsed. we attempted to exclude individuals using cannabis for acute medical cannabis for chronic pain 169 pain or non-pain complaints by removing those with less than 30 days of cannabis use (i.e., less than 30-days between their first and last recorded cannabis sessions), or who reported mild pain or less at baseline (i.e., < 4 on a 0 to 10-point nrs for pain). we excluded patients that recorded sessions with cannabis products that did not have an accompanying certificate of analysis to confirm thc:cbd composition. individuals with missing data for age or sex were also excluded. cannabis chemotypes we used the classification system proposed by jikomes & zoorob (jikomes & zoorob, 2018) to classify cannabis products in the dataset as either high thc, high cbd, or a balanced ratio of thc:cbd (table 1). table 1. cannabis chemotypes defined by the ratio of thc to cbd chemotype thc:cbd ratio high thc (chemotype i) 5:1 or greater balanced thc:cbd (chemotype ii) less than 5:1 and greater than 1:5 high cbd (chemotype iii) 1:5 or lower data analysis we used descriptive statistics to summarize demographic information. we reported categorical data as proportions, and continuous data as means and standard deviations (sds) if normally distributed and as medians and interquartile ranges (iqrs) if not. we defined a product change when patients switched from one cannabis product to another (high cbd, balanced ratio of thc:cbd, high thc), and added up the number of changes for each patient. we constructed a multilevel linear mixed effects model to explore the associations of age, sex, type of pain (i.e., muscle, joint, or nerve pain), cannabis formulation (high cbd, balanced cbd:thc, or high thc), route of administration (inhaled or ingested), duration of medical cannabis use, and cannabis use before vs. during the covid-19 pandemic, with change in pain scores after treatment. a linear mixed effects model allows for examination of change in pain score by considering both withinand between-subject variability despite differences in the number of observations across individuals. it estimates timevariant slope variables at the within-subject level that are then used to predict change at the between-subject level. our model included fixed effect terms for age at baseline (for every 10-year increase), sex (female vs. male), and type of chronic pain (muscle vs. joint vs. nerve pain). we also included an interaction term (cannabis*duration) to account for possible interactions between cannabis formulation and duration of use. we modelled our independent factors and outcome (pain change scores) as functions of time/sessions at the within-subjects level, and used the slopes of these regressions (i.e., regression coefficients) to test for betweensubjects level effects. we conducted covariance structure modeling for our linear mixed model, which combines factor analysis, path analysis, and multiple regression to model the relationships between observed and unobserved variables. selection of a covariance structure that is too simple leads to the loss of precision in parameter estimates, whereas choosing one that is too complex can result in the loss of parsimony and efficiency. there are several covariance structures that can be tested to identify a best fit for model data (e.g., autoregressive, compound symmetry, unstructured, variance components; kaplan, 1990). we found an unstructured covariance matrix for perceived stress most optimized the fit statistics (akaike's information criterion, bayesian information criterion) to predict changes in pain severity over time. negative coefficients indicate reduction in pain. all statistical analyses were performed with stata 15.1 (statacorp lp, college station, tx, usa). results our cohort was comprised of 741 individuals that used cannabis for chronic pain and entered a total of 83,622 strainprint sessions. (figure 1). the median age of participants was 39 years (iqr 31 to 46), and approximately two thirds of strainprint users were female (63%). treatment sessions most often targeted joint pain (41%) or muscle pain (40%), with nerve pain being the focus for 19% of total sessions (table 2). cannabis, a publication of the research society on marijuana 170 figure 1. participant flow diagram inhaled products were used for 78% of treatment sessions, with 45% delivered by vaporizer and 32% by smoking. the remaining 22% of treatment sessions involved ingesting cannabis products, mostly (21%) by consumption of cannabis oil. two-thirds of treatment sessions (65%) involved high thc cannabis products, 21% used products with a balanced thc:cbd ratio, and only 15% involved high cbd products. participants recorded a median of 24 sessions (iqr 9 to 93), and the median duration for use of the strainprint app was 214 days (iqr 85 to 490). participants changed products a median of 2 times (iqr 0 to 11) over the course of their recorded cannabis use (table 2). table 2. participant and product characteristics (n = 741 participants, 83,622 sessions) age, mean (sd) 38.9 years (11.1) gender, n (%) female male 464 (63%) 277 (37%) type of pain treated per session, n (%) joint pain muscle pain nerve pain 34,202 (41%) 33,736 (40%) 15,684 (19%) route of administration per session, n (%) ingested* oil sublingual oil sublingual tincture inhaled vaporized smoked concentrate dab bubbler 17,698 (21%) 606 (0.7%) 43 (0.1%) 37,303 (45%) 26,738 (32%) 1,104 (1%) 100 (0.1%) dab portable 30 (0.04%) cannabis chemotype per session, n (%) strainprint customers that endorsed use of inhaled or ingested cannabis for muscle, joint, or nerve pain (n = 1682) excluded patients (n = 940) • less than 30 days of cannabis use (n = 830) • sessions that recorded products without a certificate of analysis (n = 88) • missing data on age or sex (n = 21) • baseline pain score of <4/10 (n = 1) final dataset of strainprint customers (n = 741) medical cannabis for chronic pain 171 high thc balanced thc:cbd high cbd no. of treatment sessions, median (iqr) 24 (9 to 93) treatment duration, median (iqr) 214 days (85 to 490) no. of product changes during treatment, median (iqr)† 2 (0 to 11) note. * oil products are either oil-filled capsules that are swallowed, or liquid cannabis-infused oil that is taken orally with a dropper. sublingual oil is administered under the tongue for faster absorption. †the total number of changes from one product to the other. impact on pain the median reported change in pain scores across treatment sessions for participants was -3.0 points on a 10-point nrs (iqr -4.5 to -2.0). our linear mixed model found that male sex was associated with greater pain relief versus female sex (-0.69 points, 95%ci -0.91 to -0.46). other factors showed either no significant association, or associations that were statistically significant but trivial. specifically, joint pain was associated with a -0.05-point reduction in pain vs. muscle pain, cannabis products with a balanced ratio of thc:cbd at longer term use showed a -0.01-point reduction in pain vs. high cbd products at shorter term use, and cannabis use during the covid-19 pandemic was associated with a 0.18-point increase in pain severity (figure 2, table 3). figure 2. predictive margins for three types of cannabis and duration of treatment predictive margins of cannabis with 95& ci’s note. *negative values represent pain reduction on a 10-point numeric rating scale for pain. l in e a r p re d ic ti o n , f ix e d p o rt io n duration of treatment (months) cannabis, a publication of the research society on marijuana 172 table 3. linear mixed effect model for pain reduction factors beta coefficient (95%ci) p-value. age every 10-year decrease -0.006 (-0.10 to 0.09) .90 sex female reference male -0.69 (-0.91 to -0.46) <.001 symptom muscle pain reference joint pain -0.05 (-0.08 to -0.01) .01 nerve pain -0.03 (-0.08 to 0.02) .22 chemotype high cbd reference balanced thc/cbd -0.01 (-0.08 to 0.06) .82 high thc -0.08 (-0.14 to -0.01) .02 route of administration inhaled reference ingested -0.04 (-0.10 to 0.007) .09 duration of treatment (months) every 1-month increase -0.003 (-0.008 to 0.002) .20 cannabis x duration high cbd at shorter term reference balanced thc/cbd at longer term -0.003 (-0.008 to -0.003) .004 high thc at longer term -0.004 (-0.01 to 0.001) .08 covid-19 pandemic before pandemic reference <.001 during pandemic† 0.18 (0.12 to 0.25) note. * negative values represent pain reduction on a 10-point numeric rating scale for pain. † the world health organization declared covid-19 viral disease a pandemic on march 11, 2020. discussion our study of a consecutive cohort of 741 individuals using cannabis for relief from chronic pain found the majority were seeking to address joint or muscle-related pain with inhaled products, most often administered with a vaporizer. two thirds of all recorded treatment sessions involved high thc products, and participants changed products a median of 2 times over the course of their recorded cannabis use. on average, participants reported large reductions in pain across treatment sessions with a median reduction that was double the minimally important difference, and male sex was associated with greater pain relief versus female sex. relevant literature our findings are aligned with previous observational reports of cannabis use for chronic pain (lee et al., 2023; li et al., 2019; tait et al., 2023); however, the reductions in pain we observed (median of -3 points on a 0-10 point nrs) was much larger than randomized trials have reported when accounting for non-specific effects medical cannabis for chronic pain 173 (weighted mean difference of -0.5cm on a 10cm vas; cuttler et al., 2022; li et al., 2019; wang et al., 2021). the most recent clinical practice guideline made a conditional recommendation for the use of non-inhaled medical cannabis for chronic pain due to the close balance between benefits and harms along with high variability in patient preferences (busse et al., 2021). the state of the evidence on sex dependant differences in pain reduction after the administration of cannabinoids is limited, and preclinical evidence has shown mixed results. female rodents may exhibit greater reductions in pain after acute treatment with cannabinoids relative to male rodents; however, these differences may attenuate or even show larger benefits in male rodents with repeated cannabis administration (cooper & haney, 2016; craft et al., 2013). an experimental study that looked at pain responses after the administration of a coldpressor test found that men had decreased pain sensitivity after they consumed thc while women had no decrease (cooper & haney, 2016). further, a prior observational study of 1249 chronic pain patients using vaporized thc found no difference in pain relief between men and women, but also suffered from a 47% loss to follow-up that may have introduced bias.(aviram et al., 2023) whether men or women benefit more from using medical cannabis for pain relief remains uncertain and further research is needed to address this knowledge gap. we found cannabis use during the covid-19 pandemic was slightly less effective for pain relief. this is unlikely to be due to reduced access, as cannabis sales in general increased during the pandemic;(mackillop et al., 2021) however, 78% of cannabis consumed by participants in our cohort was inhaled and respiratory infection due to covid-19 may have resulted in reduced intake. we also found that cannabis products with balanced ratios of thc:cbd were slightly more effective than high cbd products at longer term use, and cannabis was slightly more effective for joint vs. muscle pain. while these findings are consistent with prior cohort studies (aviram et al., 2023; li et al., 2019), the associations we found were statistically significant but clinically trivial. our findings highlight the importance of presenting associations in absolute terms to facilitate interpretation (busse et al., 2015). the way that individuals consumed cannabis in our dataset was diverse and we found that switching products was common. a likely explanation for this behaviour could be attempts by patients to improve symptom relief, reduce adverse effects, or both. additional factors which could result in switching products may include lack of availability or price changes. our findings are in-line with a prior study wherein, over a 12month period, 86% of medical cannabis patients changed the type of product they were using (kalaba et al., 2021). additionally, some researchers have found that medical cannabis users may administer multiple products and different routes of administration to relieve different symptoms, a practice termed “dose layering” (boehnke et al., 2019). limitations there are several limitations to this study. first, all the data used in our study is selfreported and users may not accurately report the product or dose they used. second, strainprint does not require users to distinguish between acute and chronic pain. we did remove participants from our dataset that used cannabis for less than 30 days to focus on chronic pain, and the median duration of cannabis use among our participants was 214 days (iqr 85 to 490) which suggests most pain complaints were chronic. third, the lack of a control group was another important limitation that introduced non-specific effects. further, patients that find benefit from cannabis may be more likely to continue use, while those that do not benefit may not. therefore, our data may over-represent individuals that derive benefit from using medical cannabis. conclusion our analysis of observational data from chronic pain patients who use medical cannabis found large reductions in pain, and that men were more likely to experience greater pain relief than women. our findings require confirmation in 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(2021). medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials. the bmj, 374, n1034. https://doi.org/10.1136/bmj.n1034 wang, y., devji, t., carrasco-labra, a., king, m. t., terluin, b., terwee, c. b., walsh, m., furukawa, t. a., & guyatt, g. h. (2023). a step-by-step approach for selecting an optimal minimal important difference. the bmj, 381, e073822. https://doi.org/10.1136/bmj-2022073822 funding and acknowledgements: this was an unfunded study. mr. giangregorio was supported by a michael g. degroote centre for medicinal cannabis research graduate fellowship. dr. busse is supported, in part, by a canadian institutes of health research canada research chair in the prevention and management of chronic pain. strainprint provided access to the data analysed for this study. we thank rachel j. couban for assistance with formatting our references. each author contributed substantially to the conception and design of the article. giangregorio and wang analyzed the data, and giangregorio drafted the initial manuscript. each author revised the manuscript critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work. data sharing: the analysis code can be accessed by contacting dr. li wang (wangli1@mcmaster.ca). copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: giangregorio, a., wang, l., sprague, s., arbus, m., & busse, j. m. (2024). predictors of response to medical cannabis for chronic pain: a retrospective review of real-time observational data. cannabis, 7(3), 167–176. https://doi.org/10.26828/cannabis/2024/000259 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 176 research article 90 ved abstract objective: the relationship between cannabis use and mental health has garnered significant attention in recent decades. however, studies have largely been in general populations or in countries in which recreational cannabis use is illegal. method: the current cross-sectional study examines the relationship between cannabis use, mood disorders, anxiety, and psychosis in an inpatient psychiatric population with severe concurrent mental health and substance use disorders, exploring the potential moderating effect of the legalization of recreational cannabis in canada. results: cannabis use compared to non-use was associated with higher self-reported depression, anxiety, and psychotic symptoms but was not associated with diagnosis of a mood, anxiety, or psychotic disorder. frequency of cannabis use was unrelated to mental health outcomes, but age of first use was negatively associated with self-reported psychoticism symptoms. there were some significant associations between recreational cannabis legalization and mental health, but legalization was largely unrelated to outcomes. there were also some significant differences by demographics. conclusions: while findings are relatively consistent with prior literature, some significant associations differed, suggesting the importance of examining concurrent disorder patients as a unique population when examining relationships between cannabis use and mental health. key words: = cannabis; substance use disorders; mood disorders; anxiety; depression; psychosis karina a. thiessen1,2& christian g. schütz1,2,3 1department of psychiatry, faculty of medicine, university of british columbia 2djavad mowafaghian centre for brain health, faculty of medicine, university of british columbia 3british columbia mental health and substance use services, provincial health services authority cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000258 volume 7, special issue 3 examining the relationship between cannabis use and mood, anxiety, and psychotic symptoms in psychiatric patients with severe concurrent mental health and substance use disorders before and after recreational cannabis legalization in canada corresponding author: karina thiessen, ba bed, university of british columbia, 430 5950 university blvd, vancouver, bc, v6t 1z3. phone: (604) 827-4287. email: karina.thiessen@ubc.ca cannabis, a publication of the research society on marijuana 91 cannabis use is the second most commonly used recreational substance, following alcohol (health canada, 2021). approximately 50% of canadians report ever using cannabis and approximately 25% report past-year use (government of canada, 2024; health canada, 2021). the world health organization estimates the global prevalence of cannabis use at approximately 2.5% (world health organization, 2024). the landscape of cannabis regulations and use has been changing rapidly across the world. a growing number of regions have decriminalized or legalized either medical or recreational cannabis in the past 20 years. in canada, medical cannabis use was legalized in 1999 (controlled drugs and substances act, 1996; health canada, 2016), and recreational cannabis use was legalized in 2018 (cannabis act, 2018). there has also been an increase in novel consumer products (spindle et al., 2019), such as cannabis beverages and ecigarettes (“vapes”; giroud et al., 2015), and in cannabinoid concentrations in cannabis products (chandra et al., 2019). with the many changes in cannabis legislation and consumption, there is continued interest in the public health implications of these changes. the relationship between cannabis and mental health has been widely debated in the scientific community and in the general public. there have been a considerable number of studies, systematic reviews, and meta-analyses examining the relationship between cannabis and mental health in both clinical and general populations. many people report using cannabis to cope with mental health disorder symptoms and stress (hyman & sinha, 2009; walsh et al., 2013; yau et al., 2019). cannabinoids have been proposed by some as a potential therapeutic for a range of psychiatric disorders and related symptoms (hoch et al., 2019; lowe et al., 2018; sarris et al., 2020; stith et al., 2020). while some evidence is mixed and the potential causal role of cannabis is not established (lowe et al., 2018), cannabis use–especially early use–is often associated with increased risk for adverse mental health outcomes, including anxiety, depression, and psychosis (gobbi et al., 2019; halah et al., 2016; hall, 2006; halladay et al., 2020; leadbeater et al., 2019; lowe et al., 2018; van ours & williams, 2011; van ours & williams, 2012). yet, these studies were predominantly conducted in regions in which recreational cannabis was not yet legalized, and/or in which preand post-cannabis legalization analyses were not possible. legalization may impact cannabis use prevalence, potency of products, and psychiatric outcomes (hall et al., 2023). furthermore, studies that have examined the potential impacts of legalization have primarily been limited to easily accessible populations. vulnerable populations, including psychiatric patients with the most severe and comorbid mental health and substance use disorders, are frequently excluded from research due to an emphasis on studying single disorders or pairings of disorders. individuals suffering from severe concurrent disorders are difficult to recruit and assess. for example, epidemiological studies are often based on household surveys or emergency room data. high rates of homelessness among psychiatric populations limit their inclusion. findings using standard population-based samples may not be generalizable to psychiatric inpatient populations. a study of psychiatric patients found higher rates of past-month cannabis use compared to general populations (bahorik et al., 2013). people with psychiatric disorders are also more likely to use high-potency cannabis (chan et al., 2017), which has become increasingly available post-legalization (hall et al., 2023). also, the impact of cannabis in psychiatric populations is often less emphasized in clinical contexts (wiese et al., 2024), and thus may be under-addressed. overall, there is a need for cannabis research in inpatient populations at the more severe end of the spectrum (atakan, 2008) in regions where recreational cannabis has been legalized. the current study examined the relationship between cannabis use, including use and non-use, frequency of use, age of first use, and mental health outcomes in an inpatient population with severe comorbid mental health and substance use disorders (“concurrent disorders”) in british columbia. we also explore recreational cannabis legalization as a potential moderator of the relationship between cannabis use and mental health. we hypothesized that cannabis use, higher frequency of use, and earlier onset of cannabis use would be associated with increased mental health symptoms and diagnoses. we further hypothesized that cannabis legalization mental health and cannabis preand post-legalization 92 may moderate this effect, such that this association may decrease post-legalization as commercial access to cannabis became available to non-medical users. methods participants and treatment facility participants at the time of assessment were inpatients at the red fish healing centre for mental health and addictions (formerly the burnaby centre for mental health and addictions) from british columbia, canada. the red fish healing centre is a tertiary integrated treatment centre servicing british columbia and yukon territory for people with concurrent disorders that have exhausted the treatment options available to them in their local health authority (lee-cheong et al., 2021; schütz et al., 2013). the treatment program is designed for a 6to 9-month stay, but the average length of treatment is approximately 4to 5months. patients receive services including pharmacotherapy, psychotherapy (group therapy), physical therapy, social work services, and recreational activities. for further information on the treatment centre, see lee-cheong et al. (2021) and schütz et al. (2013). to be eligible for the study, participants had to be in treatment for at least one month, determined stable enough to participate in the study by medical staff at the treatment centre, able to complete the study assessments in english, and consent to the use of medical chart data in the study. while we did not have data on the typical percentage of patients that remain in treatment for at least one month, clinician estimates suggest that at least 90-95% of patients are in treatment for at least 1 month. procedure the study was approved by the clinical research ethics board at the university of british columbia and operational approval was obtained from bc mental health and substance use services. to recruit participants, patients were informed about the study by research assistants during individual free time and group activities. posters were also displayed at the treatment center. if patients expressed interest in participating, eligibility was confirmed by treatment centre staff. written informed consent was obtained from all participants prior to study enrollment. participants completed a crosssectional survey, including demographic information, the maudsley addiction profile (marsden et al., 1998), the symptom checklist-90revised (scl-90-r; derogatis & unger, 2010), and a clinical cannabis use questionnaire with questions including frequency of use and age of onset of cannabis use. admission date and diagnoses at admission were collected from medical charts. assessments mental health symptoms and diagnoses. the scl-90-r (derogatis & unger, 2010) is a standardized and validated 90-item questionnaire used to evaluate a range of mental health disorder symptoms and psychological distress. depression, anxiety, and psychosis subscales were selected for the present study due to their clinical relevance in the patient population and overlapping symptoms with medical chart diagnosis classifications (mood, anxiety, and psychotic disorders) and the currently available literature examining the relationship between cannabis use and mental health disorders in other populations. the scl90-r is an established instrument and has over 1,000 independent studies supporting is reliability and validity. in one validation study in a psychiatric population, the internal consistency coefficient ratings were 0.84, 0.83, and 0.69 for depression, anxiety, and psychoticism, respectively (kostaras et al., 2020). medical chart data collected included demographic information, date of admission, medication, dsm-5 diagnoses (american psychiatric association, 2013) at admission. patients’ diagnoses are determined by comprehensive assessment by psychiatrists in collaboration with an interdisciplinary clinical care team at the treatment centre. care providers, including psychiatrists, spend extensive time reviewing patients’ medical history, interacting directly with patients, and considering patients’, families’, and care providers’ perspectives. for our analyses, diagnoses were classified according to dsm-5 categories: mood disorders (depressive and bipolar disorders), anxiety disorders (e.g., generalized anxiety disorder), and schizophrenia spectrum disorders. in accordance with the dsm5, substance-induced psychosis was not included cannabis, a publication of the research society on marijuana 93 as a schizophrenia spectrum disorder and posttraumatic stress disorder (ptsd) was not classified as an anxiety disorder. cannabis use. cannabis use was assessed via self-reported data. recent cannabis use and frequency of cannabis use was evaluated using the map (marsden et al., 1998). the map is a standardized and validated questionnaire to assess substance use, physical health and health behaviors, psychological wellbeing, and daily functioning. the map average intraclass correlation coefficients for eight substances were 0.94 and 0.81 across health and social domains (marsden et al., 1998). patients reported on their typical monthly cannabis use prior to entering treatment. patients were classified as using cannabis if they reported at least 1 day of use in the map cannabis use scale. history of cannabis use, including age of first use, was assessed using a clinically developed questionnaire for assessment at the treatment centre. analysis linear regressions were computed to assess relationships between cannabis use and scl-90r scores. first, we compared if cannabis use compared to non-use predicted scl-90-r depression, anxiety, and psychosis scores. next, we examined cannabis use patterns in relation to scl-90-r scores within cannabis users, assessing for frequency of use and age of first use. similarly, logistic regressions were computed to examine cannabis use/non-use, and within cannabis users, frequency of cannabis use, and age of first use in relation to mood, anxiety, and psychotic disorder diagnoses at admission. to examine the potential moderating effect of recreational cannabis legalization, the legal status of recreational cannabis at the time of admission was included as an interaction term with our primary predictive variables (cannabis use/non-use and frequency of use). age and gender differences in mental health disorders are common. women are more likely to be diagnosed with mild and moderate depression, while men may be more likely to be diagnosed with severe depression (shi et al., 2021). younger adults (askari et al., 2023) are more likely to be diagnosed with a mental health disorder. as such, age and gender were included as potential covariates in all regression models. while the study was not powered to account individually for each other substance use, number of major noncannabinoid addictive substance classes (alcohol, stimulants, opioids, and sedatives) used were also included as covariates. box-cox or square root transformations were applied to dependent variables when assumptions of normality were violated. missing values were addressed via imputation. analyses were computed in rstudio (rstudio team, 2015; hebbali 2024). we report adjusted models including all regressors of interest and unadjusted models for each regressor of interest in our results. results demographics demographics are summarized in table 1, and descriptive statistics of scl-90-r symptom ratings and diagnostic status are summarized in table 2. a comparison of cannabis users in the sample with national statistics are available in the supplementary materials (table s1). a total of 211 (65 self-identified female; 146 self-identified male) participants completed the cannabis survey. of those, 100 (38 female; 62 male) reported no recent cannabis use, and 111 (27 female; 84 male) reported typically using cannabis at least once every 30 days. there was a significantly higher proportion of female to male participants in the non-cannabis group compared to the cannabis group. the mean age of participants was significantly different between groups: 38.6 years in the non-cannabis group, and 34.8 years in the cannabis group. those that reported using cannabis also reported a higher mean number of non-cannabinoid substances used. as such, these were included as covariates in our regression models. there was no significant difference in proportion of participants that were admitted to the treatment centre pre-cannabis legalization compared to post-legalization. differences between scl-90-r ratings and diagnoses by cannabis use status are reported in table 3 as part of our primary analyses. table 1. sample demographics mental health and cannabis preand post-legalization 94 demographics total n (%) or �̅� ± sd non-cannabis users n (%) or �̅� ± sd cannabis users n (%) or 𝑋 ̅± sd statistic p-value n gender male female age ± sd2 number of other substance classes used3 cannabis legal status at admission illegal legal 30-day cannabis use frequency age of first cannabis use scl-90-r subscale ratings depression anxiety psychoticism diagnoses mood missing anxiety missing schizophrenia spectrum missing 211 149 (70.6) 65 (30.9) 36.82 ± 11.5 2.19 ± 0.8 131 (62.1) 80 (37.9) 1.2 ± 0.9 0.8 ± 0.7 0.8 ± 0.8 93 (44.1) 5 (2.4) 33 (15.6) 5 (2.4) 154 (73) 6 (2.8) 100 62 (62.0) 38 (38.0) 39.8 ± 11.8 2.0 ± 0.9 57 (57.0) 43 (43.0) 1.1 ± 0.9 0.7 ± 0.7 0.7 ± 0.7 46 (46) 1 (1) 18 (18) 1 (1) 68 (68) 1 (1) 111 84 (75.7) 27 (24.3) 34.1 ± 10.5 2.3 ± 0.7 74 (66.7) 37 (33.3) 16.2 ± 11.4 14.1 ± 2.58 1.3 ± 0.8 0.9 ± 0.8 0.9 ± 0.9 47 (42.3) 4 (3.6) 15 (13.5) 4 (2.4) 86 (77.5) 4 (4.5) 4.001 3.662 -2.922 1.701 .046 .000 .004 .193 note. 1. chi-square; 2. t-test; 3. includes alcohol, opioids, stimulants, and sedatives. sd = standard deviation. significant betweengroup differences are indicated in bold. table 2. symptom and diagnostic outcome descriptives symptom/diagnosis total n (%) or �̅� ± sd non-cannabis users n (%) or �̅� ± sd cannabis users n (%) or �̅� ± sd scl-90-r subscale ratings depression anxiety psychoticism diagnoses mood missing anxiety missing schizophrenia spectrum missing 1.2 ± 0.9 0.8 ± 0.7 0.8 ± 0.8 93 (44.1) 5 (2.4) 33 (15.6) 5 (2.4) 154 (73) 6 (2.8) 1.1 ± 0.9 0.7 ± 0.7 0.7 ± 0.7 46 (46) 1 (1) 18 (18) 1 (1) 68 (68) 1 (1) 1.3 ± 0.8 0.9 ± 0.8 0.9 ± 0.9 47 (42.3) 4 (3.6) 15 (13.5) 4 (2.4) 86 (77.5) 4 (4.5) note. sd = standard deviation. differences between scl-90-r ratings and diagnoses by cannabis use status are reported in table 3 as part of our primary analyses. mental health among people who use cannabis compared to people who do not use cannabis our first set of regressions compared people who use cannabis with people who do not use cannabis, with the legal status of cannabis examined as a potential moderator. scl-90-r results are detailed in table 3. age and gender were not a significant predictor of any scl-90-r scores. the number of non-cannabinoid substances used was positively associated with scl-90-r depression scores in both the cannabis, a publication of the research society on marijuana 95 unadjusted and adjusted models, while cannabis was not associated with scores in the unadjusted model but was positively associated with scores in the adjusted model. there was no significant impact of cannabis legal status in the unadjusted or adjusted models. the number of non-cannabis substances used and cannabis use were significantly positively associated with the scl-90-r anxiety ratings in both the unadjusted and adjusted models. there was also a significant interaction effect between cannabis use and the legal status of cannabis in the unadjusted and adjusted models. post-hoc pairwise comparisons with tukey’s honestly significant difference (hsd) multiplecomparisons correction revealed significantly higher scl-90-r anxiety scores for people who used cannabis pre-legalization compared to those who did not (t = -3.45, p = .003) and significantly higher anxiety scores for those who used cannabis post-legalization compared to those who used cannabis pre-legalization (t = 3.23, p = .008). with regards to the scl-90-r psychoticism scale, cannabis use significantly predicted higher psychoticism scores in the unadjusted and adjusted models. a higher number of substances used significantly predicted higher psychoticism scores in the unadjusted and adjusted models. legal status had no significant associations. in summary, the number of non-cannabinoid substances used and cannabis use status were significantly associated with higher scl-90-r symptom ratings for all three scales, with a moderating effect of cannabis legalization for anxiety scores only. table 3. regression models for self-reported mental health symptoms by age, gender, cannabis legal status at admission, and cannabis use/non-use unadjusted adjusted β 95% ciβ p β 95% ciβ p scl-90-r depression1 age gender number of substances used can legal status can use can legal status x can use scl-90-r anxiety1 age gender number of substances used can legal status can use can legal status x can use scl-90-r psychoticism2 age gender number of substances used can legal status can use can legal status x can use 0.00 -0.02 0.10 -0.07 0.11 -0.02 0.01 -0.06 0.13 -0.09 0.11 -0.37 0.00 -0.03 0.14 -0.11 0.13 -0.27 -0.00, 0.01 -0.15, 0.10 0.03, 0.17 -0.19, 0.05 0.00, 0.23 -0.44, 0.04 0.00, 0.01 -0.19, 0.06 0.06, 0.20 -0.20, 0.03 0.01, 0.23 -0.59, -0.14 0.00, 0.01 -0.18, 0.12 0.05, 0.22 -0.25, 0.04 0.00, 0.27 -0.55, 0.01 .272 .718 .005 .257 .059 .098 .617 .307 .000 .130 .039 .002 .642 .700 .002 .143 .050 .059 0.00 -0.01 0.09 0.03 0.17 -0.16 0.00 -0.06 0.11 0.10 0.20 -0.32 0.00 -0.02 0.11 0.04 0.19 0.22 0.00, 0.00 -0.14, 0.12 0.01, 0.16 -0.14, 0.20 0.01, 0.32 -0.40, 0.08 0.00, 0.01 -0.18, 0.06 0.04, 0.18 -0.05, 0.26 0.06, 0.35 -0.55, -0.10 0.00, 0.01 -0.17, 0.13 0.03, 0.20 -0.16, 0.24 0.01, 0.37 -0.51, 0.05 .105 .087 .023 .071 .035 .183 .364 .339 .001 .193 .006 .005 .328 .792 .011 .701 .035 .112 note. 1. box-cox transformed outcome variable. 2. square-root transformed outcome variable. can = cannabis; ci = confidence interval. se = standard error. gender: reference level = male. cannabis legal status: reference level = prelegalization. unadjusted model statistics are reported for each regressor, in addition to statistics for the adjusted multivariate models. significant findings are indicated in bold. diagnosis results are detailed in table 3. for mood disorder diagnoses, males were more likely to be diagnosed but there were no other significant predictors. there were no significant predictors of anxiety disorder diagnosis. while cannabis use and illegal cannabis status individually predicted a schizophrenia spectrum disorder in unadjusted models, these relationships were no longer significant in our adjusted models. there were no mental health and cannabis preand post-legalization 96 other significant predictors of a schizophrenia spectrum disorder. table 4. regression models for diagnosis at admission by age, gender, cannabis legal status at admission, and cannabis use/non-use unadjusted adjusted β or 95% cior p β or 95% cior p mood disorder age gender number of substances used can legal status can use can legal status x can use anxiety disorder age gender number of substances used can legal status can use can legal status x can use psychotic disorder age gender number of substances used can legal status can use can legal status x can use 0.02 -0.74 -0.01 -0.19 -0.10 0.11 0.00 0.12 0.12 -0.08 -0.31 -1.18 -0.01 -0.04 -0.13 -0.74 0.67 -0.35 1.02 0.47 0.99 0.83 0.90 1.12 1.00 1.13 1.13 0.93 0.73 0.31 0.99 0.96 0.88 0.48 1.96 0.71 1.00, 1.05 0.25, 0.87 0.70, 1.39 0.47, 1.46 0.52, 1.56 0.36, 3.51 0.97, 1.03 0.50, 2.46 0.71, 1.80 0.42, 1.98 0.34, 1.55 0.05, 1.55 0.96, 1.01 0.49, 1.94 0.59, 1.31 0.25, 0.91 1.03, 3.78 0.19, 2.63 .096 .018 .945 .523 .714 .845 .979 .759 .603 .846 .417 .169 .308 .909 .531 .024 .041 .603 0.02 -0.77 0.07 -0.34 -0.24 0.28 0.00 0.06 0.13 0.40 0.02 -1.17 -0.01 0.20 -0.31 -0.56 0.92 -0.44 1.02 0.46 1.32 0.72 0.78 1.31 1.00 1.06 1.14 1.49 1.02 1.13 0.99 1.23 0.73 0.57 2.51 0.64 0.99, 1.04 0.24, 0.87 0.74, 1.55 0.31, 1.63 0.37, 1.66 0.41, 1.55 0.96, 1.03 0.45, 2.40 0.70, 1.84 0.52, 4.24 0.37, 2.83 0.05, 1.59 0.97, 1.03 0.60, 2.60 0.48, 1.12 0.24, 1.37 0.99, 6.61 0.17, 2.43 .130 .019 .428 .524 .718 .645 .830 .888 .595 .451 .962 .177 .738 .586 .153 .212 .055 .512 note. ci = confidence interval. or = odds ratio. gender: negative β indicates higher score for male participants. cannabis legal status: negative β indicates higher odds pre-legalization compared to post-legalization. unadjusted model statistics are reported for each regressor, in addition to statistics for the adjusted multivariate models. significant findings are indicated in bold. frequency of cannabis use, age of first use, and mental health our next set of analyses was within people who used cannabis, with legal status of cannabis explored as a potential moderator. scl-90-r results are detailed in table 4. within people who reported cannabis use, there were no significant predictors of scl-90-r depression scores. both scl-90-r anxiety and psychoticism scores were significantly positively associated with number of substances used and were lower post-legalization compared to pre-legalization in our unadjusted models but these relationships became nonsignificant in our adjusted models. they were not significantly associated with any other variables. results regarding diagnoses are detailed in table 4. age at admission was positively associated with mood disorder diagnoses. there were no other significant predictors of mood disorder diagnoses. anxiety disorders were significantly associated with a later age of first cannabis use. schizophrenia spectrum disorders were significantly negatively associated with the legal status of cannabis. table 5. regression models for self-reported mental health symptoms by age, gender, cannabis legal status at admission, frequency of use, and age of first use among cannabis use (n = 111) unadjusted adjusted β 95% ciβ p β 95% ciβ p scl-90-r depression age 0.01 -0.01, 0.02 .237 0.01 -0.01, 0.02 .311 cannabis, a publication of the research society on marijuana 97 gender -0.08 -0.45, 0.30 .683 0.00 -0.38, 0.38 .982 number of substances used 0.13 -0.10, 0.35 .269 0.10 -0.14, 0.33 .413 age of first can use 0.06 0.00, 0.12 .060 0.05 -0.02, 0.11 .168 can legal status -0.28 -0.62, 0.06 .102 -0.01 -0.62, 0.59 .963 frequency of can use -0.01 -0.02, 0.01 .477 0.00 -0.02, 0.02 .886 can legal status x can frequency of use -0.02 -0.05, 0.01 .287 -0.01 -0.04, 0.02 .458 scl-90-r anxiety1 age 0.00 -0.01, 0.01 .758 0.00 -0.01, 0.01 .948 gender -0.10 -0.30, 0.10 .310 -0.05 -0.24, 0.14 .618 number of substances used 0.14 0.03, 0.25 .017 0.12 0.00, 0.23 .047 age of first can use 0.03 0.00, 0.06 .054 0.02 -0.01, 0.06 .158 can legal status -0.29 -0.47, -0.12 .001 -0.12 -0.42, 0.19 .441 frequency of can use 0.00 -0.01, 0.01 .822 0.01 0.00, 0.01 .204 can legal status x can frequency of use -0.01 -0.02, 0.01 .275 -0.01 -0.02, 0.01 .358 scl-90-r psychoticism1 age 0.00 0.01, 0.01 .945 0.00 -0.01, 0.01 .985 gender 0.03 -0.20, 0.25 .811 0.05 -0.17, 0.28 .630 number of substances used 0.13 0.00, 0.27 .045 0.10 -0.04, 0.24 .151 age of first can use 0.02 -0.01, 0.06 .228 0.02 -0.56, 0.16 .281 can legal status -0.23 -0.43, -0.03 .026 -0.20 -0.56, 0.16 .384 frequency of can use -0.01 -0.01, 0.00 .146 0.00 -0.02, 0.01 .397 can legal status x can frequency of use 0.00 -0.01, 0.02 .936 0.00 -0.02, 0.02 .880 note. ci = confidence interval. se = standard error. gender: negative β indicates higher score for male participants. cannabis legal status: negative β indicates higher score pre-legalization compared to post-legalization. unadjusted model statistics are reported for each regressor, in addition to statistics for the adjusted multivariate models. significant findings are indicated in bold. table 6. frequency of cannabis use per 30 days and age of first use with mental health diagnoses (n = 111) unadjusted adjusted β or 95% cior p β or 95% cior p mood disorder age 0.05 1.05 1.01, 1.09 .016 0.05 1.05 1.01, 1.10 .013 gender -0.51 0.60 0.23, 1.47 .274 -0.46 0.63 0.23, 1.65 .357 number of substances used -0.14 0.87 0.50, 1.49 .612 -0.15 0.86 0.48, 1.53 .615 age of first can use 0.09 1.09 0.94, 1.30 .255 0.08 1.08 0.92, 1.31 .363 can legal status -0.14 0.87 0.38, 1.95 .738 -0.92 0.40 0.08, 1.80 .241 frequency of can use 0.00 1.00 0.97, 1.04 .790 -0.02 0.98 0.94, 1.03 .486 can legal status x can frequency of use 0.02 1.03 0.95, 1.10 .496 0.05 1.05 0.97, 1.14 .206 anxiety disorder age 0.01 1.01 0.96, 1.07 .597 0.01 1.01 0.96, 1.07 .658 gender -0.83 0.44 0.07, 1.73 .297 -0.35 0.70 0.10, 3.19 .674 number of substances used 0.15 1.17 0.54, 2.53 .693 0.21 1.23 0.52, 2.99 .641 age of first can use 0.35 1.42 1.13, 1.88 .008 0.35 1.42 1.11, 1.96 .016 can legal status -0.81 0.45 0.10, 1.53 .237 -1.00 0.37 0.02, 3.53 .423 frequency of can use -0.01 0.99 0.94, 1.04 .671 -0.01 0.99 0.92, 1.05 .657 mental health and cannabis preand post-legalization 98 can legal status x can frequency of use 0.00 1.00 0.88, 1.12 .964 0.03 1.03 0.90, 1.17 .652 psychotic disorder age -0.01 0.99 0.95, 1.04 .800 0.00 1.00 0.95, 1.05 .945 gender 0.26 0.77 0.42, 4.89 .676 0.75 2.11 0.58, 10.02 .294 number of substances used 0.45 1.29 0.38, 1.53 .448 -0.41 0.66 0.30, 1.42 .296 age of first can use 0.16 1.17 0.95, 1.50 .184 0.25 1.28 0.99, 1.73 .078 can legal status -0.89 0.41 0.14, 1.11 .078 -2.41 0.09 0.01, 0.53 .010 frequency of can use 0.02 1.02 0.98, 1.07 .289 -0.01 0.99 0.93, 1.06 .866 can legal status x can frequency of use 0.08 1.08 0.98, 1.19 .111 0.10 1.10 1.00, 1.23 .595 note. ci = confidence interval. or = odds ratio. gender: negative β indicates a higher score for male participants. cannabis legal status: negative β indicates higher odds pre-legalization compared to post-legalization. unadjusted model statistics are reported for each regressor, in addition to statistics for the adjusted multivariate models. significant findings are indicated in bold. discussion compared to those who did not report using cannabis, the cannabis-using group had a higher proportion of males, tended to be younger, and used more variety of substances, suggesting that this is a group with unique demographic characteristics. legalization did not impact the proportion of people who used cannabis compared to those who did not. it is possible that legalization does not impact cannabis use status in a population that already uses illicit substances often. our findings suggest some similarities and some differences across self-reported symptoms and medical chart diagnoses. the significant associations of both cannabis use and number of substances used with self-reported depression, anxiety, and psychotic symptoms was as expected. in contrast to self-reported symptoms, cannabis use status did not significantly predict diagnoses except for schizophrenia spectrum disorders. the positive associations we found with mental health symptoms are relatively consistent with prior literature in other populations in which cannabis use has often been associated with worsened mental health (although some evidence is mixed; halah et al., 2016; halladay et al., 2020; hasan et al., 2020; lev-ran et al., 2013; lowe et al., 2018; van ours & williams, 2011). there are several epistemological theories as to why cannabis may be related to mental health: it may be due to shared risk factors for mental illness and cannabis use, the self-medication theory in which individuals use cannabis to cope with mental illness, negative causal effects of cannabis on mental health, or a combination of these (mueser et al., 1998). our findings indicate that this association is true even in individuals with severe concurrent substance use disorders and severe mental disorders. interestingly, cannabis use status was not associated with mood, anxiety, and schizophrenia spectrum disorder diagnoses in our study, despite it being associated with self-reported symptoms. it is possible that the assessments used are not valid, but the scl-90-r has been validated in more than 1000 studies, including studies with similar substance-using and psychiatric populations (e.g., benjamin et al., 2006; kostaras et al., 2020; grande et al., 2014), and clinician diagnoses are determined after extensive assessments. the discrepancy between findings for diagnoses and self-reported symptoms may be due to the binary nature of diagnoses compared to the continuous nature of a symptom score. also, symptoms may be subthreshold or captured under another diagnosis due to the transdiagnostic nature of many mental health symptoms. it is important to note that the scl-90-r is not intended as a diagnostic assessment, but rather to capture general distress as manifested by a range of symptoms (e.g., carrozzino et al., 2023; derogatis & unger, 2010). while differential diagnoses may not be determinable from the scl90-r, psychiatrists may be able to make more nuanced clinical judgments through more comprehensive assessment. alternatively, some of these symptoms may be determined by psychiatrists as attributable to substance (including cannabis) withdrawal or drug craving, in which case they would not qualify for a psychiatric diagnosis. anxiety and depressive symptoms are known effects of withdrawal from many substances. in wang et al. (2023), scl-90r scores including depression, anxiety, and cannabis, a publication of the research society on marijuana 99 psychoticism scores were positively associated with drug craving and negatively correlated with abstinent time in patients in treatment for drug withdrawal. in contrast, wetterling and junghanns (2020) found no significant relationships between scl-90-r scores and alcohol withdrawal symptoms. further research may be needed to elucidate how psychiatric symptoms are attributed to substance-related factors or to dsm-5 diagnosis. unlike some previous studies (patton et al., 2002; rup et al., 2021; van der pol et al., 2013), frequency of cannabis use was unrelated to outcomes. this may be due to a ceiling effect. the cannabis group in our sample used cannabis frequently compared to the general population. according to a national survey, most cannabis users use cannabis a maximum of three times in a typical month (government of canada, 2022), although past-30-day users report 14.2 days in the past month. in our sample, most of the cannabis use group used cannabis at least one day per week, with the average frequency of use being more than half of the days per month. also, while we expected earlier age of first use to be associated with higher self-reported mental health symptoms and with diagnostic status among people who used cannabis, this was not the case. surprisingly, later onset of cannabis use was associated with a higher likelihood of an anxiety disorder diagnosis, yet there is substantial literature that has found that early cannabis use increases the risk for adverse mental health outcomes. our differential findings may be due to the unique nature of our population. for example, in our sample, most participants’ age of onset of cannabis use was approximately 11 to 17 years old, with a mean of 14.1 years old, compared to the national average of 20.5 years (government of canada, 2022). this suggests that most of our participants would be considered early-onset users. one study of young adults found that cannabis use was only associated with poorer mental health in those who reported using cannabis to cope with distress (brodbeck et al., 2007), and another study (haug et al., 2017) found that young people are more likely to use cannabis to relieve boredom, while older adults are more likely to use cannabis for coping. there were a few contexts in which cannabis legal status impacted outcomes. people who used cannabis pre-legalization reported higher scl90-r anxiety scores compared to those who did not use cannabis pre-legalization. this was prerecreational cannabis legalization; medical cannabis was already legalized at this time. those who used cannabis pre-legalization may have been accessing medical cannabis to cope with anxiety-related symptoms, while those who did not have as severe anxiety symptoms were less likely to access medical cannabis. also, people who used cannabis post-legalization reported higher anxiety scores compared to those who used cannabis pre-legalization. the legalization of cannabis was associated with a decreased likelihood of a schizophrenia spectrum disorder diagnosis among people who used cannabis. this result was quite surprising. while we were unable to find specific data regarding the age of onset, changes in the availability of other drugs such as fentanyl and crystal meth may have replaced cannabis use in the often street-entrenched population served at red fish healing centre. this is speculative, as we were unable to find data to verify or dismiss this hypothesis. furthermore, results may have been confounded by other temporally related factors, such as the covid-19 pandemic (e.g., anxiety increased nationally during the pandemic; dozois & mental health research canada, 2021). cannabis legalization was otherwise unrelated to mental health outcomes. this could be explained by the overall limited changes in the prevalence of cannabis use in our sample. the legal status of a substance may not make a substantial impact on substance use in our sample, given that many of them have multiple substance use disorders, and that most substances used in our sample are controlled or illicit substances. also, medical cannabis, including for mental health symptoms, was widely available prior to the legalization of recreational cannabis, and the prevalence of cannabis use was already quite high in canada (rotermann, 2020). our sample may have already been accessing medical cannabis prior to recreational cannabis legalization. furthermore, a recent systematic review found mixed evidence for the relationship between cannabis legalization and mental health (walker et al., 2023). our findings regarding demographics further highlight the complexities of the relationships between substance use and mental health in individuals with concurrent disorders. in our mental health and cannabis preand post-legalization 100 study in a concurrent disorder population, men were more likely to be diagnosed with a mood disorder, despite other literature reporting that the prevalence of mood disorder diagnoses are at least equal, if not greater, in women (dell’osso et al., 2021; moreno-agostino et al., 2021). however, mood disorders are often underdiagnosed in men (whitley, 2021), and men tend to report more severe depression compared to women (shi et al., 2021). in a structured inpatient treatment centre that includes comprehensive mental health assessment at intake, it is possible that a mood disorder is more likely to be identified in men compared to other settings and that severe depression (which is more common in men) is more prevalent. patient age was not a significant predictor of diagnosis or self-reported symptoms in the whole sample, but older age predicted a mood disorder diagnosis within people who use cannabis. treatment options for mood disorders, especially depressive disorders, are relatively accessible compared to treatments for other disorders. because the treatment facility is tertiary, patients must have exhausted all other treatment options in the service region. it is possible that younger people with depression are first referred to other services, while older people with depression are more likely to have exhausted their treatment options and qualify for tertiary treatment. alternatively, clinicians generally may consider mood disorders to be less severe compared to some other disorders and may only refer patients with persistent, long-term depression to tertiary care, resulting in an older patient group with depression. people who use cannabis that are older may also be more likely to use cannabis for coping motives (haug et al., 2017), and thus their use may be more linked to mental health outcomes compared to younger adults (brodbeck et al., 2007). overall, the differential findings in this study may be due to the unique and complex nature of this population. people with severe concurrent disorders are frequently excluded from research. the vast majority of patients at the treatment centre are often homeless or in temporary housing without a permanent address, excluding them from population-based studies that use telephone or mail-based surveys. additionally, this sample draws from a psychiatric population with high comorbidity of mental health and substance use disorders (lee-cheong et al., 2021; schütz et al., 2013). while some studies sample from noninstitutionalized populations, studies involving psychiatric populations often focus on a single disorder or the relationship between two disorders, excluding those with additional comorbidities. this present sample represents an understudied population, and thus findings from previous studies may not reflect unique patterns of substance use and mental health in populations with severe concurrent disorders. limitations and future directions this study has some limitations. first, it is a cross-sectional study, and causality of the relationships cannot be established. retrospective data may be susceptible to recall bias. there were significant demographic differences between the cannabis use and non-use groups; however, all variables included in our regression models met the assumption of independence of observations. additionally, motives for use were not examined but may be a relevant mediator in the relationship between cannabis use patterns and mental health (brodbeck et al., 2007; glodosky & cuttler, 2020). further, there is vast heterogeneity of cannabis use behaviors (e.g., route of administration, dose, cannabinoids) that may have differential, or even interacting, effects, with potential individual differences that can modulate cannabis effects (atakan, 2012). lastly, cannabis legalization may be confounded by other temporally related factors, such as the covid-19 pandemic. longitudinal studies are needed to better elucidate directionality of these findings. other areas to examine further include cannabis use motives and differential use patterns that may mediate relationships between mental health and cannabis use. direct comparisons between inpatient populations and appropriate controls in the general population may be warranted to better understand divergent findings. lastly, multivariate analyses to examine interactions between cannabis use and more specific mental health and substance use outcomes may provide insight into relevant subgroups and interactions, including interactions between cannabis and other individual substances. conclusions cannabis, a publication of the research society on marijuana 101 cannabis has been proposed both as a therapeutic agent and a potential risk factor for mental health and substance use disorders. this study explored the associations between cannabis use and mental health outcomes in individuals with severe concurrent mental health and substance use disorders, a population often excluded from research. our results indicate that cannabis use in this group correlates with poorer self-reported mental health, though variations may exist depending on the age of onset of use and legal status. additionally, distinct demographic differences emerged in our analysis. these findings provide critical insights into the role of cannabis in mental health among a highly vulnerable population, particularly through direct comparisons of cannabis use before and after legalization. while some conclusions from broader population studies may be applicable to this subgroup, they are not universally generalizable, as evidenced by our results. individuals with severe concurrent disorders have unique risk profiles that warrant dedicated investigation, as substance use and its mental health impacts may differ from those in other populations. although cannabis is often considered of lower clinical concern compared to higher-risk substances, our study highlights its relevance to mental health discussions within substance-using populations. further research is essential to clarify differences between general and clinical populations and to better understand how cannabis use intersects with mental health in the context of severe concurrent disorders. references allick, a., park, g., kim, k., vintimilla, m., rathod, k., lebo, r., nanavati, j., & hammond, c. j. 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(2019). characterization of mental health in cannabis dispensary users, using structured clinical interviews and standardized assessment instruments. bmc psychiatry, 19(1), 1–12. https://doi.org/10.1186/s12888-019-2324-z funding and acknowledgements: this study was funded by the canadian centre on substance use and addiction (ccsa; gr018652). kat has received additional student funding support from the university of british columbia, brain canada, and the canadian institute of health research (cihr) canadian consortium of clinical trial training (cantrain). the authors would like to thank the study funders, research and medical staff, and the patients at red fish healing centre for mental health and addictions for making this research possible. cgs has received in-kind contributions from medipharm labs for an unrelated study. medipharm labs was not involved with this study. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: thiessen, k. a. & schütz, c. g. (2024). examining the relationship between cannabis use and mood, anxiety, and psychotic symptoms in psychiatric patients with severe concurrent mental health and substance use disorders before and after recreational cannabis legalization in canada. cannabis, 7(3), 90–105. https://doi.org/10.26828/cannabis/2024/000258 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ ved age-gating and marketing differences between storefront and non-storefront cannabis retailers cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000234 volume 8, issue 1 joshua u. rhee1, alisa a. padon2, lynn d. silver2, lingling li1, ethan n. k. nguyen1, jacob paredes1, & david s. timberlake1 1department of population health and disease prevention, program in public health, college of health sciences, university of california, irvine 2public health institute, oakland, ca abstract objective: the study investigated whether california storefront and non-storefront cannabis retailers are adhering to online age-gating requirements and whether differences in website marketing practices exist. methods: websites of 134 storefront and 115 non-storefront licensed retailers were randomly selected. bivariate associations were tested between retailer type and website marketing, age-gating methods, and presence of age-gating at various purchase stages. results: among the 200 (80.3%) websites with age-gating when entering, 182 (91%) employed an ineffective method where users click either “yes” or “no” to confirm their age. moreover, 49 (19.68%) websites lacked age-gating when entering. amongst those requiring photo identification during checkout (n = 100, 40.16%), 97% allowed users to proceed after uploading an irrelevant image. significantly more storefront retailers employed combined age-gating at entry, mandatory account registration, and age-gating during checkout than non-storefront retailers, x2 (1, n = 249) = 7.69, p < .01. retailer websites frequently displayed “clean” labels (n = 200, 80.32%), followed by positive state claims (n = 198, 79.52%), physical health claims (n = 166, 66.67%), and mental health claims (n = 146, 58.63%). significantly more storefront retailers displayed physical health claims, x2 (1, n = 249) = 7.52, p < .01, and health warnings than non-storefront retailers, x2 (1, n = 249) = 4.13, p = .04. conclusions: most cannabis retailers comply with age-gating requirements; however, methods employed are easily circumvented. youths’ easy and unrestricted access to cannabis retailer websites may increase positive attitudes about cannabis and encourage use. key words = cannabis; age-gating; storefront; marketing; policy 100 research article 100 age-gating and marketing of cannabis retailers 43 cannabis, a publication of the research society on marijuana as more states legalize cannabis, an increase in harmful cannabis and adolescent use is of great concern. nationally, cannabis vaping in the past 30 days among 12th graders increased steadily from 4.9% to 14.8% between 2017 and 2022 (johnston et al., 2023), and past-month overall cannabis use increased from 6% in 2003 to 10.9% in 2019 among adults (national survey on drug use and health, 2005; national survey on drug use and health, 2020). in california, a near doubling of cannabis use occurred during pregnancy over a decade, as well as major increases in cannabis-related emergency room visits and the tripling of daily use in adults (center for community research, 2022; padwa et al., 2022; young-wolff et al., 2022). public health advocates have argued that lax regulations have failed to properly restrict the promotion of cannabis use, which may exacerbate the increasing trend of cannabis use. as such, public health approaches are needed (barry & glantz, 2016; kilmer, 2014; padon et al., 2022; silver et al., 2020).corresponding author: joshua rhee, mph, department of population health and disease prevention, program in public health, college of health sciences, university of california, irvine, california, 92697, united states. email: rheeju@uci.edu. there is a legitimate concern that adolescents may be able to purchase cannabis via online retailers. in 2016/2017, most high school students in los angeles, ca obtained cannabis either for free (72.1%) or by purchasing it from others (50.9%), while only a few used a fake identification (id) (3.1%) or online delivery service (1.7%) (kelleghan et al., 2022). however, the mode of obtaining cannabis may have shifted due to the passage of california’s proposition 64, the adult use of marijuana act, which legalized retail sales of cannabis on january 1, 2018. the prior study utilized data from 2016-2017, which is before the 2019 allowance of both medicinal and recreational cannabis deliveries in all jurisdictions in california. since proposition 64’s implementation, the downward trend of cannabis use among adolescents has shifted, where cannabis use among high-schoolers has increased (paschall et al., 2021). given that research has shown that there is increased cannabis use by youth within areas with denser legal retail storefronts (borodovsky et al., 2017) and when youth have closer proximity to storefronts (albers et al., 2024), creation of an expanded retail storefront and delivery infrastructure, especially when age verification or id checks are flawed, could lead to the expanded adolescent use of fake id and use of online delivery services. the reduced surveillance of compliance at the point of cannabis delivery compared to at a brick-and-mortar storefront may be attractive to adolescents interested in obtaining cannabis from a legal retailer. these concerns warrant an examination of online age verification methods used by licensed cannabis retailers. california requires age confirmation (i.e., age-gating), such as a simple pop-up message to confirm legal age, before engaging in any communication with patrons on retail websites (cal. bus. & prof. code § 26151, 2017). california regulation also states that to effectuate a sale of adult-use cannabis, including an online sale, a licensed retailer must verify a government-issued identification (cal. code regs. tit. 4, § 15404, 2024). exposure to online and traditional cannabis marketing has been associated with positive attitudes toward cannabis, lower perceptions of harm, and substantial increases in past year cannabis use among exposed adolescents (cohn et al., 2023; trangenstein et al., 2019; whitehill et al., 2020). some states have placed restrictions on the online marketing of cannabis (colo. code regs. § 212-3-720, 2024; wash. rev. code § 69.50.369, 2022). additionally, cannabis licensees may not publish or disseminate health-related advertising that is untrue or leads to misleading impressions regarding the health effects of cannabis consumption (cal. bus. & prof. code § 26154, 2017). although age-gating regulations are in place to curb minors’ exposure to online cannabis marketing and sales, compliance with these rules and the effectiveness of current age-gating methods are unclear. further, retailers’ adherence to health claims regulations has been shown to be inconsistent. two-thirds of cannabis retailer websites from 10 u.s. states with legal markets displayed health claims and over half had claims of benefits of using cannabis with little or no evidence (cavazos-rehg et al., 2019). in a more recent study of five cities, more than 90% of retailers endorsed use for anxiety, insomnia, and/or pain, and 54.3% for pregnancy associated nausea (romm et al., 2024). only a handful of researchers have estimated the prevalence of age-gating practices among cannabis retail websites. bierut and colleagues (2017) found that 41% of retailers in colorado and 35% in washington lacked any form of age verification, which is likely due to the lack of age-gating requirements in both states (colo. code regs. § 212-3-720, 2024; wash. rev. code § 69.50.369, 2022). cavazos-rehg et al. (2019) found that among randomly selected retailer websites across the u.s., 75% had no form of age-gating in 2016. in contrast, madson (2022) found that 90% of retailer websites in arizona, where age verification is required (ariz. rev. stat. § 36-2859, 2024), employed some form of age-gating in 2022. it is possible that storefront retailers, who are allowed to sell products online or at a physical store in california, may be more likely to comply with regulations to reduce the risk of license suspension, a costly risk given the high overhead and operational costs for running a physical location. non-storefront retailers, who are only allowed to sell via delivery, may focus less on age-gating patrons at the initial entry to their website, and more on age verification during the checkout process. the present study aims to test for differences between storefront and non-storefront cannabis retailer website marketing practices and adherence to california’s age-gating requirements. given the increasing accessibility of legal cannabis for both adults and adolescents, continued monitoring of industry adherence to marketing restrictions and age-verification methods is needed. since specific retailer characteristics may correlate with adherence to the regulations, identifying such characteristics may help improve policies or enforcement efforts. to our knowledge, there has been no previous research investigating differences in age-gating or marketing practices between websites of storefront and non-storefront cannabis retailers. methods seletion of retailer websites the full set of cannabis retailers legally operating as of october 2022 in california was obtained from the state’s department of cannabis control (dcc). types of retailers included businesses with a type 9 (non-storefront) retail license and microbusinesses with a non-storefront license were categorized as non-storefront cannabis retailers. those with a type 10 (storefront) retail license and microbusinesses with a storefront license were categorized as storefront cannabis retailers. non-storefront retailers are restricted to sales via delivery only, while storefront retailers may sell at a physical location and by delivery (department of cannabis control, n.d.). utilizing a chi-square test, a minimum sample of 113 storefront and 113 non-storefront cannabis retailers was estimated to be sufficient to detect a statistically significant bivariate association (mchugh, 2013; serdar et al., 2021; sullivan & feinn, 2012) based on the following parameters: 1-β of .85, w of 0.2, df of 1, and α of .05. however, we chose a slightly larger stratified random sample of 134 storefront and 115 non-storefront retailers (n = 249) for the analyses. standalone websites, which are operated by the retailer, were found by utilizing both their legal business name and doing-business-as (dba) name from the dcc database. standalone websites were searched by inputting the respective business name in the google search engine and were checked by cross-referencing their physical store location or delivery boundaries, business email, business phone number, and business license number in the dcc database. retailers without a standalone website or those who only used third-party retailer websites (e.g., www.weedmaps.com) were replaced by another storefront or non-storefront retailer randomly selected from the dcc database. coding of the selected websites was carried out in october, 2022 algorithim & coding procedures a prototype algorithm based on work by barry et al. (2021) and jones et al. (2014) on alcohol retailers was modified for the present project. a total of three coders were trained in coding cannabis retailer websites utilizing the prototype algorithm. during this training process, the prototype algorithm was iteratively adjusted until no further variables were added or removed due to strong inter-rater reliability. the coders had an average pairwise cohen’s ⲕ of 0.844 for all 35 coded variables. the algorithm was designed to first code for the presence and type of initial age-gating, which is age-gating occurring when entering the website (see appendix a). coders would deliberately fail the age-gating process and record whether they were properly blocked from progressing onto the website. if initial age-gating was present, the visibility of health claims or health warnings during or before initial age-gating was recorded, to assess whether dialogue from the retailers began before age confirmation. regardless of whether age-gating was present, coders visited every page on the retailer’s website to also code for the presence of physical health claims, mental health claims, positive state messages, “clean” labels, and health warnings. next, we additionally coded the type of age-gating employed during checkout (e.g., required upload of photo id), the consequences of failing those age-gating methods (e.g., inputting an underage date of birth), use of a third-party web payment system, and retailer’s exclusive use of a customer pick-up service. furthermore, the presence of mandatory account registration, where retailers require patrons to create an account to proceed within their website, which may also act as an additional form of age-gating prior to sale in california, was also coded (see appendix b). completion of cannabis purchases was not assessed in this study. health claims, positive states, and clean labels health claims were coded into two categories: (1) physical health claims were defined as any statement or imagery that describes or insinuates a reduced risk of a physical disease or alleviation of a physical health-related condition (e.g., physical pain, cancer), including sleep-related disturbances (e.g., insomnia) (hoeper et al., 2022). (2) mental health claims describe or imply a relationship between cannabis and alleviation of a psychological health-related condition or mental illness (e.g., anxiety) (hoeper et al., 2022). “positive state” was coded for any statement or imagery suggesting that cannabis use induces positive emotions (e.g., zen, wellness, well-being). sites were categorized as displaying “clean labels” if any terms or visuals conveyed one or more of the following properties: (1) minimal industrial processing or plant modifications (e.g., non-gmo); (2) reduced health risk (i.e., gluten-free); (3) animal cruelty-free testing; (4) environmental consciousness (e.g., organic); (5) absence of contaminants or additives (e.g., pesticide-free); or of (6) high quality (asioli et al., 2017; negowetti et al., 2022). data analysis univariate (frequency) and bivariate (chi-square test of independence) methods were used to examine each coded variable by type of retailer (storefront/non-storefront). the following composite variables were also tested for their association with retailer type: (1) presence of physical and/or mental health claims; (2) implementation of initial age-gating and/or mandatory account registration; (3) implementation of initial age-gating, age-gating during checkout, and mandatory account registration; (5) requiring either a photo id or id number during the mandatory account registration or checkout process; and (6) requiring a photo id during mandatory account registration or checkout. a fisher’s exact test was used for variables that had expected cell frequencies of less than five by retailer type (mccrum-gardner, 2008). results descriptive statistics initial age gating. two hundred websites (80.32%) had initial age-gating; among them, 174 utilized age-gating immediately upon entering the homepage and 26 when entering their product page. the remaining 49 (19.68%) had no form of initial age-gating. among retailers with initial age-gating, most (n = 182) employed a simple method of having users click either a “yes” or “no” button to confirm they are of legal age to use cannabis products (21+, in some cases providing an option for 18+ with a medical card), followed by those only offering a “yes” option to confirm their legal age (n = 15). among the websites that had either a simple (i.e., yes/no) or manual date-of-birth (dob) entry age-gating system, three websites asked visitors to reconfirm their response when deliberately failing the age-gating, while one site allowed immediate website access even after deliberately failing the age-gating test. age gating during account registration. of the 249 websites, 105 (42.17%) required account registration at some stage in the process. only 56 (53.3%) of these required users to upload a driver’s license and 10 (9.50%) required a driver's license number. of the 249 retailers, 215 (86.35%) had either initial age-gating or required a later mandatory account registration to proceed, 90 (36.14%) implemented both initial age-gating and an account registration system only, and 121 (48.59%) comprehensively implemented initial age-gating, age-gating during checkout, and mandatory account registration. while 164 (65.86%) retailers required a driver’s license or id number during the checkout process or mandatory account registration, one-third of retailers did not require any documentation, and this did not differ significantly by retailer type. see appendix c for more descriptive statistics on age-gating and marketing behaviors stratified by retailer type. table 1. prevalence and bivariate associations of website age-gating practices by storefront and non-storefront cannabis retailers operating in california, 2022 characteristic storefront retailers non-storefront retailers total chi-squaref p-value cramér's v age-gating and age-gating type n = 134 (% of total storefront retailers) n = 115 (% of total non-storefront) n = 249 (% of all retailers) initial age-gating implemented 112 (83.58%) 88 (76.52%) 200 (80.32%) 1.53 .22 0.08 no initial age-gating implemented 22 (16.42%) 27 (23.48%) 49 (19.68%) 1.53 .22 0.216 initial age-gating type: ‘yes’ or ‘no’ option 100/112 (89.29%)a 82/88 (93.18%)a 182/200 (91%)a 0.50 .48 0.05 initial age-gating type: only ‘yes’ option 9/112 (8.04%)a 6/88 (6.82%)a 15/200 (7.50%)a 0.003 .96 .004 initial age-gating effectiveness immediate restricted access when deliberately failed at initial age-gating 102/103 (99.03%)b 82/82 (100%)b 184/185 (99.46%)b 0.08 .78 0.02 allowed entry by deliberately passing initial age-gating followed by failed attempt 100/103 (97.09%)b 81/82 (98.78%)b 181/185 (97.84%)b 0.17 .68 0.03 age-gating at checkout presence of age-gating during checkout 94 (70.15%) 54 (46.96%) 148 (59.44%) 11.85*** < .001 0.22 checkout age-gating: upload photo identification 50/94 (53.19%)c 50/54 (92.59%)c 100/148 (67.57%)c 0.95 .33 0.06 checkout age-gating: input identification number 12/94 (12.77%)c 10/54 (18.52%)c 22/148 (14.86%)c 0.00 .99 0.00 effectiveness of age-gating at checkout unable to proceed after deliberately failing age-gating during checkout 67/94 (71.28%)c 35/54 (64.81%)c 102/148 (68.92%)c 0.19 .66 0.04 unable to proceed after uploading an irrelevant photo identification 0/50 (0%)d 3/50 (6%)d 3/100 (3%)d age-gating during mandatory account registration & type mandatory account registration required 40 (29.85%) 65 (56.52%) 105 (42.17%) 16.98*** < .001 0.26 account registration age-gating: upload photo identification 19/40 (47.50%)e 37/65 (56.92%)e 57/105 (53.33%)e 0.55 .46 0.07 account registration age-gating: input identification numberg 5/40 (12.50%)e 5/65 (7.69%)e 10/105 (9.52%)e 0.59 .50 combined initial age-gating & signup implemented either initial age-gating or mandatory account registration 115 (85.82%) 100 (86.96%) 215 (86.35%) 0.01 .94 0.01 implemented both initial age-gating and mandatory account registration 37 (27.61%) 53 (46.09%) 90 (36.14%) 8.37** < .01 0.18 implemented initial age-gating, age-gating at checkout, and mandatory account registration 77 (57.46%) 44 (38.94%) 121 (48.59%) 7.69** < .01 0.18 required identification number or photo identification at either the mandatory account registration or checkout process 77 (57.46%) 87 (75.65%) 164 (65.86%) 0.04 .84 0.02 required photo identification at the mandatory account registration and checkout process 0 (0%) 0 (0%) 0 (0%) note. percentages in each cell were calculated using the total number of retailers of the respective type (storefront retailers n = 134, non-storefront retailers n = 115) apart from those marked “a” where percentages were calculated by dividing the frequency counts of each coded variable by the total number of respective retailer type which implemented initial age-gating (storefront n = 112, non-storefront n = 88); those marked “b” where percentage of the respective frequency counts of the variable by retailer type which implemented initial age-gating, excluding those which only had the ‘yes’ option type of age-gating (storefront n = 103, non-storefront n = 82); those marked “c” where percentage of respective frequency counts of the variable by retailer type which had any presence of age-gating during checkout (storefront n = 94, non-storefront n = 54); those marked “d” where percentage of the respective frequency counts of the variable divided by the number of each retailer type which required uploading a photo id during the checkout process (storefront n = 50, non-storefront n = 50); and those marked “e” where percentage of respective frequency counts of the variable divided by the number of each retailer type which required mandatory signup to proceed with navigating the website (storefront n = 40, non-storefront n = 65); fpresented chi-square tests of independence had one degree of freedom. significance at the level: *p < .05; **p < 0.01; ***p < .001. gfisher exact test utilized where odds ratios are reported within the chi-square test effect size instead. cramer’s v are reported for chi-square tests to observe substantive significance, but were omitted for variables which utilized the fisher exact test. consequences of a failed age-gating test. among the websites with initial age-gating (n = 200), excluding those with the “yes” only type of initial age-gating (n = 15), a failed age-gating test frequently redirected users to the google search engine (n = 55). nine websites either redirected users to entertainment websites catering to children (e.g., nickelodeon) or websites selling children’s clothes (e.g., cookie monster shirts). among the 148 websites which had one or more age-gating methods implemented during checkout, 31% of them still allowed the user to proceed after deliberately failing the age-gating. among the 100 retailers which required photo id as part of their implemented age-gating methods during checkout, 97% allowed users to still proceed with the checkout process even after uploading an irrelevant document. health claims, positive states, clean labels, and health warnings. among the 249 retailer websites, 166 (66.67%) had physical health claims, 146 (58.63%) had mental health claims, and 179 (71.89%) had either physical or mental health claims located anywhere on their website. physical health claims commonly referred to improving sleep or relieving sleep-related conditions and chronic pain, but others mentioned cannabis for the treatment or relief of asthma, allergies, diabetes, cancer, human immunodeficiency virus, headaches, multiple sclerosis, arthritis and so on. mental health claims commonly referred to relieving stress, anxiety, and depression, but also for managing obsessive-compulsive disorder, post-traumatic stress disorder, and bipolar disorder. a total of 198 websites (79.52%) had a positive state claim on their website, often used when describing their displayed products. the following were common keywords used to imply an induced positive state from using cannabis: blissful, calming, creative, elevated, energizing, euphoric, focused, giggly, invigorating, and uplifting. next, 200 websites (80.32%) had one or more clean labels. clean labels were also often used to promote displayed products. the following were common clean label words utilized: all-natural, clean, ethically grown, hand-grown, natural, organic, and pesticide-free. lastly, only 27 websites (10.84%) displayed health warnings, most often california’s mandatory proposition 65 cancer warning and statement on reproductive harm. among the 200 retailer websites with initial age-gating, 42 (21%) had physical health claims or mental health claims visible prior to or during the age-gating process. four websites (2%) had health warnings visible prior to or during the age-gating process. bivariate associations a significant association was observed between retailer type and age-gating practices. a higher percentage of storefront retailers employed a combination of all three age-gating types (i.e., initial, during checkout, and mandatory account registration) than non-storefront retailers (57.46% vs. 38.94%, x2 (1, n = 249) = 7.69, p < .01). however, a higher percentage of non-storefront retailers employed age-gating during checkout (70.15% vs. 46.96%, x2 (1, n = 249) = 11.85, p < .001) and employed the slightly weaker combination of two methods, initial age-gating and mandatory account registration than storefront retailers (46.09% vs 27.61%, x2 (1, n = 249) = 8.37, p < .01). no significant differences were found in the practice of requiring photo id or id numbers during the mandatory account registration or checkout process between storefront and non-storefront retailers. among the stores that required mandatory account registration, none required a photo id to be uploaded during checkout. no significant association was detected between storefront and non-storefront retailers for the initial age-gating practices or displaying health claims, clean labels, or health warnings during or before the initial age-gating process. however, significantly more storefront retailers displayed physical health claims (74.63% vs. 57.39%, x2 (1, n = 249) = 7.52, p < .01), any type of health claim (79.10% vs. 63.48%, x2 (1, n = 249) = 6.72, p = .01), and health warnings (14.93% vs. 6.09%, x2 (1, n = 249) = 4.13, df = 1, p = .04) on their website compared to non-storefront retailers. storefront retailers also had more positive states displayed compared to non-storefront retailers, but did not reach significance (x2 (1, n = 249) = 3.51, df = 1, p = .06). see table 2 for more chi-square test results and their respective cramér's v effect sizes. table 2. prevalence and bivariate associations of different health claim practices by storefront and non-storefront cannabis retailers operating in california, 2022 characteristic storefront retailers non-storefront retailers total chi-squareb p-value cramér's v health claims by type n = 134 (% of total store front retailers) n = 115 (% of total non-storefront) n = 249 (% of all retailers) health claims or clean labels visible at initial age-gating 20/112 (17.86%)a 22/88 (25%)a 42/200 (21%)a 1.12 .29 0.07 health warnings visible at initial age-gatingc 2/112 (1.79%)a 2/88 (2.27%)a 4/200 (2%)a 1.18 .99 presence of physical health claims 100 (74.63%) 66 (57.39%) 166 (66.67%) 7.52** < .01 0.17 presence of mental health claims 80 (59.70%) 66 (57.39%) 146 (58.63%) 0.06 .81 0.02 presence of both health claims 74 (55.22%) 59 (51.30%) 133 (53.41%) 0.24 .62 0.03 presence of either health claims 106 (79.10%) 73 (63.48%) 179 (71.89%) 6.72** .01 0.03 health warnings, clean labels, and positive states presence of positive state claims 113 (84.33%) 85 (73.91%) 198 (79.52%) 3.51 .06 0.12 presence of clean labels 108 (80.60%) 92 (80%) 200 (80.32%) 0.00 .99 0.00 presence of health warnings 20 (14.93%) 7 (6.09%) 27 (10.84%) 4.13* .04 0.13 note. percentages in each cell were calculated using the total number of retailers of the respective type (storefront retailers n = 134, non-storefront retailers n = 115) apart from those marked with “a” where percentages were calculated by dividing the frequency counts of each coded variable by the total number of respective retailer type which implemented initial age-gating (storefront n = 112, non-storefront n = 88). significance at the level: *p < .05; **p < 0.01; ***p < .001. bpresented chi-square tests of independence had one degree of freedom. cramer’s v are reported for chi-square tests to observe substantive significance. cfisher exact test utilized where odds ratios are reported within the chi-square test effect size instead. cramer’s v are reported for chi-square tests to observe substantive significance, but were omitted for variables which utilized the fisher exact test. discussion findings indicate that storefront and non-storefront cannabis retailers predominantly employed some method of age-gating and mandatory account registrations; yet, the former used more comprehensive age-gating methods than the latter. nevertheless, age-gating methods employed by either retailer were likely ineffective as a prospective customer could easily bypass these measures. health claim messages were often visible to patrons prior to and during the age-gating process. one in five retailers used no form of age-gating, failing to prevent access to home page or product page cannabis marketing. further, one-third did not require any documentation of age at registration or checkout, suggesting significant levels of noncompliance with legal requirements. irrelevant photos submitted for photo ids were almost universally accepted. health claims of varying types were also widely displayed, especially physical health claims among storefront retailers. lastly, the provision of any relevant health warnings on the use of cannabis and cannabis products overall was rare, especially among non-storefront retailers. the utilization of initial age-gating by both storefront (83.58%) and non-storefront (76.52%) retailers, albeit using weak methods, differs from findings of prior studies. bierut et al. (2017) reported that roughly 59% and 65% of adult-use cannabis retailers in colorado and washington, respectively, implemented some form of initial age-gating. given their data was from 2015, cannabis retailers may have expanded implementation of age-gating systems since legalization. moreover, colorado and washington do not explicitly require age confirmation of patrons visiting cannabis retailer websites but only require online retailers to limit marketing to patrons 21 or older (colo. code regs. § 212-3-720, 2024; wash. rev. code § 69.50.369, 2022). thus, age-gating for online retailers located in colorado and washington is more of an indirect suggestion, differing from california’s explicit requirements on website age-gating (cal. bus. & prof. code § 26151, 2017). although most storefront and non-storefront retailers properly blocked website access after failing the initial age-gating (99.03% and 100%, respectively), a prospective customer could simply change their response to enter, further illustrating the ineffectiveness of these allowed age-gating methods. similarly, even when moving through the site to the mandatory account registration and checkout phase, uploading documentation was not required by one-third of retailers, and uploading irrelevant images was accepted, suggesting that systems can easily be circumvented by minors. although age-gating has been used by other industries (e.g., alcohol), its effectiveness has been questioned by researchers (barry et al., 2021; madson, 2022; williams et al., 2015; williams & ribisl, 2012). this should sound the alarm for regulators, policymakers, parents, and industry alike on the need to implement a more effective system to prevent minors from accessing online cannabis marketing. a more stringent age verification method for online purchases, such as required use of independent third-party sites for verification of a government-issued id should be considered, similar to that recommended in the previous united states food and drug administration’s (fda) guidance for e-cigarettes (fda, 2020) and by the online gambling industry (nash et al., 2015). moreover, states could consider implementing practices used in tobacco and alcohol control to discourage retailers from selling to minors, such as minor decoy operations (cal. bus. & prof. code § 22590, 2024). a complete prohibition of delivery is also an option, such as that adopted in 2021 by oregon for tobacco, after concluding that enforcement was more feasible in the storefront environment (or. admin. r. 845-025-1300, 2024). despite the limited evidence on the medicinal benefits of cannabis for health-related outcomes, past research has found cannabis retailers use a wide array of health claims to market cannabis on websites (bierut et al., 2017; boatwright & sperry, 2020; hoeper et al., 2022). in this study, nearly 67% of all retailers displayed physical health claims, and 59% displayed mental health claims. moreover, storefront retailers were more likely to display physical health claims compared to non-storefront retailers. in addition, clean labels were widely used to market cannabis products (80.32%). clean labels have been used previously by the tobacco industry to market cigarettes (e.g., american spirit) (dewhirst, 2022) and e-cigarettes (phua et al., 2018). the fda recognized that promoting cigarettes using clean labels misled adolescents into initiating tobacco use (iles et al., 2021; moran et al., 2021), and prohibited clean labeling of tobacco products in 2017 (neuhauser & simoneau, 2017). cannabis retailers appear to be taking full advantage of the lack of regulation of ‘clean’ labeling claims for cannabis products. in addition, the vast majority (80%) of retailers used positive states to promote their products, which may affect youth in particular. adolescents have been shown to favor advertisements appealing to positive experiential outcomes (chen & yoon, 2021; nash et al., 2009; padon et al., 2018) and may be more receptive to messages that suggest a positive emotional experience (pechmann et al., 2005). our study also reveals that non-storefront websites are significantly less likely to display health warnings on the use of cannabis. public health advocates have strongly recommended the need for clear and comprehensive health warnings similar to those proposed by fda for cigarette packages and used globally (fda, 2021; cal. legis. assemb. s. b. 1097. reg. sess. 2021-2022, 2022). the state of california only requires a 6-point-font warning on or inside of cannabis product packages, but some cities and counties have implemented additional warning requirements for local storefront and non-storefront retailers, such as posting warnings in stores or handing them out at delivery (padon et al., 2022). strengths and limitations to our knowledge, this is one of the first studies to compare age-gating and marketing behaviors of storefront and non-storefront cannabis retailer websites. it also examines a representative sample of retailers in a more mature legalized market compared to earlier studies (bierut et al., 2017; cavazos-rehg et al., 2019). however, a few limitations should be noted. first, the current study was limited to analyzing standalone retailer websites, not encompassing retailers utilizing solely 3rd party websites (e.g., weedmaps). secondly, we assessed neither age verification during final checkout, nor confirmation of physical documentation of age upon pickup or delivery, as federal research restrictions precluded purchasing cannabis. these would provide more comprehensive verification of rigor of age confirmation for purchase. lastly, this study only examined legal cannabis retailers. it did not capture online marketing of the illicit cannabis sector or the growing sector of hemp-derived psychoactive cannabis products which have no age requirement for sale in california. conclusion the present study contributes to the nascent body of research on the cannabis retail market, which operates extensively online with limited enforcement of required age-gating and marketing restrictions. findings suggest that roughly one-fifth of cannabis retailers are not complying at all with minimum legal requirements for age-gating, and most existing practices are easily circumvented. rigorous fda-recommended practices, such as third-party verification of identification, are not widely used. lastly, significant differences in age-gating and health marketing practices between storefront and non-storefront retailers were identified. use of weakly regulated and monitored health claims, positive states, and clean labels is widespread. altogether, easy access to cannabis retailer websites and exposure to cannabis marketing messages and claims may increase positive adolescent attitudes about cannabis, and encourage underage use. results call for government officials in california to improve regulation and enforcement of the content of online cannabis marketing, and of the guardrails that prevent underage access to the marketing and sales. references albers, l., rogers, c. j., steinberg, j., vos, r. o., soto, d., lee, r., wu, s. w., & unger, j. b. 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(2012). internet alcohol sales to minors. archives of pediatrics & adolescent medicine, 166(9), 808-813. https://doi.org/10.1001/archpediatrics.2012.265 young-wolff, k. c., sarovar, v., tucker, l., ansely, d., goler, n., conway, a., ettenger, a., foti, t. r., brown, q. l., kurtzman, e. t., adams, s. r., & brown, q. l. (2022). trends in cannabis polysubstance use during early pregnancy among patients in a large health care system in northern california. jama network open, 5(6), article e2215418. https://doi.org/10.1001/jamanetworkopen.2022.15418 funding and acknowledgements: no conflicts of interest are declared by the authors. the authors thank the california department of cannabis control for funding this study (rg-1603164402-80) and providing the list of licensed cannabis retailers to conduct the study. we also thank bethany j. simard, m.p.h., aurash jason soroosh, m.s.p.h., r.d., and cornelia pechmann, ph.d. for their assistance on the methodological aspects of our study. the present study was funded by the california department of cannabis control (rg-1603164402-80). copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: rhee, j. u., padon, a. a., silver, l. d., li, l., nguyen, e. n. k., paredes, j., & timberlake, d. s. (2025). age-gating and marketing differences between storefront and non-storefront cannabis retailers. cannabis, 8(1), 95-108. https://doi.org/10.26828/cannabis/2024/000234 issue date: february 1, 2025 image2.tiff image1.png image10.png brief report 23 ved abstract introduction: risky alcohol use patterns, characterized by heavy episodic drinking (hed) and alcoholinduced blackout, are prevalent in college students. however, it is not clear if experiencing hed and blackout among college-attending cannabis users heightens risk for adverse cannabis use consequences. the purpose of this study was to examine whether heavy episodic drinking and blackout episodes moderate the relationship between cannabis consumption and cannabis use consequences among college students. methods: undergraduate college students (n = 4331) were recruited from a midwest university in 2021. this analysis used a subset of data from past 6-month cannabis users (n= 772; 17.8% of the full sample). among cannabis users, 64.5% identified as female and 87.8% were white with an average age of 19.99 (sd=2.88). a linear regression was conducted with two two-way interactions of cannabis consumption and hed frequency as well as cannabis consumption and alcohol-induced blackout episodes. results: results showed a statistically significant positive association between cannabis consumption and cannabis use consequences (b=0.73, p<.001), adjusting for the other variables in the model. blackout, but not hed, was a significant moderator (b=0.19, p=.003). discussion: the findings of this study indicate that blackout experiences amplify the relationship between cannabis use and cannabis-related consequences among college students. this underscores that blackouts not only signal a risk of problematic drinking but also exacerbate the association between cannabis use and its negative consequences. conclusion: findings may inform college campus interventions targeting cannabis and alcohol concurrent-users who experience alcohol-induced blackouts to reduce their additional risk for cannabis-related consequences. key words: cannabis consumption; cannabis use consequences; heavy episodic drinking (hed); alcoholinduced blackout; college undergraduate students cannabis use is prevalent among college students (patrick et al., 2022). according to a national report, 24% of young adults aged 18 to 25 years consumed cannabis in the past month, which is the highest prevalence compared to other age groups (samhsa, 2022). of concern, cannabis use is associated with a range of adverse consequences including cannabis-related motor vehicle accidents (hammond et al., 2020), mental illness (hosseini & oremus, 2019), physical health and sleep problems (tuvel et al., 2023), and cannabis use disorder (connor et al., 2021). ying guo1, chia-liang dai1, rose marie ward2, w. alex mason3 1university of nevada, las vegas 2university of cincinnati 3university of nebraska-lincoln cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000193 the interaction of cannabis consumption with heavy episodic drinking and alcoholinduced blackouts in relation to cannabis use consequences among recent undergraduate college cannabis users corresponding author: ying guo, ph.d., university of nevada-las vegas, school of public health, 4700 s. maryland parkway, suite #335, las vegas 89119. email: ying.guo@unlv.edu. cannabis, a publication of the research society on marijuana 24 however, a significant portion of the variance in cannabis use negative consequences is unexplained by cannabis consumption alone (pearson, 2019), which underscores the need for a broader array of risk factors to comprehensively understand the etiology of such consequences among cannabis users. one pivotal aspect to consider is the use of other substances, particularly alcohol. alarming rates of alcohol use, including heavy episodic drinking and alcohol-induced blackouts, persist among college students throughout the united states (mundt & zakletskaia, 2012; siqueira & smith, 2015). based on the 2021 national survey on drug use and health (nsduh), nearly half (49.3%) of full-time college students (18 to 22 years old) reported alcohol consumption within the past month, with approximately 27.4% engaging in heavy episodic drinking (niaaa, 2023). notably, approximately 50% of college students who consume alcohol report experiencing one or more episodes of alcoholinduced blackout during their lifetime (mundt & zakletskaia, 2012). heavy episodic drinking (4/5 drinks for women/men) (white & hingson, 2013) is associated with significantly graver outcomes in contrast to moderate or light alcohol consumption (hingson & white, 2012), including incidents as severe as sexual assaults and fatalities (siqueira & smith, 2015). alcohol-induced blackouts (davis et al., 2021) serve as a significant marker of problematic drinking behavior (hingson et al., 2016), denoting episodes of anterograde amnesia induced by alcohol consumption (white, 2003). during a blackout, individuals remain conscious but lack memory retention of their actions (lee et al., 2009), potentially engaging in activities without recollection. this phenomenon has adverse impacts on cognitive and behavioral functioning, ranging from suicide ideation to increased risk of injury and alcohol dependence (bae et al., 2015; hingson et al., 2016; studer et al., 2019). concurrent use of both cannabis and alcohol refers to using both substances within a specified time frame (though not necessarily simultaneously). such use is common among college students (gonçalves et al., 2022; gunn et al., 2022; hai et al., 2022; jackson et al., 2020; lee et al., 2022) and the bulk of studies have shown that the concurrent use of cannabis and alcohol among college students increases risk for alcoholrelated negative outcomes (davis et al., 2021; stevens et al., 2022). concurrent use also may be associated with heightened risk for negative cannabis-related consequences (hammond et al., 2020). a study conducted by barnwell and colleagues (2005) found a stronger positive association between cannabis consumption and cannabis dependence among undergraduate college students who also engaged in more frequent or high quantity alcohol use. this finding suggests that higher risk patterns of alcohol use might operate as a moderator of the link between cannabis use and cannabis-related outcomes among college students. while research on the concurrent use of cannabis and alcohol among college students is growing (e.g., linden-carmichael & wardell, 2021), the extent to which multiple manifestations of alcohol use, especially those involving higher risk drinking behaviors like heavy episodic drinking and blackouts, heighten the risk for adverse cannabis-related consequences among cannabis users remains a critical gap. understanding which types of alcohol use pose the greatest risk for cannabis users can inform screening and referral efforts aimed at preventing cannabis-related harms among those most susceptible. thus, the purpose of this study is to examine whether past 30-day heavy episodic drinking and past 30-day blackout episodes moderate the relationship between cannabis consumption and cannabis use consequences among college students. it is expected that both greater heavy episodic drinking and greater blackout episodes will exacerbate the relationship between cannabis consumption and cannabis use consequences. methods participants and procedures the researchers recruited undergraduate college students (n=4331; 20.3% response rate) from a midwest university in 2021. participants were predominantly female (65.7%) and white (82.2%) with an average age of 20.3 (sd=4.35). this study used a subset of data from all past 6month cannabis users (n=772; 17.8% of the full sample). among cannabis users, 64.5% (n=492) identified as female, 32.9% (n=251) as male, and 2.6% (n=20) as other genders including 0.3% (n=2) cannabis, heavy drinking, and consequences 25 transwoman, 2.3% (n=18) as genderqueer/gender non-conforming. overall, 87.8% were white (n=675), 3.3% (n=25) were black, 2.6% (n=20) were asian, and 1.2% (n=9) were other race; 5.2% (n=40) were multi-race. average age of the subsample was 19.99 (sd=2.88). the survey included a selection of measures of alcohol use, cannabis use, other substance use, sexual assault experiences, and mental health issues. to minimize response burden, only a random sample of the participants received all of the measures in this study (i.e., planned missingness). upon completion of the survey, students received a $3 coupon for a local coffee shop. this study was approved by the university’s internal review board. measures demographics. age, gender, and race were included in the analysis as covariates. age was measured by asking “what is your age?” gender was measure by asking “what is your current gender identity?” with response options (0=woman/female, 1=man/male, 2=transwoman, 3=transman, 4=genderqueer/gender nonconforming, 5=a gender not listed here, 7= prefer not to answer, 8=intersex). gender was recoded into 3 categories with 0=female, 1=male, and 2=other, 5 and 7 were coded as missingness, and then two dummy variables were created with female as the reference group. race was measured by asking each respondent to “describe your race/ethnicity. please check all that apply.” response options included black/african american, american white/caucasian, asian or asian american, hawaiian or pacific islander, native american or alaskan native, and other. to capture race, analyses included 6 dummy-coded variables with white as the reference group. furthermore, since some students selected more than one race, a count variable was created by adding all the categories to identify students with multiple racial identities and then dichotomized to reflect multi-race (coded 1) or not (coded 0) for use as an additional covariate. cannabis use. cannabis use was measured by one question “have you used any cannabis (i.e., marijuana) over the past six months?” with responses options (1=yes, and 0=no). the final sample only included individuals who indicated “yes.” the online qualtrics survey was designed with a skip function such that only those who responded yes to this question were directed to the additional cannabis questions; those who selected no skipped to a different set of questions. cannabis consumption. cannabis consumption was the sum of 2 items drawn from the cannabis use disorder test-revised (cuditr; adamson et al., 2010). as indicated in the cudit-r documentation, cannabis consumption is covered by 2 of the measure’s 8 items, including cannabis use frequency and cannabis use quantity over the past six months. cannabis use frequency was measured by asking “how often do you use cannabis?” with response options (0=never, 1=monthly or less, 2=2-4 times a month, 3=2-3 times a week, 4=4 or more times a week). cannabis use quantity was measured by “how many hours were you ‘stoned’ on a typical day when you had been using cannabis?” with response options (0=less than 1, 1=1 or 2, 2=3 or 4, 3=5 or 6, and 4=7 or more). because the response options were different between two items, the items were standardized as z scores before creating a composite variable of cannabis consumption. internal consistency (cronbach’s alpha) is .46 based on the subsample (n=772). note that this measure is similar to the two-item cannabis use quantity-frequency measure used in the barnwell et al. study (2005). cannabis use consequences. the outcome variable was the sum of 3 items drawn from the cannabis use disorder test-short form (cuditsf; bonn-miller et al., 2016). items included “how often in the past 6 months did you find that you were not able to stop using cannabis once you had started?/have you devoted a great deal of your time to getting, using, or recovering from cannabis?/have you had a problem with your memory or concentration after using cannabis?” with response options (1=never, 2=less than monthly, 3=monthly, 4=weekly, 5=daily or almost daily). the responses were recoded as 0 for never and 1-4 for the rest of the response options. internal consistency (cronbach’s alpha) is .82 based on the subsample (n=772). alcohol use heavy episodic drinking (hed). hed frequency was included in the analysis as one moderator that was measured by asking “think back over the last month. how many times have cannabis, a publication of the research society on marijuana 26 you consumed 5 or more drinks in one day?” with responses (1=never, 2=once, 3=2 to 3 times, 4=4-6 times, 5=7 or more times). the responses were recoded as 0 for never, and 1-4 for responses options 2-5. alcohol-induced blackout. the second moderator was measured by one question “in the past 30 days, have you had a blackout as a result of your alcohol consumption?” with responses (1=don’t drink, 2= didn’t drink in the past 30 days, 3=no blackouts, 4=yes, during one drinking episode, 5=yes, during a few drinking episodes, 6=yes, during most of my drinking episodes, 7=yes, during all of my drinking episodes) (ward & guo, 2020). the responses were recoded as 0 for response options 1, 2, and 3 and 1-4 for responses options 4-7. the survey also provided the definition of an alcohol-related blackout which “is defined as a period of time during a drinking event in which you cannot recall all or parts of the event.” analysis plan product-term linear regression modeling was conducted in two steps to examine the association between cannabis consumption and cannabis use consequences and moderation by hed and blackout. models were conducted using the maximum likelihood-robust (mlr) estimator in mplus version 8.5 (muthén & muthén, 1998– 2017). in the first step, the measure of cannabis use consequences was regressed on demographic variables (age, gender, race), cannabis consumption, hed frequency, alcohol-induced blackout episodes, and two two-way interactions: one between cannabis consumption and heavy episodic drinking frequency and one between cannabis consumption and blackout episodes. the predictor (cannabis consumption) and the two moderators (hed and alcohol-induced blackout) were mean centered prior to analysis. if there was no evidence of statistically significant moderation, then the subsequent step was to drop the interaction term and re-run the model with only the main effect. if there was evidence of statistically significant moderation, then the subsequent step was to probe the interaction at one standard deviation below the mean, at the mean, and one standard deviation above the mean per standard procedures (aiken & west, 1991). results among the cannabis users, 72.7% had at least one day of heavy episodic drinking in the past month, and 28% experienced at least one blackout episode in the past month. table 1 provides correlations, means, and standard deviations for all variables. heavy episodic drinking frequency, alcohol-induced blackout episodes, and cannabis consumption had expected positive associations with cannabis use consequences. male gender was positively associated with cannabis use consequences but race and age had no relationship with cannabis use consequences. table 1. correlation matrix and descriptive statistics for cannabis users (n=772) 1 2 3 4 5 6 7 8 9 10 11 1.age 1.00 2.gender_m -.01 1.00 3.gender_o .05 -.12 1.00 4.race_b .09 .01 -.03 1.00 5.race_a .01 -.05 -.03 -.03 1.00 6.race_o .00 .001 -.02 -.02 -.02 1.00 7.race_m -.03 -.01 .07 -.04 -.04 -.03 1.00 8.hed -.09 .23 -.18 -.11 -.05 -.06 -.04 1.00 9.blackout -.08 .05 -.09 -.09 -.02 -.05 -.02 .46 1.00 10.cc .06 .16 -.03 .05 -.01 .06 .02 .12 .08 1.00 11.cuc .01 .12 -.002 .01 -.03 .06 -.04 .11 .15 .53 1.00 m 19.99 .33 .03 .03 .03 .01 .05 1.74 .42 .03 1.14 sd 2.88 .47 .16 .18 .16 .11 .22 1.42 .75 1.60 2.33 note. bold=p<.05; gender_m=gender dummy variable for male; gender_other=gender dummy variable for other; race_b=race dummy variable for black; race_a=race dummy variable for asian; race_o=race dummy variable for other; race_m=race dummy variable for multi-race; hed=heavy episodic drinking; cc=cannabis consumption; cuc=cannabis use consequences. cannabis, heavy drinking, and consequences 27 the linear regression model (see table 2) showed a statistically significant positive association between cannabis consumption and cannabis use consequences (b=0.72, p<.001) adjusting for the other variables in the model. multi-race status was negatively associated with cannabis use consequences (b=-0.51, p=.01). the cannabis consumption x blackout interaction effect was statistically significant (b=0.18, p=.01). however, the cannabis consumption x hed interaction effect was not statistically significant (b=0.01, p=.89). since no statistically significant moderation was observed between cannabis consumption and hed, the interaction term was removed. the final model was then re-run with only the interaction term of cannabis consumption and blackout, along with the main effects. in the final model (see table 3), the cannabis consumption x blackout interaction effect remained statistically significant (b=0.19, p=.003). multi-race status remained significant in the final model. table 2. regression model of cannabis consumption, heavy episodic drinking, blackout, and cannabis use consequences with two two-way interactions model predictors b se p age 0.01 0.02 .76 gender_male 0.17 0.17 .32 gender_other 0.41 0.45 .36 race_black -0.10 0.38 .79 race_asian -0.30 0.33 .36 race_other 0.76 1.14 .51 race_multi-race -0.51 0.21 .01 hed -0.02 0.06 .78 blackout 0.27 0.11 .01 cc 0.72 0.06 .00 hed × cc 0.01 0.05 .89 blackout × cc 0.18 0.07 .01 note. bold=p<.05; gender_m=gender dummy variable for male; gender_other=gender dummy variable for other; race_b=race dummy variable for black; race_a=race dummy variable for asian; race_o=race dummy variable for other; race_m=race dummy variable for multi-race; hed=heavy episodic drinking; cc=cannabis consumption. table 3. final regression model of cannabis consumption, heavy episodic drinking, blackout, and cannabis use consequences with one two-way interaction model predictors b se p age 0.01 0.02 .76 gender_male 0.16 0.17 .33 gender_other 0.41 0.45 .36 race_black -0.10 0.38 .79 race_asian -0.30 0.33 .36 race_other 0.77 1.13 .50 race_multi-race -0.51 0.21 .01 hed -0.02 0.06 .80 blackout 0.27 0.11 .02 cc 0.73 0.06 .00 blackout × cc 0.19 0.06 .003 note. bold=p<.05; gender_m=gender dummy variable for male; gender_other=gender dummy variable for other; race_b=race dummy variable for black; race_a=race dummy variable for asian; race_o=race dummy variable for other; race_m=race dummy variable for multi-race; hed=heavy episodic drinking; cc=cannabis consumption. cannabis, a publication of the research society on marijuana 28 probing the interaction (see figure 1) showed that blackout was statistically significant at one standard deviation below the mean (b=0.54, p<.001), one standard deviation at the mean (b=0.73, p<.001), and one standard deviation above the mean (b=0.91, p<.001), with an increasing magnitude of association at higher levels of cannabis consumption. this indicates that a higher number of blackout episodes exacerbated the relationship between cannabis consumption and cannabis consequences, controlling for heavy episodic drinking frequency and the other covariates. figure 1. plot of the interaction of blackout with cannabis consumption in relation to cannabis use consequences note. x-axis=cannabis consumption, and y-axis=cannabis use consequences; blackoutlow= simple slope of cannabis consumption when blackout episodes was 1 sd bellow the mean; blackoutmean= simple slope of cannabis consumption when blackout episodes was at the mean; blackouthigh= simple slope of cannabis consumption when blackout episodes was 1 sd above the mean. discussion cannabis remains a popular substance among college students, particularly in light of the changing cannabis legalization landscape in the u.s. thus, studies examining cannabis use behaviors and consequences among college students are warranted. the present findings align with previous research, suggesting that cannabis consumption is a robust predictor of negative cannabis-related outcomes, demonstrating a medium-sized association (gunn et al., 2020; pearson, 2019). furthermore, experiences of alcohol-induced blackout significantly moderated the link between cannabis consumption and cannabis-related consequences such that this association was strengthened with an increasing number of episodes of alcohol-induced blackout. among students who engaged in frequent and/or highquantity cannabis use, and who had recently experienced alcohol-induced blackouts, the likelihood of experiencing cannabis-related consequences was higher. this finding underscores that blackouts not only signal a risk of problematic drinking (hingson et al., 2016; studer et al., 2019) but also enhance the association between cannabis use and its resulting consequences. moreover, this finding extends a prior study that found heavy drinking moderated the relationship between cannabis use and cannabis-related consequences (barnwell et al., 2005), although that study did not simultaneously consider multiple forms of alcohol involvement, including blackouts. hed was weakly correlated with both cannabis use consumption and cannabis use -3 -2 -1 0 1 2 3 4 5 6 interaction of blackout with cannabis consumption blackoutlow blackoutmean blackouthigh cannabis, heavy drinking, and consequences 29 consequences but both the main effect of hed and the interaction effect of hed with cannabis consumption were found to be non-significant. while simultaneous use of cannabis and alcohol is typical among young adults engaging in hed (boyle et al., 2023), it did not appear to moderate the relationship between cannabis consumption and its consequences in our adjusted analyses. in contrast, alcohol-induced blackouts enhanced the relationship between cannabis consumption and cannabis use consequences. this may be potentially attributed to the nature of blackouts, representing a more severe pattern of alcohol use typically induced by hed with a rapid increase in blood alcohol concentration over a short period of time (rose & grant, 2010; hermens & lagopoulos, 2018). acute alcohol intoxication disrupts cellular communication in the hippocampus and other related brain structures and regions (siqueira & smith, 2015; zeigler et al., 2005). this leads to impairment in memory retrieval and deficits in the encoding process, interfering with the brain’s ability to transfer short-term memories into longterm ones, ultimately resulting in partial or complete memory loss (siqueira & smith, 2015; white, 2003). moreover, students who have a history of blackouts tend to endorse positive drinking expectancies (lee et al. 2009). in the context of college cannabis users with a blackout history, it is conceivable that memory impairment experienced during blackouts might lead them to downplay the negative effects of cannabis use. this could result in a sustained positive perception of cannabis use, potentially elevating their risk for experiencing negative consequences associated with cannabis use. the findings of this study are concerning given the well-documented harms associated with blackouts (lorkiewicz et al., 2022; wetherill & fromme, 2016). it is crucial to consider the intricate interplay between blackout, cannabis use, and negative cannabis use consequences. previous studies have indicated that the simultaneous use of alcohol and cannabis amplifies the likelihood of experiencing severe alcohol-related outcomes, such as blackouts (davis et al., 2021; jackson et al., 2020). in addition, deniel et al. (2021) reported that the consumption pattern of cannabis use and binge drinking contributes to memory and executive impairments among college students. it is important to recognize that blackouts can also serve as a moderator in this relationship. specifically, blackouts may exacerbate the connection between cannabis use and its associated consequences, highlighting a concerning public health issue. this suggests that the combined effect of alcohol-induced blackout and cannabis use could engender a heightened susceptibility to cannabis-related problems. this is a critical consideration for individuals, healthcare professionals, and policymakers in developing effective harm reduction strategies and public health interventions to consider screening for blackout history among college cannabis users. college campus prevention strategies should also be adapted and tailored to address concurrent use of cannabis and alcohol use. experiencing blackouts, in particular, may have wide-ranging effects on college students not only as a direct result of alcohol ingestion but also may increase the likelihood that cannabis use leads to significant cannabis-related impairments. the current study is the first to examine blackouts in the relationships between cannabis use and cannabis-related consequences. however, this study has some limitations. first, this is a crosssectional study that relied solely on self-report assessments. drawbacks of this type of study include potential bias related to memory recall and inability to address the direction of causal relationships between predictors and outcomes. thus, future longitudinal studies will be necessary to confirm the direction of the associations. second, several measures, including blackout experiences, were based on a single item with unknown reliability and validity. however, a recent study provided evidence for valid measurement of two different types of blackout-induced memory loss: complete blackouts (also known as en bloc), and fragmentary blackouts, as well as for measurement of the frequency of alcohol-related blackouts (miller et al., 2019). since we did not intend to study two dimensions of blackout experience, we chose a single-item blackout measure. still, additional studies with multi-item assessment of key study constructs are needed (e.g., miller et al., 2019). third, we did not have measures of simultaneous use of alcohol and cannabis together at the same time. fourth, the internal consistency of cannabis consumption tends to be low for 2-item scales. but it is not uncommon in this circumstance, especially those two items capturing discrete behavior of cannabis consumption. fifth, the heavy episodic drinking measure only accounts for 5 or more drinks, which is the standard for males, but it does not include 4 or more drinks for females. finally, data were collected from students on one college campus, the participation rate was low, and cannabis, a publication of the research society on marijuana 30 respondents were predominantly caucasian and female. generalization of the results should proceed with caution. conclusion the current study found that higher frequency and quantity of cannabis use increased the likelihood of cannabis-related consequences among college students. further, among those who also experienced alcohol-induced blackouts, the risk of cannabis use adverse consequences increased. findings may inform interventions targeting cannabis users who also drink alcohol to the point of blackout. this study suggests that blackout history should be incorporated into cannabis use prevention initiatives for college undergraduate students. references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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cannabis use; cigarette smoking; infection reporting; immunomodulation; prospective cohort study although smoke exposures have long been known to increase susceptibility and severity of respiratory tract infection (blake et al., 1988; cohen et al., 1993; feldman et al., 2015; kark et al., 1982; noah et al., 2012; rebuli et al., 2019; rogot & murray, 1980), the effects of cannabis nadia milad1,2, kyla belisario3,4, james mackillop3,4, & jeremy a. hirota1,2,5,6 1firestone institute for respiratory health – division of respirology, department of medicine, mcmaster university 2mcmaster immunology research centre, mcmaster university 3peter boris centre for addictions research, mcmaster university & st. joseph’s healthcare 4department of psychiatry and behavioural neurosciences, mcmaster university 5department of biology, university of waterloo 6department of medicine, university of british columbia cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000248 volume 7, special issue 3 dried cannabis use, tobacco smoking, and covid-19 infection: findings from a longitudinal observational cohort study corresponding author: jeremy alexander hirota, ph.d., firestone institute for respiratory health, st. joseph’s healthcare. 50 charlton avenue east, hamilton, on l8n 4a6, canada. phone: 1(905) 522-1155 ext. 33683. email: hirotaja@mcmaster.ca. cannabis, a publication of the research society on marijuana 178 smoke on respiratory tract viral infection remain poorly understood. there is some evidence that individuals who use cannabis report increased incidence of bronchitisand pneumonia-related respiratory symptoms (macleod et al., 2015; tetrault et al., 2007), as well as increased hospitalization rates and length of stay associated with respiratory tract infections compared to those who do not use cannabis (polen et al., 1993; rosoff et al., 2021a). in preclinical models, it was shown that both direct administration of the cannabinoid tetrahydrocannabinol (thc; (buchweitz et al., 2007; buchweitz et al., 2008) and exposure to cannabis smoke (milad et al., 2023) before and after influenza a infection in mice suppressed aspects of the antiviral inflammatory response, leading to reduced immune cell recruitment and an increased pulmonary viral load. therefore, in the wake of widespread legalization and potential for future global pandemics, it is crucial that we understand to what extent cannabis use might impact pulmonary host-defense and antiviral responses. the sars-cov-2 (covid-19) virus has dramatically affected the pulmonary health of millions of people globally, but there is ambiguity surrounding the potential additional risks among cigarette and cannabis smokers. some early studies suggested there was a “smoker’s paradox,” where cigarette smokers were found to be underrepresented among patients with severe covid-19 infection (lippi et al., 2020; lombardi et al., 2021; meini et al., 2021), although data regarding the relationship between covid-19 and smoking status are conflicting (lippi et al., 2020; zhou et al., 2020) (guo, 2020; kozak et al., 2020; liu et al., 2020; lowe et al., 2021; patanavanich & glantz, 2020, 2021; rosoff et al., 2021b; yu et al., 2020; zheng et al., 2020). similarly, the potential link between cannabis smoking and covid-19-associated disease has also been debated. initially, several published reviews and editorials suggested that cannabis use might dampen pulmonary inflammation associated with covid-19 infection through the immunomodulatory effects of cannabinoids, namely thc and cannabidiol (cbd), and thus alleviate symptoms and improve outcomes (onaivi & sharma, 2020; paland et al., 2021; pascual pastor et al., 2020; pérez et al., 2022). when clinical data were collected, studies showed conflicting results, where some suggested a protective effect (huang et al., 2022; shover et al., 2022), no effect (rosoff et al., 2021a, 2021b) or a negative effect (hasin et al., 2022; huang et al., 2022; merianos et al., 2022) on covid-19 infection rate and/or severity. further complicating research into these topics are reports that substance use, e.g. alcohol and cannabis, may have increased early in the pandemic (imtiaz et al., 2021; levitt et al., 2023; newport et al., 2023), though it subsequently decreased over the ensuing reopening and return to work. overall, the impact of tobacco and cannabis smoking on covid-19 outcomes remains poorly understood, which has significantly complicated public messaging during the recent covid-19 pandemic (pascual pastor et al., 2020). a common limitation of previous studies has been crosssectional data collection. in addition, the investigation of how substance use might affect respiratory tract infections is complicated by the potentially confounding factor of vaccine hesitancy, as it is possible that significant differences in covid19 infections and outcomes between users and nonusers may be related to reduced vaccine uptake in substance users. in the current study, a cohort of participants recruited pre-pandemic in 2018 were assessed for tobacco and cannabis use at regular intervals (3-6 months), with covid-19 measurements added after the onset of the pandemic. this prospective observational cohort study enabled quantification of self-reported tobacco and cannabis use over 44 months spanning several covid-19 infection waves, providing a higher resolution perspective on consumption of cannabis and tobacco in relation to covid-19 outcomes. methods patient recruitment, baseline characteristics, and covid-19 self-reporting the study population of n = 1,502 was recruited from the population for assessment of tomorrow’s health (path) registry of 2,165 community-based adults from hamilton, ontario, canada. the registry was a one-time, in-person assessment from 20162018 which captured biometric indices (sex, weight, height, heart rate, blood pressure, etc.). inclusion criteria were as follows: between the ages of 18-65, minimum 9th grade education for adequate literacy to complete online assessments, willingness to receive invitations to future assessments, and no current terminal illnesses to ensure ability to participate in future assessments. the first web-administered assessment occurred in september 2018, with online cannabis, tobacco, and covid-19 179 follow-ups every 6 months (supplementary figure 1) via research electronic data capture (redcap) software (harris et al., 2009). two additional followups spaced at 3-month intervals were administered in the acute phase of the covid-19 pandemic (specifically, july 2020 and january 2021). cannabis was legalized in canada in october 2018; therefore, data on substance use was collected preand postlegalization. attrition analysis can be found in supplementary table 1. quality control was administered at each wave, which consisted of asking participants to correctly answer at least 3 of 5 questions embedded throughout the assessment correctly. these questions had unambiguous correct responses, such as “for this question, choose ‘strongly disagree.’” retention in each wave is high, with few excluded due to low quality control (qc) where the mean average passing qc = 99.4%. the study was approved by the hamilton integrated research ethics board (protocol #4699), all participants underwent informed consent, and all procedures complied with the helsinki declaration. to analyze covid-19 infection self-reporting, participants were included in the final sample if they had data at either t10 (april 2022) or t11 (october 2022), as these waves captured a fulsome window of the pandemic, including the omicron strain (breznik et al., 2023). this saw a total of 1,343 individuals included in analysis (89% retention), in which most had data for all 11 survey waves (m = 10.65; median = 11). it is also in these waves that we administered a question asking about all prior covid-19 infections. covid-19 infections were self-reported, and thus include individuals who had confirmed covid-19 positive tests via pcr or rapid antigen testing, as well as participants who did not test but strongly suspected they had a covid-19 infection. the covid-19 vaccination status of participants was also determined via self-reporting, and participants were stratified into two categories: booster vaccination (1-2 primary vaccines plus a bivalent booster dose) or no booster vaccination (includes unvaccinated and primary vaccine only without bivalent booster dose). these groups were selected in order to explore whether differences in covid-19 infection reporting may be influenced by group differences in vaccination hesitancy, since 1 or 2 primary vaccinations were mandated by the canadian government in september 2021, while booster vaccination was always optional (bowdish et al., 2024; "ontario regulation 645/21; rules for areas at step 3 and the roadmap exit step," 2021), an unvaccinated group (<5% of cohort) was not included in the analyses. cannabis and tobacco use frequency cannabis was legalized in canada in october 2018, and dried cannabis use was defined as consumption of any dried flower cannabis across all waves of the study. among dried cannabis users, dried leaf/flower could be smoked and/or vaped in a heating device that did not lead to combustion, although 92% of dried cannabis users chose combustion or combustion plus vaping as their main route of administration. conversely, edibles were considered a separate usage group not included in our analysis. an average frequency of use across all surveys (2018-2022) in which the participant has data was used as a predictor of the covid-19 related outcomes. in addition to frequency, typical amount of dried cannabis used per occasion in which cannabis was consumed was also collected, in which the average amount of dried cannabis product in grams consumed across waves was multiplied by frequency and used as a predictor of covid-19 infection. to mitigate improper estimating of dried cannabis use self-reporting, a scaling image is provided within the survey comparing the size of 1 gram of dried cannabis to a bottle cap (supplementary figure 2). tobacco use was defined as smoking any cigarettes across all waves of the study. the average number of cigarettes consumed across waves for which participants have data was used as a predictor of the covid-19 related outcomes. see online supplementary materials for additional information on cannabis and tobacco cigarette use questions. throughout the manuscript, tobacco cigarettes will simply be referred to as tobacco or cigarettes. to attempt to establish a dose-response relationship between substance use and covid-19 infection, we 1) compared substance use frequency between those reporting a covid-19 infection and those not reporting a covid-19 infection and 2) performed univariate (unadjusted) and multivariate (adjusted) logistical regression analyses of substance use frequency and covid-19 infection reporting. statistical analyses chi-squared tests were used to test differences in proportions, and two-sided t-tests (welch’s t-test when non-normality of variance was detected) were used when comparing the means of two groups. cannabis, a publication of the research society on marijuana 180 univariate and multivariate (sex, age, continuous income, and substance use as covariates) logistic regressions were performed using the entire n = 1,343 sample to predict odds ratios (or) of having 1 or 2+ covid-19 infections. similarly, univariate (unadjusted) and multivariate (adjusted) logistic regressions were performed for a subset of participants with a prior covid-19 infection who endorsed a) cigarette use or b) dried cannabis use to determine if significant predictors remain significant in a subset of substance users. raw p values are reported throughout with a conservative significance value of α = .005 per benjamin et al. (2018), and effect sizes using cohen’s d are reported for statistically significant t-tests (lakens, 2013). results baseline characteristics and covid-19 outcomes among the 1,343 included participants, we found that 248 individuals endorsed smoking cigarettes (18.5% of cohort), and 753 individuals endorsed using dried cannabis (56.1% of cohort) during the study period. dividing participants by cannabis use revealed that participants who endorsed dried cannabis use were significantly younger, had lower median income, and reported increased tobacco use throughout the study (supplementary table 2). furthermore, when looking at vaccination status, there was a trend towards lower reporting of covid19 booster vaccination among dried cannabis users compared to non-users, t(1) = 2.26, p = .0256 (supplementary table 2). when comparing baseline characteristics, there was a trend towards white race, significantly lower median income, and significantly higher cannabis use among individuals who endorsed smoking cigarettes compared to those who did not (supplementary table 2). self-reported vaccination status was also significantly different depending on cigarette use, where a smaller proportion of tobacco smokers had received a primary covid-19 vaccination compared to non-smokers, 89.9% vs 95.5%, x2(1) = 11.5, p = .000840, and a smaller percentage of tobacco smokers had received a covid-19 booster vaccine, 64.1% vs 79.7%, x2(1) = 26.8, p < .0001, supplementary table 2. dual use of tobacco and dried cannabis was relatively common: 199 participants, or 14.8% of the whole cohort, endorsed using both substances, which represents 80.2% of cigarette smokers and 26.4% of dried cannabis users (figure 1). figure 1. distribution of covid-19 infection reporting among cigarette and dried cannabis single or dual users in the cohort note. self-reported covid-19 infections divided by cigarette and dried cannabis use as follows: non-users (blue), cigarette only users (grayscale), dried cannabis only users (green) and dual cigarette and dried cannabis users (yellow). one square represents one participant. therefore, participants were divided into mutually exclusive substance use groups as follows: no use, cigarette-only use, dried cannabisonly use, and dual cigarette and cannabis use. baseline characteristics were also compared for mutually exclusive groups, where booster cannabis, tobacco, and covid-19 181 vaccination was found to be lower in the dual use group compared to substance no use and dried cannabis-only use, 63.8% vs 81.1% and 78.3%, respectively, x2(3) = 29.0, p < .0001, cannabis use throughout the study was higher in dual use group compared to cannabis-only use, and median income was significantly lower in dual use group compared to dried cannabis-only use (table 1). table 1. baseline characteristics of cohort of mutually exclusive cigarette/cannabis use groups characteristic no use cigarette only dried cannabis only dual use statistics n (overall %) 541 (40.3%) 49 (3.7%) 554 (41.3%) 199 (14.8%) n (%) female 351 (64.9%) 36 (73.5%) 321 (57.9%) 114 (57.3%) x2 = 9.95 p = .0190 n (%) white ethnicity 429 (79.3%) 47 (95.9%) 428 (77.3%) 161 (80.9%) x2 = 9.97 p = .0189 prior respiratory conditions: copd: 16 (3.0%) 1 (2.0%) 13 (2.3%) 8 (4.0%) x2 = 1.89 p = .597 asthma: 92 (17.0%) 8 (16.3%) 106 (19.1%) 40 (20.1%) x2 = 2.43 p = .488 vaccination status: primary vaccination (1-2 vaccine) 492 (90.9%) 40 (81.6%) 509 (91.9%) 169 (84.9%) x2 = 12.5 p = .00572 booster vaccination (1-2 vaccines + booster) 439 (81.1%)b 32 (65.3%) 434 (78.3%)a 127 (63.8%)a,b x2 = 29.0 p <.0001 cigarette use (mean # cigarettes throughout study +/ sd) n/a 13,328.91 +/13,884.93 n/a 8,526.23 +/ 13,173.57 t = 2.26 p = .0246 cannabis use (mean grams throughout study +/sd) n/a n/a 285.67 +/ 898.01 902.68 +/ 1,700.4 t = 3.71 p = .000256 alcohol use (mean standard number of drinks throughout study +/sd) 9,70.9 +/ 1,126.15c 1,601.38 +/ 1,740.71 1,618.85 +/ 1,732.23a,c 2,421.48 +/ 2,505.98a f = 39.2 p <.0001 median income** $90,000 $104,999 $75,000 $89,999 $75,000 $89,999a $45,000 $59,999a f = 25.0 p <.0001 mean +/sd age at end of 2022 (median age) 43.83 +/ 14.98c 46.98 +/13d 35.3 +/ 12.3c,d 35.54 +/ 11.78 f = 47.6 p <.0001 note. apost-hoc: significant difference between cannabis only use and dual use (p < .005), bpost-hoc: significant difference between no substance use and dual use (p < .005), cpost-hoc: significant difference between cannabis only use and no substance use (p < .005), dpost-hoc: significant difference between cannabis only use and cigarette only use (p < .005). cannabis, a publication of the research society on marijuana 182 dried cannabis use and covid-19 infection in the whole cohort, 820 (61.1%) reported at least one covid-19 infection, and 143 (10.6%) reported two or more covid-19 infections. when comparing individuals who endorsed using dried cannabis to those who did not, dried cannabis use was associated with increased reporting of a single, trend, x2(1) = 6.01, p = .0142, or multiple covid-19 infections, x2 (1) = 11.9, p = .000573, supplementary table 3. in contrast, there was no significant difference in covid-19 infection self-reporting associated with tobacco use (supplementary table 3). to ensure that any associations between multiple covid-19 infections and cigarette/cannabis use were not the result of participants quitting or reducing their use after a covid-19 infection, substance use before and after a participant reported their first covid-19 infection were compared, and no significant change in substance use was observed preand post-infection (supplementary table 4). since dual use was common, covid-19 infections were also assessed for the mutually exclusive groups: no use, cigarette-only use, dried cannabis-only use, and dual cigarette/cannabis use. there was a significant increase in reporting of a single covid19 infection among the dried cannabis-only use group (67.6%) compared to no use (56.8%; p = .000307) and dual use (54.3%; p = .00115; figure 1 and table 2). similarly, a significant increase in reporting multiple covid-19 infections was observed for dried cannabis-only use group (13.4%) compared to no use (6.7%; p = .000267), with trends (p < .05) towards increases for cigarette-only use and dual use groups when compared to no use (figure 1 and table 2). table 2. covid-19 infection self-reporting among cigarette smokers, dried cannabis users, and dual users mutually exclusive substance use groups n (% of use group) no use (n = 541) dried cannabisonly use (n = 554) cigarette-only use (n = 49) dual use (n = 199) statistics 1+ covid-19 infection 307 (56.7%) 374 (67.5%)a,b 31 (63.3%) 108 (54.3%) x2 =17.9 p = .000466 2+ covid-19 infections 36 (6.7%) 74 (13.4%)a 7 (14.3%)c 26 (13.1%)d x2 =15.2 p = .00162 note. a post-hoc: significant difference between dried cannabis-only use vs no use, b post-hoc: significant difference between dried cannabis-only use vs dual use, c post-hoc: trend towards difference between cigarette-only use and no use (p < .05), d post-hoc: trend towards difference between dual and no use (p < .05). frequency of substance use and covid-19 infection self-reporting interestingly, both cigarette use and dried cannabis use among those reporting a covid-19 infection consumed on average fewer grams of dried cannabis (0.19 vs 0.32; trend p = .00569) and fewer cigarettes (3.51 vs 6.31) per day throughout the study than those not reporting a covid-19 infection (supplementary table 5), initially suggesting an inverse correlation between substance use and covid-19 infection. to assess the possible interaction between dried cannabis and tobacco use among those endorsing dual substance use, analyses were repeated using mutually exclusive substance use groups. analysis revealed that the trend that participants endorsing dried cannabis use and reporting a covid-19 infection consumed less dried cannabis daily on average than those not reporting an infection only remained a trend (0.63 vs 0.33 grams/day; p = .0112) in the dual use group, with no difference observed in the dried cannabis-only use group (0.16 vs 0.15 grams/day; table 3). similarly, the decrease in cigarettes consumed per day by individuals reporting a covid-19 infection was only present in the dual use group (5.93 vs 2.9 cigarettes/day; p = .00111), not in the cigarette-only use group (table 3). cannabis, tobacco, and covid-19 183 table 3. dried cannabis and tobacco consumption by covid-19 infection reporting mutually exclusive substance use groups mean +/sd (median) no use (n = 541) dried cannabis only use (n = 554) cigarette only use (n = 49) dual use (n = 199) average cigarettes per day no covid-19 infection 0 +/0 (0) 0 +/0 8.23 +/7.82 (5.59) 5.93 +/8.1 (1.36) covid-19 infection 0 +/0 (0) 0 +/0 5.63 +/6.2 (3.55) 2.9 +/4.6 (0.48) significance t = 1.29; p = .204 t = 3.31 p = .00111 effect size (cohen’s d) d = 0.47 average daily cannabis grams no covid-19 infection 0 +/0 (0) 0.16 +/0.37 (0.01) 0 +/0 0.63 +/1.0 (0.1) covid-19 infection 0 +/0 (0) 0.15 +/0.48 (0.01) 0 +/0 0.33 +/0.65 (0.02) significance t = 0.115; p = .910 t = 2.56 p = .0112 effect size (cohen’s d) d = 0.36 to further probe potential dose-response relationships, logistic regression analyses were performed to assess whether there was a correlation between total substance use throughout the study and covid-19 infection self-reporting. initially, the univariate analysis revealed a trend that each gram of dried cannabis consumed per day was associated with a 29% reduction in the odds of reporting a covid-19 infection (or = 0.71; p = .00745); however, dried cannabis use frequency was not a significant predictor of covid-19 infection reporting after accounting for sex, age, household income, alcohol consumption, and tobacco cigarette smoking in the multivariate analysis (table 4). similarly, although cigarette smoking frequency was negatively associated with covid-19 infection self-reporting in the univariate analysis (or = 0.94; p = .0015), this relationship was no longer significant when data were adjusted for age, sex, household income, alcohol consumption, and dried cannabis use via multivariate analysis (table 4). overall, the dose-response pattern that increased substance use is associated with reduced covid19 infection self-reporting was only significant for tobacco smoking in the dual use group, and this relationship disappears for both tobacco and dried cannabis use once data were adjusted, suggesting it is related to confounding variables. table 4. univariate and multivariate odds ratios (ors) for covid-19 infection self-reporting among substance use groups or 1+ covid-19 infection p-value unadjusted analysis cannabis grams per day dried cannabis use (n = 753) 0.71 (0.55 – 0.91) .00745 cigarettes per day 0.94 (0.90 0.97) .00154 cannabis, a publication of the research society on marijuana 184 cigarette use (n = 248) adjusted analysis* cannabis grams per day dried cannabis use (n = 753) 0.82 (0.62 – 1.08) .161 cigarettes per day cigarette use (n = 248) 0.97 (0.93 – 1.01) .147 note. *adjusted for age, sex, household income, alcohol consumption and other substance use booster vaccination and self-reported covid-19 infection as previously outlined in table 1, individuals endorsing dried cannabis and tobacco use exhibited different covid-19 vaccination patterns. to assess the potentially confounding factor of vaccination on covid-19 infection selfreporting, data were stratified based on covid19 booster vaccination status. in the whole cohort, the proportion of individuals having received a booster vaccination was not significantly different between those reporting a single covid-19 infection versus no infection, while those reporting multiple covid-19 infections were less likely to report receiving a booster vaccination compared to those declaring fewer than two covid-19 infections: 67.1% vs 78.0%, respectively (supplementary table 6). when we assessed the impact of dried cannabis and tobacco use on covid-19 infection reporting only among participants with the same vaccination status, dried cannabis use among participants with a booster vaccination was associated with trends towards increased selfreporting of a single covid-19 infection (63.3% vs 56.5%; p = .0227) or multiple covid-19 infections (11.6% vs 6.6%; p = .00806; supplementary table 7). conversely, no significant difference was observed in self-reporting of one or multiple covid-19 infections between those endorsing cigarette use and those not endorsing cigarette use, regardless of booster vaccination status (supplementary table 7). when participants were divided into mutually exclusive substance use groups, we found that, among individuals with a booster vaccine, dried cannabis-only use was associated with increased reporting of at least one covid-19 infection (66.6% vs 55.8%; p = .00338) compared to the no substance use group (table 5). overall, this suggests that despite differences in vaccine uptake between substance use groups, dried cannabis use among individuals with a booster vaccine is linked to a higher likelihood of reporting a covid-19 infection. table 5. self-reported covid-19 infection stratified by booster vaccination and substance use mutually exclusive substance use groups n (%) no use (n = 541) dried cannabisonly use (n = 554) cigarette-only use (n = 49) dual use (n = 199) statistics 1+ covid-19 infection no booster vaccination 62 (60.8%) 85 (70.8%) 10 (58.8%) 40 (55.6%) x2 = 5.22 p = .157 booster vaccination 245 (55.8%) 289 (66.6%)a 21 (65.6%) 68 (53.5%) x2 = 13.7 p = .00338 note. apost-hoc: significant difference between dried cannabis only use and no use (p < .005) discussion the impact of dried cannabis use and tobacco cigarette smoking on viral infections has been a topic of growing interest, particularly in the context of the sars-cov-2 (covid-19) pandemic. in this study, we aimed to explore the association between dried cannabis use and/or cigarette smoking and covid-19 infection. we found that dried cannabis use was associated with increased self-reporting of covid-19 infections while, conversely, tobacco cigarette smoking led to cannabis, tobacco, and covid-19 185 trends towards reduced covid-19 infection selfreporting. even among individuals who received a booster vaccine, dried cannabis use was associated with increased reporting of one or multiple covid-19 infections. when looking at use frequency, there were initially indications of inverse dose-response relationships between substance use and covid-19 self-reporting: increased dried cannabis or cigarette consumption among individuals not reporting a covid-19 infection compared to those reporting an infection and lower odds ratios. however, when multiple substance use was accounted for by dividing individuals into mutually exclusive use groups or by multivariate regression analyses, no significant associations between the frequency of dried cannabis or cigarette use and self-reported covid-19 infections was observed. overall, our findings suggest that dried cannabis and tobacco use impact covid-19 self-reporting in distinct and complex ways. we are not the first to observe features of a “smoker’s paradox,” where reports early in the covid-19 pandemic showed a reduced proportion of those being admitted to hospital for covid-19 were tobacco smokers compared to the general population (lippi et al., 2020; lombardi et al., 2021; meini et al., 2021). many mechanisms underlying the seemingly protective effect of tobacco smoking on covid-19 self-reporting have been posited, including both behavioural and biological pathways. from the behavioural angle, cigarette smokers underestimate the negative health consequences of inhaling smoke (krosnick et al., 2017), a perception that may also apply to covid-19 symptoms that would contribute to reduced self-reporting of an infection. from the biological side, tobacco smoke exposure increases the expression of angiotensin converting enzyme 2 [ace2; lombardi et al. (2021)] and, although ace2 is a receptor used by sars-cov-2 to enter cells, it also has profound anti-inflammatory effects and has been shown to exhibit protective effects in the response to lung injury (imai et al., 2005). in our study, we observed increased mean tobacco cigarettes smoked per day in participants who did not report a covid-19 infection compared to those reporting one or multiple covid-19 infections only found for the dual use group, not the tobacco-only use group. although this suggests a protective effect of tobacco smoking, no dose-response correlations persisted after correcting for age, sex, income, and other substance use. however, it is important to note that in our study, the number of participants in the cigarette-only use group was quite small (n = 49; 3.6% of cohort), since 80.2% of individuals who endorsed cigarette use also endorsed dried cannabis use, which makes specifically dissecting the impact of cigarette smoking on covid-19 infection rate in this group of individuals particularly challenging. taken together with previous findings, our results suggests that the “smoker’s paradox” trends observed are not strong and largely disappear when other important variables are taken into account. the fact that increased tobacco use was associated with reduced covid-19 reporting only in the dual cigarette/cannabis use group is of interest, indicating that studying individual substance use is crucial to understanding their distinct effects on respiratory infections. there is also a lot of debate regarding the effect of cannabis smoking and covid-19associated disease. although cannabinoids have long been known to exhibit anti-inflammatory effects (klein et al., 1998), there is no consensus as to the impact of cannabis use on covid-19 outcomes, with studies offering inconsistent results: positive effects (shover et al., 2022), no effect (rosoff et al., 2021a, 2021b), or negative effects (hasin et al., 2022; huang et al., 2022; merianos et al., 2022). several factors may explain these conflicting findings, including differences in study design, population characteristics, and type/frequency of cannabis use. interpretation of these data is further limited by the fact that little is known about usage pattern, with cannabis users being identified as anyone who endorsed previously using cannabis without information on frequency, dose, potency, route of administration, or history of use. in our study, we isolated dried cannabis users only, excluding other forms of cannabis use such as edibles and tinctures. we found that dried cannabis use was associated with increased selfreporting of one or multiple covid-19 infections. the possible confounding factor of tobacco smoking among cannabis users was also assessed, where it was shown that the dried cannabis-only use group was still significantly more likely to report one or multiple covid-19 infections compared to the no use group. although this seems to suggest that dried cannabis use is cannabis, a publication of the research society on marijuana 186 associated with increased risk of covid-19 selfreporting, dried cannabis use frequency was not significantly associated with covid-19 infection. in fact, initially there was a trend towards reduced covid-19 infection reporting with increased daily dried cannabis use or increased daily cigarette smoking; however, this “smoker’s paradox” did not persist when individuals endorsing dual substance use were excluded or when multivariate analyses were performed. the lack of any significant dose-response relationship is not surprising given the nature of the data collected, where information about potency and cannabinoid content were not gathered. therefore, although no correlation was observed between dried cannabis use frequency and covid-19 infection, we found that endorsing dried cannabis use is associated with increased reporting of covid-19 infections. the increase in self-reporting of multiple covid-19 infections observed among those endorsing dried cannabis use may reflect physiological changes associated with dried cannabis use or other behavioral factors that may contribute to the increased infections such as lower adherence to government guidelines, scepticism towards medical interventions, increased risk of infection related to sharing of cannabis joints between individuals, and belief in the efficacy of cannabis as a natural medicine. furthermore, there are several social factors, such as rural/urban housing, which could have affected covid-19 infection but were not captured in this study. though some clinical studies have found that individuals who endorse using cannabis or cigarette did not exhibit differences in vaccine hesitancy (lum et al., 2022; yang et al., 2021), one systematic review showed that vaccine acceptance and uptake was lowest in individuals who identify as tobacco and/or marijuana users (49.1%) compared to the general population (77.9%), as well as other hesitant groups such as pregnant women (53.8%) and religious groups (60.2%), suggesting that covid19 vaccination may differ significantly between users and non-users (yasmin et al., 2021). consequently, booster vaccination status was considered as a potential confounding factor in our study. in our cohort, there were differences in the rates of primary and booster covid-19 vaccination between substance use groups. when analyses were stratified by vaccination status, it was shown that, even among individuals that received a booster covid-19 vaccination, individuals endorsing dried cannabis use only still exhibited higher self-reporting of a covid-19 infection compared to those vaccinated participants who did not endorse using either substance. since previous animal studies have found that cannabinoids dampen the humoral response to an antigen (karmaus et al., 2013; karmaus et al., 2012; milad et al., 2023), our data may also suggest that the protective effects of vaccination may be impaired by cannabis use. however, one clinical study looking at circulating spike receptor-binding domain-specific immunoglobulin g (igg) levels 31-122 days following a covid-19 booster vaccination in both cancer and non-cancer patients were unaffected by cannabis use, though participants in the cannabis group were significantly younger than those in the no use group (idan et al., 2022). therefore, the impact of substance use on the protective effects of covid-19 vaccination and the adaptive immune response requires further investigation in larger and more controlled studies designed to address these important questions. while our study provides valuable insights into the additional risks associated with cigarette smoking and dried cannabis use on covid-19 infection outcomes, there are several limitations that should be acknowledged. firstly, our study relies on self-reported data, which may be subject to several sources of error such as recall bias, underreporting of asymptomatic cases, lack of athome testing early in the pandemic, and underlying behaviours and perceptions of health. participants may also underreport their substance use or covid-19 infection due to stigma or social norms, leading to potential inaccuracies in the data. secondly, although responses related to covid-19 infections were collected at each time-point, our infection data are not based on covid-19 test results nor medical records and we were unable to assess covid-19 symptom severity and could not confirm covid19 infection diagnoses. furthermore, while we adjusted for age, sex, income, and other substance use in our multivariate analyses, there may be other relevant variables, such as underlying health conditions, workplace and home environment, or adherence to covid-19 safety measures, which were not accounted for and could cannabis, tobacco, and covid-19 187 influence the results. the timing of data collection and participant follow-up may also have affected reporting of covid-19 infections and of substance use. for instance, participants who experienced a covid-19 infection during the later waves of the study may have been more or less likely to report an infection compared to those infected earlier, considering the evolving pandemic situation, new variants of the virus, differences in symptomology, and changes in public health measures. another complicating factor in our study is that many features of cannabis consumption could not be incorporated (e.g., strain, cannabinoid content, etc.). although we observed a trend towards reduced self-reporting of covid-19 infections with increased daily dried cannabis use, this trend was no longer present when data were adjusted in the multivariate analyses and, furthermore, the dose-response relationship between substance use and covid-19 outcomes is difficult to elucidate without details of cannabis potency and route of administration. firstly, we considered any participant who endorsed using dried cannabis at any point during the study period as a dried cannabis user, meaning there were many participants who reported using less than 1 gram over the 4-year period. therefore, our substance use groups are likely diluted with participants who only tried cannabis once or twice and would not be considered cannabis users in a clinically relevant way; nevertheless, we still see important differences between non-users and dried cannabis users indicating the strength of the association. it would be prudent for future studies of cannabis use to establish use cutoffs to differentiate between “regular users” and “nonregular users,” as has been done by the centre for disease control (cdc) for tobacco smoking, where individuals are considered current or former smokers if they have consumed more than 100 cigarettes in their lifetime (adult tobacco use glossary). secondly, dried cannabis flower can differ dramatically in cannabinoid content and, although both cbd and thc exhibit significant anti-inflammatory effects (klein et al., 1998), it is unclear to what extent the individual cannabinoids may contribute to covid-19 infection risk. finally, dried cannabis can be consumed in many ways, including but not limited to dry-herb vaping (non-combustion) and smoking dried cannabis alone or mixed with tobacco (russell et al., 2018). how these routes of administration differ in their impact on the immune response to infection has yet to be explored. preclinical studies comparing cannabis strains of differing cannabinoid contents as well as comparing cannabis smoke and cannabis vapour exposures are required to mechanistically determine the impact of thc/cbd ratios and route of administration on respiratory tract infection outcomes. in subsequent clinical studies, thorough examination of cannabinoid content and specific routes of administration will allow us to better elucidate the contribution of each cannabinoid and truly assess dose-response relationships. in conclusion, our study suggests that cigarette smoking and dried cannabis use have distinct, and in some ways unexpected, effects on covid-19 infection reporting. while those endorsing cigarette use exhibited trends towards reduced self-reporting of covid-19 infection, especially among the dual cigarette/cannabis use group, these effects were greatly mitigated by corrections for age, sex, income, and other substance use. on the other hand, dried cannabis use was associated with increased covid-19 infection reporting, even among those that received a covid-19 booster vaccine. although this study relies on infection and substance use self-reporting, our findings support further study into the impact of cigarette smoking and cannabis use on covid-19 outcomes and overall adaptive immune competency. understanding the consequences of inhaled psychoactive substances on respiratory tract infections is critical to develop effective, evidence-based public health strategies and to adequately inform the public. as the covid-19 pandemic continues to evolve and future pandemics are inevitable (the lancet respiratory, 2022), ongoing observational and experimental investigations will be essential to shed light on these complex relationships. references centers for disease controls. 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(2020). clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet, 395(10229), 1054-1062. https://doi.org/10.1016/s0140-6736(20)30566-3 funding and acknowledgements: this work was supported by funding from canadian institutes for health research (cihr, #437075), canada research chair in translational addiction research (crc-2020-00170) and peter boris cannabis, a publication of the research society on marijuana 192 chair in addictions research. jm is a principal and senior scientist in beam diagnostics, inc and has consulted to clairvoyant therapeutics, inc. the other authors have no conflicts of interest to disclose. thank you to jane de jesus, jessica gillard, emily vandehei, and laura lee for helping to collect data and give invaluable feedback throughout the manuscript writing process. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: milad, m., belisario, k., mackillop, j., & hirota, j. a. (2024). dried cannabis use, tobacco smoking, and covid-19 infection: findings from a longitudinal observational cohort study. cannabis, 7(3), 178–192. https://doi.org/10.26828/cannabis/2024/000248 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ v5i3a3_authors_v2 research article 23 ved abstract objective: among a prospective sample of canadian university students, this study aimed to: 1) document changes in cannabis use and perceived harmfulness of use before and after the legalization of recreational cannabis; 2) examine correlates of perceived harmfulness; and 3) explore changes in perceived harmfulness as a function of cannabis use patterns. method: a random sample of 871 students at one western canadian university were assessed preand post-legalization of recreational cannabis. descriptive and inferential statistics were used to explore changes in cannabis use and perceived harmfulness. a random effects model was developed to assess whether cannabis legalization was associated with perceptions of harmfulness of regular cannabis use. results: twenty-six percent of the sample used cannabis during the past three months at both timepoints. the majority of the sample perceived regular cannabis use as a high-risk behaviour at each timepoint (57.3% and 60.9%, respectively). results from the random effects model showed that after controlling for covariates, cannabis legalization was not associated with changes in perceived harmfulness. perceptions of harm remained relatively stable regardless of cannabis use pattern. respondents who endorsed cannabis use at both timepoints reported a significant increase in their frequency of cannabis use post-legalization. conclusions: legalization of cannabis for recreational use was not associated with substantive changes in perceptions of harm among post-secondary students, yet it might lead to increases in cannabis use among those who already use the substance. ongoing monitoring of policies is needed, as are targeted public health initiatives to identify post-secondary students who are at risk for cannabis-related consequences. key words: = cannabis use; young adults; cannabis legalization; perceived risk; post-secondary students in 2018, canada passed bill c-46, becoming the second country to legalize recreational cannabis use for adults. of significant interest from a public health standpoint is whether the legalization of cannabis for recreational use promotes permissive norms or is associated with changes in the incidence, prevalence, or patterns of cannabis use among youth. in a study of cannabis use among post-secondary students at washington state university, miller et al. (2017) found an increase in the frequency of use following legalization of recreational cannabis. in a similar study, kerr et al. (2017) compared students attending studies in oregon, a state where cannabis was legalized for non-medicinal use in 2015, to students attending universities in states joel mader1, jacqueline m. smith1, jennifer smith1, arfan r. afzal2, ameila m. arria3, brittany a. bugbee3, ken c. winters4 1 faculty of nursing, university of calgary 2alberta health services, government of alberta 3center on young adult health and development, department of behavioral and community health, university of maryland school of public health 4oregon research institute cannabis 2022, volume 5 (3) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.03.003 correlates of perceived harmfulness of regular cannabis use among canadian university students before and after legalization corresponding author: joel mader, m.ed., university of calgary, pf122, 2500 university dr. nw. calgary, alberta, canada t2n 1n4. phone: (403) 220-3015. email: jmader@aarc.ab.ca perceived harm of cannabis use preand post-legalization 24 where recreational cannabis use remained illegal (n = 12, 963) via repeated cross-sectional surveys. the authors found that a significant trend existed from 2012 – 2016, with students reporting increases in cannabis use at six of the seven universities included in the study. students attending studies in oregon demonstrated the largest increase in use, although this only occurred among those who had endorsed recent heavy use of alcohol. in a subsequent study of a large sample from us states that had recently legalized marijuana, cerdá and colleagues (2020) found a significant increase in the prevalence of cannabis use disorder (cud)1 among adolescents ages 12 to 17 from preto post-legalization. the authors also found a significant increase in the frequency of past month cannabis use as well as an increase in cud among adults aged 26 and older. there was, however, no increase in frequency of cannabis use among adolescents, nor was there any significant changes in frequency of use or cud among 18to 25-year-olds. in another study in washington state completed by kilmer et al. (2022), the authors found an increase in cannabis use and cud symptomology following the legalization of non-medicinal cannabis among a sample of 12,963 young adults, ages 18 – 25. whether or not legalization of cannabis for personal use results in an increase in consumption is not a trivial concern. research has shown that up to 30% of those who use cannabis develop cud (hasin et al., 2015), with the risk being even higher among those who initiate cannabis use early in adolescence (volkow et al., 2021), and among those who use cannabis more frequently (curran et al., 2019; simpson et al., 2021; steeger et al., 2021). thus, if cannabis use increases, it is expected that the prevalence of cud will increase as well. further, there have been substantial increases in thc potency in recent years (chandra et al., 2019), prompting concerns about the possible adverse impacts of high-potency thc products on risk for cud, neurocognitive functioning, and mental health (e.g., stuyt, 2018). frequent cannabis use has also been associated with negative outcomes including increased risk of psychosis, poorer academic achievement, and increased risk of respiratory issues such as chronic cough (national academies of sciences, engineering and medicine, 2017). among all age groups, youth and young adults (those between the ages of 18 and 25) are the most likely to use cannabis. recent findings from a national canadian survey showed that the prevalence of using cannabis during the past three months was twice as high among adolescents ages 15 to 24 as it was for adults 25 and older (i.e., 30% versus 16%, respectively; government of canada, 2019). cannabis use during these developmental periods might have particularly deleterious effects given that adolescence and young adulthood are stages marked by ongoing neuromaturation (lubman et al., 2015). beyond age and legal status, factors that have been shown to increase the odds of using cannabis are complex and include environmental factors such as parental permissiveness and experiences of childhood adversity (bogdan et al. 2016), and individual traits such as higher impulsivity, antisociality, and sensation seeking (scheier & griffin 2021). perceptions of cannabis risk also appear to influence choices regarding use. for example, franelić and colleagues (2011) found that perceived availability of cannabis and perceived use among peers were among the largest correlates of cannabis use in an international sample of adolescents ages 15 to 16. at a population level, declining perceptions of harmfulness have been associated with increased prevalence of cannabis use (compton et al., 2016; keyes et al., 2016; terry-mcelrath et al., 2017). this association was shown to be most robust among male cannabis users, who rated harms associated with cannabis use as being less risky, while endorsing higher levels of cannabis use than females (hellemans et al., 2019). there has been a gradual decline over the last two decades in perceived harmfulness with a growing majority of youth and adults reporting that cannabis use possesses minimal to no risk. for example, compton and colleagues (2016) reported that among us high school students, there was a significant decline from 50.4% in 2004 to 33.3% in 2014 in perceived cannabis risk, a finding consistent with cerdá and colleagues who found a decline in perceived harmfulness among an adolescent sample following legalization (cerdá et al., 2017). yet, the results are mixed on the issue of legalization and its subsequent effect on perceptions of harmfulness, and it is unclear 1cud is a condition marked by a loss of control of use, engagement of use in risky situations/contexts, physiological dependence (e.g., tolerance, cravings and withdrawal) and social impairment (american psychiatric association, 2022). cannabis, a publication of the research society on marijuana 25 what effect the declining perception of harmfulness is having on rates of cannabis use. for example, in a us sample of youth ages 16 to 19, wadsworth and hammond (2018) found no significant difference in perceptions of harm between those who resided in states where cannabis was legal for recreational use versus those who resided in states where it was illegal. sarvet and colleagues (2018) found that while perceived risk declined substantially among a nationally representative sample of twelfth graders in the us, there has not been an appreciable change in cannabis use in recent years. despite some divergence in findings from studies, changes in estimated harm related to cannabis consumption has been suggested to be a key indicator to monitor for jurisdictions and countries who have legalized the substance for retail sale (wallingford et al., 2019). continuous monitoring of perceived harmfulness is needed as findings might provide important insights regarding public perceptions towards cannabis, perceptions which in turn could impact consumer choices or patterns of use. furthermore, much of the research on legalization policies has focused on us states where cannabis has been legalized for medicinal or recreational use, while little research has been completed regarding the effect of canada’s national legalization policy on cannabis use and perceived harmfulness (turna et al., 2021). to build on the existent literature, this study surveyed a sample of canadian university students before and after the country’s legalization of recreational cannabis to: 1) document changes in cannabis use and perceived harmfulness of cannabis use before and after legalization; 2) examine correlates of perceived harmfulness; and 3) understand subgroup variation in changes of perceived harmfulness. methods study design in march 2018, 4,000 university of calgary students were randomly selected by the university registrar’s office and invited via email to complete an online survey before the legalization of recreational cannabis. the legalization of cannabis had been announced by the government of canada well before students were invited to participate in the survey. this change in national drug policy was widely covered in the news and media, and it was common knowledge that non-medicinal cannabis would be legal in october 2018. the email inviting to students to participate directly referenced the upcoming legalization, and it was assumed all students were aware of the change in the legal status of cannabis while completing the survey. although cannabis was legalized nationally in canada in october 2018, each province was responsible for the oversight and regulation of the retail sales of the substance. in alberta, where the university of calgary is located, the legal minimum age for purchasing recreational cannabis is 18 years old. cannabis can only be purchased legally in alberta via licensed retailers or by ordering online from alberta cannabis, a website operated and owned by the alberta gambling, liquor and cannabis agency. in addition to variation in policies, important differences exist provincially with respect to cannabis use and consumption. for instance, a national survey completed pre-legalization found albertans were among the highest consumers of cannabis, with residents of british columbia and nova scotia holding the second highest and highest rates of consumption, respectively (government of canada, 2017). to be eligible for participation in the study, students had to be 18 years or older and enrolled in at least one university class on campus. the response rate for the time 1 (pre-legalization) survey was 55%, with 2,212 individuals choosing to participate. all time 1 respondents were given the option of completing a future survey, and 1,202 respondents (54%) agreed to be contacted. all respondents who completed the time 1 survey and consented to be contacted were eligible to participate regardless of student status at time 2 (post-legalization). in march 2019 (approximately six months post-legalization), an email was sent to these 1,202 individuals, and 890 (74%, or 40% of the original time 1 sample) chose to participate in the second survey. of these respondents, 19 cases were dropped due to missing values on key variables (i.e., frequency of cannabis use at time 2), resulting in an analytic sample of 871. the study was approved by the university of calgary conjoint health research ethics boards (reb18-0184). the recruitment methods employed in this study followed the protocols described by dillman et al. (2014). for both surveys, four perceived harm of cannabis use preand post-legalization 26 reminders were sent via email over a period of six weeks. informed consent was obtained prior to each survey, and respondents were provided with a gift card as an honorarium for their time ($10 for the pre-legalization survey and $15 for the postlegalization survey). the incentive for the postlegalization survey was increased to maximize participation and reduce attrition. transparency and openness the data for this study represent a portion of a larger dataset that was collected as part of the university of calgary’s campus experience with cannabis study. two papers have been published from this study, both of which described crosssectional data collected via the pre-legalization survey in march 2018 (mader et al., 2019 & smith et al., 2019). no findings from the postlegalization survey were presented in those studies, as the follow-up survey had not been sent yet to participants. all de-identified data, analysis code, and research materials are available upon request. this study’s design and its analysis were not pre-registered, and sample size was not calculated in advance to data collection or analysis. measures frequency of cannabis use. at both time 1 and time 2, frequency of cannabis use in the past three months was measured using the second item of the world health organization’s alcohol, smoking and substance involvement screening test (who assist working group, 2002). specifically, respondents were asked “in the past three months, how often have you used cannabis products (marijuana, pot, grass, hash, etc.)”? possible responses to this item were never, once or twice, monthly, weekly, or daily or almost daily. to explore changes in perceptions of harmfulness based on patterns of cannabis use, we later created a composite variable where respondents were grouped based on their endorsement of past three month use at time 1 and time 2. the four groups were: “abstinence” (respondents who did not report use at either time point); “initiation/re-initiation” (respondents who only endorsed past three-month use at time 2); “persistent” (respondents who endorse past threemonth use at both time points); and “cessation” (respondents who endorsed past three-month use at time 1 but not time 2). perceived harmfulness of regular cannabis use. respondents’ estimation of the harm associated with regular cannabis use was measured using an item from the monitoring the future survey (inter-university consortium for political and social research, 2018). this item asked respondents to indicate how much people risk harming themselves (physically or in other ways) if they smoke marijuana regularly. the ordinal response options for this item were no risk, slight risk, moderate risk, great risk, or can’t say. later, we dichotomized respondents’ responses to perceived harmfulness by collapsing “no risk” and “slight risk” into one category representing lower perceived risk, and “moderate” and “great risk” into another representing higher perceived risk. recoding was done to simplify the statistical analyses, as this allowed for the use of logistic model versus multinomial. respondents who selected “can’t say” were treated as missing in the analyses. socio-demographic characteristics. demographic information was collected at both time 1 and time 2. respondents were asked their age at time 1 and a composite variable was created for time 2 where 1 year was added to each case. respondents were asked to indicate their gender at time 1 by selecting from one of three categories (female, male, and other). only five respondents in the analytic sample selected “other” for gender and because there were so few cases for this category, these values were treated as missing for the analyses. maternal education served as a proxy measure for socioeconomic status. respondents were asked to indicate their mother’s highest level of completed education via an ordinal item at time 1, with possible responses ranging from no schooling to a professional/doctoral degree. student status was measured at time 2. part-time and full-time statuses at time 2 were later collapsed into one larger category, with enrolled in academic studies serving as the reference. student status was not measured at time 1 as the sample was drawn from a student population enrolled in classes at the university of calgary. respondents were asked to indicate their race/ethnicity at time 2 by selecting from a comprehensive list of racial/ethnic categories. due to the preponderance of respondents identifying as white or asian, race/ethnicity was collapsed into three categories (white, asian, and cannabis, a publication of the research society on marijuana 27 other race/ethnicity groups). data on employment status was collected at time 2, where respondents were asked if they were unemployed, employed part time, or employed full time. analytical plan to evaluate if changes occurred preand postlegalization, the analytic sample was limited to respondents who participated in both the time 1 and time 2 surveys (n = 871). the first step in the analysis was to assess the degree of attrition bias by comparing the sample of individuals who participated in both surveys to the sample who only completed the initial survey. second, respondents were classified into one of four patterns based on their reported cannabis use at time 1 and time 2: abstinence, initiation/reinitiation, persistence, and cessation. third, descriptive statistics were used to understand changes in cannabis use and perceived harmfulness of regular cannabis use. fourth, to explore if intergroup differences existed based on pattern of cannabis use and changes in perceived harmfulness between time 1 and time 2, four mcnemar tests were completed, one for each of the four patterns. finally, we developed a random effects (re) model (laird & ware, 1982) to evaluate the association between student status, age, gender, race/ethnicity, frequency of cannabis use, time (preversus post-legalization), and perceived harmfulness of regular cannabis use. we did not control for employment status, as this information was only collected at time 2. when repeated measurements are collected for each subject, the observations at different time points tend to be correlated. re modeling was chosen as it accounts for this correlation and produces statistically efficient estimates with correct standard errors (laird & ware, 1982). the structure of re model is selected based on bayesian information criterion (bic; schwarz, 1978). the bic statistic balances model parsimony with model fit, with lower bic statistics suggesting a better model. for the re model, observations for repeated measures collected at time 1 and time 2 were combined into composite variables. this was done for both perceived harmfulness and frequency of use. this allowed for intra-subject correlation to be estimated (e.g., correlations within subject at time 1 and time 2) and adjusted for when producing estimates. time was added as a variable and was entered into the model to explore if there were changes in perceptions of harmfulness pre and post legalization. the dependent variable entered into the re model was perceived harmfulness of regular cannabis use at time 1 and time 2. forty-five cases were dropped from the analysis as they endorsed “can’t say” when asked to evaluate risk at either time 1 or time 2. an additional 8 respondents were excluded due to missing values for gender (4), race/ethnicity (3), and age (1). this left a total of 818 complete cases to be included in the model. given the exploratory nature of the study, we also investigated if there were any significant interaction effects using time (preand postlegalization), frequency of cannabis use, gender, ethnicity, and student status. analyses were conducted using ibm spss statistics 25 and stata se 15.1. given the number of inferential tests and comparisons being made, alpha was set to .01. results attrition analysis compared to the students who only participated in the time 1 survey (n = 1322), the analytic sample had a significantly greater proportion of females (53.6% versus 62.3%, respectively; x2 = 15.4, p < .001). respondents in the analytic sample were also, on average, one year younger than those who only participated in the time 1 survey (22.7 versus 23.5, respectively; t = 3.32, p = .001). the prevalence of lifetime cannabis use at time 1 was significantly higher among respondents who completed both surveys (55.3%) compared to those who only completed the time 1 survey (49.2%; x2 = 5.3, p = .02). these respondents also demonstrated greater frequency of past three-month cannabis use at time 1 when compared to respondents who did not complete the time 2 survey (u = 4.2, p < .001). the groups did not differ with respect to maternal education. sample characteristics table 1 presents the characteristics of the total sample as well as respondents stratified by pattern of cannabis use. the majority of the sample perceived harm of cannabis use preand post-legalization 28 table 1. sample characteristics total sample (n = 871) abstinence (n = 488) initiation/ re-initiation (n = 100) persistent (n = 231) cessation (n = 52) variable n (%) n (%) n (%) n (%) n (%) gender (n, % female) 543 (62.3) 318 (65.2) 62 (62) 128 (55.4) 35 (67.3) ethnicity white 469 (53.8) 228 (46.7) 58 (58) 153 (66.2) 30 (57.7) asian (south and east asian) 308 (35.4) 211 (43.2) 32 (32) 50 (21.6) 15 (28.8) other 91 (10.4) 47 (9.6) 10 (10) 27 (11.7) 7 (13.5) maternal education <high school 68 (7.8) 45(9.2) 6 (6) 13 (5.6) 13 (25) high school 119 (13.7) 60 (12.3) 12 (12) 38 (16.5) 9 (17.3) some technical school, college, or university 129 (14.8) 63 (12.9) 24 (24) 36 (15.6) 6 (11.5) completed technical school 67 (7.7) 43(8.8) 5 (5) 13 (5.6) 6 (11.5) completed college or university 360 (41.3) 204 (41.8) 36 (36) 99 (42.9) 21 (40.4) professional or graduate degree 127 (14.6) 73 (15.0) 16 (16) 32 (13.9) 6 (11.5) time 2 employment status full-time employment 170 (19.5) 79 (16.2) 17 (17) 61 (26.4) 13 (25) part-time employment 330 (37.9) 180 (36.9) 47 (47) 81 (35.1) 22 (42.3) time 2 student status full-time academic studies 615 (70.6) 366 (75) 70 (70) 149 (64.5) 30 (57.7) part-time academic studies 36 (4.1) 19(3.9) 3 (3) 13 (5.6) 1 (1.9) not employed, nor enrolled in academic studies at time 2 43 (4.9) 29 (5.9) 2 (2) 8(3.5) 4 (7.7) past three-month cannabis use at time 1 (pre-legalization) never 588 (67.5) 488 (100) 100 (100) once or twice 124 (14.2) 90 (39) 34 (65.4) monthly 65 (7.5) 52 (22.5) 13 (25) weekly 52 (6.0) 49(21.2) 3 (5.8) daily or almost daily 42 (4.8) 40 (17.3) 2 (3.8) past three-month cannabis use at time 2 (post-legalization) never 540 (62.0) 488 (100) 52 (100) once or twice 147 (16.9) 67(67) 80(34.6) monthly 46 (5.3) 12(12) 34(14.7) weekly 71 (8.2) 15(15) 56(24.4) daily or almost daily 67 (7.7) 6(6) 61(26.4) m (sd) m(sd) m(sd) m (sd) m (sd) time 2 age 23.7 (4.7) 24.0 (5.4) 22.8 (3.5) 23.7(3.9) 22.9 (2.8) was female (62.3%), and slightly more than half of the respondents were white. most respondents indicated at time 2 that they were enrolled in fulltime studies (70.6%), while a minority endorsed taking classes part-time (4.1%). cannabis use the largest pattern of use was abstinence, with 56.0% of the sample reporting no cannabis use at either time point. the second most common pattern was persistent, with 26.5% of cases having endorsed cannabis use in the three months preceding the preand post-legalization surveys. eleven percent were classified under the initiation/re-initiation pattern2, while 6.0% reported use at time 1 but not at time 2. with respect to changes in frequency of cannabis consumption, we compared frequency among respondents those who endorsed a persistent pattern of use (i.e., endorsed cannabis use in the past three months at both time points; n = 231). a significant increase was observed at time 2 when compared to time 1 (w = 3.5. p = .001), indicating there was an increase in frequency of use post-legalization among this group. as seen in table 1, the proportion of those with a persistent pattern of use showed an increase in cannabis daily or near daily from 17.3% at time 1 to 26.4% at time 2. 271% of students categorized as initiators/re-initiators endorsed having used cannabis in their lifetime at time 1 but did not report having used cannabis in the three months preceding the pre-legalization survey. cannabis, a publication of the research society on marijuana 29 table 2. perceived harmfulness based on pattern of cannabis use preto post-legalization total sample (n = 871) abstinence (n = 488) initiation/re-initiation (n = 100) persistent (n = 231) cessation (n = 52) perceived harm time 1 time 2 time 1 time 2 time 1 time 2 time 1 time 2 time 1 time 2 n % n % n % n % n % n % n % n % n % n % no risk 93 10.7 73 8.4 18 3.6 10 2.0 12 12.0 8 8.0 56 24.2 49 21.2 7 13.2 6 11.3 slight risk 249 28.6 250 28.7 93 19.0 100 20.5 35 35.0 38 38.0 103 44.6 96 41.5 18 34.0 16 30.2 no or slight risk, combined 39.3 37.1 22.7 22.5 47.0 46.0 68.8 62.8 48.1 42.3 moderate risk 297 34.1 346 39.7 183 37.5 212 43.4 35 35.0 41 41.0 57 24.7 72 31.2 22 41.5 21 39.6 great risk 202 23.2 185 21.2 173 35.5 153 31.4 13 13.0 12 12.0 12 5.2 12 5.2 4 7.5 8 15.1 moderate or great risk, combined 57.3 60.9 73.0 74.8 48.0 53.0 29.9 36.4 50.0 55.8 can’t say* 30 3.4 17 2.0 21 4.3 13 2.7 5 5.0 1 1.0 3 1.3 2 0.9 1 1.9 1 1.9 *participants were categorized into the patterns of use based on their reported cannabis use: “abstinence” (those who endorsed no past three-month use at time 1 or time 2); “initiation/re-initiation” (those who only endorsed past three-month use at time 2); “persistent” (those who endorsed past three-month use at both time 1 and time 2); cessation” (those who endorsed past three-month use at time 1 but not time 2) participants who selected “can’t say” for perceived harm at either time point were excluded from the mcnemar’s tests and the re model. perceived harm of cannabis use preand post-legalization 30 perceived harmfulness preand post-legalization table 2 presents respondents’ perceptions of harm preand post-legalization. at both time 1 and time 2, the majority of the sample perceived regular cannabis use as being high risk (57.3% and 60.9%, respectively). without controlling for covariates, there was no significant difference between time 1 and time 2 regarding perceived harmfulness of regular cannabis use (w = .72, p = .47). the persistent group demonstrated the largest change in perceptions of harmfulness, with 6.5% more individuals endorsing that regular cannabis carried moderate or great risk at time 2. however, mcnemar tests revealed no significant within-group changes existed in perceptions of harmfulness based on pattern of use (abstinence, p = 0.919; initiation/re-initiation, p = 1.000; persistent p = 0.104; cessation p = 0.791). random effects model the best fitting model was selected using the bic statistic and is presented in table 3. a significant intraclass correlation coefficient (icc) was found 0.57 (95% ci: 0.48-0.65, p < .001), indicating that a moderate correlation existed among observations from each student. of the variables included in the model, cannabis use frequency and ethnicity were significantly associated with perceptions of harm. specifically, frequency of cannabis use was inversely related to perceived harmfulness, such that more frequent consumers were less likely to endorse higher perceived risk. similarly, white respondents demonstrated significantly lower perceptions of risk when compared to asian students. although time 2 had the third largest effect size (odds ratio = 1.41), it was not found to be a significant predictor of perceived harmfulness (p = 0.03). no significant interaction effects were observed. discussion in this canadian university sample, no changes in the perceived harmfulness of regular cannabis use were observed preto postlegalization of recreational cannabis. approximately one-quarter of the sample endorsed having used cannabis in the prior three months at both time points; these participants also reported a significant increase in selfreported frequency of cannabis use from preto post-legalization. in terms of perceptions of harmfulness, those who had abstained at both table 3. factors associated with higher perceived harmfulness of cannabis preand post-legalization variables odds ratio 95% ci se p-value legal status time 1 (pre-legalization) ref time 2 (post-legalization) 1.41 [1.03, 1.92] 0.22 .03 cannabis use frequency 0.44 [0.37, 0.52] 0.04 <.001 ethnicity asian ref other 0.53 [0.24, 1.17] 0.21 0.11 white 0.41 [026, 0.65] 0.10 <.001 age 1.03 [0.99, 1.07] 0.02 .20 gender male ref female 1.04 [0.68, 1.60] 0.23 .89 student status at time 2 no ref yes 1.19 [0.70, 2.05] 0.33 .51 note. ref = reference category. cannabis, a publication of the research society on marijuana 31 time points viewed smoking cannabis regularly as being a riskier activity compared to their counterparts who reported a persistent pattern of use. perceptions of risk remained relatively stable over time based on pattern of cannabis use. among the total sample, no significant changes were observed with respect to perceived harmfulness of regular cannabis use preto postlegalization after controlling for demographic variables and frequency of cannabis use. however, white ethnicity and frequency of cannabis use were found to be significantly associated with lower perceptions of harmfulness. although a causal relationship cannot be drawn, the increases in frequency of use preto post-legalization among individuals who reported cannabis use at both time 1 and time 2 is concerning. increases in frequency of cannabis use, especially daily use, among post-secondary students is likely to translate into more cannabisrelated harms downstream, which could include poorer psychosocial outcomes (meier, 2021), lower academic achievement (arria, et al., 2015), and higher incidence of cud (kroon et al., 2020). ongoing monitoring of these possible negative outcomes, as well as interventions and initiatives that seek to reduce risk of harm among this population are needed. this could include the development and evaluation of campus policies that discourage cannabis use among students (e.g., prohibiting sales, advertisement and consumption of cannabis on campus) as well as the promotion of brief interventions and substance use counselling services which target cannabis use among students (winters et al., 2021). while the present study asked about perceived harm related to smoking marijuana, more varied cannabis products are becoming available on the legal market (e.g., vaping, edibles, drinks, etc.). these other methods of administration also warrant consideration (wallingford et al., 2019), as consumers might evaluate these products differently when considering risk. similarly, the current study explored generalized perceptions of harm (e.g., harm to others) versus personalized perceptions of harm (e.g., harm to self). exploring changes in the evaluation of risk as it relates to self and others within a legal context are important areas that warrant further monitoring. nonetheless, our finding that legalization of recreational cannabis use was not associated with significant changes in the perceptions of harmfulness of regular cannabis use is consistent with wadsworth and hammond’s (2018) findings. as in their study, perceptions of harm in our sample remained stable despite changes in legal status of cannabis. it is worth noting that past research has shown that lower perceptions of harmfulness are associated with greater support for legalization of non-medicinal cannabis (campbell et al., 2017). it is plausible that fluctuating perceptions of harm may have preceded changes in attitudes towards legalization and that legal status may not result in substantive changes regarding perceptions of harm, at least in the short-term. further longitudinal research is needed to better understand the long-term impacts legalization might have on attitudes and evaluations of risk regarding the use of cannabis. phenomenon such as confirmation bias could be explored within this context, as this bias would predict that an individual’s perception of harm would influence their views on legalization in a confirmatory manner. moreover, notable differences existed with respects to perceptions of harmfulness when comparing students who abstained versus those who were consumers of cannabis. this difference was most notable between the “persistent” and “abstinent” groups. further research is needed as legalization becomes more standard to determine if, and how, consumption patterns may change in concert with perception of harmfulness, and whether subgroup variations may exist based on patterns of use. further investigation is also needed to better understand what may have contributed to white students demonstrating lower perceptions of harmfulness when compared to their asian counterparts, and whether this same finding exists among other college aged or university samples. it should be noted that the university of calgary has a large representation of international students from asian countries. given that so few countries have legalized the substance, the majority, if not all, international students would have been from countries where cannabis remains an illegal substance. it is plausible that norms regarding cannabis use in these countries may be less permissive when compared to canada, and this may have informed international students’ perceptions of harmfulness regarding the substance. perceived harm of cannabis use preand post-legalization 32 our finding that individuals who reported greater frequency of cannabis use demonstrated lower ratings of perceived harmfulness is consistent with past research that has shown these two variables share an inverse relationship (compton et al., 2016; keyes et al., 2016). this consistency across studies is concerning, as those who might be at greatest risk of experiencing negative consequences seem to downplay the risk or may be less aware of the potential for harms associated with regular use. although educational campaigns have been launched in canada, a survey completed shortly after legalization showed that only 1/3 young adults in ontario reported having been exposed to some form of public health messaging (leos-toro et al., 2020). such findings underscore the need for more targeted public health initiatives in postsecondary settings. this could include the development and implementation of policies by university administrators to limit accessibility of cannabis campus and prohibiting advertisement. educational programs targeting those who use cannabis the most about the possible adverse effects of cannabis use may also prove useful. limitations the generalizability of the findings from this study is limited given the sample was from one geographic location (e.g., calgary, alberta), and as noted, there are significant differences in provincial and municipal policies and bylaws for the regulation of retail sales of cannabis. selfreported changes in cannabis use postlegalization among the persistent group may reflect respondents being more willing to report their use in a legalized context versus representing changes in use. several variables were only measured at time 2 (e.g., part-time/fulltime student status; employment) and because of this changes in these variables could not be included a covariates in the analysis. similarly, measuring socioeconomic status via maternal education was not ideal, and more comprehensive information could have been collected (e.g., postal code of residence, paternal education etc.). the assessments of cannabis use, and perceptions of harm were also limited (e.g., two categorical variables), and a more in-depth assessment of these constructs could have yielded more nuanced findings. for example, future studies should collect data on types of cannabis products used, average monies spent on cannabis, or the potency of products selected. however, given that the current study represented a subset of a larger dataset, which addressed a variety of topics, assessments of these constructs were restricted to ensure the survey was not excessively long or cumbersome to complete. when compared to the group who completed only the pre-legalization survey, respondents who participated in both surveys were younger, and there was a greater representation of females. this is notable, as males have been consistently shown to demonstrate higher rates of cannabis use when compared to their female counterparts. the study results may have also been biased by an over-representation of students who had an interest in cannabis, given those who completed both surveys showed higher rates of lifetime use. finally, less than 25% of the original sampling frame participated in both time 1 and time 2 surveys. thus, different results might have been obtained if the full sample had been retained. this study represents a brief snapshot given that the survey was completed by respondents approximately six months post-legalization. it is likely that as more time passes, further changes will occur with respect to public perceptions regarding cannabis, including the perceived harmfulness of the substance. similarly, there were only two waves of data collection. this limited the statistical methods that could be employed, and, as a result, we were unable to complete more sophisticated analyses such as structural equation modelling, which could have provided greater insights with respect to the longitudinal relationships between variables (e.g., the direction of the relationship between perceived harmfulness and cannabis use). despite these limitations, the study had a number of strengths, most notably the prospective design which allowed for changes in cannabis use preto post-legalization to be captured within a single sample. the potential effect of legalization on perception of harm was able to be explored while controlling for covariates. conclusions in summary, cannabis use and perceptions of harm related to cannabis are important indicators to be monitored during and after the legalization, cannabis, a publication of the research society on marijuana 33 especially among at-risk populations. among this sample of post-secondary students in canada, there did not appear to be a substantive change with respect to perceived harm of regular cannabis use preto post-legalization. however, perceptions of harm were associated with frequency of use and ethnicity, with white students and higher frequency cannabis users demonstrating lower perceptions of risk. students who reported no use preand post-legalization demonstrated higher perceived harm, whereas those who endorsed cannabis use preand postlegalization generally viewed regular use as being less risky. significant increases in the frequency of cannabis use were observed among these persistent users. this increase is cause for concern as this might translate into greater incidents of cannabis-related harm. although these preliminary findings require replication, the results underscore the need for effective prevention and public health initiatives on college and university campuses. moreover, ongoing monitoring and longitudinal research is required to better understand the long-term impact of legalization on post-secondary populations. references american psychiatric association. 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(2002). the alcohol, smoking and substance involvement screening test (assist): development, reliability and feasibility. addiction, 97(9), 1183–1194. funding and acknowledgements: this work was supported by the internal special call grant, faculty of nursing, university of calgary; calgary police services. none of the authors have any conflicts of interest to declare. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. v5i2a1_authors_final research article 1 ved abstract increased parental monitoring is protective against cannabis use (cu) for justice involved youth, although discrepancies across parent/adolescent reports of monitoring may confer risk. baseline data were drawn from two randomized clinical trials (152 adolescents; mage= 15.9; 68% male). adolescents reported on past 60-day cu and adolescents and parents completed a measure of parental knowledge, parental solicitation, parental control, and child disclosure. multiple regression models that varied operationalization of discrepancies were performed, in which cu was predicted from each monitoring construct. inclusion of main effects of parent and adolescent reports improved prediction of cu, particularly parental knowledge and child disclosure. when operationalized categorically, discrepancies improved prediction of cu for parental knowledge. discrepancies did not improve prediction of cu for the other aspects of parental monitoring. findings diverge from previous research on adolescent alcohol use; explanations of findings and implications for treatment are discussed. key words: = cannabis use; juvenile justice; youth; parental monitoring; sources of parental knowledge the prevalence of past-year cannabis use (cu) increased among justice-involved youth (jiy) in recent years (vaughn et al., 2020) and this trend is expected to continue as the cannabis legalization landscape evolves; as states continue to legalize adult cu, studies show corresponding increases in use among youth who had previous contact with the justice system (kan et al., 2020). this pattern suggests that less-restrictive policies surrounding cannabis and resulting changes in nationwide perceptions of recreational cu, as well as access to cannabis, may beget increased cu within a group already at risk for cu (kan et al., 2020). this is concerning because there are negative consequences associated with regular cu among jiy. for example, the presence of a substance use disorder(s) (including cannabis use disorder) in court-involved, non-incarcerated youth was associated with increased risk for general recidivism (aebi et al., 2021). this evidence lauren micalizzi1,2, nazaret suazo3, claudia paszek3, lynn hernández4, kathleen kemp3,5, kristina m. jackson1,2, anthony spirito3 1center for alcohol & addiction studies, brown university, school of public health 2department of behavioral and social sciences, brown university 3department of psychiatry and human behavior, warren alpert medical school of brown university 4cuny school of medicine, the city college of new york 5rhode island family court mental health clinic cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.001 discrepant parent-adolescent reports of parental monitoring and their relations to cannabis use among justice-involved youth corresponding author: lauren micalizzi, phd, center for alcohol & addiction studies, brown university school of public health, box g-s121-5 providence, ri, 02903; department of behavioral and social sciences, box g-s121-5, brown university school of public health, providence, ri, 02912. phone: (401) 863-6640. fax: (401) 863-6697. email: lauren_micalizzi@brown.edu monitoring discrepancies and cannabis use 2 highlights the importance of studying and minimizing the risk factors associated with cu among jiy. one of these risk factors is familial context; increased parental monitoring is associated with reduced recidivism and related risks for youth who were previously arrested (kennedy et al., 2018). parental monitoring and knowledge are two of the most frequently evidenced protective familial management strategies for youth substance use (crouter & head, 2002). consequently, targeting parental knowledge and monitoring of teen’s substance use has been a focus in treatment in order to promote and support positive behavior change for adolescents (mcgillicuddy & eliseoarras, 2012). it is important to characterize which dimensions of parental monitoring are most protective against substance use to improve and better implement familial interventions, and this begins with thoughtful operationalization of parental monitoring and related aspects of monitoring. parental monitoring reflects a set of discrete parenting behaviors that involve attention to and tracking of the child’s behaviors (dishion & mcmahon, 1998). this definition implies that parents intentionally and actively seek information about their adolescent’s behavior (crouter & head, 2002). parental knowledge represents what parents know about their children’s behavior, while sources of knowledge represent information acquisition methods—that is, how parents come to learn about their child’s behavior (stattin & kerr, 2000). three sources of knowledge have been proposed: parental solicitation involves parental garnering of information; parental control entails parental imposition of rules on activities; and child disclosure is the unprompted reception of information from the child. evaluating sources of parental knowledge is most relevant if the goal of the research question is to identify discrete parenting behaviors (and thus, active ingredients) that may be targeted through intervention (micalizzi et al., 2019). mounting research across early (baker et al., 1999), middle (beck et al., 1999; mott et al., 1999; richards et al., 2004), and late adolescence (barnes et al., 2000; siebenbruner et al., 2006) shows that greater monitoring and knowledge (particularly child disclosure) are associated with lower alcohol, cigarette, and illicit drug use among general population samples (abar et al., 2014; leventhal & brooks-gunn, 2000; li et al., 2000; micalizzi et al., 2019). parental monitoring and knowledge may be especially protective among jiy, as research among delinquent youth (who are not necessarily justice involved) highlights this possibility. for example, a meta-analysis of parenting behaviors and delinquency indicated that higher parental monitoring was strongly negatively associated with delinquency (hoeve et al., 2009). there may also be reciprocal associations between parental knowledge and delinquent behavior, such that low levels of parental knowledge longitudinally predict increased delinquent behavior and that high levels of delinquent behavior predict lower levels of parental knowledge (laird et al., 2003). more recent studies suggest that the sources of parental knowledge, specifically, are a significant factor to consider when predicting problem behavior. child disclosure of behaviors emerged as a stronger predictor of changes in delinquent behavior over time compared to active parental monitoring (kerr & stattin, 2000; kerr et al., 2010). thus, the relations between aspects of parental monitoring and problem behaviors are complex, prompting further inquiry into the nature of these associations among jiy. parental monitoring tends to be assessed via self-report, which begs the question of who should report on the behavior. studies that assess parental monitoring reported by both non-jiy adolescents and parents find that parents report higher levels of monitoring than their adolescents (e.g., abar et al., 2014) and that there is only small or moderate correspondence across reports. this pattern indicates that each member of the dyad may capture different aspects of parental monitoring (abar et al., 2014) or that they perceive the salience and effectiveness of these aspects of monitoring differently. discrepant parent/adolescent reports of parental monitoring do not solely represent measurement error; rather, the lack of correspondence across ratings may have predictive value. for example, increased rater discrepancies indicate higher risk for adverse adolescent outcomes, including substance use (abar et al., 2014; tremblay pouliot & poulin, 2020) and delinquency (de los reyes et al., 2010; ksinan & vazsonyi, 2016) among general population samples. research suggests that adolescent reports of monitoring are more strongly predictive of their own substance use than parents’ reports (e.g., kerr & stattin, 2000). however, there is also cannabis, a publication of the research society on marijuana 3 evidence for interactions between parents’ and adolescents’ reports, such that the negative association between child-reported parental knowledge and delinquency was stronger when their mother also reported high parental knowledge (reynolds et al., 2011). consequently, discrepant parent-adolescent reports of parental monitoring may have predictive utility with jiy, and more importantly, may reflect underlying mechanisms (e.g., poor communication; korelitz & garber, 2016) that should be addressed in an intervention. to date, there is a dearth of research examining discrepancies between reports of parental monitoring and associations with cu, and to our knowledge, this has not been assessed among jiy. further, parental monitoring and rater discrepancies may have differing associations with cu relative to other substances due to the evolving cannabis landscape. there are many terms used to characterize discrepancies (e.g., incongruence, inconsistencies, divergence, difference), yet in essence, all refer to the variation in agreement across parent and adolescent ratings (de los reyes et al., 2010). while there is clear utility in evaluating discrepancies, care must be taken in operationalizing them. many researchers test agreement/discrepancy hypotheses using difference scores (i.e., rater 1 [adolescent] minus rater 2 [parent]; osborne & lonigan, 2019), yet there are conceptual and statistical limitations to this approach (laird, 2020; laird & de los reyes, 2013). to this end, a previous study (abar et al., 2014) tested the utility of different conceptualizations of parent/adolescent discrepancies in reports of parental monitoring and their utility in predicting alcohol use over time. the researchers found that adolescent reports were better predictors of alcohol use than parent reports, yet greater discrepancies were uniquely associated with higher likelihood of alcohol use. building off this foundational work (abar et al., 2014; laird, 2020; laird & de los reyes, 2013), the current study examines the utility of various operationalizations of parent/adolescent discrepancies of parental knowledge and sources of parental knowledge in predicting past 60-day cannabis use among jiy. it was hypothesized that: 1) for both adolescent and parent reports of parental monitoring, increased monitoring would be associated with less frequent cu; 2) there would be modest correspondence across parent and adolescent reports of all aspects of parental monitoring; 3) parents would report higher levels of parental knowledge, parental control, parental solicitation, and child disclosure relative to adolescents; 4) consistent with abar et al., 2014, the operationalization of discrepancies based on categorical groupings (i.e., categorical groupings based on adolescent report [high/low] and parent report [high/low]) would be most predictive of cu; and 5) adolescent reports of child disclosure would be most predictive of adolescent cu. due to the disproportionate involvement of youth of color in the juvenile justice system, as well as in the present study samples, it is important to probe potentially differing effects of parental monitoring on substance use among youth from different racial and ethnic backgrounds. although there are some mixed findings (e.g., smith & krohn, 1995), most studies find that parental monitoring is protective against deviant behaviors among hispanic/latine youth (e.g., caldwell, 2006; forehand et al., 1997). this suggests that lower correspondence in reports of parental monitoring across hispanic/latine families may be a strong indicator of risky adolescent substance use, but to our knowledge, this has not been explored. additionally, there is some evidence for racial differences in parental monitoring (e.g., blustein et al., 2015; latendresse, ye, chung, hipwell, & sartor, 2017), yet there is mixed evidence for racial/ethnic differences related to the protective effect of parental monitoring (e.g., bohnert et al., 2009; latendresse et al., 2017). to our knowledge, this has not been assessed for cu. consequently, we explored ethnic and racial differences in discrepancies in exploratory analyses. methods participants and procedure baseline data (i.e., prior to the intervention) were drawn from two randomized clinical trials (rct) involving cannabis-using court-involved, non-incarcerated youth (n=152) and a participating caregiver. youth involved in these studies were in the diversion stage of their involvement with the juvenile justice system, often having a first-time offense or low-level second time offense. participants were eligible if they were english and/or spanish speakers. monitoring discrepancies and cannabis use 4 study 1: 83 youth (73.49% male; mage=15.93 years) who reported past-year cu at intake to a family court in the northeast united states, were 18 years of age or younger, and lived at home with a parent or guardian were recruited for a study of the effectiveness of a brief motivational interview plus parenting intervention to reduce youth cu (kemp et al. , 2022). participants were referred for status (12.64%) and delinquent (87.36%) offenses. youth in study 1 self-reported race as: 49.37% white, 24.05% black or african american, 2.53% native hawaiian or other pacific islander, 1.27% american indian or alaskan native and 1.27% asian, 10.13% other, 11.39% multiracial; 55% identified as hispanic/latine. parents in study 1 (n=80; 74.07% female; mage=41.69) self-reported race as: 17.72% non-hispanic black or african american, 6.33% hispanic black; 12.66% hispanic white, 48.10% non-hispanic white, 1.27% american indian or alaskan native, 1.27% asian, 10.13% other, and 2.53% preferred not to answer. caregivers included: biological parents (88%), step parents (4%), adoptive parents (4%) relative guardians (2%) and non-relative guardians (2%) . study 2: 69 youth (60.87% male; mage=15.82) who were between 13 and 18 years of age, lived at home with parent or legal guardian, used cannabis at least three times in the prior 90 days, and had a history of truancy in the past school year were recruited for a study evaluating the feasibility, acceptability, and preliminary efficacy of motivational enhancement therapy plus the family check-up for parents; see spirito et al. (2018) for more information. participants had histories of truancy and thus were referred for status offenses. youth in study 2 self-reported race as: 40.58% non-hispanic white, 13.04% hispanic white, 18.8% non-hispanic black or african american, 4.35% hispanic black, and 23.19% multiracial. parents in study 2 (n=69; 91.3% female; mage=42.1) self-reported race as: 47.83% non-hispanic white, 17.39% hispanic white, 17.39% non-hispanic black or african american, 4.35% hispanic black, 11.59% multiracial, and 1.45% other. all caregivers were biological parents; 91% of adolescents lived with the participating biological parent and 9% lived with their other biological parent. these studies were approved by brown university and/or lifespan hospital irbs. measures demographics. youth and caregivers reported their age, sex, race, and ethnicity. cannabis use. the timeline followback (tlfb; dennis et al., 2004; sobell & sobell, 1992) covered the number of days of cannabis use over the 60 days prior to the baseline assessment. parent monitoring questionnaire (pmq; stattin & kerr, 2000), also referred to as sources of parental knowledge, is a 24-item youth and parent report measure designed to assess parental knowledge as well as three sources of parental knowledge (child disclosure, parental solicitation, parental control). adolescents reported the proportion of time they experience monitoring strategies on a likert scale (ranging from 1= “no, never [0%]” to 5= “yes, always [100%]”). scale scores were computed by reverse scoring items where necessary and averaging relevant items. parents and adolescents responded to nine items about parents’ monitoring (i.e., parental knowledge). an example item from the adolescent version includes, “how often do your parents know what you do during your free time?” parent items reflected identical content but were phrased from the parent’s perspective. cronbach’s α teen= .84, parent=.86. child disclosure (5 items) evaluated adolescents’ spontaneous disclosure of information about daily activities (e.g., “if you are out at night, when you get home, do you tell what you have done that evening?”; parent items were worded from their perspective); cronbach’s α teen=.90, parent=.79. parental solicitation (5 items) tapped parental garnering of information about their adolescents’ behavior (e.g., “in the last month, have your parents talked with the parents of your friends?”); cronbach’s α teen= .74, parent=.77. parental control (5 items) evaluated parental rules and restrictions to control and gain information about their child (e.g., “do you need to have your parents’ permission to stay out late on a weekday evening?”); cronbach’s α child=.88, parent=.82. data analysis plan associations among parent and child reports of each monitoring-related construct (parental knowledge, parental control, parental solicitation, and child disclosure) were first evaluated using cannabis, a publication of the research society on marijuana 5 bivariate correlational analyses. parent and adolescent means for each aspect of monitoring were then compared using dependent samples t tests. next, following abar et al. (2014), a series of hierarchical multiple regressions were performed. for each aspect of monitoring, four models reflecting different methods to measure parent/adolescent discrepancies were run. in all models, frequency of past 60-day cannabis use was the dependent variable. sex and age were included as predictors in step 1 for each model (i.e., model 0). in model 1, main effects of parent and adolescent reports of parental monitoring were entered in step 2. we took two approaches to measuring discrepancy: forming an interaction between adolescent and parent report (model 2) and creating a categorical variable based on child and parent report (high/low; model 3). in model 2, parent and adolescent reports were standardized and multiplied to create a two-way interaction term and the main effects and interaction term were entered in step 2. following laird, 2020, if the interaction terms were significant, polynomial equations were added in a subsequent step. for model 3, four groups were created based on mean splits for each aspect of monitoring: 1) low parent/low adolescent (i.e., if both the parent and adolescent fell below the mean on each aspect of parental monitoring); 2) high parent/low adolescent; 3) low parent/high adolescent; and 4) high parent/high adolescent. three dummy codes were created to reflect these groups and were entered in step 2 for model 3; low/low served as the reference group. residual diagnostics were performed using the dharma package in r (hartig, 2021) to inform selection of model distributions. based on these results, a count model with a quasipoisson distribution was used for all models with the exception of one model (model 2 for parental control), which was modeled using the negative binomial distribution. incidence rate ratio (irr) values are reported, which reflect changes in incidence rate for every 1 unit increase in the predictor variable. a value of 1 indicates that there are no changes in the incidence rate of cu for every 1 unit increase in the predictor variable. values greater than 1 indicate that the incidence rate for cu increases with higher values of the predictor variable, while values less than 1 indicate that the incidence for cu decreases with higher values of the predictor variable. if the confidence interval includes 1, the parameter is not significant. goodness of model fit was assessed using chisquare (χ²) difference tests. the relative fit of the expanded model was determined by the loglikelihood difference between an expanded model and a nested model and corresponding change in degrees of freedom (δdf). a significant difference test indicates that the extended model fits significantly better than the nested model. for all monitoring-related constructs, models 1 (i.e., the main effects model), 2 (i.e., the main effects plus interaction term model), and 3 (i.e., the categorical groups model) were compared to model 0 (i.e., model included age and sex as predictors of cu). model 2 was then compared to model 1. models 1 and 3 are not nested and thus cannot be compared using formal difference tests. however, we evaluated aic values to compare fit across non-nested models. results baseline differences between the two samples were found on two measures of monitoring; in study 1, youth reported significantly higher levels of child disclosure (t[150]=4.05, p<.001) and parental knowledge (t[150]=3.47, p<.001) relative to youth in study 2. there were no significant differences across groups for cu. descriptive statistics and correlation coefficients are presented in table 1. on average, adolescents used cannabis on approximately 24 of the prior 60 days (range=0-60, skew=0.52, kurtosis=-1.16). cu was negatively associated with parent and adolescent reports of all aspects of monitoring. there was low-to-moderate correspondence (range=.24, .42) across parent and teen ratings for all monitoring variables. parent reports of each monitoring-related construct were significantly and positively associated with one another (range=.31, .66), and the same pattern emerged for adolescents (range=.44, .67). results of the dependent samples t-tests indicate that parent ratings of solicitation (t[151]=5.82, p<.001) and control (t[151]=8.40 p<.001) were significantly higher than adolescents’ ratings of the same subscales; there were no significant reporter differences for knowledge and disclosure. monitoring discrepancies and cannabis use 6 table 1. means (standard deviations) and correlation coefficients on cannabis use and monitoring subscales 1 2 3 4 5 6 7 8 9 1. cannabis use 24.39 (21.07) 2. knowledge (p) -.17* 3.56 (0.76) 3. knowledge (a) -.21* .42*** 3.43 (0.84) 4. solicitation (p) -.23** .56*** .29*** 3.37 (0.88) 5. solicitation (a) -.18* .26** .56*** .24** 2.84 (0.92) 6. control (p) -.21* .38*** .20* .37*** .11 4.48 (0.78) 7. control (a) -.24** .34*** .59*** .19* .48*** .41*** 3.71 (1.19) 8. disclosure (p) -.16* .66*** .33*** .50*** .21* .31*** .19* 3.23 (0.86) 9. disclosure (a) -.18* .40*** .67*** .17* .54*** .09 .44*** .33*** 3.22 (0.85) note. p=parent report; a=adolescent report. bolded cells depict the correlation between adolescents’ reports and parents’ reports on the same aspect of monitoring. * p < 0.05, ** p < 0.01, *** p < 0.001. table 2. model fit comparisons model parental knowledge parental solicitation parental control child disclosure aic δχ² (δdf) p aic δχ² (δdf) p aic δχ² (δdf) p aic δχ² (δdf) p model 0 1276.5 — — 1276.5 — — 1276.5 — — 1265.4 — — model 1 (vs. model 0) 1274.3 6.17 (2) .04 1273.9 6.60 (2) .04 1274.2 6.30 (2) .04 1260.2 9.20 (2) .01 model 2 (vs. model 0) 1276.3 6.20 (3) .10 1275.8 6.71 (3) .08 1276.7 5.76 (3) .12 1262.1 9.35 (3) .03 model 3 (vs. model 0) 1271.6 10.91 (3) .01 1275.2 7.26 (3) .06 1276.5 6.00 (3) .11 1264.5 6.93 (3) .07 model 2 (vs. model 1) 1276.3 0.03 (1) .86 1275.8 0.10 (1) .74 1276.7 0 (1) 1.0 1262.1 0.14 (1) .71 note. model 0 = base model (age and sex); model 1 = main effects of adolescent and parent reports; model 2 = main effects of adolescent and parent reports plus interaction term; model 3 = mean-split groups. aic=akaike’s information criterion; δχ² = log-likelihood (not reported) difference between nested and expanded model; δdf = change in degrees of freedom of expanded model relative to nested model. bolded models were the best fitting models for each aspect of parental monitoring. cannabis, a publication of the research society on marijuana 7 table 3. coefficients and incidence rate ratios from hierarchical regressions for parental knowledge b se p irr (b) (95 % ci) β (95 % ci) irr (β) (95 % ci) model 0 age 0.11 0.06 0.06 1.11 (1.00, 1.25) 0.27 (-0.01, 0.54) 1.31 (0.99, 1.72) sex (0=male) 0.05 0.15 0.72 1.05 (0.79, 1.40) 0.05 (-0.22, 0.32) 1.05 (0.80, 1.37) step 2 model 1 age 0.09 (0.06) 0.10 1.10 (0.98, 1.22) 0.23 (-0.04, 0.50) 1.26 (0.96, 1.64) sex (0=male) 0.003 (0.15) 0.98 1.00 (0.75, 1.34) <.001 (-0.27, 0.27) 1.00 (0.77, 1.31) adolescent reports -0.17 (0.09) 0.04 0.84 (0.71, 0.99) -0.29 (-0.58, -0.01) 0.75 (0.56, 0.99) parent reports -0.06 (0.09) 0.51 0.94 (0.79, 1.13) -0.09 (-0.37, 0.18) 0.91 (0.69, 1.20) step 2 model 2 age 0.09 (0.06) 0.10 1.10 (0.98, 1.22) 0.23 (-0.04, 0.49) 1.25 (0.96, 1.64) sex (0=male) 0.01 (0.15) 0.97 1.01 (0.75, 1.34) <.001 (-0.27, 0.28) 1.01 (0.77, 1.32) adolescent reports -0.17 (0.09) 0.04 0.84 (0.71, 0.99) -0.29 (-0.58, -0.01) 0.75 (0.56, 0.99) parent reports -0.06 (0.09) 0.49 0.94 (0.78, 1.13) -0.10 (-0.38, 0.18) 0.91 (0.68, 1.20) adolescent*parent -0.02 (0.10) 0.86 0.98 (0.81, 1.20) -0.04 (-0.55, 0.46) 0.96 (0.58, 1.59) step 2 model 3 age 0.10 (0.05) 0.06 1.11 (1.00, 1.23) 0.25 (-0.01, 0.51) 1.28 (0.99, 1.66) sex (0=male) 0.02 (0.14) 0.86 1.03 (0.77, 1.36) 0.02 (-0.24, 0.29) 1.02 (0.79, 1.33) high parent, low adolescent -0.47 (0.19) 0.02 0.63 (0.43, 0.91) -0.47 (-0.84, -0.09) 0.63 (0.43, 0.91) high adolescent, low parent -0.44 (0.20) 0.03 0.65 (0.43, 0.96) -0.44 (-0.83, -0.04) 0.65 (0.43, 0.96) high adolescent, high parent -0.52 (0.17) 0.002 0.59 (0.43, 0.82) -0.52 (-0.85, -0.19) 0.59 (0.43, 0.82) note. b=unstandardized coefficients, se=standard error, β=standardized coefficients, irr=incidence rate ratio corresponding to unstandardized coefficient. bolded estimates were significant. parental knowledge. results from the model fit comparisons are reported in table 2. models 1 and 3 (i.e., the main effects model and the categorical model) fit significantly better than model 0. model 2 did not significantly improve explanation of cu relative to model 1, indicating that the interaction did not aid in the prediction of cu beyond the main effects. model 3 was the best fitting model, but similar aic values across models 1 and 3 indicated comparable fit of these expanded models relative to the base model. parameter estimates from the hierarchical regression models for parental knowledge are presented in table 3. in model 1, adolescents’ reports of parental knowledge were negatively related to cu; parent reports did not significantly predict use. in model 2, the main effect of adolescent report remained significant and negative, while the interaction term between parents’ reports and adolescents’ reports was not a significant predictor of cu. because the interaction term was not significant, polynomial interactions were not probed. in model 3, all groups (i.e., high parent—low adolescent, low parent—high adolescent, and high parent—high adolescent) were associated with less frequent cu relative to the reference group (low parent—low adolescent). parental solicitation. model 1 was the only extended models that improved prediction of cu relative to model 0, yet in model 1, neither main effect of adolescents’ or parents’ reports of parental solicitation were significantly associated with cu (see table 4). neither the main effects nor the interaction term was significant in model 2. in model 3, membership in the high parent— high adolescent group was associated with less frequent cu relative to the low-low group. parental control. as with parental solicitation, model 1 improved fit relative to model 0. results from model 1 (see table 5) indicated that neither adolescents’ nor parents’ reports of parental monitoring discrepancies and cannabis use 8 control were associated with less frequent cu. neither the main effects nor the interaction term was significant in model 2 and none of the meansplit groups were significant predictors of cu in model 3. child disclosure. models 1 and 2 fit significantly better than model 0 (see table 6). model 3 did not improve fit relative to model 0, and model 2 did not improve fit relative to model 1, indicating that model 1 was the best fitting model for child disclosure. adolescent reports of increased child disclosure were associated with less frequent cu in model 1. this parameter remained significant in model 2, though the interaction term was not significant and fit for model 2 was not superior to the fit for model 1. as with parental knowledge, membership in the high parent—high adolescent group was protective against cu, relative to the low-low group. sensitivity analyses for racial and ethnic differences in cu exploratory sensitivity analyses were conducted to examine if there were mean differences in cu across adolescents identifying as black or african american vs. non-black or african american in our sample and across adolescents identifying as hispanic/latine vs. non-hispanic/latine. the analyses did not reveal any differences for black or african american vs. non-black or african american (f(1, 150) = [0.31], p = 0.58) or hispanic/latine vs. nonhispanic/latine (f(1, 150) = [0.02], p = 0.88). base rates were too low to explore moderation of monitoring and cu associations by racial/ethnic group. table 4. coefficients and incidence rate ratios from hierarchical regressions for parental solicitation b se p irr (b) (95 % ci) β (95 % ci) irr (β) (95 % ci) model 0 age 0.11 0.06 0.06 1.11 (1.00, 1.25) 0.27 (-0.01, 0.54) 1.31 (0.99, 1.72) sex (0=male) 0.05 0.15 0.72 1.05 (0.79, 1.40) 0.05 (-0.22, 0.32) 1.05 (0.80, 1.37) step 2 model 1 age 0.09 0.06 0.12 1.09 (0.98, 1.22) 0.22 (-0.06, 0.50) 1.25 (0.94, 1.65) sex (0=male) 0.03 0.14 0.83 1.03 (0.78, 1.37) 0.03 (-0.24, 0.29) 1.03 (0.79, 1.34) adolescent reports -0.12 0.07 0.12 0.89 (0.77, 1.03) -0.21 (-0.48, 0.05) 0.81 (0.62, 1.06) parent reports -0.13 0.08 0.10 0.88 (0.75, 1.03) -0.23 (-0.50, 0.05) 0.80 (0.61, 1.05) step 2 model 2 age 0.09 0.06 0.12 1.09 (0.98, 1.23) 0.22 (-0.05, 0.50) 1.25 (0.95, 1.65) sex (0=male) 0.03 0.14 0.83 1.03 (0.78, 1.37) 0.03 (-0.24, 0.30) 1.03 (0.79, 1.34) adolescent reports -0.12 0.07 0.11 0.89 (0.77, 1.03) -0.22 (-0.48, 0.05) 0.81 (0.62, 1.05) parent reports -0.13 0.08 0.10 0.88 (0.75, 1.02) -0.23 (-0.51, 0.04) 0.79 (0.60, 1.04) adolescent*parent -0.02 0.07 0.75 0.98 (0.84, 1.13) -0.08 (-0.55, 0.40) 0.92 (0.57, 1.49) step 2 model 3 age 0.08 0.06 0.19 1.08 (0.96, 1.20) 0.19 (-0.09, 0.47) 1.21 (0.91, 1.60) sex (0=male) 0.04 0.14 0.76 1.04 (0.79, 1.38) 0.04 (-0.22, 0.31) 1.04 (0.80, 1.36) high parent, low adolescent -0.27 0.19 0.15 0.76 (0.53, 1.10) -0.27 (-0.64, 0.10) 0.76 (0.53, 1.10) high adolescent, low parent 0.003 0.19 0.99 1.00 (0.68, 1.45) <.001 (-0.38, 0.37) 1.00 (0.68, 1.45) high adolescent, high parent -0.44 0.19 0.02 0.65 (0.45, 0.93) -0.44 (-0.81, -0.07) 0.65 (0.45, 0.93) note. b=unstandardized coefficients, se=standard error, β=standardized coefficients, irr=incidence rate ratio corresponding to unstandardized coefficient. bolded estimates were significant. cannabis, a publication of the research society on marijuana 9 table 5. coefficients and incidence rate ratios from hierarchical regressions for parental control b se p irr (b) (95 % ci) β (95 % ci) irr (β) (95 % ci) model 0 age 0.11 0.06 0.06 1.11 (1.00, 1.25) 0.27 (-0.01, 0.54) 1.31 (0.99, 1.72) sex (0=male) 0.05 0.15 0.72 1.05 (0.79, 1.40) 0.05 (-0.22, 0.32) 1.05 (0.80, 1.37) step 2 model 1 age 0.06 0.06 0.34 1.06 (0.94, 1.19) 0.14 (-0.14, 0.42) 1.15 (0.87, 1.52) sex (0=male) -0.001 0.15 0.99 1.00 (0.75, 1.33) <.001 (-0.27, 0.27) 1.00 (0.76, 1.31) adolescent reports -0.09 0.07 0.17 0.91 (0.80, 1.04) -0.22 (-0.53, 0.09) 0.80 (0.59, 1.10) parent reports -0.13 0.09 0.16 0.87 (0.73, 1.05) -0.21 (-0.50, 0.08) 0.81 (0.61, 1.09) step 2 model 2 age 0.10 0.07 0.15 1.11 (0.97, 1.27) 0.25 (-0.09, 0.58) 1.28 (0.92, 1.79) sex (0=male) 0.16 0.18 0.39 1.17 (0.82, 1.67) 0.15 (-0.19, 0.48) 1.16 (0.83, 1.62) adolescent reports -0.13 0.08 0.07 0.87 (0.75, 1.01) -0.32 (-0.67, 0.03) 0.73 (0.51, 1.03) parent reports -0.14 0.12 0.26 0.87 (0.68, 1.11) -0.22 (-0.59, 0.16) 0.81 (0.55, 1.18) adolescent*parent -0.04 0.07 0.58 0.96 (0.83, 1.11) -0.15 (-0.70, 0.39) 0.86 (0.50, 1.48) step 2 model 3 age 0.08 0.06 0.16 1.08 (0.97, 1.21) 0.20 (-0.08, 0.47) 1.22 (0.92, 1.60) sex (0=male) -0.02 0.15 0.92 0.98 (0.74 1.32) -0.01 (-0.29, 0.26) 0.99 (0.75, 1.29) high parent, low adolescent -0.04 0.20 0.84 0.96 (0.64, 1.43) -0.04 (-0.44, 0.36) 0.96 (0.64, 1.43) high adolescent, low parent 0.06 0.24 0.81 1.06 (0.67, 1.68) 0.06 (-0.41, 0.52) 1.06 (0.67, 1.68) high adolescent, high parent -0.35 0.19 0.06 0.70 (0.49, 1.02) -0.35 (-0.72, 0.02) 0.70 (0.49, 1.02) note. b=unstandardized coefficients, se=standard error, β=standardized coefficients, irr=incidence rate ratio corresponding to unstandardized coefficient. monitoring discrepancies and cannabis use 10 table 6. coefficients and incidence rate ratios from hierarchical regressions for child disclosure b se p irr (b) (95 % ci) β (95 % ci) irr (β)(95 % ci) model 0 age 0.11 0.06 0.06 1.11 (1.00, 1.25) 0.27 (-0.01, 0.55) 1.31 (0.99, 1.73) sex (0=male) 0.06 0.15 0.67 1.06 (0.80, 1.42) 0.06 (-0.21, 0.33) 1.06 (0.81, 1.39) step 2 model 1 age 0.12 0.05 0.03 1.13 (1.01, 1.25) 0.30 (0.03, 0.56) 1.35 (1.03, 1.75) sex (0=male) 0.02 0.14 0.87 1.02 (0.77, 1.36) 0.02 (-0.25, 0.29) 1.02 (0.78, 1.34) adolescent reports -0.19 0.08 0.02 0.83 (0.71, 0.97) -0.32 (-0.59, -0.06) 0.72 (0.55, 0.95) parent reports -0.10 0.08 0.21 0.90 (0.76, 1.06) -0.18 (-0.46, 0.10) 0.84 (0.63, 1.11) age 0.12 0.05 0.03 1.13 (1.01, 1.26) 0.30 (0.03, 0.57) 1.35 (1.03, 1.76) sex (0=male) 0.02 0.14 0.88 1.02 (0.77, 1.36) 0.02 (-0.25, 0.29) 1.02 (0.78, 1.33) adolescent reports -0.19 0.08 0.02 0.82 (0.70, 0.97) -0.33 (-0.60, -0.06) 0.72 (0.55, 0.95) parent reports -0.11 0.08 0.21 0.90 (0.76, 1.06) -0.18 (-0.46, 0.10) 0.83 (0.63, 1.11) adolescent*parent 0.04 0.10 0.71 1.04 (0.86, 1.25) 0.10 (-0.44, 0.64) 1.11 (0.65, 1.90) age 0.11 0.06 0.04 1.12 (1.00, 1.24) 0.28 (0.00, 0.55) 1.32 (1.00, 1.74) sex (0=male) 0.04 0.15 0.81 1.03 (0.78, 1.38) 0.03 (-0.24, 0.31) 1.03 (0.79, 1.36) high parent, low adolescent -0.33 0.19 0.09 0.72 (0.49, 1.06) -0.33 (-0.71, 0.05) 0.72 (0.49, 1.09) high adolescent, low parent -0.33 0.21 0.12 0.72 (0.47, 1.09) -0.33 (-0.75, 0.09) 0.72 (0.47, 1.09) high adolescent, high parent -0.42 0.17 0.01 0.66 (0.47, 0.92) -0.42 (-0.75, -0.09) 0.66 (0.47, 0.92) note. b=unstandardized coefficients, se=standard error, β=standardized coefficients, irr=incidence rate ratio corresponding to unstandardized coefficient. bolded estimates were significant. discussion the goal of this paper was to determine if discrepancies are a useful tool for predicting cu among jiy, and if so, how best to operationalize discrepancies among this population. results indicated that increased parental monitoring was associated with less frequent cu. results from the regression models indicated that increased adolescent reports of parental knowledge child disclosure most consistently predicted less frequent cu. operationalizing discrepancies using a categorical approach best predicted parental knowledge, but overall, the discrepancy models fit similarly to the main effects models, suggesting that the inclusion of discrepancies— regardless of how operationalized—did not aid in the prediction of cu beyond the main effects of parent and adolescent report of parental monitoring. similar to abar and colleagues (2014), adolescent reports of parental knowledge were negatively associated with cu. as such, encouraging parents to participate in active monitoring and seeking knowledge of teen whereabouts and interests may create an environment that protects against cu. further, parental knowledge may be protective against cu because among families in which parents are more knowledgeable about their adolescents’ activities, this may reflect a better parent/child relationship quality; this should be assessed in future research with jiy. for parental control, adolescent reports of parental control were not significantly associated with cu. this finding diverges from previous cannabis, a publication of the research society on marijuana 11 work demonstrating that increased parental control is moderately associated with lower levels of problem behavior in early adolescence (fletcher et al., 2004; gray & steinberg, 1999). however, this finding is consistent with more recent literature demonstrating inconsistent results regarding these associations (keijsers et al., 2010). it is important to underscore that these studies were conducted in community samples; the jiy sample assessed here is likely to face punitive repercussions as a result of continued problem behavior and parental control may be more challenging and may not be an effective tool in decreasing cu among this group. parents of jiy who exert control as a means to decrease problem behavior may find that this is not an effective approach because parental control is best exerted within the context of a highly supportive parent/adolescent relationship (micalizzi et al., 2019) and involvement in the juvenile justice system and/or familial disruption that leads to risk behaviors may upset the relational balance within the home. as such, parental control may become an effective monitoring technique if the quality of the parent/adolescent relationship is positive. previous research has yielded mixed results as to effectiveness of parental solicitation as a source of knowledge. in line with the current findings, other studies indicate that parental solicitation alone is not sufficiently associated with decreases in problem behavior among adolescents (keijsers et al., 2010). laird & colleagues (2010) demonstrated that situational factors, particularly more unsupervised time alone, may impact the relation between parental solicitation and problem behavior, whereby adolescents’ perception of increased solicitation was associated with lower levels of problem behavior. as has been seen in other studies (e.g., kerr & stattin, 2000), adolescent disclosure of their cu also protected against cu. youth’s open disclosure of their own activities may be most predictive of their cu as this may reflect a more general open communication with parents which has been shown to be related to reduced adolescent substance use (bertrand et al., 2013). with regard to the pattern of the main effects findings as a whole, it is not surprising that adolescent reports of the different aspects of parental monitoring were most consistently associated with their own cu when compared to parent reports. these findings add to a mounting research base (e.g., abar et al., 2014) demonstrating this pattern of findings, yet the current study is novel in its extension of these conclusions to jiy and to cu. these results highlight that adolescent reports of parental monitoring are most predictive of their own behavior, and this pattern holds across non-jiy and jiy, as well as across substances (i.e., alcohol in abar et al., 2014 vs. cannabis in the current study). contrary to our predictions, discrepancies did not aid in the prediction of cu beyond the inclusion of parent and adolescent reports for parental solicitation, parental control, and child disclosure. previous research has demonstrated that cross-rater agreement of parental monitoring is associated with reduced adolescent substance use (e.g., abar et al., 2014). specifically, the categorical models (i.e., mean split models) in which parents and adolescents both reported above average monitoring (i.e., the high/high group) tended to be least likely to engage in alcohol use in previous work (abar et al., 2014). the high/high group was consistently the most protective group for parental knowledge, parental solicitation, and child disclosure. though the categorical model was the best fitting discrepancy model for parental knowledge, the discrepancy model was only marginally better than the main effects model. the finding that discrepancies did not universally aid in the prediction of cu may have emerged for two reasons: the nature of the study sample and the substance under investigation. first, with respect to the sample: discrepancies across parents and teens in their reports of monitoring may not be indicative of cu risk for jiy relative to non-jiy adolescents. parent/adolescent reports of monitoring may be more aligned because as families engage with the court system, parents may become aware that they no longer have control of their child’s friend groups or their comings/goings and honestly admit lack of control. alternatively, parent and adolescent reports may be misaligned, but the misalignment is not predictive of the adolescent’s cu. this may be the case because the correspondence across parents and adolescents is less protective for jiy and presumably already face challenges in the parent/adolescent dynamic as a result. second: discrepancy findings may be substance specific. previous research has monitoring discrepancies and cannabis use 12 primarily focused on adolescent alcohol use (e.g., abar et al., 2014), and thus the replication of these findings to cannabis using non-jiy-involved teens is essential to parse this pattern of results. further, it is possible that discrepancies may be related to negative consequences of cu and this should be addressed in future research. the role of the family among hispanic/latine youth is well recognized, such that the structure and function of the family may play serve both protective and exacerbating roles in adolescent substance use (wagner et al., 2010). there were no significant differences in cu across different racial and ethnic groups in the current study. though our samples are more racially and ethnically diverse than many studies, base rates were not sufficient to test for moderation of parental monitoring on cu by race or ethnicity; future research should probe the extent to which race and ethnicity moderate the effects of parental monitoring on cannabis use, particularly among justice involved samples. the present study is the first to examine discrepancies in parental knowledge and sources of knowledge among cannabis using jiy. this is also a relatively large jiy sample. this study benefited from the application of multiple methods to operationalize discrepancies and, to our knowledge, this study is the first to assess cu outcomes using this methodological framework. as such, these methodological and practical strengths highlight the relevance and application to jiy. several limitations should also be noted. first, parental relationship quality was not assessed, and as a result it was not possible to evaluate if particular monitoring strategies were more or less effective based on the context of the quality of the parent/adolescent relationship. second, all data were collected by self-report, as is the case with most of the literature, so findings may not apply if collected via interviewer or observer ratings. third, participants were recruited from a single state in the northeast united states and replication work should be performed on a more geographically representative sample. fourth, these data are cross-sectional and we hypothesize that parental monitoring is the predictor of cu based on previous research, but the opposite order of effects is also reasonable. future observational research should address the question of ordering. finally, all participating families agreed to participate in in a family-focused intervention to reduce adolescent cu which may limit generalizability to other youth involved in the justice system. in conclusion, these findings suggest that parental knowledge and child disclosure may be protective for jiy adolescents. generally, discrepancies, regardless of operationalization, did not improve prediction of cu. higher parental knowledge and child disclosure are two aspects of parental monitoring that may reflect great communication and relationship quality, which may facilitate the effectiveness of parental monitoring techniques and should be a focus on intervention programs. references abar, c. c., jackson, k. m., & wood, m. 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(2010). associations between family structure, family functioning, and substance use among hispanic/latino adolescents. psychology of addictive behaviors, 24(1), 98–108. funding and acknowledgements: this work was supported by nih grants r34da042247 (mpi: spirito, hernandez), r34da029871 (mpi: spirito, hernandez), k01da048135 (pi: micalizzi), k23mh111606 (pi: kemp). the authors have no conflicts of interests or other disclosures to report. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 109 abstract objective: metabolic syndrome is due to dysregulation that starts with fat accumulation, causing inflammatory response, insulin resistance, dyslipidemia, hypertension, and fatty liver disease. the endocannabinoid system, via cannabinoid receptor type 1 (cb1), has been shown to be involved with energy homeostasis and regulation of appetitive behavior via activity in the hypothalamus, limbic forebrain and amygdala and in the peripheral tissues including adipose, liver and muscle. therefore, two phytocannabinoids, tetrahydrocannabivarin (thcv), a cb1 neutral antagonist, and cannabidiol (cbd), a negative allosteric modulator of cb1, are expected to have therapeutic metabolic benefits, including weight loss. method: a placebo-controlled study was conducted on 44 subjects (31 females and 13 males) with an average age of 51.75. the study evaluated the efficacy of two different doses of thcv and cbd (8 mg thcv/10 mg cbd in the lower dose and 16 mg thcv/20 mg cbd in the higher dose), taken once daily for 90 days via mucoadhesive oral strips, for weight loss and improvement of certain metabolic markers. results: use of the thcv/cbd strip was associated with statistically significant weight loss, decreases in abdominal girth, systolic blood pressure, and total and ldl cholesterol. the study was limited by small sample sizes in both the high dose and placebo groups. conclusions: the 16 mg/20 mg daily dose was superior for weight loss compared to the 8 mg/10 mg daily dose; both sets of results differed from placebo in a way that was statistically significant. the results of this study were congruent with the prior unpublished studies of a hemp extract containing significant percentages of thcv, cbdv and cbd. key words: = thcv; weight loss; metabolism; metabolic syndrome; hypercholesterolemia metabolic syndrome according to the national institutes of health (nih), metabolic syndrome is a group of conditions that occur together due to the same underlying metabolic changes. metabolic syndrome follows a gradual progression from truncal adiposity, obesity, elevated blood pressure, glucose intolerance, dyslipidemia to diabetes mellitus and fatty liver disease. according to the national cholesterol education program (ncep) definition, metabolic syndrome is present if three or more of the following five criteria are met: waist circumference over 40 inches (men) or 35 inches (women), blood pressure over 130/85 mmhg, fasting triglyceride (tg) level over 150 mg/dl, fasting high-density lipoprotein (hdl). metabolic syndrome has become epidemic in societies with western diets (swarup et al., 2022). over 1.9 billion adults worldwide are overweight or obese, and almost half of these adults will have metabolic syndrome (pekgor et al., 2019). current evidence supports chronic low-grade inflammation from fat deposits as the origin of adverse metabolic effects. this happens when adipose tissue releases proinflammatory cytokines, resulting in localized insulin resistance gregory l. smith, md, mph1 1nex therapeutics, st. petersburg, fl cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000206 volume 8, issue 1 weight loss and therapeutic metabolic effects of tetrahydrocannabivarin (thcv)-infused mucoadhesive strips corresponding author: gregory smith, md, mph, nex therapeutics, 3052 w. vina del mar blvd., st. pete beach, florida 33706. phone: (813) 502-1251. email: drsmith@nex-therapeutics.com. weight loss and therapeutic effects of thcv 110 (swarup et al., 2022). genetic and epigenetic factors, excess calories, and lack of physical activity are major contributors to the condition (fathi dizaji, 2018). high caloric intake resulting in excess visceral fat storage activates most of the pathways of metabolic syndrome (fujita et al., 2006). the endocannabinoid system and appetite regulation the endocannabinoid system, via the cannabinoid receptor type 1 (cb1), has been shown to be involved with energy homeostasis and regulation of appetitive behavior in the brain, including the hypothalamus, limbic forebrain and amygdala, and in the peripheral tissues, including adipose, liver and muscle tissue (cristino, becker, & di marzo, 2014). it is thought that as humans evolved, the endocannabinoid system developed a regulatory pathway to encourage food-seeking behavior in times of food scarcity; however, since the advent of modern agriculture and increased availability of high-calorie, low-nutrient foods, we have seen an exponential rise in obesity, especially in the west. it stands to reason that decreasing endocannabinoid activity would be an effective treatment for obesity and its metabolic consequences (kunos & osei-hyiaman, 2008). tetrahydrocannabivarin (thcv) and cannabidiol (cbd) tetrahydrocannabivarin (thcv), a naturally occurring, non-psychoactive minor phytocannabinoid, is only present in tiny amounts in most cannabis sativa strains; recently, however, the biosynthesis of hemp-derived cannabidiol (cbd) has made thcv available in commercially viable quantities. being a full neutral cb1 antagonist and a partial cb2 antagonist, thcv is unique in its effects (thomas et al., 2005). although concerns have been raised that taking thcv would result in a false positive urine test for tetrahydrocannabinol (thc), this concern was noted and factored into the study design (englund et al., 2016). fasted and non-fasted mouse studies have shown decreased food intake and body weight, and increased energy expenditure, glucose tolerance, and insulin sensitivity in response to thcv (wargent et al., 2013). a similar human study suggested that thcv modulated food intake by decreasing connectivity between the amygdala and the precuneus appetite and reward centers of the brain (tuulari et al., 2015). cbd is a negative allosteric modulator of the cb1 receptor and a partial cb1 antagonist, compared to thcv, which is a full neutral cb1 antagonist (mcpartland et al., 2015). in addition, cbd has well-documented anti-inflammatory effects, which are systemically likely to be therapeutic for the low-grade inflammation underlying the pathophysiology of the metabolic syndrome (jadoon et al., 2016). because these effects of cbd work through different mechanisms, cbd may facilitate the appetite and metabolic effects seen with thcv (pertwee, 2008). previous animal studies have shown that thcv acts by neutrally blocking the cb1 receptor in the hypothalamus and the gut (pancreas, liver and intestinal tract; abioye et al., 2020). the cb1 blockade switches the body into the ‘fasting’ state, so the body defaults to burning abdominal fat (sidibeh et al., 2017). an increasing body of unpublished clinical research has shown that small daily doses of hempson oil ® (hemp-extract high in cbd, thcv and cannabidivarin, cbdv) taken orally have consistent effects of weight loss, reduction in abdominal girth, blood sugar (hgba1c), and blood lipid ratios. the current study will evaluate the efficacy of using thcv and cbd isolates infused into mucoadhesive oral strips for therapeutic effects on weight loss, abdominal girth, and improvement of certain metabolic markers. thcv and positive thc drug test a review of existing scientific literature failed to identify any study of humans using thcv showing a positive urine test for thc metabolites. however, because the possibility remains that some metabolites excreted in the urine may cause a falsepositive result on a drug test, a subgroup of subjects using thcv were submitted to urine thc screening following the study. methods this study was designed to focus on otherwise healthy obese adults in the early stages of cannabis, a publication of the research society on marijuana 111 developing metabolic syndrome. the focus was on reducing adiposity, the underlying pathophysiologic feature of the metabolic syndrome. fifty-six adults were recruited via social media ad campaigns. selection criteria were for subjects who met the clinical definition of obesity (bmi ≥ 30) without comorbid diabetes or cardiovascular disease. subjects with normal or less than stage ii hypertension (systolic bp greater than or equal to 160 mm hg and/or diastolic bp less than 100 mm hg) who were under a physician’s supervision were included; subjects with active cardiovascular or respiratory symptoms were excluded. subjects were enrolled via correspondence with an administrative assistant not otherwise involved in the study. subjects additionally underwent an entrance examination by a blinded independent physician to screen for diabetes, active cardiovascular or pulmonary disease, or other confounding health conditions prior to starting the study. all were determined to be clinically stable. two doses were used for the intervention. these were 8 mg of thcv with 10 mg of cbd and 16 mg of thcv with 20 mg of cbd once daily. the thcv doses were chosen based on the known pharmacokinetics (pk) and pharmacodynamics (pd) of the structurally similar tetrahydrocannabinol (thc) molecule, an unpublished clinical trial using thcv and cbd for the treatment of type ii diabetes, and five unpublished studies of hempson® oil, a hempderived oil with 17% thcv and 50% cbd. the addition of cbd was limited to very small doses, based on the small load bearing of the mucoadhesive strip. all primary outcome measures (defined as changes in weight and abdominal girth) and secondary outcome measures (defined as changes in systolic and diastolic blood pressure and changes in fasting blood work lipid profile, blood sugar, hgba1c, liver and kidney function studies) were determined at the beginning of the study (day 0) and at the end of the study (day 90). labcorp offices in the greater tampa area were used for all lab collection and analysis. the same lab assay and methodology were used for the repeat comparative testing. the specific assays used by labcorp were not reviewed. initial and final biometric measurements taken included blood pressure, blood oxygen, temperature, height, weight, and abdominal girth. for people with active periods, the ending biometrics were to be taken during the same phase of their menstrual cycle as when they had their initial measurement taken around 90 days later. abdominal girth was obtained using the nihrecommended procedure, in which a horizontal line is marked slightly above the outer edge of the right iliac crest, and it intersects with a vertical line along the midaxillary line; the measuring tape is then positioned horizontally around the abdomen at the same level as this marked point on the right side of the trunk. a random number generator program was used to assign subjects to one of three groups through simple randomization: group a (single dose group), group b (double dose group,) and group p (placebo/control group). the trial design was a parallel-group randomized trial, with unequal allocation ratio of 2:1:1 (group a, group b, placebo). allocation was double-blind to both the subject and the investigator. subjects, care providers, and the lead investigator were blinded to the entire group allocation process. subjects were provided with a 90-day supply of their respective dose (based on group assignment) and were instructed to take the dose once daily by mouth on an empty stomach in the morning, with no additional changes to their diet or exercise routines. subjects agreed to refrain from the use of cannabis, cbd, or other hemp products throughout the duration of the study. text message reminders were sent daily between 8 and 9 am to each subject to a prior approved personal cell phone number, advising them to take their dose, confirm once it had been taken, and report on any adverse effects. the text messaging was hipaa compliant. each subject was paid $100 upon completion of initial lab testing and another $100 after completing a 90day exit interview and final lab testing. after passing the inclusion criteria, the subjects gave their written informed consent to the independent physician using the world health organization – research ethics review committee (who erc) template for clinical trials. the hemp-based extract was considered minimal to very low risk based on prior research. a data safety monitoring plan (dsmp) was implemented and approved by the institutional review board (irb) to ensure appropriate weight loss and therapeutic effects of thcv 112 oversight and monitoring of the clinical investigation. subject monitoring was implemented through the daily text responses, as well as before and after physical examinations and before and after laboratory studies. subject privacy, data integrity, product accountability, coordination, and documentation were ensured throughout the study. follow-up on subjects ‘lost to follow-up’ was conducted. a total of 44 subjects across three groups completed the full course of the 90-day study. twenty-four subjects took one proprietary mucoadhesive strip infused with l-arginine and menthol daily, containing 8 mg of thcv and 10 mg of cbd (group a); 10 subjects took two proprietary mucoadhesive strips infused with larginine and menthol daily, containing a total of 16 mg of thcv and 20 mg of cbd (group b); and 10 subjects took one proprietary mucoadhesive strip infused with l-arginine and menthol as the placebo daily (group p). each mucoadhesive strip came in a factory-sealed aluminum foil envelope marked with a code to denote the contents to the investigators. a total of 8 subjects across the three groups did not complete the full duration of the study. of the four of these subjects initially assigned to group a, one moved away from the area, and the other three stopped responding to text messages after multiple attempts. of the two subjects initially assigned to group b who did not complete the study, one dropped out after fracturing his leg, and the other stopped because he didn’t like the taste of the strip. of the two subjects initially assigned to group p who did not complete the study, both cited moving away from the area as their reason for discontinuation. table 1. demographics by group group a b p age (years) 48 +/5.4 55 +/6.7 56 +/8.1 race 19-w, 2-b, 3-h 10-w 10-w height (cm) 170 +/4.2 172 +/7.2 171 +/5.2 male 8 3 2 female 16 7 8 # of subjects 24 10 10 note. w = white, non-hispanic, b = black, h = hispanic mucoadhesive strip the study vehicle is a proprietary mucoadhesive material infused with l-arginine and menthol. according to squier et al. (2010), menthol has been shown to increase intraoral penetration of several medications, as well as nicotine, while l-arginine applied locally has been shown to enhance vasodilation within the mucosa (schwedhelm et al., 2008). cbd has been shown to have similar effects with endothelium vasodilation (stanley et al., 2015). mucoadhesive delivery has been developed to enable prolonged absorption at the site of application. mucoadhesive polymers have many hydrophilic groups, which attach to mucous membranes and cause polymers to swell in water, thus exposing their adhesive sites. this results in enhanced bioavailability and maximum drug concentration in the plasma (cmax), and decreased time until maximum plasma concentration (tmax) of the drug (shaikh et al., 2011). the thcv and cbd isolates were submitted for independent testing at salt leaf hemp in vineyard, ut. the thcv isolate was found to contain 999 mg/g of total cannabinoids, no detectable thc, and 959.360 mg/g of thcv. the cbd isolate was found to contain 217.803 mg/g of total cannabinoids, 217.138 mg/g of cbd, and no detectable thc. results only those subjects who completed the uninterrupted 90 days of use of the intervention were included in the study analysis. the results were evaluated using the placebo group as the cannabis, a publication of the research society on marijuana 113 standard for comparison. a one-tailed p-value less than .05 was used to determine statistical significance. the paired student t-test was used to compare before-and-after results within each group. one-way analysis of variance (anova) was used to compare the results of the three different groups. in the tables below, those differences that were statistically significant are provided in bold. table 2. beginning and ending weights (kg), and abdominal girths (cm) by group group a b p weight day 0 (kg) 103.1 +/10.9 111.4 +/19.1 100.0 +/9.4 weight day 90 100.4 +/10.6 107.3 +/19.4 99.0 +/9.8 weight difference -2.6 +/1.5 -4.1 +/2.44 -0.1 +/1.24 weight difference t-test (p-value) 0.001 0.004 0.157 abdominal girth day 0 (cm) 117.2 +/7.8 123.3 +/16.3 113.3 +/5.8 abdominal girth day 90 112.2 +/7.5 119.6 +/16.0 111.8 +/6.9 abdominal girth difference -5.0 +/1.3 -3.7 +/2.64 -1.45 +/1.46 abdominal girth difference t-test (p-value) < 0.001 0.011 0.041 table 3. beginning and ending blood pressure readings by group in mm hg group a b p bp systolic day 0 139.9 +/8.3 143.3 +/18.1 139.5 +/13.0 bp systolic day 90 131.3 +/8.1 131.2 +/10.7 137.6 +/11.5 systolic bp difference -8.7 +/5.7 -12.1 +/14.2 -1.9 +/6.5 systolic bp difference t-test (p-value) 0.003 0.065 0.290 bp diastolic day 0 89.9 +/6.1 94.8 +/10.1 94.1 +/8.6 bp diastolic day 90 86.5 +/5.7 88.8 +/7.0 91.5 +/9.8 bp diastolic difference -3.46 +/3.9 -6.0 +/8.5 -2.6 +/4.0 bp diastolic difference t-test (p-value) 0.048 0.099 0.115 table 4. beginning and ending total cholesterol levels by group in mg/dl group a b p total cholesterol day 0 183 +/15.2 196.1 +/26.6 178.3 +/29.1 total cholesterol day 90 174.2 +/12.6 181.4 +/30.8 178,7 +/24.1 total cholesterol difference -8.8 +/11.1 -14.75 +/19.0 0.4 +/9.9 total cholesterol difference t-test (p-value) 0.067 0.039 0.469 table 5. beginning and ending hdl and ldl levels by group in mg/dl group a b p hdl day 0 48.4 +/3.9 53.9 +/8.0 53.0 +/7.4 hdl day 90 48.7 +/4.2 52.8 +/13.3 57.0 +/8.7 hdl difference 0.29 +/3.0 -1.1 +/6.9 4.0 +/3.7 weight loss and therapeutic effects of thcv 114 hdl difference t-test (p-value) 0.425 0.380 0.032 ldl day 0 101.5 +12.3 112.0 +/18.5 106.5 /23.4 ldl day 90 103.0 +/11.1 97.4 +/17.2 102.8 +/ 20.2 ldl difference -7.4 +/8.0 -15.5 +/7.9 -3.7 +/7.5 ldl difference t-test (p-value) 0.041 0.002 0.179 table 6. beginning and ending glucose (mg/dl) and a1c (%) levels by group group a b p glucose day 0 (mg/dl) 99.5 +/7.1 97.6 +/3.9 93.5 +/3.8 glucose day 90 96.7 +/5.2 98.5 +/3.0 95.3 +/9.5 glucose difference -2.9 +/7.7 0.9 +/4.5 1.8 +/7.9 glucose difference t-test (p-value) 0.235 0.352 0.333 a1c day 0 (%) 5.5 +/0.2 5.5 +/0.1 5.4 +/0.2 a1c 90 5.5 +/0.2 5.4 +/0.2 5.5 +/0.2 a1c difference 0.0 0.1 0.1 a1c difference t-test (p-value) 0.229 0.11 0.02 table 7. comparison of variance between various groupings student t-test p-values group a versus group b group a versus group p group b versus group p weight difference .157 .025 .003 abdominal girth .183 .002 .078 bp systolic difference .299 .092 .109 bp diastolic difference .272 .400 .242 total cholesterol difference .264 .168 .053 hdl difference .335 .859 .108 ldl difference .123 .295 .024 glucose difference .276 .242 .424 a1c difference .234 .015 .004 table 8. one way anova for factors for all three groups one way anova weight difference f 3.60, p = .036 abdominal girth f 3.89, p = .028 bp systolic difference f 1.09, p = .346 total cholesterol difference f 1.01, p = .374 ldl difference f 1.28, p = .288 a1c difference f 4.42, p = .018 cannabis, a publication of the research society on marijuana 115 exit interviews and reporting of adverse effects all subjects were encouraged to report any adverse or unusual effects throughout the 90-day study period. in addition, each of the 44 subjects went through an individual exit interview with the independent physician at the end of the study period to discuss any such effects. of the 24 subjects in group a who were assigned the single dose, 22 (91.7%) reported “no adverse effects.” nine subjects (37.5%) reported that the “taste was somewhat or too strong.” one subject (4.2%) reported “feeling like acid in my stomach” after ingesting the strip, and one (4.2%) reported “waking up feeling hungry.” of the 10 subjects in group b who were assigned the double dose, 10 (90%) reported “no adverse effects.” four subjects (40%) reported that the “taste was somewhat or too strong.” one subject (10%) reported feeling “foggy for the first day.” of the 10 subjects in group p who were assigned the placebo, 10 (100%) reported “no adverse effects.” all 10g subjects in group p (100%) reported “no issues.” urine drug testing results nine subjects of the 10 subjects who were using the 16 mg thcv dose daily, all of whom denied any current or previous thc use, consented to participate in urine thc screening on day 90 of the study. unfortunately, no prestudy urine drug testing was conducted. seven (77.8%) of the 9 tests administered came back positive. all nine subjects again denied use of thc during the course of the study, suggesting that some of the thcv metabolites excreted in urine will register as thc metabolites on a drug test. the test used was “home drug test marijuana” by new choice inc., with a threshold of 50 ng/ml and a 98% accuracy rate. liver function study changes all 44 subjects underwent liver function studies (alkaline phosphatase, alp; alanine transferase, alt; and aspartate aminotransferase, ast) on day 0 and then again on day 90 of the study. the alt levels of all subjects were in the normal range on both days 0 and 90. one subject from each group showed very mild elevations above the upper limits of normal (uln) from the normal range for alt (normal range: 629 u/l). the group a subject went from an alt of 18 to 32 u/l. the group b subject went from an alt of 22 to 33 u/l, and the group p subject went from 34 to 37 u/l. one subject in group a showed a very mild elevation from the normal range for ast (normal range: 1-35 u/l) to above the uln, from 20 to 54 u/l. none of the subjects reported any complaints or exam findings consistent with liver inflammation. discussion endocannabinoids are orexigenic mediators and are part of the leptin-regulated central neural circuitry that controls energy intake (di marzo et al., 2001). endocannabinoids promote lipogenesis and limit fat elimination in the liver, adipose tissue, and skeletal muscle. the feeling of hunger, mediated by the hypothalamus, is triggered by hormone imbalances such as elevated ghrelin, decreased leptin in circulation, and the binding of 2-ag and aea to cb1 receptors (adams et al., 2005). studies have shown that elevated glucocorticoids elevate the expression of endocannabinoids in the regulation of the hypothalamic-pituitary-adrenal axis (cristino, becker, & di marzo, 2014). put simply, the chronic, low-grade inflammation that is the hallmark of metabolic syndrome results in chronic elevated appetite, or ‘munchies’, through elevated endocannabinoid or cb1 tone, resulting in detrimental metabolic effects. this study supports thcv, via neutral negative modulation of the cb1 receptor, having anorexigenic effect and cbd, via antiinflammatory effects through cb2 receptors in the adipose and other tissues, as responsible for the therapeutic metabolic effects documented. several animal and human studies (murphy & le foll, 2020) have revealed weight loss and improvement in lipid and diabetic parameters with the use of the selective cb1 reverse antagonist called rimonabant or sr141716a (acomplia, zimulti; dol-gleizes et al., 2009). in a randomized, double-blind rimonabant-placebo weight loss and therapeutic effects of thcv 116 controlled trial, rimonabant showed a notable reduction in body weight among subjects in the groups taking 20 mg of rimonabant daily, with the total amount of weight lost ranging from 2.6 6.3 kg per subject. hba1c in obese patients decreased by 0.5 0.6% compared to metformin (glucophage, glumetza, riomet, glucophage xr, and fortamet) or sulphonyl urea and by 0.8% compared to a 0.3% reduction in the placebo group (egan & colman, 2007). high-density lipoprotein cholesterol (hdl-c) also increased significantly by 22.3%, compared with 13.4% in the placebo group, while the level of triglycerides decreased in all trials by 6.8%, compared with an increase of 8.3% in the placebo group (p  <  .001). the levels of adiponectin, a protein hormone regulating glucose level and fatty acid breakdown in humans, increased significantly by 23% from the baseline in the rimonabant group (abioye et al., 2020). unfortunately, earlier studies did not take into account the fact that endocannabinoid tone is controlled by 'on demand' release, versus cb1 receptor activity, which is always active (howlett et al., 2011). the inverse antagonist rimonabant had severe psychiatric effects, postulated to be due to suppression of the innate constitutive activity of the cb1 receptors in the brain. rimonabant was never approved by the fda, and it was taken off the market shortly after its release in europe (abioye et al., 2020). recent preclinical studies suggest that neutral, instead of inverse, antagonists of the cb1 may retain the therapeutic potential of rimonabant, without the adverse effects (murphy & le foll, 2020). weight loss a review of the results in table 2 reveals that 16 of the 24 subjects in group a lost weight over the 90-day period. the average weight loss was 2.6 kg +/1.5 kg (p = .001), and the greatest weight loss was 11.1 kg . seven out of 10 subjects in group b lost weight. the average weight loss was 4.1 kg +/2.44 kg (p = .004), and the greatest weight loss was 13.95 kg. over a 30-day period, this equates to an average weight loss of 0.86 kg for group a and 1.36 kg for group b, consistent with prior unpublished studies using 50 mg of hempson oil® gel caps daily. table 7 reveals a statistically significant difference between group a and group p, as well as group b and group p, for weight loss (p = .002). there was almost a statistically significant difference between group b and group p (p = .078) for abdominal girth. one-way anova in table 8 revealed statistically significant differences in body weight difference from day 0 to day 90 across the three groups (p = .036). abdominal girth a review of the results in table 2 reveals that 23 of the 24 subjects in group a showed a decrease in abdominal girth from day 0 to day 90 of the study. the greatest girth loss in group a measured at 12.6 cm, while the average loss across group a was 5.0 cm +/1.3 cm (p < .001). seven out of 10 subjects in group b showed a decrease in abdominal girth; the greatest decrease in girth from group b measured 13.0 cm. the average decrease across group b was 3.7 cm +/ 2.64 cm (p = .011). over a 30-day period, this equates to an average abdominal girth loss of 1.67 cm per month for group a, and 1.23 cm per month for group b, consistent with prior unpublished studies using 50 mg of hempson oil® gel caps daily. it is interesting to note that there was a barely statistically significant decrease in abdominal girth in the control/placebo group (group p); however, it is also worth noting that abdominal girth is probably the least accurate of all the biometric measurements taken for the purposes of this study. table 7 reveals a statistically significant difference between group a and group p (p = .003) respectively. one-way anova in table 8 revealed statistically significant differences in abdominal girth differences from day 0 to day 90 among the three groups (p = .028). systolic blood pressure a review of table 3 reveals that only group a showed statistically significant differences in blood pressure, with 17 out of 24 showing a decrease in systolic and 15 out of 24 showing a decrease in diastolic blood pressure. the greatest decrease was 29mm hg in systolic and 21mm hg for diastolic blood pressure, while the average decrease was 8.7mm hg +/5.7mm hg (p = .003) cannabis, a publication of the research society on marijuana 117 in systolic and 3.46mm hg +/3.9mm hg in diastolic blood pressure (p = .048). although not statistically significant, 7 out of 10 subjects in group b had decreased systolic blood pressure and 5 out of 10 had decreased diastolic blood pressure, with the average diastolic blood pressure decreasing 12.1mm hg +/14.2mm hg (p = .065). this result is consistent with prior unpublished studies using hempson oil.® total cholesterol a review of table 4 reveals a statistically significant difference in total cholesterol levels in group b of -14.75 mg/dl +/19.0 mg/dl (p = .039). the difference in group a, -8.8 mg/dl +/11.1 mg/dl (p = .067), almost reached statistical significance, consistent with the previously unpublished studies that revealed a decrease in total cholesterol seen with 50 mg of daily hempson oil® administration. hdl and ldl cholesterol a review of table 5 reveals statistically significant differences in only ldl for group a, 7.4 mg/dl +/8.0 mg/dl (p = .041), and also for group b, -15.5 mg/dl +/7.9 mg/dl (p = .002). this is consistent with the decrease in total cholesterol seen in previously unpublished studies on hempson oil®. in the hdl comparison, there was an unexpected statistically significant difference in group p levels, probably due to the small sample size. blood sugar and a1c review of table 6 reveals no statistically significant differences in blood sugar or a1c percentages across all groups. this is in contrast with prior studies that have suggested a modest effect of thcv on decreasing blood sugar and a1c, as well as prior unpublished studies utilizing high-cbd, thcv, and cbdv hempson oil®. table 7 reveals no statistically significant difference between group a and group b, but statistically significant differences between group a and group p, and group b and group p (p = .015 and p = .004, respectively). the one-way anova also revealed statistically significant differences from day 0 to day 90 among the three groups (p =.018), again suggesting that small sample size may have hindered the assessment of a1c effects in this study. positive urine thc drug screening seven out of the nine subjects in groups a or b who submitted urine for thc testing tested positive, despite never using thc in their lives. this suggests that long-term daily consumption of 8 -16 mg-dose thcv isolate is likely to register a positive result on a thc screening test, due to the presence of thc metabolites in thcv isolates. anyone using thcv should be advised of this possibility. liver function testing mild alt and ast elevations are the most frequent abnormalities seen in asymptomatic persons (swarup et al., 2022). between one and four percent of healthy adults have elevated transaminases (sidibeh et al., 2017). one out of 24 (4.1%) subjects in group a and one out of 10 (10%) subjects in group b had very mild elevations of alt. a separate subject (8.3%) in group a had a very mild elevation in ast between day 0 and day 90. these subjects were advised to schedule a follow-up with their primary care physician to explore potential causation for these elevated levels. potential causes of transient liver transaminase elevations include viral hepatitis, alcohol use, medication use, steatosis or steatohepatitis, and cirrhosis; obesity, hyperlipidemias and diabetes mellitus are associated with elevated alt and ast (swarup et al., 2022). unfortunately, we did not track subjects’ alcohol consumption, certain medications, or other potential causes of increased alt and ast over the course of the study. animal studies on thcv have failed to reveal any issues with elevated transaminases (pekgor et al., 2019). a study of very high doses (1500 mg/day) of cbd in healthy adults revealed that 7 out of 16 (44%) experienced peak serum alanine aminotransferase (alt) values greater than the upper limit of normal (uln; fujita et al., 2006). for five (31%) subjects, the value exceeded five times uln, therefore meeting the international consensus criteria for drug-induced liver injury. there was no correlation between transaminase elevations and baseline characteristics, cyp2c19 weight loss and therapeutic effects of thcv 118 genotype, or cbd plasma concentrations. all alt elevations above the uln began within 2-4 weeks of initial exposure to cbd. of the six subjects with alt elevations who were discontinued from the protocol, some had symptoms consistent with hepatitis or hypersensitivity. a review of available studies stated, “there is a low probability of serious hepatotoxicity at the high therapeutic doses [of cbd]… and a much lower risk of adverse hepatic effects and a potential for hepatoprotection effects at the lower doses commonly used in dietary supplements and food products… studies have addressed the safety, including hepatotoxic potential of, the cbd drug product epidiolexⓡ in conjunction with its efficacy in seizure and psychotic disorders. all the studies were confounded by concomitant use of antiepileptic medications, especially valproic acid, known to be associated with elevated transaminases” (stohs & ray, 2020). subject recruitment was limited by the ongoing covid-19 epidemic. due to a limited number of subjects in group b compared to group a, statistical power was lowered, limiting study results. some statistically significant associations may have been missed due to the limited number of subjects in groups b (10) and p (10) compared to group a (24.) even so, the study revealed several clinically significant findings consistent with prior pre-clinical and unpublished human studies. conclusion in summary, 90 day use of once-daily thcv and cbd-infused mucoadhesive strips was associated with clinically significant weight loss, decreases in abdominal girth, systolic blood pressure, and total and ldl cholesterol. while the study was limited by small sample sizes in both the high dose and placebo groups, overall results suggest positive effects on a1c levels. the 16 mg/20 mg daily dose in group b was superior for weight loss compared to the 8 mg/10 mg daily dose in group a. the results of this study for weight loss, abdominal girth loss, and decreases in cholesterol were congruent with the prior unpublished studies of hempson oil®, a hemp extract high in thcv, cbdv, and cbd. ninety days of daily use of 16 mg of thcv were associated with a false-positive urine drug test for thc, as well as a small risk of very mild elevations of alt or ast compared to placebo. future studies should control for risk factors for common transient elevations 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(2022). metabolic syndrome [cme module]. statpearls publishing. thomas, a., stevenson, l. a., wease, k. n., price, m. r., baillie, g., ross, r. a., & pertwee, r. g. (2005). evidence that the plant cannabinoid delta9tetrahydrocannabivarin is a cannabinoid cb1 and cb2 receptor antagonist. british journal of pharmacology, 146(7), 917-926. doi: 10.1038/sj.bjp.0706414 tuulari, j. j., karlsson, h. k., hirvonen, j., salminen, p., nuutila, p., & nummenmaa, l. (2015). neural circuits for cognitive appetite control in healthy and obese individuals: an fmri study. plos one, 10(2), e0116640. doi: 10.1371/journal.pone.0116640 wargent, e.t., zaibi, m.s., silvestri, c., hislop, d.c., stocker, c.j., stott, c.g., guy, g.w., duncan, m., di marzo, v., cawthorne, m.a. (2013). the cannabinoid δ(9)tetrahydrocannabivarin (thcv) ameliorates insulin sensitivity in two mouse models of obesity. nutrition & diabetes, 3(5), e68. doi: 10.1038/nutd.2013.9 funding and acknowledgements: this study was self-funded for the authors’ own interest. the authors declared no conflict of interest. clinical trial registration: clinical trials.gov id: nct05574049 institutional review board statement: the study was conducted according to the guidelines of the declaration of helsinki and approved by the institutional review board of medical life care planners llc (protocol code 0007, date 10/03/2022). informed consent statement: informed consent was obtained from all subjects involved in the study. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: smith, g. l. (2025). weight loss and therapeutic metabolic effects of tetrahydrocannabivarin (thcv)-infused mucoadhesive strips. cannabis, 8(1), 109-120. https://doi.org/10.26828/cannabis/2024/000206 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 30 ved abstract objective: recent studies found that recreational legalization of cannabis consumption for canadian adults has increased presentation to the emergency department (ed) among children. in this descriptive study, our objectives were to (1) understand canadian pediatric emergency medicine (pem) providers’ training and knowledge of clinical presentations associated with cannabis exposure in children and (2) describe pediatric ed presentations related to cannabis exposure across canada following legalization in 2018. method: in 2021, following ethics board approval, 230 pediatric emergency research canada (perc) network pediatric emergency medicine (pem) physicians were invited to share about their knowledge, training, and experience with patients presenting with cannabis-associated emergencies using an anonymized survey administered through redcap. results: in total, 84/230 (36.5%) invited physicians completed the survey. almost 70% of the pem physicians reported an increase in the number of cannabisassociated ed presentations they have seen since legalization, while only 15% reported no increase in presentations. more than 90% of the respondents reported an average or higher level of knowledge of cannabis-associated pediatric emergencies. more than half (n = 48, 57%) were interested in pursuing further training, preferring formal training opportunities. the main presentations to the ed were decreased level of consciousness, known unintentional (accidental) ingestion and vomiting. significantly more tests were ordered when cannabis consumption was unknown at the beginning of the assessment, compared to when it was known, however, treatment plans were the same (mainly supportive measures). conclusions: most pem providers are managing an increasing number of cannabis-associated ed presentations. pem providers should improve communication with caregivers around household cannabis use. when caregivers feel comfortable disclosing cannabis presence at home, it can help prevent unnecessary tests and interventions for their children if they present to the ed. key words: = cannabis; pediatrics; emergency medicine; cannabis exposure; clinical knowledge zina zaslawski1, stevi golden-plotnik2,3, jessica steer1, lynne warda4, lauren e. kelly1,5,6, pediatric emergency research canada (perc) 1george & fay yee centre for healthcare innovation 2division of pediatric emergency medicine, department of pediatrics, university of alberta 3stollery children’s hospital, edmonton 4department of pediatrics and child health, university of manitoba 5department of pharmacology and therapeutics, university of manitoba 6children's hospital research institute of manitoba cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000255 volume 7, special issue 3 exploring cannabis-associated presentations to canadian pediatric emergency departments: a crosssectional study corresponding author: lauren e. kelly, phd, msc, bmedsci, ccrp, university of manitoba, 405-753 mcdermot ave, winnipeg mb r3e 0t6. phone: (204) 272-3147. email: lauren.elyse.kelly@gmail.com cannabis, a publication of the research society on marijuana 31 in canada, the recreational use of cannabis amongst adults was legalized by the federal government in october 2018. however, the recreational use of cannabis is prohibited for those younger than 18–21 years, depending on the province (cannabis act, 2018). since legalization of recreational cannabis, the rates of cannabis use among 16–19-year-olds has significantly increased. according to the 2023 canadian cannabis survey, 43% of 16–19-year-olds reported using cannabis in the past 12 months, compared to 37% in 2022, and 36% in 2018 (government of canada, 2024). recent data from the us and canada found that following cannabis legalization, emergency department (ed) presentations among children under 18 increased (cohen et al., 2022; kim & monte, 2016; thomas, dickerson-young, & mazor, 2021; yeung, weaver, hartmann, hainessaah, & lang, 2021), as did intensive care unit (icu) admissions for children related to cannabis exposures (cohen et al., 2022). for canadian children presenting to eds, having a chronic disease or a history of psychiatric disorders and oral route of cannabis exposure have been shown to predict icu admission (cohen et al., 2022). a retrospective chart review found that the most frequently presenting symptoms were altered level of consciousness (76%), lethargy/somnolence (59%), and vomiting (30%; coret & rowan-legg, 2022). though knowledge about cannabis exposure in children is increasing, it remains important to determine how emergency physicians are currently diagnosing and treating these children in canada. outcomes of cannabis ingestion in children include both potentially life-threatening adverse events and short-term toxicities (campbell, phillips, & manasco, 2017; schonhofen et al., 2018; volkow, baler, compton, & weiss, 2014). there is also the potential of long-term disruption of the endocannabinoid system, which may impair neurodevelopment (campbell et al., 2017; schonhofen et al., 2018; volkow et al., 2014). as such, it is key that physicians are skilled in assessing and managing patients with cannabisassociated medical emergencies. we need to identify the knowledge baseline and the training for those who may respond to cannabis-related presentations in emergency settings. our goals with this cross-sectional study were to (1) understand canadian pediatric emergency medicine physicians’ training and knowledge of clinical presentations associated with cannabis exposure in children post-legalization and (2) describe pediatric emergency department presentations related to cannabis exposure across canada. methods study design we completed a cross-sectional survey of pediatric emergency medicine (pem) physicians across canada on their knowledge, training, and experience with patients presenting with cannabisassociated emergencies. the online survey was developed and tested with local faculty prior to being disseminated for a two-month data collection window. ethics approval was obtained by the university of manitoba health research ethics board. participants the study population was the 230 physician members of the pediatric emergency research canada (perc) network who were invited to participate in an online, de-identified survey in 2021. “perc is a well-established network of health care researchers across 15 canadian children’s hospitals that is dedicated to improving pediatric emergency care through collaborative multi-centre research” (perc, 2023). the survey had a 36.5% response rate (84/230), comparable to other online survey studies (cunningham et al., 2015; wu, zhao, & fils-aime, 2022). survey development the survey was adapted from an existing survey of canadian pediatric oncologists and pediatric palliative care physicians caring for children with cancer (oberoi et al., 2022). the existing survey was developed via a delphi protocol (burns et al., 2008), with item generation via literature review and expert opinion, then item reduction via expert panel focus groups at a 2019 in-person conference (oberoi et al., 2022). additional clinical survey items were added based on existing literature describing pediatric cannabis presentations (cameron, finkelstein, & leslie, 2020; richards, smith, & moulin, 2017) cannabis related presentations in pediatric emergency departments 32 and focus groups between three investigators (sgp, lk, lw), as well as questions regarding knowledge and training. a panel of experts (canadian pem physicians, toxicologists, and researchers) reviewed the survey and provided feedback individually. the survey was divided into three sections: (1) professional background and demographics; (2) cannabis knowledge and training; and (3) cannabis-associated pediatric emergencies. examples of survey questions regarding cannabis knowledge and training include “how would you measure your current level of knowledge regarding cannabis-associated pediatric emergencies?” and “would you be interested in pursuing further training about cannabisassociated pediatric emergencies?” examples of survey questions regarding cannabis-associated pediatric emergencies include “how many patients have you cared for with cannabisassociated ed presentations since october 2018?” and “please think of a case when cannabis consumption was known at the beginning of your assessment. in your evaluation of this patient, which investigations did you order?” lastly, we completed a pilot test of the survey with a group of 10 pem physicians and subspecialty trainees. the survey was translated into french and was available in both official languages. survey distribution we contacted perc members by e-mail, utilizing a database provided by the perc coordinator. upon registration, perc members consent to being contacted by email for such research surveys; thus, consent was implied in completion of the survey. the survey was viewed and approved by the perc executive committee prior to distribution. data were collected and stored on the research electronic data capture (redcap; harris et al., 2009) secure web-based platform hosted at the university of manitoba. an automated introductory e-mail describing the study and containing the survey link was sent to all perc members. two reminder e-mails were sent to non-respondents. the survey data collection concluded after 8 weeks. the deidentified survey responses were entered directly by the participants into redcap. data analysis frequency distributions and percentages were produced using redcap. response rate was calculated, and descriptive statistics were used to report on the respondents’ demographic characteristics, their knowledge and training, as well as their experience with cannabis exposure in pediatric eds. descriptive tables and figures were generated using excel. results demographics table 1 presents the characteristics of the physicians who completed the survey. ninety-one percent (n = 76) of respondents completed the survey in english and 9% (n = 7) completed the survey in french. overall, the physicians who completed the survey worked across 15 children’s hospitals in eight provinces. eighty-six percent (n = 72) of respondents completed medical school in canada, and 77% (n = 65) completed their postgraduate medical training in canada. regarding years of experience as a pem attending physician, there was a wide range in career length. the number of shifts worked per month had similar wide variation. table 1. demographic and professional background of respondents characteristic number of respondents (%) gender female 50 (59.5) male 33 (39.3) cannabis, a publication of the research society on marijuana 33 prefer not to answer 1 (1.2) medical practice location for perc site british columbia 7 (8.3) alberta 16 (19.0) saskatchewan 3 (3.6) manitoba 3 (3.6) ontario 25 (29.8) quebec 18 (21.4) nova scotia 8 (9.5) newfoundland and labrador 4 (4.8) highest level of post graduate medical training clinical fellowship (e.g. simulation, point-of-care ultrasonography) 2 (2.4) emergency medicine residency only 11 (13.1) pediatric residency only 9 (10.7) emergency medicine residency with pediatric emergency medicine fellowship 3 (3.6) pediatric residency with pediatric emergency medicine fellowship 56 (66.7) other 3 (3.6) years practicing as an attending physician in pem i am a trainee 2 (2.4) 0-5 years 12 (14.3) 6-15 years 36 (42.9) 16-30 years 33 (38.1) more than 30 years 2 (2.4) shifts in pem department in a typical month 1-5 15 (17.9) 6-10 38 (45.2) 11-15 29 (34.5) more than 15 1 (1.2) none 1 (1.2) out of the 84 respondents, 91.7% (n = 77) reported an average or higher level of knowledge on cannabis-associated pediatric emergencies. only 8.3% (n = 7) of the physicians reported a poor level of knowledge. eighty-six percent (n = 72) of physicians responded that they had received some informal training such as personal reading, morning rounds, and discussion with a toxicologist. in comparison, 35% (n = 29) of respondents received some formal training in the form of grand rounds, conferences, workshops, and online approved courses. most formal or informal training was within 1–5 years (n = 52, 64%) or within the last year (n = 29, 36%). more than half (n = 48, 57%) reported to be interested in pursuing further training. additionally, almost 28% (n = 23) said that they may be interested in further training, depending on the topic, and/or duration of the training session. when asked what learning topics would interest them, “clinical presentations and management recommendations” was selected as the topic of greatest interest (n = 77). “review of federal and provincial cannabis legislation” (n = 26) and “pharmacology of cannabis” (n = 27) were selected by the respondents as the least interesting topics for training. see table 2 for the full distribution of interest in different learning topics. cannabis related presentations in pediatric emergency departments 34 table 2. topics in which pem physicians in canada would like more training topics for training number of respondents (%) clinical presentations and management recommendations 77 (91.7) toxicology/pathophysiology 52 (61.9) utilization of medical cannabis in the pediatric population 45 (53.6) pharmacology of cannabis 27 (32.1) review of federal and provincial cannabis legislation 26 (31.0) other 6 (7.1) don't know 2 (2.4) participants were also asked what format or method of training they would prefer. “local pem rounds, department grand rounds, or other scheduled department teaching” (n = 59) was the preferred method of training. “videos” (n = 21) and “published literature” (n = 23) were the least preferred methods of training. see table 3 for a full distribution of preferred method of training. table 3. physicians’ preferred method or format of training format of training number of respondents (%) local pem rounds, grand rounds or other scheduled department teaching 59 (70.2) live webinar 39 (46.4) in-person (e.g. at a conference, perc meeting) 35 (41.7) online print material/infographics 33 (39.3) published literature (e.g. studies, systematic reviews) 23 (27.4) video 21 (25.0) do not feel additional training is needed 2 (2.4) unsure 2 (2.4) other 1 (1.2) experience with cannabis-associated pediatric emergencies we asked respondents if they thought that they had seen an increase in the number of cannabis-associated ed presentations from october 2018 to the time of survey completion. out of 84 respondents, 58 (69%) said yes, 13 (15.5%) said no, and 13 (15.5%) said that they do not know. most respondents reported that they recall caring for 1–5 patients (n = 30, 35.7%) or 6 –10 patients (n = 21, 25%) with cannabisassociated ed presentations since october 2018 (see figure 1). cannabis, a publication of the research society on marijuana 35 figure 1. physician reported number of patients cared for cannabis-associated ed presentations between october 2018 and july-september 2021 those who had cared for patients with cannabisassociated ed presentations (n = 81) indicated that most of their patients were adolescents, ages 13-18 (n = 54, 64.3%), and toddlers, ages 1-4 (n = 47, 56%). less common were infant patients, 12 months and younger (n = 8, 9.5%), and young children, ages 5–12 (n = 8, 9.5%). respondents were asked to select all of the primary presenting complaints for the patients they have seen with cannabis-associated ed presentations. responses were broken down into seven categories (cannabis use, neurologic, respiratory, gastrointestinal, cardiac, psychiatric, and injury), with a further 23 subcategories. the top presenting complaints were decreased level of consciousness (neurologic; n = 64, 76.2%), known unintentional (accidental) ingestion (cannabis use; n = 59, 70.2%), and vomiting (gastrointestinal; n = 59, 70.2%). see table 4 for additional presenting complaints. table 4. primary presenting complaints for patients with cannabis-associated ed presentations primary presenting complaints number of respondents (%) cannabis use known unintentional (accidental) ingestion, or advised by poison control/public health to present to the ed 59 (70.2) cannabis intoxication 52 (61.9) cannabis withdrawal 11 (13.1) neurologic decreased level of consciousness 64 (76.2) agitation or hyperactivity 31 (36.9) dizziness, syncope 23 (27.4) seizures 7 (8.3) headache 7 (8.3) respiratory respiratory distress 7 (8.3) apnea 5 (6.0) cannabis related presentations in pediatric emergency departments 36 cough 4 (4.8) gastrointestinal vomiting 59 (70.2) abdominal pain 26 (31) cardiac palpitations 23 (27.4) chest pain 9 (10.7) psychiatric anxiety 44 (52.4) psychosis 30 (35.7) paranoia 29 (34.5) depression 26 (31) suicidal ideation 22 (26.2) injury traumatic head injury 6 (7.1) musculoskeletal injury 4 (4.8) multi-trauma 1 (1.2) physicians were asked which investigations they ordered for patients for whom cannabis consumption was not known (n = 70) at the beginning of the assessment. they reported ordering a total of 196 tests (average of 2.8 investigations per presentation). the most frequently ordered tests were bloodwork (n = 58, 82.9%), ecg (n = 48, 68.6%), and urine toxicology screen (n = 41, 58.6%). interestingly, similar results were observed when cannabis consumption was known at the start of the assessment (n = 72). blood work (n = 31, 42.5%) and ecg (n = 30, 41.1%) were the most ordered tests for these patients; however, the total number of tests ordered when cannabis consumption was known was 122, for an average of 1.7 tests per presentation. additionally, 25 physicians reported that they conducted no investigations if the cannabis consumption was known at the beginning of the assessment, compared to four physicians who reported that they conducted no investigations if the cannabis consumption was not known at the beginning of the assessment. figure 2 shows investigations that were ordered when cannabis consumption was known versus unknown. figure 2. investigations ordered when cannabis consumption known versus unknown cannabis, a publication of the research society on marijuana 37 physicians were asked which medications they ordered for patients with cannabis-related presentations, as shown in figure 3. overall, when consumption was not known at the beginning of their assessment, a total of 124 medications were ordered (n = 64), and when consumption was known, 122 medications were ordered (n = 68). more specifically, the results are very similar whether the cannabis consumption was known or not at the assessment. the most commonly ordered medications were iv fluids (n = 48, 70.6%; n = 39, 60.9%) and anti-emetics (n = 27, 39.7%; n = 41, 64.1%). anti-emetics were ordered more frequently for patients with known cannabis consumption, and more iv fluids were ordered when cannabis consumption was not known. figure 3. medications ordered when cannabis consumption known versus unknown physicians were asked about the disposition plans for the patients they saw with cannabisassociated ed presentations (n = 80). the most common response was discharge (n = 71, 88.8%), followed by admission to medicine ward (n = 44, 55%; see table 5). table 5. physician reported disposition plan for cannabis-associated ed presentations disposition plans for the patients seen with cannabis-associated ed presentations number of responses (%) discharge home 71 (88.8) admission to medicine ward 44 (55) admission to psychiatric ward 15 (18.8) admission to intensive care unit 12 (15) transfer to another facility 3 (3.8) other 0 don't know 0 cannabis related presentations in pediatric emergency departments 38 discussion knowledge and training in cannabis-associated pediatric emergencies this is the first canadian national survey on training and knowledge related to cannabis exposure in children. we learned that most pem physicians believe they have an average or higher knowledge level on cannabis-associated pediatric emergencies, and about half are interested in pursuing further training. the most desirable subject for further training was “clinical presentations and management recommendations.” these results are noteworthy, as they show that pem physicians want to learn about when cannabis can be used safely, in addition to what to do in cases of unsafe consumption. clinical presentations and management recommendations along with other highly rated topics can inform the development of continuing education. these results enhance our understanding of what and how pem physicians want to learn about cannabis-associated pediatric emergencies. physicians reported that training on cannabisrelated emergencies was mostly informal within the last one to five years–a possible response to legalization, with physicians desiring more knowledge as access to cannabis increased. this finding also points to a potential gap in training opportunities for physicians–when asked their preferred method of training, most physicians selected formal training such as scheduled rounds and presentations. universities and networks such as perc and caep (canadian association of emergency physicians) should include cannabis as a subject in future educational activities, in addition to medical school training. experience with cannabis-associated pediatric emergencies the main cannabis-related presentations to the pediatric ed were decreased level of consciousness and vomiting. most patients experienced unintentional exposures and signs of intoxication. these findings are consistent with a retrospective cohort study in canadian children (cohen et al., 2022). this research contributes to the ongoing gathering of data describing how pediatric patients present with cannabis consumption. it also provides an insight into how physicians respond to these presentations, for example, what types of investigations and interventions they order. bloodwork and ecg were the most commonly ordered investigations, whether cannabis consumption was known or unknown. a retrospective chart review found similar results, with bloodwork being most common, followed by cannabinoid urine toxicology and ecg (coret & rowan-legg, 2022) . recent reports did not identify an effective anti-emetic for cannabis hyperemesis syndrome, and diagnosis of pediatric cannabis hyperemesis is not well characterized, highlighting an urgent need for pragmatic treatment solutions (lonsdale et al., 2021). not surprisingly, most of the pediatric patients were adolescents (13 –18yo) and toddlers (1–4yo). while it was beyond the scope of this initial study to account for the wide range of pediatric patients, a future study could compare tests and medications ordered, as well as outcomes for adolescents versus toddlers. significantly more tests were ordered when cannabis consumption was unknown at the beginning of the assessment compared to when it was known (as is standard of care for a pediatric patient presenting with severe symptoms of unknown etiology, such as altered level of consciousness). it is also not surprising that blood work and urine toxicology were ordered as part of the investigation when cannabis consumption was unknown. these patterns signal the need for strategies to improve disclosure rates, which could reduce unnecessary testing for children. the main disposition plan for patients who are seen with cannabis-associated ed presentations was discharge home; however, there were also patients requiring intensive care admission. limitations and future research there are a few limitations of this study. first, we expected a higher response rate for our survey, given that the participant population was a network of academic pediatric emergency physicians. our response rate did, however, align with other e-mail survey studies (cunningham et al., 2015; wu et al., 2022). the timing of data collection may have impacted our response rate; the survey was distributed over the summer cannabis, a publication of the research society on marijuana 39 months and 12 “out of office” emails were received. second, the survey collected self-reported data that relied on recall, and participants might not have accurately remembered the past events or experiences. third, this is a descriptive study that aimed to explore clinical presentations of cannabis exposure in children, and physicians’ knowledge and training related to this topic. we wanted a comprehensive understanding as there is no available research on the training and education for ed physicians on cannabis exposure in children, particularly following legalization in 2018. future research should consider a quantitative approach to determine whether the number of children presenting to the ed with cannabis exposure is significantly different following legalization, and to test whether the management of cases is significantly different if cannabis exposure is known. future research should also explore how physicians communicate with parents of children with cannabis-related emergencies: how cannabis ingestion is discussed, what resources are provided, and what tools could be developed to improve communication. conclusion this report provides a snapshot of cannabisrelated pediatric presentations to the emergency department post-legalization. we have learned that there is a need for more education opportunities for pem physicians. despite most respondents believing to have an average or higher level of knowledge on cannabis-associated pediatric emergencies, there is an interest for further formal training. pem providers must improve communication 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(2021). emergency department pediatric visits in alberta for cannabis after legalization. pediatrics, 148(4). https://doi.org/10.1542/peds.2020-045922 funding and acknowledgements: no funding was received for this project. lauren e. kelly is the scientific director for the canadian collaborative for childhood cannabinoid therapeutics (c4t) academic research team. she holds funding from the canadian institutes of health research, canadian cancer society, research manitoba, the sick kids foundation, the children’s hospital research institute of manitoba, the university of manitoba and a mitacs accelerate award in partnership with canopy growth. dr. kelly was a member of the scientific advisory board for health products containing cannabis at health canada and is president elect for the board of directors of the canadian consortium for the investigation of cannabinoids (ccic). she has no financial conflicts of interest related to this work. the other authors declare no conflicts of interest. we would like to thank all the physicians who completed the survey and perc for facilitating the survey. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: zaslawski, z., golden-plotnik, s., steer, j., warda, l., kelly., l. e., pediatric emergency research canada (perc). (2024). exploring cannabis-associated presentations to canadian pediatric emergency departments: a crosssectional study. cannabis, 7(3), 30–40. https://doi.org/10.26828/cannabis/2024/000255 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 53 abstract to assess the self-reported reasons for medical cannabis use within the southeastern united states and compare recreational and medical cannabis users. this study was a cross-sectional survey administered in 2017 through amazon’s mechanical turk and enrolled 432 adult, regular cannabis users. measures included demographics, cannabis use characteristics, and medical reasons for cannabis use. under half (47%) of respondents endorsed using cannabis for both medical and recreational reasons and 12% reported medical use only. the most commonly cited reasons for medical cannabis use were psychiatric and 60 unique medical conditions were listed. recreational and medical users were similar on several measures of current use, but did vary in their use history, methods of use, and product knowledge. despite state laws and conclusive scientific evidence to support medical cannabis use for certain conditions, cannabis is still used frequently for a range of medical issues. these data may assist healthcare providers in better understanding medical cannabis use in states with tightened restrictions and tailoring information to medical cannabis users about their specific conditions and prioritizing therapeutic options. key words: cannabis, marijuana, medical marijuana, medical cannabis, southeastern united states, recreational cannabis is a commonly used drug in the united states (us) (substance abuse and mental health services administration, 2017), with legality status that is rapidly changing at a stateby-state level. past-month cannabis use continues to rise in the us, especially among adults aged 26 and older (substance abuse and mental health services administration, 2017). a recent nationally representative study showed that the risk of cannabis use and cannabis use disorders has increased, especially in states where medical cannabis laws have been passed (hasin et al., 2017). the use of cannabis to treat medical issues and symptomology is also increasing in the us (hill, 2015) and globally (fitzcharles & eisenberg, 2018), and the rates at which people are using medical cannabis have increased in states where medical cannabis laws have been passed (cerda, wall, keyes, galea, & hasin, 2012). in california alone, which legalized medical cannabis in 1996, there were two million individuals in 2012 that were using cannabis medically (ryan-ibarra, induni, & ewing, 2015). there are also high rates of individuals self-medicating in locations without legalized medical cannabis (park & wu, 2017). cannabis 2019, volume 2 (1), 53-65 © author(s) 2018 researchmj.org doi: 10.26828/cannabis.2019.01.005 open access medical cannabis use among adults in the southeastern united states corresponding author: claudia salazar, department of psychiatry and behavioral sciences, addiction sciences division, medical university of south carolina, 67 president st., msc 861, charleston, sc 29425, email: salazarc@musc.edu, phone: (843) 792-8207 claudia a. salazar1, rachel l. tomko1, saima a. akbar1,2, lindsay m. squeglia1, erin a. mcclure1 1 department of psychiatry and behavioral sciences, medical university of south carolina, charleston, sc, usa 2 department of psychology, florida international university, miami, fl, usa medical cannabis use in the southeastern u.s. 54 as of february 2018, 29 states in the us, including the district of columbia, permit the medical use of cannabis, and another 17 states permit limited access of low δ9tetrahydrocannnabinol (thc) and highcannabidiol (cbd) products (national conference of state legislatures, 2018). in the southeastern us specifically, most of the legislation passed focuses on cbd products only and among states with passed legislation, many do not have operational systems of dissemination in place. there is a lack of data on medical cannabis use in states without passed legislation and especially within the southeastern us, which is a region where movement towards legal recreational and medical cannabis has not moved as quickly as in the western and northeastern us. there is an increasing body of research on the potential medical benefits of thc/cbd products. synthetic cannabinoid drugs (dronabinol and nabilone) have been approved in the us to treat symptoms associated with chemotherapy-induced nausea and vomiting (todaro, 2012) and are frequently used in patients with hiv to prevent weight loss and increase appetite (badowski & perez, 2016). a recent summary of the evidence supporting the use of cannabis to treat medical disorders concluded that its use may be supported for certain conditions (i.e., chronic pain for adults, nausea and vomiting for chemotherapy patients, and for treatment of multiple sclerosis spasticity), but there is insufficient evidence to support its use for other conditions at this time (national academies of sciences, 2017). despite the lack of scientific evidence supporting the use of thc or cbd for certain conditions, many are using cannabis to treat a variety of medical symptomology. cannabinoids have been proposed as a means to manage chronic pain and alleviate reliance on prescription opioids;(choo, feldstein ewing, & lovejoy, 2016; lucas & walsh, 2017; sohler et al., 2018) however, double-blind, randomized clinical trials testing the efficacy of cannabinoid usage on reducing chronic pain have not been completed. muscle-related pain and arthritis are frequently endorsed conditions that medical cannabis are used to treat (park & wu, 2017; ryan-ibarra et al., 2015; ste-marie et al., 2016), and cannabis users have self-reported that cannabis use is helpful in alleviating their psychological symptoms and social anxiety (bonn-miller, babson, & vandrey, 2014; bonn-miller, boden, bucossi, & babson, 2014). however, there remains insufficient research on the shortand long-term health effects of thc and cbd products, especially in light of novel products and preparations that have higher percentages of thc. in states with legal medical cannabis, 17% of cannabis users reported cannabis use for medical reasons, as recommended by a physician (lin, ilgen, jannausch, & bohnert, 2016). though many patients experience benefits from medical cannabis use, they may be using it to treat conditions in an unapproved manner, without the recommendation of a physician, or in place of other, potentially efficacious treatment strategies. even in states with medical cannabis dispensaries, not all advice being given by trained dispensary staff is consistently evidence-based or medically guided (haug et al., 2016; linares et al., 2016). in states where medical and recreational cannabis is not legal or is restricted, little is known about its medicinal uses, though data suggest that medical cannabis use is still prevalent regardless of legal status (compton, han, hughes, jones, & blanco, 2017). understanding medical cannabis use, especially in states where medical use is restricted and patients are likely self-medicating, is particularly necessary. this information may help inform physicians as to the conditions and symptoms underlying medical cannabis use and could lead to tailored education in states with limited medical cannabis or cbd availability. in addition to understanding the reasons for medical cannabis use in states without widespread medical cannabis availability, it’s also important to identify meaningful differences among those using cannabis for medical versus recreational reasons. previous studies have found that those who used cannabis medically were more likely to report poorer health, more frequent daily use, lower levels of other drug use (lin et al., 2016; roy-byrne et al., 2015), and less risky drug use (richmond et al., 2015). this cross-sectional survey aimed to examine the reasons for medical cannabis use among thirteen southeastern us states. this region of the us has more restrictive medical cannabis legislation and limited distribution compared to other regions of the us, making it a generally understudied area for medical cannabis use. this cannabis, a publication of the research society on marijuana 55 study had two aims: 1) compare differences in demographics and cannabis use characteristics in recreational and medical cannabis users, and 2) assess the reasons for medical cannabis use. method participants and study design this was a one-time, cross-sectional, anonymous survey conducted on amazon’s mechanical turk (mturk). mturk is a crowdsourcing marketplace that has been a successful recruitment platform in past studies of substance use (huhn, tompkins, & dunn, 2017; peters, rosenberry, schauer, o'grady, & johnson, 2017; strickland & stoops, 2015). to recruit participants, an mturk advertisement was posted and specifically asked if mturk workers had ever used marijuana and other drugs (so to not disclose inclusion criteria). mturk workers who were 18 years or older, had used cannabis on 20 of the past 30 days, and resided in south atlantic region of the us were eligible to participate. as defined by the us census, states in the south atlantic region include: alabama, delaware, district of columbia, florida, georgia, kentucky, maryland, mississippi, north carolina, south carolina, tennessee, virginia, and west virginia. at the time of survey administration (june through august 2017), the district of columbia and delaware had legalized recreational and medical cannabis, respectively. all other states either had medical cannabis legislation that had passed, but was not operational, was limited to a few specific medical conditions, or was cbd-specific. interested participants completed an eligibility screener through the web-based research electronic data capture (redcap) (harris et al., 2009). participants who were eligible for the study were linked immediately to the full survey, which took approximately 20-30 minutes to complete. participants were compensated $1.00 for survey completion and a $1.50 bonus if they answered attention check questions correctly. this compensation amount is appropriate for mturk studies and is similar to another study that successfully recruited heavy cannabis users from this platform (peters et al., 2017). of the workers who saw the advertisement, 10,175 workers completed the eligibility screener, and 472 (4.6%) were eligible. among those responding to the eligibility survey, approximately 71% resided outside of the southeastern us and were not eligible. additionally, 93% did not meet the eligibility criteria for heaviness of cannabis use (20 out of the past 30 days). of the 472 participants who were deemed eligible, 50 (11%) participants were excluded due to incomplete responses or having incongruent answers between the screener and full survey. the final sample included 432 adult cannabis users. the vast majority of survey participants came from states without widespread medical cannabis access (428 out of 432). all study procedures were approved by the institutional review board at the author’s academic institution. measures demographics. demographic characteristics collected included age, gender, race, residing state, ethnicity, marital status, employment status, current annual household income, and level of education. cannabis and tobacco use. participants were asked about their cannabis use, in terms of frequency, amount, different preparations of use, and cannabis use history. participants completed the cannabis use disorder identification test – revised (cudit-r) (adamson et al., 2010). to assess the reasons for cannabis use, participants were asked if they used the drug for medical reasons (i.e., to treat or decrease symptom(s) of a health condition), recreational/non-medical reasons (i.e., getting pleasure or satisfaction, to fit in with a group, or just for fun), or both medical and recreational reasons. if cannabis was endorsed for medical reasons, participants were asked to self-report the reason(s) for their use (open-ended text field). participants had the ability to list as many medical conditions as they choose. the open-ended answers were categorized into general systems terms. when responses did not include sufficient detail, they were categorized in an “other” category or in a “general” category within the broader system. medical cannabis use in the southeastern u.s. 56 table 1. demographics for the overall sample and separated by medical, recreational, or medical and recreational cannabis use total sample (n=432) med cannabis users (n=50) rec cannabis users (n=180) med & rec cannabis users (n=202) pvalue age – mean (sd) 32.9 (10.2) 33.8 (11.9) 32.4 (10.1) 33.1 (9.9) 0.643 gender – n (%) 0.497 male 170 (39.4) 20 (40.0) 76 (42.2) 74 (36.6) female 260 (60.2) 30 (60.0) 104 (57.8) 126 (62.4) other 2 (0.5) 0 (0) 0 (0) 2 (1.0) race – n (%) 0.196 white/caucasian 319 (73.8) 37 (74.0) 124 (68.9) 158 (78.2) black/african american 71 (16.4) 6 (12.0) 40 (22.2) 25 (12.4) more than one race 26 (6.0) 4 (8.0) 10 (5.6) 12 (5.9) unknown/other 16 (3.7) 3 (6.0) 6 (3.3) 7 (4.5) hispanic/latino – n (%) 43 (10.0) 5 (10.0) 18 (10.0) 20 (9.9) 0.999 marital status (%) 0.846 married/domestic partnership 184 (42.6) 22 (44.0) 74 (41.1) 88 (43.6) divorced/separated/widowed 52 (12.0) 6 (12.0) 19 (10.6) 27 (13.4) never been married 196 (45.4) 22 (44.0) 87 (48.3) 87 (43.1) employment – n (%) 0.044 employed 310 (71.8) 33 (66.0) 138 (76.7) 139 (68.8) unemployed 33 (7.6) 1 (2.0) 15 (8.3) 17 (8.4) other 89 (20.6) 16 (32.0) 27 (15.0) 46 (22.8) highest education– n (%) 0.361 graduated high school or below 78 (18.1) 8 (16.0) 36 (20.0) 34 (16.8) part college 158 (36.6) 22 (44.0) 56 (31.1) 80 (39.6) graduated college (2 or 4 year), post graduate 196 (45.4) 20 (40.0) 88 (48.9) 88 (43.6) annual household income– n (%) 0.361 under $20,000 89 (20.6) 10 (20.0) 35 (19.4) 44 (21.8) $20,000 $39,999 177 (41.0) 27 (54.0) 70 (38.9) 80 (39.6) $40,000 $74,999 110 (25.5) 7 (14.0) 47 (26.1) 56 (27.7) $75,000 or more 49 (11.3) 5 (10.0) 26 (14.4) 18 (8.9) not sure 7 (1.6) 1 (2.0) 2 (1.1) 4 (2.0) state – n (%) 0.165 florida† 137 (31.7) 12 (24.0) 65 (36.1) 60 (29.7) georgia‡ 63 (14.6) 6 (12.0) 27 (15.0) 30 (14.9) north carolina‡ 50 (11.6) 10 (20.0) 23 (12.8) 17 (8.4) virginia‡ 35 (8.1) 6 (12.0) 13 (7.2) 16 (7.9) all other states 147 (34.0) 16 (32.0) 52 (28.9) 79 (39.2) cannabis, a publication of the research society on marijuana 57 note. other states of residence included alabama (4.6%)‡, delaware (0.5%)*, district of columbia (0.5%)*, kentucky (6.5%)‡, maryland (6.5%)†, mississippi (2.1%)‡, south carolina (4.4%)‡, tennessee (5.8%)‡, and west virginia (3.2%)†. *legal or medical cannabis (operational at time of survey). †medical cannabis (limited dispensing or was not operational at time of survey). ‡medical cannabis (limited or low thc/cbd products at time of survey) participants were also asked if they had a referral card for their medical cannabis use. tobacco co-use was also assessed. current tobacco users were asked about frequency and amount, history with tobacco, and completed the fagerström test for nicotine dependence (heatherton, kozlowski, frecker, & fagerstrom, 1991). aside from the assessment of cannabis use disorder and nicotine dependence, assessments used in this study were either locally developed or came from another mturk survey study focused on cannabis and tobacco co-use (peters et al., 2017). statistical analyses sample descriptive statistics were calculated and separated by 1) medical only, 2) recreational or medical and 3) recreational only cannabis use status. chi-square analysis and one-way analysis of variance (anova) were conducted to analyze differences between recreational only users, medical only users, and medical and recreational users for several demographic, cannabis, and tobacco use variables. when p<0.05, post-hoc comparisons were conducted among the three groups. the bonferroni procedure (correction) was conducted for continuous variables given multiple comparisons. for ordinal/nominal variables, column proportions were compared between groups and z-scores were calculated, while adjusting p-values using the bonferroni method. all analyses were conducted using ibm spss statistics version 22.0 and an alpha level of p<0.05 was used for all statistical analyses. results medical and recreational cannabis use demographic information for the overall sample is shown in table 1 and is also separated by self-reported medical, recreational, or combined (medical and recreational) cannabis use. among all study participants (n=432), 60.2% were female, 73.8% identified as caucasian/white, and 16.4% identified as african american/black. the mean age was 32.9 (sd=10.2; range=18-76). there was sizeable representation from florida (n=137; 31.7%), georgia (n=63; 14.6%), and north carolina (n=50; 11.6%). all other states were represented with a range of 2 to 35 participants. the majority of participants (n=249; 57.6%) lived in states with cbd-only legislation, while 181 (41.9%) lived in states that legalized medical cannabis (though dispensaries with either not operational or medical use was limited), and two participants (0.5%) lived in dc. given low numbers of participants from dc and delaware (n=4), those participants were retained in this analysis. fifty participants (11.6%) reported using cannabis in the past 30 days for medical reasons only, 180 (41.7%) reported recreational/nonmedical reasons for use, and 202 (46.8%) reported using cannabis for both medical and recreational reasons. the only statistically significant demographic difference between the groups was on employment (p=0.044), in which higher numbers of medical only cannabis users endorsed “other” employment compared to other groups. the other category included; student, retired, stay at home parent, or unable to work and the difference is likely driven by those in the medical group who are unable to work (8% compared to 0.6% and 2% in the other groups). cannabis and tobacco use characteristics for the entire sample and separated by medical vs. recreational use are shown in table 2. overall, participants used cannabis an average of 27.3 (sd=3.6) out of the last 30 days and were using an average of 4.1 (sd=3.5) times per day. the primary method of cannabis use was to smoke it, though 5.6% reported vaporizer use primarily, and 2.8% reported using dabs (concentrated thc preparation). statistically significant differences between groups are shown in table 2. generally, the medical only group appeared to vary in several ways from the recreational only group and the medical and recreational group. groups medical cannabis use in the southeastern u.s. 58 table 2. cannabis and tobacco use characteristics for the overall sample and separated by medical, recreational, or medical and recreational cannabis users cannabis use characteristics overall sample (n =432) med cannabis users (n=50) rec cannabis users (n=180) med & rec cannabis users (n=202) pvalue age of first cannabis use-m(sd) 16.5 (4.6) 18.5 (8.7)* 16.4 (3.6)† 16.1 (3.7)† .004 age of regular use-m(sd) 21.0 (6.7) 23.7 (9.8)* 20.6 (6.4)† 20.6 (5.8)† .010 days of cannabis use (past 30)-m(sd) 27.3 (3.6) 27.5 (3.4) 26.9 (3.9) 27.7 (3.4) .141 times used per day (past 30)-m(sd) 4.1 (3.5) 4.0 (4.0) 3.7 (3.0) 4.4 (3.8) .113 smoke within 30 minutes of waking-n(%) .083 no 219 (50.7) 29 (58.0) 99 (55.0) 91 (45.0) yes 213 (49.3) 21 (42.0) 81 (45.0) 111 (55.0) % thc last purchased-n(%) .023 don't know 321 (74.3) 28 (56.0)* 143 (79.4)† 150 (74.3)† 1-10% 7 (1.6) 1 (2.0) 3 (1.7) 3 (1.5) 11-20% 32 (7.4) 5 (10.0) 8 (4.4) 19 (9.4) 21% or greater 72 (16.7) 16 (32.0)* 26 (14.4)† 30 (14.9)† primary method of cannabis use-n(%) <.001 smoked 392 (90.7) 39 (78.0)* 167 (92.8)† 186 (92.1)† vaporizer 24 (5.6) 9 (18.0)* 9 (5.0)† 6 (3.0)† dabsª 12 (2.8) 2 (4.0) 1 (0.6) 9 (4.5) ediblesª 4 (0.9) 3 (1.7) 1 (0.5) grams of cannabis per pipe/bowl-m(sd)a (n=343) 0.79 (1.3) (n=35) 1.17 (1.8)† (n=129) 0.95 (1.7)† (n=179) 0.60 (0.6)† .013 cudit-r total score-m(sd) 12.3 (5.7) 10.5 (5.5)‡ 12.7 (6.0)† 12.4 (5.5)† .046 concern about health effects of cannabisn(%) .589 somewhat – extremely concerned 47 (10.9) 4 (8.0) 20 (11.1) 23 (11.4) neutral 53 (12.3) 6 (12.0) 27 (15.0) 20 (9.9) only slightly – not at all concerned 332 (76.9) 40 (80) 133 (73.9) 159 (78.7) tobacco use status-n(%) .002 current daily smoker 134 (31.0) 8 (16.0)§ 58 (32.2)† 68 (33.7)† current non-daily smoker 48 (11.1) 5 (10.0) 16 (8.9) 27 (13.4) former smoker 76 (17.6) 15 (30.0)† 20 (11.1)§ 41 (20.3)† never smoker 174 (40.3) 22 (44.0)† 86 (47.8)§ 66 (32.7)† tobacco use characteristics all tobacco co-users (n=182) med cannabis users (n=13) rec cannabis users (n=74) med & rec cannabis users (n=95) cigarettes per day (past 30)-m(sd) 11.4 (7.3) 8.9 (7.2) 12.7 (7.5) 10.6 (7.1) .086 days smoking cigarettes (past 30)-m(sd) 26.1 (8.0) 25.2 (8.5) 27.0 (6.9) 25.4 (8.7) .396 age started smoking-m(sd) 16.3 (3.8) 15.8 (3.3) 16.7 (4.8) 16.0 (3.0) .494 age of regular smoking-m(sd) 18.4 (4.3) 19.5 (5.0) 18.6 (4.7) 18.0 (3.9) .433 time smoking at current rate-n(%) .559 less than 1 year 24 (13.2) 3 (23.1) 8 (10.8) 13 (13.7) 1-4 years 43 (23.6) 1 (7.7) 18 (24.3) 24 (25.3) 5+ years 115 (63.2) 9 (69.2) 48 (64.9) 58 (61.1) ftnd total score – m(sd) 3.8 (2.6) 3.2 (2.7) 4.1 (2.7) 3.7 (2.5) .307 note. cudit-r: cannabis use disorder identification test – revised; ftnd: fagerström test for nicotine dependence. apipe/bowl was the most common method of use. outliers excluded from mean calculation (outliers were values three standard deviations away from the mean). *indicates statistically cannabis, a publication of the research society on marijuana 59 significantly different from other groups (med only used as the comparator) †not statistically different. ‡different from recreational only, but not med + rec group. §different from med + rec group varied in terms of age of first cannabis use (p=0.004) and age of regular use (p=0.010) with the medical only group trying cannabis and initiating regular use at an older age than the other groups. the medical cannabis group had a higher proportion of participants knowing the percentage of thc in their last cannabis purchase and appeared to purchase higher potency cannabis (p=0.023). a greater proportion of medical users reported using a vaporizer as their primary method of cannabis use, compared to smoking cannabis (p<0.001). grams of cannabis used per pipe/bowl (most common method of use) was higher among medical users (p=0.013). cudit-r scores tended to be lower among medical only users (p=0.046). tobacco use status was statistically different between groups (p=0.002), with less current daily smoking occurring in the medical cannabis group, while no other tobacco characteristics were statistically different. reasons for medical cannabis use the number and type of medical conditions endorsed by participants who reported any medical cannabis use to treat or reduce symptoms is shown in table 3 (by general terms). among 252 participants (out of 432; 58%) endorsing cannabis for medical use, over 60 unique medical conditions were listed. the mean number of medical conditions listed among participants was 1.8 (sd=1.0; median=1; range=1-6) with a total of 445 conditions listed. the most commonly reported reason for medical cannabis use was for a psychiatric symptom or disorder (67.9%), followed by musculoskeletal and connective tissue disorders (29.4%), and gastrointestinal disorders (9.9%). a detailed list of specific conditions and their frequency of endorsement by participants is shown in the appendix. the most commonly cited psychiatric disorders listed were anxiety (or anxiety-related conditions) and depression. other common reasons for medical use included insomnia, post-traumatic stress disorder, pain, and headaches/migraine. discussion the results of this study found that within a region of the us where medical cannabis is not widely accessible, medical cannabis use is still occurring in a substantial portion of cannabis users. of our sample, 11.6% of heavy cannabis users were using cannabis medically, and 46.8% endorsed using it for both medical and recreational reasons. despite federal and state laws and sufficient scientific evidence to support the use of medical cannabis for certain conditions, some continue to use cannabis medically for a range of medical issues to alleviate their symptoms. while some participants have most likely attempted to treat table 3. participant self-reported medical conditions that were endorsed as reasons for medical cannabis use note. participants were able to endorse more than one medical condition, and as such, the last column does not add up to 100%. medical condition endorsed (general terms) n=252 % psychiatric 171 67.9 musculoskeletal and connective tissue 74 29.4 gastrointestinal 25 9.9 nervous system/neurological 25 9.9 reproductive and breast 13 5.2 metabolism and nutrition 6 2.4 cancer (and related symptoms) 4 1.6 immune system 2 0.8 endocrine 2 0.8 respiratory, thoracic and mediastinal 2 0.8 eye, ear, nose, and throat 1 0.4 renal 1 0.4 other/unknown/insufficient detail 11 4.4 medical cannabis use in the southeastern u.s. 60 their conditions with other strategies or under a physician’s care, it is likely that some in this group have not sought medical care for their condition and may not experience long-term benefit from their medical cannabis use. this is an important area of future research to determine if medical cannabis users are generally seeking other treatment options first or if they are not utilizing healthcare services in favor of cannabis use. self-medicating with cannabis is an important topic for future research and a recent study found differences among those who are licensed vs. unlicensed users of medical cannabis (sznitman, 2017). the self-reported reasons for medical cannabis use were largely due to psychiatric conditions or symptoms, with anxiety being the most common condition listed by participants. this is consistent with past literature finding similar reasons for medical use among dispensary consumers (bonnmiller, babson, et al., 2014; bonn-miller, boden, et al., 2014). another study showed that medical cannabis users are more likely to report psychiatric comorbidity compared to recreational cannabis users (martins et al., 2015). the range of other conditions listed in this study is of interest, especially given that many of these have insufficient or no evidence to support the use of medical cannabis as a treatment strategy. the results of the current study found few demographic differences between medical and recreational users, which is consistent with previous research (lin et al., 2016), though our study also found few differences regarding current cannabis frequency between groups of users. medical cannabis users did tend to differ from the recreational group and the medical/recreational group in terms of later age of cannabis use, more knowledge about thc content in recent purchases, more vaporizer use as their primary method, lower reported problematic cannabis use as determined by the cudit-r, and lower rates of current and ever tobacco use. this study had several limitations. first, data were self-reported, so validity may have been compromised if participants over or under estimated cannabis use, had difficulty with retrospection, or otherwise were poor reporters. those using for medical reasons may have wanted to avoid any indication of dependence or problems associated with use, which could have affected responses. also, there is no way of confirming diagnosis of the medical conditions listed by participants, which may not have been formal diagnoses. second, the sample used in this study was majority female (60.2%). rates of cannabis use tend to be higher among men in the us (substance abuse and mental health services administration, 2014). having more representation among female cannabis users may be a limitation, but when compared to previous cannabis studies, it contributes to a better understanding of traditionally underrepresented participants. overall, despite similar frequency of cannabis use, medical only cannabis users, at least per their own report, appeared to be a lower risk group since they reported fewer dependence symptoms, were less susceptible to harms from smoked cannabis, started using cannabis at a later age, and did not engage as frequently in co-occurring tobacco use. in fact, avoiding combustible cannabis and the use of cannabis in adolescence are two recommended ways to reduce risk associated with cannabis use (fischer et al., 2017). in contrast, medical only users tended to report use of higher thc products (when the percentage of thc purchased was known), which is thought to be a riskier practice (fischer et al., 2017). as cannabis use increases, particularly medical cannabis use, it will become essential that our measures of problematic and/or hazardous use accurately distinguish between problematic, nonproblematic, and therapeutic use (sznitman & room, 2018). for example, it may be difficult to disentangle symptoms of withdrawal from a return to an impaired pre-cannabis functioning state. further, treatments for cannabis use disorder will need to take into account an individual’s real and perceived benefits of cannabis. if participants perceive medical benefit from their cannabis use, it is unlikely that they will be motivated to quit or even reduce. instead, it may be beneficial to implement the aforementioned harm reduction efforts with these individuals through information delivered via healthcare providers or dispensary staff. the issue of medical cannabis is clearly complicated 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(2012). cannabinoids in the treatment of chemotherapy-induced nausea and vomiting. journal of the national comprehensive cancer network, 10(4), 487492. funding: we would like to thank the funding sources that allowed for conduct of this study and effort in writing the manuscript. funding to support this study was provided by the national institute on drug abuse (nida) clinical trials network (ctn) southern consortium node (ug1 da 013727). effort was supported by the following grants: nida k01 da036739 (pi: mcclure), niaaa k23aa025399 (pi: squeglia), nida r01 da 042114 (pi: gray) and u01 da031779 (pi: gray). survey administration and data collection was possible through redcap, which is provided and maintained by the biomedical informatics center (bmic) grant support at musc (nih/ncats ul1 tr001450). the funding sources had no role in the development of this manuscript or analysis of results. acknowledgments: the authors would like to thank the following individuals for their assistance in study development, survey administration, mturk expertise, data collection and cleaning: matthew carpenter, justin strickland, kelly dunn, zachary rosenberry, erica peters, kennede duncan, daniel onyekwere, kayla mcavoy, jade tuttle, and breanna tuck. http://www.samhsa.gov/data medical cannabis use in the southeastern u.s. 64 appendix. medical condition or symptom endorsed as a reason for medical cannabis use medical condition or symptom total conditions listed (n=445) psychiatric conditions 272 (61.1%) anxiety (or anxiety-related conditions) 126 depression 56 insomnia 33 post-traumatic stress disorder 24 bi-polar disorder 13 eating disorder 5 obsessive compulsive disorder 5 irritability/anger management 3 attention-deficit/hyperactivity disorder 2 mood disorder 1 personality disorder 1 substance use disorder 1 general (not otherwise specified) 2 musculoskeletal and connective tissue conditions 79 (17.7%) pain 62 arthritis 9 fibromyalgia 2 carpal tunnel 1 degenerative disc disease 1 sciatica 1 scoliosis 1 spinal osteoarthritis 1 general (not otherwise specified) 1 gastrointestinal conditions 26 (5.8%) nausea 11 gastroparesis 3 irritable bowel syndrome 3 acid reflux/gerd 2 crohns disease 2 gastrointestinal cancer 1 pancreatitis 1 ulcerative colitis 1 general (not otherwise specified) 2 nervous system conditions/neurological 25 (5.6%) headache/migraine 13 neuropathy 4 epilepsy 3 restless leg syndrome 2 seizures 2 cannabis, a publication of the research society on marijuana 65 copyright: © 2018 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. multiple sclerosis 1 reproductive and breast conditions 13 (2.9%) menstrual discomfort 5 endometriosis 2 premenstrual dysphoric disorder 2 premenstrual syndrome 2 polycystic ovary syndrome 1 reproductive issues (not otherwise specified) 1 metabolism and nutrition conditions 6 (1.3%) low appetite/appetite enhancement 6 cancer (not otherwise specified) 4 (0.8%) immune system conditions 3 (0.6%) lupus 1 general (not otherwise specified) 2 endocrine 2 (0.4%) diabetes 2 respiratory, thoracic and mediastinal conditions 2 (0.4%) asthma 2 eye, ear, nose, and throat conditions 1 (0.2%) uveitis 1 renal conditions 1 (0.2%) kidney disease 1 other/unknown/insufficient detail provided to categorize 11 (2.5%) https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ research article 77 ved abstract the present study sought to examine three distinct research questions: a) are self-control constructs (i.e., negative/positive urgency, self-regulation, and emotion-regulation) indirectly related to negative alcohol/marijuana consequences via substance use motives, b) to what extent are these indirect effects consistent across differing drugs (i.e., alcohol and marijuana), and c) are these models invariant across gender and countries. participants were 2,230 college students (mean age=20.28, sd=0.40; 71.1% females) across 7 countries (usa, canada, spain, england, argentina, uruguay, and south africa) who consumed alcohol and marijuana in the last month. two (one for alcohol and one for marijuana) fully saturated path models were conducted, such that indirect paths were examined for each self-control construct and substance use motive on negative consequences (e.g., negative urgency → coping motives → negative consequences) within the same model. within the comprehensive alcohol model, we found that lower selfregulation and higher negative urgency/suppression were related to more alcohol consequences via higher coping and conformity motives. for marijuana, we found that lower self-regulation and higher negative urgency/suppression were related to more marijuana consequences via higher coping motives (not significant for conformity motives). unique to marijuana, we did find support for higher expansion motives indirectly linking positive urgency to more negative consequences. these results were invariant across gender groups and only minor differences across countries emerged. prevention and intervention programs of alcohol and marijuana around university campuses may benefit from targeting self-control related skills in addition to motives to drug use to prevent and reduce negative drug-related consequences. key words: = alcohol; marijuana; self-control; motives; college students given high rates of problematic substance use among young adults, research has focused on identifying factors that influence risk for problematic substance use among this at-risk zannie l. montgomery1, yanina michelini2, adrian j. bravo1, angelina pilatti2, laura mezquita3,4, cross-cultural addictions study team* 1department of psychological sciences, william & mary, usa 2universidad nacional de córdoba, facultad de psicología, instituto de investigaciones psicológicas, iipsi, conicet, córdoba, argentina 3department of basic and clinical psychology and psychobiology, universitat jaume i, castellón de la plana, castellón, spain 4centre for biomedical research network on mental health (cibersam), instituto de salud carlos iii, castellón de la plana, castellón, spain cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000211 substance use motives as mediators of the associations between self-control constructs and negative substance use consequences: a cross-cultural examination corresponding author: adrian j. bravo, ph.d., department of psychological sciences, william & mary. email: ajbravo@wm.edu. cannabis, a publication of the research society on marijuana 78 population (dennhardt & murphy, 2013; stone et al., 2012). there is a need to better understand the underlying mechanisms that predict involvement in problematic alcohol and marijuana use, subsequently leading to substance-related issues. the discernment of risk and protective factors associated with substance use is paramount for the formulation and execution of effective interventions. prior investigations indicate that various facets of self-control, encompassing impulsivity-like traits, emotional regulation, and behavioral regulation, constitute pivotal underpinnings of substance use (aurora & klanecky, 2016; lau-barraco et al., 2023; wolkowicz et al., 2021). self-control is defined as a set of constructs referring to the self-initiated regulation of thoughts, feelings, and actions to face momentary desires and temptations to achieve a greater goal. to consider the different components that define self-control, researchers have focused on affect regulation (e.g., emotion regulation), behavioral regulation (e.g., self-regulation), and impulsivity as distinct markers of self-control that, in conjunction, impact numerous outcomes (e.g., problematic social media use, pilatti et al., 2021a), including substance use outcomes (hagger et al., 2019). precisely, emotion regulation refers to cognitive and behavioral efforts to control the emotions that one feels, when they occur, and how they are felt or expressed (gross, 1998; 2015). self-regulation refers to the capability of delaying immediate satisfaction, that allows people to plan, guide, and monitor their behavior to attain desired goals in the future (carey et al., 2004; strauman, 2017). impulsivity is a multidimensional construct that focuses on the tendency to act without thinking. positive and negative urgency, which refer to the propensity to act hastily when experiencing abnormally intense positive or negative emotions, respectively, are two impulsivity-like traits that researchers have uniquely examined in association with substance use outcomes (smith & cyders, 2016). previous literature has focused on examining the association of distal variables (i.e., dispositional, affective and cognitive) with substance use consequences in young people. pertinent to the present study, research has found that poor emotion regulation (e.g., lower use of cognitive reappraisal, blanchard et al., 2019), lower self-regulation (dvorak et al., 2014; hustad et al., 2009), and higher positive/negative urgency (tran et al., 2018; waddell et al., 2022; wilson et al., 2018) have all been linked to negative alcohol and marijuana consequences among young adults. given such patterns, examining potential mechanisms of these associations may also provide avenues for prevention/intervention among this at-risk population. substance use motives as mediators diverse studies (anderson et al., 2020; lucke et al., 2023; paulus et al., 2021) have supported the indirect association of components of selfcontrol with substance use via motives for substance use. alcohol and marijuana motives, defined as prominent proximal predictors of substance use outcomes (simons et al., 2005), have been shown to mediate relationships between distal factors and negative substance use consequences (for a review see cooper et al., 2016). among young adults, substance use motives (specifically coping) have been found to mediate the link between self-regulation (laubarraco et al., 2022), negative/positive urgency (adams et al., 2012), and emotion regulation difficulties (aurora & klanecky, 2016) on negative substance use consequences. while there has been a litany of research examining these relationships, fewer research has examined all of these constructs in a single model and questions remains whether such relationships are drugspecific or universal across differing drugs. moreover, the vast majority of research has focused on north american or western european populations and whether these indirect effects are universal or culturally specific is a limited area of research. purpose of present study the present study sought to replicate and extend previous research by examining three distinct research questions: a) are self-control constructs (i.e., negative/positive urgency, selfregulation, and emotion-regulation) indirectly related to negative alcohol/marijuana consequences via substance use motives, b) to what extent are these indirect effects consistent across differing drugs (i.e., alcohol and marijuana), and c) are these models invariant across gender and countries. based on prior self-control, substance use motives, and substance use problems 79 literature, we expected that coping motives would emerge as the most relevant substance use motive in the pathway between self-control constructs and negative alcohol/marijuana consequences. given prior research indicating gender (e.g., heim et al., 2021) and cross-national differences (e.g., bravo et al., 2019a, 2019b) on substance use study variables, we explored whether findings from our path models were culturally universal or culturally specific by testing the equivalence of estimated paths (i.e., test of moderation) of the model among college students from seven countries. methods participants and procedures participants were college students (n=9,171) recruited from 12 universities across seven countries (usa, canada, spain, england, argentina, uruguay, and south africa) to complete an online survey exploring risk and protective factors of substance use and addictive behaviors. the analytic sample for the present study was limited to students who reported consuming both alcohol and marijuana at least once in the past 30 days (total sample n=2,232, 69.3% female; usa n=1,144, 67.8% female; canada n=348, 66% female; south africa n=213, 80.1% female; spain, n=107, 64.5% female; uruguay n=49, 81.6% female; argentina, n=313, 71.2% female; england, n=58, 69.0% female). study procedures (see bravo et al., 2021, for more information) were approved by the institutional review boards (or the international equivalent) for each participating university. measures all appropriate measures exhibit at least metric invariance across the countries, a necessary requirement when examining associations between constructs across different groups (cieciuch et al., 2019). for all constructs, items were averaged or summed such that higher scores indicate higher endorsement of that construct. internal reliability of measures of study constructs for the total sample and across countries are presented in supplemental table 1. self-control constructs. positive and negative urgency were assessed using the short upps-p impulsive behavior scale (cyders et al., 2014) and the spanish version (bravo et al., 2018; lozanorojas et al., 2018) for spanish-speaking students. the measure assesses impulsivity-like traits (e.g., negative/positive urgency) on a 4-point scale (1 = strongly agree, 4 = strongly disagree). selfregulation was assessed using the 31-item short self-regulation questionnaire (carey et al., 2004) and the spanish version (pichardo et al., 2014) for spanish-speaking students. participants indicated their endorsement of items reflecting self-regulation on a 5-point likert scale (1 = strongly disagree, 5 = strongly agree). emotion regulation strategies were assessed using the 10item emotion regulation questionnaire (erq; gross & john, 2003) and the spanish version (cabello et al., 2013) for spanish-speaking students. the measure assesses expressive suppression (i.e., the attempt to hide, inhibit or reduce ongoing emotion-expressive behavior) and cognitive reappraisal (i.e., the attempt to reinterpret an emotion-eliciting situation in a way that alters its meaning and changes its emotional impact) using a 5-point likert scale (1 = strongly disagree, 5 = strongly agree). alcohol and marijuana use motives. drinking motives for the past month were assessed using the 12-item drinking motives questionnairerevised short form (dmq-r sf; kuntsche & kuntsche, 2009) and the spanish version (mezquita et al., 2018a) for spanish-speaking students. the measure assesses four drinking motive domains on a 5-point response scale (1 = almost never/never, 5 = almost always/always): social, conformity, enhancement, and coping. marijuana use motives for the past month were assessed using the 15-item marijuana motives questionnaire (mmq; simons et al., 1998) and the spanish version (mezquita et al., 2019) for spanish-speaking students. the measure assesses five marijuana motive domains on a 5point response scale (1 = almost never/never, 5 = almost always/always): social, conformity, enhancement, coping, and expansion. alcohol and marijuana use quantity. to evaluate marijuana use, the marijuana use grid (mug, pearson et al. [unpublished]) was employed. participants calculate their estimated gram usage for each 4-hour block of time on each day of a typical week (12–4p on monday, 4–8p on monday, etc.). we calculated an estimate of the normal amount of marijuana consumption, which cannabis, a publication of the research society on marijuana 80 is the total grams used over a typical week in the past 30 days, by adding up all the numbers across time blocks. for alcohol quantity, we used a similar grid except participants were asked to report at which times they used alcohol during a typical week in the past 30 days as well as the quantity in standard drinks consumed during that time block. we calculated typical quantity of alcohol use by summing the total number of standard drinks consumed across time blocks during the typical week. to make accurate comparisons across countries, the total number of standard drink units (sdus) consumed (summed) were transformed into grams of alcohol considering country specific sdu rates based on grams of alcohol (quantity estimates for both alcohol and marijuana >3sds above the mean were winsorized). negative alcohol and marijuana use consequences. past 30-day negative alcoholrelated consequences were assessed using the 24item brief-young adult alcohol consequences questionnaire (b-yaacq; kahler et al., 2005) and its spanish version (pilatti et al., 2014) for spanish-speaking students. past 30-day negative marijuana-related consequences were assessed using the 21-item brief marijuana consequences questionnaire (b-macq; simons et al., 2012) and its spanish version (bravo et al., 2019a) for spanish-speaking students. for both measures, we summed all items to create a composite score reflective of the number of distinct alcohol/marijuana consequences experienced in the past 30-days. data analyses plan two (one for alcohol and one for marijuana) fully saturated path models were conducted using mplus 8.7 (muthén & muthén, 1998-2022), such that indirect paths were examined for each selfcontrol construct and substance use motive on negative consequences (e.g., negative urgency → coping motives → negative consequences) within the same model. further, alcohol and marijuana use quantities were entered as covariates in the models. statistical significance of total, indirect, and direct effects of each predictor variable on alcohol/marijuana consequences was determined by 99% bias-corrected bootstrapped confidence intervals (10,000 bootstrapped samples) not containing zero. in order to test whether our mediation models were culturally specific or culturally universal, we conducted multi-group models comparing a freely estimated multi-group model to a constrained multi-group model (i.e., constraining the paths of the mediation model) to determine whether constraining the paths to be equivalent across countries and gender resulted in a worse fitting model. given the small sample size in uruguay, we combined that sample with the argentinian sample to create a “south america” sample, as done in prior research (pilatti et al., 2021b). given that the χ2 test statistic is sensitive to sample size (brown, 2015), we relied on a more stringent alpha level (.01) to determine model invariance. results bivariate correlations and descriptive statistics of all study variables in the total sample are presented in supplemental table 2. the total, indirect, and direct effects for the alcohol model are summarized in table 1 and figure 1 and for the marijuana model in table 2 and figure 2. table 1. summary of total, indirect, and direct effects of comprehensive alcohol mediation path model negative consequences predictor variable: positive urgency β 99% ci total .163 0.09, 0.24 total indirecta .029 0.004, 0.06 social motives .008 -0.002, 0.02 coping motives .011 -0.002, 0.03 enhancement motives .006 0.000, 0.02* conformity motives .005 0.000, 0.02* direct .134 0.06, 0.20 self-control, substance use motives, and substance use problems 81 predictor variable: negative urgency β 99% ci total .140 0.06, 0.22 total indirecta .049 0.02, 0.08 social motives .008 -0.003, 0.02 coping motives .025 0.01, 0.044 enhancement motives .005 0.000, 0.02* conformity motives .011 0.002, 0.03 direct .091 0.02, 0.17 predictor variable: reappraisal β 99% ci total .052 -0.02, 0.12 total indirecta .005 -0.02, 0.03 social motives .008 -0.002, 0.02 coping motives -.005 -0.02, 0.01 enhancement motives .002 -0.002, 0.01 conformity motives .001 -0.01, 0.01 direct .046 -0.02, 0.11 predictor variable: suppression β 99% ci total .012 -0.50, 0.08 total indirecta .047 0.02, 0.07 social motives .009 0.000, 0.02* coping motives .025 0.01, 0.04 enhancement motives .003 0.000, 0.01* conformity motives .010 0.002, 0.02 direct -.036 -0.10, 0.03 predictor variable: self-regulation β 99% ci total -.094 -0.17, -0.02 total indirecta -.031 -0.06, -0.004 social motives -.007 -0.02, 0.003 coping motives -.015 -0.03, -0.002 enhancement motives -.001 -0.009, 0.01 conformity motives -.008 -0.02, -0.001 direct -.064 -0.13, 0.01 note. significant associations are in bold typeface for emphasis and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. a reflects the combined indirect associations within the model. * = significant indirect effect but caution should be taken given non-significant a (i.e., self-control variable à alcohol use motive) and/or b (i.e., alcohol use motive à negative consequences) path (see figure 1). cannabis, a publication of the research society on marijuana 82 figure 1. depicts the significant standardized effects of the alcohol comprehensive mediation path model tested in the total sample. significant associations were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. the disturbances among motives were allowed to correlate. non-significant path coefficients are not shown in the figure for reasons of parsimony but are available on the osf page. model results within the comprehensive alcohol model, we found that self-regulation, suppression, and negative urgency were indirectly associated with negative alcohol-related consequences via coping and conformity motives. specifically, lower selfregulation and higher negative urgency/suppression were related to more negative alcohol-related consequences via higher coping and conformity motives. consistent with the alcohol model, we found that self-regulation, suppression, and negative urgency were indirectly associated with negative marijuana-related consequences via coping motives. specifically, lower self-regulation and higher negative urgency/suppression were related to more negative marijuana-related consequences via higher coping motives. compared to the alcohol model, no statistically significant indirect effects via conformity motives were found in the marijuana model. unique to marijuana, we did find support for expansion motives indirectly linking positive urgency and cognitive reappraisal to more negative marijuana-related consequences via higher expansion motives. self-control, substance use motives, and substance use problems 83 table 2. summary of total, indirect, and direct effects of comprehensive marijuana mediation path model negative consequences predictor variable: positive urgency β 99% ci total .017 -0.06, 0.09 total indirecta .027 -0.01, 0.06 social motives -.001 -0.01, 0.01 coping motives .010 -0.02, 0.04 enhancement motives .003 -0.003, 0.01 conformity motives .001 -0.004, 0.01 expansion motives .014 0.004, 0.03 direct -.010 -0.08, 0.06 predictor variable: negative urgency β 99% ci total .143 0.06, 0.22 total indirecta .050 0.01, 0.09 social motives .000 -0.002, 0.01 coping motives .040 0.01, 0.07 enhancement motives .004 -0.003, 0.01 conformity motives .001 -0.01, 0.01 expansion motives .005 -0.01, 0.02 direct .093 0.02, 0.16 predictor variable: reappraisal β 99% ci total .082 0.01, 0.15 total indirecta .012 -0.02, 0.05 social motives -.001 -0.01, 0.003 coping motives -.003 -0.03, 0.02 enhancement motives .005 -0.001, 0.01 conformity motives .000 -0.002, 0.01 expansion motives .011 0.002, 0.03 direct .070 0.002, 0.14 predictor variable: suppression β 99% ci total .047 -0.02, 0.11 total indirecta .047 0.02, 0.08 social motives -.001 -0.01, 0.01 coping motives .036 0.01, 0.06 enhancement motives .003 -0.003, 0.01 conformity motives .001 -0.01, 0.01 expansion motives .008 0.000, 0.020* direct .000 -0.06, 0.06 predictor variable: self-regulation β 99% ci total -.127 -0.20, -0.05 total indirecta -.038 -0.08, -0.004 social motives .001 -0.003, 0.01 coping motives -.039 -0.07, -0.013 enhancement motives -.002 -0.01, 0.01 conformity motives -.001 -0.01, 0.01 expansion motives .003 -0.01, 0.02 direct -.089 -0.16, -0.02 note. significant associations are in bold typeface for emphasis and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. a reflects the combined indirect associations within the model. * = significant indirect effect but caution should be taken given non-significant a (i.e., self-control variable à marijuana use motive) and/or b (i.e., marijuana use motive à negative consequences) path (see figure 2). cannabis, a publication of the research society on marijuana 84 figure 2. depicts the significant standardized effects of the marijuana comprehensive mediation path model tested in the total sample. significant associations were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. the disturbances among motives were allowed to correlate. non-significant path coefficients are not shown in the figure for reasons of parsimony but are available on the osf page. multi-group models constrained multi-group models compared to the freely estimated model indicated model invariance across gender for alcohol (χ2 [29] = 33.39; p = .26) and marijuana models (χ2 [35] = 44.92; p = .12) but not for countries (alcohol: χ2 [145] = 215.42; p < .001; marijuana: χ2 [175] = 271.07, p < .001). to identify where the lack of invariance in the models for country arose, we identified the paths with the greatest contribution to reducing model fit within the fully constrained models. given differences in sample sizes across countries, it is important to not over-interpret “statistically significant associations” (or lack thereof) within each country as some countries (e.g., england) may not have the statistical power to find statistically significant results even if associations are stronger than other countries. self-control, substance use motives, and substance use problems 85 in the final multi-group model for alcohol [χ2 [140] = 180.10; p = .013], all associations were constrained between countries except for one path: positive urgency → conformity motives. positive urgency was significantly negatively associated with conformity motives in the south america sample (β=-.33, 99%ci [-.56, -.11]), significantly positively associated with conformity motives in the u.s. (β=.10, 99%ci [.002, .19]), and was not statistically significantly associated with conformity motives in spain (β=.30, 99%ci [-.16, .60]), england (β=-.15, 99%ci [-.56, .28]), canada (β=.07, 99%ci [-.08, .21]), and south africa (β=.09, 99%ci [-.16, .33]). in the final multi-group model for marijuana [χ2 [160] = 200.17; p = .017], all associations were constrained between countries except for three paths: negative urgency → conformity motives, self-regulation → expansion motives, and coping motives → negative marijuana-related consequences. regarding the negative urgency → conformity motives direct effect, we found that negative urgency was significantly negatively associated with conformity motives in the south america sample (β=-.33 [-.60, -.12]), significantly positively associated with conformity motives in canada (β=.16 [.002, .32]) and south africa (β=.26 [.01, .47]), and was not statistically significantly associated with conformity motives in the u.s. (β=.08 [-.02, .18]), spain (β=.23 [-.07, .48]), and england (β=-.17 [-.57, .16]). regarding the selfregulation → expansion motives direct effect, we found no statistically significant associations in all countries although directionality of associations differed: south america (β=-.04 [-.24, .16]), u.s. (β=.03 [-.07, .13]), spain (β=-.09 [-.40, .22]), england (β=.26 [-.17, .62]), canada (β=.08 [.08, .23]), and south africa (β=-.13 [-.31, .08]). regarding the coping motives → negative marijuana-related consequences direct effect, we found that coping motives were significantly positively associated with marijuana consequences in all countries (βs ranged = .30-.39) except england (β=-.05 [-.39, .25]). discussion the present study aimed to examine three different research questions: a) are self-control constructs indirectly related to negative alcohol/marijuana consequences via substance use motives, b) to what extent are these indirect effects consistent across differing drugs, and c) are these models invariant across gender and countries. in examining the first question, we found that self-regulation, negative urgency, and suppression were indirectly associated with negative alcohol-related consequences via coping and conformity motives. when examining marijuana consequences, we found significant indirect effects between selfregulation/suppression/negative urgency and negative marijuana consequences via coping motives. unique to marijuana, we found support for expansion motives indirectly linking positive urgency and cognitive reappraisal to more negative consequences via higher expansion motives. the prominent role of coping motives is congruent with motivational models of affect regulation (cooper et al., 2016) which propose that psychoactive substance use serves as a (maladaptive) coping strategy to decrease negative affect (mezquita et al., 2018b). our results, which are similar to past research (anderson et al., 2020; yang et al., 2019), suggest that the tendency to act rashly while experiencing intense negative emotions increases the motivation to drink and use marijuana to cope with the distress and/or to avoid rejection, thereby placing these individuals at even higher risk for negative consequences of substance use. relatedly, and in accordance with previous findings (bagheri & cox, 2023), self-regulation appears to have a protective role lowering the likelihood of experiencing alcohol-related consequences. specifically, students with increased behavioral regulation appear to be more capable of avoiding engaging in substance use to regulate negative mood (lau-barraco et al., 2023) and/or to feel accepted by or integrated into their group of peers. that is, individuals with increased self-regulation seem to be more efficient at selecting alternatives that will not interfere with their long-term goals (e.g., adjusting their drinking patterns to avoid binge drinking and/or alcohol-related negative consequences). in examining our second question, we found support for coping motives being a mechanism that consistently links self-control variables to negative substance use consequences across differing drugs. however, unique findings were found across drugs, particularly involving conformity and expansion motives. conformity cannabis, a publication of the research society on marijuana 86 motives mediated the relationship between selfregulation/suppression/negative urgency and alcohol use problems. these motives involving the use of substances to avoid rejection, similar to coping motives, are considered riskier and less adaptive motives than those motivated by approaching goals like social motives (cooper et al., 2016). previous studies also show evidence of indirect associations between negative urgency and negative alcohol-related consequences via conformity motives (anderson et al., 2020; yang et al., 2019). expansion motives significantly linked positive urgency and cognitive reappraisal to more negative marijuana-related consequences. because expansion motives are not tested within the alcohol model (nor conceptualized within the drinking motives literature, see cooper et al., 2016), these “unique” findings could not be replicated across models. these findings were also consistent with prior research in which positive urgency was positively associated with marijuana problems (pilatti et al., 2021b) and expansion was a mediator of other distal variables (e.g., negative affect) and negative marijuana-related consequences (bravo et al., 2020). previous studies also observed that expansion motives were implicated with moodrelated variables (e.g., symptoms of depression and anxiety, glodosky & cuttler, 2020; neuroticism, chowdhury et al., 2016), suggesting expansion motives are a potential link to better understand the association between the tendency to act rashly in response to intense positive affect and marijuana outcomes. cross-national differences in examining our third research question, we found invariance of our effects in both models across gender but not countries. in examining country differences, we found that positive and negative urgency were significantly negatively associated with conformity motives for alcohol and marijuana use only in the south america sample. instead, for the rest of the countries, this relationship was significant and positive (i.e., for alcohol: u.s.; for marijuana: canada and south africa) or not statistically significant (i.e., for alcohol: spain, england, canada, and south africa; for marijuana: u.s., spain, and england). consistent with our results, previous studies found that higher levels of impulsivity in the context of positive and negative intense emotions were associated with higher conformity motives for alcohol use in samples from the u.s. (anderson et al., 2020; yang et al., 2019). similar results (i.e., significant positive association) were also found with college students from england (jones et al., 2014), which is different from the present study. previous studies in college students showed that personality is related to alcohol outcomes mainly through internal drinking motives (mezquita et al., 2010, 2014), and that substance use to avoid social rejection (i.e., conformity motives) present weak and inconsistent associations with personality traits (cooper et al., 2016; votaw & witkiewitz, 2021). likewise, conformity motives appear to be less commonly reported for college students who use alcohol and marijuana (votaw & witkiewitz, 2021). previous results also show that endorsement of conformity motives may be affected by the cultural characteristics of students (pilatti et al., 2022). more investigation is needed to better understand the explanatory mechanisms of these differences across different nationalities. the association between self-regulation and expansion motives was non-significant in all countries but negative in south africa, south america, and spain and positive in u.s., england, and canada. future research is needed to determine if these cross-cultural differences are replicable or just a statistical artifact. regarding the relationship between marijuana coping motives and negative consequences, all countries except england showed a significant and positive relationship between coping motives and negative consequences of marijuana use. a large body of research has supported the use of marijuana to reduce emotional distress as an important predictor of marijuana use problems (bresin & mekawi, 2019; cooper et al., 2016). the absence of a significant association in the sample from england is most likely related to the small sample size which may have affected its statistical power to reflect the association between these constructs. implications interventions targeting adaptive mood-related factors could result in increased use of adaptive coping strategies and less motivation to use drugs as a coping strategy for distress. similar approaches have been applied to personalityself-control, substance use motives, and substance use problems 87 targeted interventions of individuals predisposed to use a substance for a specific motive (e.g., sensation seeking and enhancement motives, conrod et al., 2008). studies by cameron et al. (2018) and pedrini et al. (2022) indicated that vulnerable populations (e.g., individuals with a tendency to act rashly when experiencing intense emotions) may benefit from interventions aimed at improving impulse control particularly when it is activated by intense emotional states. the evidence so far has been promising regarding the effectiveness of interventions (e.g., those targeting emotion expression or that promote mindfulness) aimed at improving emotion regulation ability (davis et al., 2019; moore et al., 2022). furthermore, college students could benefit from training programs targeting a change in motives for substance use. for instance, interventions based on cognitive behavioral treatment and motivational enhancement therapy appear effective to reduce motives for marijuana use which in turn is associated with less marijuana problems (banes et al., 2014; blevins et al., 2016; winters et al., 2021). behavioral economic-based motivational interventions like substance-free activity sessions (murphy et al., 2019; yurasek et al., 2015) and computerized interventions tailored to drinking motives (canale et al., 2015) were also efficient in preventing problematic alcohol use. limitations and future directions several limitations constrain the impact of the present study. first, a cross-sectional research design was used which prevents strong causal inferences from being made. further, our analytic sample consisted of college students who reported both alcohol and marijuana use in the past month, and whether findings are consistent among students who only use alcohol or marijuana needs further research, including comparisons between only alcohol/marijuana users vs. dual users. for assessment of marijuana, we focused primarily on estimates of flower, creating a limitation that could be addressed in future studies by including a more comprehensive examination of multiple products (e.g., edibles) and routes of administration. limitations also exist within the chosen measures for this study including the emotion regulation questionnaire (erq). future research could utilize other emotional dysregulation questionnaires (e.g., difficulties in emotion regulation scale; gratz & roemer, 2004), which may be more comprehensive. also, further research is needed to determine if our results are replicable in differing populations (including clinical samples). finally, the study relied on self-report measures of alcohol and marijuana use which is susceptible to recall bias (gmel et al., 2007) and biased estimates (prince et al., 2018). conclusions overall, the present research highlights the indirect role of coping motives in the association between self-control related constructs (i.e., negative urgency, suppression and selfregulation) and negative alcohol/marijuana consequences in a large sample of college students from seven different countries. in addition, differences between substances also emerged, as conformity motives indirectly influenced the association of negative urgency, suppression and self-regulation with negative alcohol-related consequences, while expansion motives indirectly influenced the association of positive urgency and reappraisal with negative marijuana-related consequences. these results were invariant across gender groups and only minor differences across countries emerged. prevention and intervention programs of alcohol and marijuana around university campuses may benefit from targeting self-control related skills in addition to motives for drug use to prevent and reduce negative consequences. references adams, z. w., kaiser, a. j., lynam, d. r., charnigo, r. j., & milich, r. 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(2015). a randomized controlled trial of a behavioral economic intervention for alcohol and marijuana use. experimental and clinical psychopharmacology, 23(5), 332–338. https://doi.org/10.1037/pha0000025 funding and acknowledgements: dr. bravo was supported by a training grant (t32-aa018108) from the national institute on alcohol abuse and alcoholism (niaaa) in the united states during the duration of data collection for this project. data collection was supported, in part, by grant t32-aa018108. niaaa had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. data collection in spain was also supported by grants uji-a2019-08 from the universitat jaume i and rti2018-099800-b-i00 from the spanish ministry of science, innovation and universities (mciu). data collection in argentina was also supported by grants from the national secretary of science and technology (foncyt, grant number pict 2018-3170) and by grants from the secretary of science and technologynational university of córdoba (secyt-unc). the authors report no conflict of interest. *this project was completed by the crosscultural addictions study team (cast), which includes the following investigators (in alphabetical order): adrian j. bravo, william & mary (coordinating pi); christopher c. conway, fordham university; james m. henson, old dominion university; lee hogarth, university of exeter; manuel i. ibáñez, universitat jaume i de castelló; debra kaminer, university of cape town; matthew keough, york university; laura mezquita, universitat jaume i de castelló; generós ortet, universitat jaume i de castelló; matthew r. pearson, university of new mexico; angelina pilatti, national university of córdoba; mark a. prince, colorado state university; jennifer p. read, university of buffalo; hendrik g. roozen, university of new mexico; paul ruiz, universidad de la república. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 49 ved abstract this study characterized how quantities of cannabis and alcohol use affect sleep. single-day and typical cannabis and alcohol use patterns were considered to assess acute-chronic use interactions. linear and nonlinear associations assessed dose-dependence. college students (n=337; 52% female) provided 11,417 days of data, with up to five time points per day. daily self-reported sleep duration, cannabis use quantity, and alcohol use quantity were subjected to linear mixed modeling to capture linear and curvilinear associations between single-day and typical use on same-night and typical sleep. sleep duration (difference between bedtime and waketime) was the outcome. quantity of cannabis used each day andtypical quantity used across all days were predictors in the cannabis models. parallel single-day and typical alcohol variables were predictors in the alcohol models. follow-up analyses excluded days with alcohol-cannabis co-use. main effects of single-day and typical cannabis quantity on sleep duration were observed when all cannabis-use days were modeled. higher than typical doses of single-day and typical cannabis were associated with longer sleep durations, but only to a point; at the highest doses, cannabis shortened sleep. a main effect of single-day alcohol quantity and two interactions (single-day use with both linear and curvilinear typical use) on sleep duration were observed when all alcohol-use days were modeled. greater alcohol consumption on a given day led to shorter same-night sleep, but typically heavier drinkers required higher doses than typically lighter drinkers to experience these adverse effects. follow-up models suggested alcohol co-use may contribute to the purported sleep-promoting effects of cannabis. key words: = co-use; marijuana; drinking; emerging adults; non-linear; sleep behavior insufficient sleep, difficulty falling asleep, and poor quality sleep have been widely reported in college samples for more than a decade (hershner & chervin, 2014; lund et al., 2010; owens et al., 2017). in 2022, 42% of college students reported average sleep durations of less than 7 hours per night on weeknights (american college health association, 2022) – a particularly troubling statistic considering that sleep problems elevate risk for a variety of mental and physical health neel muzumdar1,2, kristina m. jackson3, jennifer f. buckman1,2, andrea m. spaeth1, alexander w. sokolovsky3, anthony p. pawlak2, helene r. white2 1department of kinesiology and health, rutgers university – new brunswick 2center for alcohol and substance use studies, rutgers university – new brunswick 3center for alcohol and addiction studies, brown university, school of public health cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000179 dose-dependent relationships of same-day and typical substance use to sleep duration in college cannabis and alcohol users: a multilevel modeling approach using daily diary data corresponding author: kristina m. jackson, ph.d., center for alcohol and addiction studies, brown university, box g-s121-4, providence, ri 02912. phone: (401) 863-6617. email: kristina_jackson@brown.edu cannabis, a publication of the research society on marijuana 50 issues (watson et al., 2015). prevalence of cannabis and alcohol use in the college context is also high (american college health association, 2022; goodhines et al., 2019), and these substance use behaviors, while touted to promote sleep, may adversely impact sleep quantity and quality (babson et al., 2017; sharma et al., 2022a). experimental and ecological studies that capture substance use patterns and sleep at both day-level (single-day use behaviors and same-night sleep, to approximate acute effects) and person-level (typical use behaviors and typical sleep habits, to approximate chronic effects) are needed to untangle the impacts of cannabis and alcohol on sleep, particularly in the college context where insufficient sleep and frequent cannabis and alcohol use are endemic. a relationship between cannabis use and sleep has long been speculated. early, small-scale cannabis administration studies reported reduced sleep onset latency (cousens & dimascio, 1973; nicholson et al., 2004) and altered sleep architecture (feinberg et al., 1975) at varying doses; however, the higher potency products of today raise questions about the generalizability of these findings. evidence from well-powered, highquality studies remains limited (babson et al., 2017; maddison et al., 2022), and the majority of recent research on cannabis and sleep comes from survey-based studies that do not parse the effects of frequency or quantity of cannabis use on sleep. instead, these studies emphasize the relationship of sleep on the development of substance use disorders or the relationship of substance use on the development of sleep disorders. while important, these studies cannot address whether this cannabis-sleep relationship is due to the direct pharmacological actions of cannabis on body and brain processes. epidemiological studies also fail to contribute to understanding the potential biological mechanisms at play; one recent study of >21,000 participants reported that any past 30-day use of cannabis was associated with both low and high extremes of sleep duration (diep et al., 2022). such findings are hard to reconcile with other physiological and behavioral differences that are observed between infrequent/light users and chronic/heavy users. outside the sleep research field, pharmacological studies of cannabis effects on brain and cardiovascular responses suggest complex, nonlinear dose-response relationships (latif & garg, 2020; strougo et al., 2008), which parallel the extensive and complex endocannabinoid system upon which it acts. recent literature suggests that cannabis can alter systems that play an important role in sleep physiology; for example, acute use is linked to increased cortisol concentration (glodosky et al., 2021) and disrupted autonomic nervous activity (latif & garg, 2020). modulation of the cannabinoid receptor type 1 (cb1) activity by ∆9thc (delta-9-tetrahydrocannabinol, the primary psychoactive ingredient in cannabis) may also play a pivotal role in altering the maintenance of sleep architecture (kesner & lovinger, 2020). such dose-response relationships could further be affected by chronic use behaviors; for example, repeated use can reduce availability of cb1 receptors (ramaekers et al., 2020), which would adversely impact sleep homeostasis (murillorodríguez, 2008). these observations support investigation of both linear and non-linear cannabis-sleep associations as well as interactions between acute and chronic use behaviors. similarly, the effects of acute alcohol intoxication on sleep are complex (koob & colrain, 2020) and consistent with disruptions in sleep homeostasis and sleep architecture (borbély & achermann, 1999; thakkar et al., 2015) in ways that are not yet fully elucidated. alcohol use has long been acutely associated with shorter sleep onset latency (sharma et al., 2022b; stein & friedmann, 2005). in addition, sleep disruptions occur mainly during the second half of the night (chakravorty et al., 2016; ebrahim et al., 2013). therefore, there may be differential effects of alcohol on slow wave sleep, which is more prominent in the first half of the night, and rapid eye movement (rem) sleep, which is more prominent in the second half (carskadon & dement, 2011). different alcohol-sleep relationships may also exist on the ascending versus descending limb of the blood alcohol curve, a biphasic relationship such as that seen on the cardiovascular system (kajander et al., 2001; oshita et al., 1993; puddey et al., 2001). finally, like with cannabis, the acute effects of alcohol on sleep are likely to be complicated by chronic alcohol use behaviors (grotenhermen, 2003; most et al., 2014), such that a heavy drinking episode could differentially influence sleep in typically heavy versus light drinkers (brower, 2003). these observations suggest a need to characterize both relationships of substance use to sleep duration 51 linear and non-linear alcohol-sleep associations as well as interactions between acute and chronic use behaviors. the aim of the present study was to examine linear and curvilinear associations of cannabis quantity and alcohol quantity with sleep duration in college students at both the day-level (sameday) and person-level (typical). data were leveraged from a parent study wherein daily selfreported sleep duration, cannabis use, and alcohol use from two 28-day intensive longitudinal survey bursts were collected. we hypothesized non-linear relationships between single-day cannabis use quantity and same-night sleep as well as between typical cannabis use quantity and typical sleep duration, consistent with a saturable, receptormediated effect. further, we anticipated that the quantity of alcohol use on a given day would disrupt same-night sleep; a linear effect was predicted due to a lack of research into non-linear effects. cross-level interactions were exploratory; we expected that both alcohol and cannabis effects on same-night sleep would be dependent on typical use behaviors, but such interactions could reflect tolerance (i.e., dampened negative effects on sleep among individuals with higher typical use patterns) and/or sensitization (i.e., exaggerated negative effects on sleep among those with higher typical use patterns). methods design and participants undergraduate students were recruited to participate in a two-burst longitudinal study on alcohol and cannabis co-use. recruitment targeted three state universities in states with different recreational cannabis use laws (i.e., illegal, decriminalized, legal for adults 21+); medical use of cannabis was legal in all states. undergraduate students were randomly selected from each university’s database (n=8,000 at each university) to receive online screening survey invitations. of these, a total of 7,000 completed the screening survey. participants were incentivized with a lottery to win a $100 amazon.com gift card (10 per campus). eligibility criteria for the baseline survey included: (1) fulltime enrollment at one of the universities; (2) age 18–24 years; (3) past-year alcohol and cannabis use, and (4) verified e-mail address (details on recruitment and representativeness were previously published (white et al., 2019)). pastmonth alcohol and cannabis users were oversampled to ensure eligibility for the subsequent daily survey phase. eligible students (n=2,501) were e-mailed invitations to participate in the baseline survey; 1,610 enrolled and provided consent to participate. after screening for individuals who proved ineligible on the baseline survey or who encountered technical issues, the final sample was 1,390; demographic data have been published (jackson et al., 2021). compensation for the baseline survey was a $25 amazon gift card. students who reported past-month use of alcohol and cannabis “at the same time so their effects overlapped” at baseline were eligible for the daily diary phase of the study. these potential participants were stratified by frequency of pastmonth co-use occasions (i.e., 1–2 times versus 3+ times representing infrequent and frequent couse, respectively) and sex (assigned at birth), with males and frequent co-users oversampled to ensure heterogeneity relative to the larger study sample; a generally equal number of students were invited from each school. across schools, 343 of 379 invitees agreed to participate (90.5%); two students discontinued data collection during the first two days and were excluded from further analyses.thus, 341 completed the daily surveys. a flowchart depicting screening into the daily surveys has been previously published (gunn et al., 2021). participants completed a 26-day (the first two days were deleted due to technical issues) burst of intensive longitudinal experience sampling comprising five daily surveys delivered via a custom-developed smartphone application. three months later, 316 students (92.7% of the first burst) completed a repeated 28-day burst. participants were compensated $1 for each completed survey (up to $5 per day/$35 per week) with potential bonuses of $10 each week for 85% survey compliance that week and $20 at the end of 4 weeks for 90% compliance, totaling $200 maximum (amazon gift cards) per burst. daily surveys were predictably scheduled (9:00am; 2:00pm; 5:00pm; 8:00pm; 11:00pm). surveys remained active for two hours (four hours for 9:00am survey). each survey asked about behavior from the exact time that the last survey was completed until the completion time for the current survey, except when two consecutive cannabis, a publication of the research society on marijuana 52 surveys were missed, in which case the current survey used the scheduled time of the previous survey as the anchor. previously published supplemental materials (stevens et al., 2020) offer full details on missed surveys. afternoon and evening survey completion took approximately 2 minutes. morning survey completion took approximately 5 minutes and contained two parts: (1) a similar survey to the others assessing priorday substance use behavior between the time of the last completed survey and bedtime, and (2) items about bedtime (prior night) and wake time, as well as consequences from the prior day’s alcohol and cannabis use behaviors from wake time through bedtime. all procedures were approved by the institutional review board of brown university and a certificate of confidentiality was obtained from nida. measures from the daily diary data, sleep duration was calculated as the time difference between bedtime each night and wake time the next day. sleep durations above 15 hours were considered physiologically improbable and more likely associated with user error (e.g., reporting p.m. instead of a.m.) and excluded. substance use behaviors were captured from survey items that asked whether the participant used alcohol, cannabis, both, or neither for each time interval: “what did you use between [time x] and [time y]?” if alcohol and/or cannabis were endorsed, participants were presented with a timeline overlaid on a grid with time anchors (in minutes) and were instructed to tap on the screen at points corresponding to times when they used cannabis or had a drink (gunn et al., 2021). instructions were: “tap your finger in the blue box each time you had a drink/used marijuana at the corresponding time”). day-level cannabis and alcohol use quantity were indexed as the sum of the number of cannabis uses (taps) and drinks (taps), respectively, across all surveys in a given day; screenshots have been previously published (jackson et al., 2021). analyses the design of the study was multilevel in nature, i.e., days were nested within participants, and thus a linear mixed model (lmm) analytical approach was used with sleep duration as the outcome variable and subjects specified as a random effect. all analyses were conducted using sas software, version 9.4 from the sas institute, cary, nc. an initial null lmm (i.e., no predictors specified) was fitted using maximum likelihood estimation to compute the intraclass correlation coefficient (icc) (proportion of variance in sleep duration explained by the random effect of subject). two subsequent sets of lmms were conducted: one with measures of acute and typical cannabis use, and one with measures of alcohol use, each specified as continuous fixed effect predictors. only days with complete coverage of the 24-hour period were included; incomplete coverage was defined as missing two consecutive surveys in a 24-hour period or missing the morning survey. there was a total of 11,417 out of 15,863 (72%) days of data with complete cases: 48% (n=5510) were no-use days, 26% (n=2,915) were cannabis-only use days, 13% (n = 1,464) were alcohol-only use days, and 13% (n=1,527) were alcoholand cannabis-use days. data from four individuals were excluded by the model for having no complete coverage days, resulting in a final n=337. we disaggregated the substance use variables into within-person (mean-centered daily number of cannabis uses or drinks) and betweenperson (mean number of cannabis uses or drinks per person aggregated across all assessment days). squared person-mean-centered daily number of cannabis uses or drinks and squared mean number of cannabis uses or drinks were entered into the model to capture the curvilinear effects of those variables. all possible two-way cross level interactions (within-person by between-person effects) between the linear and curvilinear daily and mean use variables were specified in each model based on prior research and current hypotheses. details of analysis methods are included in supplemental materials (s1). follow-up models were tested to isolate the effects of cannabis (versus cannabis and alcohol co-use) and alcohol (versus alcohol and cannabis co-use) on sleep, with only days during which cannabis use, but not alcohol use, was reported and days when alcohol use, but not cannabis use, was reported. the significant results of each lmm model were graphed using mathematical interpolation of the final regression equation in smoothed function plots in sas proc plm. for each model, only the relationships of substance use to sleep duration 53 specific main and/or interaction effects that were statistically significant, p <.05, were considered for graphical interpolation. the 95% confidence intervals for the interpolated functions were also computed and graphed. results average reported sleep per person from the daily surveys was 7.9 + 0.9 hours per night. although all participants invited into the daily survey stage reported cannabis and/or alcohol use on the baseline survey, 23 (6.7%) students did not report cannabis use and another 10 (2.9%) students did not report alcohol use during the daily survey stage. the null lmm indicated that the random effect of subjects explained a statistically significant amount of the sleep duration variance (13.1%). cannabis use and sleep table 1 shows the results of the lmm that included all days during which cannabis was consumed. significant linear day-level and person-level main effects both indicated a positive association between cannabis use and sleep. significant curvilinear dayand person-level main effects appeared as concave-down associations between cannabis use and sleep (figure 1), indicating that there was an optimal consumption quantity, below which cannabis showed a positive association with sleep duration and above which cannabis exhibited a negative relationship with sleep duration. sample-wide cross-level interactions were not significant. to isolate the effects of cannabis (versus alcohol and cannabis co-use) on sleep, a follow-up model was performed with data from days on which cannabis use, but not alcohol use, was reported. the linear and curvilinear main effects of person-level cannabis use were no longer significant, but a significant interaction was observed between curvilinear day-level and linear person-level cannabis use (table 2). figure 2 shows that on days when typical cannabis use quantities were exceeded, lighter average users demonstrate shorter sleep durations, whereas heavier average users demonstrated longer sleep durations. figure 1. the curvilinear relationship between cannabis use and sleep duration at the daily (within-person) and average (between-person) levels. note. sleep duration (measured in hours) as a function of person mean-centered daily number of cannabis uses (top panel) and average number of cannabis uses (bottom panel) across the assessment period. the function lines are smoothed regression lines that were mathematically interpolated from a lmm that showed only significant main effects for linear and curvilinear cannabis use. the 95% confidence intervals (shaded gray) were computed based on the results of the lmm. data are mean centered; thus, 0 daily number of cannabis uses implies cannabis use at typical (personmean-centered) levels. the yellow shaded band denotes the recommended sleep durations of 7-9 hours per night for young adults and is included to aid interpretation. cannabis, a publication of the research society on marijuana 54 figure 2. the interaction effect of daily and average cannabis use on sleep duration for days when only cannabis was used. note. sleep duration (measured in hours) as a function of person mean-centered daily number of cannabis uses and average number of cannabis uses across the assessment period. the function lines shown are smoothed regression lines that were mathematically interpolated from a lmm that showed a significant cross-level interaction between curvilinear daily cannabis use and linear average cannabis use when only cannabis was used. the 95% confidence intervals (shaded gray) were computed based on the results of the lmm. data are mean centered; thus, 0 daily number of cannabis uses implies cannabis use at typical (person-mean-centered) levels. the yellow shaded band denotes the recommended sleep durations of 7-9 hours per night for young adults and is included to aid interpretation. alcohol use and sleep table 3 shows the results of the lmm that included all days during which alcohol was consumed. a significant linear day-level main effect indicated that more alcohol use on a given day was associated with lower same-night sleep duration. the curvilinear main effect was not significant, indicating that the dose-response relationship was the same at every dose. neither the linear nor curvilinear person-level main effects were significant, indicating that typical alcohol use did not substantively affect average sleep duration. interactions demonstrated that the effect of daily alcohol use on sleep duration changed as a function of an individual’s mean alcohol consumption (figure 3). a significant interaction of linear single-day alcohol use with linear typical alcohol use indicated that moderately heavier typical use (2-4.5 average drinks) attenuated the main effect of the negative relationship between alcohol use and same-night sleep. a significant interaction of linear single-day alcohol use with curvilinear typical alcohol use indicated that the attenuation of this relationship diminished with higher average amounts of daily drinks, i.e., typically heavy drinkers showed a more pronounced negative relationship between the number of daily drinks and sleep duration than typically moderate drinkers. to isolate the effects of alcohol (versus alcohol and cannabis co-use) on sleep, a follow-up model was performed with only days during which alcohol use, but not cannabis use, was reported. the pattern of results changed such that only the interaction between curvilinear day-level and curvilinear person-level alcohol use was significant (table 4). figure 4 shows evidence for greater alcohol-related sleep reductions in all groups; this was most pronounced and curvilinear among those with the highest number of average daily drinks. discussion using data from 11,417 days collected as part of a longitudinal study about alcohol and cannabis co-use among college students, this study provides a preliminary, fine-grained quantitative assessment of how substance use affects sleep. by considering factors such as interactions between acute and chronic use patterns and non-linear dose-response curves, this study reveals several novel observations related to cannabis and alcohol. importantly non-linear relationships between cannabis use quantities and sleep duration were observed and suggested that moderate doses were associated with longest sleep duration; the left panel of figure 1 suggests that using less than or more than usual on a given day shortens sleep. the right panel of figure 1 further suggests that both typically light and typically heavy cannabis users show shorter average sleep durations than moderate cannabis users. the cross-level interaction in this model was relationships of substance use to sleep duration 55 figure 3. the interaction effect of same-day and typical alcohol use on sleep duration. note. sleep duration (measured in hours) as a function of person mean-centered daily number of drinks and average number of drinks aggregated across the assessment period. the function lines are smoothed regression lines that were mathematically interpolated from a lmm with significant cross-level interaction effects between linear daily and linear and curvilinear average effects of drinking. the 95% confidence intervals (shaded gray) were computed based on the results of the lmm. data are mean centered; thus, 0 daily number of drinks implies drinking at typical (person-meancentered) levels. the yellow shaded band denotes the recommended sleep durations of 7-9 hours per night for young adults and is included to aid interpretation. figure 4. the interaction effect of daily and average alcohol use on sleep duration for days when only alcohol was used. note. sleep duration (measured in hours) as a function of person mean-centered daily number of drinks and average number of drinks aggregated across the assessment period. the function lines shown are smoothed regression lines that were mathematically interpolated from a lmm that showed a significant cross-level interaction between curvilinear daily and curvilinear average drinking when only alcohol was used. data are mean centered; thus, 0 daily number of drinks implies drinking at typical (person-meancentered) levels. the 95% confidence intervals (shaded gray) were computed based on the results of the lmm. the yellow shaded band denotes the recommended sleep durations of 7-9 hours per night for young adults and is included to aid interpretation. table 1. linear mixed regression model of cannabis use on sleep duration for all days when cannabis was consumed. b se t p constant 7.8417 0.05401 145.20 <.0001 daily # can use 0.04468 0.02006 2.23 0.0260 (daily # can use)2 -0.00446 0.001894 -2.36 0.0184 mean # can use 0.07921 0.02812 2.82 0.0049 (mean # can use)2 -0.00379 0.001515 -2.50 0.0123 daily # can use x mean # can use -0.00432 0.004002 -1.08 0.2808 (daily # can use)2 x mean # can use 0.000484 0.000360 1.34 0.1795 daily # can use x (mean # can use)2 0.000116 0.000141 0.83 0.4082 (daily # can use)2 x (mean # can use)2 4.219e-6 0.000018 0.24 0.8137 note. # = number; can use = cannabis uses; daily # can use = individual person-mean-centered daily cannabis use; mean # can use = mean cannabis use per person across all days of bursts 1 and 2; (daily # can use)2 = curvilinear effect of daily # can; (mean # can use)2 = curvilinear effect of mean # can. bolded text denotes statistical significance. dfconstant = 333; dfnon-constant parameters ≈ 1e4 cannabis, a publication of the research society on marijuana 56 table 2. linear mixed regression model of cannabis use on sleep duration for days when only cannabis was consumed. b se t p constant 7.8822 0.1107 71.19 <.0001 daily # can use 0.1030 0.04587 2.25 0.0248 (daily # can use)2 -0.00973 0.003977 -2.45 0.0145 mean # can use 0.06486 0.03967 1.63 0.1022 (mean # can use)2 -0.00219 0.001731 -1.27 0.2052 daily # can use x mean # can use -0.01228 0.008764 -1.40 0.1613 (daily # can use)2 x mean # can use 0.001392 0.000684 2.03 0.0420 daily # can use x (mean # can use)2 0.000361 0.000291 1.24 0.2152 (daily # can use)2 x (mean # can use)2 -0.00003 0.000024 -1.23 0.2189 note. # = number; can use = cannabis uses; daily # can use = individual person-mean-centered daily cannabis use; mean # can use = mean cannabis use per person across all days of bursts 1 and 2; (daily # can use)2 = curvilinear effect of daily # can; (mean # can use)2 = curvilinear effect of mean # can. bolded text denotes statistical significance. dfconstant = 258; dfnon-constant parameters = 2490 table 3. linear mixed regression model of alcohol use on sleep duration for all days when alcohol was consumed. b se t p constant 7.9308 0.07982 99.36 <.0001 daily # drinks -0.09396 0.03340 -2.81 0.0049 (daily # drinks)2 0.001076 0.003807 0.28 0.7776 mean # drinks 0.01883 0.07393 0.25 0.7990 (mean # drinks)2 -0.00326 0.01246 -0.26 0.7933 daily # drinks x mean # drinks 0.04115 0.02000 2.06 0.0397 (daily # drinks)2 x mean # drinks -0.00104 0.001996 -0.52 0.6037 daily # drinks x (mean # drinks)2 -0.00537 0.002374 -2.26 0.0238 (daily # drinks)2 x (mean # drinks)2 0.000120 0.000209 0.57 0.5668 note. # = number; daily # drinks = individual person-mean-centered daily alcohol use; (daily # drinks)2 = curvilinear effect of daily # drinks; mean # drinks = mean alcohol use per person across all days of bursts 1 and 2; (mean # drinks)2 = curvilinear effect of mean # drinks. bolded text denotes statistical significance. dfconstant = 333; dfnon-constant parameters ≈ 1e4 table 4. linear mixed regression model of alcohol use on sleep duration for days when only alcohol was consumed. b se t p constant 8.1513 0.2108 38.67 <.0001 daily # drinks -0.01112 0.09399 -0.12 0.9058 (daily # drinks)2 -0.01002 0.008453 -1.19 0.2359 mean # drinks -0.2763 0.1825 -1.51 0.1304 (mean # drinks)2 0.04757 0.03559 1.34 0.1816 daily # drinks x mean # drinks -0.03331 0.05938 -0.56 0.5750 (daily # drinks)2 x mean # drinks 0.007285 0.004790 1.52 0.1286 daily # drinks x (mean # drinks)2 0.01121 0.008158 1.37 0.1698 (daily # drinks)2 x (mean # drinks)2 -0.00144 0.000619 -2.34 0.0197 note. # = number; daily # drinks = individual person-mean-centered daily alcohol use; (daily # drinks)2 = curvilinear effect of daily # drinks; mean # drinks = mean alcohol use per person across all days of bursts 1 and 2; (mean # drinks)2 = curvilinear effect of mean # drinks. bolded text denotes statistical significance. dfconstant = 253; dfnon-constant parameters = 1129 relationships of substance use to sleep duration 57 non-significant, suggesting that chronic cannabis use shifts, but does not distort, the dose-response curve for sleep duration.interestingly, when cannabis use days that also included alcohol use were excluded from the model (figure 2), the cross-level interaction became significant. this suggests that, in the absence of alcohol, the sleeppromoting versus sleep-disrupting effects of cannabis were dependent on typical use quantities and that cannabis affects the heaviest users qualitatively differently than lighter users. further, quantity of alcohol consumed on a given day was negatively associated with samenight sleep in a dose-dependent manner, and this relationship was exponentially exacerbated by heavier typical alcohol use patterns. when days that potentially included cannabis co-use were excluded from the analyses, the relationship of acute and chronic alcohol use behaviors appeared more complex, particularly for those with heavier typical drinking patterns (figure 3 versus figure 4). the effects of cannabis on sleep a novel and important finding from this study was that cannabis-sleep relationships were nonlinear. up to a point, higher doses of cannabis were associated with longer sleep durations both at the day-level and the person-level, but, at the highest doses, cannabis shortened sleep. the inverted u-shaped dose-response curve of singleday cannabis quantities on same-night sleep suggests a ‘diminishing returns’ effect where, as doses approached the axis of symmetry (i.e., the dose corresponding to the curve’s apex), the beneficial effect of cannabis on sleep waned. also noteworthy is the fact that this vertex appeared just above the person-centered average use quantities, suggesting a consistent need to gradually increase dosing to optimize sleep benefits. together, this is consistent with the concept of tolerance and may speak to diminishing returns of medicinal efficacy, at least if used as a sleep aid. a similar curvilinear phenomenon was observed for typical use patterns. in this case, this inverted u-shaped graph can be interpreted as typically moderate cannabis users exhibited longer sleep durations than either lighter or heavier users; non-users were not included in these analyses. across numerous scientific domains, non-linear cannabis dose-response curves have been observed (calabrese & rubiocasillas, 2018; childs et al., 2017; hodges, marshall, & ashpole, 2020; latif & garg, 2020; zuardi et al., 2017). for example, recent epidemiological studies (corroon et al., 2017; cuttler et al., 2018) and some administration research (childs et al., 2017; fusar-poli et al., 2010) suggest that low-to-moderate cannabis consumption has some anxiolytic properties, but higher doses can be anxiogenic (bossong et al., 2013; karniol et al., 1974; petrie et al., 2021; sharpe et al., 2020). much more rigorous human experimental research on cannabis is needed, but such observations are in keeping with current theories about a homeostatic role of the endocannabinoid system (aizpurua-olaizola et al., 2017; huestis, 2007), the primary physiological target of phytocannabinoids. interestingly, follow-up analyses that explored cannabis-sleep relationships after data from days that included both alcohol and cannabis use were excluded found a significant interaction rather than significant main effects. comparison of the graphs from these models (figure 1 versus figure 2) reveals that when the effects of alcohol are controlled, cannabis had only nominal sleep benefits for light and moderate users; sleep promotion is only observed among the heaviest cannabis users, who required substantially more than their typical dose to experience sleep promoting benefits. unexpectedly, this increase in sleep duration occurred in excess of the 7-9 hour recommendations for this age group, making the clinical significance of this effect unclear. taken together, the cannabis-sleep models raise the question of whether some of the purported sleeppromoting effects of cannabis are related to co-use of alcohol and cannabis, and whether the effects of cannabis on sleep are dependent on an individual’s typical sleep behaviors. such observations require further investigation, including experimental studies that can carefully control timing and dose of both drugs and objectively measure indicators of sleep. the effects of alcohol on sleep the current study identified a linear day-level dose-dependent main effect, wherein greater alcohol consumption on a given day led to shorter same-night sleep. in addition, typical drinking cannabis, a publication of the research society on marijuana 58 behaviors appeared to impact sleep duration, but in such a way that two people consuming the same number of drinks on a given night could have different sleep disruptions. specifically, sleep duration declined below eight hours (i.e., the sample mean), and outside the range of recommended sleep durations, only when an individual’s average use quantities were exceeded. thus, typically heavier drinkers require higher doses than typically lighter drinkers to experience adverse effects on sleep duration. it is also noteworthy that when average use quantities were exceeded, typically heavier drinkers showed a more precipitous reduction in sleep duration compared to typically lighter drinkers. taken together, these results suggest a tolerance-like effect, wherein sleep habituates to the effects of alcohol over time, as well as a sensitization-like effect, wherein heavier drinkers appear increasingly vulnerable to greater alcohol-related sleep disruptions. the latter finding is also consistent with physiological tolerance interacting with the sedative properties of alcohol at higher doses (hendler et al., 2013). that alcohol reduces overall sleep duration on a drinking night is commonly reported, but supporting data are mainly from self-report studies that categorically compare drinking to non-drinking nights, often over a small number of nights (arnedt et al., 2011; goodhines et al., 2019; stein & friedmann, 2005). the current study meaningfully contributes to the research by suggesting that the sleep-alcohol relationship is dose dependent and that interactions exist between acute and chronic alcohol use behaviors. future studies are needed to parse whether the reduced sleep duration is associated with pharmacological actions of alcohol on the brain or with other sleep-disrupting lifestyle factors, such as sociocultural tendencies of late-night drinking, elevated academic and social stress, or concomitant effects of other drug co-use. in addition, the low subjective accuracy of intoxication, particularly in college students, who are often new drinkers, can further elevate risk for compounding alcohol and sleep problems (grant et al., 2012). due to the nature of the sample used in these analyses, co-use of alcohol and cannabis was observed on 13% of days. thus, the alcohol-sleep relationship was further explored in follow-up models that excluded data from days during which both cannabis and alcohol were used. the results of this model differed from that of the model that included all alcohol-use days, but, when graphed (figures 3 and 4), several similarities were revealed: alcohol tends to disrupt sleep when average use quantities are exceeded, and this disruption is more pronounced in the heaviest drinkers. this observation appears exacerbated when cannabis using days were excluded, suggesting that co-use of cannabis may offset some of the negative effects of alcohol on sleep. the models mainly differ in relation to the heaviest drinkers who averaged 6.5 or more drinks per day (bottom right panels of figures 3 and 4). when cannabis using days were excluded, these drinkers were more likely to sleep outside the recommended 7-9 hours – showing shorter– than-optimal sleep durations when less-thanaverage alcohol or greater-than-average alcohol was consumed and possibly longer-than-optimal durations when use quantities aligned with typical drinking habits. while this model was exploratory and requires confirmation, these results align with concepts of withdrawal and the development of adverse consequences from not using alcohol. feed-forward reciprocal associations wherein sleep deprivation encourages continued and escalating alcohol use in an effort to “self-medicate” sleep, but ethanol's toxicity on sleep-related brain systems erodes sleep behavior and physiology, can potentially exacerbate dysregulated sleep and/or development of problematic alcohol use behaviors (brower, 2003). limitations and future research this study provides compelling novel evidence that cannabis and alcohol affect sleep in complex ways that are dependent on daily and typical use patterns. nonetheless, this study should be considered in context of several limitations, most notably the sole reliance on self-reported sleep and substance use data. in terms of the sleep data, for example, we cannot verify whether participants remained asleep for the full time between bedtime and waketime, nor assess sleep quality. future work would be strengthened by the inclusion of objective sleep behavior strategies (i.e., actigraphy) and measures of sleep quality, as well as physiological measures of alcohol and cannabis use. relationships of substance use to sleep duration 59 in terms of cannabis use, we cannot verify the individual conceptualization of a ‘dose’ (e.g., a hit, a bowl, etc.); users themselves tend to be unaware of the dosage. this is further exacerbated by lack of phytochemical standardization across the sample. cannabidiol (cbd) and thc are widely speculated to produce distinct and potentially competing physiological effects (de almeida & devi, 2020; freeman et al., 2019; fusar-poli et al., 2010). with the vast variety of ‘strains’ available in the recreational market, it is difficult to control for differences in cannabinoid profiles. nonetheless, because our analyses were primarily within-person, these issues of quantity and potency are less troublesome. although we performed follow-up analyses that focused exclusively on days that included cannabis, but not alcohol, use and alcohol, but not cannabis, use, future studies that can pharmacologically quantify cannabis and alcohol co-use are still needed. cannabis and alcohol have potentially interacting pharmacokinetic profiles and, based on evidence that sleep physiology changes across a sleep epoch, understanding the biological ramifications of co-use is needed. however, the timing of cannabis and alcohol use in relation to each other is likely an important determinant of their effects on sleep. alcohol exhibits different physiological actions on the ascending and descending limbs of the blood concentration curves. less is known about the ascending and descending limbs of the blood cannabis curve. likewise, examining co-use/polyuse of other drugs, including caffeine, tobacco/nicotine, cocaine, and psychedelics, warrants further analysis, as nearly all drugs can have effects on sleep behavior and physiology, especially if used proximally to bedtime. in addition, exam schedules, work and course schedules, and perceived stress, which all place pressure on sleep timing, are important considerations for assessing the specific relationship between substance use and sleep behaviors. analyses that include these other factors will require complex modeling and large sample sizes to capture the dynamics of drug-drug interactions. future research also should include individuals with extremely heavy cannabis, alcohol, and co-use use patterns and/or who meet criteria for a substance use disorder. studies should target older adults as well as young adults who are not enrolled in a four-year college, who may have different sleep patterns as well as different cannabis use habits and motivations (especially with respect to using cannabis as a sleep aid). future research focused on individuals with dysregulated sleep is also needed; sleep deprivation is linked to dysregulation of neuroendocrine and autonomic reactivity (meerlo et al., 2008), which may interact with cannabis and alcohol pharmacodynamics, and substance use is linked to neuroadaptations that may affect sleep regulatory systems (bowers, 2003). like sleep research, cannabis research is a rapidly changing field and one that is garnering enormous public interest. studies such as this continue to triangulate towards understanding the true impact of cannabis use on human health and behavior, but federal restrictions on conducting human experimental research with cannabis to date have severely limited our ability to establish accurate guidelines for safe recreational and medical doses. the present study was not designed as a rigorous pharmacological study, and thus cannabis doses most appropriate for sleep promotion cannot be determined. nonetheless, this study adds to a growing consensus for harm reduction strategies that focus on moderating acute cannabis doses. these results suggest that a dosage guideline – that incorporates both acute dose as well as topographical use patterns that best support continued efficacy – may ultimately be possible. references aizpurua-olaizola, o., elezgarai, i., rico-barrio, i., zarandona, i., etxebarria, n., & usobiaga, a. 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(2017). inverted ushaped dose-response curve of the anxiolytic effect of cannabidiol during public speaking in real life. frontiers in pharmacology, 8, 259. https://doi.org/10.3389/fphar.2017.00259 funding and acknowledgements: this was worked supported by the national institute on drug abuse (r01 da040880, kmj/hrw) and national institute of alcohol abuse and alcoholism (k02aa025123, jfb and r01aa028286, jfb/ams). the authors declare no conflicts of interest. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 14 ved abstract objective: in october 2018, the government of canada legalized cannabis for recreational use nationwide. the effects of legalization on cannabis use have been primarily assessed through cross-sectional surveys. method: in the present study, a two-wave longitudinal design was used to explore potential demographic, substance use and behavioral addiction, and mental health predictors of change in cannabis use status following legalization. canadian online panelists (18+) were initially surveyed about their gambling and substance use in 2018 (i.e., before cannabis legalization). from the original sample, 4,707 (46.2%) were retained in the follow-up survey one year later, post-cannabis legalization. these respondents were the focus of the present study. results: when queried about how legalization would impact their use, 61.8% said, ‘i’ll never use it’, 21.1% stated “i’ll use it about the same as i do now,” 10.3% indicated, “i may try it for the first time,” 5.0% answered, “i’ll use it more,” and 1.9% responded that, “i’ll use it less.” consistent with these sentiments, within the retained sample there was a modest but significant increase in cannabis use from baseline (18.4%) to follow-up (26.1%). regressions established that younger age, being male, substance use, tobacco or e-cigarette use, problematic gambling, and stated intention to use cannabis were predictors of later cannabis use. conclusions: this national cohort design indicates that cannabis use appears to have increased in canada following legalization. the present study makes a unique contribution by also identifying variables that statistically forecast movement toward and away from cannabis use. key words: = cannabis; marijuana; substance use; canada; legalization; longitudinal on october 17, 2018, recreational cannabis use was legalized in canada for those 19 years and older (18 in alberta and quebec, with the age limit increased to 21 in quebec approximately one year later; cannabis act, 2018). one year later, on october 17, 2019, the act was amended to allow for the legalized purchase and sale of cannabis edibles, extracts, and topical products. data from the annual cross-sectional canadian cannabis survey (ccs) administered by health canada daniel s. mcgrath1, robert j. williams2, youssef allami1,2, darren r. christensen2, david c. hodgins1, fiona nicoll3, carrie a. shaw2, & rhys m.g. stevens4 1department of psychology, university of calgary 2faculty of health sciences, university of lethbridge 3department of political science, university of alberta 4library, university of lethbridge cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000247 volume 7, special issue 3 predictors of change in cannabis use status from pre to post-recreational cannabis legalization in canada: evidence from a two-wave longitudinal national survey corresponding author: daniel mcgrath, phd, university of calgary, administration building (ad), department of psychology, 2500 university drive nw. calgary, alberta, canada, t2n 1n4. email: daniel.mcgrath@ucalgary.ca cannabis, a publication of the research society on marijuana 15 revealed an initial increase in the past 12-month self-reported cannabis use among canadians 16 years and older, increasing from 22% in 2017 (health canada, 2017a) and to 25% in 2018 (health canada, 2018). the latest ccs data from 2023 found a prevalence rate of 26% (health canada, 2023).1increased rates of recreational cannabis use in canada post-legalization have also been identified in a number of other empirical studies (bahji et al., 2022; fischer et al., 2021; pham et al., 2022). one of the primary concerns with the legalization of cannabis is the possibility for cannabis non-users to experiment with or become regular users of cannabis. recent cross-sectional studies also investigated changes in cannabis use and prevalence before and after cannabis legalization in 2018. first, comparing data from the 2017 canadian tobacco, alcohol and drugs survey (ctads) to the 2019 canadian tobacco and nicotine survey, pham and colleagues (2022) found an increase from 9% to 11% in past 30-day cannabis use. however, the focus and content of these two surveys were somewhat different, and the 2% increase was not confirmed statistically. being male, being between 20 to 24 years of age, current tobacco use, vaping, and residing in a province that allowed personal cultivation were all associated with cannabis use over non-use. analyses of the 2018 and 2019 national cannabis survey (ncs) also identified predictors of past 3month cannabis use, including being between 20 to 24 years of age, endorsing poor physical health, and residing outside the province of quebec (ashoorion et al., 2023). to date, far fewer longitudinal studies have been conducted on cannabis legalization. a recent longitudinal examination of legalization in three u.s. states revealed that cannabis use among adolescents (aged 13 to 18) did not meaningfully increase preversus postlegalization (bailey et al., 2023). in canada, two longitudinal investigations using data from a community sample of 1,502 adults from hamilton, ontario, were conducted. in the first, three waves of data (1-month prior to legalization, 6-months post, 12months post) were collected (turna et al., 2021). respondents who were cannabis users before legalization actually evidenced a decrease in their use, frequency, and levels of misuse on average after legalization. in contrast, 24% of the initial cannabis non-users stated that they used cannabis at post-legalization follow-ups, a significant yet small effect. moreover, 74% of respondents correctly predicted their cannabis use status after legalization. the second longitudinal study in ontario explored migration from using medicinal cannabis to recreational cannabis after legalization (aminilara et al., 2023). among those who reported dual use of cannabis (i.e., medical and non-medical) before legalization, almost 1 in 4 became exclusive users of recreational cannabis after legalization. predictors of switching to recreational use included being younger, male, and not having approval for medicinal cannabis. while there has been an increased research focus on the effects of cannabis legalization in canada, there has never been a national longitudinal cohort study that assesses its impact on canadians. examining changes within a national cohort over time is the only unambiguous way of determining whether there has been a genuine change in the prevalence of cannabis utilization that is not an artifact of differing response rates, survey solicitations, or other unique methodological differences that exist between cross-sectional studies. cohort studies are also the best way to shed light on variables with a potential etiological relationship to cannabis initiation or cessation by virtue of their temporal relationship to subsequent behavior. this, then, is the purpose of the present study, which analyzes the results of a large-scale national cohort of people who gamble at least once per month. respondents were assessed in the three months prior to the october 2018 legalization of cannabis and then again one year later in the fall of 2019. the primary objectives of the present study were to (1) identify the overall 1the ccs prevalence rates are likely inflated due to the very low response rates (ranging from 11.5% to 21.1%) combined with the survey solicitation asking people to participate in a “survey on knowledge about and use of cannabis”, as topic interest is one of the primary determinants of survey response (groves et al., 2004; williams & volberg, 2009). as evidence of this, the ctads with a 35.7% response rate and without an exclusive focus on cannabis only obtained a 15.0% past year prevalence rate in 2017 (health canada, 2017b) compared to 22.0% in the 2017 ccs. similarly, the apparent decrease in cannabis prevalence in the ccs 2021 may simply be a function of this year having the highest response rate (21.1%) resulting in a more representative (less cannabis-focused) sample cannabis legalization 16 demographic profile of cannabis users and cannabis non-users; (2) describe perceptions of how legalization would influence cannabis use; (3) identify demographic, substance use and behavioral addiction, and mental health predictors of change in cannabis use status after legalization; and (4) identify the change in the prevalence of past-year cannabis use within the cohort from prior to legalization to one-year postlegalization. methods sample and procedure the data collected in this study were from the online panel survey conducted as part of the alberta gambling research institute (agri) national study on gambling (anp; see https://www.ucalgary.ca/research/nationalgambling-study/). respondents for the surveys were all adults (18 years and over) who were preregistered with the leger opinion’s (leo) online panel. the leo online panel is comprised of over 400,000 members who are geographically and demographically representative of the population of canada. all survey respondents were recruited through email and asked to take part in “a very important academic study.” however, people were subsequently screened out of the survey unless they had gambled on one or more forms of gambling at least once a month in the past year. potential participants were emailed repeated solicitations until a sample of at least 10,000 was achieved, with an equal number from each province/region of canada. although the primary focus of the survey was on gambling attitudes and behavior, substance use, mental health, and certain aspects of personality were also comprehensively assessed. moreover, cannabis use and gambling are known to frequently co-occur in population surveys (mcgrath et al., 2023; punia et al., 2021). the baseline survey was administered between august 16 and october 10 of 2018, with data collection completed prior to cannabis legalization on october 17, 2018. the baseline sample was matched to the 2018 canadian community health survey (cchs; statistics canada, 2018), such that questions contained the same wording, allowing for survey data to be weighted with the cchs. all of those who finished the baseline survey were then re-contacted between august 20 and november 30, 2019, to complete the follow-up survey. the survey took an average of 19.5 minutes to complete (range of 14 to 28 minutes). attention checks were included in the survey to identify any respondents who were not paying sufficient attention to the questions. individuals who did not pass attention checks were not included in the final dataset. the survey did permit skipped questions, with the exception of portions of the survey that were not applicable to the respondent. respondents were paid $10 cad for taking the follow-up survey, as well as additional compensation from leger. ethics approval for the entire anp project was provided by the human ethics review board at the university of lethbridge. a total of 4,707 respondents were retained for the follow-up survey, representing 46.2% of all baseline participants. attrition analyses were conducted using two forward stepwise logistic regressions with an entry level of p = .01 and a removal level of p = .05. nineteen demographic baseline variables were included in the model (i.e., gender, age, income, education, employment, marital status, and ethnicity), and the outcome variable was whether or not a respondent took part in the follow-up survey. among baseline cannabis non-users, only age (or = 1.19), indigenous origin (or = 0.69), and african origins (or = 0.50) were significant predictors of retention. the nagelkerke r-squared was 4.8%. for baseline cannabis users, being single (or = 1.30), age (or = 1.28), and indigenous cultural origins (or = 0.58) were significant predictors of retention. the nagelkerke r-squared was 2.8%. cannabis questions the baseline and follow-up surveys contained six questions pertaining to cannabis use, adapted from the 2018 canadian community health survey (cchs; statistics canada, 2018) and the 2018 national cannabis survey (ncs; health canada, 2018). the primary item which served to categorize cannabis users and cannabis non-users was “during the past 12 months, how often did you use marijuana, hashish, or any cannabis product?”. other items included, “what methods did you use in the past 12 months to consume cannabis?”. in addition, in the baseline survey, all respondents were asked, “how will the legalization of cannabis for recreational use impact your use of cannabis?”. cannabis, a publication of the research society on marijuana 17 demographic variables the survey included several questions on demographic variables, including province of residence, regions within provinces, sex, age, income, education, employment, ethnicity, and marital status. mental health variables, substance use and behavioral addictions, and impulsivity a series of questions were included in both surveys that assessed mental health and addictions. mental health variables included: number of significant life events in the past 12 months (adapted from the life events questionnaire; vuchinich et al., 1986), levels of stress, history of child abuse/neglect, and past year post-traumatic stress disorder (ptsd), generalized anxiety (ga), panic disorder (pd), and major depression. substance use and behavioral addictions variables included: levels of alcohol use, tobacco or e-cigarette use, use of illicit drugs, having a dsm-5 substance use disorder (sud), presence of any behavioral addiction, and scores on the problem gambling severity index (pgsi; ferris & wynne, 2001). lastly, scores on the impulsivity facet of the neo personality inventory—revised (neo pi-r; costa & mccrae, 2008) were included in the baseline survey. data analyses all analyses were conducted using ibm spss statistics version 29 (ibm corp.). first, we assessed baseline cannabis use and then follow-up use one year later. the personal impact of cannabis legalization question asked in the baseline survey was then examined. next, a series of forward stepwise binary logistic regression analyses were conducted to assess the most relevant potential baseline demographic, substance use, behavioral addiction, and mental health predictors of cannabis use status one year later. variable selection was largely exploratory, and variables were entered into the model sequentially with forward stepwise conditional criterion. baseline variables entered into the regression model included: age (continuous), sex (0 = male, 1 = female), marital status (married, single), level of education (ten categories treated continuously), household income (eight categories treated continuously), employed full-time (no, yes), and ethnic origin (seven categories). a set of substance use and behavioral addiction variables were included: tobacco/e-cigarette use, frequency of alcohol use (continuous), illegal drug use (no, yes), substance use disorder (continuous), having a current behavioral addiction (no, yes), a previous behavioral addiction (no, yes), and scores on the problem gambling severity index (ferris & wynne, 2001). one set of predictors focused on mental health and trauma and included: total number of negative life events, scores on the impulsivity facet of the neo pi-r (costa & mccrae, 2008), major depression (no, yes), generalized anxiety disorder (no, yes), posttraumatic stress disorder (ptsd), panic disorder (no, yes), and a history of child abuse/neglect (yes, no). the final set of predictors were the four response options to the question on the personal impact of cannabis legislation (never use, first try, use less, use the same, use more).2 the outcome variables of interest in the regression models were focused on change in cannabis use status. they included: baseline nonuser that remained a non-user, baseline non-user that changed to user, baseline user that remained a user, and baseline user that changed to nonuser. results cannabis use in the baseline survey the baseline assessment included a total of 10,199 (53.2% female, 46.7% male, 0.1% other) respondents. among all respondents, 21.2% confirmed at least some past 12-month use of cannabis, with 78.8% indicating no cannabis use in the past 12 months.3 among cannabis users (n = 2,597), 30.3% stated they used cannabis “less 2any ‘prefer not to answer’ responses were not included in the regression analyses. all binary categorical variables were coded as 0 = no, 1 = yes. 3the proportions reported here represent application of the cchs survey weights. the unweighted percentages are 25.5% ‘cannabis users’ and 74.5% ‘cannabis non-users’. in this study, the weighting variable was applied to prevalence estimates, but not the remaining analyses (e.g., comparisons between cannabis users and non-users or regression analyses). cannabis legalization 18 than one a month”, 11.7% “once a month,” 11.9% “2 to 3 times a month,” 6.7% “once a week,” 10.0% “2 to 3 times a week,” 8.2% “4 to 6 times a week,” and 21.1% “every day.” in terms of routes of administration, the most prevalent were smoking joints (67.5%), edibles (32.7%), handheld pipes (32.5%), vaping (23.3%), and waterpipes (18.7%). cannabis use in the follow-up survey 1 year later of the original 10,199 respondents, 4,707 (46.2%) were retained and completed the followup survey one year later. of those 4,707 follow-up respondents, 1,028 (18.4%) were baseline pastyear cannabis users, and 1,391 (26.1%) were follow-up past-year cannabis users.4 change in cannabis use status from the baseline survey to the follow-up survey was assessed. first, of the 3,679 baseline cannabis non-users, 3,192 (86.8%) were still non-users at the follow-up. however, 487 (13.2%) became cannabis users during the 12 months prior to the follow-up survey. among these new cannabis users, 45.0% stated, “less than once a month,” 13.1% “once a month,” 12.7% “2 to 3 times a month,” 9.7% “once a week,” 7.0% “2 to 3 times a week,” 3.1% “4 to 6 times a week,” and 9.4% “every day.” next, among the 1,028 baseline cannabis users retained, 904 (87.9%) reported still using cannabis 12 months later; yet, 124 (12.1%) became cannabis non-users at the follow-up survey. among the 904 respondents who remained cannabis users, 17.4% stated, “less than once a month,” 9.8% “once a month,” 10.4% “2 to 3 times a month,” 10.4% “once a week,” 14.7% “2 to 3 times a week,” 12.6% “4 to 6 times a week,” and 24.7% “every day.” the prevalence of cannabis use was statistically compared between baseline and follow-up surveys. a mcnemar's matched-pairs test was conducted to determine if there was a difference in the number of people who transitioned to cannabis use (n = 487) compared to the number of people who ceased using cannabis (n = 124). as a significant difference was found (p < .001), it can be concluded that there was a significant transition to cannabis use at follow-up. finally, demographic comparisons were conducted between cannabis users (n = 1,391) and non-users (n = 3,316) who were retained in the follow-up survey (see table 1 for the complete set of comparisons). notably, it was found that cannabis users were more likely to be male, younger on average, to be single, have lower household incomes, and were less likely to be retired. personal impact of cannabis legislation included in the baseline survey was a question about the upcoming legalization of cannabis in canada: “how will the legalization of cannabis for recreational use impact your use of cannabis?”. in the overall sample, the responses were as follows: 61.8% indicated, “it will have no impact, as i’ll never use it,” 21.1% stated, “no real impact, i’ll use it about the same as i do now,” 10.3% indicated, “i may try it for the first time,” 5.0% answered, “i’ll use it more often than i do now,” and 1.9% responded that, “i’ll use it less than i do now.” next, the responses of cannabis users and nonusers were examined separately. among baseline cannabis non-users, 11.3% stated that, “i may try it for the first time” and 2.6% indicated, “i’ll use it more often than i do now”. for baseline cannabis users, the majority (68.7%) stated “no real impact, i’ll use it about the same as i do now”; however, 12.0% indicated “i’ll use it more often than i do now” and 6.4% said, “i’ll use it less than i do now.” among the 487 baseline cannabis non-users who became cannabis users, 283 (58.3%) had previously stated, “it will have no impact, as i’ll never use it” in the baseline survey. notably, 101 (20.7%) respondents had indicated that “i may try it for the first time,” and 35 (7.2%) indicated, “i’ll use it more often than i do now.” for retained baseline cannabis users who later became nonusers (n = 124), only 3 stated, “i’ll use it less than i do now,” whereas 92 (74.2%) stated, “no real impact, i’ll use it about the same as i do now.” baseline predictors of cannabis status at the follow-up survey 4the proportion reported here represent application of the cchs survey weights. the unweighted cannabis prevalence was 21.8% at baseline and 29.6% at follow-up. cannabis, a publication of the research society on marijuana 19 four forward stepwise binary logistic regressions were conducted to identify multivariate baseline predictors of cannabis use status at follow-up. first, we focused on baseline cannabis nonusers who did not change to cannabis use at the follow-up. the outcome variable was baseline user status at the follow-up (0 = all remaining respondents, 1 = remained a non-user). the final model was statistically significant, χ2 (8) = 1,871.44, p < .01, with 2,822 respondents included in the analysis. nagelkerke r-squared was 18.8%, with eight significant predictors in the model. the overall classification accuracy was 76.3%, with 98.2% correct classification of baseline non-users who remained non-users (see table 2). as seen in table 2, the regression results identified several significant predictors. first, stating, “it will have no impact, as i’ll never use it,” “i may try it for the first time,” and “i’ll use it more often than i do now” each predicted stability of not using cannabis over time. younger age and being male were associated with decreased odds of non-user status over time. finally, tobacco or e-cigarette use, higher total pgsi scores, and illicit drug use all predicted a lack of stability in non-user status. a second binary logistic regression was conducted to identify baseline predictors of cannabis non-users who did change to cannabis use at the follow-up. the outcome variable was baseline user status at the follow-up (0 = all remaining respondents, 1 = changed to user). the final model was significant, χ2 (6) = 138.50, p < .01. the nagelkerke r-squared was very low at 9.5%, and overall classification accuracy was 58.5%, with 57.3% of baseline cannabis non-users who changed to cannabis use being correctly classified and 67.9% of the remaining respondents being correctly classified (see table 3). first, age, stating, “no real impact, i’ll use it about the same as i do now,” illicit drug use, and indicating, “i’ll use it less than i do now” were all negatively associated with changing from non-use to use. lastly, both tobacco or e-cigarette use and “i may try it for the first time” predicted a greater likelihood of changing from non-use to use. in the third regression, baseline cannabis users who did not change to non-use were assessed. the outcome variable was baseline user status at the follow-up (0 = all remaining respondents, 1 = remained a user). in this case, the final model was statistically significant, χ2 (2) = 110.09, p < .01. the nagelkerke r-squared was 15.5%, and the overall classification accuracy was 96.8%. as seen in table 4, there were two significant predictors. stating, “it will have no impact, as i’ll never use it” was associated with changing user status from baseline to follow-up, whereas “no real impact, i’ll use it about the same as i do now” predicted remaining a cannabis user at the follow-up. finally, the fourth regression examined baseline predictors of cannabis users who did change to non-use at the follow-up. the outcome variable was baseline user status at the follow-up (0 = all remaining respondents, 1 = changed to non-user). the final model was found to be statistically significant, χ2 (9) = 1,910.64, p < .01. the nagelkerke r-squared was 71.4%, and overall classification accuracy was 86.6%, with 97.4% of baseline cannabis users who remained users being correctly classified. as seen in table 5, indicating, “no real impact, i’ll use it about the same as i do now,” “i’ll use it more often than i do now,” “i’ll use it less than i do now,” tobacco or ecigarette use, pgsi total, and illicit drug use were all associated with changing to non-user status. in contrast, stating, “it will have no impact, as i’ll never use it,” older age, and greater alcohol use were each associated with being less likely to change to non-use. discussion research on the impact of cannabis legalization in canada on public health is still in its infancy. to date, the majority of studies which have investigated possible predictors of change in cannabis use status following legalization have been cross-sectional in nature. the primary aim of the present study was to expand our knowledge of potential predictive variables of cannabis use in a canadian national survey, which included two waves of data collected just before and after the legalization of cannabis. to our knowledge, this study represents the first longitudinal assessment of changes in cannabis use status following legalization using a large, national canadian sample. the baseline survey indicated that 21.2% had used cannabis at least once in the previous 12 months. this is in line with cannabis prevalence statistics revealed in the 2017 (22%) and 2018 (22%) versions of the ccs. consistent with crosscannabis legalization 20 sectional research, within the retained baselinefollow-up sample, there was a significant increase in cannabis use from baseline (18.4%) to follow-up (26.1%), with 13.2% of baseline non-users using at follow-up (and 12.1% of baseline users not using cannabis at follow-up). however, the large majority of both non-users and users retained their same cannabis use status in the follow-up survey, suggesting a sizeable degree of stability over time. in addition, it is also noteworthy that among new cannabis users at the follow-up, a sizeable proportion reported use of “less than once a month” (45.0%) or “less than weekly” (70.8%), indicating relatively infrequent use. this may suggest that respondents who tried cannabis at the follow-up are possibly experimenting with the drug rather than regularly using it. moreover, the frequency of use among this group is also less than that of respondents who were cannabis users at both the baseline and follow-up surveys, which provides further indications of “less risky” use among people who began using cannabis after legalization. one of the goals of the study was to identify potential predictors of change in cannabis use status from preto postlegalization. to do this, we examined four separate groups of respondents. first, a logistic regression examining stability between not using cannabis at the baseline and remaining a non-user at the follow-up identified several key predictors of stability. for instance, respondents who stated that, “i will never use it” or “i may try it for the first time,” were statistically less likely to use cannabis one year later. however, somewhat paradoxically, indicating that, “i’ll use it more often than i do now” was also associated with not using cannabis at the follow-up. in contrast, younger age, being male, tobacco or e-cigarette use, higher greater pgsi scores, and illicit drug use were all linked with a lower likelihood of remaining a non-user over time. the second regression focused on the chances of changing from non-use to later cannabis use. in this case, several of the same variables were also associated with later use, such as age, illicit drug use, and tobacco or e-cigarette use. the final two binary logistic regressions focused on cannabis users who reported remaining users and those who later changed their status to non-users, respectively. first, stating, “i’ll never use it” was linked with changing to non-use, and “no real impact, i’ll use it about the same as i do now” predicted continued use. in other words, intentions to not use cannabis, as well as those to continue using it, were both aligned with their respective behavioural outcomes. the fourth regression revealed significant predictors similar to those of the previous models. for instance, younger age, gambling severity, illicit drug use, and, this time alcohol frequency, were all associated with continued cannabis use. interestingly, tobacco or e-cigarette use was statistically predictive of changing to non-use, although this represented only a 6% increase in the odds for later non-use. when all of the regression results are considered in aggregate, a number of themes emerge. first, being male and younger age are linked with cannabis use, while older age was associated with a decreased likelihood of using cannabis after legalization. this is perhaps unsurprising given that youth and young adulthood, especially in males, have been more commonly associated with greater cannabis use in canada (hammond et al., 2021; kourgiantakis et al., 2022). yet, despite higher rates of use when compared with other countries, recent surveys of youth in canada have reported no pronounced increases in cannabis use following the early years of legalization (haines-saah & fishcer, 2021). disentangling the possible role of cannabis legalization on youth cannabis initiation and concerns around potential lifelong use will require more time to fully assess. in addition, the results indicate that both substance use as well as problematic gambling largely go hand-in-hand with cannabis use. first, the fact that tobacco and nicotine use was associated with later cannabis use is unsurprising, and this may be linked to the frequent simultaneous co-use of both drugs reported in the literature (lemyre et al., 2019). similarly, considerable research evidence indicates correlations between the use of cannabis, alcohol, and other illicit drugs (e.g., gooding et al., 2023) and that cannabis use frequently co-occurs among individuals who are experiencing problematic gambling (punia et al., 2021). our findings further confirm these patterns and demonstrate their influence over time and through legislative changes to cannabis laws. cannabis, a publication of the research society on marijuana 21 overall, the results of this study are generally consistent with those from cross-sectional studies, as well as other longitudinal studies conducted in canada. for instance, a study which included a community sample from ontario found a decrease in use among many cannabis users from preto post-legalization, yet also found that 24% of initial cannabis non-users later reported use following legalization (turna et al., 2021). the potential reasons for why these individuals changed their cannabis use status are difficult to determine, as the anp project was not designed to directly assess this question. however, turna et al. (2021) speculated that the increased availability of legal cannabis and subsequent reduction in the supply of illicit cannabis may have influenced the decision of some previous cannabis users to discontinue their use. among at least some baseline cannabis users, the removal of potential consequences associated with use (e.g., potential charges, a criminal record) may have influenced their decision to try cannabis now that it is legal. interestingly, the 2018 version of the cannabis survey (health canada, 2018) asked respondents about their willingness to disclose cannabis use. it was reported that 31% stated that they would be more willing to admit to using cannabis if recreational use was legal. based on these findings, it is conceivable that prevalence estimates of cannabis use prior to legalization were underreported and that the fear of legal ramifications kept some people from using it despite a desire to do so. this study has several strengths, including a large sample of canadians recruited from coast to coast. the timing of data collection for both the baseline and follow-up surveys allows for a unique opportunity to assess the potential role of the legalization of recreational cannabis on patterns of use. furthermore, the survey contained a wide array of demographic, substance use, and mental health variables. this permitted the inclusion of many potential baseline predictors of change in cannabis use status in the follow-up survey. to our knowledge, no other longitudinal dataset includes the same breadth and depth of information on cannabis use in canada. this study also contained potential limitations which warrant consideration. first, the original project (williams et al., 2021; williams, shaw, et al., 2023) was primarily designed to assess patterns of gambling behavior in a sample of canadian gamblers. as part of the inclusion criteria for a larger study of gambling behavior, people were required to gamble at least once a month or more to be included in the study. as a result, the sample was actually comprised of regular “gamblers,” which would not be considered representative of cannabis users in canada. that stated, cannabis use and gambling are known to frequently co-occur in population surveys (punia et al., 2021). second, overall attrition from the baseline survey to the follow-up was 46.2%. given the relatively high rate of attrition over the one-year period, it is possible that change in cannabis use status may not be accurately reflected among the remaining participants. in other words, it is possible that patterns of cannabis use at the follow-up would be different if the entire sample was retained.5 while the timing of data collection is a strength, it can also be considered a limitation. first, the timing of baseline data collection was very close to the enactment of legalization. given this, it could be the case that perceptions of whether or not cannabis legalization is beneficial had already been developed long before the survey was conducted. moreover, given that only one year passed between the two surveys, the longer-term impacts of legalization are still unknown. also, the legalization of the recreational use of cannabis edibles, extracts, and topical cannabis products took place on october 17, 2019 (health canada, 2023), which was immediately following the completion of the follow-up survey. as a result, the extent to which smokeless cannabis products were adequately accounted for in our results is difficult to establish. finally, although the present study was able to determine the number of respondents who changed their cannabis use status following 5that said, attrition is a problem when it is associated with extreme loss of data at the high or low end of a variable, as longitudinal analysis essentially looks at the strength of the relationship between ivs and the dependent variable (dv). thus, it is important that the ivs and dv retain their range, as the strength of the association is largely unaffected by sample size at each point on the range. in the present situation, there is relatively little reason for concern as (a) attrition analysis found relatively little difference in completers versus non-completers, and (b) the large sample size better ensures range retention for each variable. cannabis legalization 22 legalization, the exact reasons why individuals either started using cannabis or abstained from use are not clear. future research dedicated to exploring these motivations is needed. conclusion to date, longitudinal research dedicated to assessing the role of the legalization of cannabis on patterns of use has been lacking. this study makes an important contribution to the nascent literature on this topic by presenting the results of a longitudinal examination of cannabis use pre and post-legalization in a large canadian sample. the findings indicate that a statistically significant portion of baseline cannabis non-users had changed their cannabis use status at the follow-up. furthermore, there was a significant overall increase in cannabis use within the cohort from baseline to follow-up. regression results indicate that among baseline cannabis non-users, tobacco or e-cigarette use, age, and anxiety were unique predictors of cannabis use status at the follow-up assessment. future research that is comprised of a more representative sample of cannabis users and that continues to assess the ongoing role of cannabis legalization in cannabis use patterns is needed. cannabis, a publication of the research society on marijuana 23 table 1. demographic comparisons between cannabis users and cannabis non-users in the baseline survey cannabis users (n = 1,391) cannabis non-users (n = 3,316) significance test variable n % / m(sd) n % / m(sd) χ2 p sex male 726 52.2% 1,561 47.1% 10.41 <.01* female 664 47.7% 1,751 52.8% other 1 0.1% 4 0.1% age group 18 to 24 61 4.4% 31 0.9% 625.85 <.01* 25 to 34 286 20.6% 188 5.7% 35 to 44 307 22.1% 333 10.0% 45 to 54 290 20.8% 650 19.6% 55 to 64 315 22.6% 987 29.8% 65 to 74 122 8.8% 868 26.2% 75 or older 10 0.7% 259 7.8% marital status single 401 28.8% 529 16.0% 117.61 <.01* married/common law 790 56.8% 2,196 66.2% separated 43 3.1% 82 2.5% divorced 109 7.8% 285 8.6% widowed 38 2.7% 193 5.8% prefer not to say 10 0.7% 31 0.9% ethnic/cultural origins† western and northern european 819 58.9% 2,157 65.0% 16.04 <.01* eastern european 185 13.3% 431 13.3% 0.08 .78 indigenous north american 86 6.2% 108 3.3% 21.23 <.01* southern european 50 3.6% 86 2.6% 3.50 .06 chinese 45 3.2% 91 2.7% 0.84 .36 african 32 2.3% 24 0.7% 20.72 <.01* south asian 28 2.0% 44 1.3% 3.06 .08 south east asian 24 1.7% 35 1.1% 3.55 .06 latin american 18 1.3% 20 0.6% 5.84 <.05* middle eastern and arab 17 1.2% 11 0.3% 13.14 <.01* east asian 12 0.9% 20 0.6% 0.98 .32 central and northern asian 8 0.6% 12 0.4% 1.05 .31 other 54 3.9% 192 5.8% 7.20 <.01* unsure 92 6.6% 199 6.0% 0.63 .43 prefer not to say 50 3.6% 141 4.3% 1.09 .30 cannabis legalization 24 household income less than $20,000 106 7.6% 180 5.4% 50.10 <.01* $20,000-$39,000 224 16.1% 479 14.4% $40,000-$59,000 242 17.4% 559 16.9% $60,000-$79,000 207 14.9% 492 14.8% $80,000-$99,000 184 13.2% 410 12.4% $100,000-$119,000 136 9.8% 295 8.9% $120,000-$139,000 74 5.3% 148 4.5% $140,000+ 109 7.8% 274 8.3% uncertain 10 0.7% 21 0.6% prefer not to say 99 7.1% 458 13.8% employment employed full-time 754 54.2% 1,240 37.4% 313.99 <.01* employed part-time 159 11.4% 343 10.3% sick leave, maternity, disability 76 5.5% 83 2.5% homemaker 62 4.5% 121 3.6% unemployed 80 5.8% 98 3.0% full-time student 24 1.7% 20 0.6% retired, not working 219 15.7% 1.359 41.0% prefer not to say 17 1.2% 52 1.6% educational attainment secondary or less 315 22.6% 781 23.6% 1.41 .84 some vocational/postsecondary 358 25.7% 847 25.5% diploma or bachelor’s degree 571 41.0% 1,332 40.2% professional or graduate degree 128 9.2% 320 9.7% prefer not to say 19 1.4% 36 1.1% note.*p < .05. † in the questionnaire, the item for ethnic origins was worded as follows: ‘what are the main ethnic or cultural origins of your ancestors? (check as many as apply)’. as respondents could choose more than one, the response items had to be coded separately. a separate crosstabs analysis was then conducted for each category. cannabis, a publication of the research society on marijuana 25 table 2. binary logistic regression predictors of baseline cannabis non-users who remained nonusers 95% odds ratio ci variable b se wald p odds ratio lower upper i’ll never use it 3.66 .146 629.96 <.01 38.76 29.13 51.58 i may try it for the first time 2.85 .193 217.77 <.01 17.30 11.85 25.26 tobacco use or e-cigarettes -1.23 .121 102.67 <.01 0.29 0.23 0.37 age 0.41 .045 83.30 <.01 1.50 1.38 1.64 i’ll use it more 1.26 .236 28.56 <.01 3.54 2.23 5.62 pgsi total -0.08 .018 21.39 <.01 0.92 0.89 0.95 illicit drug use -1.17 .329 12.55 <.01 0.31 0.16 0.59 sex 0.34 .120 8.17 <.05 1.41 1.11 1.78 note. nagelkerke r squared = 65.3%; overall classification accuracy = 76.3% table 3. binary logistic regression predictors of baseline cannabis non-users who changed to users 95% odds ratio ci variable b se wald p odds ratio lower upper age -0.33 .045 53.83 <.01 0.72 0.66 0.79 i’ll use it about the same as i do now -1.04 .171 37.00 <.01 0.35 0.25 0.50 tobacco use or e-cigarettes 0.61 .132 21.15 <.01 1.84 1.42 2.38 illicit drug use -1.02 .311 10.71 <.01 0.36 0.20 0.67 i may try it for the first time 0.49 .171 8.29 <.05 1.64 1.17 2.29 i’ll use it less -2.04 .734 7.72 <.05 0.13 0.03 0.55 note. nagelkerke r squared = 9.5%; overall classification accuracy = 58.5% cannabis legalization 26 table 4. binary logistic regression predictors of baseline cannabis users who remained users 95% odds ratio ci variable b se wald p odds ratio lower upper i’ll never use it -1.96 .456 18.41 <.01 0.14 0.06 0.35 i’ll use it about the same as i do now 1.08 .284 14.42 <.01 2.94 1.69 5.14 note. nagelkerke r squared = 15.5%; overall classification accuracy = 96.8% table 5. binary logistic regression predictors of baseline cannabis users who changed to non-users 95% odds ratio ci variable b se wald p odds ratio lower upper i’ll use it about the same as i do now 3.40 .246 191.02 <.01 29.93 18.48 48.46 i’ll use it more 2.47 .287 73.90 <.01 11.77 6.71 20.66 i’ll use it less 3.48 .468 55.42 <.01 32.51 13.00 81.31 tobacco use or e-cigarettes 1.06 .144 53.92 <.01 2.88 2.17 3.82 pgsi total 0.11 .019 31.41 <.01 1.10 1.07 1.15 i’ll never use it -1.47 .300 24.04 <.01 0.23 0.13 0.41 age -2.04 .052 15.66 <.01 0.82 0.74 0.90 illicit drugs 0.98 .281 12.09 <.01 2.65 1.53 4.60 how often drink alcohol -0.13 .043 8.55 <.05 0.88 0.81 0.96 note. nagelkerke r squared = 71.4%; overall classification accuracy = 86.6% cannabis, a publication of the research society on marijuana 27 references aminilari, m., busse, j. w., turna, j., & mackillop, j. 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(2009. impact of survey description, administration format, and exclusionary criteria on population prevalence rates of problem gambling. international gambling studies, 9(2), 101– 117. https://doi.org/10.1080/14459790902911653 funding and acknowledgements: this study was conducted as part of the agri national project (anp), a national study that received funding from the canadian consortium for gambling research, the canadian centre for substance abuse and addiction, gambling research exchange ontario, and the alberta gambling research institute. more details can be found here: https://www.ucalgary.ca/research/ nationalgambling-study/. dm discloses a speaker’s honorarium from spectrum therapeutics. the authors declare no conflict of interest that would impact the current study content, conclusions, or presentation. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: mcgrath, d. s., williams, r. j., allami, y., christensen, d. r., hodgins, d. c., nicoll, f., shaw, c. a., & stevens, r. m. g. (2024). predictors of change in cannabis use status from preto post-recreational cannabis legalization in https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 29 canada: evidence from a two-wave longitudinal national survey. cannabis, 7(3), 14–29. 10.26828/cannabis/2024/000247 issue date: december 12, 2024 research article 65 ved abstract objective: the government of canada legalized recreational cannabis use in october of 2018 with the implementation of the cannabis act. the act aimed to reduce the illicit cannabis market, improve consumer health outcomes, and reduce youth access to cannabis. however, little is known about the attitudes and behaviors of young adults, who have been shown to have a high prevalence of cannabis use, towards cannabis after legalization. method: in this descriptive study, we examined cannabis use, attitudes, and purchasing preferences among canadian university-attending young adults both before and after the legalization of cannabis. participants were recruited from a large canadian university from 2017 to 2021. results: our findings showed that there was an increase in cannabis use immediately following legalization that subsequently decreased in later years. additionally, attitudes about the legalization of cannabis became more favorable in later years (following legalization), particularly among those who did not use cannabis. most young adults were also keen to purchase cannabis from a government-owned store before legalization. however, with the exception of past-month consumers, this preference decreased substantially following legalization. conclusions: the current research adds to the knowledge base about changes in cannabis-related attitudes and use after legalization and focuses on a key population – young adults. key words: = cannabis; legalization; young adults the government of canada’s policy on the use of recreational cannabis has shifted tremendously in the past decade—a shift that has corresponded with public perceptions on the legalization of cannabis (cunningham, 2020). indeed, most canadians now accept a public health approach to cannabis, which focuses on reducing cannabisrelated harms (as opposed to abstinence) whilst recognizing that most cannabis-related harm is concentrated among a minority of high-risk consumers (crepault, 2014). the shift toward a public health approach to cannabis mirrors the one canada has taken with alcohol, tobacco, and gambling (pacula et al., 2014; wood et al., 2017). ultimately, these changing tides culminated in the cannabis act, which came into effect on october 17th, 2018. this date marked the beginning of dried cannabis flower and cannabis oil sale in retail stores, followed by cannabis edible products and concentrates exactly one year later (october 17, 2019; government of canada, 2021a). the act created a legal framework for controlling the production, distribution, sale, and possession of cannabis across canada (government of canada, 2021b). the legal age to purchase, grow, and use cannabis ranges based on the province; however, in ontario, canada, the legal age is 19 years (canadian center on substance use and addiction [ccsa], 2023). the expressed purpose for legalizing cannabis was three-fold: 1) reduce the illicit cannabis market (i.e., lessen the burden on the criminal justice abigail h. m. bradley1, melissa salmon1, michael j. a. wohl1, & andrea l. howard1 1department of psychology, carleton university cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000203 impact of legalization on cannabis use, attitudes, and purchasing preferences: a repeated cross-sectional survey of canadian young adults corresponding author: andrea howard, phd, carleton university, 1125 colonel by drive. ottawa, ontario, canada, k1s 5b6. phone: (613) 520-2600 x 3055. email: andrea.howard@carleton.ca. cannabis, a publication of the research society on marijuana 66 system and deter illicit activities through appropriate sanctions and measures), 2) improve consumers’ health outcomes by providing access to quality-controlled supplies of cannabis, and 3) reduce access to cannabis among youth (cannabis act s.c. 2018, c. 16, 2018; fischer et al., 2021; zuckermann et al., 2021). due in large part to the legalization of cannabis, a growing body of research has emerged from canada that has sought to better understand overall trends in attitudes, use, and potential risk associated with cannabis (armstrong, 2022; cunningham & koski-jännes, 2019; macquarrie & brunelle, 2022; rotterman, 2021). in general, findings suggest that after legalization, cannabis use increased, perceived risks related to cannabis decreased, opinions surrounding the consumption of cannabis become more favorable, and the purchasing of cannabis from governmentregulated sites rose (fischer et al., 2021; rotermann, 2020; rudy et al., 2021; schuermeyer et al., 2014). despite the increased knowledge about cannabis-related beliefs and behaviors postlegalization (bae & kerr, 2020), few canadian studies tracked and compared cannabis attitudes and use before and after legalization, and fewer have continued to examine the effects of legalization years later. the purpose of the current research was to provide descriptive summaries that add to the knowledge base about possible changes in cannabis-related attitudes and use after legalization (compared to pre-legalization), focusing on a key population—young adults—who have been shown to have a high prevalence of cannabis use and cannabis-related problems (allen & holder, 2014; mader et al., 2019; substance abuse and mental health services administration [samhsa], 2006). estimates suggest that 18to 24-year-olds report the highest rates of lifetime, past-year, and past-month use of cannabis (bonar et al., 2017; hellemans et al., 2019). however, most people who consume cannabis, including young adults, do so without developing a dependency (caulkins et al., 2016; room et al., 2010). nonetheless, little is known about the beliefs and behaviors of this cohort, particularly regarding possible changes in their belief and behaviors in the aftermath of legalization. to address these gaps, we examined cannabis use among canadian young adults, as well as their attitudes and purchasing preferences, over a five-year period spanning the introduction of the cannabis act in canada. we expected that more young adults would report using cannabis after legalization versus before, and that views on legalization would become more favorable toward cannabis and its status as a legal substance in later years. with the increasing presence of government-licensed and privatized cannabis stores, we expected a growing share of young adults to prefer purchasing cannabis in a store. methods hypotheses and descriptive analysis plans for this study were preregistered prior to examining the data (https://osf.io/w5hj3). all figures and descriptive statistics were created and performed using r software (r core team, 2021) and packages dplyr (wickham & françois, 2017), epidisplay (chongsuvivatwong, 2018), ggplot2 (wickham, 2016) and patchwork (pedersen, 2019). participants and procedure from 2017 to 2021, undergraduate students at a large canadian university in the province of ontario were recruited through the university’s online research system (i.e., sona) at the start of the fall semester (i.e., september) as part of a department-wide mass-testing of students enrolled in introductory psychology courses. participants completed a battery of items online that assessed an array of topics and received course credit as remuneration. our team was granted access to data drawn only from the subset of measures described below. sample sizes varied by year, owing to changes in enrollment and numbers of people who elected to participate in mass-testing: 2017 (n = 1,372), 2018 (n = 1,440), 2019 (n = 742), 2020 (n = 764), and 2021 (n = 907). our preregistered plan called for a slightly larger sample size each year, however we elected to exclude participants who reported being 35 years of age or older from this study, causing a minimal decrease in sample size. mean age across all five years was 19.2 years (sd = 2.6) and approximately 75.0% (n = 3,851 of 5,189) identified as female. age and gender did not considerably vary across years; supplemental table 1 on our project page (https://osf.io/nrm2s/) displays key demographic information for each year. cannabis use preand post-legalization 67 measures attitudes toward cannabis legalization. we used a single item (adapted from palamar, 2014; rudy et al., 2020) to assess attitudes toward legalization. in 2017 and 2018 (i.e., pre-legalization) this item was: “there has been a great deal of public debate about whether marijuana use should be legal. not counting ‘medical marijuana’ (with a doctor's prescription), which of the following policies would you favour?” on the 2019 to 2021 surveys (i.e., post-legalization), this item was: “there has been a great deal of public debate now that cannabis use is legal. not counting ‘medical cannabis’ (with a doctor's prescription), which of the following policies would you favour?” response options both preand postlegalization were: using cannabis should be entirely legal; it should be a minor violation—like a parking ticket—but not a crime; it should be a crime; and i don’t know. attitudes toward the legal use of cannabis. we used another single item to assess willingness to use cannabis. in 2017 and 2018 (i.e., pre-legalization) we asked: “aside from ‘medical marijuana’ (with a doctor's prescription), if marijuana were legal to use and legally available, which of the following would you be most likely to do?” on the 2019 to 2021 surveys (i.e., post-legalization), we asked: “now that cannabis is legal to use and legally available, which of the following have you done?” response options were as follows (regardless of whether the item was posed preor post-legalization): not use it, even if it were legal and available; try it; use it about as often as i do now; use it more often than i do now; use it less often than i do now; and i don’t know (on the prelegalization surveys). attitudes on cannabis purchasing. a single item was used to assess where participants would prefer to purchase cannabis. in the 2018 survey (i.e., prelegalization; not asked in 2017) this item read: “if you were to decide to purchase marijuana once it becomes legally available for sale, where would you feel most comfortable making your purchase?” in the 2019 to 2021 surveys (i.e., post-legalization), this item read: “now that cannabis is legally available for sale, where do you feel most comfortable making your purchase?” responses options both preand postlegalization were: i would prefer to buy marijuana at a government owned store; i would prefer to buy marijuana at a privately-owned store; i would prefer to buy marijuana from an individual, not a store; i don’t have a preference; and i don’t know. cannabis use behaviors. participants reported their consumption frequency (“on how many occasions have you used marijuana (weed, pot) or hashish (hash, hash oil)?”) in their lifetime, in the past year (12 months), and in the past month (30 days; johnston et al., 2020). response options for each timeframe were: 0 occasions; 1-2 occasions; 3-5 occasions; 6-9 occasions; 10-19 occasions; 20-39 occasions; 40 or more occasions. as per our preregistration, supplemental table 3 contains summary statistics of additional variables pertaining to cannabis that do not form part of our primary analysis, and is available on our project page. data quality for all years of data collection, data were excluded from analyses if participants were missing all data on measures of interest, or if participants’ cannabis use behaviors were inconsistent (i.e., responded to using cannabis on many occasions in the past month but also to never using cannabis in their life). attention checks were also introduced to mass-testing in 2019, at which point data were excluded from participants who failed two or more attention check items (e.g., failing to select “strongly agree” in response to “please respond with ‘strongly agree’ for this item”). in the 2019 to 2021 surveys, three data quality check items were added at the end of the survey asking participants to rate their attention paid to the survey, their degree of honesty in responding, and their opinion of whether their data should be used. participants who reported paying no or little attention, or who indicated that their data should not be used for analyses, were excluded (n = 206 in 2019; n = 136 in 2020; and n = 180 in 2021). a detailed description of the attention checks can be found on our project page (attention check codebook; https://osf.io/nrm2s/). results cannabis use across the five years of data, an average of 48.0% (n = 2,505 of 5,213) of participants reported having never used cannabis, 27.3% of participants used cannabis in the past month, 42.7% used 1marijuana may be used interchangeably with cannabis. cannabis, a publication of the research society on marijuana 68 cannabis 1-2 times a month, and 7.8% used 40 or more times a month (see supplementary table 2 on our osf project page for detailed annual frequencies of use). figure 1 shows the frequencies of cannabis use by year of data collection. focusing on past-month use, rates climbed from 24.2% to 32.0% from 2017 to 2019; annual relative increases of 18.0% (2017 to 2018) and 12.0% (2018 to 2019), but dropped back to 26.2% in 2020 (a relative decrease of 18.0% in the second full year following legalization, and the first year of the covid-19 pandemic). past-month use then remained constant into 2021. overall, the year-to-year proportion of cannabis use (both before and after legalization) in the current sample of young adults was relatively stable. table 1 reports the pre-and-post-legalization sample sizes of participants at each level of cannabis use. figure 1. percentage of participants who were never, lifetime, past-year and past-month cannabis consumers from 2017 to 2021 note. pre-and-post-legalization, participants were asked “on how many occasions have you used marijuana (weed, pot) or hashish (hash, hash oil)? in your lifetime? during the last 12 months? during the last 30 days?” table 1. participant sample sizes at various levels of cannabis use both before and after legalization pre-legalization post-legalization cannabis use 2017 2018 2019 2020 2021 never 664 652 328 396 472 lifetime 140 142 60 71 86 past year 226 232 115 113 106 past month 328 411 237 205 235 missing 14 3 2 1 8 total 1372 1440 742 786 907 cannabis use preand post-legalization 69 attitudes toward legalization figure 2 shows that attitudes varied depending on whether participants used cannabis or not. before and after legalization, most participants who believed that cannabis should be entirely legal were past or current cannabis consumers; however, an increase in this belief was evident across all participants after legalization. there was also a relative decrease from preto post-legalization in the belief that cannabis use should be a minor violation, as well as the belief that cannabis use should be a crime. this decrease was observed among all participants. overall, beliefs about the illegality of cannabis (minor violation, crime) converged with students’ actual cannabis use after legalization. figure 2. preand post-legalization attitudes towards cannabis policies for participants who have never used cannabis or who have used at least once in their life, past year and past month note. pre-legalization years were 2017 to 2018, where the single item was framed as “if cannabis were legal”. postlegalization were 2019 to 2021, where the item was framed as “now that cannabis is legal”. response options are as follows: legal (using cannabis should be entirely legal), minor (it should be a minor violation – like a parking ticket – but not a crime), and crime (it should be a crime). non-overlapping pre/post confidence intervals are represented in bold. figure 3 shows rates of willingness to use cannabis when it becomes legal (2017 and 2018 surveys) and willingness to use now that it’s legal (2019 to 2021 surveys). most participants who never used cannabis reported that they would not use cannabis in the future. results were similar among those who used it at least once in their life. notably, however, among participants who never used cannabis, the proportion stating that they would never use cannabis in the future increased from 73.3% before to 98.4% after legalization. among participants who had used cannabis in the past month, the proportion stating that their use would stay the same dropped from over 75.0% to cannabis, a publication of the research society on marijuana 70 nearly 50.0% after legalization. a similar trend was observed among past-year consumers of cannabis (i.e., belief that their cannabis use would stay the same dropped post-legalization relative to pre-legalization) as well as a shift in their attitudes toward trying cannabis postlegalization. lastly, among participants who used cannabis in the past month, there was a 17.3% increase (preto post-legalization) in the proportion who believed they would use cannabis more after legalization than before legalization. figure 3. preand post-legalization attitudes towards using cannabis for participants who have never used cannabis or who have used at least once in their life, past year and past month note. pre-legalization years were 2017 to 2018 and participants were asked their opinions “if marijuana were legal”. post-legalization years were 2019 to 2021 and participants were asked their opinions “now that cannabis is legal” (“i don’t know” was not a response option in the post-legalization surveys). non-overlapping pre/post confidence intervals are represented in bold. purchasing preferences figure 4 shows participants’ preferred locations to purchase cannabis. prior to legalization, over half of participants who used cannabis in the past year, less often, or never, said they would prefer to purchase cannabis from a government-owned store, compared to 35.5% of past-month consumers. following legalization, fewer participants who used cannabis in the past year, less often, or never, expressed a preference for purchasing from a government-owned store, while the proportion stating they didn’t know doubled or tripled. only current (past-month) cannabis consumers remained somewhat stable in their purchasing preferences before and after legalization, although the proportion stating a preference to purchase from an individual more than doubled after legalization. cannabis use preand post-legalization 71 figure 4. preand post-legalization attitudes towards purchasing cannabis for participants who have never used cannabis or who have used at least once in their life, past year and past month note. pre-legalization years were 2017 to 2018, however the 2017 survey did not ask about purchasing preferences. in 2018, the single item was framed as “if you were to decide to purchase marijuana once it becomes legally available for sale”. post-legalization were 2019 to 2021 and the single item was framed as “now that cannabis is legally available for sale”. response options are as follows; gov (government owned store), private (privately-owned store), and individual (individual – not a store), and no pref (no preference). non-overlapping pre/post confidence intervals are represented in bold. discussion this descriptive study aimed to illuminate possible changes in university-attending young adults’ attitudes and behaviors towards cannabis before and after legalization, as well as multi-year trends. we found that past-month cannabis use increased after legalization in 2018 but decreased in the subsequent years. this trend was not observed for past-year or lifetime consumers, as these rates slightly declined from 2017 to 2021. most participants who never used cannabis or who used it at least once in their lifetime indicated no future intent to use, especially after legalization. all young adults in this study, regardless of cannabis use frequency, had less favorable views of purchasing cannabis from the government after legalization than before. among past-year and past-month consumers, we observed a greater preference for purchasing cannabis from an individual post-legalization. from 2017 to 2021, approximately half of the young adults sampled in the present study never used cannabis, and just over one quarter reported past-month use. these rates mirror a u.s. study that examined college students’ cannabis use, harm perceptions, and attitudes toward policies (rudy et al., 2021). among students with cannabis use histories, over 25.0% were past-month consumers, and nearly 8.0% used 40 or more times a month (i.e., daily use). according to a 2021 canadian cannabis survey, 20.0% of 16to 19year-olds and 29.0% of 20to 24-year-olds reported daily or almost daily cannabis use cannabis, a publication of the research society on marijuana 72 (government of canada, 2021b). the rate of cannabis use underpins the necessity for research to better understand how this age cohort feels about cannabis and cannabis-related topics. we also observed increases in past-month cannabis use in 2018 (18.0% increase) and 2019 (12.0% increase), the two timepoints immediately preceding and following legalization (for a similar pattern, see fischer et al., 2021; rotermann, 2020; statistics canada, 2020). these trends may reflect the anticipation of and gradual new uptake in cannabis use, owing in part to delays in retail availability and sales of novel cannabis products such as edibles and concentrates (sandhu et al., 2019). the canadian centre on substance use and addiction (ccsa, 2022) similarly reported increases in cannabis use following the introduction of novel cannabis products. importantly, however, following this “second wave” of legalization, we observed a nearly 20.0% decrease in past-month use and a 6.5% decrease in past-year use in 2020 (two years after legalization). one reason for the decrease in use in 2020 may be the limited accessibility or living disruptions experienced during covid-19. indeed, although cannabis stores were initially considered an essential service at the onset of the pandemic, thus allowing the public to purchase cannabis within stores regardless of closures to noncannabis retailers, cannabis retail operations were subsequently limited to curb-side pick-up and home delivery (ccsa, 2021). additionally, university classes shifted to remote virtual learning in march of 2020 (and large classes remained online through 2021), prompting dormitory closures and relocation of students. approximately 6.0% of young adults moved back in with their parents due to the pandemic, and this rate was higher among those living in ontario (mcknight, 2021). restrictions on freedom or privacy that go along with returning to parents’ homes may have made it more difficult for young adults to access or use cannabis. additionally, living away from peers during this time may have hampered the potential of peer influence and social cues to use cannabis. first-year students have been found to be susceptible to trying cannabis as a way to heighten sociability, ease emotional distress from the transition to university, and grow autonomy from parents (suerken et al., 2014; beck et al., 2009). because this sample comprises only undergraduates, our results do not reflect preto post-legalization cannabis use and attitudes of other young adults. generally, those not in college are less likely to initiate cannabis use (miech et al., 2017). our findings are likely overestimates of the general population of young adults, except for those not in employment, education, or training (neet), who are typically more vulnerable and more likely to use cannabis (baggio et al., 2015). numerous parallels between cannabis use and attitudes towards cannabis policies, desire to use, and purchasing were also observed. in general, young adults who reported any current or past use of cannabis endorsed less restrictive legal measures. this finding is like that reported by blomgyist (2009), who found that familiar, less stigmatized drugs tend to be perceived as lower risk compared to unfamiliar, more stigmatized drugs. additionally, cohn and colleagues (2016) found that young adults in the u.s. who were current cannabis users were more likely to support cannabis legalization compared to nonusers. in the current study, over half of participants (51.8%) supported legal use of cannabis both before and after legalization. however, rates were lowest among those who never used cannabis, with just under 30.0% of participants thinking it should be legal. after legalization, more non-users agreed that cannabis should be legal (37.4%), echoing the notion that rates of substance use in society act as a key predictor of attitudes towards cannabis policies (macquarrie & brunelle, 2022). we expected that young adults, regardless of past cannabis use, would express a desire to try the substance once it became legal. instead, findings showed a general pattern of attitudes better aligning with behaviors. for example, prior to legalization, almost 16.0% of students who had never used cannabis said they would try it if cannabis became legal, compared to just 1.2% after legalization. prior to legalization, non-users of cannabis comprised students who were either uninterested in using cannabis or who were interested but hesitant to try an illegal substance. after legalization, non-users of cannabis were strictly those who did not want to use it. this is important from a public policy perspective, in that the legalization of cannabis likely did not tempt those who had no intention of using it prior to legalization to start consuming the product after cannabis use preand post-legalization 73 legalization. more generally, our findings reflect the results of a similar study, which found that approximately one in five canadians were likely to try or increase their cannabis use after legalization for recreational purposes (sandhu et al., 2019). ease of access as stores began to open, and the expansive selection of cannabis products such as edibles, drinks and concentrates, may explain cannabis users’ expectations of increased use after legalization. indeed, consumption of edible cannabis products grew in canada from 2020 to 2021 (ccsa, 2022). in terms of purchasing preferences, most participants were keen to purchase cannabis from a government-owned store before legalization. however, with the exception of past-month consumers, this preference decreased substantially after legalization. past-month consumers also expressed a greater preference to purchase cannabis from an individual (e.g., dealer, friend) after legalization (compared to before legalization), suggestive of loyalty to one’s dealer. however, this interpretation is purely speculative and in need of future study. moreover, this finding was contrary to expectations and previous research that has found that people tend to perceive cannabis purchased via government-regulated channels to be safer, more convenient, of greater quality and safer to use (wadsworth et al., 2022). additionally, according to the ccsa (2022), such channels captured a large portion of the cannabis market. one possibility is that the price of cannabis tends to be relatively higher at government-regulated stores (goodman et al., 2022; government of canada, 2019), which may be cost prohibitive to young adults attending university. additionally, privacy concerns may impede young adults from purchasing cannabis from government and privately-owned stores. to the point, cannabis consumers—particularly young adults—may not want the government of canada to know they are purchasing cannabis. we also ruled out accessibility challenges as there are several (5+) stores within walking distance of the university campus, and an abundance across the city. moreover, almost all dispensaries have a same day (if not within the hour) delivery service. cannabis accessibility is on par with alcohol, perhaps more so, considering their typically late operating hours, and in our view accessibility is unlikely to be a strong factor driving our reported rates. limitations there are a few limitations to the current research that should be noted. first, participants in our study were more likely to be female (~ 75.0%), creating a gender-imbalanced sample. second, data quality checks were not introduced until 2019, which could have led to lower-quality responses before cannabis legalization. third, clearer definitions could have been provided for participant clarification alongside response options. for example, response options regarding purchasing cannabis included government-owned stores as well as privately-owned stores; this may have influenced results because participants may not have been aware of the differences between the two sources of legal cannabis. for participant clarity, we should have explicitly listed the differences between options. fourth, the sample is limited to emerging adults in a university setting who decided to enroll in an introductory psychology course, and thus generalizability may be limited. fifth, our study is strictly descriptive and does not formally test any links to addiction or mental health that might explain attitudes, rates of use, and purchasing preferences. sixth, it is possible that the covid-19 pandemic influenced cannabis use. because this study was strictly descriptive, we did not adjust (or control) for the possible influence of the pandemic on our results. lastly, we were limited to just two years prior to and three years following legalization, leaving out valuable information about longerterm trends and changes that are as yet unknown. conclusion our study found that, over five years, cannabis use increased among samples of young adults immediately following legalization but decreased two years following legalization. however, further research is needed to understand what constitutes typical fluctuations in annual rates of use as well as the long-term effects of legalization on attitudes toward cannabis and cannabis use. overall, this study contributes to the growing body of literature on the consequences of cannabis legalization for attitudes, use, and purchasing preferences among young adults that can inform future policy and public health decisions in this area. cannabis, a publication of the research society on marijuana 74 references allen, j., & holder, m. d. 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(2021). trends in youth cannabis use across cannabis legalization: data from the compass prospective cohort study. preventive medicine reports, 22, 101351. https://doi.org/10.1016/j.pmedr.2021.101351 funding and acknowledgements: no funding was received to assist with the preparation of this manuscript. the authors declare that there are no potential conflicts of interest with respect to authorship, and/or publication of this article. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 82 ved abstract objective: perseverative cognitive processes, such as rumination, may indirectly influence effects of personality traits on cannabis use and related problems. understanding relations among personality, rumination, and cannabis use motives may lead to better understanding of problematic cannabis use. the present study examined personality traits’ influence on negative cannabis-related consequences via rumination and cannabis use coping motives. methods: we tested a sequential path model across two independent samples such that the model was tested in one sample and replicated in the second sample. participants were u.s. undergraduate students from multiple universities who reported using cannabis at least once in the prior thirty days. results: results partially supported hypotheses such negative urgency and distress tolerance were indirectly related to negative cannabis-related consequences via rumination and coping motives. specifically, higher negative urgency and lower distress tolerance were related to higher rumination. higher rumination was related to higher coping motives; which in turn was related to more negative cannabis-related consequences. results indicate that rumination is a risk factor belying associations between personality and cannabis use to cope and negative consequences of use. conclusions: implementing techniques that attenuate rumination for individuals high in negative urgency or low in distress tolerance may reduce or prevent problematic cannabis and unintended outcomes. key words: = sensation seeking; impulsivity; distress tolerance; emotion dysregulation; negative urgency cannabis use rates continue to rise in the united states (center for behavioral health statistics and quality [sahmsa], 2015; hasin et al., 2015, mauro et al., 2018). additionally, higher cannabis potencies have paralleled the increase in use frequency (elsohly et al., 2016), which amplifies the risk of experiencing harmful outcomes (brook et al., 2008; hasin et al., 2015). individuals who use cannabis are also more likely to experience downward social mobility and increased financial problems, as well as engage in more disruptive work-based behaviors (cerdá et al., 2016; trudeau et al., 2015). those most at-risk for long-term cognitive impairment and negative bradley t. conner1, adrian j. bravo2, naomi win3, ryan l. rahmknigge1, cross-cultural addictions study team**, stimulant norms and prevalence (snap) study team*** 1department of psychology, colorado state university 2department of psychological sciences, william & mary 3department of education and human development, university of colorado, denver cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000172 examination of rumination’s mediating role in the relation between distal personality predictors, cannabis coping motives, and negative cannabis-related consequences corresponding author: bradley conner, phd, colorado state university, 1876 campus mail, fort collins, colorado, 80523. phone: (970) 491-6197. email: brad.conner@colostate.edu. cannabis, a publication of the research society on marijuana 83 use consequences are youth (jacobus & tapert, 2015; shrivastava et al., 2015) and emerging adults (sahmsa, 2015; wisk & weitzman, 2016), particularly those enrolled in college (meich et al., 2017). given increases in prevalence, potency, and negative outcomes of cannabis use, identifying risk factors among adolescents and young adults is an important area of research and intervention. personality traits as predictors of use and consequences previous studies have established certain personality traits as distal antecedents of cannabis use and negative consequences of cannabis use (e.g., dvorak & day, 2014; kentopp et al., 2019; pearson et al., 2018). such traits include sensation seeking, impulsivity, and emotion dysregulation. sensation seeking is the desire for novel experiences and the willingness to take such risks (conner, 2021). impulsivity can be conceptualized via the upps-p five-factor model, which includes the factors of negative urgency (the tendency to act impulsively in response to negative emotions), lack of premeditation (acting without reflecting), lack of perseverance (not completing tasks), sensation seeking, and positive urgency (acting impulsively in response to positive emotions; cyders et al., 2007; whiteside & lynam, 2001). emotion dysregulation includes the inability to accept emotions, suppress emotion, problem-solve, redirect attention, or reappraise (bonn-miller et al., 2008). related to emotion dysregulation is low distress tolerance, or a reduced coping threshold for negative emotions, which has been associated with coping motives for cannabis use (semcho et al., 2016). overall, these traits have robust relationships with increased cannabis use and undesirable use consequences (brook, et al., 2016; conner, 2021; hayaki et al., 2011; neugebauer et al., 2019; pearson et al., 2018; rinehart & spencer, 2021; vanderveen et al., 2016). further, negative consequences of use often exacerbate cannabis use (day et al., 2013; martin-santos et al., 2017). in addition to these relationships, previous research highlights the importance of considering differential pathways between personality traits and cannabis use and unintended outcomes of use. for example, one study distinguished between traits comprising behavioral self-regulation, such as sensation seeking and self-control, and emotion self-regulation, including distress tolerance and emotional instability (dvorak & day, 2014). behavioral self-regulation was associated with increased cannabis use, while emotional selfregulation and urgency were associated with increased cannabis use problems. because of the differential paths from personality traits to cannabis use and unintended outcomes of use, further exploration of distinct variables that influence (i.e., mediate) these relationships may inform clinical invention (dvorak & day, 2014). rumination perseverative cognitive processes, such as rumination, may influence the effects of personality traits on cannabis use and related problems. response styles theory defines rumination as a preoccupation on symptoms of distress that interferes with solving the problem causing the distress (nolen-hoeksema, 2012). rumination not only fails to down-regulate, but actively prolongs and exacerbates the experiencing of the negative emotion. it is the tendency to focus repetitively on the symptoms of emotional stress, as well as the potential meaning, causes, and consequences of the symptoms, without solving the contributing problems (i.e., it is a focus on the problem, as opposed to solutions; nolen-hoeksema & jackson, 2001). multiple theories postulate rumination to comprise mechanisms of brooding, reflection, and emotional self-awareness (johnson & whisman, 2013; nolen-hoeksema, 2012). in support of negative affect models (e.g., baker et al., 2004), rumination mediates relations between negative affect and cannabis motives and consequences (bravo et al., 2019). however, research examining the mediating role of rumination in linking personality traits to cannabis motives and outcomes is limited. personality and rumination while research has established links between personality and cannabis consequences (e.g., dvorak & day, 2014; kentopp et al., 2019; pearson et al., 2018), the pathway is not expressly understood, and, given that personality is difficult to change (wagner et al., 2020), this information does not inform effective interventions to stop individuals from experiencing these personality, rumination, coping motives, and marijuana problems 84 consequences. personality first forms during childhood, solidifies in adolescence and young adulthood, and typically remains stable across the rest of the lifespan. thus, personality is a fairly static variable that provides boundaries for potential behavioral responses (robinson et al., 2019). cognitive processes, such as rumination, likely play a role in determining how personality traits influence behavior in the moment. having a better understanding of the mechanisms through which specific personality traits influence motives, behavior and outcomes will identify leverage points for intervention to disrupt the link between personality and consequences. in other words, it is quite difficult to change personality. so, if intermediate steps that can be addressed, in this case rumination, can be identified, then effective interventions to lower the probability of experiencing negative health outcomes, such as negative consequences from cannabis use, can be identified and changed. for instance, individuals who score high on impulsivity due to their inability to tolerate negative affect (i.e., negative urgency) and who also tend to ruminate may use cannabis as a coping motive to stop ruminating, and thus may increase their chances of experiencing negative cannabis consequences. present study the present study examined personality traits’ influence on negative cannabis-related consequences via rumination and cannabis use coping motives. specifically, we examined a sequential mediation model such that personality factors (i.e., impulsivity, sensation seeking, distress tolerance, and emotion regulation facets) would associate with rumination. in turn, higher rumination would be associated with higher endorsement of cannabis coping motives, which would be associated with more negative cannabisrelated consequences. given that the field of psychology is currently undergoing a rather strong indictment regarding effects that are not reproducible (e.g., simmons et al., 2011), we examined the proposed comprehensive model across two independent samples of college students (project cms, project snap). specifically, we first tested the comprehensive model in the project cms sample and based on results of the model, we then trimmed the model (i.e., removed non-significant direct effects [but kept those variables in as covariates]) and examined if significant results replicated within the project snap sample (as well as tested for model fit). methods participants/procedures project cms sample the participant sample for this present study was comprised of college students from eight universities across five countries (the u.s., spain, argentina, uruguay, and the netherlands). participants completed an online survey exploring risk and protective factors of cannabis use and subsequent outcomes (for more information, see bravo et al., 2019). due to the design of the parent study, several constructs (i.e., distress tolerance, emotion regulation) assessed in the present study were only collected at the u.s. institutions. given the aims of the present study, the analytic sample was limited to 698 students across multiple u.s. universities located in four states (colorado, new mexico, new york, virginia) who reported using cannabis at least once in the past 30 days. the majority of participants identified as being nonhispanic white (60.2%), female (64.5%), freshman (53.9%) and reported a mean age of 19.53 (median = 19.00; sd = 2.72) years. study procedures were approved by the institutional review boards for each participating university. project snap sample participants were college students recruited to participate in an online survey (standardized across sites) from psychology department research participant pools at seven universities across six u.s. states (colorado, new mexico, new york, virginia [2 sites], texas, and wyoming) between fall 2019 and spring 2020 (for more information, see looby et al., 2021). given the aims of the present study, the analytic sample was limited to 1,447 students who reported using cannabis at least once in the past 30 days. the majority of participants identified as being nonhispanic white (47.6%), female (69.7%), freshman (48.6%) and reported a mean age of 19.61 (median = 19.00; sd = 2.55) years. this study was cannabis, a publication of the research society on marijuana 85 conducted after receiving single-site irb approval. measures for all measures (unless specified), composite scores were created by first reverse-coding items when appropriate such that higher scores indicate higher levels of the construct and then averaging across items. all measures (except for coping cannabis motives) were assessed in both project cms and project snap samples. distress tolerance distress tolerance was assessed using the 15item distress tolerance scale (simons & gaher, 2005). the items measure participants’ expectations and evaluations of negative emotional states along four dimensions that constitute the meta-emotion construct of distress tolerance, namely: tolerance, appraisal, absorption, and regulation of negative emotional states. participants respond to items using a 5point likert response scale (1 = strongly agree, 5 = strongly disagree). the total score was found to be internally consistent across both samples (project cms sample, α = .94; project snap sample, α = .93). impulsivity positive urgency, negative urgency, premeditation, and perseverance were assessed as facets of impulsivity, using the 20-item short upps-p impulsive behavior scale (cyders et al. 2014). participants respond to items using a 4point likert response scale (1 = agree strongly, 2 = agree some, 3 = disagree some, and 4 = disagree strongly). reliability for the current study was excellent: positive urgency (project cms sample, α = .89; project snap sample, α = .89), negative urgency (project cms sample, α = .86; project snap sample, α = .82), premeditation (project cms sample, α = .90; project snap sample, α = .88), and perseverance (project cms sample, α = .82; project snap sample, α = .83). note that a separate scale was used to assess sensation seeking, so the sensation seeking subscale of the supps-p was not used in the present study. sensation seeking the sensation seeking personality trait scale (conner, 2021) was used to assess experience seeking (the desire for novel experiences) and risk seeking (the willingness to take risks for those experiences). sample items from the experience seeking subscale include: “i think it is important to try as many new things as i can” and “i like to experience anything and everything i can,” whereas sample items from the risk seeking subscale include: “i think that excitement is more important than safety” and “i enjoy participating in unsafe activities.” experience seeking (project cms sample, α = .83; project snap sample, α = .80) and risk seeking (project cms sample, α = .86; project snap sample, α = .80) exhibited good internal consistency in the present study. emotion regulation emotion regulation was assessed using the 10item emotion regulation questionnaire (gross & john, 2003), a self-report measure assessing use of cognitive reappraisal and expressive suppression as emotion regulatory strategies. reliability for the current study was acceptableexcellent: cognitive reappraisal (project cms sample, α = .92; project snap sample, α = .91) and emotional suppression (project cms sample, α = .76; project snap sample, α = .73). rumination rumination was assessed using the ruminative thought style questionnaire (rtsq; brinker & dozois, 2009). this measure assesses participants’ overall tendency toward ruminative thinking via self-report. it comprises 20-items and uses a 7-point response scale (1 = not at all, 7 = very well). reliability for the current study was excellent: project cms sample, (α = .95); project snap sample, (α = .95). cannabis coping motives in project cms, the marijuana motives measure short form (mmm-sf, simons et al, 1998) was used to assess coping cannabis motives (α = .89). in project snap, the comprehensive marijuana motives questionnaire (lee et al., personality, rumination, coping motives, and marijuana problems 86 2009) was used to assess cannabis coping motives (α = .84). cannabis use and consequences typical cannabis use frequency and quantity (covariates in our models) were assessed using the marijuana use grid (pearson & marijuana outcomes study team, 2021). specifically, each day of the week was broken into six 4-hour blocks of time (12a-4a, 4a-8a, 8a-12p, etc.), and participants were asked to report at which times they used cannabis during a “typical week” in the past 30 days, as well as the quantity of grams consumed during that time block. we calculated typical frequency of cannabis use by summing the total number of time blocks for which they reported using during the typical week (ranges: 042). we calculated typical quantity of cannabis use by summing the total number of grams consumed across time blocks during the typical week (quantity estimates >3 sds above the mean were winsorized). negative cannabis-related consequences were assessed using the 21-item brief marijuana consequences questionnaire (simons et al., 2012). answers to specific items are summed across facets for a single consequence score. reliability for the current study was as follows: project cms sample, (α = .87); project snap sample, (α = .89). statistical analyses to test the study aims, a fully saturated path model (see figure 1) in which personality variables were modeled as predictors of negative cannabis-related consequences via rumination and cannabis coping motives was estimated using mplus 8.3 (muthén & muthén, 1998-2017) within the cms sample. figure 1. significant standardized direct effects of the comprehensive mediation model in project cms sample. note. the covariances among distal antecedents and effects of covariates (i.e., marijuana use frequency, marijuana use quantity, social motives, enhancement motives, conformity motives, and expansion motives) are not depicted for parsimony but are available upon request. significant associations were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. cannabis, a publication of the research society on marijuana 87 within this model, cannabis use frequency, cannabis use quantity, social motives, enhancement motives, conformity motives, and expansion motives were entered as covariates. based on results of the model tested in project cms sample, we then trimmed the model (i.e., removed non-significant direct effects but kept variables as covariates) and examined if significant results replicated within the project snap sample (as well as tested for model fit to determine if the trimmed model was adequate) using mplus 8.3 (muthén & muthén, 1998-2017). for both models, missing data were handled using full information maximum likelihood (muthén & muthén, 1998-2017). we examined the total, direct, and indirect effects using biascorrected bootstrapped estimates (efron & tibshirani, 1993), which provides a powerful test of mediation (fritz & mackinnon, 2007) and is robust to small departures from normality (erceghurn & mirosevich, 2008). statistical significance was determined by 99% bias-corrected bootstrapped confidence intervals not containing zero in both models. results comprehensive mediation model in project cms bivariate correlations and descriptive statistics of study variables in project cms are presented in table 1. table 1. bivariate correlations of variables in the mediation model in project cms sample. note. significant correlations are bolded and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. er = emotion regulation. correlations with covariates (i.e., marijuana use frequency, marijuana use quantity, social motives, enhancement motives, conformity motives, and expansion motives) are available upon request. the total, total indirect, specific indirect, and direct effects of the comprehensive mediation model are summarized in table 2 and figure 1. within the model, only distress tolerance (negative association) and negative urgency (positive association) were significantly associated with rumination after controlling for effects of other personality predictors and covariates. several personality variables and rumination were significantly directly associated with cannabis coping motives: distress tolerance (negative association), negative urgency (positive association), risk seeking (negative association), emotion regulation suppression facet (positive association), and rumination (positive association). negative urgency (positive association) and cannabis coping motives (positive association) were the only variables significantly associated with negative cannabis-related consequences after controlling for effects of all other variables. 1 2 3 4 5 6 7 8 9 10 11 12 m sd 1. distress tolerance -- 3.22 0.81 2. negative urgency -.35 -- 2.09 0.78 3. positive urgency -.22 .54 -- 1.88 0.75 4. perseverance -.05 .08 -.05 -- 3.08 0.66 5. premeditation .06 -.22 -.20 .41 -- 3.12 0.73 6. risk seeking .04 .14 .34 -.06 -.28 -- 2.89 0.72 7. experience seeking .21 -.15 -.05 .20 .06 .42 -- 3.58 0.58 8. er – reappraisal .27 -.18 -.11 .14 .19 -.07 .26 -- 4.70 1.12 9. er – suppression -.13 .12 .20 -.03 -.05 .10 .00 .26 -- 4.11 1.26 10. rumination -.33 .37 .15 .10 -.11 .00 -.04 -.04 .12 -- 4.11 1.30 11. coping marijuana motives -.25 .32 .16 -.03 -.12 -.02 -.12 -.05 .17 .28 -- 2.29 1.24 12. marijuana consequences -.11 .22 .09 -.02 -.12 .07 -.06 -.02 .01 .14 .28 --3.51 4.01 personality, rumination, coping motives, and marijuana problems 88 table 2. summary of total, indirect, and direct effects of distal antecedences, rumination, and marijuana coping motives on negative marijuana-related consequences in a comprehensive mediation model in project cms sample. outcome variables rumination coping marijuana motives negative marijuanarelated consequences predictor variable: distress tolerance β 95% ci β 95% ci β 95% ci total -.245 -0.36, -0.13 -.136 -0.23, -0.05 -.056 -0.16, 0.04 total indirecta -----.039 -0.07, -0.02 -.036 -0.08, 0.000 specific indirect: rumination -----.039 -0.07, -0.02 -.015 -0.05, 0.02 coping marijuana motives ---------.015 -0.04, -0.001 rumination à coping marijuana motives ---------.006 -0.02, -0.002 direct -.245 -0.36, -0.13 -.097 -0.19, 0.001 -.020 -0.13, 0.08 predictor variable: negative urgency β 95% ci β 95% ci β 95% ci total .307 0.19, 0.43 .230 0.12, 0.34 .210 0.10, 0.32 total indirecta ----.049 0.02, 0.09 .054 0.01, 0.11 specific indirect: rumination ----.049 0.02, 0.09 .019 -0.02, 0.06 coping marijuana motives --------.028 0.01, 0.06 rumination à coping marijuana motives --------.008 0.002, 0.02 direct .307 0.19, 0.43 .181 0.08, 0.29 .156 0.04, 0.28 predictor variable: positive urgency β 95% ci β 95% ci β 95% ci total -.060 -0.20, 0.07 -.026 -0.13, 0.08 -.053 -0.17, 0.07 total indirecta -----.010 -0.04, 0.01 -.008 -0.03, 0.01 specific indirect: rumination -----.010 -0.04, 0.01 -.004 -0.03, 0.004 coping marijuana motives ---------.002 -0.02, 0.02 rumination à coping marijuana motives ---------.001 -0.01, 0.001 direct -.060 -0.20, 0.07 -.016 -0.12, 0.09 -.045 -0.17, 0.07 predictor variable: perseverance β 95% ci β 95% ci β 95% ci total .074 -0.04, 0.19 .005 -0.09, 0.09 .033 -0.07, 0.13 total indirecta ----.012 -0.01, 0.04 .005 -0.01, 0.03 specific indirect: rumination ----.012 -0.01, 0.04 .005 -0.004, 0.03 coping marijuana motives ---------.001 -0.02, 0.01 rumination à coping marijuana motives --------.002 -0.001, 0.01 direct .074 -0.04, 0.19 -.007 -0.10, 0.08 .027 -0.07, 0.13 predictor variable: premeditation β 95% ci β 95% ci β 95% ci total -.110 -0.23, 0.01 -.051 -0.14, 0.04 -.039 -0.15, 0.07 total indirecta -----.018 -0.05, 0.001 -.015 -0.05, 0.004 specific indirect: rumination -----.018 -0.05, 0.001 -.007 -0.03, 0.01 coping marijuana motives ---------.005 -0.03, 0.01 rumination à coping marijuana motives ---------.003 -0.01, 0.000 direct -.110 -0.23, 0.01 -.034 -0.13, 0.06 -.024 -0.13, 0.08 cannabis, a publication of the research society on marijuana 89 predictor variable: risk seeking β 95% ci β 95% ci β 95% ci total -.053 -0.17, 0.06 -.126 -0.24, -0.01 .052 -0.06, 0.16 total indirecta -----.009 -0.03, 0.01 -.023 -0.06, -0.002 specific indirect: rumination -----.009 -0.03, 0.01 -.003 -0.02, 0.004 coping marijuana motives ---------.018 -0.05, -0.002 rumination à coping marijuana motives ---------.001 -0.01, 0.001 direct -.053 -0.17, 0.06 -.117 -0.23, -0.01 .075 -0.04, 0.19 predictor variable: experience seeking β 95% ci β 95% ci β 95% ci total .044 -0.07, 0.17 .013 -0.09, 0.13 -.042 -0.15, 0.08 total indirecta ----.007 -0.01, 0.03 .005 -0.02, 0.03 specific indirect: rumination ----.007 -0.01, 0.03 .003 -0.004, 0.02 coping marijuana motives --------.001 -0.02, 0.02 rumination à coping marijuana motives --------.001 -0.002, 0.01 direct .044 -0.07, 0.17 .006 -0.10, 0.12 -.046 -0.16, 0.07 predictor variable: erq – reappraisal β 95% ci β 95% ci β 95% ci total .048 -0.07, 0.17 -.030 -0.12, 0.07 .064 -0.04, 0.16 total indirecta ----.008 -0.01, 0.03 -.002 -0.02, 0.02 specific indirect: rumination ----.008 -0.01, 0.03 .003 -0.004, 0.02 coping marijuana motives ---------.006 -0.03, 0.01 rumination à coping marijuana motives --------.001 -0.002, 0.01 direct .048 -0.07, 0.17 -.038 -0.13, 0.06 .066 -0.04, 0.16 predictor variable: erq – suppression β 95% ci β 95% ci β 95% ci total .053 -0.05, 0.17 .115 0.03, 0.20 -.060 -0.16, 0.03 total indirecta ----.008 -0.01, 0.03 .021 0.004, 0.05 specific indirect: rumination ----.008 -0.01, 0.03 .003 -0.004, 0.02 coping marijuana motives --------.016 0.003, 0.04 rumination à coping marijuana motives --------.001 -0.001, 0.01 direct .053 -0.05, 0.17 .107 0.02, 0.20 -.081 -0.18, 0.01 predictor variable: rumination β 95% ci β 95% ci β 95% ci total ----.160 0.07, 0.25 .085 -0.04, 0.20 indirect effect via coping marijuana motives --------.025 0.01, 0.05 direct ----.160 0.07, 0.25 .061 -0.06, 0.18 note. significant associations are in bold typeface for emphasis and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. a reflects the combined indirect associations within the model. within the model, coping marijuana motives was significantly positively associated with negative marijuana-related consequences (β = .15). effects of covariates (i.e., marijuana use frequency, marijuana use quantity, social motives, enhancement motives, conformity motives, and expansion motives) are available upon request. personality, rumination, coping motives, and marijuana problems 90 as expected based on the direct effects, only negative urgency and distress tolerance were indirectly related to negative cannabis-related consequences via rumination and coping motives. specifically, higher negative urgency and lower distress tolerance were related to higher rumination. higher rumination was in turn related to higher coping motives, which in turn was related to more negative cannabis-related consequences. it is important to note that cannabis coping motives uniquely statistically significantly mediated the associations between both risk seeking and distress tolerance and negative cannabis-related consequences (both negative indirect effects), as well as between both negative urgency and emotion regulation (suppression facet) and negative cannabis-related consequences (both positive indirect effects). replication mediation model in project snap bivariate correlations and descriptive statistics of study variables in project snap are presented in table 3. table 3. bivariate correlations of variables in the mediation model in project snap sample. note. significant correlations are bolded and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. er = emotion regulation. correlations with covariates (i.e., marijuana use frequency and marijuana use quantity) are available upon request. based on the results of the model tested in the project cms sample, we trimmed the model for project snap such that only significant direct effects found in project cms (see figure 1) were entered as predictors of the mediation effects (all other variables were entered as covariates) in the replication model. it is important to note that other motives were assessed but not included in the replication mediation model, given discrepancies across cannabis motives measures. the replication mediation model provided an acceptable fit to the data based on most fit indices (hu & bentler, 1999), cfi=.987, rmsea=.045, 90% ci [.026, .064], srmr=.019. the total, total indirect, specific indirect, and direct effects of the replication mediation model in project snap are summarized in table 4 and figure 2. 1 2 3 4 5 6 7 8 9 10 11 12 m sd 1. distress tolerance -- 3.10 0.83 2. negative urgency -.44 -- 2.24 0.77 3. positive urgency -.25 .45 -- 2.04 0.79 4. perseverance -.07 .10 -.05 -- 3.04 0.67 5. premeditation -.01 -.16 -.11 .53 -- 3.11 0.63 6. risk seeking -.01 .17 .40 -.13 -.24 -- 2.82 0.66 7. experience seeking .12 -.15 -.03 .17 .10 .38 -- 3.45 0.58 8. er – reappraisal .33 -.34 -.14 .17 .24 -.02 .30 -- 4.55 1.26 9. er – suppression .01 -.02 .04 -.05 -.00 .03 .01 .28 -- 4.05 1.34 10. rumination -.26 .25 -.00 .15 -.06 .06 .14 .05 .24 -- 4.53 1.28 11. coping marijuana motives -.31 .29 .22 -.05 -.13 .18 -.04 -.11 .18 .24 -- 2.29 1.19 12. marijuana consequences -.14 .19 .18 -.07 -.14 .17 -.05 -.02 .08 .13 .40 --4.27 4.59 cannabis, a publication of the research society on marijuana 91 table 4. summary of total, indirect, and direct effects of distal antecedences, rumination, and marijuana coping motives on negative marijuana-related consequences in replication mediation model in project snap sample. outcome variables rumination coping marijuana motives negative marijuana-related consequences predictor variable: distress tolerance β 95% ci β 95% ci β 95% ci total -.278 -0.49, -0.05 -.234 -0.35, -0.11 ---- total indirecta -----.041 -0.10, -0.004 -.067 -0.11, -0.03 specific indirect: rumination -----.041 -0.10, 0.004 ---- coping marijuana motives ---------.056 -0.10, -0.02 rumination à coping marijuana motives ---------.012 -0.03, -0.001 direct -.278 -0.49, -0.05 -.193 -0.32, -0.05 ---- predictor variable: negative urgency β 95% ci β 95% ci β 95% ci total .263 0.03, 0.49 .120 -0.01, 0.24 .090 -0.03, 0.21 total indirecta ----.039 0.002, 0.11 .034 -0.003, 0.07 specific indirect: rumination ----.039 0.002, 0.11 ---- coping marijuana motives --------.023 -0.02, 0.07 rumination à coping marijuana motives --------.011 0.001, 0.03 direct .263 0.03, 0.49 .081 -0.06, 0.22 .055 -0.06, 0.17 predictor variable: risk seeking β 95% ci β 95% ci β 95% ci total ----.121 -0.03, 0.26 ---- total indirecta ------------ specific indirect: -------- rumination ------------ coping marijuana motives --------.035 -0.01, 0.08 rumination à coping marijuana motives ------------ direct ----.121 -0.03, 0.26 ---- predictor variable: erq – suppression β 95% ci β 95% ci β 95% ci total ----.143 0.04, 0.25 ---- total indirecta ------------ specific indirect: -------- rumination ------------ coping marijuana motives --------.041 0.01, 0.07 rumination à coping marijuana motives ------------ direct ----.143 0.04, 0.25 ---- predictor variable: rumination β 95% ci β 95% ci β 95% ci total ----.148 0.01, 0.27 ---- indirect effect via coping marijuana motives --------.043 0.002, 0.09 direct ----.148 0.01, 0.27 ---- note. significant associations are in bold typeface for emphasis and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. a reflects the combined indirect associations within the model. within the model, coping marijuana motives was significantly positively associated with negative marijuana-related consequences (β = .29). effects of covariates (i.e., marijuana use frequency, marijuana use quantity, positive urgency, perseverance, premeditation, experience seeking, and emotion regulation reappraisal) are available upon request. personality, rumination, coping motives, and marijuana problems 92 figure 2. standardized direct effects of the replication mediation model in project snap sample. note. depicts the standardized direct effects of the replication mediation model in project snap sample. the covariances among distal antecedents and effects of covariates (i.e., marijuana use frequency, marijuana use quantity, positive urgency, perseverance, premeditation, experience seeking, and emotion regulation reappraisal) are not depicted for parsimony but are available upon request. significant associations are in bold and were determined by a 99% bias-corrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. findings in the replication mediation model in project snap largely replicated findings from the comprehensive mediation model in project cms. specifically, rumination was indirectly associated with more negative cannabis-related consequences via higher cannabis coping motives (even when using a different measure of cannabis coping motives). regarding indirect effects of distress tolerance and negative urgency on negative cannabis-related consequences, findings were consistent with those found in project cms. specifically, higher negative urgency and lower distress tolerance were associated with more negative cannabis-related consequences via higher rumination and higher coping motives. the significant indirect effects of negative urgency and risk seeking on negative cannabis-related consequences via cannabis coping motives did not replicate between project cms and project snap. however, the indirect effects of emotion regulation (suppression facet) and low distress tolerance via cannabis coping motives did replicate across samples. discussion past research indicates that cognitive processes (such as cannabis refusal self-efficacy, cognitive reappraisal of emotions, and premeditation) are strategies effectually moderating predictive associations between highrisk traits, coping use motives, and negative use consequences (bonn-miller at al., 2008; brook et al., 2016.; cerdá et al., 2016; dvorak & day, 2014; kentopp at al., 2019; pearson at al., 2018; prosek et al., 2018; vanderveen, 2016). given this, we sought to further understand the potential effect of rumination (as a form of cognitive processing), potentially linking the associations between distal predictors, cannabis coping motives, and negative use consequences. our results across two independent samples were consistent with our hypotheses, in that we found that rumination is a cannabis, a publication of the research society on marijuana 93 risk factor belying associations between personality (particularly distress tolerance and negative urgency) and cannabis use to cope and negative consequences of use. a possible explanation for these results might lie in sense of engaged-avoidance caused by low distress tolerance and negative urgency. the inability to cope with negative emotional states and the likelihood of having a rash behavioral reaction simultaneously express a need to avoid and a need to engage. cognitive and emotional processes that increase distress tolerance, reduce negative urgency, and are associated with reduction in substance use and use-related problems (aldao et al., 2010; cooper et al., 1988; hayaki et al., 2011; lynch, et al., 2007) require engagement with the problem at hand and appraisal of the distress it’s causing. rumination, however, mimics the sense of engagement in this dynamic but redirects it towards distress, avoiding the problem. circumventing the problem leads to a positive feedback loop of engagedavoidance, where the problem is not reduced and distress from the problem is exacerbated. this redirection away from the problem towards fixation on the distress may act in tension with the need to alleviate the distress, which may lead individuals to seek alternative (maladaptive) coping strategies such as using cannabis. clinical implications results of the current study imply that interventive techniques targeted to disrupt ruminative mechanisms in individuals with increased negative urgency and lower distress tolerance may disrupt pathways to negative cannabis use consequences via decreasing use of cannabis to cope. put conversely, the implication is that individuals with low distress tolerance and higher negative urgency are more likely to engage in rumination, which encourages the likelihood of using cannabis to cope with ruminative thoughts and, in turn, experience negative consequences from use. research on alcohol use suggests personality-targeting interventions can manage high-risk traits with regard to drinking-to cope (conrod et al., 2006), but this line of thinking has been less documented with regard to cannabis use. although preliminary, our results support the empirical pursuit of interventions targeting high-risk trait management as a disruption of pathways leading to negative cannabis use consequences. specifically, our results suggest that individuals, screened for low distress tolerance and higher negative urgency, may benefit from interventions designed to replace rumination with cognitive processes such as reappraisal, refusal self-efficacy, and premeditation. due to the preliminary nature of this study, rumination was considered as a single-factor construct in order to retain focused scope. further empirical work examining its mediating role in associations with cannabis use and use-related outcomes might consider examining rumination as a multidimensional construct. it’s been suggested that different kinds of rumination (e.g., angry rumination vs. depressed rumination) have a role in which of the aforementioned facets are most engaged with (ciesla et al., 2011). further research examining facets of rumination as mediators of associations between cannabis use motives and negative use consequences may further refine data informing the design of interventions aimed to reduce negative cannabis use consequences. limitations a limitation of this study is the potential for recall bias in the self-report measures used, due to them being retrospective in nature. further empirical work might benefit from using ecological momentary assessments in order to reduce this bias and provide more insight into any temporal ordering that might be present in the studied associations. relatedly, the use of the cross-sectional survey design in our study means we’re unable to demonstrate temporal precedence with regard to mediation of associations, and therefore we cannot make causal inferences. lastly, the present study’s use of convenience samples may also limit the generalizability of the present study’s findings. conclusions the rise in cannabis use and use-related problems are positively correlated, with the differentiated pathways between use motive variables and negative use consequences impacted by antecedent personality traits and temperament factors. given that cognitive personality, rumination, coping motives, and marijuana problems 94 processes (e.g., reappraisal, premeditation) interrupt associations between multiple trait factors and cannabis use-related outcomes, we sought to better understand the role of rumination, a perseverative cognitive coping process, in mediating these associations. our multidimensional approach yielded results indicating that to no small effect, rumination plays a role in influencing an individual’s use of cannabis to cope and subsequent experiences of negative use consequences, especially among those high in negative urgency and low in distress tolerance. we therefore conclude that rumination is a mechanism catalyzing some high-risk distal predictors of use towards negative use consequences, via higher use of cannabis to cope. thus, interventions designed to decouple rumination from distal factors contributing to negative emotional states (i.e., distress tolerance and negative urgency) implicates reduction in negative use consequences via lower use of cannabis to cope. references aldao, a., nolen-hoeksema, s., & schweizer, s. 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(2016). substance use patterns through early adulthood. american journal of preventive medicine, 51 (1), 33-45. https://doi.org/10.1016/j.amepre.2016.01.029 funding and acknowledgements: dr. bravo was supported by a training grant (t32-aa018108) from the national institute on alcohol abuse and alcoholism (niaaa) in the united states during the duration of data collection for project cms. data collection was supported, in part, by grant t32-aa018108. niaaa had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. the author(s) thank the office of the provost of w&m university for a faculty summer research grant to dr. bravo in support of this work. **this project was completed by the crosscultural addictions study team (cast, castresearcher@gmail.com), which includes the following investigators (in alphabetical order): personality, rumination, coping motives, and marijuana problems 98 adrian j. bravo, william & mary, usa (coordinating pi); james m. henson, old dominion university, usa; manuel i. ibáñez, universitat jaume i de castelló, spain; laura mezquita, universitat jaume i de castelló, spain; generós ortet, universitat jaume i de castelló, spain; matthew r. pearson, university of new mexico, usa; angelina pilatti, national university of cordoba, argentina; mark a. prince, colorado state university, usa; jennifer p. read, university at buffalo, usa; hendrik g. roozen, university of new mexico, usa; paul ruiz, universidad de la república, uruguay ***this project was completed by the stimulant norms and prevalence (snap) study team, which includes the following investigators (in alphabetical order): adrian j. bravo, william & mary (co-pi); bradley t. conner, colorado state university; mitch earleywine, university at albany, state university of new york; james henson, old dominion university; alison looby, university of wyoming (co-pi); mark a. prince, colorado state university; ty schepis, texas state university; margo villarosa-hurlocker, university of new mexico. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ v5i2a7_authors_final brief report 74 ved abstract health behavior theory establishes that exposure to media messages about a topic influences related knowledge, attitudes, and behavior. marijuana-related messages proliferating on digital media likely affect attitudes and behavior about marijuana. most research studying marijuanarelated media effects on behavior relies on self-reported survey measures, which are subject to bias; people find it difficult to recall timing, frequency, and sources of messages. we calculated an exogenous measure of exposure to marijuana-related messages on digital media based on emerging public communication environment (pce) theory. aggregated online searches and social media posts related to marijuana for a given place reflect the marijuana-related pce, where people are exposed to and engage with messages from multiple sources. exogenous measures overcome bias in self-reported exposure and outcome data: simultaneity bias and endogeneity. the pce reflects both potential exposure and relative importance of the topic in the local community, which may influence real-world marijuana use. using 2017 twitter and google search data, we measured the marijuana-related pce to quantify where opportunities for exposure to marijuana-related posts were high and examined relationships between potential exposure and current marijuana use among youth and young adults in 2018. we found that marijuana-related online search and tweeting at the media market level are associated with offline marijuana use, controlling for demographics and state marijuana policy. the marijuana-related digital media environment may reflect and/or influence youth and young adult marijuana use. social media and online search data offer platforms to monitor the marijuana-related pce and supplement survey data to study media exposure and marijuana use behavior. key words: = twitter; google trends; marijuana use; public communication environment multiple health behavior models have documented the finding that exposure to messages about a topic influences knowledge, attitudes, and behavior related to that topic (ajzen & fishbein, 1980; fishbein & ajzen, 1975; mcguire, 1985; pierce et al., 2017). digital media (e.g., social media, websites, online ads) are an important channel for marijuana-related marketing, consumer engagement, and policy advocacy (clayton, 2021; leafly, 2015). retailers advertise cannabis products on social media, often using tactics appealing to young people – e.g., celebrity/influencer endorsement and promotion (bierut et al., 2017; lim et al., 2021). social media posts, such as on the popular site twitter, also reflect attitudes toward marijuana yoonsang kim1, lisa vera2, jidong huang phd3, sherry emery1 1 social data collaboratory, department of public health, norc at the university of chicago 2veracite inc. 3department of health policy & behavioral sciences, school of public health, georgia state university cannabis 2022, volume 5 (2) © author(s) 2022 researchmj.org doi: 10.26828/cannabis/2022.02.007 marijuana content on digital media and marijuana use among young people in the united states corresponding author: yoonsang kim, norc at the university of chicago, 55 east monroe street, 30th floor, chicago, il 60603. email: kim-yoonsang@norc.org cannabis, a publication of the research society on marijuana 75 policy, with more marijuana-related communications with positive sentiment generated in states with legal recreational marijuana policies (daniulaityte et al., 2017; van draanen et al., 2020). young people may learn and reinforce their behaviors by observing others through digital media. young people are exposed to and search for cannabis-related information and express intentions, opinions, and beliefs on digital media (cavazos-rehg et al., 2014; yang et al., 2018). many such messages convey positive sentiment and normalize marijuana use (cavazos-rehg, krauss, et al., 2016; cavazos-rehg, sowles, et al., 2016), with potential influence on attitudes, beliefs, and behaviors. for example, @*e***j*** posted a tweet saying “beat the heat and stay chill this summer with these ultra dank weed ice creams” with a link to its website marketing cannabis ice cream. emerging research has studied the association between marijuana-related digital media and marijuana use. one study found young adult marijuana use to be associated with active and passive exposure to marijuanarelated tweets (cabrera-nguyen et al., 2016). a study with 18-34-year-old past-month marijuana users found that over half viewed marijuana ads in the previous month, commonly on digital media; those who actively sought ads often used internet search engines and social media, and ad exposure was associated with heavier use (krauss et al., 2017). further research discovered that cannabis advertising exposure differed by policy jurisdiction, social media was a frequently-cited advertising channel, and higher ad exposure was associated with higher marijuana use rates (rup et al., 2020). however, these studies measure exposure and outcomes via survey, likely introducing both simultaneity bias and endogeneity. in the highly-fragmented digital environment, selfreported exposure has bias because people have difficulty accurately recalling where, when, and how often they saw and engaged with messages (slater, 2004). an alternative approach to measuring exposure is needed to avoid such bias. an exogenous measure offers an alternative to surveys for assessing potential exposure, and communication theory provides a framework for such a measure (liu & hornik, 2016). people are exposed to and engage with messages from multiple communication sources, which constitute the public communication environment (pce) (hornik et al., 2019; hornik et al., 2022). similar to using television ratings as an objective measure of how many people see a televised program or advertisement (emery et al., 2012; layton et al., 2017), we can consider the aggregation of online searches and social media posts on a given topic and place to reflect the local pce. because individuals’ online social networks overlap substantially with their offline social networks (dunbar et al., 2015), we can measure the local marijuana-related pce by aggregating geolocated messages about marijuana. this exogenous measure of potential exposure may enable inferences about how those messages affect individual behavior. the local pce reflects both opportunity for exposure and relative importance of the topic in the local community (hornik et al., 2022). for example, in communities where retailers post social media messages about products promotions and marketing, local enthusiasts may follow the shops’ accounts and thus have direct message exposure; they may also re-post or share the messages, increasing potential exposure among their followers (cygnis media editor, 2012; fishbein & hornik, 2008; hothi, 2012). similarly, individuals may deliberately seek information about the topic using online search engines; this sought information also reflects the pce. online search increases chances of exposure to relevant information, and greater relative search frequency by a given community implies higher interest in the topic. hornik et al. (hornik et al., 2013) differentiate between information-seeking and informationscanning behaviors, positing that while a single exposure to a topic as a result of a deliberate search may be more influential than a single episode of scanning behavior on the same topic, scanning behavior is much more frequent and – when taken in the aggregate – may be more marijuana use and digital media 76 influential. proliferation of messages reflects and influences community norms, culture, and marketing that constitute the local marijuanarelated pce, which may influence real-world marijuana use. using twitter and google search data, we can measure the local pce related to marijuana and examine where and when opportunities for exposure to marijuana-related content were high. google is currently the top search engine with over 80% market share. as of 2018 32% of online teens used twitter (anderson & jiang, 2018; smith & anderson, 2018), and as of 2021, 42% of young adults (aged 18-29) used twitter (auxier & anderson, 2021). both google search and twitter have been considered important data sources to monitor and address emerging public health and epidemiological issues (eichstaedt et al., 2015; ginsberg et al., 2009; jordan et al., 2019; pelat et al., 2009; seifter et al., 2010). this paper explores whether selfreported marijuana use among us youth and young adults is associated with marijuanarelated google search volume and tweets. methods data and measures a us representative sample of 6,684 youth and adults were interviewed about their tobacco use, marijuana use, and sociodemographic characteristics between april-june 2018. we selected a sample of youth and young adults (13-24 years) for this study. a general population sample of youth (13-17 years) and young adults (18-24 years) was selected from norc’s amerispeak panel and gfk’s knowledge panel for this study. a total of 3,886 respondents completed the survey (1,810 from amerispeak panel and 2,076 from knowledgepanel). of those, 43 did not report on marijuana use and 1 respondent did not provide information about where they lived; the final sample size was 3,842. the survey was offered in english, via phone or online for the amerispeak panel and online only for the knowledge panel. cumulative response rate was 4.5% for knowledgepanel teens, 7.0% for amerispeak teens, 3.5% for knowledgepanel adults, and 9.2% for amerispeak adults; cumulative response rate for the sample of youth and young adults was not separately calculated. statistical weighting was performed to account for nonresponse, subgroup oversampling, and combining two panels in reference to population total benchmarks for age, race/ethnicity, education, gender, census division, and e-cigarette ever-use. respondents were asked “do you now use marijuana or hashish?” and categorized as current marijuana users if they reported “every day” or “some days” use. google search volume data (march 2017– february 2018) were compiled by designated market area (dma) from google trends (http://trends.google.com), using keywords ‘marijuana’ and ‘cannabis.’ google trends data represent relative popularity of the search term; relative search volume (rsv) is defined as the number of searches for a particular term relative to the total number of searches done on google during the observation period. the rsv is then divided by the highest number of searches for the particular term during the observation period, resulting in a value that ranges from 0–100 (google news initiative, n.d.). duplicate searches done by the same person are excluded. dmas are comprised of contiguous counties typically centered in and near large cities and correlated with metropolitan areas. marijuana-related tweets (january– december 2017) were collected from gnip’s historical powertrack using marijuanarelated search queries. our search queries included prominent accounts that marketed marijuana products or advocated marijuana use and relevant policy change; in addition, our queries included terms indicating marijuana product, use, and regulation. we developed the queries using boolean cannabis, a publication of the research society on marijuana 77 operators for a focused search; for instance, “smoke” and “kush”; “smoking” and “legalize” not “cigarette.” our general strategy to develop and test search queries is described elsewhere (kim et al., 2016). the complete list of search queries is available upon request. about 3.17 million marijuanarelated tweets were collected, of which 952,428 (30%) were geolocated to dmas. we used two pieces of location data provided by twitter: user-tagged locations and gnip’s predicted locations. the latter is based on information extracted from user profiles; many users publicly indicate location either by selecting a city and state from a preset list or by directly typing place names in their profiles. gnip uses this information to geolocate twitter users’ locations by matching place names against the geonames.org database. more details for identifying tweet geolocation and the fitness for use of geolocated tweets are reported elsewhere (kim et al., 2020). tweet sentiment was assessed using vader, resulting in a score between −100 (highly negative) and 100 (highly positive) (hutto & gilbert, 2014). vader calculates standardized sentiment score based on lexicon ratings (degree of positive, neutral, and negative) and the proportion of the text that falls into each sentiment category. we calculated an average sentiment score over tweets posted from each dma. statistical analysis average sentiment score of tweets and google search volumes were linked with the survey data based on dmas where respondents lived. the bivariate relationships between marijuana use and google search volume as well as tweet sentiment score were analyzed by age group (youth and young adults). we categorized google search volume and tweet sentiment score by quartile and calculated the prevalence of current marijuana use and 95% confidence interval within each category. we used multivariate logistic models to control for individual-level covariates likely associated with marijuana use, including age group, sex, race/ethnicity, household income, and state marijuana policy in 2018 (legal adult use vs. other). in 2018, recreational marijuana use was legal in nine states and the district of columbia. however, the legalization law in vermont took effect on july 2018, which was after the survey was in the field; thus, we treated vermont as one of the “other” states. three models were estimated to understand whether and to what extent digital media measures additionally explain variation in the outcome: model without digital media measures; model with search volume; model with tweet sentiment score. the effects of digital media and marijuana policy on marijuana use may differ by age. thus, the models also included interactions of digital media and age group as well as marijuana policy and age group; we calculated odds ratios for digital media measures and marijuana policy for youth and young adults separately. weighted prevalence and odds ratios were estimated using sas/stat version 15.1. volumes of ‘marijuana’ search and ‘cannabis’ search on google showed very similar relationships with current marijuana use. we present the results based on ‘marijuana’ search volume. results summary statistics of demographics and state marijuana policy for youth and young adult respondents by marijuana use status are presented in table 1. of marijuana users, 30.4% had household income <$25,000, while 20.9% of non-marijuana users had income <$25,000. marijuana users were more likely to be black and latino than non-users. as anticipated, larger proportions of marijuana users lived in states with legal adult marijuana use (29.7% vs. 19.9%). prevalence of current marijuana use was 9.7% (ci=7.2%, 12.3%) among youth and 21.7% (ci=19.0%, 24.3%) among young adults. figure 1 displays bivariate relationships marijuana use and digital media 78 table 1. summary statistics for sociodemographics of youth and young adults by marijuana use status variables marijuana usersa marijuana non-users n mean/% (95% ci) n mean/% (95% ci) age youth 101 23.9 (18.1, 29.7) 1932 44.6 (42.2, 47.1) young adult 402 76.1 (70.3, 81.9) 1408 55.4 (52.0, 57.8) gender female 290 47.6 (41.4, 53.8) 1984 52.5 (49.9, 55.0) male 213 52.3 (46.1, 58.5) 1355 47.5 (44.9, 50.0) income <$25,000 196 30.4 (25.1, 35.6) 732 20.9 (18.9, 23.0) $25,000-49,999 121 20.2 (15.7, 24.7) 729 22.2 (20.0, 24.4) $50,000-99,999 113 27.3 (21.4, 33.3) 1095 31.2 (28.9, 33.5) $100,000+ 72 22.1 (16.3, 28.0) 783 25.6 (23.5, 27.8) race/ white nhb 164 44.4 (38.2, 50.7) 1726 56.1 (53.6, 58.5) ethnicity black nhb 132 17.9 (13.9, 21.8) 519 12.9 (11.3, 14.4) other nhb 8 1.4 (0.2, 2.7) 62 1.9 (1.3, 2.6) hispanic 134 26.9 (21.0, 32.8) 674 21.8 (19.7, 23.8) multirace nhb 40 5.7 (3.1, 8.3) 167 4.0 (3.1, 5.0) asian nhb 25 3.6 (0.9, 6.2) 191 3.3 (2.5, 4.1) policyc other 375 70.3 (64.5, 76.0) 2769 80.1 (78.0, 82.2) legal 128 29.7 (24.0, 35.4) 570 19.9 (17.8, 22.0) a current marijuana use was measured by asking “do you now use marijuana or hashish every day, some days, or not at all?” every day and some days users were categorized as current marijuana users. b nh: non-hispanic/non-latinx c state marijuana policy: legal for adults/recreational vs. other (reference) figure 1. current marijuana use, marijuana search volume on google trends, and sentiment of marijuana-related tweets note. prevalence for young adults is indicated by dark grey bars █ and prevalence for youth is indicated by light grey bars █. current marijuana use and cannabis search volume showed very similar trend displayed in (a). cannabis, a publication of the research society on marijuana 79 table 2. multivariate logistic models of current marijuana usea and digital media variables no digital media marijuana search tweet sentiment or (95% ci) p or (95% ci) p or (95% ci) p ageb youth 1.00 <.001 1.00 <.001 1.00 <.001 young adult 2.83 (1.90, 4.21) 2.59 (1.71, 3.93) 2.87 (1.92, 4.28) youth digital mediac - 1.79 (1.23, 2.60) .002 1.19 (0.91, 1.55) .200 policyd other 1.00 .022 1.00 .906 1.00 .060 legal 2.16 (1.12, 4.15) 0.95 (0.41, 2.22) 1.93 (0.97, 3.84) young adult digital mediab - 1.19 (0.88, 1.61) .254 1.27 (1.01, 1.59) .037 policyd other 1.00 .038 1.00 .688 1.00 .308 legal 1.48 (1.02, 2.15) 1.12 (0.63, 1.99) 1.23 (0.82, 1.84) youth & young adult gender female 1.00 .232 1.00 .240 1.00 .279 male 1.18 (0.90, 1.57) 1.18 (0.89, 1.57) 1.17 (0.88, 1.54) income <$25,000 1.00 .234 1.00 .190 1.00 .259 $25,000-49,999 0.69 (0.49, 0.98) 0.68 (0.47, 0.97) 0.70 (0.49, 0.99) $50,000-99,999 0.83 (0.58, 1.19) 0.83 (0.58, 1.18) 0.83 (0.58, 1.18) $100,000+ 0.86 (0.57, 1.32) 0.90 (0.59, 1.37) 0.87 (0.57, 1.32) race/ white nhe 1.00 .023 1.00 .008 1.00 .013 ethnicity black nhe 1.76 (1.24, 2.50) 1.89 (1.33, 2.69) 1.84 (1.29, 2.61) other nhe 0.70 (0.28, 1.77) 0.74 (0.29, 1.86) 0.73 (0.29, 1.85) hispanic 1.47 (0.99, 2.17) 1.57 (1.06, 2.32) 1.51 (1.02, 2.24) multirace nhe 1.66 (0.92, 2.99) 1.65 (0.90, 3.00) 1.72 (0.95, 3.11) asian nhe 1.32 (0.58, 3.03) 1.36 (0.60, 3.08) 1.33 (0.58, 3.07) a current marijuana use was measured by asking “do you now use marijuana or hashish every day, some days, or not at all?” every day and some days users were categorized as current marijuana users. b the odds ratios for young adults vs. youth were calculated conditional on the mean values of digital media measures and for those living in states where marijuana use is not legal for adults. the odds ratios conditional on legal marijuana use are greater. c marijuana search volume (march 2017–february 2018) and tweet sentiment scores (january–december 2017) were divided by their standard deviations to estimate the odds ratio for one standard deviation change. d state marijuana policy: legal for adults/recreational vs. other (reference) e nh: non-hispanic/non-latinx marijuana use and digital media 80 relationships between current marijuana use and (a) ‘marijuana’ search volume on google and (b) sentiment scores of marijuana-related tweets. overall, both digital media measures exhibit positive relationships with marijuana use. youth living in the dmas in the highest quartile of marijuana search volume were more likely to report current marijuana use than those living in dmas in the lowest quartile (15.0% [ci=9.2%, 20.9%] vs. 2.4% [ci=0.6%, 4.2%]). prevalence of young adults’ marijuana use appears to increase with the tweet sentiment. table 2 presents three multivariate logistic regressions: (1) model without digital media, (2) model with search volume, and (3) model with tweet sentiment. age group was significantly associated with reporting current marijuana use; the odds of marijuana use for young adults were larger than twice that for youth, controlling for other covariates. latino and non-latino black respondents were more likely to use marijuana than non-latino white respondents. in the first model without digital media measures included, state marijuana policy was strongly associated with current marijuana use; those living in states where recreational use was legal were more likely to use marijuana. the second model with google search volume showed that for youth, the odds of reporting current marijuana use was 79% greater (or=1.79; ci=1.23, 2.60) as the search volume increased by one standard deviation (=13.8), while a similar pattern was not observed for young adults. the third model with tweet sentiment score showed that for young adults, the odds of reporting current marijuana use was 27% greater (or=1.27; ci=1.01, 1.59) as tweet sentiment score changed by one standard deviation (=5.4) in a positive direction, although a similar pattern was not observed for youth. interestingly, the association of state marijuana policy with the outcome was dampened when digital media measures were included. state policy was associated with the outcome as well as both digital media measures. youth and young adults living in states where recreational marijuana use was legal had higher search volume on average (47.9% vs. 27.3%). similarly, states with recreational laws had tweets with an average sentiment score indicating neutral sentiment, while states without recreational laws had tweets with slightly more negative sentiment (-0.001 vs. -0.041). discussion this study sought to determine associations between marijuana-related tweets and google search volume and selfreported marijuana use among youth and young adults in the us. we found that dmalevel marijuana-related online search was associated with youth marijuana use and tweeting was associated with young adult marijuana use, controlling for demographics and state marijuana policy. our findings suggest that the marijuana-related digital media environment may reflect and possibly influence marijuana use among youth and young adults. further research is required to understand why different types of digital media are associated with offline marijuana use by age group. previous studies reported that youth and young adult marijuana use was associated with self-reported exposure to marijuana advertisements on the internet (dai, 2017; krauss et al., 2017; rup et al., 2020) and marijuana-related tweets (cabrera-nguyen et al., 2016). our study demonstrates that community-level digital media data can provide valuable and rapid measures of potential exposure to marijuana-related information on digital media. these exogenous measures reflect the community environment and social norms surrounding marijuana use and overcome bias in selfreported exposure data; and can be used as an indicator of the likelihood that an individual cannabis, a publication of the research society on marijuana 81 residing in a region may encounter marijuana-related messaging. thus, digital media data may be used as a proxy for the local pce around marijuana use and supplement survey data to enhance understanding of factors influencing young people’s substance use. we also observed that state marijuana policy was associated with marijuana-related tweets and google search; this correlation suggests that the pce may either reflect and/or influence the policy environment, and both appear to be associated with marijuana use. we considered dma as the unit of pce measures to quantify opportunities for exposure to marijuana-related digital media content. dma has been widely used as the unit of measure to analyze the media effect. twitter users may indicate the core city as their location, although they may reside in a suburban area, and people easily travel within metropolitan areas. most dmas are defined based on metropolitan areas and often cross state boundaries. on the other hand, the legality of marijuana use is bounded by state and associated with relevant attitudes and use of state residents. however, people may purchase marijuana in neighboring states. in 2018, recreational marijuana use was legal in nine states and the district of columbia, although the sale and purchase remain illegal in the district of columbia. some study limitations must be stated. we used twitter and google search data, whereas several more media channels contribute to the pce. we did not consider legacy media sources, such as the new york times, which also comprise part of the pce. however, we believe our measures still reflect the pce, and much legacy media content can be found on twitter (e.g., @nytimes) and via google search. second, the level of individuals’ exposure may vary from the exogenous measure. using an exogenous measure of exposure to topical messaging may be complicated by the fact that consumers’ digital media patterns are recorded in cookies and search histories and used to fine-tune targeted marketing strategies. nonetheless, our team has demonstrated in prior work that such measures are correlated with tobacco product sales and youth attitudes and beliefs about tobacco use (berg et al., 2019; liu et al., 2019). third, using the vader to calculate sentiment score may not accurately capture proversus anti-marijuana opinions; it reflects emotional valence in tweets, and some pro-marijuana tweets may convey negative sentiment, for example. finally, we analyzed the survey data collected in late spring 2018, linking with 2018 state marijuana policy, tweets posted in january–december 2017, and google search data from march 2017– february 2018. since then, more states have legalized recreational marijuana use, and digital media related to marijuana have likely evolved. however, we believe that our findings still speak to the relationship between marijuana-related pce and marijuana use. our findings suggest that youth and young adults living in areas where more people search for cannabis information on google and post cannabis-related tweets with positive sentiment are more likely to use marijuana. social media and online search data 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(2020). geographic differences in cannabis conversations on twitter: infodemiology study. jmir public health and surveillance, 6(4), e18540. yang, q., sangalang, a., rooney, m., maloney, e., emery, s., & capella, j. n. (2018). how is marijuana vaping portrayed on youtube? content, features, popularity and retransmission of vaping marijuana youtube videos. journal of health communication, 23(4), 360–369. funding and acknowledgements: this study was supported by a grant r01ca194681 (pi: jidong huang) and another r01ca248871 (pi: ganna kostygina) from the national institutes of health, national cancer institute. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors declare that they do not have any conflict of interest. the authors would like to thank steven binns and hy tran, norc at the university of chicago for their contribution to twitter data collection and aggregation. copyright: © 2022 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 11 ved abstract background: sexual minority young adults (smyas) experience discrimination and have high cannabis use prevalence. discrimination may be associated with cannabis use, including hazardous use and co-use with tobacco, depending on emotion regulation and gender. methods: fall 2020 survey data assessed discrimination, use frequency of emotion regulation strategies (i.e., cognitive reappraisal, expressive suppression), current cannabis use, hazardous use, and cannabis-tobacco dual use among smyas (age 1834) in 6 united states metropolitan areas (women: n=450, mage =24.1, sd=4.7, 69.6% bisexual, 18.2% lesbian/gay, 12.2% other; men: n=254, mage=24.7, sd=4.5, 33.5% bisexual, 54.3% gay, 12.2% other). multivariable logistic regression examined the moderating roles of cognitive reappraisal and expressive suppression on associations of discrimination with cannabis use outcomes, stratified by gender and adjusted for age, race and ethnicity, and employment. results: among smya women, 89.5% experienced any discrimination; 53.1% reported current cannabis use, of whom 49.4% and 47.7% reported hazardous use and cannabis-tobacco dual use, respectively. adjusting for sociodemographics, experiencing greater discrimination was associated with greater odds of hazardous cannabis use (aor=1.08, 95% ci [1.02, 1.15]) and cannabis-tobacco dual use (aor=1.04, 95% ci [1.01, 1.08]) among smya women with greater use of expressive suppression. among smya men, 83.9% experienced any discrimination; 49.2% reported current cannabis use, of whom 55.2% and 44.0% reported hazardous use and cannabis-tobacco dual use. discrimination and emotion regulation were unrelated to cannabis use outcomes among men. conclusions: given high rates of discrimination experiences among smyas, emotion regulation skills training may empower smyas, particularly women, to cope with discrimination without using cannabis. key words: = emotion regulation; sexual minority; cannabis; tobacco; discrimination; lgb; expressive suppression cannabis use and associated problems are more prevalent among sexual minority (sm) than heterosexual individuals. in a 2016-2017 survey of united states (u.s.) adults, significantly greater proportions of sm women (19.9% 30.0%, varying by sexual orientation) and sm men (27.3% 29.1%) reported current cannabis use, versus heterosexual women (6.0%) and heterosexual men (11.5%) (gonzales, 2020). cannabis use disparities by sexual orientation erin a. vogel1,2, katelyn f. romm1,2, carla j. berg3,4 1tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center, oklahoma city, ok, usa 2department of pediatrics, college of medicine, university of oklahoma health sciences center, oklahoma city, ok, usa 3department of prevention and community health, milken institute school of public health, george washington university, washington, dc, usa 4george washington cancer center, george washington university, washington, dc, usa cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000217 emotion regulation moderates associations between discrimination and cannabis use patterns among sexual minority young adult women corresponding author: erin a. vogel, phd, tset health promotion research center, university of oklahoma health sciences center, 655 research pkwy #400, oklahoma city, ok 73104. phone: (405) 271-8001 ext. 50493. e-mail: erin-vogel@ouhsc.edu. cannabis, a publication of the research society on marijuana 12 may be especially pronounced among young adults (yas). in 2020, 37.0% of lesbian, gay, or bisexual (lgb) yas (versus 26.1% of lgb adults age 26+) reported past-month cannabis use and 22.9% of lgb yas (versus 13.6% of lgb adults age 26+) met criteria for cannabis use disorder in the past year (substance abuse and mental health services administration, 2022). discrimination may contribute to cannabis use disparities observed among some minoritized populations (feldstein ewing et al., 2022). moreover, among sexual minority adults, experiences of discrimination peak in young adulthood (schuler et al., 2018). sm individuals may be particularly vulnerable to using cannabis to cope with discrimination during young adulthood. minority stress theory (meyer, 2003) states that socially minoritized individuals, such as sm individuals, experience minority-specific stressors (e.g., prejudice, discrimination) that contribute to negative health outcomes. sm individuals may use cannabis to alleviate negative affect following an experience of discrimination (dyar et al., 2022; newberger et al., 2022). after experiencing discrimination, sm individuals may ruminate on the event and experience psychological distress (hatzenbuehler, 2009). cannabis has both euphoric and calming effects that may temporarily alleviate distress (national institute on drug abuse, 2020). however, using cannabis to cope with discrimination and other stressors may lead to the development of more problematic use patterns, including more use sessions, greater intoxication, consuming a greater quantity of cannabis, and more use consequences, compared to using cannabis for non-coping reasons (bonar et al., 2017; dyar et al., 2022). co-use of cannabis with tobacco products (cohn et al., 2019) and with alcohol (cohn et al., 2016) are also common problematic use patterns among young adults. however, examining co-use of cannabis and tobacco is of particular importance due to common underlying vulnerability factors between cannabis and tobacco use (rabin & george, 2015) and common routes of administration (e.g., smoking, vaping). some cessation strategies (e.g., discarding smoking and vaping paraphernalia, substituting gum or candy for substances) could help mitigate both cannabis and tobacco use. among sexual and gender minority (sgm) individuals, experiencing greater discrimination is associated with greater odds of using multiple tobacco products (budenz et al., 2022), which suggests the potential of co-use to cope with discrimination. emotion regulation may attenuate the association between discrimination, hazardous cannabis use (i.e., misuse and/or dependence) (adamson et al., 2010), and co-use with tobacco. emotion regulation refers to strategies used to influence the experience and expression of one’s responses to situations, such as cognitive reappraisal (i.e., reframing one’s thoughts around a situation before the emotional response occurs) and expressive suppression (i.e., inhibiting outward expression of the emotional response once it has occurred) (gross, 1998; gross & john, 2003). cognitive reappraisal is typically more effective and adaptive than expressive suppression; thus, lesser use of cognitive reappraisal and/or greater use of expressive suppression may reflect emotion dysregulation, or difficulty identifying, selecting, and implementing an appropriate strategy (gross, 2015). experiencing discrimination may tax individuals’ emotion regulation ability. as a minority stressor, discrimination may prompt sm individuals to use cannabis to cope. in the general population, emotion dysregulation is associated with using cannabis to cope with stress and distress, and with experiencing more cannabisrelated problems (buckner et al., 2017; bujarski et al., 2012; cavalli & cservenka, 2021; lucke et al., 2021). the association of psychological distress with cannabis use is stronger among sgm than non-sgm individuals (bränström & pachankis, 2018), and experiencing discrimination is concurrently associated with cannabis use at the daily level among sm women and gender diverse individuals who report using cannabis to cope (dyar et al., 2023). ultimately, the effects of discrimination may compound over time, culminating in risk of harmful cannabis use patterns among smyas who have difficulty with emotion regulation. associations between discrimination, cannabis use, and emotion regulation may differ by gender. studies have shown that, among sm men but not women, ever experiencing discrimination was associated with substance use disorders (lee et al., 2016). moreover, in the general population, emotion dysregulation was more strongly associated with problematic discrimination, emotion regulation, and cannabis 13 cannabis use among men than women (cavalli & cservenka, 2023). however, other research has found that among women (relative to men), coping motives (i.e., intentionally using cannabis to manage difficult emotions or problems) are more strongly associated with cannabis use (simons et al., 1998). compared to among men, coping motives more strongly mediate distress intolerance and cannabis use-related problems among women (bujarski et al., 2012), and emotion regulation is a stronger mediator in the relationship between cannabis use and mental health among women than men (weidberg et al., 2023). these mixed findings underscore the need for more research addressing these associations. moderation analyses may help identify subpopulations of smyas who could most benefit from targeted interventions to build emotion regulation skills. this study examined associations between discrimination, emotion regulation, and cannabis use outcomes (i.e., current use, hazardous use, couse with tobacco) among smyas in the u.s. we hypothesized that main effects of discrimination and emotion regulation on cannabis use outcomes would be qualified by significant interactions. specifically, we predicted that experiencing more (vs. less) discrimination would be associated with greater odds of: a) current cannabis use, b) hazardous cannabis use, and c) co-use with tobacco, among smyas with: a) lower (vs. higher) use of cognitive reappraisal, and b) higher (vs. lower) use of expressive suppression. methods participants and procedures this study analyzed survey data from a 2-year longitudinal study of yas (aged 18-34) designed to examine correlates of cigarette and e-cigarette use among individuals recruited from 6 metropolitan statistical areas (msas: atlanta, boston, minneapolis, oklahoma city, san diego, seattle) with varied tobacco legislative contexts (public health law center, 2020). this study, detailed elsewhere (berg, 2021), was approved by the george washington university institutional review board. participants were recruited in fall 2018 and surveyed biannually until fall 2020 (total of 5 waves). to recruit participants, advertisements were posted on facebook and reddit and targeted individuals by using indicators reflecting those eligible (i.e., ages 18-34, residing in one of the 6 msas, english speaking). after clicking on an ad, individuals were directed to a webpage with a study description, consent form, and eligibility screener. eligible individuals then completed the online wave 1 survey via alchemer. upon completion, participants were asked to confirm their participation in the study a week later. other fraud prevention efforts included not disclosing eligibility requirements before screening and performing validity checks (e.g., duplicate ip addresses, email addresses, or phone numbers; illogical responses; unrealistically short survey completion time) prior to distributing incentives (bauermeister et al., 2012; sullivan et al., 2013). purposive, quota-based sampling ensured the sample represented sufficient numbers of cigarette and e-cigarette users (roughly one-third each), roughly equal numbers of men and women, and 40% racial or ethnic minority (subgroup enrollment was capped by msa). of the 10,433 individuals who clicked on ads, 9,847 consented, of whom 2,751 (27.9%) were excluded due to: (a) ineligibility (n=1,472) and/or (b) their subgroup target being met (n=1,279). among the remaining 7,096 individuals, 48.8% (n=3,460) provided complete data, and 86.9% (n=3,006) confirmed participation (berg, 2021). the current analyses involve the use of baseline sociodemographic data and fall 2020 data (n=2,476, 82.4%), which assessed perceived discrimination, emotion regulation, and cannabis use outcomes. a greater proportion of men (versus women, χ2=4.69, p=.030) dropped out of the study prior to the fall 2020 wave. moreover, those who dropped out prior to fall 2020 were significantly younger in age (t= 2.66, p=.008). there were no significant differences in attrition based on sexual orientation, race, ethnicity, or employment. current analyses focus on sm-identifying (i.e., gay/lesbian, bisexual, or another non-heterosexual identity) yas with baseline and fall 2020 data (n=450 women, n=254 men). measures sample selection variable: sexual orientation participants were asked, “do you consider yourself: heterosexual or straight; gay or lesbian; bisexual; another sexual orientation; prefer not to answer.” those who reported gay or lesbian, cannabis, a publication of the research society on marijuana 14 bisexual, or another sexual orientation were included in current analyses. stratification variable: gender participants were asked, “what is your gender: male; female; or other.” participants who selected “other” (n=68) were excluded from primary analyses due to stratification but explored in descriptive analyses. cannabis use outcomes to assess current cannabis use, participants indicated whether they used cannabis >1 day of the past 30 days (yes, no). among current cannabis users, hazardous cannabis use was assessed via the cannabis use disorder identification test – revised (cudit-r), which assesses cannabis consumption, misuse, and dependence. scores were dichotomized such that scores of >8 indicate engagement in hazardous cannabis use (adamson et al., 2010). finally, among current cannabis users, a dichotomous variable was created for current cannabis-tobacco dual use, using data from past 30day assessments of tobacco use (specifically cigarettes, e-cigarettes, traditional cigars, little cigars/cigarillos, hookah). those who reported using any tobacco product >1 day of the past 30 days were coded as a current cannabis-tobacco dual user. primary predictor: discrimination participants completed the everyday discrimination scale (short version) (sternthal et al., 2011), a 6-item scale designed to measure the frequency of perceived discrimination across multiple domains on a 6-point scale (0=never to 5=almost every day). sample items include: “in your day-today life how often have any of the following happened to you: you are treated with less courtesy or respect than other people; people act as if they think you are not smart.” responses were summed with higher scores indicating more frequent experiences of discrimination (α=.84). moderators: emotion regulation strategies participants completed the emotion regulation questionnaire (gross & john, 2003), a 10-item scale designed to measure respondents’ tendency to regulate their emotions in 2 ways: cognitive reappraisal (6 items) and expressive suppression (4 items) on a 7-point scale (1=strongly disagree to 7=strongly agree). sample items include: “i control my emotions by changing the way i think about the situation i’m in” (reappraisal) and “i keep my emotions to myself” (suppression). responses to each subscale were averaged with higher scores indicating greater cognitive reappraisal (α=.87) and expressive suppression (α=.80), respectively. sociodemographic covariates participants self-reported their age (continuous variable), race (categorized as white, black, asian, or another race due to group sizes), ethnicity (hispanic vs. non-hispanic), and employment status (i.e., student, unemployed, employed full-time, employed part-time). due to limited racial and ethnic variability among sm women and men, participants were categorized as non-hispanic white versus racial or ethnic minority for primary analyses. data analysis all analyses were conducted among women (n=450) and men (n=254), separately, using mplus version 8.8. first, bivariate analyses (i.e., chi-square tests, independent samples t-tests) examined associations among sociodemographics (i.e., age, race, ethnicity, employment), discrimination, and emotion regulation strategies (i.e., cognitive reappraisal, expressive suppression) with cannabis use outcomes (i.e., current cannabis use, hazardous cannabis use, cannabis-tobacco dual use). next, multivariable logistic regression models were built for each cannabis use outcome and included: 1) sociodemographic covariates; 2) discrimination and emotion regulation strategies; and 3) interactions between discrimination and emotion regulation strategies (i.e., discrimination x reappraisal, discrimination x suppression). results discrimination, emotion regulation strategies, and cannabis use outcomes among women among women (mage=24.11 [sd=4.65]; 3.8% black, 8.0% asian, 12.4% another race, 10.0% hispanic), 69.6% identified as bisexual, 18.2% lesbian, and 12.2% another sexual orientation (i.e., queer, pansexual, asexual). additionally, discrimination, emotion regulation, and cannabis 15 53.1% reported current cannabis use. among those reporting current cannabis use, 49.4% and 47.7% reported hazardous cannabis use and cannabis-tobacco dual use, respectively. moreover, 89.5% reported experiencing any discrimination. use of cognitive reappraisal (m=4.53, sd=1.18) and expressive suppression (m=3.46, sd=1.40) averaged near the midpoint of the 7-point scale, with higher scores indicating greater use of each strategy. bivariate analyses (table 1) indicated that women who reported hazardous cannabis use (vs. no hazardous use) and cannabis-tobacco dual use (vs. no dual use) reported significantly greater discrimination frequency. those who reported cannabis-tobacco dual use (vs. no dual use) were also more likely to indicate any (vs. no) discrimination and reported significantly greater suppression. multivariable logistic regressions indicated that, among women (table 3, upper panel), greater discrimination predicted greater odds of hazardous cannabis use (aor=1.06, 95% ci=1.01, 1.11) and cannabis-tobacco dual use (aor=1.09, 95% ci=1.03, 1.15). a significant interaction among discrimination and suppression emerged for hazardous cannabis use (aor=1.08, 95% ci=1.02, 1.15) and cannabis-tobacco dual use (aor=1.04, 95% ci=1.01, 1.08), such that discrimination was associated with greater odds of both outcomes among women with higher levels of suppression (hazardous use: simple slope=0.51, p=.026; dual use: simple slope=0.63, p=.015), but not lower levels of suppression (hazardous use: simple slope=0.01, ns; dual use: simple slope=0.01, ns). regarding sociodemographic correlates, older age (aor=0.94, 95% ci=0.90-0.99) and being a student (vs. employed full-time; aor=0.45, 95% ci=0.26, 0.80) were associated with lower odds of current cannabis use. being unemployed (vs. employed fulltime) was associated with greater odds of hazardous cannabis use (aor=3.23, 95% ci=1.29, 8.12) and cannabis-tobacco dual use (aor=3.65, 95% ci=1.37, 9.71). being employed part-time (vs. full-time) was also associated with greater odds of cannabis-tobacco dual use (aor=2.24, 95% ci=1.12, 4.49). discrimination, emotion regulation strategies, and cannabis use outcomes among men among men (mage=24.68 [sd=4.48]; 3.9% black, 6.7% asian, 9.8% another race, 13.0% hispanic), 33.5% identified as bisexual, 54.3% gay, and 12.2% another sexual orientation (i.e., queer, pansexual, asexual). additionally, 49.2% reported current cannabis use. among those reporting current cannabis use, 55.2% and 44.0% reported hazardous cannabis use and cannabistobacco dual use, respectively. moreover, 83.9% reported experiencing any discrimination. similar to women, men’s use of cognitive reappraisal (m=4.37, sd=1.17) and expressive suppression (m=3.81, sd=1.44) averaged around the scale’s midpoint. bivariate analyses (table 2) indicated that a greater proportion of men employed parttime and a smaller proportion of men employed full-time reported hazardous cannabis use (vs. no hazardous use). additionally, a greater proportion of men identifying as racial or ethnic minority reported current (vs. no) cannabis-tobacco dual use. multivariable logistic regressions (table 3, lower panel) indicated no significant associations between discrimination or emotion regulation and cannabis use outcomes among men. with regard to sociodemographic correlates, men employed part-time (vs. full-time) displayed greater odds of hazardous cannabis use (aor=5.36, 95% ci=1.66, 7.25) and those identifying as racial or ethnic minority (vs. non-hispanic white) displayed greater odds of cannabis-tobacco dual use (aor=2.47, 95% ci=1.02-5.99). sub-analyses: “other” reports for gender of the 68 participants excluded from primary analyses due to reporting another gender (mage=23.65 [sd=4.04]; 4.4% black, 2.9% asian, 16.2% another race, 10.9% hispanic), 33.8% identified as bisexual, 23.5% gay or lesbian, and 42.6% another sexual orientation (i.e., queer, pansexual, asexual). additionally, 97.1% reported experiencing any discrimination, and 52.9% reported current cannabis use, of whom 58.3% and 47.2% reported hazardous cannabis use and cannabis-tobacco dual use, respectively. cannabis, a publication of the research society on marijuana 16 table 1. bivariate analyses characterizing cannabis use outcomes among smya women note. bold values denote statistical significance at p<.05. aassessed as experiencing any discrimination (> 1 discriminatory experience; vs. no discrimination). bassessed on a scale of 0=never to 5=almost every day. cassessed on a scale of 1=strongly disagree to 7=strongly agree. current cannabis use hazardous cannabis use cannabis-tobacco dual use variables total (n=450, 100.0%) yes (n=239, 53.1%) no (n=211, 46.9%) p yes (n=118, 49.4%) no (n=121, 50.6%) p yes (n=114, 47.7%) no (n=125, 52.3%) p women sociodemographics age, m (sd) 24.11 (4.65) 23.79 (4.49) 24.46 (4.82) .128 23.79 (4.35) 23.80 (4.63) .981 23.11 (4.47) 24.42 (4.42) .025 race, n (%) .050 .374 .069 white 341 (75.8) 187 (78.2) 154 (73.0) 87 (73.7) 100 (82.6) 81 (71.1) 106 (84.8) black 17 (3.8) 4 (1.7) 13 (6.2) 2 (1.7) 2 (1.7) 2 (1.8) 2 (1.6) asian 36 (8.0) 16 (6.7) 20 (9.5) 9 (7.6) 7 (5.8) 11 (9.6) 5 (4.0) another race 56 (12.4) 32 (13.4) 24 (11.4) 20 (16.9) 12 (9.9) 20 (17.5) 12 (9.6) hispanic, n (%) 49 (10.9) 29 (12.1) 20 (9.5) .367 18 (15.3) 11 (9.1) .145 12 (10.5) 17 (13.6) .467 racial or ethnic minority, n (%) 140 (31.1) 73 (30.5) 67 (31.8) .782 44 (37.3) 29 (24.0) .025 42 (36.8) 31 (24.8) .044 employment status, n (%) .002 .031 .002 student 110 (24.4) 46 (19.2) 64 (30.3) 23 (19.5) 23 (19.0) 15 (13.2) 31 (24.8) unemployed 53 (11.8) 29 (12.1) 24 (11.4) 19 (16.1) 10 (8.3) 19 (16.7) 10 (8.0) employed full-time 141 (31.3) 74 (31.0) 67 (31.8) 27 (22.9) 47 (38.8) 28 (24.6) 46 (36.8) employed part-time 146 (32.4) 90 (37.7) 56 (26.5) 49 (41.5) 41 (33.9) 52 (45.6) 38 (30.4) any discrimination, n (%)a 400 (89.5) 215 (90.0) 185 (88.9) .727 110 (93.2) 105 (86.8) .098 110 (96.5) 105 (84.0) .001 discrimination, m (sd)b 8.23 (5.64) 8.15 (5.53) 8.32 (5.77) .743 9.03 (5.29) 7.29 (5.64) .015 9.54 (5.73) 6.88 (5.03) <.00 1 cognitive reappraisal, m (sd)c 4.53 (1.18) 4.57 (1.20) 4.49 (1.16) .479 4.60 (1.27) 4.54 (1.26) .684 4.56 (1.20) 4.58 (1.20) .876 expressive suppression, m (sd)c 3.46 (1.40) 3.39 (1.40) 3.53 (1.39) .268 3.45 (1.46) 3.33 (1.34) .507 3.63 (1.46) 3.17 (1.32) .012 discrimination, emotion regulation, and cannabis 17 table 2. bivariate analyses characterizing cannabis use outcomes among smya men note. bold values denote statistical significance at p<.05. aassessed as experiencing any discrimination (> 1 discriminatory experience; vs. no discrimination). bassessed on a scale of 0=never to 5=almost every day. cassessed on a scale of 1=strongly disagree to 7=strongly agree. current cannabis use hazardous cannabis use cannabis-tobacco dual use variables total (n=254, 100.0%) yes (n=125, 49.2%) no (n=129, 49.2%) p yes (n=69, 55.2%) no (n=56, 44.8%) p yes (n=55, 44.0%) no (n=70, 56.0%) p men sociodemographics age, m (sd) 24.68 (4.48) 24.30 (4.57) 25.04 (4.39) .192 24.07 (4.52) 24.59 (4.65) .531 24.73 (4.90) 23.97 (4.29) .360 race, n (%) .651 .830 .255 white 202 (79.5) 101 (80.8) 101 (78.3) 56 (81.2) 45 (80.4) 43 (78.2) 58 (82.9) black 10 (3.9) 3 (2.4) 7 (5.4) 1 (1.4) 2 (3.6) 3 (5.5) 0 (0.0) asian 17 (6.7) 8 (6.4) 9 (7.0) 4 (5.8) 4 (7.1) 3 (5.5) 5 (7.1) another race 25 (9.8) 13 (10.4) 12 (9.3) 8 (11.6) 5 (8.9) 6 (10.9) 7 (10.0) hispanic, n (%) 33 (13.0) 17 (13.6) 16 (12.4) .777 9 (13.0) 8 (14.3) .840 11 (20.0) 6 (8.6) .064 racial or ethnic minority, n (%) 71 (28.0) 34 (27.2) 37 (28.7) .792 19 (27.5) 15 (26.8) .925 20 (36.4) 14 (20.0) .041 employment status, n (%) .393 .046 .784 student 78 (30.7) 35 (28.0) 43 (33.3) 20 (29.0) 15 (26.8) 14 (25.5) 21 (30.0) unemployed 14 (5.5) 9 (7.2) 5 (3.9) 5 (7.2) 4 (7.1) 3 (5.5) 6 (8.6) employed full-time 116 (45.7) 55 (44.0) 61 (47.3) 24 (34.8) 31 (55.4) 25 (45.5) 30 (42.9) employed part-time 46 (18.1) 26 (20.8) 20 (15.5) 20 (29.0) 6 (10.7) 13 (23.6) 13 (18.6) any discrimination, n (%)a 208 (83.9) 103 (83.7) 105 (84.0) .956 57 (83.8) 46 (83.6) .978 45 (83.3) 58 (84.1) .914 discrimination, m (sd)b 7.61 (6.41) 7.33 (5.85) 7.89 (6.93) .497 7.53 (5.45) 7.09 (6.36) .681 7.74 (6.23) 7.01 (5.56) .497 cognitive reappraisal, m (sd)c 4.37 (1.17) 4.51 (1.10) 4.24 (1.22) .066 4.49 (0.95) 4.54 (1.27) .776 4.69 (1.10) 4.37 (1.09) .102 expressive suppression, m (sd)c 3.81 (1.44) 3.79 (1.48) 3.82 (1.41) .890 3.74 (1.52) 3.87 (1.44) .622 3.81 (1.44) 3.79 (1.51) .943 cannabis, a publication of the research society on marijuana 18 table 3. multivariable logistic regression analyses predicting current cannabis use, hazardous cannabis use, and cannabis-tobacco dual use among women and men note. bold values denote statistical significance at p<.05. discussion this study examined how emotion regulation may moderate associations between discrimination and cannabis use among smya women and men. among smya women with greater use of expressive suppression (e.g., keeping emotions to oneself), which can indicate emotion dysregulation (gross, 2015), greater discrimination was associated with greater odds of hazardous cannabis use and cannabis-tobacco dual use. among smya women with lower use of expressive suppression, experiencing discrimination was not associated with cannabis use. discrimination and emotion regulation were not significantly associated with cannabis use outcomes for smya men. associations of greater discrimination with greater odds of hazardous cannabis use and cannabis-tobacco dual use among smya women are consistent with extant literature suggesting that using cannabis to cope is associated with more frequent and problematic cannabis use patterns, at the daily level or event level (bonar et al., 2017; dyar et al., 2022). the present study supports the possibility of a cumulative effect, such that smya women who experience discrimination over an extended period of time may develop problematic or hazardous cannabis use patterns, which can develop into clinically significant cannabis use disorder (adamson et al., current cannabis use hazardous cannabis use cannabis-tobacco dual use variable aor 95% ci aor 95% ci aor 95% ci women age 0.94 0.90, 0.99 1.02 0.96, 1.09 0.92 0.86, 0.99 racial or ethnic minority 0.98 0.64, 1.50 1.73 0.94, 3.16 1.28 0.68, 2.40 employment status (ref: employed full-time) student 0.45 0.26, 0.80 2.08 0.91, 4.76 0.68 0.28, 1.63 unemployed 1.05 0.55, 2.00 3.23 1.29, 8.12 3.65 1.37, 9.71 employed part-time 1.16 0.69, 1.94 2.24 1.12, 4.49 1.91 0.93, 3.94 discrimination 0.99 0.96, 1.03 1.06 1.01, 1.11 1.09 1.03, 1.15 cognitive reappraisal 1.08 0.92, 1.28 1.06 0.85, 1.33 1.06 0.83, 1.35 expressive suppression 0.91 0.79, 1.04 1.02 0.83, 1.25 1.19 0.96, 1.47 discrimination x reappraisal 0.99 0.96, 1.02 0.99 0.95, 1.04 1.03 0.98, 1.09 discrimination x suppression 1.01 0.99, 1.04 1.08 1.02, 1.15 1.04 1.01, 1.08 nagelkerke r2 .060 .106 .218 men age 0.94 0.88, 1.01 1.02 0.92, 1.12 1.03 0.93, 1.13 racial or ethnic minority 0.90 0.50, 1.61 0.99 0.41, 2.40 2.47 1.02, 5.99 employment status (ref: employed full-time) student 0.65 0.32, 1.33 2.01 0.69, 5.88 0.65 0.22, 1.95 unemployed 1.91 0.58, 6.34 1.70 0.40, 7.21 0.47 0.10, 2.25 employed part-time 1.23 0.58, 2.63 5.36 1.66, 7.25 1.25 0.43, 3.60 discrimination 0.99 0.95, 1.04 0.99 0.93, 1.06 1.02 0.95, 1.09 cognitive reappraisal 1.23 0.98, 1.55 0.90 0.63, 1.28 1.31 0.91, 1.89 expressive suppression 1.00 0.83, 1.20 0.95 0.72, 1.24 0.96 0.74, 1.26 discrimination x reappraisal 1.01 0.98, 1.04 1.01 0.96, 1.05 0.97 0.93, 1.02 discrimination x suppression 1.02 0.99, 1.05 1.03 0.98, 1.08 1.02 0.97, 1.07 nagelkerke r2 .059 .108 .118 discrimination, emotion regulation, and cannabis 19 2010). moreover, co-using cannabis with tobacco is associated with nicotine dependence and poorer tobacco cessation outcomes among young adults (dugas et al., 2022; vogel et al., 2018). however, current cannabis use was not associated with discrimination, which might suggest other reasons for cannabis use, such as to think creatively, fit in socially, and enhance experiences (simons et al., 1998). as hypothesized, among smya women, discrimination was associated with cannabis use outcomes only for those reporting greater use of expressive suppression, potentially implying their use of cannabis as a coping mechanism. those who suppress emotional expression may use cannabis to alleviate negative affect rather than effectively processing their emotions with others. using cannabis may further exacerbate expressive suppression, as cannabis use is associated with deficits in emotion processing (troup et al., 2016). smya women with stronger emotion regulation may cope with discrimination earlier in the emotion regulation process by removing themselves from the situation, modifying the situation, or redirecting their attention (gross, 2015). expression suppression and substance use are both examples of response modulation, which occurs when the response is well underway (gross, 2015). using cognitive reappraisal may also be an effective way to cope with discrimination; however, cognitive reappraisal did not moderate associations between discrimination and cannabis use, suggesting strategy selection even earlier (e.g., situation selection). interactions between discrimination and emotion regulation that would imply use of cannabis to cope were not observed among men. use of cannabis to cope may be more prevalent among women than men (simons et al., 1998). however, this study only measured use of cognitive reappraisal and use of expressive suppression. prior research has found that among adults who use cannabis, associations between problematic cannabis use and several dimensions of emotion regulation were stronger among males than females. specifically, males with more severe (versus less severe) problematic cannabis use reported greater overall emotion dysregulation, nonacceptance of emotional responses, difficulty with goal-oriented behavior and with impulse control, and limited access to emotion regulation strategies (cavalli & cservenka, 2023). smya men may use cannabis to cope with discrimination if they have difficulty using effective emotion regulation strategies in general. future research measuring additional facets of emotion regulation (e.g., difficulty with impulse control) would enhance understanding of discrimination, emotion regulation, and cannabis use among smyas of all genders. notably, 89.5% of women and 83.9% of men reported experiencing discrimination. cannabis use prevalence was also high, with 53.1% of women and 49.2% of men reporting current cannabis use. discrimination has profound impacts on health and well-being, including but not limited to substance use (meyer, 2003). structural-level and individual-level discrimination toward sm individuals persist, as evidenced by widespread workplace harassment, housing discrimination, non-affirming medical and mental health care, and insufficient legal non-discrimination protections (medina & mahowald, 2023). societal change is urgently needed to protect the health and well-being of the sm community. emotion regulation skill development interventions may additionally empower smyas, especially women, to cope with discrimination without resorting to hazardous cannabis use patterns. limitations and future directions first, this analysis was cross-sectional. we adjusted for several factors known to influence cannabis use outcomes. reverse causation is possible (i.e., cannabis use leading to discrimination), or a third variable may influence discrimination, emotion regulation, and cannabis use. however, discrimination leading to cannabis use, with emotion regulation as a moderator, is both plausible and well-supported by the literature. second, motives for cannabis use were not measured in this study. results suggest that smya women with greater expressive suppression may use cannabis to cope with discrimination; however, future research should additionally measure cannabis use motives. third, all participants resided in metropolitan areas in the u.s. while their states of residence had varying legislative contexts around cannabis use, it is unknown whether results generalize to individuals in rural areas or other countries. cannabis, a publication of the research society on marijuana 20 greater diversity would enable examination of differences in the strength or direction of associations between discrimination, emotion regulation, and cannabis use among smyas of different races and ethnicities. this is especially important because sexual identity may intersect with other minoritized identities. survey items regarding discrimination were not specific to sexual identity, and some participants’ responses may reflect experiences of discrimination on the basis of race, ethnicity, gender, or other characteristics. future research could account for intersecting identities in analyses, or specifically ask about discrimination based on sexual identity. fourth, not all problematic cannabis use patterns were measured in this study. for example, future research should examine associations between discrimination, emotion regulation, frequent and/or heavy cannabis use, and co-use of cannabis with heavy alcohol use. fifth, response options for “gender” in the baseline survey were “male,” “female,” and “other.” best practice is to measure sex and gender separately (national academies of sciences engineering and medicine et al., 2022). some participants who selected “male” or “female” may be transgender men or women, who may experience discrimination based on their minoritized gender identity. the subsample of participants who selected “other” as their gender was too small to include in stratified analyses, but nearly all (97.1%) reported experiencing discrimination, and 52.9% reported current cannabis use. smyas who identify outside the gender binary should be included in future research. finally, rates of cannabis use in this study should not be interpreted as prevalence estimates, as young adults with tobacco use were intentionally oversampled and may be more likely than their peers to use cannabis. conclusions smyas experience discrimination on the basis of their minoritized identity that may tax their ability to effectively regulate their emotions without resorting to behaviors such as hazardous cannabis use patterns. this study found that among smya women who use expressive suppression to regulate their emotions, experiencing discrimination was associated with hazardous cannabis use and cannabis-tobacco couse. bolstering emotion regulation skills may help smya women cope with discrimination when the experience cannot be avoided. references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2016). an event-related potential study on the effects of cannabis on emotion processing. plos one, 11(2), e0149764. https://doi.org/10.1371/journal.pone.0149764 vogel, e. a., rubinstein, m. l., prochaska, j. j., & ramo, d. e. (2018). associations between marijuana use and tobacco cessation outcomes in young adults. journal of substance abuse treatment, 94(69-73). https://doi.org/ 10.1016/j.jsat.2018.08.010 funding and acknowledgements: this work was supported by the us national cancer institute (r01ca215155-01a1; pi: berg). drs. vogel and romm are supported by oklahoma tobacco settlement endowment trust (tset) contract #r22-03 and the national cancer institute grant awarded to the stephenson cancer center (p30ca225520). dr. vogel is also supported by the national institute on drug abuse (k01 da055073). dr. romm is supported by the national institute on drug abuse (r25da054015; mpis: obasi, reitzel) and the american cancer society (134128-irg-19-142; pi: romm). dr. berg is also supported by other discrimination, emotion regulation, and cannabis 23 us national institutes of health funding, including the national cancer institute (r01ca278229, mpis: berg, kegler; r01ca275066, mpis: yang, berg; r21ca261884, mpis: berg, arem), the national institute on drug abuse (r01da054751, mpis: berg, cavazos-rehg), the fogarty international center (r01tw012456, mpis: berg, paichadze, petrosyan), and the national institute of environmental health sciences/fogarty (d43es030927, mpis: berg, caudle, sturua). the authors declare no conflicts of interests. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 18 ved abstract abstract objective: this study used data from early stages of non-medical cannabis legalization in washington state to 1) compare cannabis dispensary density measures by urbanicity, 2) test if dispensary density was associated with cannabis use overall and by urbanicity. method: data are from the privatization of spirits in washington surveys (n = 2,162 adults) and licensing records. we graphed six cannabis dispensary density measures by urbanicity. logistic regressions tested if dispensary density was associated with 1) cannabis use at least bimonthly and 2) daily/near-daily cannabis use after adjusting for urbanicity. regressions stratified by urbanicity determined whether associations differed in urban vs. suburban/rural areas. results: crude counts and counts per population were higher in suburban/rural areas. counts per land area, counts in a 3to 5-mile buffer, proximity, and clustering detected greater densities in urban areas. monthly/bimonthly cannabis use was associated with counts per buffer in the full sample (aor = 1.08 [1.02, 1.14]) and urban areas (aor = 1.08 [1.02, 1.14]). clustering was associated with monthly/bimonthly use in suburban/rural areas (aor = 7.85 [1.31, 47.17]). daily/near-daily use was associated with proximity and clustering in the full sample (proximity: aor = 0.78 [0.64, 0.97]; clustering: aor = 2.44 [1.32, 4.51]), urban areas (proximity: aor = 0.67 [0.49, 0.92]; clustering: aor = 2.29 [1.22, 4.32]), and suburban/rural areas (proximity: aor = 0.66 [0.45, 0.97]; clustering: aor = 11.10 [1.55, 79.36]). conclusions: in washington’s early non-medical cannabis market, dispensary availability (counts) was associated with monthly/bimonthly use. accessibility (proximity) and clustering were associated with daily/near-daily use. dispensary density thresholds and minimum distances between dispensaries may reduce regular and frequent cannabis use in washington. key words: = cannabis dispensary density; non-medical cannabis; cannabis policy several aspects of the environment, such as the density of retailers in an area , the distances between individuals and retailers, and the respective retailer’s attractiveness, may determine how likely a customer is to visit a retailer (huff, 1963). alcohol availability theory furthers that making purchases more convenient, such as by increasing the number of retailers, may reduce the total cost of buying a product, which may increase consumption by altering routine behaviors (stockwell & gruenewald, 2004). an emerging literature applies availability theory to cannabis (ambrose et al., 2021; mair et al., 2015), finding cannabis dispensary density is associated with cannabis use patterns in the united states (us) (manthey et al., 2023) and abroad (palali & pamela j. trangenstein1, thomas k. greenfield1, deidre m. patterson1, & william c. kerr1 1alcohol research group, public health institute cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000235 volume 8, issue 2 measuring the association between cannabis dispensary density and adult consumption in a statewide setting: does urbanicity matter? corresponding author: pamela j. trangenstein, phd, alcohol research group, 6001 shellmound street, suite 450, emeryville, ca 94608. phone: (510) 597-3440. email: ptrangenstein@arg.org cannabis, a publication of the research society on marijuana 19 van ours, 2015). however, most of this literature has focused solely on medical cannabis (freisthler & gruenewald, 2014; mair et al., 2015; shi et al., 2018; shih et al., 2019) or adolescents/young adults (garcía-ramírez et al., 2019; harpin et al., 2018; hust et al., 2020; paschall & grube, 2020; shih et al., 2021). studies on cannabis dispensary density and adult non-medical cannabis use are needed to appraise the potential consequences of emerging non-medical cannabis markets more fully. several studies have compared cannabis dispensary density measurement methods (ambrose, 2020; ambrose et al., 2021; wadsworth et al., 2021; young-wolff et al., 2021) with inconsistent results. most comparative studies conclude continuous measures of distance/time to the nearest retailer are associated with cannabis use patterns (ambrose et al., 2021; young-wolff et al., 2021). the number of dispensaries within a 15-minute drive from pregnant women’s homes in california were monotonically associated with prenatal cannabis use (young-wolff et al., 2021). yet, past 30-day adult cannabis use prevalence and frequency was not associated with zip codelevel counts of dispensaries in washington (wa) after adjusting for time to the nearest dispensary (ambrose et al., 2021). while comparisons of cannabis dispensary density measurement are increasingly common, few have explored the conceptual underpinnings for these measures and what differences across measurement methods suggest about the dynamics of cannabis dispensaries and use. penchansky and thomas’ seminal conceptualization of access (penchansky & thomas, 1981) and availability theory (stockwell & gruenewald, 2004) suggests cannabis dispensary density measures that summarize the overall availability of cannabis (i.e., counts) or clustering of retailers (i.e., spatial access indices) may begin to indicate the degree of competition among dispensaries, thus affecting prices. conversely, proximity measures (i.e., time/distance to the nearest dispensary) may measure accessibility and convenience for cannabis purchases. in geographically diverse areas, urbanicity likely affects the performance of cannabis density measures, particularly those that account for underlying population when data are sparse (waller & gotway, 2004). distance functions differently in urban and suburban/rural settings, where people typically travel longer distances (guagliardo, 2004). for example, the association between time to the nearest dispensary and cannabis use was stronger in rural/suburban wa than in urban wa (ambrose et al., 2021). further exploration into the role of urbanicity in cannabis dispensary density measurement and associations may identify opportunities to improve the validity of future spatial studies. to address these gaps, this study had three aims: 1) graphically compare cannabis dispensary density measurement methods by urbanicity, 2) determine whether the availability, accessibility, and clustering of non-medical cannabis dispensaries were associated with cannabis use patterns, and 3) test whether urbanicity modifies the association between cannabis dispensary density and cannabis use patterns. based on previous research (fiala, 2020) and the dispensary allocation process (caulkins & dahlkemper, 2013), we hypothesized cannabis dispensary density would be higher in urban (vs. suburban/rural) settings. based on availability theory, we also hypothesized that greater cannabis dispensary density controlling for urbanicity would be associated with higher odds of monthly/bimonthly and daily/near-daily cannabis use. methods data sources cannabis use and individual leveldemographics. cannabis use data are from the privatization of spirits in washington (psw) surveys. the psw survey comprised six crosssectional waves conducted between january 2014 and december 2016: january-april 2014 (wave 1, n = 1,202), september-october 2014 (wave 2, n = 805), march-may 2015 (wave 3, n = 824), augustoctober 2015 (wave 4, n = 663), march-april 2016 (wave 5, n = 611), and september-december 2016 (wave 6, n = 1,392). during all waves, random digit dialing recruited adult respondents (aged 18+ years). approximately half of the sample involved landline interviews, and the other half were cell phone interviews. the aapor2 cooperation rate ; landline, cell) were: wave 1 (50.8%, 59.5%), wave 2 (45.8%, 62.4%), wave 3 (43.7%, 61.5%), wave 4 cannabis dispensaries, use, and urbanicity 20 (41.7%, 59.6%), wave 5 (49.4%, 60.9%) and wave 6 (45.3%, 63.0%). wave 1 occurred before nonmedical cannabis sales began in wa; therefore, we restricted the analysis to waves 2 through 6 (n = 4,295). respondents received a $10 dollar gift card on completion to thank them for their time. surveys lasted about half an hour on average. the public health institute institutional review board approved the psw study protocol. respondents provided their residential address, nearest intersection, or zip code. we geocoded the respondents’ street address or closest intersection. street address data were cleaned in excel and then geocoded and re-matched in arcmap, requiring a minimum match score and spelling sensitivity score of 80. we excluded respondents who only provided a zip code (n = 1,844) or did not provide any geographic information (n = 287). we would have had to use a zip code centroid for these respondents, and they may live long distances from those centroids, particularly in rural/suburban areas. in these instances, density measures may not validly measure their retail exposures; therefore, we excluded these respondents. cannabis dispensaries. cannabis dispensary licensing data were obtained from the washington state liquor and cannabis board by month and year. in wa, dispensaries are licensed for nonmedical cannabis sales, and most also possess permissions to sell medical cannabis. we lagged the dispensary data one month before the start of each data collection wave: july 2014 (wave 2), february 2015 (wave 3), july 2015 (wave 4), february 2016 (wave 5), and august 2016 (wave 6). the cannabis dispensary locations were matched to coordinates with 99% accuracy. finally, the coordinates of the respondents’ and cannabis dispensaries’ locations were spatially joined to a wa census tract (ct) shapefile to determine the ct in which the respondent resided. urbancitiy. the us department of agriculture economic research service provided 2013 rural-urban commuting areas (ruca). these ruca codes are based on the office of management and budget metropolitan and nonmetropolitan categories and were calculated by combining data from 2010 and 2013 (university of washington rural health research center.). covariates. the american community survey 5-year estimates provided area-level demographic covariates by year (us census bureau, 2015, 2016, 2020). the ct identifier was used to match american community survey ctlevel data to the respondents’ location. measures dependant variables. there were two cannabis use outcomes: cannabis use at least monthly (“monthly/bimonthly use”) and daily/near-daily use. these variables dichotomized responses from the survey question: how often have you used marijuana, hash or pot during the last twelve months? monthly or bimonthly cannabis use was defined as cannabis consumption that occurred at least every month or two and was measured as yes (combined every month or two, once every 2 or 3 weeks, about once a week, and every day or nearly every day) or no (reference group; combined never last year and less often than bimonthly). daily or near-daily use was defined as cannabis consumption that occurred every day or nearly every day and was measured as yes (every day or nearly every day) vs. no (combined all other responses; reference group). the dependent cannabis use variables did not include cbd use. independent variables: cannabis dispensary density. we compared six cannabis dispensary density variables. three were measured at the ct level: 1) crude count: number of cannabis dispensaries in the ct, 2) population exposure: number of cannabis dispensaries in the ct divided by population, and 3) dispensary density: number of cannabis dispensaries in the ct divided by land area. the other three were anchored to the respondent’s address: 1) count per buffer, which was measured as the number of cannabis dispensaries in a 3(urban) or 5-mile buffer (suburban/rural). we selected the 3and 5mile buffer radii by rounding the median distance for urban (3.03 miles) and suburban/rural (5.33 miles) respondents to the nearest mile. 2) proximity, defined as the network distance to the nearest cannabis dispensary. 3) clustering, calculated as a spatial accessibility index for the seven dispensaries closest to the respondent’s address using network distance. spatial accessibility indices sum a set of n inverse distances from reference point, ∑ 1 𝑑𝑖𝑠𝑡𝑎𝑛𝑐𝑒 𝑛 1 . the proximity and clustering variables were cannabis, a publication of the research society on marijuana 21 transformed using the natural logarithm because they were highly skewed. effect measure modifier: urbancity. ruca codes classified the respondent’s ct as urban (metropolitan areas) vs. suburban or rural (reference group; includes micropolitan areas, small towns, and rural areas). the most recent ruca codes available used the 2010 decennial census and measured population density, urbanization, and commuting patterns (economic research service, 2020). demographic covariates. at the individual level, we adjusted for age, sex, race, ethnicity, income, educational attainment, employment, and alcohol use. age in years was continuous. sex was a dichotomous variable (female [reference group] vs. male) and included because cannabis use is more prevalent among males (carliner et al., 2017; substance abuse and mental health services administration [samhsa], 2022). the race variable had four categories: black, white (reference group), 2+ racial or ethnic groups, and other racial groups or unknown. black adults and adults who identify with two or more races have higher odds of monthly and weekly cannabis use (wu et al., 2016). ethnicity was measured using a dichotomous variable (not hispanic/latinx [reference group] vs. hispanic/latinx), as cannabis use rates are lower among hispanic/latinx people (mitchell et al., 2020). cannabis use is more common among those with lower incomes (mitchell et al., 2020). respondent’s self-reported annual income was measured using four categories: <$20,000, $20,001-$60,000 or missing, $60,001-$100,000, and $100,001+ (reference group). educational attainment was measured using a three-category variable that indicated whether the respondent reported a high school degree or less (reference group), some college, or a college degree or more. employment was a four-category variable measured as employed (reference group), unemployed, retired, or other statuses (combined disabled, never worked, homemaker, and student). finally, we adjusted for current (pastyear) drinking status (yes vs. no [reference group]), as more than 75% of current cannabis users also drink alcohol (pape et al., 2009). at the ct level, we included a measure of material deprivation because cannabis dispensary densities are higher in places with economic deprivation (amiri et al., 2019). we calculated material deprivation using the townsend deprivation index, which sums z-scores of four indicators: household crowding, unemployment, renter-occupied households, and households without a car (townsend et al., 1988). higher values of the index indicate greater levels of material deprivation. we included the data collection wave as a final covariate to adjust for any temporal trends. the reference group was wave 2 (september-october 2014). analysis and analytic sample we first graphed the dispensary density variables by urbanicity to assess whether mean density was higher in urban or suburban/rural areas. all graphs were made in microsoft® excel® (microsoft corporation, 2018). the graphs used two analytic samples, depending on whether the dispensary density measurement method was calculated at the ct level (n = 1,445 cts) or anchored to respondents’ residential address (n = 2,162 adults). next, logistic regressions tested whether cannabis dispensary density was associated with adult cannabis use patterns. the regressions used the same analytic sample as the second set of graphs. table s-1 in the supplemental appendix compares characteristics of respondents excluded (vs. included) because they did not provide a street address or intersection. briefly, a larger percentage of respondents who provided their address were current drinkers (74.4% vs. 66.6%, p < .01), and respondents with and without streetlevel geographic information differed by ct-level material deprivation (p < .01). we tested whether the outcomes clustered in cts by calculating the intraclass correlation coefficient (icc). the icc for daily/near-daily cannabis use was greater than 0.1 (icc = 0.12), so we clustered standard errors within cts. we forced age, sex, race, ethnicity, and data collection wave into the models based on previous research (carliner et al., 2017; hasin et al., 2019; mitchell et al., 2020). we then selected additional covariates as variables that were significant in at least one adjusted regression. adjusted logistic regressions tested whether cannabis dispensary density was associated with cannabis use patterns (i.e., monthly/bimonthly and daily/near-daily cannabis use). we ran each regression three times cannabis dispensaries, use, and urbanicity 22 to test the association between different dimensions of dispensary density: availability (counts of dispensaries), accessibility (proximity), and clustering. based on the graphs and ease of interpretation, we measured availability using the number of cannabis dispensaries in the buffer around the respondent’s home. we also assessed whether urbanicity modified the association between cannabis dispensary density and cannabis use via stratification. descriptive and regression analyses were performed in stata v.16.1 (statacorp, 2019). we reported simplified results for the key independent variables to aid interpretation, but full tables including covariates appear in the supplemental appendix (table s-2 and s-3). sensitivity analyses later waves. there were relatively few dispensaries open in wa through early 2015, so half (48.99%) of the respondents did not have a cannabis dispensary within 3 or 5 miles of their home during waves 2-6. this may have reduced variability in this predictor, so we conducted a sensitivity analysis that limited the analytic sample to waves 4-6 (tables s-4 and s-5). medical cannabis recommendations. wa legalized medical cannabis in 1998 but did not incorporate medical dispensaries into a formal, licensed regulatory structure until 2015 (washington state legislature, 2015). thus, cannabis dispensary licensing records may have provided an undercount of operational retailers in 2014. further, adults with a medical recommendation potentially have a longer history of improved access to legal cannabis, which may have resulted in higher access to dispensaries than those who use for exclusively non-medical purposes. to address this limitation, we considered the role of medical cannabis recommendations in the relationship between dispensary density and cannabis use patterns (tables s-6 and s-7). results sample description half the respondents (50.1%) were male, and the mean age was 46.7 years (table 1). most of the sample was white (77.1%), not hispanic/latinx (90.6%), had less than a college degree (68.5%), and/or lived in an urban ct (88.0%). the prevalence of monthly/bimonthly cannabis use differed by age (p < .001), sex (p = .01), race (p = .03), income (p < .001), educational attainment (p < .001), employment (p < .001), and drinking status (p < .001). one third of respondents (34.6%) had two or more dispensaries within a buffer 3-/5mile buffer from their home, 36.7% lived more than 6 miles away from the nearest dispensary, and 32.7% had high levels of dispensary clustering around their home. post-hoc analyses revealed the prevalence of self-reported monthly/bimonthly cannabis use was higher for respondents with 2+ dispensaries in their 3to 5mile buffer (vs. no dispensaries, p < .01 and 1 dispensary, p =.01) and high (vs. moderate) dispensary clustering (p = .02). more respondents who lived within 1.5 miles (vs. 1.5 to 6 miles away, p = .01 and 6+ miles away, p = .03) of a dispensary reported daily/near-daily cannabis use. table 1. sample demographics and cannabis dispensary density exposure respondent characteristic weighted % monthly/ bimonthly cannabis use daily/ near-daily cannabis use no % yes % p value no % yes % p value number of dispensaries in buffera 0 48.99 51.19 42.36 <.01 49.95 42.69 .11 1 16.43 17.48 13.27 16.89 13.41 2+ 34.58 31.33 44.37 33.16 43.90 proximity <1.5 miles 21.05 18.11 29.95 <.001 19.49 31.33 .02 >1.5 miles but <6 miles 42.28 43.65 38.12 43.33 35.33 >6 miles 36.67 38.24 31.93 37.17 33.35 clustering low 24.11 24.69 22.36 .06 24.29 22.89 .50 cannabis, a publication of the research society on marijuana 23 medium 43.20 44.74 38.57 43.81 39.21 high 32.69 30.57 39.07 31.90 37.90 urban ct 88.01 87.97 88.15 .94 88.17 87.01 .71 medical recommendation 6.64 0.71 24.70 <.001 2.25 36.00 <.001 age 18-39 years 40.73 35.97 55.08 <.001 38.22 57.22 <.001 40-59 years 33.37 33.92 31.72 33.60 31.84 60+ years 25.90 30.11 13.20 28.17 10.94 male sex 50.08 47.68 57.33 .01 48.56 60.07 .02 race black 4.00 4.06 3.81 .03 4.18 2.83 <.001 other racial and ethnic groups + missing 12.19 10.97 15.87 10.42 23.83 white 77.09 79.50 69.80 79.91 58.50 2+ races 6.73 5.47 10.52 5.49 14.85 hispanic/latinx 9.43 8.10 13.46 .06 8.30 16.87 .03 income <$20,000 21.34 19.10 28.12 <.001 20.21 28.81 <.01 $20,001-$60,000 or missing 42.13 40.73 46.34 40.94 49.93 $60,001-$100,000 20.62 22.77 14.13 21.83 12.63 >$100,001 15.91 17.40 11.40 21.83 12.63 college degree or more 31.49 34.69 21.80 <.001 33.92 15.45 <.001 employment employed 60.05 59.86 60.62 <.001 59.97 60.61 .01 unemployed 5.66 5.16 7.21 5.35 7.75 retired 17.64 20.61 8.58 19.03 8.26 other statuses 16.65 14.37 23.60 15.65 23.38 current drinker 75.10 71.40 86.27 <.001 73.79 83.70 .02 material deprivation index low deprivation 27.51 28.55 24.36 .11 27.98 24.37 .31 moderate deprivation 30.68 31.54 28.09 31.24 27.03 high deprivation 41.81 39.91 47.55 40.78 48.59 data collection wave wave 2 20.08 21.10 17.01 .20 20.05 20.31 .41 wave 3 21.18 22.34 17.71 22.21 14.41 wave 4 20.29 20.06 20.99 19.69 24.25 wave 5 19.12 18.12 22.13 18.76 21.51 wave 6 19.32 18.36 22.15 19.29 19.52 note. percentages may not total to 100 due to rounding. athe buffer radius was 3 miles in urban census tracts and 5 miles in suburban//rural census tracts. aim 1: graphical comparisons of cannabis dispensary density measurement methods crude counts (i.e., no denominator) and population exposure (i.e., population denominator) per ct categorized density as higher in suburban/rural cts (figure 1). cannabis dispensaries, use, and urbanicity 24 figure 1. average cannabis dispensary density by month/survey wave and urbanicity census tract-level cannabis dispensary density measures a. mean dispensaries per census tract b. mean dispensaries per 100,000 population c. mean dispensaries per 100 square miles cannabis dispensary density measures relative to the respondent’s address d. dispensaries in a 3(urban) or e. distance to the nearest dispensary f. spatial accessibility index for 7 nearest 5-mile (suburban/rural) buffer dispensaried ______________________________________________________________________________________________________________________ 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2014 2015 2016 n u m b e r o f d is p e n s a ri e s month and year 0 1 2 3 4 5 6 7 8 9 10 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2014 2015 2016 n u m b e r o f d is p e n s a ri e s p e r 1 0 0 k p e rs o n s month and year 0 2 4 6 8 10 12 14 16 18 20 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2014 2015 2016 n u m b e r o f d is p e n s a ri e s p e r 1 0 0 s q u a re m ile s month and year 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 1 2 3 4 5 6 n u m b e r o f d is p e n s a ri e s i n b u ff e r survey wave 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 1 2 3 4 5 6 d is ta n c e t o t h e n e a re s t d is p e n s a ry ( m ile s ) survey wave 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 1 2 3 4 5 6 s p a a ti a l a c c e s s ib ili ty i n d e x survey wave legend cannabis, a publication of the research society on marijuana 25 this figure shows cannabis dispensary density in urban and suburban/rural census tracts as calculated by six different measures: a) a crude count of the number of dispensaries in the census tract, b) population exposure, measured by dividing the number of dispensaries in the census tract by the population, c) dispensary density, measured by dividing the number of dispensaries by the census tract land area, d) buffer density, measured by counting the number of dispensaries in a 3(urban) or 5-mile (suburban/rural) buffer, e) proximity, measured as the distance to the nearest dispensary, and f) clustering, measured as a spatial accessibility index to the seven nearest dispensaries. all graphs show that cannabis dispensary density gradually increased from july 2014 through december 2016, although there is an inverse association for proximity because shorter distances indicate higher densities. suburban/rural density is depicted with grey circles, and yellow circles indicate urban densities. panels a and b (crude counts and population exposure) show grey circles above the yellow ones, depicting these measures detected higher densities in suburban/rural census tracts. the other panels (density, buffer density, proximity, and clustering) show yellow circles above the grey ones (the reverse is true for proximity, which has an inverse association with availability), indicating that they found higher densities in urban census tracts. cannabis dispensaries, use, and urbanicity 26 conversely, counts per buffer, density (i.e., counts per land area), proximity (i.e., distance to the nearest), and clustering showed higher values in urban areas. post-hoc analyses showed the average population was 21% higher in urban cts (4,738) than in suburban/rural cts (3,910). however, average land area was more than ten times higher in suburban/rural cts (196.15 square miles) than in urban ones (18.54 square miles). aim 2: association between cannabis dispensary density and cannabis use, adjusting for urbanicity each additional dispensary in the 3to 5-mile buffer around the respondent’s home was associated with 8% higher odds of monthly/bimonthly cannabis use (aor = 1.08, 95% ci = 1.02, 1.14, p = .01, see table 2). every additional mile between the respondent’s home and the nearest dispensary was associated with 31% lower odds of daily/near-daily cannabis use (aor = 0.69, 95% ci = 0.53, 0.91, p = .01, see table 3). in addition, each 2.7-fold increase in clustering was associated with 2.4 times the odds of daily/near-daily use (aor = 2.4, 95% ci = 1.32, 4.51, p = .01). table 2. regression results for the association between cannabis dispensary density and monthly/bimonthly consumption overall and by urbanicity and measurement method, waves 2-6 predictor dispensaries in buffera proximity clusteringb aor 95% ci p value aor 95% ci p value aor 95% ci p value full sample (n = 2,162) dispensaries in buffera 1.08 1.02, 1.14 .01 — — proximity (log-transformed) — 0.87 0.74, 1.03 .10 — clustering (log-transformed)b — — 1.69 0.98, 2.89 .06 suburban/rural ct (vs. urban) 1.54 0.90, 2.63 .11 1.58 0.92, 2.73 .10 1.47 0.87, 2.50 .15 respondents who live in urban cts (n = 1,901) dispensaries in buffera 1.08 1.02, 1.14 .01 — — proximity (log-transformed) — 0.87 0.73, 1.03 .10 — clustering (log-transformed)b — — 1.56 0.89, 2.73 .12 respondents who live in suburban/rural cts (n = 261) dispensaries in buffera 1.47 0.93, 2.32 .10 — — proximity (log-transformed) — 0.77 0.53, 1.11 .17 — clustering (log-transformed)b — — 7.85 1.31, 47.17 .02 note. aor = adjusted odds ratio, ci = confidence interval, ct = census tract, bolding denotes p < .05. athe buffer radius was 3 miles in urban census tracts and 5 miles in census tracts. bclustering was measured using a spatial accessibility index, calculated as the sum of the network (road-based) distances from the respondent’s home address to the seven closest cannabis dispensaries. this value was then transformed using the natural logarithm. table 3. regression results for the association between cannabis dispensary density and daily/near-daily consumption overall and by urbanicity and measurement method, waves 2-6 predictor dispensaries in buffera proximity clusteringb aor 95% ci p value aor 95% ci p value aor 95% ci p value full sample (n = 2,162) dispensaries in buffera 1.06 0.97, 1.15 .17 — — proximity (log-transformed) — 0.69 0.53, 0.91 .01 — clustering (log-transformed)b — — 2.44 1.32, 4.51 < .01 suburban/rural ct (vs. urban) 1.48 0.74, 2.96 .27 1.66 0.81, 3.41 .16 1.53 0.76, 3.08 .23 respondents who live in urban cts (n = 1,901) dispensaries in buffera 1.05 0.97, 1.14 .21 — — proximity (log-transformed) — 0.77 0.62, 0.97 .03 — cannabis, a publication of the research society on marijuana 27 clustering (log-transformed)b — — 2.29 1.22, 4.32 .01 respondents who live in suburban/rural cts (n = 261) dispensaries in buffera 1.10 0.60, 2.02 .75 — — proximity (log-transformed) — 0.66 0.45, 0.97 .03 — clustering (log-transformed)b — — 11.10 1.55, 79.36 .02 note. aor=adjusted odds ratio, ci = confidence interval, ct = census tract, bolding denotes p < .05. athe buffer radius was 3 miles in urban census tracts and 5 miles in census tracts. bclustering was measured using a spatial accessibility index, calculated as the sum of the network (road-based) distances from the respondent’s home address to the seven closest cannabis dispensaries. this value was then transformed using the natural logarithm. aim 3: models stratified by urbancity the association between counts of dispensaries per buffer and monthly/bimonthly use persisted in urban settings at the same magnitude (aor = 1.08, 95% ci = 1.02, 1.14, p = .01). in addition, more clustering was associated with higher odds of monthly/bimonthly cannabis use in suburban/rural settings (aor = 7.85, 95% ci = 1.31, 47.17, p = .02). respondents who lived farther away from the nearest cannabis dispensary had lower odds of daily/near-daily cannabis use in both urban (aor = 0.77, 95% ci = 0.62, 0.97, p = .03) and suburban/rural settings (aor = 0.66, 95% ci = 0.45, 0.97, p = .03). similarly, respondents with more dispensary clustering around their home had greater odds of daily/near-daily cannabis use in both urban (aor = 2.29, 95% ci = 1.22, 4.32, p = .01) and suburban/rural settings (aor = 11.10, 95% ci = 1.55, 79.36, p = .02). sensitivity analysis in the models restricted to waves 4-6, the results were consistent with the main models except for four differences. first, counts per buffer were associated with monthly use in suburban/rural settings after restricting the data to waves 4-6 (table s-4). second, proximity was associated with monthly/bimonthly use in the full sample and urban settings when using waves 4-6. third, clustering was no longer associated with monthly use in suburban/rural areas but was associated with monthly use overall. finally, proximity and clustering were no longer associated with daily/near-daily consumption in suburban/rural settings (table s-5). results for the monthly/bimonthly models held after including the medical cannabis recommendation interaction (table s-6). there was no evidence that the association between cannabis dispensary density and monthly/bimonthly use differed for people with (vs. without) a medical cannabis recommendation. however, having a medical recommendation emerged as a strong predictor of monthly/bimonthly and daily/near-daily use (table s-7). proximity and clustering were no longer associated with daily/near-daily use after adjusting for having a medical recommendation. the interaction between medical recommendation and number of dispensaries in a buffer was significant for daily/near-daily use such that the association was only significant for people with a medical recommendation. discission during the first three years of wa’s nonmedical cannabis market, adults with more cannabis dispensaries near their home had higher odds of monthly/bimonthly cannabis use, and those who lived closer to a cannabis dispensary or in areas with higher dispensary clustering had greater odds of daily/near-daily cannabis use. dispensary availability was associated with monthly/bimonthly use, while accessibility and clustering were associated with daily/near-daily use. combining our findings and the conceptual underpinnings of the different cannabis dispensary density measures suggests monthly/bimonthly and daily/near-daily cannabis users may interact with dispensaries differently. monthly/bimonthly cannabis users may prioritize diversity of product and price options, which would increase with the number of dispensaries. conversely, daily/near-daily cannabis users may prefer convenience and prices, which shorter travel times and dispensary clustering would facilitate. urbanicity appears to play a key role in how cannabis dispensary density measures classify cannabis dispensaries, use, and urbanicity 28 locations. the washington state liquor and cannabis board store allocation methods resulted in a disproportionate number of dispensaries in urban settings (caulkins & dahlkemper, 2013), but only measures that used distance or adjusted for land area – number of dispensaries in a ct per land area, number of dispensaries in a given buffer, distance to the nearest dispensary, and dispensary clustering – detected this distribution. still, statewide and national analyses of cannabis dispensary density and cannabis use frequently use population denominators (borodovsky et al., 2016; everson et al., 2019; wadsworth et al., 2021). per capita ratios align with metrics used to quantify dispensary density thresholds in policies and regulations and, thus, are well-suited to research designed to inform such limits. however, future research may also wish to consider the concepts underlying cannabis dispensary density measures to ensure analyses include the most relevant variables and to potentially yield more specific recommendations for substance use prevention. our finding that cannabis dispensary availability near adults’ homes is associated with monthly/bimonthly cannabis use builds on and is consistent with previous findings that mostly focus on medical cannabis and adolescents/young adults. the number of dispensaries within 4to 5miles of a respondents’ home was associated with higher odds of past-month cannabis use (pedersen et al., 2021) and daily use (shih et al., 2021) among adolescents and young adults. cannabisrelated hospitalizations were higher in california zip codes with more medical dispensaries (mair et al., 2015), and the prevalence and frequency of wa adult cannabis use rose as the number of dispensaries in a zip code increased (ambrose et al., 2021). these findings suggest that establishing a threshold for the maximum number or density of cannabis dispensaries may protect against monthly/bimonthly cannabis use. we found that distance and clustering – not the number – of dispensaries was associated with daily/near-daily use. these results demonstrate the importance of considering potential multilevel drivers of daily/near-daily use, particularly when those who use every day or nearly every day have eight times the risk of meeting criteria for cud when compared to people who use cannabis several times a year (robinson et al., 2022). these heavy users consume the majority of cannabis sold in legal markets, with the heaviest 10% responsible for over two-thirds of all cannabis sales (callaghan et al., 2019). our comparison of cannabis dispensary density measures and their associated conceptual underpinnings suggests potential dynamics that may underplay how different types of cannabis users interact with the cannabis environment. most states limit nonmedical cannabis purchase quantities, which means daily/near-daily users may need to make more frequent trips to dispensaries than others who use cannabis less frequently. under these conditions, adults may prefer the convenience of dispensaries located closer to their home. similarly, the competition induced by clustering dispensaries together may result in lower prices that could entice customers who purchase larger volumes of product over time. future research should investigate how frequent cannabis users select dispensaries to patronize and whether establishing minimum distances between dispensaries could reduce frequent cannabis use. results from sensitivity analyses suggested that medical recommendations play an important role in the dynamics of daily/near-daily use. at a minimum, these findings show the importance of multilevel investigations into daily/near-daily use, which may inform tailored or targeted substance use prevention initiatives. in our sample, most (71%) people with a medical recommendation used cannabis daily/near-daily, but only 9% of those without a medical recommendation used cannabis this way. given its sizable odds ratio and a p-value less than 0.10, it is possible that the association between cannabis dispensary clustering and daily/neardaily use is stronger for those with medical recommendations, but we were underpowered to detect this. we encourage future research that explores the dynamics of cannabis dispensary density, medical recommendations, and cannabis use patterns with larger sample sizes. to our knowledge, ours is one of the first studies to investigate whether urbanicity modifies the association between cannabis dispensary density and cannabis use. two differences emerged between urban and suburban/rural settings. first, dispensary availability was not associated with monthly cannabis use in suburban/rural areas even though this association existed in the full sample and urban areas. the count per buffer variable contained cannabis, a publication of the research society on marijuana 29 more zeroes in suburban/rural settings, as a result of dispensaries primarily opening in urban settings, particularly in the initial stages of the cannabis market. second, dispensary clustering was associated with monthly cannabis use in suburban/rural areas but not urban areas. as the levels of clustering are lower in suburban/rural settings, this could suggest a saturation model in which the initial levels of clustering may exert a larger effect on monthly cannabis use patterns. if this is the case, then policies and regulations that intentionally aim to more evenly distribute cannabis dispensaries in appropriately zoned areas may be an important tool in reducing and preventing daily/near-daily cannabis use. studies that associate dispensary density with consumption assume density affects cannabis purchases and, consequently, use. thus, cannabis dispensary density measures ought to capture dispensary attributes most relevant to customer purchasing behaviors. when asked to report the attributes relevant to purchase decisions, people ranked product quality, price, and strain availability as most important; on average, they ranked distance 11th (zhu et al., 2021). we also note that affordability (economic availability) is the fourth dimension of access as conceptualized by penchansky and thomas (penchansky & thomas, 1981). given the large literature on the role of price in cannabis purchasing behaviors (donnan et al., 2022) and the potential role of pricing reduction in cannabis dispensary clustering, research investigating potential additive effects of spatial and economic availability may be warranted. retail observations may also enhance density analyses by allowing researchers to investigate how dispensary density intersects with their characteristics in shaping purchasing behaviors. limitations the pooled surveys were cross-sectional, so our results should not be interpreted as causal. it is possible that cannabis dispensaries opened in places with higher demand/consumption. relatedly, unlicensed medical dispensaries operated in wa prior to legalizing adult nonmedical use. we were unable to adjust for exposure to medical cannabis prior to their incorporation into the formal, licensed cannabis market (washington state legislature, 2015). however, our cannabis dispensary density measures account for the influx of medical cannabis dispensaries when these two systems merged. in addition, our cannabis consumption data were self-reported, so they are limited by possible recall errors and underreporting due to social desirability bias. cannabis consumption patterns are also shaped by economic availability, and we did not have data on cannabis pricing by dispensary that would allow us to account for this. further, prices fell sharply as the wa market began to commercialize (smart et al., 2017). in july 2015, wa raised the retail cannabis excise taxes from 25% to 37%, while eliminating the 25% tax rates on producers and processers, reducing the overall tax burden substantially. these changes may have affected cannabis consumption patterns. finally, our data generalize to wa, but they may not be representative of other states with non-medical cannabis markets. conclusions adults who live in areas with higher cannabis dispensary density had higher odds of using cannabis monthly/bimonthly and daily/near-daily during the first three years of wa’s non-medical cannabis market. these results suggest that potential public health importance of regulatory agencies limiting the number of retail cannabis dispensaries in support of lower frequency of cannabis use. this may be achieved via the use of density thresholds or by establishing minimum distance requirements between dispensaries to prevent clusters from forming. references ambrose, c. a. 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(2016). trends in cannabis use disorders among racial/ethnic population groups in the united states. drug and alcohol dependence, 165, 181-190. https://doi.org/10.1016/jdrugalcdep.2016.06.0 02 young-wolff, k. c., adams, s. r., padon, a., silver, l. d., alexeeff, s. e., van den eeden, s. k., & avalos, l. a. (2021). association of cannabis retailer proximity and density with cannabis use among pregnant women in northern california after legalization of cannabis for recreational use. jama network open, 4(3), e210694-e210694. https://doi.org/10.1001/jamanetworkopen.202 1.0694 zhu, b., guo, h., cao, y., an, r., & shi, y. (2021). perceived importance of factors in cannabis purchase decisions: a best-worst scaling experiment. int j drug policy, 91, 102793. https://doi.org/10.1016/j.drugpo.2020.102793 funding and acknowledgements: this work was supported by the u.s. national institute on drug abuse (nida; r01 da048526, pi kerr). the content is solely the responsibility of the authors and does not necessarily represent the official views of nida or the national institutes of health, which played no role in data collection, data analysis, writing the manuscript or the decision to submit the manuscript for publication. the authors declare no conflicts of interest. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: trangenstein, p. j., greenfield, t. k., patternson, d. m., & kerr, w. c. (2025). measuring the association between cannabis dispensary density and adult consumption in a statewide setting: does urbanicity matter? cannabis, 8(2), 18 32. https://doi.org/10.26828/cannabis/2025/000235 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ microsoft word 2021 rsmj abstracts for publication final.docx special section conference abstracts 75 ssppeecciiaall sseeccttiioonn eeddiittoorr bbeennjjaammiinn oo.. llaadddd,, pphh..dd.. kkeeyynnoottee aaddddrreessss tthhee uunnppaarraalllleelleedd eevviillss ooff ccaannnnaabbiiss mitch earleywine university at albany, suny ppoosstteerr pprreesseennttaattiioonnss all poster presentations and symposia were peerreviewed by the 2021 conference program committee of the research society on marijuana (rsmj) (bradley t. conner, colorado state university, benjamin o. ladd, washington state university vancouver, kristina t. phillips, kaiser permanante, verlin joseph, university of new mexico). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. tthhee eeffffeeccttss ttaaiilloorreedd iinntteerrvveennttiioonnss oonn ccaannnnaabbiiss uussee mmoottiivveess alejandra contreras, bonnie leadbeater, sybil goulet-stock (university of victoria) background: the motives for cannabis affect on cannabis use and cannabis use consequences. coping with stress is among the frequent motives for cannabis use. however, non stressed youth may use cannabis for self-enhancing motives like boosting confidence. both motives are associated with higher frequency of cannabis use and more negative consequences (e.g., effects on schoolwork quality). interventions targeting these distinctive motives may need to be tailored to assist youth trying to reduce cannabis use. the purposes of this study were: to examine the effect of cannabis use interventions on the change in motives of use; and whether motives for use are associated with hours per week using cannabis. methods: participants were from a cross national study including us and canadian youth (n= 781). participants included in the current analysis were from two canadian universities (n = 397, 54% female, median age = 21) were randomized into either the cannabis echeckup to go or healthy stress management (hsm) intervention. both interventions were administrated online and assessed at baseline and at a 4to 6-week followup. eligible youth reported using cannabis more than once a week and wanted to reduce their cannabis use. the 19 items to the question “what do you like about cannabis” were used as an assessment of motives for use (e.g., i feel more courageous, i feel more confident, cannabis helps me reduce stress, cannabis helps me sleep). confirmatory factor analysis showed that a 2factor model of cannabis use motives (selfconfidence and stress-coping) fit the data adequately (cfi = 0.795, rmsea [90% ci] = .063 [.057, .069]) after removing 2 poorly fitting items. results: across conditions self-confidence motives (t1: echeckup condition m = 4.05(2.55), hsm condition m = 4.13(2.43); t2: echeckup condition m = 4.09(2.50), hsm condition m = 4.36(2.28)) were endorse less than stress-coping motives (t1: echeckup condition m = 6.48(1.92), hsm condition m = 6.25(1.78); t2: echeckup condition m = 6.20(1.99), hsm condition m = 6.32(1.96)). stress-coping motives were significantly correlated with the time spent high (hours a week) (t1 r= .21, t2: r=.26). a repeated measures manova showed a significant interaction between time and intervention condition for the stress-coping motives only (f(1)= 4.08, p = .04). participants in the healthy stress management condition reported a significant decrease in the amount of stress-coping motives at the follow-up. conclusions: these results demonstrate that motives of cannabis use can change over the course of a short online intervention for students seeking to reduce their use. in particular, the cannabis 2022, 5 (1), 75-112 © author(s) 2022 researchmj.org abstracts from the 2021 virtual scientific meeting of the research society on marijuana july 23rd, 2021 conference abstracts 76 healthy stress management condition helped participants reduce their stress-coping motives at t2. neither intervention affected self confidence motives in the short term. these may be harder to address and may fuel continued use over time, even for youth hoping to change. aassssoocciiaattiioonnss ooff ccaannnnaabbiiss uussee mmoottiivveess aanndd ccaannnnaabbiiss ddeemmaanndd iinn yyoouunngg aadduullttss michelle castro (university of florida) ricarda pritschmann, meredith berry (university of florida) richard yi (university of kansas) ali yurasek (university of florida) background: cannabis is the most commonly used illicit substance among young adults and is associated with a variety of negative consequences. studies have shown that both cannabis demand and certain cannabis motives are associated with higher levels and frequency of cannabis use, as well as associated problems. no study has yet to examine the relationship between cannabis use motives and cannabis demand. the purpose of the current study was to examine the associations between individual cannabis motives and cannabis demand. methods: data were collected from 95 young adult cannabis users who reported using cannabis at least once in the last 30 days. (m age = 20.63; female = 50.5%; m cannabis use days per month = 14.64). participants completed questionnaires assessing cannabis use frequency, cannabis use motives, and a cannabis purchase task. amplitude, representative of the amount consumed at an unrestricted price, and persistence, representative of sensitivity to escalating price, were calculated and used in the analyses. results: initial correlational analyses demonstrated significant relationships between demand and total number of cannabis motives and conformity, enjoyment, coping, experimentation, boredom, celebration, and sleep motives (ps < .05). a series of hierarchical linear regressions were conducted to determine the specific associations between the aforementioned individual cannabis motives and amplitude and persistence. step one controlled for age, gender, and cannabis use frequency, and the motives were added in step two. regression models indicated that total number of motives, enjoyment, conformity, and coping motives were significant predictors of persistence even after controlling for cannabis use frequency. motives were not significant predictors of amplitude. conclusion: findings from this study suggest that young adults who use cannabis for enjoyment, conformity, or coping reasons may experience greater reinforcement efficacy of cannabis which may place them at increased risk to develop cannabis use disorder or other related problems associated with their use. further, young adults with these cannabis use motives may be less sensitive to increases in price and continue to purchase cannabis at higher prices. these findings can be used to inform cannabis interventions by targeting specific motives for use. jjuusstt ssaayy nnoo:: tthhee rreellaattiioonnsshhiipp bbeettwweeeenn ccoonnffoorrmmiittyy mmoottiivveess,, rreeffuussaall sseellff--eeffffiiccaaccyy,, aanndd ccaannnnaabbiiss--rreellaatteedd ccoonnsseeqquueenncceess alyssa rice, gabrielle longo (university of houston) faith shank (rowan university) clayton neighbors (university of houston) cannabis use on college campuses is common, with more than half of students reporting use within the past year (schulenberg, et. al, 2020). additionally, a 2017 study found that approximately 90% of past-month cannabis users reported having experienced at least one negative consequence (pearson, liese, & dvorak, 2017). numerous studies have evaluated the association between conformity motives and cannabis-related consequences such as driving under the influence or poor academic performance (glodosky & cuttler, 2019; lee, neighbors, & woods, 2007). research suggests that while those users who endorse conformity motives generally report lower use and frequency (zvolensky et al., 2007), they may be at high risk of experiencing negative cannabis-related consequences (buckner, walukevich, & lewis, 2019). one construct that has been shown to predict lower cannabis-related problems in young adults is refusal self-efficacy (papinczak, connor, harnett, & gullo, 2018; hayaki et al., 2011). refusal self-efficacy in relation to cannabis use is one’s belief that they will be able to resist, refuse, or turn down cannabis when offered. as refusal self-efficacy is prominent in conformity-driven situations, it is conference abstracts 77 important to understand how refusal self-efficacy may mediate the relationship between conformity motives and cannabis-related consequences. as this relationship has not yet been tested we aim to examine this mediational relationship. we hypothesized that refusal self-efficacy mediates the relationship between motives and cannabis-related problems, such that refusal selfefficacy explains the preexisting relationship between conformity motives and problems related to cannabis use. participants included 567 undergraduate students (49.02% white, 77.21% female). cannabis use prevalence among the sample was 61.25% lifetime, 36.53% within the past 6 months, and 28.92% within the past 30 days. the relationship between conformity motives, refusal self-efficacy, and problems was examined using structural equation modeling in stata version 15.1. results found that the relationship between conformity motives and cannabis-related problems was partially mediated by cannabis refusal self-efficacy. the direct path from conformity motives to problems was significant and positive (b = .167, se = .063), indicating a competitive mediation (zhao, lynch, & chen, 2010). the standardized regression coefficient between conformity motives and refusal selfefficacy was statistically significant (b = -.337, se = .053), as was the standardized regression coefficient between refusal self-efficacy and cannabis-related problems (b = -.411, se = .06). we tested the significance of the indirect effect using bootstrapping procedures. unstandardized indirect effects were computed for each of the 5,000 bootstrapped samples. the bootstrapped unstandardized indirect effect was .357, and the 95% confidence interval ranged from .180, .533. thus, the indirect effect was statistically significant. this indicates that part of the reason that those with conformity motives have cannabis-related problems is due to their inability to refuse cannabis when offered. however, due to the fact that this was a partial mediation, there are other potential mediators to be accounted for, such as social anxiety (buckner & schmidt, 2008). eelluucciiddaattiinngg tthhee nnaattuurree ooff tthhee lliinnkkss bbeettwweeeenn ccaannnnaabbiiss uussee aanndd aatttteennttiioonn deficit/hyperactivity disorder amanda stueber, carrie cuttler (washington state university) many individuals with mental health disorders use cannabis to self-medicate for their symptoms. attention-deficit/hyperactivity disorder (adhd) is a neurological disorder associated with increased cannabis use but, relative to other mental disorders (e.g., anxiety, psychosis, posttraumatic stress disorder), far less attention has been paid to examining cannabis use by people with adhd. nevertheless, there is some limited evidence to suggest that people with adhd might use cannabis to self-medicate for their symptoms and that they perceive it to be beneficial for this purpose. the goal of this study was to better understand the nature of the relationships between cannabis use and a total of 1,382 undergraduate students completed an online survey measuring their adhd symptoms, and cannabis use patterns. participants who reported they have used cannabis to manage their adhd were further asked to report their perceptions of whether acute and/or chronic cannabis use improves, worsens, or has no effect on their adhd symptoms. participants who reported they have been prescribed adhd medication and use cannabis also reported their perception of how cannabis use affects the effectiveness of their medication, and adhd medication side effects. evidence from this study revealed that adhd symptom severity is associated with consuming cannabis more frequently and with more severe symptoms of cannabis use disorder. participants with adhd reported that cannabis has acute detrimental effects on memory but beneficial effects on many of their other core symptoms of adhd, including hyperactivity, impulsivity, restlessness, and mental frustration. while most participants on adhd medications reported that cannabis does not influence their medication effectiveness, they did report that cannabis helps with many of the side effects associated with their adhd medications including headaches, loss of appetite, sleep disturbances, moodiness/irritability, and anxiety. the knowledge gained from this study will help people with adhd and their healthcare providers by providing them with a better understanding of the use of cannabis by individuals with adhd including the possible risks and benefits of such use on cannabis use disorder, adhd symptoms, and medication side effects. conference abstracts 78 ssoolliittaarryy ccaannnnaabbiiss uussee dduurriinngg tthhee ccoovviidd--1199 ppaannddeemmiicc:: aassssoocciiaattiioonnss wwiitthh aaffffeecctt,, ssoocciiaall ffaaccttoorrss,, aanndd ppaannddeemmiicc--rreellaatteedd ssttrreessss amelia v. wedel, aesoon park (syracuse university) introduction: emerging evidence suggests that cannabis use has increased since the start of the covid-19 pandemic. many cannabis users report using at a greater frequency and attribute this change in part to a desire to cope with changes to mental health (e.g., depression, social anxiety) and stress associated with the pandemic. despite increases in social isolation due to quarantine and social-distancing requirements, little is known about how the social context of cannabis use (i.e., how much cannabis use is conducted with others vs. alone) may be associated with affective and social factors as well as cannabis-related consequences. this cross-sectional study explored associations of solitary cannabis use frequency with depression, social anxiety, loneliness, interpersonal sensitivity, pandemic-related stress, and cannabis use consequences. method: participants (n = 168; 53% female, mean age = 18.71 [sd = 0.99]; 67% white, 11% hispanic/latinx) were college students who reported lifetime cannabis use. participants completed a single-wave online survey assessing solitary and overall cannabis use frequency, depression, social anxiety, loneliness, interpersonal sensitivity, pandemic-related stress, and cannabis consequences. first, independent-samples t-tests and zero-inflated negative binomial regression were used to explore associations of at-least monthly solitary (vs. exclusively or majority social use) cannabis use with proposed correlates and cannabis use consequences, respectively. second, all affective factors were entered into a multinomial logistic regression predicting past-year (but no past-month) and pastmonth solitary cannabis use (with no past-year solitary use as reference). age and sex were controlled for given prior associations with solitary cannabis use and cannabis use consequences. results: compared to exclusively or predominantly social use, past-month solitary cannabis use was independently associated with greater depression (t[166]=2.49, cohen’s d=0.41), interpersonal sensitivity (t[166]=3.09, cohen’s d=0.51), pandemicrelated stress (t[166]=3.95, d=0.67), and cannabis use consequences (irr=2.28, <.001). results from the multinomial regression showed that male sex (or=3.48, p=.032) and greater pandemic-related stress (or=1.41, p=.001) were associated with higher odds of past-year solitary use, while male sex (or=2.98, p=.016), greater interpersonal sensitivity (or=1.12, p=.044), and greater pandemic stress (or=1.34, p<.001) was associated with higher odds of past-month solitary use. conclusion: findings expand upon pre-pandemic findings that solitary cannabis use is associated with social anxiety and cannabis use consequences, and further emphasize associations of frequent solitary cannabis use with greater cannabis consequences. findings further implicate interpersonal sensitivity and pandemicrelated stress as risk factors for higher frequency solitary cannabis use. taken together, findings suggest a) screening for solitary use may have utility for identifying higher-risk users among college students and b) individuals who use cannabis alone may benefit from treatment targeting concurrent issues with stress management and interpersonal sensitivity. mmaarriijjuuaannaa,, ssoocciiaall iissoollaattiioonn,, aanndd lloonneelliinneessss aammoonngg oollddeerr aadduullttss:: rreessuullttss ffrroomm tthhee 22001188 hheeaalltthh aanndd rreettiirreemmeenntt ssttuuddyy jie yang (eastern carolina university) andrew yockey (university of north texas health science center) introduction: marijuana is the most used substance across all age groups and as of recently, there has been a significant increase in use among older adults (i.e. individuals ages 65+). moreover, older adults also report higher levels of loneliness and social isolation, which are significant risk factors for initiation of marijuana use. however, these relationships have yet to be examined among older adults. the purpose of the present study was to examine whether social isolation and loneliness predicted marijuana use among a national sample of us older adults and examine differences in past-year use. methods: a secondary data analysis of the 2018 health and retirement study was conducted. the health and retirement study is a national study examining health, income, retirement, and other psychosocial variables. for the present study, we utilized the newest marijuana module. we created a loneliness scale (α = .88), social isolation scale conference abstracts 79 (α = .85), and assessed differences based on demographics and perceptions of marijuana. weighted logistic regression models were built to determine conditional associations to past-year marijuana use. the level of significance was set at p <.05. results: a total of 1,661 adults ages 65+ was the final analytic sample. nearly 1 in 10 (9.85%) adults reported past-year use of marijuana. neither loneliness (p = .43) or social isolation (p= .39) were significant predictors of marijuana use. adjusting for demographics, adults who reported past year drinking (aor: 7.84, 95% 2.13, 28.9) were more likely to report use. individuals who thought marijuana should be legalized for medicinal purposes were 44.6 times more likely to report past year use. discussion: to our knowledge, this is one of the first studies to examine loneliness, social isolation, and its association with past-year marijuana use among a large sample of older adults in the united states. findings from the present study can inform policy prevention efforts, address facets in healthy people 2030, and clinical interventions. aasssseessssmmeenntt ooff iimmppaaiirreedd ccoonnttrrooll oovveerr ccaannnnaabbiiss ccoonnssuummppttiioonn:: ppssyycchhoommeettrriicc pprrooppeerrttiieess ooff tthhee iimmppaaiirreedd ccoonnttrrooll ssccaallee--ccaannnnaabbiiss ((iiccss--cc)) korina kaye taguba, matthew t. keough (york university) adrian j. bravo (william & mary) jeffrey d. wardell (york university, university of toronto, and centre for addiction and mental health, toronto, canada) background: impaired control over substance use is a construct that is central to addiction and appears to play an early role in the development of addictive behaviors. the impaired control scale (ics) was developed to measure impaired control over alcohol, which has been associated with problem drinking and alcohol-related problems in young adults. however, there is relatively less research regarding impaired control over cannabis, and currently there is a lack of a comprehensive and valid scale that specifically measures this construct. this study addresses this gap in the literature by introducing the impaired control scale-cannabis (ics-c), an adaptation of the ics designed to measure impaired control over cannabis. we conducted a preliminary examination of the factor structure, reliability, and validity of the ics-c. methods: an online survey was administered to introductory psychology students (n=362; 63% women; 66% white, mean age=19.91) at two canadian universities who reported using cannabis at least once in the past month (average frequency = 9.34 days; sd = 9.60). all participants completed the ics and ics-c along with measures of cannabis use and problems, including the impaired control subscale of the marijuana consequences questionnaire (macq-ic). a subset of participants completed additional measures of impulsivity and self-regulation. results: an exploratory factor analysis (efa, with an oblique rotation) of the 25 items of the ics-c yielded 3 factors, one of which was comprised solely of reverse keyed items (despite reverse coding items prior to the efa). these items were trimmed from the measure and the efa was rerun. two factors emerged: attempted control (i.e., frequency of attempts to control cannabis use) and a factor comprised of items assessing both failed control (i.e., unsuccessful attempts in limiting cannabis use) and perceived control (i.e., beliefs about the ability to control cannabis use in the future). given that the failed and perceived control items unexpectedly loaded on the same factor, suggesting high redundancy in the concepts of failed and perceived control, the items assessing perceived control were dropped from subsequent analyses. the final solution consisted of two factors, attempted control (alpha=0.96) and failed control (alpha=0.88). high correlations between the macq-ic and icsc attempted control (r=0.42, p<.001) and failed control (r=0.67, p<.001) scales provided evidence for convergent validity. weaker correlations between ics (alcohol version) and ics-c attempted control (r=0.36, p<.001) and failed control (r=0.34, p<.001) scales supported discriminant validity. concurrent validity was demonstrated based on the moderate and statistically significant correlations of the ics-c failed control subscale and frequency of cannabis use (r=0.47, p<.001) and grams of cannabis used (r=0.44, p<.001). additional evidence for concurrent and discriminant validity were also found in the patterns of correlations between the conference abstracts 80 ics-c subscales and measures of impulsivity and self-regulation. conclusions: ics-c is a promising tool that can be used to assess impaired control over cannabis in young adults. future research should confirm the factor structure of the ics-c and examine its utility to screen for impaired control in the context of prevention and early intervention for cannabisrelated problems. uunnppllaannnneedd vvss.. ppllaannnneedd ssiimmuullttaanneeoouuss aallccoohhooll aanndd ccaannnnaabbiiss uussee iinn ddaaiillyy lliiffee:: wwhhaatt aarree tthhee mmoottiivveess,, ccoonntteexxttss,, aanndd oouuttccoommeess?? angela k. stevens, rachel l. gunn, holly k. boyle (center for alcohol and addiction studies, brown university school of public health) helene r. white (center of alcohol and substance studies, rutgers, the state university of new jersey) kristina m. jackson (center for alcohol and addiction studies, brown university school of public health) alcohol and cannabis are commonly used by u.s. college students and often used simultaneously (simultaneous alcohol and marijuana [sam] use). better understanding situations in which sam use is planned or unplanned and related consequences of these distinct sam use events will inform prevention and intervention efforts. we extended previous daily-level research by examining motives and contexts (social, physical) as indicators of unplanned vs. planned sam use occasions, as well as by parsing specific plans for alcohol use and for cannabis use on sam use occasions. specifically, we examined: unplanned alcohol and marijuana (uam) use, planned monosubstance (either alcohol or cannabis but not both) use (msu), and planned sam use. college student sam users (n=341; 53% women) were recruited from three u.s. universities and completed 56 days of data collection with five repeated surveys each day. most sam use occasions were planned (73% of occasions), followed by planned msu (18%), and by uam use (10%). two-level generalized linear mixed-effects models were conducted to account for nesting of occasions within persons and the three-category nominal outcome. all models included age, sex, recruitment site (school), weekend, and other drug use as covariates. at the within-person level, using for social or enhancement reasons was related to higher odds of planned sam use (vs. uam use). these reasons for use were also related to planned sam use when compared to planned msu, whereas using because it was offered or to cope was related to lower odds of planned sam use (vs. planned msu). using at home or alone was linked to lower odds of planned sam use (vs. uam use), and using at a party, friend’s place, with friends, with more intoxicated people, and with more people using cannabis was associated with higher odds of planned sam use. an identical pattern was found when comparing planned sam use to planned msu. when disaggregating “planned msu” into planned alcohol use-unplanned cannabis use vs. planned cannabis use-unplanned alcohol use, using for social or enhancement reasons was related to higher odds of planned alcohol-only use. likewise, using at a party, with friends, with strangers/acquaintances, with more intoxicated people, and with more people using cannabis were related to higher odds of planned alcohol-only use. using at home or alone was linked to lower odds of planned alcohol-only use. findings suggest that interventions should target days when college students are planning for sam use. mobile health interventions could also focus on higher risk motives (e.g., social) and contexts (e.g., party) that were indicators of planned sam use, as well as target individuals who endorse using substances to cope or because substances were offered, with these latter individuals being at risk for unplanned sam use when only msu was originally planned. specifically, ecological momentary interventions and just-in-time adaptive interventions could send protective behavioral strategies to individuals endorsing intentions for use and high-risk motives or contexts to reduce the heavy alcohol and cannabis consumption that was associated with planned sam use. ddiiffffeerreenncceess iinn mmaarriijjuuaannaa uussee,, ccoonnsseeqquueenncceess,, aanndd mmoottiivveess bbaasseedd oonn yyoouunngg aadduullttss’’ iinntteerreesstt iinn rreedduucciinngg tthheeiirr mmaarriijjuuaannaa uussee oorr ccoonnsseeqquueenncceess:: mmaayy 22002211 ddaattaa ffrroomm aa hhiigghh--rriisskk ccoommmmuunniittyy ssaammppllee anne m. fairlie, christine m. lee, mary e. larimer (university of washington) conference abstracts 81 purpose. this study contributes to our understanding of the factors associated with young adults’ interest in reducing their marijuana use or consequences during the covid-19 pandemic. this study compared high-risk young adults who indicated they were open to or thinking about changing their marijuana use to those who were satisfied with their marijuana use. these two groups were compared on biological sex, age, marijuana use, consequences, and 12 motives. method. the data were part of a larger longitudinal study that recruited a community sample of young adults from the seattle wa area (ages 18-25 at recruitment), who reported recent alcohol use and also simultaneous alcohol and marijuana use. participants were recruited through various methods including social media and craigslist advertisements. participants completed a baseline survey and six 2-week bursts of online daily surveys across two years as well as other follow-up surveys. data presented here were collected in may 2021, the final follow-up assessment point. may 2021 data were collected from 376 participants (92% of the original recruited sample), and the current analyses focus on the 265 participants who reported using marijuana in the past month (50.6% females, 48.68% non-hispanic/latinx white, mean age = 24.58 (sd = 2.20). results. over one-third (37.7%, n = 100) indicated they were open to changing or currently thinking about changing their marijuana use by using less or by reducing marijuana’s negative effects. almost two-thirds (60.4%, n = 160) indicated they were satisfied with their use of marijuana, 1.5% (n = 4) indicated they were currently seeking or in treatment for marijuana use, and 0.4% (n = 1) did not provide a response. more men (44.60%) than women (32.30%) indicated they were open to changing or currently thinking about changing their marijuana use by using less or by reducing marijuana’s negative effects. young adults who indicated they were open to or thinking about changing their use reported significantly more hours high in a typical week and more marijuana consequences than those who were satisfied with their use of marijuana. finally, young adults who indicated they were open to or thinking about changing their use reported significantly higher scores for the following seven marijuana motives: coping, boredom, altered perceptions, social anxiety, perceived low risk, sleep, and availability. no differences were found for five marijuana motives: enjoyment, conformity, experimentation, alcohol-related, and celebration. conclusions. findings underscore the potential role of negative consequences as a motivator for young adults’ interest in reducing their marijuana use. coping motives, social anxiety motives, and sleep motives may be of particular importance with respect to young adults’ self-motivation to change and facilitating the process of change. mmoobbiillee aapppp ddeetteeccttiioonn ooff tthhcc--rreellaatteedd ccooggnniittiivvee iimmppaaiirrmmeenntt iinn hheeaavvyy uusseerrss ari p. kirshenbaum (saint michael's college & driveabilityvt, llc) chris lewis (driveabilityvt, llc) andy kaplan (university of vermont, college of medicine, driveabilityvt, llc) the degree to which frequent users of cannabis experience cognitive impairment from acute selfadministration has been questioned on the basis of behavioral tolerance to thc. "indicator" is a downloadable mobile software app that assesses cognitive, perceptual, and motor skills using a variety of brief videogames. in the course of one month (april 2021), the app was used by 199 adult users who self-identified as either use cannabis "frequently" or "continuously." sixty-one of these heavy users played at least two of the videogames available in the app while sober, and this was on the first occasion of using the app. ninety-six used the app while intoxicated by cannabis, and also on their first instance of using the app. independentsamples t-test was performed to compare soberversus-intoxicated performance on each of two separate videogames, and these videogames specifically assessed (a) time perception and (b) reaction speed and accuracy. clear evidence of cannabis-related impairment was evident for both videogames (p < 0.05) for this heavy-using population. this evidence suggests that neurocognitive performance-related deficits are apparent in a population of users who are wellaccustomed to the psychopharmacological influence of thc. aanneeccddootteess uusshheerreedd iinn mmaarriijjuuaannaa lleeggaalliizzaattiioonn:: aa mmaacchhiinnee lleeaarrnniinngg--aaiiddeedd bbiigg ddaattaa aannaallyyssiiss ooff rreeddddiitt ddiissccoouurrssee ((22000088--22001199)) conference abstracts 82 babak hemmatian, aryan srivastava, nathaniel goodman, jonathan lee, carsten eickhoff, steven a. sloman (brown university) at least two fundamental types of evidence feature in attempts to persuade: anecdotal and generalized (baesler & burgoon, 1994). experimental research has found anecdotal evidence more effective at changing attitudes in issues marked by personal significance and health-relevance (freling et al., 2020). these apply to marijuana legalization, where a massive shift in american attitudes (from 35% to 67% in favor during 2008-2019; pew research center, 2019) was followed by rapid legalization. however, no research to date has examined whether the movement benefited from anecdotal framing. since the attitude shift coincided with the rise of social media, we developed the largest corpus of marijuana legalization discussions from reddit to address this gap (more than 3m comments from 2008-2019, comprising more than 300m words). the dataset is the first to separate marijuana legalization discourse from general mentions of cannabis (e.g., product advertisements) across an entire popular platform. we then developed neural network models to distinguish anecdotal from generalized text in the dataset based on three clause-level features derived from linguistic theory: whether a clause is about a generic kind rather than specific instances, whether it presents a reliable state or an event, and whether events are bounded in time. principal components analysis provided a reliable composite score of the three features, treated as a measure of the degree to which major themes of discourse are anecdotal versus generalized. we combined topic modeling (latent dirichlet allocation; blei et al., 2003) with hierarchical clustering and smoothed polynomial regressions to track themes’ prominence over time and bin them into broader categories. anecdotal themes were less prevalent but present in most comments. we trained separate neural networks on human annotations of attitude and persuasion attempt. within non-argumentative discourse, anecdotes became more prominent only later in time, presumably as a consequence of softening societal attitudes. but they played a more prominent role throughout in arguments favoring legalization, suggesting that they were actively used to persuade others. were such anecdotal arguments timed in a way that benefitted legalization ballot initiatives? to answer, we inferred user locations and compared the rate of anecdotal themes before and after legalization in comments from pioneering states. despite the experimental evidence favoring anecdotal argumentation, we found that the 2012 and 2016 legal milestones followed shortterm increases in generalized arguments instead. the particular content, however, varied between the two periods. character judgments were prominent in 2012, while crime and politics took center-stage in 2016. the generalized precedents of legalization in leading states were argumentative and moralistic but had distinctive clause-level profiles. meanwhile, legal and medical arguments were sidelined, meaning the novel consensus was not informed by much of the relevant information, anecdotal or otherwise. together, our results show that while the emerging consensus probably benefited from anecdotal argumentation, the legalization movement’s success happened despite its reliance on less effective generalized discussions with less concrete information content. addressing this discrepancy between experimental research and the direction of societal discourse may help bring about more informed discussions while better enabling the changing of attitudes. iinniittiiaall vvaalliiddaattiioonn ooff aa bbrriieeff aasssseessssmmeenntt ooff ccaannnnaabbiiss ddeemmaanndd aammoonngg yyoouunngg aadduulltt ccoolllleeggee ssttuuddeennttss benjamin l. berey, elizabeth r. aston (brown university) ricarda k. pritschman (university of florida) cara m. murphy (brown university) ali m. yurasek (university of florida) behavioral economic models of addiction posit that cannabis’s reinforcing value (demand) is linked to use. the marijuana purchase task (mpt; aston et al., 2015) quantifies demand by assessing hypothetical cannabis consumption across escalating price points. indices generated from mpt performance include intensity (i.e., amount consumed when free), omax (i.e., peak expenditure), pmax (i.e., price at peak conference abstracts 83 expenditure), elasticity (i.e., degree that consumption decreases as price increases), and breakpoint (i.e., cost suppressing consumption to zero). cannabis demand is linked to engagement in risky behaviors and cannabis use disorder (cud) symptomology. however, the length of the mpt makes repeated assessment of statedependent changes in cannabis demand difficult, which limits clinical utility. brief assessments of alcohol and cigarette demand exist that measure intensity, omax, and breakpoint. thus, the aim of the current study was to develop and validate a brief assessment of cannabis demand. college students (n=211, mage=19.91, sd=1.44; 63% female; 56.4% non-hispanic caucasian) who reported past-month cannabis use ≥3 times completed an online survey. participants completed the mpt, a 3-item brief assessment of marijuana demand (bamd) assessing intensity, omax, and breakpoint, and measures of demographics, cannabis use frequency, cannabisrelated negative consequences, cud symptomology based on dsm-5 criteria, and cannabis craving. convergent validity was examined via bivariate correlations of demand indices on the bamd, mpt, and cannabis outcome measures. divergent validity was assessed via independent samples t-tests to examine whether demand indices on the bamd differed based on the presentation or absence of cud. a one-way between-subjects anova with planned comparisons was tested to compare effects of cud severity (mild/moderate/severe) on bamd demand indices. intensity, omax, and breakpoint were significantly correlated across the mpt and bamd (rs=.30 – .79, ps<.01). intensity, omax, and breakpoint on the mpt and bamd were significantly correlated with current cannabis craving, cud severity, and cannabis-related negative consequences (rs=.18 – .48, ps<.05). only intensity and omax were significantly correlated with cannabis use (rs=.16 – .43, ps<.01). individuals with (versus without) a cud reported significantly greater intensity and omax (ps< .01), but not breakpoint, on the mpt and bamd. there were significant effects of cud severity on b-mpt demand indices (ps<.05). planned comparisons revealed that individuals with a moderate or severe cud had significantly elevated intensity, omax, and breakpoint on the bamd compared to individuals with a mild cud. only breakpoint differentiated individuals with a moderate and severe cud. this is the first study to validate a brief assessment of cannabis demand. consistent with prior alcohol and tobacco research, the bamd espoused convergent validity with the mpt and divergent validity by differentiating individuals with and without a cud and along the cud severity continuum. thus, the bamd may be a useful tool to assess links between specific indices of cannabis demand and clinically-relevant outcomes over time and in real-world settings. however, given the rise in novel cannabis products with different modes of administration and varying potencies, future research should examine whether demand differs based on these factors. further, replicating these findings among more diverse populations is essential. ddeevveellooppmmeenntt aanndd iinniittiiaall vvaalliiddaattiioonn ooff mmaarriijjuuaannaa iiddeennttiittyy iimmpplliicciitt aassssoocciiaattiioonnss tteessttss aammoonngg llaattee aaddoolleesscceennttss iinn wwaasshhiinnggttoonn ssttaattee jason j. ramirez, christine m. lee, elliot c. wallace, kristen p. lindgren (university of washington) the current climate surrounding adolescent marijuana use in the u.s. is facing unprecedented circumstances. rates of daily use are at or near all-time highs and perceptions of risk are at an alltime low in the history of the monitoring the future study among 8th, 10th, and 12th graders. these rates are occurring despite research demonstrating worse long-term health outcomes associated with earlier age of marijuana use onset and increasing thc levels among marijuana products. as a result, there is an urgent need to identify risk factors that may represent screening markers of risk or targets for prevention and intervention among adolescents. one important risk factor for alcohol and tobacco is the extent to which one identifies with each substance. this aspect of identity can be measured with adaptations of the implicit association test (iat), a reaction time measure that aims to assess associations held in memory between constructs (e.g., marijuana and one’s self-concept). the aim of the current study was to develop and test two marijuana identity iats among late adolescents in washington state, one using images and another using words to represent marijuana and its control category. the current study included conference abstracts 84 169 adolescents between the ages of 15-18 (mean age = 16.9, sd age = 0.9, 50% female, 66% high school student) with recruitment stratified by marijuana use (to include participants that range from non-users to heavy users) and gender. data described here come from the online baseline assessment that included the marijuana identity iats and self-report measures of marijuana use, consequences, and explicit (i.e., self-reported) marijuana identification. results from the iats reveal two normal distributions of iat scores that were both positive on average indicating faster reaction times when marijuana was categorized with the self (and a neutral category categorized with other people). split-half reliabilities of the iats revealed internal consistencies in the range of previous substance-related iats (word-based iat, r = 0.52; imaged-based iat, r = 0.40). in negative binomial regression models that controlled for age and sex, both iats were significantly associated with use and consequences such that faster reaction times categorizing marijuana with the self were associated with more marijuana use and consequences (ps< .01). when controlling for selfreported identification marijuana, only the imagebased iat was significantly associated with marijuana use and consequences (ps< .05). the findings demonstrate relationships between iat performance and marijuana use outcomes that compare favorably to past marijuana-related iats lending support to implicit associations between the marijuana and the self as an important marker of marijuana use behaviors. despite this promise, the relative inferiority of the internal consistency of these iats to self-report measures may limit their utility as tools for screening. future experimental and longitudinal research is warranted however, to examine identification with marijuana as a causal candidate for marijuana misuse to examine its potential as a prevention and intervention target. pprreevvaalleennccee aanndd ccoorrrreellaatteess ooff ccaannnnaabbiiss uussee aanndd ccoo--uussee iinn cciiggaarreettttee ssmmookkeerrss aanndd nnoonn--ssmmookkeerrss:: aann eemmeerrggeennccyy ddeeppaarrttmmeenntt ssttuuddyy carol b. cunradi, raul caetano, william ponicki (pacific institute for research and evaluation) harrison alter (alameda health system) background: compared to the general household population, elevated rates of cannabis and cigarette smoking are found among adults seeking medical care at urban safety-net hospital emergency departments (ed). the goal of this study is to assess the prevalence and identify the demographic and psychosocial correlates of cannabis use with and without cigarette co-use in comparison to non-cannabis/tobacco users in an urban ed population. methods: secondary analysis was conducted on cross-sectional data collected in 2017 for a study on intimate partner violence, drinking and drug use among married/partnered adults ages 18-50 who were english or spanish speakers seeking non-acute care at an urban ed (n=1,037; 53% female). face-to-face survey interviews were conducted after obtaining informed consent from participants. we measured past 12-month cannabis use and past 30-day cigarette smoking. data were collected on demographic (age, gender, level of education, race/ethnicity) and mental health factors (anxiety, depression, ptsd, past 12-month risky drinking [females/males drank 4+/5+ drinks]). study participants were categorized as tobacco users without cannabis use (13.5%); cannabis users without tobacco use (13.8%); cannabis users with tobacco use (13.3%); and those who used neither substance (59.5%). we conducted chi-square analysis to examine the relationship between demographic and psychosocial factors and cannabis/tobacco co-use status, and multinomial logistic regression to estimate the factors associated with each type of cannabis/tobacco co-use category relative to nonusers. results: approximately half of cannabis users smoked cigarettes. compared to women, men had greater odds of smoking cigarettes without cannabis (aor=3.26; 95% ci 2.12, 5.00), using cannabis without cigarettes (aor=2.38; 95% ci 1.54, 3.69), or being a cannabis/tobacco co-user (aor=3.72; 95% ci 2.30, 6.02). latinx participants were less likely to smoke cigarettes without cannabis (aor=0.24; 95% ci 0.10, 0.56), use cannabis without cigarettes (aor=0.18; 95% ci 0.08, 0.42), or co-use cannabis/tobacco (aor=0.05; 95% ci 0.02, 0.11) than white participants. participant age was inversely associated with using cannabis without cigarettes (aor=0.93; 95% ci 0.91, 0.96) and being a cannabis/tobacco co-user (aor=0.95; 95% ci 0.93, conference abstracts 85 0.98). regarding psychosocial factors, those who screened positively for anxiety had greater odds for using cannabis without cigarettes (aor=1.93; 95% ci 1.20, 3.10) and being a cannabis/tobacco co-user (aor=3.40; 95% ci 2.04, 5.66) compared to those who screened negatively. those who screened positively for ptsd had elevated odds for using cannabis without cigarettes (aor=1.65; 95% 1.00, 2.75) compared to those who screened negatively. those who had engaged in risky drinking had greater odds of smoking cigarettes without cannabis (aor=2.27; 95% ci 1.47, 3.48), using cannabis without cigarettes (aor=2.54; 95% ci 1.61, 4.02), or being a cannabis/tobacco couser (aor=4.34; 95% ci 2.71, 6.97) compared to those who had not engaged in this behavior. conclusions: over one quarter of an urban ed sample used cannabis either with or without cigarettes. the results suggest that there are distinct demographic and mental health risk and protective factors associated with cannabis use and co-use in cigarette smokers and non-smokers. cannabis users who smoke cigarettes may be especially vulnerable to mental health problems. rreeaassoonnss ffoorr iinnddiivviidduuaall aanndd ccoonnccuurrrreenntt uussee ooff vvaappeedd nniiccoottiinnee aanndd ccaannnnaabbiiss:: tthheeiirr ssiimmiillaarriittiieess,, ddiiffffeerreenncceess,, aanndd aassssoocciiaattiioonn wwiitthh pprroodduucctt uussee danielle m. smith (university at buffalo; roswell park comprehensive cancer center) lynn kozlowski (university at buffalo) richard j. o'connor, andrew hyland, maciej goniewicz (roswell park comprehensive cancer center) r. lorraine collins (university at buffalo) background: understanding similarities, differences, and associations between reasons people use vaped nicotine and cannabis may be important for identifying underlying contributors to co-use. methods: a cross-sectional survey of n=112 cousers of vaped nicotine and cannabis was conducted in 2020. participants reported on their use of nicotine and cannabis products (vaped and smoked), along with reasons for individual product use, nicotine-cannabis co-use, and engagement with sequential use and coadministration. results: cannabis vaping and smoking exhibited similar ratings for user experience and product/substance-related reasons for use. reasons related to product utility were similar for cannabis vaping and nicotine vaping. ratings for utility-related reasons for use were significantly higher for cannabis vaping than cannabis smoking (mean (sd):3.6(±1.0) vs. 2.6(±1.2), difference=0.98, t=7.84, p<0.0001). harm reduction-related reasons for use were rated higher for nicotine vaping than cannabis vaping (2.4(±1.6) vs. 1.8(±1.4), difference=0.65, t=4.24, p<0.0001). regression models showed higher ratings for utility-related and harm reductionrelated reasons for nicotine vaping were significantly associated with more frequent nicotine vaping (both p<0.05). greater endorsement of instrumentality-related reasons for co-use corresponded with more frequent monthly nicotine vaping and a three-fold increase in odds of ever chasing cannabis with nicotine. conclusions: vaping serves purposes that differ by substance; nicotine vaping was more closely related to reducing tobacco smoking-related harms, and cannabis vaping was more closely related to circumventing social problems posed by cannabis smoking. lifetime sequential co-use practices and more frequent nicotine vaping were associated with enhancing the intoxicating effects of cannabis. findings have implications for understanding nicotine and cannabis co-use. aassssoocciiaattiioonnss bbeettwweeeenn uussee ppaatttteerrnnss ffoorr iinnhhaalleedd nniiccoottiinnee aanndd ccaannnnaabbiiss pprroodduuccttss aammoonngg aadduullttss wwhhoo vvaappee bbootthh ssuubbssttaanncceess danielle m. smith (university at buffalo; roswell park comprehensive cancer center) lynn kozlowski (university at buffalo) richard j. o'connor, andrew hyland, maciej goniewicz (roswell park comprehensive cancer center) r. lorraine collins (university at buffalo) background: co-occurring use (co-use) of nicotine and cannabis is common, and represents a broad range of use behaviors, including concurrent use, sequential use, and co-administration. co-use has primarily been examined through the lens of smoked tobacco and cannabis. little is known conference abstracts 86 about those who co-use vaped nicotine and cannabis, and the degree to which specific co-use behaviors are associated, based on mode of use and/or substance. methods: we conducted an online pilot survey on use behaviors related to inhaled forms of nicotine and cannabis. the survey was administered to 112 concurrent vapers of these substances. descriptive analyses examined sample characteristics and co-administered vaping and smoking behaviors. logistic regressions examined associations in use behaviors by mode and substance. results: participants who vaped nicotine and cannabis monthly also reported monthly smoking of cannabis (100%), and cigarettes (58%). most exhibited moderate-to-high degrees of mental health and substance use problems. monthly concurrent use exhibited weaker associations by mode, and stronger associations by substance. specific sequential use practices showed modespecific associations; with greater frequency of cigarette smoking and nicotine vaping. coadministration was associated with more frequent tobacco and cannabis smoking. conclusions: those who regularly vape nicotine and cannabis tend to engage in some form of smoking. different subsets of nicotine and cannabis co-use behaviors showed different associations with patterns of use and modes of drug delivery. findings underscore the diversity of nicotine and cannabis use behaviors among cousers, and the importance of considering influences by both substance and mode of use. tthhee rreellaattiioonnsshhiipp bbeettwweeeenn aannxxiieettyy ssttaattuuss aanndd ccaannnnaabbiiss uussee aammoonngg ooeeff//ooiiff vveetteerraannss:: ssoommaattiizzaattiioonn aass aa mmooddeerraattoorr denise d. tran, jennifer wang, reagan e. fitzke, jordan p. davis, eric r. pedersen (university of southern california) american veterans are vulnerable to high rates of anxiety and substance use. notably, veterans with mental health challenges report higher rates of cannabis use than those without mental health concerns. in the general population, anxiety often overlaps with a variety of somatic symptoms. however, less is known regarding the effects of both anxiety and somatization on cannabis use behaviors in veterans. online surveys were completed by 1006 veterans (mage=34.74, 75.1% male) with a three-month follow-up. negative binomial regression was used to test whether baseline somatization moderated the relationship between baseline anxiety and frequency of past 30-day cannabis use three months later at followup. compared to those who screened negative, those who screened positive for anxiety reported greater past 30-day cannabis use rates at followup (irr=6.74; 95% ci [4.68, 9.71]). higher levels of somatization also predicted greater past 30-day cannabis use rates (irr=1.30; 95% ci [1.24, 1.36]). somatization moderated the relationship between anxiety and past 30-day cannabis use frequency. at both low and high levels of somatization, those who screened positive for anxiety reported greater cannabis use days compared to those who screened negative for anxiety. however, among those who screened negative for a probable anxiety disorder, an increase in somatization is associated with an increase in past 30-day cannabis use frequency. findings suggest that those who screen positive for anxiety and those who screen negative for anxiety, but endorse high levels of somatization, may likely benefit most from cannabis use prevention and/or intervention. sseellff--ddeetteerrmmiinnaattiioonn tthheeoorryy ccoorrrreellaatteess ooff ccaannnnaabbiiss-rreellaatteedd oouuttccoommeess aammoonngg aa llaarrggee,, mmuullttii--ssiittee ssaammppllee ooff ccoolllleeggee ssttuuddeenntt dylan k. richards, jude g. chavez, matthew r. pearson (university of new mexico) craig a. field (university of texas at el paso) addiction research team (university of new mexico) background: self-determination theory (sdt) is a general theory of human motivation that has been applied to understand why people engage in healthy behaviors. that is, more autonomous reasons for engaging in healthy behaviors is associated with an increased likelihood of initiating and maintaining healthy behaviors. recent research has shown that this framework is useful for understanding engagement in harm reduction behaviors for alcohol among college students. it stands to reason that this framework may be equally useful for cannabis with the potential to inform intervention efforts for reducing harms associated with unhealthy conference abstracts 87 cannabis use. in the present study, we examined autonomous functioning and psychological need satisfaction per sdt as correlates of cannabisrelated outcomes among a large, multi-site sample of college students who use cannabis. method: participants were 5497 students recruited from psychology department participant pools at 10 universities in 8 states across the u.s (ak, ca, co, id nm, tx, va, wa) who completed an online survey for partial course credit. we restricted analyses to those who reported consuming cannabis at least once in the past month (n=1398, about one-fourth of the total sample). the analytic sample was 20.25 years of age on average (sd=3.88) and mostly female (68.9%) and non-hispanic white (59.4%). participants completed measures assessing the three facets of autonomous functioning (authorship, interest-taking, and susceptibility to control) and satisfaction and frustration of the psychological needs for autonomy, competence, and relatedness, as well as a variety of measures assessing cannabis-related outcomes, including severity of use (i.e., cannabis use disorder identification test [cudit]), negative consequences (i.e., marijuana consequences questionnaire [macq]), and harm reduction behaviors (i.e., protective behavioral strategies for marijuana [pbsm]). results: consistent with hypotheses, overall autonomous functioning was positively correlated with pbsm (r=.179, p<.001) and negatively correlated with cudit (r=-.160, p<.001) and macq (r=-.092, p=.017). separating autonomous functioning by subscale (i.e., domain), the correlations were largest in magnitude for the authorship domain (r=.250, r=-.240, and r=-.168, respectively, p<.001). also consistent with hypotheses, greater satisfaction of each psychological need was positively correlated with pbsm (.149<rs<.203, ps<.001) and negatively correlated with cudit (-.146<rs<-.120, ps<.01) and macq (-.171<r<-.132, ps<.01); generally, these correlations were largest in magnitude for relatedness satisfaction. in contrast, greater frustration of each psychological need was negatively correlated with pbsm (-.144<rs<-.121, ps<.001) and positively correlated with cudit (.199<rs<.229, ps<.001) and macq (.133<rs<.215, ps<.01); the correlations were largest in magnitude for relatedness frustration with pbsm and competence frustration with cudit and macq. conclusions: the present study is the first to demonstrate that higher autonomous functioning and greater psychological need satisfaction are protective factors for cannabis-related outcomes, including less consumption, fewer negative consequences, and more frequent use of harm reduction behaviors. sdt provides a rich framework for understanding not only why college students may engage in healthy cannabis-related behaviors, but also the conditions that foster that engagement, making it an ideal theory to inform cannabis interventions. the present findings warrant replication but suggest promise for sdt as a framework for understanding cannabisrelated outcomes that future research should investigate further. eeaarrllyy bbiirrddss aanndd nniigghhtt oowwllss:: ddiissttiinngguuiisshhiinngg pprrooffiilleess ooff ccaannnnaabbiiss uussee hhaabbiittss bbyy uussee ttiimmeess wwiitthh llaatteenntt ccllaassss aannaallyyssiiss eleftherios hetelekides (william and mary) verlin joseph (university of new mexico) adrian j. bravo (william and mary) mark a. prince, bradley t. conner (colorado state university) matthew r. pearson (university of new mexico) negative consequences associated with excessive use of cannabis are well documented. previous findings indicate timing of use is an important factor when assessing severity of dependence for use of substances including alcohol and cigarettes. however, little attention in the academic literature has been paid to timing of cannabis use and its associations with negative consequences. the present study employed a latent class analysis on data collected from college students who use cannabis, located across four u.s. universities in four different states (n = 1,122). the goal was to examine whether distinct classifications of cannabis use exist based on timing (i.e., hour of day and day of week), and whether these classifications differ on cannabis use indicators (marijuana use grid; mug), cannabis-related negative consequences (marijuana consequences questionnaire; conference abstracts 88 macq), and cannabis use disorder symptoms (cannabis use disorder identification testrevised; cudit-r). the mug assesses the amount (in grams) of cannabis used during a week of typical marijuana use in the past 30 days on each of the seven days per week (monday-sunday) during each of six 4-hour time periods (12a-4a, 4a8a, 8a-12p, 12p-4p, 4p-8p, 8p-12p). by summing across time periods for each day, we binarized the presence of cannabis use (0 = no use, 1 = use) for each day of the week. by summing across days for each time period, we binarized the presence of cannabis use for each time period. based on the lo-mendell-rubin likelihood ratio test (lrt) and other fit indices, we found support for a 4class solution with high classification precision (relative entropy = .905). the four classes were characterized as follows: (1) daily (greater than 98% of the class endorsed use on each day of the week), common morning use (n = 140.17, 12.5%), (2) daily (greater than 88% of the class endorsed use each day of the week), uncommon morning use (n = 241.02, 21.5%), (3) weekend, common morning use (n = 72.22, 6.4%), and (4) weekend, uncommon morning use (n = 668.59, 59.6%). individuals reporting daily, common morning use experienced the highest cannabis-related negative consequences (macq m = 7.53) and reported the highest levels of cannabis use disorder symptoms (cudit-r m = 15.74), whereas individuals reporting weekend, uncommon morning use experienced few cannabis-related negative consequences (macq m = 2.24)) and reported low cannabis use disorder symptoms (cudit-r m = 5.45). taken together, our classes were defined by crossing the presence/absence of morning cannabis use by the presence/absence of weekday cannabis use, and we found evidence that both the timing of week and timing of day contribute to the level of cannabis-related harms that individuals experience. additional research is needed to explore the unique contributions of time of week and time of day while controlling for other characteristics of one’s cannabis use (i.e., frequency, quantity, product type, route of administration, etc.). ccaannnnaabbiiss ddeemmaanndd aanndd uussee aammoonngg vveetteerraannss:: aa pprroossppeeccttiivvee eexxaammiinnaattiioonn elizabeth r. aston (brown university) lidia z. meshesha (university of central florida) angela k. stevens (brown university) brian borsari (university of california, san francisco) jane metrik (brown university) background: cannabis demand (i.e., relative value), assessed cross-sectionally via a hypothetical marijuana purchase task (mpt), has been associated with cannabis use, problems, and dependence symptoms, among others. however, neither the prospective stability of the mpt, nor the cyclical relationship between demand and use over time has been investigated. moreover, cannabis demand among cannabis using veterans has yet to be examined. method: two waves of data from a veteran sample (n=133) reporting current (past 6-month) cannabis use were analyzed to assess stability and change in cannabis demand over six months. autoregressive cross-lagged panel models assessed the longitudinal associations between demand indices (i.e., intensity, omax, pmax, breakpoint) and cannabis use. results: models revealed unique directions of effects for each demand index. baseline cannabis use predicted greater intensity (ß = .32, p<.001), omax (ß = .37, p<.001), breakpoint (ß = .28, p<.001), and pmax (ß = .21, p = .017) at 6-months. conversely, baseline intensity (ß = .14, p=.028), breakpoint (ß = .12, p=.038), and pmax (ß = .12, p = .043), but not omax, predicted greater use at 6-months. discussion: cannabis demand indices demonstrated prospective stability over six months and varied along with natural changes in cannabis use. importantly, intensity, pmax, and breakpoint displayed bidirectional predictive associations with cannabis use, and across indices, the prospective pathway from use to demand was consistently stronger. findings highlight the value of assessing cannabis demand longitudinally, particularly among clinical samples, to determine how demand fluctuates in response to experimental manipulation, intervention, and treatment. tthhee rreellaattiioonnsshhiipp bbeettwweeeenn mmeennttaall hheeaalltthh ssyymmppttoommss aanndd mmaarriijjuuaannaa ccoonnsseeqquueenncceess mmeeddiiaatteedd bbyy ccooppiinngg mmoottiivveess ffoorr mmaarriijjuuaannaa uussee elliot c. wallace, tessa frohe, jason j. ramirez (university of washington) conference abstracts 89 as marijuana continues to be legalized across the united states, it is imperative to investigate risk factors and consequences related to use. previous studies among adult samples have found that mental health symptoms, including both depression and anxiety symptoms, are significant predictors of increased frequency of marijuana use. little is known however regarding mental health symptoms and marijuana use among adolescents. this risk is particularly salient for adolescents given that many mental health disorders, like depression and anxiety, begin to emerge during this developmental period, and because earlier of age of marijuana use onset is associated with worse prospective health outcomes. further, coping motives for marijuana use (i.e., using marijuana as an external avoidance or escape-based strategy) may serve as a mechanism for some adolescents to avoid distressing anxiety and depressive states. to address this gap in research, the aims of the current analysis were to 1) examine associations between mental health symptoms, marijuana use, and consequences among adolescents, and 2) examine coping motives as a mediator between mental health symptoms and marijuana outcomes. the current study included 107 late adolescents (15-18 years old, mage = 17.01, sdage = 0.92, 51% female, 85% white/caucasian, 60% high school student, 27% college student) recruited from washington state. the sample was stratified by gender and marijuana use such that participants ranged from reporting infrequent to daily marijuana use. participants were asked to complete three online assessments across six months. these included the phq-4, a 4-item measure of depression and anxiety symptoms in the past 2 weeks, in addition to measures of marijuana use, marijuana-related consequences, and marijuana use motives. we conducted two separate mediator models to examine if baseline mental health symptoms were mediated by coping motives at month 3 on (1) marijuana use and (2) marijuana-related consequences both reported at month 6. there was no significant mediation effect for baseline mental health symptoms predicting overall marijuana use at month 6 (b = .27, se = .25, 95% ci [-.23, .76], p = .28). for the second model, motives at month 3 fully mediated the relationship between mental health symptoms at baseline and marijuana-related consequences at month 6 (b = .71, se = .27, 95% ci [.17, 1.24], p ≤ .01). thus, higher levels of mental health symptoms at baseline were associated with higher marijuana-related consequences as mediated by coping motives reported at month 3. our results suggest that adolescents who experience more mental health symptoms do not use marijuana more than others who report fewer symptoms. however, these individuals may be at greater risk for experiencing negative consequences that result from their use. further, results also suggest that the relationship between mental health symptoms and negative consequences may be largely accounted for by stronger motives to use marijuana to cope with mental health. screening for mental health symptoms during adolescence may be beneficial in preventing negative outcomes by providing early interventions for healthy coping strategies for anxiety and depression. hheeaalltthh wwaarrnniinnggss oonn ccaannnnaabbiiss ddiissppeennssaarryy wweebbssiitteess gabrielle longo (university of houston) frida de luna (university of houston clear lake) mahnoor ahmad (university of houston) cannabis users are increasingly turning towards the internet for information about cannabis, especially medicinal patients, who generally have low to moderate knowledge of important aspects of cannabis like medicinal effectiveness. potential for misuse of cannabis is much higher when there is a lack of accurate information (kruger et al., 2020). overuse of cannabis can be associated with discontinued enrollment in school, trouble dealing with anxiety and stress, and an increased risk of schizotypy (blavos et al., 2017). cannabinoid exposure during pregnancy has been shown to have negative effects on the fetal immune system (dong et al., 2019), is associated with low birth weight, stunted development (gusstafson & jacobsson, 2019), and cognitive impairment (grant et al., 2018). cannabis dispensary employees have been found to make health suggestions without proper qualifications (dickson 2018), and advertising on dispensary websites often suggests strains for specific medical conditions, despite the lack of conference abstracts 90 empirical evidence supporting these claims (kruger et al., 2020; luc 2020). this increasing medicalization of cannabis by those unqualified to do so is concerning in such a fast-growing field. the present study assesses the presence of health warnings on cannabis dispensary websites, specifically (a) the presence of facts or warnings about potential psychological consequences (e.g., paranoia, increased vulnerability to psychosis), (b) facts or warnings about use in pregnant women, and (c) general dosage warnings. dispensaries were selected at random in all states that have legal cannabis. 15 dispensaries were selected from each state. if the state had less than 15, all dispensaries in the state were included in coding, for a total of 389 dispensary websites. dispensaries were identified via informal cannabis websites like leafly.com and potguides.com, as the purpose of the study was to identify dispensary websites that the average person would find when searching the internet. previous studies have utilized state agency lists and informal lists (cavazos-rehg et al., 2019). three trained research assistants coded each website for the relevant information. 30% of websites coded had psychological consequence warnings (n = 111), 21.53% had gynecological health warnings, and 45.65% had general use warnings. three separate logistic regression analyses were performed with the three types of health warnings as the binary outcome variable (the information is either present = 1, or not present = 0) and legality status as the predictor. legality status had no impact on the presence of psychological consequence information (or = .737, se = .174, p = .196) or general dosage information (or = .786, se = .479, p = .279), but legality did have a significant influence on the presence of gynecological consequences (or = .499, se = .129, p = .007), indicating that when cannabis was recreationally legal, the state was less likely to have information about gynecological health consequences on their dispensary websites. this is troubling, because cannabis is much more easily accessible in states with recreational legalization than medicinal, and the consequences of cannabis use during pregnancy can be severe. ttrreennddss iinn ccaannnnaabbiiss uussee aammoonngg uuss aadduullttss aammiidd tthhee ccoovviidd--1199 ppaannddeemmiicc savannah g. brenneke, courtney d. nordeck, kira e. riehm, ian schmid, kayla n. tormohlen, emily j. smail, renee m. johnson, luther g. kalb, elizabeth a. stuart, johannes thrul (johns hopkins university bloomberg school of public health) background: the covid-19 pandemic has had an impact on mental health and alcohol use in the us, however there is little research on its impacts on cannabis use. considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. therefore, this study examined changes in self-reported cannabis use among us adults in the context of covid-19 pandemic by (1) describing trends of use during the first 8 months of the pandemic among adults who used cannabis in this period; and (2) characterizing trajectories of use within sociodemographic subgroups and by state cannabis policy status. methods and findings: the sample consisted of 1,761 us adults who used cannabis at least once during the 8 month study period from the nationally representative understanding america study. linear mixed-effect models were used to model changes in the number of days of past-week cannabis use across 16 waves from march 10, 2020, to november 11, 2020. compared to early march, the number of days cannabis was used per week was significantly higher at the start of april (β=0.11, 95% ci=0.03, 0.18) and may (β=0.21,95% ci=0.05, 0.36). in subsequent months (june november), the number of days of cannabis use returned to levels comparable to early march. trajectories of cannabis use across the study period generally did not differ across sociodemographic groups. conclusions: in the us, adults who used cannabis reported statistically significant increases in cannabis use days at the start of the pandemic (april may 2020), compared to march 2020, in the overall sample and among several sociodemographic groups. in summer and fall 2020, cannabis use days attenuated to levels comparable to march. though increases in use were marginal among many groups, the evolving pandemic and the growing concern for the mental health of segments of the u.s. population warrant close monitoring of coping behaviors, including substance use. conference abstracts 91 ppaarreennttaall rreejjeeccttiioonn,, ccaannnnaabbiiss ccrraavviinngg,, aanndd aallccoohhooll ccrraavviinngg aammoonngg sseexxuuaall mmiinnoorriittyy yyoouutthh jamie e. parnes (brown university) ethan h. mereish (american university) samuel n. meisel, hayley treloar padovano, robert miranda, jr. (brown university) parental rejection is associated with poor mental health and addiction liability outcomes for sexual minority youth (smy; e.g., lesbian, gay, bisexual). theoretical models purport that smy who experience greater parental rejection and nonacceptance related to their sexual orientation may have greater risk for substance use, including cannabis and alcohol use. cross-sectional and longitudinal studies provide initial support for this contention by showing that smy who perceive heterosexist rejection from their parents have greater substance use as young adults. however, research has yet to examine whether experiencing greater parental rejection is associated with drug craving as an adolescent. understanding the impact of parental rejection at this level may be of particular importance, as sexual minority young adults report greater alcohol craving in response to heterosexist stigma, above and beyond general negative mood. since adolescent cannabis and alcohol use are influenced by contextual factors (e.g., availability), craving has been examined as a salient proxy for substance use in this population. this study leveraged data collected from ecological momentary assessment (ema) to examine how varying levels of heterosexist parental rejection may influence in-the-moment levels of cannabis and alcohol craving. smy who used nicotine were recruited for an ema study. participants completed a baseline survey measuring lifetime parent rejection experiences (m = 0.34, sd = 0.33) and a timeline followback of past-month substance use. next, participants completed a 30-day ema period where they responded to approximately 5 random prompts per day measuring current level of cannabis and alcohol craving (range 0 to 10). the analytic sample included a subset of smy who reported baseline cannabis (n = 37) or alcohol (n = 32) use. craving was dichotomized to either no craving (0) or any craving (1). multilevel logistic regression was conducted using n = 2,885 observations to examine the associations between baseline parental rejection and momentary substance craving, controlling for baseline substance use frequency, weekday versus weekend, time of day, age, and presence of peers. results indicated that greater baseline parental rejection was associated with greater odds of reporting momentary cannabis craving (b = 1.71, p = .05, or = 5.51) and alcohol craving (b = 2.53, p = .035, or = 12.55) in the natural environment. findings underscore the influence of parental rejection on adolescent substance craving. smy who experience greater parental rejection likely perceive having less supportive parental relationships. consistent with the minority stress model, smy may be more likely to experience identity-related distress (e.g., heterosexist parental rejection) and, in turn, may use cannabis and alcohol to cope. this may explain why parental rejection experiences were related to greater day-to-day substance cravings. clinical implications support the importance of providing family interventions to reduce parental rejection for smy, as these may result in a myriad of benefits, possibly including reduced substance use craving. future research should examine how lifetime versus recent parental rejection experiences may influence smy substance craving. ddiissttrreessss ttoolleerraannccee aanndd hhaazzaarrddoouuss ccaannnnaabbiiss uussee:: ddooeess tthhee ffoorrmm ooff ccaannnnaabbiiss mmaatttteerr?? melissa sotelo, anita cservenka (oregon state university) objectives. among cannabis users, low distress tolerance may result in greater vulnerability for hazardous cannabis use and cannabis use disorder. although this relationship has been reported in the past, the role of primary form of cannabis used has not been examined as a moderator of this association. while marijuana flower remains the preferred form of cannabis used, there has been an increasing popularity of other forms of cannabis, including concentrates and edibles. the aim of the current study was to examine the association between distress tolerance and hazardous cannabis use, as well as to determine whether the primary form of cannabis used would have a moderating effect on this relationship. conference abstracts 92 methods. participants completed a survey on cannabis use, including questionnaires on distress tolerance and hazardous cannabis use. 695 (67.60% male) past-month cannabis users were included in the current analyses. multiple linear regressions were used to assess whether distress tolerance, primary form of cannabis used, and their interaction were associated with hazardous cannabis use, while controlling for covariates such as demographic variables and past 30-day alcohol and cannabis use frequency. results. there was a significant regression equation (f(13, 681) = 33.31, p < .001, r2 = 0.39) that included a main effect for distress tolerance (b = 0.64, p < 0.001), indicating that lower tolerance for distress was significantly related to hazardous cannabis use. there was also a main effect for primary form of cannabis used, where preference for using concentrates compared to marijuana flower was associated with hazardous cannabis use (b = 1.38, p = 0.006), preference for using marijuana flower compared to edibles was associated with hazardous cannabis use (b = -4.39, p < 0.001), and preference for using concentrates compared to edibles was associated with hazardous cannabis use (b = -5.76, p < 0.001). furthermore, the primary form of cannabis used significantly moderated the relationship between distress tolerance and hazardous cannabis use (f(2, 681) = 3.77, p = 0.024, r2 change = 0.01). specifically, the relationship between low distress tolerance and more hazardous cannabis use was moderated by preference for marijuana flower (b = 0.64, p < 0.001) and concentrates (b = 0.69, p < 0.001), but was not moderated by preference for using edibles as the primary form of cannabis (b = 0.18, p = 0.25). conclusions. by determining which particular cannabis users have the strongest relationship between lower tolerance for distress and hazardous cannabis use, these findings can help inform interventions geared towards aiding individuals to better tolerate stressful situations so as to minimize their hazardous cannabis use. iissrraaeell:: tthhee llaanndd ooff mmiillkk,, hhoonneeyy aanndd ccaannnnaabbiiss stacy shoshan (israel ministry of health, association for public health, tel aviv university) iris levy, paola rosca (israeli ministry of health) cannabis use in israel has escalated exponentially leading to paralleled increases in psychiatric disorders and admissions to residential drug treatment facilities. our data from the israeli ministry of health department for the treatment of substance abuse shows that mental and behavioral disorders due to cannabis use have gone up 825% between 2010 and 2019. also in 2019, amongst drug and alcohol residential treatment centers, where polysubstance use has become the norm, cannabis was reported as the primary substance leading to treatment admission. 52% of those admitted to treatment listed cannabis as their drug of choice, with a huge gap between cannabis and alcohol in second place at 21%. these statistics are particularly concerning since cannabis is currently available not only in the black market and online in israel, but also as "medical cannabis." the most alarming issue is that israel will most likely become the 3rd nation in the world to officially legalize cannabis within the next year. mmaarriijjuuaannaa uussee aammoonngg ppeerrssoonnss lliivviinngg wwiitthh cchhrroonniicc ppaaiinn:: aa qquuaalliittaattiivvee ssttuuddyy verlin joseph (university of new mexico) deepthi varma, xinguang chen, roger b fillingim, diana j wilkie, robert cook (university of florida) chronic pain is presently the most expensive disease condition in the united states; with roughly 1 in 5 americans currently reporting chronic pain. traditionally, clinicians and patients have utilized prescription medications to manage chronic pain, however, attitudes towards standardized prescription treatment have waned due to a number of factors including the recent opioid epidemic. consequently, attitudes towards marijuana use as an alternative pain therapy have continued to grow with 36 states approving use for medical purposes. clinical trials have reported lower pain severity scores among participants receiving marijuana for pain compared to participants in the control arms. however, little is known regarding the psychological/physiological mechanisms by which marijuana provides relief for chronic pain. research is also needed to identify how current marijuana users developed optimal patterns (i.e. dose, frequency, and quantity) of use for chronic conference abstracts 93 pain. we sought to address these scientific gaps by conducting semi-structured interviews among community members. participants (n=13) were eligible for participation if they reported having any pain during the previous 3 months and if they reported past 30-day marijuana use. the interviews lasted approximately 60 minutes following a semi-structured interview guide over zoom telecommunications. each interview was subsequently transcribed and then analyzed using atlas t.i. a summary of each code was developed and key themes regarding marijuana use and pain were summarized. multiple themes emerged including mechanism of pain relief (physical, mental, or both), patterns of marijuana use for pain relief, other benefits of marijuana use, comparisons to prescription drug use, descriptions of pain, and side effects of marijuana use. our analysis identified several themes that add to the growing literature concerning marijuana use for chronic pain. these qualitative data indicate current marijuana users’ favorable opinions towards using marijuana as an alternative pain therapy. as legislation legalizing marijuana use for medicinal purposes continues to expand, qualitative studies are needed to examine the extent to which marijuana use is effective in managing pain. eeffffoorrtt--bbaasseedd ddeecciissiioonn mmaakkiinngg aanndd sseellff--rreeppoorrtteedd aappaatthhyy iinn ffrreeqquueenntt ccaannnnaabbiiss uusseerrss aanndd hheeaalltthhyy ccoonnttrroollss kimberly c. vele, jessica m. cavalli, anita cservenka (oregon state university) background: cannabis use rates have been escalating in recent years within the united states, and the effects of cannabis on motivation and effort-based decision making have been of increased interest. amotivational syndrome is a term used to refer to lack of motivation, passive personality, non-productive behavior, and lower educational attainment related to chronic cannabis use. however, past literature has reported mixed findings for the effects of cannabis on motivation across both behavioral and selfreport studies; therefore, the current study aimed to evaluate the association between frequent cannabis use, motivated behavior, and selfreported apathy in individuals 18 years and older. methods: cannabis users who reported, on average, 3 or more days/week of cannabis use over the past year, and healthy controls who reported once/month or less cannabis use over the past year were recruited. participants withheld from substance use 12 hours prior to the study visit. they completed a breathalyzer test, urine toxicology screen, the apathy evaluation scale (aes), and the effort expenditure for rewards task (eefrt), a computerized button-pressing task that measures effort-based decision making whereby individuals must increase effort for monetary reward. there were no significant differences between groups on any demographic characteristics except for past 30-day alcohol use (p = 0.001), and depression scores (p = 0.005; determined by the beck depression inventory-ii), which were both greater in cannabis users relative to healthy controls. a repeated measures analysis of covariance (ancova) was used to examine the effects of group, reward magnitude, probability, and their interaction on hard task selections on the eefrt, controlling for alcohol and depressive symptoms. a separate ancova examined between-group differences on the aes with the same covariates. results: the main results indicated that relative to healthy controls, cannabis users were significantly more likely to select hard tasks on the eefrt regardless of reward magnitude or probability of winning the reward (p = 0.014, partial η2=0.10). self-reported apathy was higher in cannabis users relative to controls (p = 0.02), but after controlling for alcohol use and depressive symptoms, these group differences were no longer significant (p = 0.46). furthermore, the number of hard task selections on the eefrt was not significantly related to selfreported apathy in cannabis users (p = 0.68), or healthy controls (p = 0.52). conclusions: these findings indicate that cannabis users exhibit a greater likelihood of exerting more effort for reward, suggesting enhanced motivation relative to healthy controls. thus, the current results do not support the amotivation hypothesis in adult frequent cannabis users. despite some harms of frequent cannabis use, amotivation may not be among them. conference abstracts 94 ddiiffffeerreennttiiaall eeffffeeccttss ooff uurrggeennccyy aanndd sseennssaattiioonn sseeeekkiinngg oonn ccaannnnaabbiiss uussee aanndd rreellaatteedd pprroobblleemmss vviiaa mmoottiivveess caitlin a. falco, alison looby (university of wyoming) the stimulant norms and prevalence study team a reliable predictor of substance use is impulsivity, a multidimensional construct in which specific facets demonstrate differential associations with aspects of substance use. though research has delineated the association between substance use and impulsivity generally, work examining facets and their relation to cannabis use specifically is more limited. additionally, motivational models of substance use suggest that an individual’s reasons for use are the most proximal predictors of substance use, serving as a mediating mechanism by which other variables operate to influence use and related behaviors. to obtain a more comprehensive understanding of the mechanisms underlying cannabis use, the current study assessed the relation between three facets of impulsivity that have demonstrated compelling associations with cannabis (i.e., positive urgency, negative urgency; and sensation seeking) and their association with frequency of cannabis use and related consequences via motives. college students (n = 652, mage = 19.59, 72.2% female) from seven universities that reported past-month cannabis use completed an online survey assessing frequency of past-month cannabis use, number of related problems, facets of impulsivity, and cannabis use motives. a bootstrapped path analysis was conducted, in which negative urgency, positive urgency, and sensation seeking were modeled as simultaneous predictors of pastmonth cannabis-related problems via parallel mediators of enjoyment, coping, and social anxiety motives, and via past-month days of cannabis use. positive and negative urgency were significant mediators in the same pathways: 1) social anxiety motives positively mediated the association between urgency and frequency of past-month cannabis use (negative urgency: β=0.37, 95% ci [0.046, 0.86]; positive urgency: β=0.87, 95% ci [0.44, 1.43]); 2) coping motives positively mediated the association between urgency and cannabisrelated problems (negative urgency: β=0.47, 95% ci [0.28, 0.71]; positive urgency: β=0.31, 95% ci [0.11, 0.55]; and 3) a serial mediation effect such that urgency was positively associated with anxiety motives, which in turn were associated with higher frequency of past-month use, which was associated with greater cannabis-related problems (negative urgency: β=0.05, 95% ci [0.01, 0.12]; positive urgency: β=0.12, 95% ci [0.06, 0.21]). further, two indirect effects were found for sensation seeking: 1) enjoyment motives positively mediated the association between sensation seeking and frequency of past-month use (β=0.23, 95% ci [0.40, 0.53]); and 2) a serial mediation effect such that sensation seeking was positively associated with enjoyment motives, which in turn were associated with higher frequency of past-month use, which in turn was associated with greater cannabis-related problems (β=0.03, 95% ci [0.005, 0.01]). results appear to suggest that individuals high in urgency using to avoid or cope with negative affect or social anxiety and individuals high in sensation seeking endorsing use to feel good or enhance mood may be at greater risk of cannabis-related problems, providing evidence that cannabis use a means of improving emotional experience may not be an adequate emotion regulation strategy. ddoo ccoonnssuummeerrss sseeeekk oouutt tteerrppeenneess iinn tthheeiirr vvaappiinngg pprroodduuccttss?? ffiinnddiinnggss ffrroomm aa ppiilloott ssttuuddyy ooff ccoonnccuurrrreenntt vvaappeerrss ooff nniiccoottiinnee aanndd ccaannnnaabbiiss danielle m. smith (university at buffalo; roswell park comprehensive cancer center) r. lorraine collins, lynn kozlowski (university at buffalo) richard j. o'connor, andrew hyland, maciej goniewicz (roswell park comprehensive cancer center) background: terpenes are aromatic compounds found in nicotine and cannabis vaping products. terpenes are promoted by the cannabis industry as having beneficial health effects, yet the evidence on this topic is still evolving. we examined whether vapers consider terpenes as a factor in their cannabis purchasing decisions, and their awareness of terpenes in their vaping products. methods: we used amazon mechanical turk to administer a survey on nicotine and cannabis use to 112 concurrent vapers of both substances, who resided in legal cannabis policy environments. conference abstracts 95 participants were asked to select from a list of 14 non-mutually exclusive factors that influence their cannabis purchases, including terpene content. those who endorsed terpenes as a factor in their cannabis purchases were asked to identify specific terpenes they sought. a subset of vapers who used cannabis e-liquids (n = 86) were asked to identify ingredients present in their products from a list of six pre-specified constituents, including terpenes. responses were assessed using descriptive statistics. results: the top five factors influencing cannabis purchasing decisions were thc content (83%), price (79%), smell/taste (59%), availability (58%), and strain (47%); terpene content ranked 11th (13%) out of the list of 14 purchase-related factors. among those who sought out terpenes (n = 13), most reported seeking products containing limonene (67%), terpinolene (40%), myrcene (40%), and linalool (33%). terpenes were the most frequently reported individual e-liquid constituent among participants who vaped cannabis oils in an e-cigarette, with nearly onequarter (24%) of participants selecting this option. conclusions: in this sample of co-users, most vaping consumers did not cite terpenes as a major factor in their cannabis purchases. among the few who did, limonene was the most commonly sought after terpene, which is also present in many nicotine containing e-liquids. nearly one-quarter of those vaping cannabis oils reported awareness of terpenes as a constituent in their vaping product. findings support monitoring consumer awareness of terpene-containing products as well as any increases in use as the cannabis vaping market evolves. sseexx mmooddeerraatteess aassssoocciiaattiioonnss bbeettwweeeenn ddiimmeennssiioonnss ooff eemmoottiioonn ddyyssrreegguullaattiioonn aanndd pprroobblleemmaattiicc ccaannnnaabbiiss uussee jessica m. cavalli, anita cservenka (oregon state university) background. research consistently finds that male cannabis users report greater problematic cannabis use (i.e., negative outcomes related to one’s cannabis use), compared to female cannabis users. further, emotion dysregulation is a transdiagnostic risk factor for substance use and addiction and is associated with greater problematic cannabis use. therefore, the current study examined whether sex moderates associations between emotion dysregulation (overall and dimensions of emotion dysregulation) and problematic cannabis use. methods. 741 adults reporting past-month cannabis use (31.44% female) completed an online anonymous survey, including questions on demographics, substance use, problematic cannabis use (via the marijuana problem scale) and emotion dysregulation (via the difficulties in emotion regulation scale). independent samples t-tests and hierarchical multiple linear regressions were performed. results. male cannabis users reported significantly higher scores on overall emotion dysregulation and five of six dimensions (nonacceptance, impulse, awareness, strategies, and clarity) compared to female cannabis users. further, sex moderated associations between emotion dysregulation (overall, nonacceptance, goals, impulse, awareness, and strategies) and problematic cannabis use. overall, nonacceptance, goals, impulse, and strategies were positively associated with problematic cannabis use, and these relationships were stronger in male cannabis users. lack of emotional awareness was negatively associated with problematic cannabis use in male cannabis users and no relationship was found for female cannabis users. conclusions. overall, these results denote the importance of examining individual differences in emotion dysregulation as they relate to problematic cannabis use. interventions and treatments may need to be tailored for male cannabis users with a focus on specific emotion dysregulation dimensions. pprroodduucctt tteexxtt llaabbeellss iinnddiiccaattee tthhee pprreesseennccee ooff ootthheerr pphhaarrmmaaccoollooggiiccaallllyy aaccttiivvee iinnggrreeddiieennttss iinn mmaannyy oottcc hheemmpp- aanndd ccbbdd--ccoonnttaaiinniinngg pprreeppaarraattiioonnss jasan khangura, melanie flores (oregon state university and oregon health science university college of pharmacy) dr. jane ishmael (oregon state university college of pharmacy) introduction: the 2018 farm bill changed the legal status of cannabis plants that meet the definition of industrial hemp and allowed for the rapid expansion of hemp-based products into commercial spaces. with an emphasis on industrial hemp as the source of naturallyconference abstracts 96 occurring cannabinoid compounds, a niche market for cannabidiol (cbd)-containing products was quickly established in pharmacies and grocery stores. although the u.s. food and drug administration (fda) has retained oversight of all cannabis-based products, labelling of hempderived products for retail markets remains largely unregulated. under federal law, cbd cannot be added to foods, beverages, sold as a dietary supplement or marketed for a therapeutic benefit, however the perceived health benefits of cbd as an acceptable and safe ingredient contribute to the growing market for these health products. objective: the objective of this study was to evaluate the range of over-the-counter (otc) hempand cbd-based products available to consumers and determine the prevalence of other pharmacologically active agents identified as ingredients in these products. labels were scored for the presence of: active and inactive ingredients, percent cbd, full-spectrum hemp, full-spectrum cbd or cbd isolate. methods: two large pharmacy chains and one medium-sized grocery store located in the pacific northwest were surveyed between may 2020 and february 2021 and otc hemp-derived products on display were recorded. identification of pharmacologically active ingredients on the product label was validated using the national medicines comprehensive database. products that were noted to have cbd or hemp ingredients were included in the study, while any products that did not accurately report the amount of cbd in the product were excluded. products that did not list the total weight of the product were excluded from the analysis. results: thirty-three unique products were recorded from 19 different manufacturers. 39% of product labels indicated the presence of fullspectrum hemp as part of the base product, while 66% of products listed hemp extract as the base product. text labels on cbd-containing products, on average, indicated more than 3 additional pharmacologically active ingredients were contained in each product. topical cbd products were more likely to have other ingredients such as arnica montana, menthol and camphor, whereas products for oral ingestion were more likely to have only cbd as the primary active ingredient. text labels on 52% of topical cbd products listed the presence of 10% menthol. average concentrations of cbd in otc products was found to be 1.12% ± 1.48 %, based on dry weight. conclusion: product text labels on otc hemp-and cbd-containing preparations is varied and presented in a non-standardized format. topical cbd products were more likely to contain other pharmacologically active natural products that can be used for the treatment of pain symptoms. concentrations of arnica montana, menthol and camphor were as much as 10-fold higher than the proportion of cbd contained in these products. the absence of a standard format for labelling of otc hempand cbd-derived products and the frequent presence of other active ingredients has the potential to create confusion and risk for the consumer. yyoouunngg aadduullttss’’ ppeerrcceeppttiioonnss ooff ccaannnnaabbiiss rriisskkss,, bbeenneeffiittss,, aanndd qquuaalliittyy ooff lliiffee bbyy cchhrroonniicc ppaaiinn ssttaattuuss bethany shorey-fennell, renee e. magnan, benjamin o. ladd, jessica l. fales (washington state university vancouver) many young adults experience chronic pain and may be more likely to self-medicate with cannabis. the present study examined perceptions of personal risks and benefits of cannabis use among young adult users, assessed if these perceptions varied by chronic pain status, and identified relationships among perceived risks and benefits, health-related quality of life, and cannabisrelated problems. young adult regular cannabis users (n=176), half of whom met criteria for chronic pain, reported their perceptions of lifetime risks and benefits associated with cannabis use, as well as their physical and mental healthrelated quality of life and cannabis-related problems. overall, participants perceived low risk associated with their cannabis use and moderate benefits. perceived risks and benefits of cannabis use were associated with mental, but not physical health-related quality of life. only perceived risk was associated with cannabis-related problems. cannabis use, problems, risks, and benefits did not differ by chronic pain status. as expected, young adults without chronic pain reported better physical and mental health-related quality of life than those with chronic pain. finally, chronic pain status moderated the relationships between perceived benefits and physical health-related quality of life and cannabis problems. the current study offers insight into the role of perceived risks conference abstracts 97 and benefits in young adults’ cannabis use and associations with physical and mental health outcomes. the effects of perceived benefits on physical health-related quality of life and cannabis-related problems may be conditional based on chronic pain status. future research should further explore the relationship of perceived benefits of cannabis use on health outcomes and cannabis-related problems. uunnwwiittttiinngg aadduulltt mmaarriijjuuaannaa ppooiissoonniinngg:: aa ccaassee sseerriieess andy t. hsueh, kelly k. fong (loma linda university school of medicine) kayla kendrics (loma linda university) nadia siddiqi (nova southwestern university college of osteopathic medicine) tammy phan, ellen reibling, brian wolk (loma linda university) study purpose: with increasing state legalization, marijuana use has become commonplace throughout much of the united states. this has resulted in expected and potentially dangerous consequences. existing literature on unintentional exposure focuses primarily on the pediatric population. despite mounting cases of unintentional exposure to marijuana, minimal research has been published on the effects of nonconsensual marijuana consumption in adults. here, we report on a cluster of adults with unwitting marijuana exposure. methods: a cluster of patients who presented to the emergency department (ed) within one hour of ingesting marijuana-contaminated food at a wedding reception event were subsequently referred to the medical toxicology service. we conducted a retrospective analysis of twelve subject charts who were exposed to the marijuana-contaminated food and a qualitative analysis of six of the 12 subjects’ experiences who willingly consented to be interviewed. the interviews were then analyzed and coded to categorize common themes within the subjects’ experiences. themes categorically selected throughout the interview analysis included “thoughts & feelings” and “effect on work.” the study was approved by the institutional review board. results: three of the subjects (25%) required prolonged observation due to persistent symptoms of acute marijuana intoxication. eleven (92%) were urine immunoassay positive for tetrahydrocannabinol (thc). two subjects (17%) tested positive for ethanol in their blood. none of the subjects reported a prior history of marijuana use. common symptoms experienced by the subjects included confusion (50%), difficulty speaking (67%), nausea (25%), tremors (17%), and feelings of unreality (33%). all interviewed subjects reported sleepiness and three (50%) reported a negative impact on work. subjects also reported multiple emotions, including anger, confusion, disbelief, and helplessness. none of the cases resulted in admission to the intensive care unit or death. conclusions: our case series illuminates the effects of unwitting and/or unintentional marijuana exposure in adults, with sufficient systemic effects resulting in individuals seeking emergency care. legal and ethical barriers have limited the study of marijuana outside of controlled conditions. while the exposure in this study did not result in admission to the icu or death, it did result in psychological distress and reported symptoms lasting weeks after the incident. as marijuana becomes readily available, the potential as an unwitting or even malicious intoxicant may increase. ddiiffffeerreenncceess iinn mmaarriijjuuaannaa mmoottiivvaattiioonnss,, uussee,, aanndd ccoonnsseeqquueenncceess aammoonngg 22- aanndd 44--yyeeaarr ccoolllleeggee ssttuuddeennttss jennifer c. duckworth, abigail c. stites (washington state university) christine m. lee (university of washington) purpose: as marijuana laws in the u.s. have become more liberal, marijuana use among college students has increased (schulenberg et al., 2020). while nearly 40% of college students in the u.s. attend 2-year institutions, little is known about marijuana use and risk factors for use among 2year students relative to 4-year students. collegeaged adults that use marijuana report many motivations for use (e.g., enhancement, conformity, coping motives) which are related to both the frequency of use and the likelihood of experiencing related consequences (lee et al., 2009). this study examines differences in conference abstracts 98 marijuana motivations, use, and consequences between 2and 4year college students and tests whether college status moderates associations between marijuana motives and marijuana outcomes. method: participants included a sample of 1402 undergraduate students (35% 2-year; 59% female) aged 18-25 (m=20.53, sd=1.72) who completed a screening survey for a longitudinal study examining alcohol expectancies and use. participants reported past-month motives for marijuana use, number of occasions of past-month and past-year marijuana use, and two marijuanarelated consequences (i.e., number of times they drove to/from campus high and/or attended class high). independent sample t-tests were conducted to assess mean differences between 2and 4-year students in marijuana use and consequences, and also motives for use, including social, enhancement, conformity, coping, and boredom motives. controlling for gender, age, college status, and academic quarter, poisson regression analyses were conducted to examine associations between marijuana motives and use and negative binomial regression analyses were conducted to examine links between marijuana motives and consequences. subsidiary analyses examined if links between marijuana motives and outcomes were moderated by college status. results: on average, participants reported using marijuana 6-9 times in the past month (sd=1.79) and 10-19 times in the past year (sd=1.61). over 15% (n=213) reported they had driven to/from campus high at least once and 40% (n=565) reported they had attended class high. relative to 4-year students, 2-year students reported greater past-month and past-year marijuana use, and were more likely to have driven to/from campus high and to have attended class high (ps<.05). two-year students reported greater coping motives but decreased social and conformity motives compared to 4-year students (ps<.05). in regression analyses controlling for co-variates, enhancement, boredom, and coping motives were associated with increased past-month and pastyear marijuana use, whereas social and conformity motives were associated with decreased past-month and past-year use (ps<.05). coping and boredom motives were positively associated with driving to/from campus high and coping and enhancement motives were positively associated with attending class high (ps<.05). in tests of moderation, associations between coping, boredom, and conformity motives and driving to/from campus high were more pronounced for 2year relative to 4-year students. conclusions: two-year students endorsed marijuana motives differently than 4-year students and reported greater marijuana use and marijuana-related consequences. two-year status moderated associations between motives and driving to or from campus high and 2-year students were more likely than 4-year students to endorse coping motives for using marijuana. as such, marijuana and mental health interventions targeting 2-year college students are needed. ppaatttteerrnnss ooff eexxppeeccttaanncciieess hheelldd aammoonngg ssiimmuullttaanneeoouuss aallccoohhooll aanndd mmaarriijjuuaannaa ((ssaamm)) uusseerrss katherine a. berry, caitlin a. falco stimulant norms and prevalence (snap) study team alison looby (university of wyoming) simultaneous alcohol and marijuana (sam) use (i.e., using the two substances during the same period of time so that their effects overlap) is common among young adults. sam use tends to be associated with greater negative consequences compared to the use of only one drug. thus, understanding factors that may influence sam use is necessary to inform interventions and limit harm. substance use expectancies (i.e., beliefs regarding the anticipated positive and negative outcomes of engaging in a substance) are a strong predictor of alcohol and marijuana consumption and consequences, and may similarly explain sam use. positive expectancies (i.e., wanted outcomes, such as sociability) tend to predict the frequency of both alcohol and marijuana use, while negative expectancies (i.e., unwanted outcomes, such as cognitive and behavioral impairment) have been found to predict abstinence and a lower likelihood of use. yet, alcohol and marijuana expectancies have not been sufficiently examined as related to sam use. to address this gap in the literature, the present study examined 1012 college students (70.9% female, 51.8% white, mage = 19.63) from seven us universities who reported past-month alcohol and marijuana use (77.2% of the sample reported sam use). participants completed expectancy conference abstracts 99 measures for alcohol (7 factors) and marijuana (6 factors), and past-month sam frequency. collapsing individual expectancy factors into positive and negative expectancies by drug, a hierarchical multiple regression revealed that positive expectancies (f(2,1005) = 6.11, p = .002), but not negative expectancies (f(2,1003) = 0.04, p = .96), were significant predictors of sam frequency above and beyond quantity and frequency of alcohol and marijuana use. specifically, higher frequency of sam use was associated with weaker positive alcohol (β = -0.08, p = .038) and stronger positive marijuana expectancies (β = 0.11, p = .003). a second hierarchical multiple regression examined which specific alcohol and marijuana expectancy factors accounted for these effects. after accounting for use variables, sam frequency was associated with weaker social alcohol expectancies (β = -0.14, p = .007) and stronger sexual and social facilitation marijuana expectancies (β = 0.11, p = .009). again, no negative expectancy factors were significant predictors of sam frequency, nor did they incrementally contribute to model improvement. contrary to the general expectancy literature, positive expectancies do not uniformly appear related to increased sam use, as positive alcohol expectancies were inversely related to use. positive marijuana expectancies, specifically social expectancies, on the other hand, were positively associated with sam use. it is possible that individuals with strong social marijuana expectancies may add marijuana to their alcohol when they want to enhance socialization, perhaps, even more so when they believe that alcohol alone is not sufficient for obtaining optimal social functioning. future research should further examine these relationships to understand whether these patterns of expectancies are causally related to sam use or occur consequently. moreover, given the positive associations between sam use and positive marijuana expectancies, it may be efficacious to target positive marijuana expectancies when implementing intervention efforts that are designed to reduce sam use. wweeeeddiinngg oouutt tthhee ssttiiggmmaa:: eexxppeerriieenncceess sshhaarreedd bbyy oollddeerr vveetteerraannss kelly lynn clary (texas state university) hyojung kang, laura quintero silva (university of illinois at urbana-champaign) julie bobitt (university of illinois at chicago) background: cannabis use today is the highest it has been in three decades, approaching 36.5% prevalence for past year use (schulenberg et al., 2017). from a 2014 nationwide sample of veterans over 18, approximately 9% reported past year cannabis use (davis et al., 2018). it also showed that in states where medical cannabis was legal, 41% of veterans who used cannabis in the past year reported doing so for medical purposes. modern research findings continue to point to medical cannabis as a potentially effective alternative to prescription medications (i.e., opioids and benzodiazepines) for treating a broad range of medical conditions. aims: the goal of our larger study was to develop a deeper understanding of cannabis use in us older veterans (60 years +) who are using cannabis as a substitute or complement for opioids and/or benzodiazepines. while research exists on the use levels of cannabis, to our knowledge, limited research on the perceived stigma of using cannabis among older veterans exists. for the current study, we sought to develop an understanding of stigma associated with older veterans using cannabis. methodology: we surveyed 121 older veterans who were enrolled in the illinois medical cannabis patient program during fall 2020. we then used maximum variation sampling to select a subset of 32 veterans who completed the initial online survey. from november 2020 to february 2021, two researchers conducted 30-minute audiotaped semi-structured interviews. participants represented diversity regarding the age of cannabis initiation, type of cannabis user, military branch, type of healthcare provider, and race/ethnicity. interview topics included (1) use of cannabis, opioids, and benzodiazepines, (2) interactions with medical providers, (3) stigma regarding cannabis use, and (4) educational materials for older veterans. for the current study, we present findings from the third topic regarding stigma associated with using cannabis. the interviews were transcribed verbatim for data analysis purposes. weekly meetings among two coders ensued to debrief on coding procedures, reflect on biases and interpretations, and reach consensus regarding coding discrepancies. the conference abstracts 100 final codebook reached an 87% inter-rater reliability. then, the two coders independently coded the transcripts and employed a rigorous thematic analysis approach using nvivo12 qsr. a narrative was woven together with exemplary quotes to illustrate major themes. findings: we identified three stigma focused themes: (1) stereotypes regarding people who use cannabis, (2) hesitation of disclosing cannabis use with others, and (3) media portrayal (i.e., movies, television shows) of cannabis users. implications: stigma creates situations in which older veterans are hesitant to disclose their use of cannabis with physicians and friends/family which can be dangerous and also socially isolating. additionally, older veterans may benefit from shared experiences about cannabis use for medical purposes, but this often does not occur. the empirically-based insights gained from this work have the potential to inform public health leaders, healthcare administrators, and public messaging regarding the use of medical cannabis. additional research is needed to expand upon our findings with more generalizable methods and a representative sample of older veterans. pprreelliimmiinnaarryy eeffffeeccttss ooff aa ffaacceebbooookk iinntteerrvveennttiioonn oonn ppoollyyssuubbssttaannccee uussee aanndd ttrraannssddiiaaggnnoossttiicc ppssyycchhoollooggiiccaall ssyymmppttoommss aammoonngg aadduullttss wwiitthh ccaannnnaabbiiss uussee ddiissoorrddeerr aanndd mmaajjoorr ddeepprreessssiioonn kiefer cowie (ucla integrated substance abuse programs) helene chokron garneau (stanford university) anne bellows lee, melissa garcia (ucla integrated substance abuse programs) frances kay-lambkin (the university of newcastle) alan budney (dartmouth university) alfonso ang, suzette glasner (ucla integrated substance abuse programs) purpose: cannabis use disorders are associated with a quadrupling of the risk of developing depression, and the use of cannabis to alleviate depressive symptoms is increasingly widespread. despite high rates of cannabis use among individuals with affective disorders, those who suffer from depression do not frequently access traditional treatment. our prior work has demonstrated that a technologyand social media-assisted intervention combining cognitive behavioral therapy (cbt), motivational enhancement therapy (met), and social media support via facebook showed promise in changing cannabis use and mood symptoms among depressed individuals with cannabis use disorder (cud). the current project examined alcohol couse and anxiety in this population, effectiveness of this approach in changing drinking behaviors and anxiety, and perceived helpfulness of the intervention. methods: in a 10-week pilot intervention study, adults (n=20) with cud and major depressive disorder (mdd) received an intervention combining computer-assisted cbt/met targeting depression and cannabis use with peer and therapist support via facebook, connected cannabis users’ network for enhancement of cognitive therapy (connect). self-reported past 30 day alcohol and cannabis use was assessed using a calendar-assisted timeline follow back interview at baseline and treatment-end. anxiety was measured using the gad-7. perceived helpfulness of the intervention was evaluated qualitatively in individual participant interviews. results: from baseline to treatment-end, connect participants reduced the frequency of both cannabis use (m=24 vs. 8.9 days, p<0.05) and heavy alcohol use (m=1.7 vs. 0.4 days, p<0.05). anxiety also declined over the course of treatment (m=5.4 vs. 3.2, p<0.05). more than half (57%) of connect participants reported the social media intervention was helpful for their mood as well as cannabis use, and 72% indicated that they would recommend it to a friend. qualitative data indicate that connect was most helpful in 3 core areas: (1) social support/not feeling alone with their problems, (2) cbt skills training, (3) bolstering motivation to change substance use. conclusion: combining technology-assisted and social media interventions may be an effective strategy for populations struggling with concurrent depression and cud. beyond primary outcome variables (i.e., depression and cannabis use), participants also reported reductions in heavy alcohol use and anxiety, indicating that this intervention may effectively produce transdiagnostic process changes. in light of the growing demand for telemedicine and digital health interventions in the wake of covid-19, conference abstracts 101 further research and potential dissemination of this approach appears warranted. ccaannnnaabbiiss uussee iinn pprreeggnnaannccyy lauren micalizzi, rachel l. gunn (brown university) concern for adverse effects of prenatal cannabis use (pcu) is warranted. the american academy of pediatrics recommends refraining from pcu, because δ⁹-tetrahydrocannabinol (thc) crosses the placenta at approximately 10% of maternal levels, which can result in adverse offspring outcomes. little is known about patterns and contexts of pcu; to advance this effort, 64 pregnant women who use cannabis were recruited from amazon’s mechanical turk for a study of pcu thoughts and behaviors. women were, on average, 22 years of age (range 22-49); mean income was ~$44,000 (range $0$150,000). 53.3% of respondents were in the first trimester, 43.3% were in the second and 3.4% were in the third. polysubstance use was common; 25% reported prenatal alcohol use and 64% reported prenatal tobacco use. approximately 40% reported using about the same amount of cannabis as before pregnancy. regarding availability and patterns, approximately 44% indicated that cannabis was “somewhat” or “very” easy to get. women in the third trimester reported the most frequent pcu. across all trimesters, the majority of women reported using cannabis with roughly equal parts thc and cannabidiol and pcu primarily consisted of consumption of leaf and concentrates. the most common modes of administration were joints in the first trimester and hand pipes in the second and third trimesters. on a typical pcu day, approximately 70% of participants reported consuming ¼ gram of flower or less, 73% reported taking 5 or fewer hits of concentrates, and 85% reported ingesting 10 milligrams of thc or less in edibles. pcu among social networks was prevalent; over 50% reported that their spouse/partner used cannabis during their pregnancy and approximately 80% reported that a few, several, or most of their family and friends use cannabis. regarding contexts, during a typical week, women reported pcu in their homes (alone [30%], with others [54.7%]), at friends’ or family members’ homes (alone [28%], with others [39%]), in bars/nightclubs/restaurants/breweries (alone [30%], with others [34%]), as well as outdoors (alone [34%], with others [33%]), at work (alone [34%], with others [36%]), at school (alone [23%], with others [36%]), in the car (alone [31%], with others [36%]) or elsewhere (alone [23%], with others [39%]). pcu was perceived as ‘highly effective’ (as reported by 75-95%) at managing nausea, distress (anxiety, depression), and physical discomfort (e.g., backaches). perceived harm of pcu was low, more than half of participants believed pcu would harm the fetus (~60%) or herself (~64%) “not at all” or “a little.” in conclusion, polysubstance use, particularly tobacco use, is common among women who use cannabis during pregnancy. although quantity of pcu consumption was relatively low in our sample, any amount is concerning and may have negative impact on the developing fetus. the majority of women’s social networks used cannabis and, in all contexts (with the exception of outdoor use), pcu was typically in the company of others. perceived efficacy of pcu for symptom modulation was high across a variety of conditions, and risk perceptions were low, both of which may result in riskier use trajectories. ddiissppoossiittiioonnaall mmiinnddffuullnneessss pprrooffiilleess aanndd ccaannnnaabbiiss uussee aammoonngg ccoolllleeggee ssttuuddeennttss jenny d. earnest, hannah carlon, margo c. hurlocker (university of new mexico) the benefits of mindfulness have been well documented across several domains, including stress reduction, coping with chronic diseases, and relationship satisfaction. previous research cites mindfulness as a protective factor against risky substance use, but the specific association between dispositional mindfulness (also known as trait mindfulness) and cannabis use has been inconsistent, with some studies finding a negative association and one reporting no significant relationship. notably, much of the previous research has relied on variable-centered approaches. only a handful of prior studies within the marijuana literature have utilized personcentered approaches, and only one has specifically examined dispositional mindfulness in relation to patterns of use. the present work advances scientific understanding by using a latent profile analysis to identify subtypes of dispositional mindfulness and their relation to cannabis use behaviors (i.e., cannabis use frequency, cannabis conference abstracts 102 problems, and hazardous cannabis use) in a sample of college students. college students from seven universities across six states participated in an online survey of substance use and risk/protective factors. the current sample comprised 2,249 students who completed the five facet mindfulness questionnaire (ffmq) and measures of cannabis use. findings revealed four discrete profiles of dispositional mindfulness: high-traits profile (13%; characterized by high scores across all dispositional mindfulness facets), a moderate-traits profile (65%; characterized by moderate scores across all dispositional mindfulness facets), a non-judgmentally aware profile (10%; marked by low scores on observing and nonreactivity, but high scores on nonjudgment and acting with awareness), and an observing nonreactive profile (12%; composed of individuals with high scores on observing and nonreactivity). the observing nonreactive class reported the highest levels of marijuana consequences and hazardous use, while the remaining three groups did not differ significantly from one another in terms of problematic use. however, the moderate-traits class reported significantly more consequences than those in the high traits and non-judgmentally aware profiles. these results build upon the only known study that investigates how dispositional mindfulness relates to cannabis use. we found four homogenous profiles rather than three, including two classes that were previously uncovered (high traits and non-judgmentally aware). this research lends support to the finding that distinct facets of dispositional mindfulness differentially relate to cannabis use. specifically, whereas high levels of the nonjudgmental and awareness facets appear protective against risky cannabis use, the observing and nonreactive facets appear related to risky cannabis use, and thus, merit further scrutinization. further research is needed to elucidate the relationship between the five facets of dispositional mindfulness and cannabis use—gaining clarity on how the facets predict marijuana outcomes can help guide the substance use field toward more effective prevention and treatment of cannabis misuse and cannabis use disorder. ppaarrttnneerr iinnccaarrcceerraattiioonn aanndd mmaatteerrnnaall ssuubbssttaannccee uussee:: iinnvveessttiiggaattiinngg tthhee mmeeddiiaattiinngg eeffffeeccttss ooff ssoocciiaall ssuuppppoorrtt aanndd nneeiigghhbboorrhhoooodd ccoohheessiioonn megan e. marziali, seth j. prins, silvia s. martins (columbia mailman school of public health) introduction: the united states is responsible for the highest rate of incarceration globally. the impacts of incarceration extend beyond those incarcerated and can result in adverse outcomes for chosen romantic or life partners and the family unit. this study aimed to explore the impact of partner incarceration on maternal substance use and whether the relationship between partner incarceration and maternal substance use is mediated by financial support, emergency social support, or neighborhood cohesion. methods: using data from the fragile families and child wellbeing study, a longitudinal cohort following new parents and children, this analysis quantifies the relationship between paternal incarceration and maternal substance use (n=2246). responses from mothers at years 3 (2001-2003), 5 (2003-2006), 9 (2007-2010), and 15 (2014-2017) were assessed, restricted to mothers who responded across waves. the exposure, partner incarceration, was operationalized as mothers reporting their current partner or child’s father to be ever incarcerated at year 3. the outcome, substance use in the past year (yes vs. no), was assessed at each time point. respondents were asked whether they used marijuana, sedatives, tranquilizers, amphetamines, prescription painkillers, inhalants, cocaine, hallucinogens, or heroin. three mediators were investigated at years 5 and 9: neighborhood cohesion, financial support, and emergency social support. confirmatory factor analysis (cfa) was employed to construct support-related mediators. counting on someone to loan $200, providing a temporary place to stay, and providing emergency childcare were hypothesized to load onto one factor (emergency social support) and counting on someone to loan $1000, co-sign a bank loan for $1000 and co-sign a bank loan for $5000 were hypothesized to load onto a separate factor (financial support). items were weighted by factor loadings and responses were summed to create a scale for financial support and emergency social support, with a higher score denoting greater degree of support. impact of partner incarceration and maternal substance use was modeled using multilevel modeling to account for repeated measures, adjusting for appropriate confounders conference abstracts 103 (age of mother at child’s birth, race, education, employment, and history of intimate partner violence). results: nearly half (42.7%, n=958) of participants reported partner incarceration. among mothers who described partner incarceration, the odds of reporting substance use are 96% (adjusted odds ratio [aor]: 1.96; 95% confidence interval (ci):1.56-2.46) greater in comparison to those who reported no partner incarceration. financial support at year 5 mediated 17% of the relationship between partner incarceration at year 3 and substance use at year 9 (p-value = 0.006); financial support at year 9 was not a significant mediator of the relationship between partner incarceration at year 3 and substance use at year 15. neither emergency social support nor neighborhood cohesion were significant mediators at either year 5 or year 9. conclusions: these findings demonstrate that partner incarceration impacts maternal substance use. financial support acts as a partial mediator in the short term, which has important implications for families disrupted by mass incarceration. lleevveerraaggiinngg mmoobbiillee tteecchhnnoollooggyy:: aa ssyysstteemmaattiicc rreevviieeww ooff mmhheeaalltthh iinntteerrvveennttiioonnss wwiitthh ccaannnnaabbiiss uusseerrss claire sharp, lani blanchard, jenn barnett, michael phillips (university of northern colorado) cannabis is commonly used by young adults (1825), and these transitional years can be crucial as they tend to have the highest rates (5%; 1.8 million in the u.s.) of cannabis use disorder (cud; samhsa, 2016). current survey data suggest 25% of university students use cannabis monthly or greater and 6% daily (schulenberg et al., 2019) and even higher (38-39%) in states with legal recreational cannabis use (pearson et al., 2017). burgeoning research has shown that chronic, heavy cannabis use is associated with a host of negative consequences, including symptoms/diagnosis of cud, as well as anxiety, depression, and psychosis, among other health issues (arseneault et al., 2002; buckner et al., 2010; degenhardt et al., 2003; midanik, tam, & weisner, 2007; simons et al., 2010; solowij & pesa, 2010). with the number of young adults diagnosed with cud, there is a growing need for intervention strategies. however, rates of individuals seeking formal treatment for cannabis use has been low (prince et al., 2020). with widespread access, it has become easier to employ mobile technology for health interventions (kumar et al., 2013). the overall objective of this systematic review was to explore the utilization of different mhealth interventions for cannabis users to investigate different types and ways these interventions are implemented, targeted outcomes, along with the types of studies being conducted (e.g., rct, feasibility, interviews, usability, etc.). methods: a search of psycinfo and pubmed was conducted for relevant articles with the following search terms: mhealth app/web-based intervention/internet-based intervention/telehealth/jitai/emi/ecological momentary intervention/just-in-time adaptive intervention/in the moment/mobile intervention/smartphone intervention/wearable devices and cannabis/marijuana peer-reviewed original research in english was targeted, which focused on mhealth interventions for adults (over 18 years of age) targeting cannabis use and needed both a mobile intervention and provided data on at least one outcome (e.g., reduced craving or cannabis use) or feasibility of intervention. qualitative, quantitative, and mixed methods were all included. results: the total number of records identified that fit the criteria based on a review of titles and abstracts were 33 (9 from psycinfo and 24 from pubmed). after duplicates were removed, 27 were screened and 9 records were excluded for failure to meet search criteria after full review of the articles. the remaining records (n=18) were assessed for eligibility and data were extracted. based on preliminary findings, the majority have been feasibility and usability studies (83%). roughly half were conducted in the u.s., with the rest in european countries, and one in singapore. the timeframe for using the mobile intervention ranged from 1-hour (for usability studies) to 8 months in duration. the types of mobile interventions have varied from text messaging, using a smartphone app, to directing individuals to websites. roughly 50% have been standalone mhealth interventions, while the other half have been paired with face-to-face counseling sessions. the majority of these interventions have conference abstracts 104 personalized intervention strategies for their participants. vvaalliiddaattiioonn ooff tthhee mmaarriijjuuaannaa ppuurrcchhaassee ttaasskk aammoonngg aaddoolleesscceenntt mmaarriijjuuaannaa uusseerrss nicole r. schultz (university of washington) elizabeth r. aston (brown university school of public health) jane metrik (brown university school of public health, providence va medical center) jason j. ramirez (university of washington) marijuana is the most commonly used illicit substance, with daily use rising among 8th and 10th graders. adolescents view marijuana use as carrying minimal risk despite a host of associated psychosocial consequences. within the behavioral economic framework, the marijuana purchase task (mpt) has been used to understand demand (i.e., relative value) for marijuana. the mpt is a hypothetical purchase task that produces five demand indices reflective of the relative reinforcing value of marijuana and include intensity (i.e., amount consumed at zero cost), omax (i.e., maximum expenditure), pmax (i.e., price at maximum expenditure), breakpoint (i.e., cost at which consumption is suppressed to zero), and elasticity (i.e., rate at which consumption decreases as price increases). to date, the mpt has only been validated with adult samples; thus, the current study aimed to validate the mpt with a late adolescent sample who presumably have less experience in purchasing and using marijuana relative to adult users. convergent validity was established via correlations between demand indices and marijuana outcomes (i.e., marijuana use, consequences, craving, and recent marijuana expenditures). divergent validity was established via t-tests to examine group differences between hazardous and nonhazardous users as differentiated by the cannabis use disorders identification test-revised (cudit-r; scores of 8 or greater indicate hazardous use). participants were 115 adolescents (mage = 16.94, sdage = 0.88; 52% female; 64% high school student) between the ages of 15-18 who reported lifetime marijuana use and current marijuana demand. as expected, results showed that as price increased, hypothetical marijuana use decreased. convergent validity was established via significant associations between demand indices and marijuana outcomes. omax, breakpoint, and elasticity were significantly correlated with marijuana use outcomes in predicted directions such that greater demand was associated with more use, consequences, craving, and recent expenditures (ps <.05). intensity was positively correlated with craving and expenditures (ps < .05). pmax was not significantly correlated with any marijuana use outcome. divergent validity was also established; compared to non-hazardous users (n = 39), hazardous users (n = 76) exhibited significantly higher omax (t = 3.11, p <.01), pmax (t = 2.08, p <.05), breakpoint (t = 3.71, p < .001), and elasticity (t = 3.11, p <.01). there was no difference in intensity across user types. findings from the current study are unique in several ways. first, in contrast with previous literature, intensity was less consistently associated with marijuana outcomes. however, indices related to price sensitivity are important metrics in this age group, as evidenced by significant associations between omax, breakpoint, and elasticity and marijuana outcomes. these findings are further evidenced by the ability of omax, pmax, breakpoint, and elasticity to differentiate nonhazardous versus hazardous users. together, these findings suggest that the mpt is a valid measure for assessing the reinforcing value of marijuana among adolescents. future research should replicate these findings, as well as examine the factor structure of the mpt among adolescents. pprroobbaabbiilliittyy aanndd pprreeddiiccttoorrss ooff ccaannnnaabbiiss uussee ddiissoorrddeerr aammoonngg ccaannnnaabbiiss uusseerrss wwiitthh ddeepprreessssiivvee ddiissoorrddeerrss ofir livne, deborah hasin, silvia martins (columbia university) introduction and aims: cannabis use and cannabis use disorders (cud) have been increasing in the us. recent studies have aimed to assess the rates of transition from cannabis use to cud over time across several sociodemographic corelates (e.g., age and sex). depressive disorders are a strong clinical correlate of cannabis use, and carry a substantial burden of disease. the underlying mechanisms involved in the relationship between depression and cannabis use conference abstracts 105 are still not fully understood. while certain studies have examined changes in rates of cannabis among depressed and non-depressed individuals over time, no studies have quantified the effect of depressive disorders on cannabis users’ transition rates to cud. methods: participants were individuals ≥18 years interviewed in the national epidemiologic survey on alcohol and related conditions-iii in 2012– 2013. survival plots assessed the probability of transition from cannabis use to cud over time. differences in probability of transition to cud was assessed among cannabis users with and without predisposing depressive disorders ( major depressive disorder or dysthymia with an initial diagnosis prior to onset of cannabis use). results: among lifetime cannabis users (n = 11,272), the 5-year probability of transition to cud was approximately 3.9% for cannabis users without depressive disorders and 7.3% for those with a depressive disorder. a higher probability of transition from cannabis use to cud among those with a predisposing depressive disorder was observed over all time points that were examined in the study. cannabis users with depressive disorders who were male and belonging to an early-onset of cannabis use age group (<16) transitioned significantly more rapidly to cud than females and those with a lateronset of cannabis use conclusions: this is the first study to explore the effect of depressive disorders on rates of transition from cannabis use to the dsm-5 cud diagnosis. the current study identified specific predictors of this transition. findings inform clinicians who treat individuals with depressive disorders that initiate cannabis use as to the risk of developing cud and the need for harm prevention targeted at this specific population. sslleeeepp--rreellaatteedd ccaannnnaabbiiss eexxppeeccttaanncciieess qquueessttiioonnnnaaiirree ((ssrr--cceeqq)):: rreepplliiccaattiioonn aanndd ppssyycchhoommeettrriicc vvaalliiddaattiioonn aammoonngg ccoolllleeggee ssttuuddeennttss uussiinngg ccaannnnaabbiiss ffoorr sslleeeepp aaiidd aubriana a. schwarz, patricia a. goodhines, amelia v. wedel, lisa r. larowe, aesoon park (syracuse university) introduction: emerging evidence suggests that cannabis is commonly used to aid sleep among college students. although outcome expectancies have been associated with the progression of cannabis use, sleep-related expectancies have not been included in widely-used cannabis expectancy measures. recently, the sleep-related cannabis expectancies questionnaire (sr-ceq; goodhines et al., 2020) was developed and initial evidence for its 2-factor structure was obtained in a general college sample (including non-cannabis users). however, the sr-ceq’s associations with sleep and cannabis use behaviors among cannabis sleep aid users is unknown. this study aimed to replicate the previous factor structure and test construct and concurrent validity of the sr-ceq among college students using cannabis for sleep aid. method: cross-sectional data were drawn from 94 college students reporting at least bimonthly cannabis use for sleep aid. five multivariate outliers on the sr-ceq were excluded, resulting in an analytic sample of 89 (mage=19.92 [sd=1.19; range=18-22]; 66% female; 72% white, 12% multiracial, 7% asian, 5% black or africanamerican, 1% self-reported other and 3% did not disclose; 14% hispanic/latinx). students completed an online survey of sleep and substance use behaviors. a confirmatory factor analysis (cfa) replicated the 2-factor structure (positive and negative sleep-related cannabis expectancies), bivariate correlations tested associations with related constructs (sleep and cannabis use behaviors/beliefs), and independentsamples t-tests further explicated relevant group differences. results: after dropping item 5 (factor loading<.40), cfa with a 2-factor structure indicated good fit to the data (χ2(41)=66.76, p=.01; cfi=0.94; srmr=0.07; rmsea=0.08 [90% ci=0.05, 0.12]). positive sleep-related cannabis expectancies (α=.84) were associated with dysfunctional beliefs about sleep (r=.24, p=.02), but not insomnia symptoms, poor sleep quality, or frequencies of cannabis use (ps>.05). students who used cannabis more frequently in general (≥36 of 60 days, per median split) reported more positive sleep-related cannabis expectancies (t[86]=1.99, p=.05, cohen’s d=0.42). negative sleep-related cannabis expectancies (α=.80) were not associated with any cannabis or sleep variables assessed (ps>.05). negative sleeprelated cannabis expectancies were marginally lower among students with greater frequency of general cannabis use (t[87]=-1.89, p=.06, cohen’s d=0.40) and cannabis use for sleep aid (≥3 conference abstracts 106 times/week, per median split; t[87]=-1.87, p=.06, cohen’s d=0.40). further, greater negative sleeprelated cannabis expectancies were reported among male (versus female) students (t[87]=2.30, p=.02, cohen’s d=0.51). conclusion: overall, replication of this 2-factor structure showed good fit to the data and both subscales demonstrated good internal consistency. although replication is needed, results suggest that college students using cannabis for sleep aid may have less negative sleep-related expectancies about sleep. positive sleep-related cannabis expectancies were associated with dysfunctional beliefs about sleep, but not sleep behaviors or cannabis use. current novel findings extend existing knowledge of general non-sleep related cannabis expectancies among cannabis users in terms of cannabis use correlates. findings can help identify at-risk students and modifiable risk factors that can be targeted to minimize harm with cannabis sleep aid use. future research is needed among larger samples to (a) assess generalizability to varied populations and (b) clarify temporal sequencing of potential consequences through longitudinal designs. eeaarrllyy ccaannnnaabbiiss iinniittiiaattiioonn iiss aassssoocciiaatteedd wwiitthh dduuaall ssiimmuullttaanneeoouuss ssuubbssttaannccee uussee aanndd ttrrii--uussee priscila dib goncalves, megan e. marziali, joão mauricio castaldelli-maia, silvia s martins (department of epidemiology, mailman school of public health, columbia university) introduction: cannabis use combined with other substances, such as tobacco and/or alcohol, is related to heavy patterns of substance use and adverse social outcomes. we aimed to examine whether early age of cannabis initiation was associated with dual simultaneous substance (tobacco + cannabis / alcohol + cannabis) use and tri-use (tobacco + alcohol + cannabis). methods: we included participants aged between 12-21 years old (n= 21,127) that reported any cannabis use in the 2016-2019 national survey on drug use and health. blunt use was defined as smoking part of a cigar with cannabis in it (“taking some tobacco out of a cigar and replace it with marijuana”) and simultaneous alcohol/cannabis use as “using marijuana/hashish at the same time or within a couple of hours of last alcohol use”. we created four-level categorical variables, one for the exposure (age of cannabis initiation) and one for the outcome (simultaneous use). the exposure variable was comprised of the following levels based on different adolescent developmental stages: 1) 12-13 years old; 2) 14-15 years old, 3) 16-18 years old), and 4) 19-21 years old. the four outcome categories were defined as: 1) cannabis use only (no simultaneous use), 2) blunt use (simultaneous cannabis and tobacco use), 3) simultaneous alcohol/cannabis, and 4) triuse (tobacco, cannabis and alcohol). weighted multinomial logistic regression was used to obtain adjusted odds ratios (aor) for categories of use, adjusting for sociodemographic characteristics (reference outcome category: cannabis use only). results: most participants were 16+ years old (88%), non-hispanic white (56%), with a family income equal or higher than $40k (54%) and a mean age of cannabis initiation of 15 years old. when examining simultaneous use outcomes, 70% of the participants reported some form of simultaneous use (54.85% blunt use, 14.72% triuse, and 1.12% simultaneous alcohol/cannabis). regarding age of cannabis initiation, 18.97% started at age 12-13, 31.85% at age 14-15, 42.18% at age 16-18 and 7.00% at age 19-21. cannabis initiation in early adolescence (< 16 years old) was associated with simultaneous use outcomes when compared to cannabis initiation at age 16 and older. more specifically, when comparing with cannabis initiation at age 19-21, individuals reporting cannabis initiation at age 12-13 had 24.26 times the likelihood of tri-use (95% ci=17.33-33.95); and 6.64 times the likelihood of blunt use (95% ci=5.15-8.55), however, no associations were found with simultaneous alcohol/cannabis use (aor 2.98, 95% ci= 0.94-9.37). when using cannabis initiation at age 16-18 as reference, cannabis initiation at age 12-13 was associated with six times the likelihood of tri-use (95% ci= 5.02-7.86), three times of blunt (95% ci= 2.42-3.71), and twice of simultaneous alcohol/cannabis use (95% ci= 1.26-4.40). conclusions: cannabis initiation in early adolescence was associated with dual and tri simultaneous substance use. interventions focused on delaying cannabis initiation could have a positive impact on decreasing dual and trisubstance use. considering that 1 in 5 individuals reporting cannabis use started in early conference abstracts 107 adolescence, primary prevention strategies should start before the age of 12. mmiilliittaarryy sseexxuuaall vviioolleennccee aanndd ccaannnnaabbiiss uussee ddiissoorrddeerr aammoonngg ooeeff//ooiiff vveetteerraannss reagan e. fitzke, daniel s. lee, denise d. tran, jordan p. davis, eric r. pedersen (university of southern california) sexual violence experienced during military service can have lasting negative psychosocial effects on veterans long after service ends. current research reports veterans who have experienced military sexual violence are more likely to develop mental health and substance use disorders. little is known, though, about the relationship between military sexual violence and subsequent cannabis use disorder (cud). the current study investigated prevalence of military sexual violence among a large sample of oef/oif veterans (n = 1,005), its effect on later cud, and the potential moderating role of resilience. first, t-tests examined differences in experience of military sexual violence between lgbq vs. heterosexual and female vs. male veterans. then, using logistic regressions controlling for sex, sexual orientation, and race/ethnicity, we assessed the effects of sexual violence on cud (cannabis use disorder identification test score of 12 or higher), followed by adding resilience into the model to examine independent and moderation effects. t-test results indicated that female (t(99) = -7.46, p < 0.001) and lgbq veterans (t(38) = -3.85, p < 0.001) were significantly more likely to experience military sexual violence. veterans who experienced military sexual violence had higher odds of screening for cud (or = 3.37; 95% ci = [1.76, 6.45]). greater resilience was associated with lower odds of cud (or = 0.40; 95% ci = [0.23, 0.70]), but it did not moderate the relationship between sexual violence and cud. our findings are in line with prior work that female and lgbq veterans may experience sexual violence during military service at higher rates. we also showed that veterans who experience military sexual violence are at increased risk for subsequent cud. this suggests the importance of screening for military sexual violence among veterans, including among those seeking care for cud, as well as screening for cud symptoms among those who have experienced military sexual violence. since we found that greater levels of resilience were associated with lower odds of cud, programs and treatments aimed at building resilience to adverse events may have independent protective effects on cud. eexxpplloorriinngg sseennssaattiioonn--sseeeekkiinngg aanndd ffiirrsstt ccaannnnaabbiiss uussee eexxppeerriieenncceess aass ccoorrrreellaatteess ooff ccuurrrreenntt ccaannnnaabbiiss uussee pprroobblleemmss iinn yyoouunngg aadduulltt ccaannnnaabbiiss aanndd ttoobbaaccccoo ccoo--uusseerrss.. riley j. wyatt, amy m. cohn, sarah j. ehlke (university of oklahoma health sciences center) introduction: current cannabis use is high in young adults (ages 18-24) and cannabis use disorder (cud) rates have increased over the last decade. subjective responses to one’s first use of cannabis may explain continued use, wherein more positive first use experiences influence progression to regular and problematic use. sensation seeking is associated with cannabis use and may also influence cannabis problem severity. this study examined the relationship between subjective experiences at first cannabis use and sensation seeking on cannabis use behavior and cud diagnosis. method: participants were 97 young adult current cannabis and tobacco cousers (55.7% male, 50.5% white) who completed the baseline survey of a longitudinal study examining daily patterns of tobacco and cannabis use and co-use. participants completed the 4-item brief sensation seeking scale and indicated intensity of 15 sensations at first cannabis use (1 = not at all to 5 = intense): dizziness, lightheadedness, nausea, paranoia, confusion, happiness, anxiety, taste, smell, relaxation, energy, difficulty inhaling, coughing or choking, giddiness or laughter, and rush or “buzz.” cannabis use outcomes included: (1) past 30-day number of days used cannabis; (2) past 30-day cannabis intoxication intensity (1 = not at all high to 10 = extremely high); and (3) likelihood of a cud (score ≥ 12 on the cannabis use disorder identification testrevised). analyses: a principal components analysis (pca) reduced the 15 sensations into factors. next, separate regression analyses (linear or binary logistic) were conducted to examine the associations of the pca-derived factors and sensation seeking on the cannabis outcomes, controlling for gender, race, and age at first cannabis use. conference abstracts 108 results: over half (61.9%) of the participants met criteria for a cud. pca results indicated a 4factor solution: (1) “positive emotional experiences” (e.g., happy); (2) “negative physical experiences” (e.g., dizzy); (3) “negative emotional experiences” (e.g., paranoia); and (4) “taste and smell.” regression results indicated greater negative physical experiences were associated with an increased likelihood of a cud diagnosis (aor = 1.93, p = .038) and lower average cannabis intoxication (b = -0.343, p = .049). greater negative emotional experiences at first use were associated with less frequent cannabis use in the past 30 days (b = -2.043, p = .028). conclusion: negative emotional experiences associated with first use of cannabis may impede continued use. negative physical experiences (e.g. nausea, lightheadedness) may be variable in perception, which could explain the inconsistent associations of this factor with cud diagnosis and past 30-day use. understanding subjective experiences of first cannabis use could be used as a treatment target by helping patients identify reinforcing sensations associated with their use, and guiding them to sober activities with similar sensations. uunneexxppeecctteedd ppuubblliicc hheeaalltthh eemmeerrggeenncciieess——aa ddeessccrriippttiivvee aannaallyyssiiss ooff ttrreennddss iinn tthhee mmaassssaacchhuusseettttss mmeeddiiccaall aanndd aadduulltt--uussee ccaannnnaabbiiss mmaarrkkeettss samantha m. doonan, olivia laramie (massachusetts cannabis control commission) jessica liu (harvard t.h. chan school of public health, harvard university) marianne sarkis, julie k. johnson (massachusetts cannabis control commission) in the united states (u.s.), access to legal cannabis through regulated state markets is rapidly changing, but little is known about consumer behavior when states with legal access choose to restrict access due to public health or safety concerns. this exploratory study examines the massachusetts recreational (“adult-use”) and medical cannabis markets before and during two major public health crises that changed consumer access: (1) the e-cigarette or vaping use-associated lung injury (“evali”) crisis and state requirements to stop vape product sales in the adult-use and medical markets from 9/24/201912/12/2019, and (2) the sars-cov-2 (“covid19”) crisis and state emergency order that temporarily halted all adult-use retail sales but not medical sales from 3/24/20-5/24/20. we used the massachusetts seed-to-sale tracking system (i.e., metrc) to run descriptive statistics examining medical sales for patients and all adult-use sales across the largest product segments: buds, vapes and concentrate (each), edibles, and other categories (i.e., prerolls, concentrate, infused nonedible, infused beverage, kief, shake/trim, suppository) spanning may 2019-december 2020. to account for classification changes in the dataset, sales for vape products and concentrate (each) product were summed into a single category. we further examined trends in registered patients and “per patient” spending across cannabis product types (i.e., monthly sales per product category divided by monthly registered patients). our findings showed a decline in market share for the vape and concentrate (each) product category in the adult and medical markets during the evali crisis when sales were halted, while buds, followed by edibles and other products increased in market share during this time. after vape products could be sold again, the market share of vape and concentrate (each) products rose but did not return to pre-evali levels. we did not observe an overall shift in market share by product type in the medical market during the covid-19 adultuse store closure. although gross medical sales trended upward, increases in the medical market did not account for the vast majority of prior spending in the adult-use market during the market’s closure. the number of registered active patients also trended upward. from december 2020 to december 2021, there was a 56% increase in patients (59,173 to 92,148 patients), and we observed a marked increase following the temporary halt of adult-use sales. during and prior to halted adult-use sales, we observed an increase in per patient monthly spending for cannabis products. this was particularly salient for buds. per patient monthly spending for buds peaked in may 2020. study limitations include a single state sample and that this study does not examine changes to the illicit market. we cannot make any causal claims and any long-term implications of trends observed during the evali and covid-19 crises are unknown. our exploratory findings suggest that there are a conference abstracts 109 range of consumer responses in the legal market in response to temporary loss of access, including evidence of consumers changing legal markets (i.e., adult-use to medical) and changing product types. more research is needed, particularly to understand potential concurrent changes in the illicit market during these crises. ppaatttteerrnnss ooff mmaarriijjuuaannaa uussee aanndd sseexxuuaall vviioolleennccee aammoonngg sseexxuuaall mmiinnoorriittyy hhiigghh sscchhooooll ssttuuddeennttss:: ppeerrssppeeccttiivveess ffrroomm tthhee ccaalliiffoorrnniiaa hheeaalltthhyy kkiiddss ssuurrvveeyy grisel garcia-ramirez, sabrina islam (university of california, berkeley and prevention research center of pacific institute for research and evaluation) background: sexual minority students are at risk for adverse outcomes associated with substance use and violence. the vast majority of research literature, however, has focused on university students and alcohol consumption. there is an increased need to understand the distinct vulnerabilities of youth who have a nonheterosexual sexual orientation, and marijuana use as more state legalize and normalize the recreational use of marijuana in various forms. this study examines marijuana use and sexual victimization among high school students by sexual minority status. methods: we analyzed data from 9th (n=50,973) and 11th (n=41,692) graders who participated in the california healthy kids survey during the 2018-2019 school year. students were asked to report their sexual identity and orientation (‘straight,’ ‘gay/lesbian,’ ‘bisexual,’ ‘something else,’ ‘i am not sure yet’, ‘decline to respond’), whether they had ever been sexually assaulted, marijuana use in their lifetime and past 30 days, and demographic characteristics. we conducted multi-level logistic regression analysis to assess relationships between lifetime and past-30-day marijuana use, sexual minority status and sexual victimization (sv). analyses were performed using stata, version 15.1. results: the initial model indicated that the interaction terms for sexual minority status and sexual assault were not significantly associated with lifetime and past 30-day marijuana use. analyses without the interaction terms suggest that students who identify as gay or lesbian, and who selected ‘i am not sure yet’ and ‘something else’ had higher odds of reporting past-30-day marijuana use than their ‘straight’ peers (or=1.50 p<0.01 95%ci: 1.15, 1.96; or=1.34 p<0.01 95%ci: 1.20, 1.50; or=2.33 p<0.01 95%ci: 2.11, 2.59). results also suggested that students who identified as gay or lesbian, bisexual, and students who selected ‘something else’ as their sexual orientation had higher odds to report lifetime marijuana use than their ‘straight’ peers (or=1.90 p<0.01 95%ci: 1.43, 2.52; or=1.45 p<0.05 95%ci: 1.03, 2.04; or=1.57 p<0.01 95%ci: 1.29, 1.92). however, students who declined to respond about their sexuality are less likely to report lifetime marijuana use than their ‘straight’ peers (or=0.82 p<0.05 95%ci: .68, .99) additionally, students who reported sexual assault have almost six times higher odds of reporting lifetime and past-30-day and lifetime marijuana use (or=6.68 p<0.01 95%ci: 3.99, 11.20; or=6.03 p<0.01 95%ci: 3.80, 9.56). overall, students who are in 11th grade, are male, and hispanic have higher odds of reporting marijuana use. conclusion: overall, risks of marijuana use tend to be more pronounced among sexual minority students who have experienced sexual violence. our findings suggest that students who identified as ‘something else’ may be at particular risk. these results are congruent with prior research on college populations that have identified undergraduate students who are bisexual and unsure of their sexual identity at heightened risk for sa. greater efforts are needed to examine the intersection of substance use and sexual victimization and the disproportionate burden facing adolescents across multiple categories of sexual orientation. lleeggaalliizzaattiioonn ooff ““ssmmookkaabbllee”” mmeeddiiccaall mmaarriijjuuaannaa wwaass aassssoocciiaatteedd wwiitthh ssiiggnniiffiiccaannttllyy iinnccrreeaasseedd tthhcc uussee ppeerr cceerrttiiffiieedd ppaattiieenntt iinn tthhee fflloorriiddaa mmeeddiiccaall mmaarriijjuuaannaa pprrooggrraamm:: aann iinntteerrrruupptteedd ttiimmee sseerriieess aannaallyyssiiss sebastian jugl, ruba sajdeya, melanie buhlmann, robert l. cook, joshua d. brown, almut g. winterstein, amie goodin background/objective: tetrahydrocannabinol (thc) is the primary psychoactive cannabinoid in cannabis. thc has potential therapeutic efficacy for some conditions but can lead to adverse drug events when used in higher concentrations. conference abstracts 110 higher concentrations are typical for smokable medical marijuana (mmj) products which often contain 20 % thc or more. on march 18, 2019, florida senate bill 182 (sb182) authorized cannabis flower for smoking. the objective of this study was to assess the effect of sb182 on the weekly dispensed amount of thc per certified mmj patient in florida. methods: data were obtained from the florida department of health office of medical marijuana use (ommu) weekly reports, which detailed aggregate mmj utilization from 04/06/2018 (onset of reporting) until 03/13/2020 (onset of covid-19 emergency orders). we calculated the weekly amount of dispensed thc per certified patient by summing the total weekly amount of thc in dispensed mmj across all non-smokable and smokable routes of administration in the preand postperiods. these totals were divided by total certified mmj patients in that week. given the lack of information of thc content in smokable mmj products in florida, we calculated thc amounts using averages of thc concentrations in smokable products (10% and 20%) based on published estimates from other states with mmj programs. interrupted time series analysis without control was conducted by fitting a generalized least squares linear model to estimate changes in the overall trend and changes in the level after sb182. we used a phase-in period to allow for time between the first dispensed mmj products in a form of smoking (3/22/2019), and measurable effects of sb182 (07/19/2019). autocorrelation and moving averages were ruled out by using autocorrelation and partial autocorrelation plots. results: in the scenario with 10% average thc in smokable products, sb182 led to a significant level increase of 35.1 mg (95% ci: 4.85-56.34 mg) in the weekly dispensed amount of thc per mmj patient. this was an increase of roughly 10.7% compared to the estimated amount in the week before the phase-in period (328.20 mg). in the same scenario, a continuously increased trend of 2.23 mg per week (95% ci: 1.16-3.31 mg) was observed in the 35 weeks following sb182. in the second scenario (assumed 20% average thc in smokable products), sb182 was associated with a level increase of 138.4 mg (95% ci: 102.14-174.75 mg) in the weekly dispensed amount of thc per mmj patient, which corresponds to an increase of 42.2%, compared to 328.20 mg, and a trend increase of 5.62 mg (95% ci: 4.33-5.61 mg) per week in the following 35 weeks from law implementation. conclusion: the inclusion of smokable mmj in the florida mmj program was associated with a significant increase of the weekly dispensed amount of thc per certified mmj patient, by increasing the level, as well as the overall trend following law implementation. further studies should investigate the potential health and safety impacts of increases in dispensed thc in mmj programs. eexxpplloorriinngg ssoocciiaall ssuuppppoorrtt aass aa mmooddeerraattoorr bbeettwweeeenn aaddvveerrssee cchhiillddhhoooodd eexxppeerriieenncceess aanndd ccaannnnaabbiiss uussee sterling m. hubbard, shelby a. king, sarah n. elder, matthew j. woodward, jenni b. teeters (western kentucky university) background: research shows that unresolved childhood trauma can lead to an abundance of health disparities and increase the risk for problematic substance use in adulthood, particularly problematic cannabis use. individuals who have experienced four or more adverse childhood experiences (aces) double their risk of problematic substance use, but research has shown that protective factors, such as social support, can buffer against this cumulative risk. although past research has found that social support can buffer against problematic alcohol use, there is a need to understand how social support relates to aces and problematic cannabis use. the present study aims to identify if perceived social support moderates the association between aces and cannabis use. in addition to overall perceived social support, various domains of perceived social support (friends, family, and significant other support) were examined to determine whether these domains differentially impacted the association between aces and cannabis use. methods: data were collected using a university online subject pool (n = 382) from a college student sample from a mid-southern university (75% caucasian, 78% female). the participants completed a battery of measures assessing perceived social support (i.e., the multidimensional scale of perceived social support; mspss), childhood trauma (i.e., the adverse childhood experiences scale; aces), and conference abstracts 111 the number of days of cannabis use in the past month (i.e., the drug use questionnaire). results: moderation analyses were used to analyze if overall perceived social support and the various domains of mspss (family, friend, and significant other) moderated the relation between aces and cannabis use. findings revealed that perceived support from a significant other significantly moderated the association between aces and cannabis use (b = .17, p = .04) such that the relation between aces and cannabis use was stronger when there was higher perceived support from a significant other. overall social support and support from friends and family members did not moderate this association. discussion: overall, these findings contradict the previous literature in that more support from a significant other did not buffer the association between aces and cannabis use. rather, the relation between aces and cannabis use was strongest at higher levels of significant other support. this suggests that perceived social support may play a unique role alternative to buffering the relationship between aces and cannabis use. future work is needed to examine factors such as level of cannabis use within a trauma survivor’s social network or significant other accommodation of symptoms, which may enhance perceptions of support but also encourage cannabis use. ddrriivviinngg uunnddeerr tthhee iinnfflluueennccee ooff ccaannnnaabbiiss:: aassssoocciiaattiioonnss wwiitthh llaatteenntt pprrooffiilleess ooff ssuubbssttaannccee uussee aanndd eexxeeccuuttiivvee ccooggnniittiivvee ffuunnccttiioonniinngg tammy chung, marc steinberg, mary bridgeman, yingying chen background: driving under the influence of cannabis (duic) almost doubles car crash risk (odds ratios range: 1.28-2.49). known duic correlates include male gender, low perceived danger of duic, and greater frequency of cannabis and other drug use. less is known about the role of executive cognitive functioning (e.g., skills in planning, organization) as a correlate of duic. deficits in executive cognitive functioning could precede, and be exacerbated by heavy cannabis use, potentially contributing to duic risk. objectives: this cross-sectional survey study used a person-centered analysis (latent profile analysis) to (1) identify prototypical profiles representing aspects of executive functioning and substance use in young adults, and (2) determine which profiles were associated with self-report of duic. we hypothesized that at least two profiles would be identified: mainly or only cannabis use vs polysubstance use. we also predicted that the polysubstance use profile would be associated with worse executive functioning and self-report of duic. method: young adults (n=69; ages 1825; mean age=20.0 [sd=1.9]; 62.3% female; 75.4% white, 13.0% black, 11.6% other race/ethnicity) who reported weekly cannabis use were recruited from the community in pittsburgh, pa to participate in a study of cannabis effects on cognition. baseline collected demographics, selfreported age of cannabis use onset (age <16 vs age >16), nida modified assist, marijuana withdrawal checklist, alcohol use disorders identification test (audit), behavior rating inventory of executive functioning (brief) (working memory, organization/planning scales), and marijuana consequences questionnaire (item on “driven a car when high” in past 6 months). latent profile analysis (latentgold 5.1) was used to identify distinct classes, testing the fit of 1-5 classes. each model included 10 indicators: age of cannabis use onset, frequency of cannabis and tobacco use, cannabis withdrawal severity, assist scores for cannabis, cocaine and hallucinogens (the substances most often reported), audit score, and brief working memory, and organization/planning scores. for the best fitting model, covariates (i.e., self-report of duic, age, gender) were examined as profile correlates in a separate, final step. results: a model with 3 latent profiles was selected (see figure). the profiles represented “polysubstance use” (40.8%), “primary cannabis” (22.3%), and “later onset cannabis” (36.9%). polysubstance use profile reported more cannabis-related problems and other drug use, and more problems with executive functioning than the other profiles (p<.05). later onset (vs polysubstance use) profile had older onset age (p<.05), and had the lowest level of cannabis involvement. primary cannabis and later onset profiles did not differ in report of problems with executive functioning. duic in the past 6 months (reported by 50.7% of the total sample) was more likely to be reported by polysubstance use than later onset profile (p<.01). polysubstance use profile was younger than primary cannabis profile (p<.05). the profiles did not differ by gender. conclusions: as conference abstracts 112 hypothesized, polysubstance use profile (which reported early cannabis use onset; and worse executive functioning, including problems with memory, planning/ organization) was associated with self-report of duic. results highlight the role of self-reported executive functioning difficulties in duic risk, and the importance of targeting polysubstance use in preventing duic. ffrreeqquueennccyy ooff ccaannnnaabbiiss uussee aanndd ppaaiinn iinntteennssiittyy:: rreessuullttss ffrroomm aa nnaattiioonnaall ssaammppllee verlin joseph (university of new mexico) brenda w. dyal, tasha schoppee, keesha roach, miriam o. ezenwa, yingwei yao, diana j. wilkie (university of florida) background: chronic pain has become a leading public health concern with roughly 20% of americans currently living with chronic pain. individuals living with chronic pain are more likely to report lower quality of life, additional comorbidity, and increased medical expenditures than individuals without pain. many individuals have initiated cannabis use to manage their pain as an alternative to opioid use. however, studies examining associations between cannabis use and pain intensity rarely include the frequency of cannabis. aim: our study aim was to address this scientific gap by elucidating the frequency of cannabis use and its association with pain intensity in an adult sample from across the united states. methods: in a cross-sectional study, we surveyed n=2,206 adults using three sampling approaches, a national panel, a florida panel, and a community-engaged sample. participants completed surveys including pain and substance use. pain intensity was measured using the pain intensity number scale (pins, 0-10 scale) by asking participants to rate their current pain and least and worst in the past 24 hours. average pain intensity (api) was the mean of the aforementioned pins scores. frequency of cannabis use was measured by asking individuals to indicate any past 30 day use and to indicate how often they currently use cannabis: once a month, more than once a month but less than weekly, 1 to 6 days a week, or every day. bivariate and multiple linear regressions were utilized to identify associations between pain intensity, cannabis use, and sociodemographic factors. results: our sample was majority female (54.1%), non-hispanic white (63.1%), and 45.9 ± 17.60 (sd) years of age. participants reported an api score of 1.50 ± 2.49. for the 35.3% reporting pain greater than 0, the api score was 4.26 ± 2.40. of the responding participants (n=600), 52% reported they never used cannabis and 25% indicated current cannabis use; with 9.0% of our sample indicating use once a month, 5.7% indicating use more than once a month but less than weekly, 4.0% reporting use 1 to 6 days a week, and 6.1% reporting using every day. sociodemographic factors including race/ethnicity, education, and employment were associated with pain intensity at the bivariate level. substance use factors including frequency of cannabis use and alcohol use were also associated with pain intensity at the bivariate level. after controlling for sociodemographic and substance use factors, using cannabis once a month (β=1.879), more than once a month but less than weekly (β=0.981), 1 to 6 days a week (β=1.830), and every day (β=1.491) were associated with api (p<.001). additionally, having a disability (β=1.965) was associated with api (p≤.001). discussion: we found above average pain intensity in this sample and about 48% of respondents were using cannabis. increased frequency of cannabis use was statistically associated with higher average pain intensity after controlling for sociodemographic and substance use factors. as individuals continue to use cannabis, researchers should continue to assess frequency of cannabis use within the context of pain. copyright: © 2022 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 67 ved abstract objective: college students high in social anxiety are at increased risk for cannabis-related problems. this may be particularly true when they hold strong coping-related expectancies and motives for cannabis. however, few studies have examined these constructs together in accordance with the motivational model, which posits that substance use is proximally influenced by motives and more distally influenced by expectancies. thus, the current study examined whether the relation between social anxiety and cannabisrelated problems was indirectly explained through coping-related expectancies, motives, and cannabis use. method: past-month cannabis users (n = 660; 71.6% female, 47.3% white non-hispanic) from seven u.s. universities completed an online survey assessing social anxiety, and cannabis use frequency, problems, expectancies, and motives. a saturated path model examined social anxiety as a predictor of cannabis problems via coping-related expectancies and motives, and cannabis frequency. results: there was a positive indirect effect of social anxiety on cannabis problems through cognitive and behavioral impairment expectancies, depression coping motives, and cannabis use. social anxiety also indirectly positively related to cannabis problems via social and sexual facilitation expectancies, social anxiety coping motives, and cannabis use. further, social anxiety indirectly positively related to cannabis problems through relaxation and tension reduction expectancies, both depression and social anxiety coping motives, and cannabis use. these indirect effects were invariant by sex assigned at birth. conclusions: results support using a theoryinformed model of coping-related cannabis cognitions to understand the relation between social anxiety and cannabis problems. interventions that modify coping-related cognitions may reduce cannabis-related problems in college students high in social anxiety. key words: = cannabis; social anxiety; college students; expectancies; motives national estimates indicate that traditionalaged college students (i.e., 18-25 years of age) have the highest rates of cannabis use (center for behavioral health statistics and quality, 2021). in fact, national surveys suggest that nearly half of college students report past-year cannabis use, with 25% reporting past-month use (schulenberg et al., 2020). cannabis use is associated with a variety of academic/occupational, social, legal, psychological, and physical health consequences (e.g., korn et al., 2018; pearson et al., 2017; volkow et al., 2014). prior work has found that 90.8% of past-month college student cannabis users experienced at least one consequence from their cannabis use (pearson et al., 2017). thus, college students represent an important group to study with regard to cannabis use. concerningly, college students with high levels of social anxiety (i.e., a fear of being negatively evaluated in social situations) appear to be particularly susceptible to katherine a. berry1, nicholas r. livingston1, emmajo briles1, alison looby1, & stimulant norms and prevalence (snap) research team* 1department of psychology, university of wyoming cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000189 examining the relation between social anxiety and cannabis problems among college students through coping-related expectancies and motives corresponding author: katherine berry, b.a., university of wyoming, 1000 e. university ave, dept. 3415. laramie, wy, 8207. email: kberry11@uwyo.edu. cannabis, a publication of the research society on marijuana 68 experiencing cannabis problems, despite using cannabis at similar rates as students low in social anxiety (single et al., 2022). social anxiety is characterized by both high negative affect and low positive affect (brown et al., 1998). relative to other anxiety disorders, low positive affect is unique to social anxiety and appears more closely related to the characteristics of depression (kashdan, 2007). college students high in social anxiety may be compelled to use cannabis to modify both their high negative and low positive affective states (buckner et al., 2013; walukevich-dienst et al., 2020), potentially as a form of self-medication (khantzian, 1997). further, research on the pharmacological effects of cannabis demonstrates that cannabis can produce acute anxiolytic effects (crippa et al., 2009), suggesting that social anxiety may pose a salient risk for cannabis use because of the desire to reduce anxiety in social situations. as such, college students who are high in social anxiety may be particularly motivated to use cannabis based on their expectations for certain copingrelated drug effects, which are known to be associated with greater risk for problems (e.g., foster et al., 2016). cannabis expectancy effects refer to beliefs regarding the anticipated outcomes of cannabis use, and have been found to relate to different patterns of cannabis use (e.g., brackenbury et al., 2016). these expectancies can be broadly understood as higher-order positive (i.e., desirable) and negative (i.e., undesirable) effects (goldman, 1994). positive expectancies tend to be positively associated with cannabis use and problems, and negative expectancies are associated with lower use and abstinence (brackenbury et al., 2016; hayaki et al., 2010). however, in some cases negative expectancies may be associated with greater use and problems, likely reflecting increased exposure to or experience with the drug (buckner & schmidt, 2008). higher-order expectancy factors are each comprised of several lower-order factors that provide a more nuanced understanding of expected effects (goldman, 1994). cognitive and behavioral impairment (e.g., slowing one’s thinking and actions), social and sexual facilitation (e.g., talking more than usual), and relaxation and tension reduction (e.g., feeling calm) are three lower-order expectancy factors that may be exceptionally relevant in understanding why students high in social anxiety may use cannabis to reduce social anxiety symptoms. though cognitive behavioral impairment is a negative expectancy, holding strong cognitive behavioral impairment expectancies may positively relate to cannabis use, and subsequently problems, due to the expectation that cannabis will slow down anxious thoughts and change perceptions of social situations in the moment (schafer & brown, 1991). prior work examining this notion has been mixed, as buckner and schmidt (2009) found that cognitive behavioral impairment expectancies mediated the positive relation between social anxiety and cannabis problems among undergraduate students, though this effect was not replicated in another sample (buckner & schmidt, 2008). as such, more work is needed to examine whether cognitive behavioral impairment expectancies can explain the relation between social anxiety and cannabis use and problems. in addition, social and sexual facilitation expectancies may positively relate to cannabis use due to the expectation that cannabis will function as a social lubricant and help foster social interactions that individuals would usually be too anxious to initiate or participate in. to date, little research has examined relations between social and sexual facilitation, social anxiety, and cannabis use and problems. one study of college students did not find significant associations between social anxiety and social and sexual facilitation expectancies (buckner & schmidt, 2008), while another found that social and sexual facilitation expectancies mediated the negative relation between social anxiety and cannabis use (di blasi et al., 2015). yet, relations between social and sexual facilitation expectancies and cannabis problems have not been examined. finally, individuals high in social anxiety may endorse strong relaxation and tension reduction expectancies, expecting that cannabis will reduce anxious tension in social situations and help manage negative affect. again, limited research has examined relations between social anxiety, relaxation and tension reduction expectancies, and cannabis use and problems, yielding mixed results. for example, buckner and schmidt (2008) found that social anxiety was negatively related to relaxation and tension reduction expectancies, whereas buckner and schmidt (2009) failed to social anxiety & cannabis problems 69 find a significant relation between social anxiety and relaxation and tension reduction expectancies. given the limited nature of extant work examining social anxiety-relevant coping expectancies on the relation between social anxiety and cannabis use and problems, further research is warranted. importantly, though expectancies are known to relate to substance use and problems, cox and klinger’s (1988) motivational model indicates that they are not the most proximal predictor of these outcomes. instead, expectancies relate to substance use motives, or reasons for using, which are conceptualized as the final common pathway to use. thus, cannabis use behaviors can be understood as being influenced by expectancies, with motives mediating this relationship (foster et al., 2016). more specifically, emotion-focused motives, such as coping (i.e., to alleviate negative mood) motives, have been found to be the most influential motives in predicting cannabis use and cannabis-related problems (bravo et al., 2019; phillips et al., 2017). cannabis coping motives are particularly relevant for those high in social anxiety because individuals may use cannabis to cope with social anxiety-related negative affect. accordingly, research finds that coping motives play a causal role in the link between social anxiety and cannabis problems, including among undergraduate students (buckner et al., 2007; 2012). of note, this work has only examined coping motives as a broad construct related to general negative mood. lee and colleagues (2009) proposed that cannabis coping motives should be differentiated into motives to cope with negative/depressed mood and motives to cope with social anxiety. teasing apart these motives may be particularly relevant to understanding the relation between social anxiety and cannabis problems, given that individuals high in social anxiety may be prone to using cannabis to manage their emotions, though potentially not in the same way for both depression and anxiety. as no research to date has examined these betterspecified coping motives, it represents an important area for further investigation. considering that prior work has demonstrated indirect paths from social anxiety and cannabis use and problems through either expectancies and motives separately, it is important to examine these constructs together to clarify the literature and inform intervention efforts designed to reduce cannabis problems among individuals with social anxiety. however, a comprehensive model theoretically informed by cox and klinger’s (1998) motivational model has yet to be examined. in addition, it remains unknown whether certain expectancies and motives that may be particularly relevant to social anxiety explain the relation between social anxiety and cannabis problems. thus, the purpose of the current study was to examine whether the relation between social anxiety and cannabisrelated problems was indirectly explained through coping-related motives and expectancies (i.e., those related to managing social anxiety symptoms). informed by prior work and theory, we posited that there would be unique paths through which social anxiety and cannabis problems would be indirectly explained based on type of expectancy and motive. we hypothesized a positive indirect association between social anxiety and cannabis problems through cognitive behavioral impairment expectancies, depression coping motives, and cannabis use (social anxiety à cognitive behavioral impairment expectancies à depression coping motives à cannabis use à cannabis problems). in addition, we hypothesized that social anxiety would indirectly relate to cannabis problems via stronger social and sexual facilitation expectancies, greater social anxiety coping motives, and increased cannabis use (social anxiety à social and sexual facilitation expectancies àsocial anxiety coping motives à cannabis use à cannabis problems). moreover, we hypothesized that social anxiety would indirectly relate to cannabis problems via stronger relaxation and tension reduction expectancies, greater social anxiety coping motives, and increased cannabis use (social anxiety à relaxation and tension reduction expectancies à social anxiety coping motives à cannabis use à cannabis problems). lastly, we tested model invariance across sex assigned at birth, given that prior research has found sex/gender differences with both cannabis use and social anxiety. specifically, college men use cannabis at greater frequencies than college women (e.g., park et al., 2022), and women are more likely to have a social anxiety diagnosis than men (for a review, see asher et al., 2017). we did not posit any hypotheses related to sex invariance testing, as these analyses were exploratory. cannabis, a publication of the research society on marijuana 70 methods participants and procedures participants were 660 college students from seven universities in the united states who reported past-month cannabis use. students were recruited via psychology department participant pools during the 2019-2020 academic year (for more information see looby et al., 2021), and were compensated with research credit in psychology courses. after providing informed consent, students completed an online survey assessing their substance use and mental health, including cannabis use, problems, expectancies, and motives. this study was approved by the university of wyoming institutional review board. participants had a mean age of 19.69 years (sd = 2.85) and were largely assigned female sex at birth (72.6%). the majority of the sample was white non-hispanic (47.6%), followed by multiracial/ethnic (26.4%), black/african american (13.5%). hispanic/latinx (7.4%), asian (3%), other (1.4%), american indian/alaska native (0.5%), and native hawaiian/pacific islander (0.2%). measures cannabis use. the marijuana use grid (mug; pearson & marijuana outcomes study team, 2018) assessed past-month weekly cannabis use in any form (e.g., flower, edibles, concentrates, etc.). the mug assessed cannabis use using a grid measure in which each day of the week was broken down into six 4-hour time blocks (12am-4am, 4am-8am, 8am-12pm, etc.). participants were asked to report their quantity of use within each time block that occurred for any form of cannabis in a “typical week.” cannabis use frequency was calculated by summing the total number of time blocks for which they reported using any amount during a typical week (range: 042), with higher scores reflecting greater cannabis use frequency. cannabis problems. the 21-item brief marijuana consequences questionnaire (bmacq; simons et al., 2012) assessed past-month cannabis problems. example items include “i have been unhappy because of my marijuana use,” “when using marijuana i have done impulsive things that i regretted later,” and “i have become very rude, obnoxious, or insulting after using marijuana.” participants answered whether or not they experienced each cannabis problem using a dichotomous “yes” or “no” response format. number of consequences endorsed were summed to create a total problems score (α = 0.90). cannabis expectancies. the 48-item marijuana effect expectancy questionnaire (meeq; schafer & brown, 1991) assessed cannabis expectancies. example items include “marijuana slows my thinking and actions,” “i’m more social when i use marijuana,” and “marijuana makes me calm.” participants indicated the extent to which they believed or expected each cannabis-related outcome to occur if they were to use cannabis, using a five-point scale (1 = disagree strongly, 5 = agree strongly). the meeq assesses six lower-order expectancies, but for the purpose of the present study, only the relaxation and tension reduction (α = 0.86), social and sexual facilitation (α = 0.75), and cognitive behavioral impairment (α = 0.83) factors were included in the model. items for each factor were summed and averaged, with higher scores indicating stronger expectancies. cannabis motives. the comprehensive marijuana motives questionnaire (cmmq; lee et al., 2009) assessed past-month cannabis motives. this 36-item measure assesses 12 different motives for cannabis use, with items rated along a five-point scale (1 = almost never/never, 5 = almost always/always). for the purpose of the present study, only social anxiety (α = 0.83) and depression-coping (i.e., labeled as “coping motives” in the cmmq; α = 0.85) motives were examined. depression-coping motives assess coping with negative affect, with example items such as “because you were depressed” and “to escape from your life.” example items of the social anxiety motives include “because it makes you feel more comfortable in an unfamiliar situation” and “because it relaxes you when you are in an insecure situation.” items for each motive were summed and averaged, with higher scores indicating more frequent endorsement of cannabis use for that motive. social anxiety. the 20-item social interaction anxiety scale (sias; mattick & clarke, 1998) assessed social anxiety. example items include “i have difficulty talking with other people” and “i worry about expressing myself in case i appear awkward.” participants rated the extent to which social anxiety & cannabis problems 71 they believed each item was characteristic or true of them on a five-point scale (0 = not at all, 4 = extremely). items were summed, with higher scores indicating greater social anxiety (α = 0.94). data analysis a fully saturated path model was evaluated using mplus 8.6 (muthén & muthén, 1998-2017). we examined specific cannabis expectancies (i.e., relaxation and tension reduction, cognitive behavioral impairment , social and sexual facilitation) and motives (i.e., coping, social anxiety) as parallel mediators in a multiple mediation model: social anxiety symptoms à cannabis expectancies à cannabis motives à cannabis use à cannabis problems. all variables were standardized (i.e., z-scores) to produce standardized regression coefficients. we examined the total, direct, and indirect effects using bias-corrected bootstrapped estimates based on 10,000 bootstrapped samples. given our large sample size and to reduce type i error, statistical significance was determined based on 99% bias-corrected bootstrapped confidence intervals that did not contain zero. results descriptive statistics and bivariate correlations among all study variables are presented in table 1. on average, participants reported 11.32 (sd = 10.67) weekly cannabis use blocks in the past month. social anxiety symptoms ranged from 074, with most of the sample (69.1%) falling below the clinical cut-off for significant social anxiety (brown et al., 1997). social anxiety symptoms were positively significantly associated with all other study variables except cannabis use, and they were also associated with being assigned female at birth. despite this finding, we opted to retain cannabis use as an outcome in the path model because prior work has found that social anxiety is not directly related to cannabis use, though it does have indirect effects (single et al., 2022). cannabis problems were positively significantly associated with all other study variables, as well as with being assigned male at birth. finally, all expectancies and motives were significantly positively associated with one another. table 1. bivariate correlations and descriptive statistics among all study variables 1 2 3 4 5 6 7 8 9 m sd 1. sexa -- 0.72 0.45 2. sa symptoms .14 -- 27.44 14.04 3. rtr expectancies .06 .11 -- 3.57 0.86 4. ssf expectancies .01 .15 .63 -- 3.10 0.64 5. cbi expectancies .03 .23 .18 .16 -- 3.14 0.78 6. sa motives -.01 .26 .43 .43 .11 -- 2.22 1.18 7. coping motives .03 .28 .36 .22 .24 .62 -- 2.31 1.21 8. cannabis use -.09 .05 .30 .22 -.08 .32 .24 -- 11.32 10.67 9. cannabis problems -.11 .15 .25 .16 .33 .31 .43 .44 --4.41 4.69 note. a sex was coded 0 = male, 1 = female. significant correlations at p < .001 are in bold typeface for emphasis. sa = social anxiety; rtr = relaxation/tension reduction; ssf = social/sexual facilitation; cbi = cognitive/behavioral impairment. path analysis we did not find evidence of significant direct effects from social anxiety symptoms to cannabis use or problems when accounting for all other variables in the model. however, several significant indirect effects of social anxiety symptoms on cannabis use and problems were supported. regarding cannabis use, there were positive indirect effects of social anxiety symptoms through relaxation and tension reduction expectancies, β = 0.02, 99% ci [0.003, 0.05] and social anxiety motives, β = 0.04, 99% ci [0.01, 0.08] on cannabis use. conversely, there was a negative indirect effect of social anxiety symptoms through cognitive behavioral cannabis, a publication of the research society on marijuana 72 impairment expectancies on cannabis use, β = 0.04, 99% ci [-0.07, -0.01]. further, two serial mediation effects from social anxiety symptoms to cannabis use were indicated: social anxiety symptoms were positively associated with relaxation and tension reduction and social and sexual facilitation expectancies, which were positively associated with social anxiety motives, and in turn associated with increased cannabis use, both paths: β = 0.01, 99% ci [0.001, 0.02]. regarding cannabis problems, there were positive indirect effects from social anxiety symptoms via cognitive behavioral impairment expectancies, β = 0.07, 99% ci [0.04, 0.11] and coping motives, β = 0.06, 99% ci [0.03, 0.10]. in addition, social anxiety symptoms were positively associated with both relaxation and tension reduction and cognitive behavioral impairment expectancies, which in turn were associated with greater coping motives, which were associated with greater cannabis problems, relaxation and tension reduction: β = 0.01, 99% ci [0.002, 0.03]; cognitive behavioral impairment: β = 0.01, 99% ci [0.002, 0.02]. next, social anxiety symptoms were positively associated with relaxation and tension reduction expectancies, which were associated with greater cannabis use, which was in turn associated with increased problems, β = 0.01, 99% ci [0.001, 0.02]. conversely, social anxiety symptoms were positively associated with cognitive behavioral impairment expectancies, which in turn were associated with reduced cannabis use, which was then associated with fewer cannabis problems, β = -0.02, 99% ci [-0.03, -0.01]. in addition, there was a positive indirect effect of social anxiety symptoms on cannabis problems via a positive association between social anxiety motives and cannabis use, β = 0.02, 99% ci [0.004, 0.03]. finally, there were four serial indirect effects for the comprehensive model. social anxiety symptoms were positively associated with relaxation and tension reduction and social and sexual facilitation expectancies, which were positively associated with social anxiety motives, which were then positively associated with cannabis use, and in turn associated with greater cannabis problems (social anxiety symptoms à relaxation and tension reduction/social and sexual facilitation expectancies à social anxiety motives à cannabis use à cannabis problems; relaxation and tension reduction: β = 0.002, 99% ci [0.00, 0.01]; social and sexual facilitation: β = 0.003, 99% ci [0.001, 0.01]). in addition, social anxiety symptoms were positively associated with relaxation and tension reduction and cognitive behavioral impairment expectancies, which were positively associated with coping motives, which were positively associated with cannabis use, and in turn was associated with greater cannabis problems (social anxiety symptoms à relaxation and tension reduction/cognitive behavioral impairment expectancies à coping motives à cannabis use à cannabis problems; both paths: β = 0.001, 99% ci [0.00, 0.01]). the total and indirect effects for the path model are detailed in table 2 and direct effects are shown in figure 1. table 2 . summary of total, indirect, and direct effects of social anxiety symptoms on cannabis problems via cannabis motives, expectancies, and cannabis use cannabis use β 99% ci cannabis problems β 99% ci predictor: social anxiety symptoms total 0.05 -0.05, 0.16 0.15 0.05, 0.24 total indirecta 0.06 0.01, 0.12 0.16 0.09, 0.24 rtr expectancies 0.02 0.00, 0.05 0.00 -0.02, 0.01 ssf expectancies 0.01 -0.01, 0.03 -0.01 -0.03, 0.01 cbi expectancies -0.04 -0.07, -0.01 0.07 0.04, 0.11 sa motives 0.04 0.01, 0.08 -0.01 -0.03, 0.02 coping motives 0.02 -0.01, 0.05 0.06 0.03, 0.10 cannabis use -0.00 -0.05, 0.04 rtr expectancies – sa motives 0.01 0.00, 0.02 0.00 -0.01, 0.01 ssf expectancies – sa motives 0.01 0.00, 0.02 0.00 -0.01, 0.01 social anxiety & cannabis problems 73 cbi expectancies – sa motives -0.00 -0.01, 0.00 0.00 -0.01, 0.01 rtr expectancies – coping motives 0.00 -0.00, 0.01 0.01 0.01, 0.03 ssf expectancies – coping motives -0.00 -0.01, 0.00 -0.00 -0.01, 0.01 cbi expectancies – coping motives 0.00 -0.00, 0.01 0.01 0.00, 0.02 rtr expectancies – cannabis use 0.01 0.00, 0.02 ssf expectancies – cannabis use 0.00 -0.01, 0.01 cbi expectancies – cannabis use -0.02 -0.03, -0.01 sa motives – cannabis use 0.02 0.00, 0.03 coping motives – cannabis use 0.01 -0.00, 0.02 rtr expectancies – sa motives – cannabis use 0.00 0.00, 0.01 ssf expectancies – sa motives – cannabis use 0.00 0.00, 0.01 cbi expectancies – sa motives – cannabis use 0.00 -0.00, 0.00 rtr expectancies – coping motives – cannabis use 0.00 0.00, 0.01 ssf expectancies – coping motives – cannabis use 0.00 -0.00, 0.00 cbi expectancies – coping motives – cannabis use 0.00 0.00, 0.00 direct -0.01 -0.11, 0.09 -0.02 -0.10, 0.07 note. significant associations are in bold typeface for emphasis and were determined by a 99% bias-corrected bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. significant confidence intervals that appear to include zero are the result of rounding and do not truly include zero. a reflects the combined indirect associations within the model. rtr = relaxation/tension reduction; ssf= social/sexual facilitation; cbi = cognitive/behavioral impairment; sa = social anxiety. exploratory sex invariance testing given prior research demonstrating differences across study variables based on sex assigned at birth or gender, we performed an exploratory multi-group analysis to evaluate whether model associations were invariant based on sex assigned at birth. specifically, χ2 difference tests were used to examine whether a freely estimated multi-group model differed as compared to a constrained multi-group model. because the χ2 statistic is sensitive to sample size (brown, 2015), invariance was determined at p > .01, and decreases in cfi and tli of greater than .01 from the freely estimated model (putnick & bornstein, 2016). results from the fully constrained model indicated that this model was not invariant across sex assigned at birth due to a decrease of .011 in cfi and .022 in tli compared to the freely estimated model. to identify an invariant model, we identified the path with the greatest contribution to reducing model fit within the fully constrained model. once we identified the path and allowed for it to be freely estimated, we identified and freely estimated the next path with the greatest contribution at reducing model fit, repeating this procedure until we achieved acceptable model fit. in the final multi-group model, χ2 (25) = 25.97, p = .41; cfi = 1.0, tli = 1.0, all associations were constrained between sex except for two paths: (a) the path between cognitive behavioral impairment expectancies and coping motives, and (b) the path between social and sexual facilitation expectancies and social anxiety motives. further, the association between social and sexual facilitation and cognitive behavioral impairment expectancies was also unconstrained. the relation between cognitive behavioral impairment expectancies and coping motives was positive and significant for male students, β = 0.24, 99% ci [0.10, 0.38], but not significant for females, β = 0.09, 99% ci [-0.02, 0.19]. the relation between social and sexual facilitation expectancies and social anxiety motives was positive and significant for females, β = 0.27, 99% ci [0.15, 0.38], yet nonsignificant for males, β = 0.13, 99% ci [-0.03, 0.30]. further, the relation between social and sexual facilitation and cognitive behavioral impairment expectancies was positive and significant for female students, β = 0.19, 99% ci [0.08, 0.30], but not males, β = -0.01, 99% ci [-0.17, 0.15]. examination of indirect effects involving cannabis, a publication of the research society on marijuana 74 figure 1. path model depicting the direct effects of social anxiety and cannabis-related problems vis cannabis expectancies, cannabis motives, and cannabis use note. depicts the standardized effects of the path model predicting cannabis-related problems. significant associations were determined by 99% biascorrected standardized bootstrapped confidence interval (based on 10,000 bootstrapped samples) that does not contain zero. non-significant paths are not depicted for parsimony but are available upon request. ssf = social/sexual facilitation; rtr = relaxation and tension reduction; cbi = cognitive behavioral impairment; sa = social anxiety. social anxiety & cannabis problems 75 these pathways in the multigroup model indicated one indirect path that was significant in the original model that was not invariant by sex: social anxiety à cognitive behavioral impairment à coping motives à cannabis problems. this indirect effect was significant for male students, β = 0.01, 99% ci [0.00, 0.02], but not female students, β = 0.01, 99% ci [-0.002, 0.01]. all other significant indirect effects identified in the overall model were invariant across sex assigned at birth. discussion informed by the motivational model (cox & klinger, 1988), the current study tested a path model of the relation between social anxiety and cannabis use and problems through copingrelated expectancies and motives among a sample of past-month undergraduate cannabis users. replicating prior work (single et al., 2022), social anxiety was not significantly directly related to cannabis use, though it was positively associated with cannabis problems. this finding suggests that college students high in social anxiety may not be vulnerable to using cannabis more frequently than their peers who are lower in social anxiety; however, they may be at a heightened risk for experiencing cannabis problems. despite a significant bivariate correlation, there was not a significant direct association between social anxiety and cannabis problems after including relevant expectancies and motives into the path model, suggesting that the relation between social anxiety and cannabis problems may be explained by these cognitions. we did find significant direct effects in the path model between social anxiety and all included expectancies and motives, providing support for their relevance to social anxiety as coping-related cognitions. in addition, there were unique indirect and direct effects depending on type of expectancies and motives endorsed, highlighting the necessity of using a theory-informed model of coping-related cannabis cognitions to understand the relation between social anxiety and cannabis problems. consistent with our hypothesis, there was a positive indirect association between social anxiety and cannabis problems through cognitive behavioral impairment expectancies, depression coping motives, and cannabis use. this is consistent with previous research showing that cognitive behavioral impairment expectancies and coping motives independently mediate the positive relation between social anxiety and cannabis problems (buckner & schmidt, 2008; buckner et al., 2007). this indirect effect was similarly significant when cannabis use was the outcome in our model. it is possible that cannabisrelated cognitive and behavioral impairment may be desirable among individuals who are high in social anxiety, especially when they believe that the impairment will help them cope with their depression symptoms, which increases cannabis use and risk for problems. interestingly, there was a positive indirect association between social anxiety and cannabis problems through cognitive and behavioral impairment expectancies, but this effect was negative when cannabis use was the outcome in our model. given that the measure of cannabis problems used in the current study is comprised of some items that reflect delayed problems such as, “when using marijuana i have done impulsive things that i have later regretted” and “i have become very rude, obnoxious, or insulting after using marijuana,” it is possible that individuals who are high in social anxiety report greater cannabis consequences because they ruminate on the actions that they made while they were cognitively and behaviorally impaired from cannabis, resulting in greater selfreport of problems later in time despite not having used frequently. notably, there was no direct effect between, nor a significant indirect effect involving, cognitive behavioral impairment expectancies and social anxiety motives, as hypothesized. as such, it is possible that students high in social anxiety who endorse strong cognitive behavioral impairment expectancies may not use cannabis to cope with their symptoms of social anxiety because they either do not expect that the impairment from cannabis will assist with concerns over negative evaluation, or they are concerned that the impairment may exacerbate negative evaluation. also consistent with our hypotheses, we found a positive indirect effect from social anxiety to cannabis problems that ran through social and sexual facilitation expectancies and social anxiety coping motives. similarly, this indirect effect remained significant when cannabis use was examined as the outcome variable. students high in social anxiety may expect cannabis to make them more sociable and/or sexual, which in turn motivates them to use cannabis to alleviate their cannabis, a publication of the research society on marijuana 76 social anxiety symptoms. for example, college students high in social anxiety may use cannabis to help them better fit into their social environments and consequently draw less attention to themselves, which could reduce potential fears of being negatively evaluated. importantly, social and sexual facilitation expectancies were only related to social anxiety motives, and not depression coping motives. college students high in social anxiety may be motivated to use cannabis to cope with their social anxiety symptoms because they expect that cannabis will directly lower their social anxiety symptoms by making them feel more confident, comfortable, and social, but this expectation does not extend to being motivated to use cannabis to improve depression symptoms. further, social and sexual facilitation expectancies do appear to align well with social anxiety motives, given that both reference cognitions pertaining to social interactions, whereas depression coping motives reference negative affect more broadly (e.g., “to forget your problems”). we further hypothesized that social anxiety would indirectly positively relate to cannabis problems via relaxation and tension reduction expectancies, social anxiety motives, and increased cannabis use. while this hypothesis was supported, we also found a positive indirect effect from social anxiety to cannabis problems that ran through relaxation and tension reduction expectancies, depression coping motives, and cannabis use. similarly, paths through relaxation and tension reduction expectancies and both types of motives remained significant when cannabis use was examined as the outcome. college students who are high in social anxiety may expect cannabis to reduce their anxious tension, which in turn motivates them to use cannabis to cope more broadly with their negative affect. in other words, it does not appear that college students who are high in social anxiety who endorse strong relaxation and tension reduction expectancies are only motivated to use cannabis to cope with their symptoms relating to depression or anxiety, but instead they may be using cannabis to cope more broadly. this finding may be understood by considering the negative affectivity characterized by both symptoms of depression and anxiety. given that relaxation and tension reduction expectancies involve anticipation of reduced tension and increased relaxation, it is not surprising that college students who are high in social anxiety may find the potential tension/relaxation effects of cannabis to be desirable and a means of managing the negative emotional states that they experience from both their symptoms of depression and social anxiety. overall, results from this study highlight the necessity of using a comprehensive model of cannabis cognitions to understand the relation between social anxiety symptoms and cannabis consequences. that is, inclusion of cognitive factors (i.e., expectancies and motives) outlined in motivational models of cannabis use (cox & klinger, 1998) elucidate nuanced pathways that can be used to understand these relations and identify at-risk users. for example, the finding that there was a negative indirect relation between social anxiety symptoms and cannabis problems via increased cognitive behavioral impairment expectancies and reduced cannabis use, but a positive indirect relation when coping motives were added to the model, suggests that specific combinations of expectancies and motives may alter relations between social anxiety and cannabis problems. in turn, our findings suggest that those with increased relaxation and tension reduction or social sexual facilitation expectancies and increased social anxiety motives, as well as those with increased relaxation and tensions reduction or cognitive behavioral impairment expectancies and coping motives maintain the most risk for cannabis problems when social anxiety is present. in sum, individuals with social anxiety may use cannabis to alleviate distressing social anxiety and depression-relevant symptoms, but then may be prone to increased risk of negative consequences due to greater cannabis use. accordingly, these combinations of expectancies and motives warrant further investigation as possible risk factors and consequent targets for treatment. as an exploratory aim, we tested model invariance across sex assigned at birth, given that prior research has found sex/gender differences with both cannabis use and social anxiety. we found two direct paths that differed by sex. first, we found that the relation between cognitive behavioral impairment expectancies and depression coping motives was significant for individuals assigned male at birth, but not females. male college students, especially those social anxiety & cannabis problems 77 high in social anxiety, may endorse the belief that cannabis-related impairment will help them cope with their depression symptoms more strongly than female college students. in addition, we found that the link between social and sexual facilitation expectancies and social anxiety motives was only significant for college students who were assigned female at birth, indicating that female students may be motivated to use cannabis to cope with social anxiety symptoms because they believe that cannabis will help make them feel more social/sexual. given that males reported greater cognitive behavioral impairment expectancies than females, it is possible that females expect cannabis to help facilitate their social interactions more strongly because they do not believe that they will be too impaired to carry out social/sexual interactions, whereas males may believe the opposite. when examining invariance across indirect paths, we found that the indirect path between social anxiety and cannabis problems through cognitive behavioral impairment expectancies and depression coping motives, which was significant in the overall model, was not invariant, such that it was only significant for male students. interestingly, there was only a sex difference when cannabis use was not included in the model. this finding may suggest that male college students who endorse strong cognitive behavioral impairment expectancies and coping motives experience greater cannabis problems than college student females, but not necessarily because they are using cannabis at greater frequencies. it may instead be that male students experience greater cannabis-related problems because they consume their cannabis differently than females and males who do not have strong cognitive behavioral impairment expectancies and coping motives. for example, they may combine their cannabis with other substances (e.g., alcohol) or use in greater quantities, and therefore experience greater cannabis-related problems, despite not necessarily consuming cannabis at greater frequencies. on the whole, nearly all paths in our model were sex-invariant, indicating that the general relations between social anxiety and cannabis problems through coping-related expectancies and motives function in similar ways for both male and female college students. results from the current study importantly highlight the necessity of using a comprehensive model of cannabis cognitions to understand the relation between social anxiety and cannabis problems; however, there are several limitations to consider. first, our cross-sectional study design precludes our ability to make causal inferences. thus, future work using longitudinal or momentary study designs is needed to increase confidence in the present findings. second, the current study used the original version of the sias, which uses the item “i have difficulty talking to attractive persons of the opposite sex.” this item introduces biases for sexual and gender minority individuals, who may systematically respond differently to this item due to their perceptions of sexual attraction. therefore, future studies may consider using a modified version of this item, such as “i have difficulty talking to attractive persons” to be more inclusive to gender and sexual minority individuals (rahm-knigge et al., 2018). although an important strength in our study is our diverse and multisite sample, our results are most specific to college students who were assigned female sex at birth and are enrolled in psychology courses. as such, future research is needed to examine the applicability of these findings across broader and more diverse undergraduate samples. our model also did not include information on quantity or type (e.g., edibles vs. concentrates) of cannabis use, which may uniquely relate with the variables included in this study and should be examined in future research. lastly, our sample was not restricted to individuals who have clinically significant social anxiety symptoms. applying this research to a clinical sample is a necessary next step. despite these limitations, the current study is the first to utilize a theory-informed motivational model of coping-related cannabis cognitions to examine the relation between social anxiety and cannabis problems in a sample of college student cannabis users, including attending to assessing type of cannabis coping motive separately. findings highlight the necessity of differentiating coping motives into motives to cope with depressed mood and motives to cope with social anxiety in order to better understand the relation between social anxiety and cannabis problem. as such, additional research is needed to examine the relation between social anxiety and cannabis problems using lee and colleagues’ (2009) betterspecified coping motives. in addition, findings from this study may be used to inform cannabis, a publication of the research society on marijuana 78 intervention efforts designed to reduce cannabisrelated harm among college students who are high in social anxiety. given that expectancies are potentially modifiable and can be challenged through expectancy challenge paradigms (e.g., darkes & goldman, 1993), intervention efforts may focus on modifying cognitive behavioral impairment, relaxation and tension reduction, and social and sexual facilitation expectancies. in addition, college students high in social anxiety may benefit from interventions focused on identifying alternative means of coping with depression and social anxiety symptoms outside of cannabis use. given that there was a direct effect between social anxiety and cannabis problems, it is possible that targeting social anxiety directly may be efficacious in reducing cannabis-related problems among college students who are high in social anxiety. specifically, individuals who are high in social anxiety may benefit from receiving either a full course of cognitive behavioral therapy (cbt) or an intervention that encompasses key components of cbt, such as exposure tasks, as cbt is considered the goldstandard 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(2020). cannabis-related impairment and social anxiety: the role of use to manage negative and positive affect in social situations. substance use & misuse, 55(2), 271–280. https://doiorg.libproxy.uwyo.edu/10.1080/10826084.201 9.1664590 funding and acknowledgements: this research was supported by an institutional development award (idea) by the national institute of general medical sciences (#82p20gm103432). no conflict declared. *this project was completed by the stimulant norms and prevalence (snap) study team, which includes the following investigators (in alphabetical order): adrian j. bravo, william & mary (co-pi); bradley t. conner, colorado state university; mitch earleywine, university at social anxiety & cannabis problems 81 albany, state university of new york; james henson, old dominion university; alison looby, university of wyoming (co-pi); mark a. prince, colorado state university; ty schepis, texas state university; margo villarosa-hurlocker, university of new mexico copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 106 ved abstract abstract objective: little is known about the population-level impact of recreational cannabis legalization on trends in opioid-related mortality. increased access to cannabis due to legalization has been hypothesized to reduce opioid-related deaths because of the potential opioid-sparing effects of cannabis. the objective of this study was to examine the relations between national retail sales of recreational (non-medical) cannabis and opioid overdose deaths in the 5 years following legalization in canada. method: using time-series data, we applied granger causality methods to evaluate the association between trends in legal recreational cannabis sales and opioid-related deaths over time. both sales and opioid deaths grew over time, with the latter exhibiting significant increases following the onset of the covid-19 pandemic. results: we found no support for the hypothesis that increasing post-legalization sales granger caused changes in opioid-related deaths in british columbia, ontario, or at the national level. conclusions: these findings suggest that increases in legal recreational cannabis sales following legalization were not meaningfully associated with changes in opioid-related mortality. further examination with longer follow-up periods will be needed as the legal cannabis market becomes more entrenched in canada, but these findings converge with previous work suggesting legalization is not related to opioid overdose mortality and further undermine that hypothesized link as a basis for legalization in other jurisdictions. key words: = cannabis; legalization; opioid; mortality; behavioural economics as more jurisdictions legalize recreational (non-medical) cannabis, there has been obvious interest regarding how legalization impacts cannabis use (kelsall, 2018), but also its collateral impact on use of other substances including opioids (mathur & ruhm, 2023). in canada, more than 30,000 people have died from opioid-related overdoses since 2016, which is more than all other accidental death causes combined (fischer et al., 2023). the opioid overdose epidemic has been recognized as a public health crisis in canada (public health agency of canada, 2023), and, andré j. mcdonald1-3*, alysha cooper1-3*, amanda doggett1-3, kyla belisario1-3, james mackillop1-3 1peter boris centre for addictions research, st. joseph's healthcare hamilton 2department of psychiatry and behavioural neurosciences, mcmaster university 3michael g. degroote centre for medicinal cannabis research, mcmaster university *co-first (equal contributions) cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000261 volume 7, special issue 3 legal recreational cannabis sales and opioid-related mortality in the 5 years following cannabis legalization in canada: a granger causality analysis corresponding author: andré mcdonald, phd, mcmaster university. 100 west 5th street, hamilton, ontario, canada, l8p 3p2. email: mcdona36@mcmaster.ca cannabis, a publication of the research society on marijuana 107 based on potential substitutability relationships —so-called “opioid-sparing effects” where cannabis reduces the need for opioids without loss of analgesic efficacy (nielsen et al., 2017)—there is interest in whether regulatory changes in cannabis access may have a favorable impact (mathur & ruhm, 2023). previous research—mostly from the u.s— examining the relationship between cannabis legalization and opioid-related outcomes is mixed. some studies have found a substitution effect between cannabis legalization and opioid-related mortality (e.g., chan et al., 2019; powell et al., 2018), with one major study suggesting that states with medical cannabis laws experienced slower increases in opioid-related deaths from 1999 to 2010 (bachhuber et al., 2014). however, a subsequent study extended the observation period and found that this trend reversed direction, suggesting that the association may be spurious (shover et al., 2019). another large study also found no significant association between state cannabis laws (recreational and medical) and opioid-related mortality (nguyen et al., 2024). meanwhile, a recent study found that legalized cannabis in the u.s. was associated with increased opioid mortality rates (mathur & ruhm, 2023), though the authors acknowledge that the association may have been driven by the emergence and proliferation of fentanyl, a particularly potent opioid in the drug supply. few national jurisdictions have legalized cannabis for recreational purposes, and those that have, such as canada in 2018, did so relatively recently, meaning little is known about the population-level impact of legal cannabis sales on trends in opioid-related mortality. this represents a significant research gap that could help inform the continuing policy response in canada and provide guidance to other jurisdictions considering cannabis policy reform. national retail sales data provide an opportunity to objectively study trends and dynamics between population-level purchasing patterns of legal commodities, including cannabis (mackillop et al., 2021), yet few studies have leveraged these data. therefore, the objective of this study was to examine the relationship between national retail sales of legal recreational cannabis in canada from its inception in relation to opioid deaths. using time-series data, we used granger causality—i.e., one variable forecasting or “granger causing” another variable—to evaluate the interrelationships between trends over time. this approach evaluates whether, in two parallel time series, indicators earlier in one time series systematically predict an indicator at later points in a second time series (granger, 1969). methods data sources this study used national level data as well as provincial level data from ontario and british columbia, the two provinces with the greatest number of opioid-related deaths (public health agency of canada); monthly data were not available from other provinces. at the national level, data included cannabis sales ($ cad) and number of opioid-related deaths from october 2018 to june 2023. given that the national data were measured quarterly for opioid-related deaths, the total monthly cannabis sales were aggregated into quarterly sales. given the small number of data points of the quarterly time series, only a single time lag was considered when fitting the model. in bc, data were available from october 2018 to september 2023, and in ontario from october 2018 to march 2023. for the sales data, we adjusted for inflation and price changes (cannabis prices declined markedly over the study period) by dividing the series by the consumer price index series and multiplying by 100 to revert to the original scale. the number of opioid-related deaths were divided by the estimated jurisdictional population for the given time frequency and reported as number of deaths per 1 million. national and provincial sales data were collected from table 20-10-0056-01 in statistics canada (2023a), consumer price index (cpi) data were collected from table 18-10-0004-10 (statistics canada, 2023b), the number of opioid-related deaths in bc was collected from the british columbia centre for disease control (bccdc, 2024), the quarterly estimates of the population in bc were collected from table 17-10-0009-01 in statistics canada (2023c), and both the number of opioid-related deaths in ontario along with the estimated population were collected from the interactive opioid tool available through public health ontario (2023). we note that for bc, monthly data were only available for unregulated drug deaths at the aggregate level, which included legal cannabis sales and opioid deaths in canada 108 some deaths that were related to drugs other than opioids; however, on average, over 85% of unregulated drug deaths involved fentanyl, and 24% involved other opioids for the years studied (bccdc, 2024). national level opioid-related death data were obtained from the public health agency of canada (2023). all data used in this study are publicly available (see etable 1 in supplementary materials for all time-series data used for this study). vector auroregression and granger causality vector autoregression (var) is a series of regression equations where each variable at time t is predicted by time lags of itself and the other variable(s) in the series. the number of time lags, p, included in the model can be chosen using information criteria and/or final prediction error (fpe). in this study, we chose the number of time lags based on the majority vote between the akaike information criterion (aic; akaike, 1969), schwarz criterion (sc; schwarz, 1978), hannan-quinn criterion (hq; hannan & quinn, 1979), and the fpe. after fitting the var models, the granger causality tests were conducted to determine whether one variable could be used to forecast another variable. prior to conducting granger causality, it is important to ensure that all model assumptions of the var model are met. the assumptions of the var model include non-serially correlated residuals, homoscedastic residuals, normally distributed residuals, and stability of parameter estimates. the asymptotic portmanteau test was conducted to evaluate whether model residuals were serially correlated. it is recommended to conduct the portmanteau test at lags considerably larger than p, but not too large such that the power of the test is reduced (kilian & lütkepohl, 2017). therefore, we considered lags from p+2 to f (i.e., the frequency of the series) in the portmanteau test to ensure the results were robust across lags. in addition, the arch-lm test (engle, 1982) was conducted to evaluate whether or not there was evidence of heteroskedasticity of model residuals from 1 to f lags. finally, the jarque-bera (jb) test (jarque & bera, 1987) was used to determine whether there was evidence of deviation from the normal distribution in the model residuals, and the ols-cusum test (ploberger & krämer, 1992) was applied for evaluating the stability of model parameters. var models can also include other variables which may change over time. therefore, to ensure that the onset of covid-19 did not change our results, all analyses were re-conducted with a dummy variable equal to 1 during and after march 2020 and 0 otherwise. the bc government implemented a safer supply program in march 2020 (nguyen et al., 2024); therefore, for bc, the dummy variable represented both covid-19 and the safer supply program. no conclusions changed when fitting the monthly models with the dummy variable; therefore, this variable was not included in the reported analyses. all models were fit with the vars package in r (pfaff, 2008a; r core team, 2024). pre-processing data a requirement of var models is that the series are stationary (i.e., its statistical properties such as mean and variance do not depend on time). therefore, the series were evaluated for seasonal patterns and trends prior to fitting the models. in terms of the trend, if the trend was deterministic (i.e., predictable and described as a function of time), then it would be accounted for within the var models, whereas if the trend was stochastic (i.e., unpredictable movements of the series), then it would be removed from the series prior to fitting the model. in addition, if seasonality was present in the series, it would be removed prior to model fitting as well, to ensure the series in the models were white noise. a combination of the kruskal-wallis (kw) test (kruskal & wallis, 1952) and the modified qs test (maravall, 2011) was used to detect seasonality, such that the data were deemed to be seasonal if both tests were significant at the 5% level of significance. the tests were conducted within the seastests package in r (ollech, 2021). if the time series had a significant seasonal component, it was estimated with “seasonal and trend decomposition using loess” (stl; cleveland et al., 1990) and subtracted from the series. the kwiatkowski–phillips–schmidt–shin (kpss) test (kwiatkowski et al., 1992) and the augmented dickey-fuller (adf) test (dickey & fuller, 1979) were used for testing whether there was a unit root in the series. each series was first evaluated with the kpss and adf tests for whether they were stationary around a trend. if cannabis, a publication of the research society on marijuana 109 the series were found to be stationary around a trend, they were evaluated for whether they are stationary around a constant. finally, if the series were stationary around a constant, then a final adf test was conducted for whether they were stationary without a trend or constant. if a series was found to be stationary only after accounting for a trend/constant, then a trend/constant was included in the respective var model. the kpss tests were conducted with the kpss.test function within the tseries package in r (trapletti et al., 2007), and the adf tests were conducted with the ur.df function in the urca package in r (pfaff, 2008b). if the series were non-stationary at the 5% level of significance according to either the kpss test or the adf test (i.e., p < 0.05 for kpss or p > 0.05 for adf), they were first differenced until stationarity was achieved. if a time series appeared to have a structural break (i.e., sudden change in data generating process), then the structural break point would be estimated via the breakpoints function within the strucchange package in r (zeileis, kleiber, krämer, & hornik, 2003; zeileis, leisch, hornik, & kleiber, 2002). in the presence of a structural break, the zivotandrews test was conducted in addition to the kpss and adf tests. the zivot-andrews test accounts for an unknown single structural break when evaluating the stationarity of a time series. a rejection of the null hypothesis in the zivotandrews test implies the series is trend stationary with a break in either the a) intercept, b) trend, or c) the intercept and the trend, depending on the test conducted. for the purpose of our analyses, we conducted the zivot-andrews test accounting for a potential change in the intercept and trend. toda-yamamoto approach granger causality in differences can potentially be problematic if there is cointegration between the variables in the model. to ensure robustness of our results, we additionally applied the toda-yamamoto (1995) approach for testing granger causality. the toda-yamamoto approach is less sensitive to incorrect identification of the order of integration or cointegration of the series. to ensure the proper distribution of the test statistic, this approach involves augmenting a var model with additional lags up to the “max integration order”. the max integration order is defined as the order of integration required to make both series stationary. for example, if we initially fit a var model with p = 2 lags on the first-differenced data (i.e., integration order of 1), then we would fit the var model with p + 1 = 3 lags on the nonstationary data for the toda-yamamoto approach. however, the test of causality is only evaluated for the first p lags of the model and the augmented lags are not included in the test. in addition, the fourier toda yamamoto method (nazlioglu, gormus & soytas, 2016) was applied to confirm reliability of our findings when treating the structural break from covid-19 as unknown (see eresults 1 in supplemental materials for further details). interrupted time series analysis we additionally conducted interrupted time series analysis via autoregressive integrated moving average (arima) modelling to evaluate the impact of legalization on opioid deaths in bc and ontario (there were not enough quarterly data at the national level). for both ontario and bc, we used monthly opioid-related deaths spanning from january 2013 (pre-pandemic) to october 2023. these analyses included a variable that allows for a gradual change in opioid-related mortality following the onset of the covid-19 pandemic (and the safer supply program in bc). we conducted interrupted time series analysis with arima models to account for any auto-correlation in the series and/or seasonality when required. we included two variables for the potential impact of legalization implementation: a variable for a step/level change immediately following legalization and a variable for a change in the outcome over time following legalization. the breakpoint of interest for both analyses was october 2018, the date of legalization implementation. however, we also looked to see whether the passage of the cannabis act in november 2017 (cannabis act, 2018; library of parliament, 2018) had an effect or improved model fit. we also examined naloxone policy changes in ontario (naloxone provided for free in pharmacies june 2016) and bc (naloxone unscheduled in sept 2016) as intervention points. as passage of the cannabis act and naloxone policy changes did not have an effect on opioidrelated mortality in either province, we excluded these intervention points from the final models. legal cannabis sales and opioid deaths in canada 110 cannabis was not legalized until october 2018 in canada (cannabis act, 2018; library of parliament, 2018), and therefore, the data in our analyses were restricted in size, thereby limiting the methods that could be used for seasonal adjustment. we chose to use the stl approach for seasonal adjustment, as it preserves the sample size of the data and can be estimated with a few years worth of data. however, the moving average filters used in stl may reduce the power of unit root tests (ghysels & perron, 1993), and in doing so may impact the perceived order of integration. to overcome this, we could have adjusted for seasonality inside the model, as opposed to outside the model, through the inclusion of eleven seasonal dummy variables in the model. in considering the ratio of sample size to number of coefficients to estimate, we opted to seasonally adjust the data outside the model via stl. however, a sensitivity analysis confirmed that all conclusions remained the same to those reported below when adjusting for seasonal patterns inside the model as opposed to outside the model. results visualizing changes over time the time series of cannabis sales and national and provincial opioid-related mortality rates from october 2018 up to september 2023 are presented in figure 1. a steady upward trend can be observed for legal cannabis sales since legalization, increasing by more than 10 times from $42 million per month in october 2018 to $444 million per month five years later in september 2023. in terms of the opioid mortality rates, both nationally and provincially, the trend and intercept appear to change with the onset of covid-19 in march 2020, such that the mean mortality rate increased and the trend becomes more positive with the onset of the pandemic. interrupted time series analyses were conducted to examine whether the structural break in these time series were significant. nationwide, there was a significant immediate increase in the mortality rate at the onset of covid-19 (p < .001) but not a significant change in the trend (p = .466). the same findings were found for ontario, where there was a significant immediate increase in the mortality rate (p < .001), but not a change in the trend (p = .142). on the other hand, both a significant increase in the level (p < .001) and trend (p < .001) of the mortality rate were found in bc following the onset of covid-19. this structural break in the data was accounted for in the pre-processing and analysis stages of our methods. figure 1a. quarterly legal cannabis sales ($) and opioid-related mortality rate in canada between october 2018 and september 2023 cannabis, a publication of the research society on marijuana 111 figure 1b. monthly legal cannabis sales ($) between october 2018 and september 2023 and opioid-related mortality rate in ontario between october 2018 and march 2023 figure 1c. monthly legal cannabis sales ($) and opioid-related mortality rate in british columbia between october 2018 and september 2023 pre-processing data table 1 presents the results of the kw and qs tests for seasonality of each time series. due to an apparent structural break in the opioid-related mortality rates, these series were first split in two (preand postcovid-19 onset) for assessment of seasonal patterns to ensure the seasonal patterns did not change with the structural break. significant seasonality was detected in the bc cannabis sales series. the seasonality of the series was estimated with stl decomposition (stl decompositions are presented in efigure 1 in supplemental materials) and subtracted from the series. after seasonal adjustment, the tests for seasonality did not find evidence of seasonal patterns remaining in the data. all series were first differenced to achieve stationarity (see table legal cannabis sales and opioid deaths in canada 112 2). the zivot-andrews test suggested that firstdifferencing was necessary for the national opioid mortality rate data when accounting for an unknown structural break (p > .05) in addition to being necessary for both the bc and ontario opioid mortality rate data (p > .05 for each). after first-differencing, a structural break was no longer detected in the national, on, or bc time series. table 1. seasonality tests for unadjusted and seasonally adjusted time series qs kw seasonal? ca cannabis sales unadjusted 4.48 9.23** no seasonally adjusted n/a n/a n/a ca opioid mortality rate unadjusted 0.00 3.40 no seasonally adjusted n/a n/a n/a bc cannabis sales unadjusted 8.80** 21.46** yes seasonally adjusted 0.00 5.48 no bc opioid mortality rate unadjusted 1.80 17.24 no seasonally adjusted n/a n/a n/a on cannabis sales unadjusted 1.01 17.84 no seasonally adjusted n/a n/a n/a on opioid mortality rate unadjusted 6.44** 19.27* no seasonally adjusted n/a n/a n/a note. *, **, and *** denote significance at the 10%, 5%, and 1% level, respectively. n/a = not applicable; qs = modified qs test (maravall, 2011); kw = kruskal-wallis test (kruskal & wallis, 1952). table 2. kpss and adf unit root test statistics for seasonally adjusted cannabis sales ($) in canada from october 2018-september 2023, and opioid mortality rate per million in british columbia from october 2018-september 2023, ontario from october 2018-june 2022, and canada from october 2018-june 2023 kpss adf ca cannabis sales level 0.143 (t) * -2.214 (t) first difference 0.102 (c) -4.317 (c) *** ca opioid mortality rate level 0.088 (t) -2.342 (t) first difference 0.061 (c) -3.050 (n) *** bc cannabis sales level 0.248 (t) *** -2.199 (t) first difference 0.075 (c) -7.939 (c) *** bc opioid mortality rate level 0.188 (t) ** -1.885 (t) first difference 0.102 (c) -5.737 (n) *** on cannabis sales level 0.159 (t) ** -2.478 (t) first difference 0.102 (c) -4.264 (n) *** on opioid mortality rate level 0.197 (t) ** -3.376 (t) * first difference 0.061 (c) -5.844 (n) *** note. the letter in parentheses is for whether the kpss and adf tests are testing for stationarity with trend (t), stationary with constant (c), or stationary without trend/constant (n). *, **, and *** denote significance at the 10%, 5%, and 1% level, respectively. vector autoregression models and granger causality of cannabis sales and national opioid mortality rates. a var model with a single time lag was fit to the first-differenced, quarterly cannabis sales and national opioid-related mortality rate per million. cannabis, a publication of the research society on marijuana 113 the portmanteau test did not find evidence to suggest serial correlation among model residuals, (p > .05 for lags 3 and 4) and the arch-lm test verified that the residuals were homoscedastic up to 4 lags, respectively (p > .05 for all tests). the residuals did not deviate from normality, 𝜒2(4) = 6.310, p = 0.177, and the parameters of the model were stable over time. table 3 presents the summary of results for the var model. table 3. results of var models for cannabis sales ($) and rate of death per 1 million due to opioid overdose in ontario, british columbia, and canada with rate of death due to opioids as the outcome opioid deaths jurisdiction time series predictor �̂� (se) t p-value canada quarterly oct 2018 to jun 2023 constant -1.208 (2.107) -0.573 .576 cannabis(t-1) 0.193 (0.242) 0.798 .438 opioid(t-1) 2.768e-05 (1.954e-05) 1.417 .178 ontario monthly oct 2018 to mar 2023 constant 0.163 (0.248) 0.656 .515 cannabis(t-1) -1.394e-05 (2.065e-05) -0.675 .503 opioid(t-1) -0.152 (0.141) -1.079 .286 british columbia monthly oct 2018 to sept 2023 constant 0.454 (0.617) 0.730 .465 cannabis(t-1) -1.777e-04 (1.755e-04) -1.010 .317 opioid(t-1) -0.327 (0.127) -2.568 .013 first-differenced quarterly cannabis sales at time t-1 were not associated with the national opioid-related mortality rate at time t. the granger causality test did not find evidence to suggest that cannabis sales in canada granger caused changes in the national opioid-related mortality rate, f(1,28) = 2.007, p = .168. vector autoregression models and granger causality of cannabis sales and provincial opioid mortality rates. two separate var models were fit: one for the relation between first-differenced cannabis sales and opioid mortality rate per million in bc, and the other for the relation between first-differenced cannabis sales and the opioid mortality rate per million in on. a constant was included in the on model to fulfill the stability assumption, and it was also incorporated into the bc model, given that bc cannabis sales exhibited stationarity around a constant. one lag was selected for each model. the portmanteau test and the arch-lm test verified that the residuals of each model were not serially correlated between 3 and 12 lags. however, the on model had significant heteroskedasticity of model residuals at lag 1 (p < .01). to account for the heteroskedasticity of residuals, heteroskedastic-consistent standard errors were used when evaluating granger causality. the residuals did not deviate from normality for the bc model, 𝜒2(4) = 1.671, p = .796, or the on model, 𝜒2(4) = 3.746, p = .442, and the parameters of each model were stable over time. cannabis sales at time t-1 were not significantly associated with deaths caused by opioid overdose in bc, nor opioid overdose in on at time t. the granger causality test for the bc model did not find evidence of cannabis sales granger causing the opioid mortality rate in bc, f(1,110) = 1.019, p = .315, nor did the granger causality test for the on model, f(1,98) = 0.753, p = .388. the toda-yamamoto method did not find evidence that cannabis sales granger caused changes in the opioid mortality rate in bc, 𝜒2(4) = 4.839, p = .304, or on, 𝜒2(1) =1.196, p = .274. the toda-yamamoto method could not be conducted for the opioid-related mortality rate at the national level due to the small sample size. interrupted time series analysis via autoregressive integrated moving average (arima) modelling like the granger causality analyses, we did not find a significant association between legalization and opioid deaths in either ontario or legal cannabis sales and opioid deaths in canada 114 bc. we found a significant outlier in ontario in october 2017, when the mortality rate appeared to start decreasing. an arima(1,1,0) model with drift was selected, and the data was found to be non-seasonal. there was not a significant level change in mortality rate following legalization implementation (estimated level change: 0.060, se = 1.185, z = 0.051, p = .960), nor a significant change over time (estimated slope change: -0.130, se = 0.177, z = -0.732, p = .464). figure 2a below shows the observed opioid-related mortality rate versus the counterfactual rate, which is the prediction based on what would have happened had legalization implementation not occurred. covid-19 did have a significant impact on the outcome, with a gradual increase to a new level of mortality rate. figure 2a. observed opioid-related mortality rate versus the counterfactual rate in ontario in bc, we found similar results. we found a significant outlier in november 2016, where it appears that the mortality rate started to increase. an arima (0,1,1) model was selected and no seasonality was detected. there was not a significant level change in mortality rate following legalization implementation (estimated level change: -3.101, se = 2.479, z = -1.251, p = .211) and no evidence to suggest that the rate changed over time after this point (estimated slope change: -0.182, se = 0.175, z = -1.040, p = .298). figure 2b shows the observed opioidrelated mortality rate versus the counterfactual rate had legalization implementation not occurred [counterfactual based on arima(0,1,0) model]. we note that the confidence interval was wide for bc, likely because the time series was noisy prelegalization and did not follow a stable pattern. moreover, the forecast is based on the arima(0,1,0), which forecasts just a single value, and the error accumulates linearly because of this over time. as shown, covid-19 led to a significant, gradual increase to a new level of mortality rate. cannabis, a publication of the research society on marijuana 115 figure 2b. observed opioid-related mortality rate versus the counterfactual rate in british columbia discussion this study found no evidence that increasing access to cannabis following legalization, as measured by increasing cannabis sales, granger caused changes in opioid-related deaths over time. when examining each trend in isolation, cannabis sales had a pronounced and consistent increase, while the rate of opioid-related deaths increased sharply at the beginning of the covid-19 pandemic and did not return to pre-pandemic levels. this qualitative step-like increase has been recognized as a major public health problem by the government of canada (2023). potential reasons for the increase in opioid-related harms during the pandemic include border and travel restrictions contributing to unsafe and interrupted drug supply, physical distancing and isolation increasing the likelihood of solitary consumption, increased stress and worsening mental health, and reduced capacity in harm reduction services, among others (government of canada, 2023). the findings of this study add to a relatively scarce literature on the relationship between various forms of cannabis legalization and opioidrelated mortality. previous research is mixed, with some studies finding that cannabis legalization led to a reduction in opioid-related mortality (chan et al., 2020; powell et al., 2018; bachhuber et al., 2014), and others an increase (mathur & ruhm, 2023) or no effect at all (nguyen et al., 2024; shover et al., 2019). our study is largely consistent with recent studies examining recreational cannabis legalization suggesting that legalization is not associated with meaningful changes in opioid-related mortality (nguyen et al., 2024; mathur & ruhm, 2023; shover et al., 2019). as such, arguments for cannabis legalization based on the potential benefits for opioid overdoses are not rooted in evidence, nor are arguments against cannabis legalization on the grounds that it exacerbates the opioid crisis. this is one of the first studies to examine the impact of cannabis legalization on opioid-related deaths in a jurisdiction outside the us. the policy legal cannabis sales and opioid deaths in canada 116 landscape is different in canada compared to the us, as cannabis is federally legal in canada, whereas only individual states have legalized cannabis for medical and/or non-medical purposes in the us. cannabis use was already highly prevalent in canada prior to recreational cannabis legalization, with approximately 47% of people 15 years of age and over reporting lifetime cannabis use and 15% using in any given year (statistics canada, 2018). meanwhile, problematic use of opioids was reported by only 0.4% of canadians in the year prior to cannabis legalization (statistics canada, 2018); therefore, the potential for legalization to effect changes in opioid-related mortality was limited to a small subgroup of canadians. this study had several strengths. we used national and provincial data that are inherently representative and generalizable to canadians using legal cannabis. we used a time-series design, which is superior to cross-sectional designs used by most previous studies because it allowed for the establishment of temporality and followed best practices for granger causality analysis. moreover, previous research is largely based on self-reported data, whereas we analyzed sales data, which are objective and do not suffer from social desirability bias, recall bias, or underreporting. the study also had limitations. most importantly, this study did not have a nonlegalization control jurisdiction to compare to. it did not have pre-legalization data on purchasing patterns of cannabis because cannabis was still illegal, which prevented a pre-post comparison that would have allowed us to observe whether pre-legalization trends in our indicators changed or stayed the same following cannabis legalization. some of our analyses were likely underpowered due to the limited availability of post-legalization time points, especially for opioidrelated deaths. we were unable to control for the impact of naloxone distribution on opioid mortality, as no monthly or quarterly data were available over the study period, though we conducted interrupted time series analysis, which found no association between naloxone policy changes and opioid mortality. legal cannabis sales data did not measure quantity used, although we adjusted for the consumer price index of cannabis, which declined markedly over time. legal sales are also an imperfect measure of people’s access to cannabis, as many people acquired cannabis from illegal sources before and after legalization. the data we used were ecological; further studies are needed that examine the impact of legalization on subgroups of interest, such as by age, sex, and gender. finally, the covid-19 pandemic was a major event that impacted substance use and opioidrelated deaths at the population level. while we adjusted for the pandemic using a dummy variable, it is impossible to know what the counterfactual would have been had the pandemic not occurred. to our knowledge, this is the first study to provide statistical evidence of significant increases in opioid deaths following the onset of the pandemic, as well as a steeper escalation in bc. conclusions this study found that increases in legal recreational cannabis sales following legalization were not meaningfully associated with changes in opioid-related deaths. although it has been speculated that cannabis legalization might support a greater cannabis-opioid substitution effect, thereby reducing harms related to opioids, this study extends previous findings suggesting that this does not happen in practice. further studies with longer follow-up periods will be needed to confirm whether these findings hold as the legal cannabis market becomes more entrenched in canada. references bachhuber, m. a., saloner, b., cunningham, c. o., & barry, c. l. 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[software]. r package version 0.10-11. zeileis a, kleiber c, krämer w, hornik k (2003). “testing and dating of structural changes in practice.” computational statistics & data analysis, 44(1-2), 109-123. https://doi.org/10.1016/s0167-9473(03)000306 zeileis a, leisch f, hornik k, kleiber c (2002). “strucchange: an r package for testing for structural change in linear regression models.” journal of statistical software, 7(2), 1-38. https://doi.org/10.18637/jss.v007.i02 funding and acknowledgements: this project was supported by the peter boris chair in addictions research and canada research chair in translational addiction research (crc-202000170). ajm (mfe-193995) is supported by a postdoctoral fellowship from the canadian institutes of health research (cihr). jm is a principal in beam diagnostics, inc and has consulted to clairvoyant therapeutics, inc. all other authors have no conflicts of interest to declare. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 119 citation: mcdonald, a. j., cooper, a., doggett, a., belisario, k., & mackillop, j. (2024). legal recreational cannabis sales and opioid-related mortality in the 5 years following cannabis legalization in canada: a granger causality analysis. cannabis, 7(3), 106–119. https://doi.org/10.26828/cannabis/2024/000261 issue date: december 12, 2024 research article 127 ved abstract guided self-change (gsc) is a motivational interviewing (mi)-based early intervention program, infused with cognitive behavioral therapy (cbt), for individuals with substance use problems. in this study, we implemented a 4-session gsc program with the innovative addition of mindfulness-based techniques at a minority-serving institution to reduce substance use and negative consequences among self-referred university students. we investigated processes that may be associated with behavior change, including perceived risk of use and self-efficacy ratings among university students who reported their primary substance of choice was cannabis (n = 18) or alcohol (n = 18). the sample of 36 participants (mage = 24.4, sdage = 5, range 18-37) mostly identified as female (58.3%), then male (41.7%); 52.8% identified as hispanic/latine, 22.2% as black or african american, and 19.5% as a sexual minority. among cannabis primary using students, results indicated that the perceived risk of weekly cannabis use, confidence to change, and readiness to change showed statistically significant increases from preto post-assessment. among alcohol primary using students, confidence to change and readiness to change showed statistically significant increases from preto post-assessments. all results yielded large effect sizes, which may be inflated due to the small sample size. findings suggest that over the course of participation in a brief, 4session targeted gsc program, there were significant increases in perceived risk and self-efficacy among minority university students who engage in primary cannabis or primary alcohol use. key words: = brief intervention; cannabis; gsc; substance misuse; university students currently, substance use is a widespread health problem among university students. the last national survey on drug use and health (samhsa, 2021) reported that more than half of the full-time college students surveyed drank alcohol in the past month, and roughly one in three engaged in binge drinking. college students face specific stressors and environmental pressures that are often associated with alcohol or marijuana misuse (arnett, 2005; horigian et al., 2021; single et al., 2022); this could be related to the fact that most college students are within the emerging, young, and middle adulthood ranges, which are stages typically associated with social robbert j. langwerden1,2,3, staci l. morris1,2,4, sofia b. fernandez2,4, maría eugenia contreras-pérez1,2,4, michelle m. hospital1,2,5, eric f. wagner1,2,4 1community based research institute, florida international university, miami, fl, usa 2research center in a minority institution, florida international university, miami, fl, usa 3center for anxiety and related disorders, boston university, boston, ma, usa 4school of social work, florida international university, miami, fl, usa 5department of biostatistics, florida international university, miami, fl, usa cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000173 preliminary effects of a guided self-change intervention on perceived risk and selfefficacy in university students engaging in cannabis or alcohol misuse corresponding author: eric wagner, ph.d., florida international university, 11200 sw 8 street, ahc5, miami, fl, 33199. phone: (305) 348-5612. email: wagnere@fiu.edu cannabis, a publication of the research society on marijuana 128 role changes, identity development, exploration, and transitioning (arnett, 2000). starting to attend a u.s. college has been reported to be a risk factor for cannabis (miech et al., 2017) and alcohol use initiation (borsari et al., 2007). while risky drinking behavior, on average, decreases after college, drinking for stress reduction tends to increase in post-collegiate periods (perkins, 1999). college students also face unique barriers to receiving treatment, such as low confidentiality, financial constraints, and potential university involvement, which might deter students from seeking these services (welsh et al., 2019). that said, among all university students, racial, ethnic, and sexual minority students may be burdened with additional risk factors, such as microaggressions and minority stress (pittman et al., 2019; pro et al., 2018; winberg et al., 2019), increased (historical) trauma (reyes et al., 2022; skewes & blume, 2019), and potentially stressors associated with acculturation (pham & lui, 2021). these barriers may instigate disparities in substance misuse rates and access to intervention, including at minority-serving institutions. in the current study, we focus on a sample of university students (both undergraduate and graduate students), most of whom identify as a racial, ethnic, or sexual minority. the portion of university students who engage in alcohol or cannabis misuse may exhibit a broad, yet milder range of use compared to those with substance use disorders as described in the dsm5 (american psychiatric association, 2013). substance misuse describes a pattern of alcohol and/or illicit drug use that does not meet the full criteria for substance use disorder yet can have negative shortand long-term consequences. risks associated with students’ alcohol and cannabis use include, but are not limited to, being the victim or perpetrator of violent behavior (hingson et al., 2017), worsened academic performance, and risk of drop-out (buckner et al., 2010; suerken et al., 2016), unsafe sexual behavior (mair et al., 2016; rehm et al., 2017), the later development of a substance use disorder (prince et al., 2019) and adverse mental health impacts, including suicidality (coryell et al., 2022). for cannabis misuse specifically, consequences can include cognitive or motivational difficulties (buckner et al., 2010) and psychotic symptoms (wright et al., 2021). in short, misuse of alcohol and cannabis are each associated with significant psychosocial burdens and consequences. therefore, well-timed and effective intervention with student misuse has public health relevance. the risks of alcohol and cannabis misuse do suggest that intervening early in substance use problem trajectories, before use worsens into more severe suds; has significant benefits. collegeattending adults who engage in alcohol and cannabis misuse are responsive to early and brief interventions (bis), particularly when focusing on concrete impact, harm reduction, education, and coping skills training (carey et al., 2007; diclemente et al., 2017; halladay et al., 2018, 2019; hennessy et al., 2019; palfai et al., 2016). research has shown that brief interventions effectively reduce use and negative consequences in university students and young adults who engage in cannabis (halladay et al., 2019) or alcohol misuse (larimer & cronce, 2002). nonetheless, and as was pointed out by cronce and colleagues (2022), many studies have been conducted at majority non-hispanic white u.s. institutions. further research is needed on brief interventions for racial, ethnic, and sexual minority students at minority-serving institutions (cronce et al., 2022), including investigating the application of bis with minority university students who engage in cannabis or alcohol misuse. the benefits of such research include having real-world effectiveness evaluations among understudied populations who are at risk of misusing alcohol and cannabis and are at risk for other health inequities. of particular interest are bis that are rooted in motivational interviewing (mi; miller & rollnick, 2012) because of their 1) person-centered and concrete approach, 2) known effectiveness across different health outcomes (magill et al., 2018), and 3) demonstrated effectiveness in reducing substance misuse (diclemente et al., 2017). an example of an mi-based bi applied across a cbt framework is guided self-change (gsc; sobell & sobell, 2005). gsc incorporates various elemental components of mi, including the elicitation of change-talk (barnett et al., 2014), the stages of change model (prochaska & diclemente, 1994), and rogerian approaches and personalized feedback, all of which are effective in substance use reduction, including among college students (walters & neighbors, 2005). miller and preliminary effects of a guided self-change intervention 129 rollnick define change talk as “any self-expressed language that is an argument for change” (miller & rollnick, 2012, p.152). gsc fits well with university-based implementation due to its brevity, low burden on students, and lowthreshold position in the continuum of care (halladay et al., 2019). moreover, gsc has been effective in reducing substance use in minority adolescents (gil et al., 2014; wagner et al., 2014). gsc’s underlying cbt framework is based on several emotional and cognitive processes that lead to changes in substance use. at least three theories could predict these processes and their role in the behavioral change of misuse of substances. first, in line with the social learning theory (bandura & walters, 1977), observing and modeling of peers’ substance use behavior are influential, as was confirmed by empirical research on young adults (o’donnell et al., 2019). therefore, the perception of what peers perceive as “normal” versus “risky" plays a role in misuse and, more importantly, change in misuse of substances. second, the health belief model (sulat et al., 2018) predicts that perceived severity, self-efficacy, and perceived benefits of change are pivotal to behavior change. perceived risk was shown to be a strong predictor of health behavior change outcomes (ferrer & klein, 2015), including misuse of alcohol and cannabis in emerging adults (grevenstein et al., 2015). third, grevenstein and colleagues (2015) found support for perceived risk predicting future alcohol and cannabis use reduction (in line with the motivational hypothesis). however, these same scholars found that cannabis use reduction, in turn, also predicted perceived risk (in line with the risk appraisal hypothesis) in emerging adults (grevenstein et al., 2015). this indicates that these factors might be important outcomes in alcohol and cannabis misuse, which may be generalizable to college students. real-world intervention data on gsc, an mi-based bi, could provide insight into these secondary outcomes among u.s. university students, including racial, ethnic, and sexual minority students. taking into consideration social learning theory, the health belief model, and the motivation & risk appraisal hypotheses, our study investigated the perceived risk of use (perceived severity), importance to change (perceived benefits), confidence to change (selfefficacy), and readiness to change (self-efficacy) at preand post-intervention time points. based on previous findings that alcohol and cannabis use rates decreased throughout this 4-session gsc program (morris et al., 2022), we hypothesize pre to post-intervention increases in perceived severity, self-efficacy, and perceived benefits. we think gsc may positively influence these secondary outcomes due to its focus on harm reduction, pros and cons of use, antecedents, and consequences of use, training in coping skills (i.e., mindfulness training, self-care skills, communication skills), and mi-consistent reinforcement of change talk. finally, we do not investigate nor make claims about causality in this study but merely investigate potential changes that occur throughout an intervention program. methods participants participants were university students who self-referred to the guided self-change program following an intake at the institution’s counseling center. of the total participants who enrolled in the baseline research portion of the study (n = 76), less than half were included in the present study (n = 36) based on the following inclusion criteria: 1) providing informed consent and completion of both the baseline and exit survey, 2) sole use of cannabis or sole use of alcohol, 3) completing gsc (as opposed to an abbreviated program), and 4) self-referral. we excluded participants who participated in the program due to student conduct mandates or were otherwise not selfreferred to minimize social desirability bias. enrolled participants completed the program and associated surveys between august 2017 and november 2019. only participants who provided informed consent filled out the surveys. participants were compensated with a $20 gift card for each survey completion. procedures the study was part of a larger study funded by samhsa (grant number: #1h79sp021160; see morris et al., 2022). our gsc program consisted of 4 single-hour sessions across 4-5 weeks. the session content involved therapeutic exercises focused on harm reduction, personalized feedback cannabis, a publication of the research society on marijuana 130 on substance use, exploring the antecedents, consequences, pros and cons of use, and training in reflective-, communication-, and coping skills to promote non-substance-using adaptive coping. the exercises were aided using client manuals, which participants took home as educational materials and worksheets. all sessions concluded with a weekly goal, and each session started with a check-in and discussion of these goals. through non-judgmental, mi-based approaches, the program aimed to increase intrinsic motivation and behavioral change in the misuse of alcohol and cannabis. for a detailed account of our gsc program and study, please see morris et al. (2022). instruments minority aids initiative (mai) questionnaire surveys were administered before session 1 (pre) and immediately after session 4 (post). the survey is a standardized questionnaire developed by samhsa as part of the minority aids initiative (mai), which focused on hiv/sti prevention and substance use amelioration (samhsa, 2006). survey questions asked about demographics, primary substances of use (cannabis, alcohol, and/or other), past 30-day use for distinct substances, perceived risk regarding substance use, and perceived risk regarding sexual risk behaviors. in the present study, we assessed specific outcomes: the perceived risk of 1) using cannabis once or twice a week, 2) binge drinking alcohol once or twice a week, 3) using tobacco once or twice a week, 4) engaging in unprotected sexual intercourse (generally), and 5) engaging in sexual intercourse while under the influence of drugs or alcohol (generally). all perceived risk questions were rated on a 4-point rating scale (1: no risk, 2: slight risk, 3: moderate risk, 4: great risk) with “don’t know/can’t say” as an additional answer option. goals for change outcomes gsc participants provided three goals for change ratings during session 1 (pre) and session 4 (post) of the program. (1) the motivation to change rating assessed how important changing substance use was to participants on a 5-point scale (0: not important at all, 1: less important than most of the other things in my life, 2: about as important as most of the other things in my life, 3: more important than most of the other things in my life, 4: the most important thing in my life). (2) the confidence to change rating assessed perceived confidence in oneself to reduce substance use on a 5-point scale (0: not confident at all, 1: a little confident, 2: somewhat confident, 3: very confident, 4: extremely confident). (3) the readiness to change rating aimed to assess the acute readiness to change use of alcohol and cannabis on a 5-point scale (0: not ready at all, 1: a little ready, 2: somewhat ready, 3: very ready, 4: extremely ready). in this study, we used the importance to change question as a proxy for perceived benefits, while we used confidence and readiness to change as proxies for self-efficacy. analysis procedures data were analyzed using spss version 27 (ibm corp., 2020). kolmogorov-smirnov tests (kendall & george, 2008) indicated that all included variable distributions lacked normality. thus, nonparametric tests were applied to assess mean-level change in perceived risk variables and motivation to change variables. for effect size estimation, we calculated pearson’s r values based on z/√n (cutoffs: <.30: small; .30-.50: medium; >.50: large). using g*power 3 (faul et al., 2007), we calculated that power sufficed for non-parametric tests at the final sample size if effect sizes were large. results sample the final sample consisted of 36 participants; sample demographics are displayed in table 1. among the 40 participants who were excluded from further analyses were those who: did not complete the program or survey (n = 22), did not complete the program or survey and used other substances (n = 4), did not complete the program or survey and were not self-referred (n = 1), were not self-referred (n = 4), used both cannabis and alcohol (n = 3), completed a shortened program (n = 1), were not self-referred and completed a shortened program (n = 1), were not self-referred and used other substances (n = 1), and used other substances (n = 3). preliminary effects of a guided self-change intervention 131 table 1. demographics of the overall sample and by subsample overall sample n = 36 subsample cannabis n = 18 subsample alcohol n = 18 pa age m (sd) 24.4 (5) 22.8 (4.3) 25.9 (5.2) .04 range 18 – 37 18 – 36 19 – 37 gender .09 female 21 (58.3%) 8 (44.4%) 13 (72.2%) male 15 (41.7%) 10 (55.6%) 5 (27.8%) ethnicity .02 hispanic/latine 19 (52.8%) 13 (72.2%) 6 (33.3%) not hispanic/latine 17 (47.2%) 5 (27.8%) 12 (66.7%) race white 25 (69.4%) 15 (83.3%) 10 (55.6%) .052 black or african american 8 (22.2%) 3 (16.7%) 5 (27.8%) .42 asian 2 (5.6%) 0 2 (11.1%) .15 ethnicity & race hispanic/latine & white 17 (47.2%) 12 (66.7%) 5 (27.8%) .02 hispanic/latine & black or african american 1 (2.8%) 1 (5.6%) 0 .31 sexual orientation .6 heterosexual 27 (75%) 13 (72.2%) 14 (77.8%) bisexual 6 (16.7%) 3 (16.7%) 3 (16.7%) homosexual 1 (2.8%) 1 (5.6%) 0 unknown 2 (5.6%) 1 (5.6%) 1 (5.6%) housing status in own home or apartment 16 (44.4%) 9 (50%) 7 (38.9%) .85 in campus/dormitory housing 9 (25%) 4 (22.2%) 5 (27.8%) in a relative’s home 8 (22.2%) 4 (22.2%) 4 (22.2%) in a group home 2 (5.6%) 1 (5.6%) 1 (5.6%) other 1 (2.8%) 0 1 (5.6%) note: bolded p-values indicate statistical significance at the .05 significance level. percentages reflect absolute percentages, not valid percentages. overall sample statistics reflect both subsamples combined. a = p-value based on mann whitney u tests (age) or pearson chi-square tests (all other variables) to assess group differences (cannabis primary using or alcohol primary using). we compared the participants who were included in the final sample (n = 36) with those who were excluded (n = 40) on gender (pearson chi-square tests), age, baseline perceived risk outcomes, and baseline degree of use (mannwhitney u tests). there were no statistically significant differences between the two groups. half of the sample (n = 18) indicated cannabis as the only and primary substance used, and half (n = 18) indicated alcohol as the only and primary substance used. we compared the two subsamples on all demographics using mann-whitney u tests for age and pearson chi-square tests for categorical demographic variables. on average, the cannabis-using subsample was younger (p = .04), and included more hispanic/latine and white participants (p = .02) than the alcohol-using subsample. the results are listed in table 1. we did not control in any way for these differences since we only looked at outcomes within each subsample and not between. perceived risk among the cannabis-using participants, the perceived risk of using cannabis or hashish once or twice a week increased from 1.89 (no to slight risk) to 2.5 (slight to moderate risk). this increase cannabis, a publication of the research society on marijuana 132 was statistically significant with a large effect size (p = .03, r = 0.51). no other risk variables among cannabis using participants showed a statistically significant result. however, all average scores increased from preto post-assessments. this and all remaining results are provided in table 2. among the alcohol-using participants, the results indicated no statistically significant increase in perceived risk outcomes. however, all perceived risk variables, except the perceived risk of having sexual intercourse while under the influence of drugs or alcohol, showed preto postassessment increases in average scores. motivation to change among cannabis-using participants, we identified an increase in confidence to change from 2.42 (somewhat confident) to 3.14 (very confident). this increase was statistically significant with a large effect size (p = .02, r = 0.57). the results also indicated an increase in readiness to change from 2.56 (somewhat ready) to 3.25 (very ready). this increase was statistically significant with a large effect size (p = .03, r = 0.52). among alcohol-using participants, the results showed an increase in confidence to change from 2.24 (somewhat confident) to 3.08 (very confident). this increase was statistically significant with a large effect size (p = <.001, r = 0.79). the results also indicated an increase in readiness to change from 2.83 (somewhat ready) to 3.47 (very ready). this increase was statistically significant with a large effect size (p = .02, r = 0.57). importance to change increased slightly in both subsamples but did not evidence statistical significance in either. discussion we investigated pre-to-post changes in five perceived risk outcomes and three motivation to change outcomes in u.s. university students who attended a 4-session gsc program to reduce misuse of alcohol and cannabis. a substantial portion of our sample identified as racial minority (27.8%, n = 10), ethnic minority (52.8%, n = 19), or sexual minority (19.5%, n = 7). the results showed that, throughout the program, the perceived risk of using cannabis statistically significantly increased in the cannabis-using subsample but not the perceived risk of using alcohol in the alcohol-using sample. in both the cannabis-using and alcohol-using subsamples, confidence to change and readiness to change statistically significantly increased from preto post-program assessments. these results align with our hypotheses, although the lack of a statistically significant increase in perceived risk among the alcohol sample was unexpected. the findings suggest that during participation in the program, the perceived risk of cannabis use increased among those who engaged in cannabis misuse, which may supplement the previous finding that substance use, overall, decreased in this program (morris et al., 2022). while we did not directly investigate mechanisms, causality, or how participation in the program affected the perceived risk, there are several possible explanations. first, engagement in the program may result in a heightened focus on the harm cannabis use is causing to the students and their environment. the perceived risks associated with the misuse of alcohol may be more blatant than the risks with cannabis use, so while students previously did not see their cannabis use as being as harmful initially, the program may have helped them identify how the use of cannabis impaired their daily life. this notion could be supported by the average rating anchors, which went from “no to slight” to “slight to moderate” perceived risk. second, decreased use rates found previously (morris et al., 2022) may have created cognitive dissonance, such that students aligned their perception of risk with their behavior. the ambivalence created by mi-techniques could have played a role in this change, which supports the underlying hypothesis of motivational interviewing (barnett et al., 2014). we could not investigate whether the risk predicted misuse of alcohol and cannabis reduction or vice versa, but the motivational and risk appraisal hypotheses (grevenstein et al., 2015) may apply. third, part of the program is focused on training in coping skills, such as reflective skills, communication skills, mindfulness skills, and self-care. these skills may have given students the skills to be able to more clearly identify the risks associated with cannabis use that were previously unrecognized but may have offered skills as a prosocial alternative to use itself. the emphasis is on the perception of risks rather than the actual risks, with the former arguably being equally important as the latter in the context of health behaviors.. preliminary effects of a guided self-change intervention 133 table 2. perceived risk pre-post descriptives by subsample, including tests and effect sizes subsample cannabis subsample alcohol valid pair n pre m (sd) post m (sd) pa rb valid pair n pre m (sd) post m (sd) pa rb perceived risk of using cannabis or hashish once or twice a week 18 1.89 (0.76) 2.5 (0.92) .03 .51 14 2.07 (0.62) 2.36 (0.5) .1 .44 perceived risk of binge drinking alcohol once or twice a week 18 3 (0.77) 3.39 (0.7) .08 .41 16 3.44 (0.63) 3.69 (0.48) .16 .35 perceived risk of using tobacco once or twice a week 16 1.13 (0.5) 1.38 (0.89) .1 .41 16 1 (0) 1.06 (0.25) .32 .25 perceived risk of having unprotected sexual intercourse 17 2.94 (0.97) 3.35 (0.79) .08 .42 18 3.33 (0.69) 3.44 (0.62) .53 .15 perceived risk of having sexual intercourse while under the influence of drugs or alcohol 17 2.94 (0.9) 3.29 (0.85) .08 .42 18 3.56 (0.71) 3.56 (0.78) 1 0 importance to change 18 2.83 (0.9) 2.94 (0.78) .61 .12 18 2.81 (0.75) 3.19 (0.75) .053 .46 confidence to change 18 2.42 (0.97) 3.14 (0.64) .02 .57 18 2.24 (0.96) 3.08 (0.6) <.001 .79 readiness to change 18 2.56 (0.92) 3.25 (0.77) .03 .52 18 2.83 (1.15) 3.47 (0.72) .02 .57 note: bolded p-values indicate statistical significance at the two-tailed .05 significance level. statistics (m/sd) reflect the valid pair statistics based on analysis-by-analysis deletion of missing observations. a = p-value based on wilcoxon signed-rank tests; b = pearson r effect sizes. cannabis, a publication of the research society on marijuana 134 the confidence to change and readiness to change ratings increased in cannabis and alcohol use groups. this could be expected, as the program focuses on goal setting, skills-training, and reflective goal-setting exercises, which may have caused students’ confidence and readiness to change to increase. as previously reported (litt & kadden, 2015), the acquisition of new coping skills could have mediated the relationship between substance use reduction and self-efficacy (i.e., confidence and readiness to change behavior). confidence and readiness to change could be seen as indicators of self-efficacy. the finding that gsc participation could be associated with substantial increases in self-efficacy might support the validity and effectiveness of the program’s application in university settings. the finding that motivation to change did not statistically significantly increase may be the result of the effect of use reduction: the reduction caused cannabis use or alcohol use to become less important over time because other factors became more important. although these findings must be interpreted with caution due to the lack of experimentality and sufficient sample size, the findings may carefully indicate that a brief yet concrete, goaloriented program such as gsc might induce perceived risk reduction. for cannabis use, increased perceived risk may have lasting effects beyond the program due to the lessons learned during the program. while alcohol has a biologically addictive component, cannabis use is mainly influenced by a psychological and social addiction pattern. a heightened risk perception and more confidence/readiness to enforce change in one’s behavior could, therefore, positively influence the use reduction and harm reduction trajectory beyond the program, particularly when considering social learning theory (bandura & walters, 1977). importantly, participants may have gained valuable insight into their use patterns and associated contexts beyond mere use reduction and may deter students from continuing to progressively increase misuse, which is in line with harm reduction approaches. overall, these findings do not directly address the notion that gsc, as implemented in this study, is culturally and developmentally appropriate in terms of direct impact on outcomes, as was found previously (gil et al., 2004; morris et al., 2022; wagner et al., 2014). however, the increase in perceived risk, motivation, and confidence to change among (minority) u.s. university students across the gsc program, as found in the current study’s sample, is promising. we hope this indicates a substantial clinical impact of the program, which is portable and can be flexibly tailored to meet the needs of specific populations. focusing on the perception of risks (rather than actual risks) may inform dissemination and implementation campaigns to reduce cannabis or alcohol misuse on college campuses. several aspects of this study design could restrict the generalizability of these findings. the sizes for the two student subsamples were small, and the study was too underpowered to detect small effect sizes. it is not easy to collect large clinical samples in collegian contexts, and the conclusions should be interpreted carefully as we had to rely upon nonparametric tests and small samples to investigate pre-post differences. further, while we found pre-post increases in five outcomes, we did not conduct an experimental study with control groups and controlled manipulation. therefore, claims about causality (or mediation/moderation) could not be made. we minimized social desirability bias by only including self-referred participants. yet, social desirability bias, among other biases, might have still been a factor in the program because participants wanted to succeed and complete the program. for example, only including participants who completed the program may have biased the results such that participants included in this study might have been inherently more motivated to change their use. it is also worth noting that these results are areaand population-specific. the data were collected at a large institution in south florida, and findings may not be generalizable to all u.s. colleges or universities. this further underlines the need for implementation at different institutions. finally, to streamline the interpretation of study results, only participants who used either cannabis or alcohol were included. the results may differ for students who use both substances, which has been tied to worsened outcomes (jackson et al., 2020). future research could address these limitations by collecting larger sample data, implementing, and evaluating the gsc program on geographically diverse u.s. campuses. this would allow for replications of studies that preliminary effects of a guided self-change intervention 135 simultaneously investigate substance misuse, perceived risk, and self-efficacy among university students. while experimental laboratory studies are useful in identifying the exact relationship between the factors investigated in this study, community-based intervention studies are recommended because they emphasize effectiveness (i.e., real-world conditions). to further the dissemination and implementation of gsc programs, community-based studies generally assess the here-and-now needs of individuals and communities. there are added societal and community benefits to simultaneously studying early intervention implementation and providing u.s. students with services. future investigations also should study the effect of perceived risk-focused campaigns, such as online campaigns (fernandez et al., 2019). the students in this study were of diverse racial, ethnic, and sexual minority backgrounds and were self-enrolled in a brief university student cannabis or alcohol misuse reduction program. we carefully conclude from the study’s results that perceived risk of cannabis use and confidence and readiness to change cannabis and alcohol use increased during a brief guided selfchange intervention. references american psychiatric association (2013). diagnostic and statistical manual of mental disorders. https://doi.org/10.1016/b978-0-12809324-5.05530-9 arnett, 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(2021). relationship between cannabis use and psychotic experiences in college students. schizophrenia research, 231, 198– 204. https://doi.org/10.1016/j.schres.2021.04.004 funding and acknowledgements: the study was part of a larger study funded by the substance abuse mental health services administration (grant number: #1h79sp021160). the authors gratefully acknowledge the use of the services and facilities supported in part by the national institute on minority health and health disparities of the national institutes of health under award number nimhd u54md012393, florida international university research center in minority institutions. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors have no conflicts of interest to declare. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 127 ved abstract objective: cannabis vaping is increasing among college students. there is little information on risk factors for vaping cannabis. consistent with the self-medication hypothesis, experiencing depressive symptoms and having a chronic medical condition (cmc) are associated with cannabis use among young adults. individuals who experience both risk factors may be at higher risk for cannabis vaping. this study examined cross-sectional associations between depressive symptoms, cmc status, and cannabis vaping, and identified the moderating role of cmc status on depressive symptoms and cannabis vaping. method: college students (n = 3,742) self-reported on depressive symptoms, cmc status, and lifetime and current cannabis vaping (i.e., cannabis vaporizers; electronic nicotine devices to use cannabis). data were collected fall 2017 until spring 2021. the sample was predominantly female (70.9%) and white (75.4%). regression analyses were used. results: greater depressive symptoms were related to increased likelihood of cannabis vaping across outcomes. having a cmc was related to lifetime history of cannabis vaporizing. cmc status moderated the associations between depressive symptoms and lifetime cannabis vaporizing. depressive symptoms were only a risk factor for cannabis vaporizing among college students without a cmc, not those with a cmc. conclusions: interventions that teach adaptive ways of coping with depressive symptoms and the potential demands of managing a cmc in college are needed. comprehensive programs for college students, with and without cmcs, are needed to support those with comorbid depression and cannabis vaping use. key words: = college student; cannabis vaping; depression; chronic medical condition; covid-19; selfmedication hypothesis while the deleterious health effects of longterm, heavy cannabis use have been documented (fergusson, horwood, & swain-campbell, 2002; hall et al., 2016; nasem, 2017), health effects of vaping cannabis are not well understood (jones et al., 2016). the danger of vaping cannabis with electronic cigarettes (e-cigarettes) was highlighted recently during an outbreak of lung injuries: in the us, 2,807 individuals were hospitalized or died due to e-cigarette, or vaping, product use-associated lung injury (evali), with 68 confirmed deaths (cdc, 2020). yet, alexandra l. blair1,2, ashley h. clawson3,4, natalie g. keirns5,6, larry l. mullins,1,2 john m. chaney,1,2 ashley b. cole2 1center for pediatric psychology, department of psychology, oklahoma state university 2department of psychology, oklahoma state university 3center for the study of tobacco, department of health behavior and health education, fay w. boozman college of public health, university of arkansas for medical sciences 4winthrop p. rockefeller cancer institute, university of arkansas for medical sciences 5lifespan cardiovascular institute, the miriam hospital, providence, ri, 6department of medicine, warren alpert medical school of brown university cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000183 the moderating role of health status on the association between depressive symptoms and cannabis vaping corresponding author: alexandra l. blair, m.s., oklahoma state university, 116 psychology building. stillwater, oklahoma, 74078-0364, usa. email: alex.blair@okstate.edu. cannabis, a publication of the research society on marijuana 128 among those who have used cannabis, 72% believe that cannabis vaping is healthier than cannabis smoking (lee et al., 2016); perceptions that cannabis vapes result in less harm are associated with more frequent use, earlier initiation, and intensification of use or addiction (budney et al., 2015). importantly, cannabis vaping is increasing among college students, rising dramatically from 5% in 2017 to 14% in 2019 (nida, 2020), with similar rates during the covid-19 pandemic (12%; schulenberg et al., 2021). other research suggests that cannabis use has increased during the covid-19 pandemic (bartel et al., 2020; sznitman et al., 2021). this is important given that cannabis use has been linked to poorer covid-19 survival (huang et al., 2022). given the rising rates of cannabis vaping among college students, literature on the associated health effects, and because earlier initiation of cannabis use is associated with increased risk for developing cannabis use disorder (borodovsky et al., 2017; dewit et al., 2000; swift et al., 2008), it is important to understand the risk factors for cannabis vaping among college students. yet, to date, there is a lack of research focused on identifying risk factors for cannabis vaping among college students, an important step for prevention and intervention programming. in general, cannabis use during adolescence is highly comorbid with other varying psychiatric concerns (gattamorta et al., 2017; gobbi et al., 2019). jones and colleagues (2016) investigated how psychological distress related to cannabis vaping among college students (n = 482). their results identified that psychological distress (i.e., aggregate score of anxiety, depressive, and stress symptoms) was unrelated to cannabis vaping; however, greater psychoticlike experiences were related to an increased likelihood of past-year cannabis vaping. other risk factors for past-year cannabis vaping included more frequent nicotine vaping and cannabis use (i.e., using modalities other than vaping), being younger, being male, being white or latinx, having higher socioeconomic status (ses), using other substances, having positive attitudes about cannabis, and being more open to experiencing something new (jones et al., 2016). other research with college students found that risk factors for vaping cannabis with a vape pen included greater positive cannabis expectancies, cannabis peer injunctive norms, and alcohol intake (frohe et al., 2018). boakye and colleagues (2021) found that individuals who reported vaping cannabis also reported having other substance use disorders (suds) and depression symptoms (boakye et al., 2021). in addition, individuals who use more than one substance simultaneously are at greater risk for negative health outcomes, such as cognitive deficits, mental health concerns, and premature death as a result of co-occurring substance use (connor et al., 2014; schulte & hser, 2014). studies with samples of young adult populations also identified several risk factors for cannabis vaping, including but not limited to: using e-cigarettes, using cannabis more frequently (i.e., using modalities other than vaping), being male, being younger, not identifying as african american, greater impulsivity, having a higher education, using nonmedical stimulants, and being a returning medical cannabis patient (cranford et al., 2017; lee et al., 2016; morean et al., 2017 ). an understudied risk factor for cannabis vaping is depression. depression is a major concern among many college students (karmakar & behera, 2017). the self-medication hypothesis posits that individuals with depressive symptoms use cannabis to reduce depressive symptoms (khantzian, 1985; 1997). prior longitudinal research supports the self-medication hypothesis in the context of general cannabis use among young adults, identifying depressive symptoms and suicidal ideation as risk factors for later cannabis use (bolanis et al., 2020; crane et al., 2015; hooshmand et al., 2012; lazareck et al., 2012 ; rhew et al., 2017;weinberger et al., 2020; wilkinson et al., 2016; womack et al., 2016; zhang & wu, 2014). the self-medication hypothesis also overlaps with the coping motives literature that demonstrates that coping motives are important risk factors for cannabis use, including problematic cannabis use (cooper, 1994; otto et al., 2004; stewart et al., 1997; zvolensky et al., 2005). to date, the self-medication hypothesis has not been investigated for cannabis vaping; this is an important gap in the literature given the increasing rates of cannabis vaping among college students (nida, 2020). the current study investigated the selfmedication hypothesis in the context of depressive symptoms and cannabis vaping among college health status, depressive symptoms, and cannabis vaping 129 students and investigated if this hypothesis is stronger for those with chronic medical conditions (cmcs). cmcs are defined as illnesses that require ongoing medical attention and/or limit activities of daily living (cdc, 2022). this research addresses a critical gap in the literature, given that over 6% of college students have a cmc (american college health, 2018; traino et al., 2019). it can be difficult for college students with cmcs to adapt to college compared to their peers without a cmc: first-year college students with a cmc have lower health-related quality of life and more loneliness compared to their peers without a cmc (hall & degenhardt, 2013; herts et al., 2014). along with the usual stressors of transitioning to college, college students with cmcs are also experiencing stressors associated with managing their cmc (tuchman et al., 2008). specifically, there are increased academic and personal responsibilities and changes in relationships (brougham et al., 2009; compas et al., 1986; dusselier et al., 2005; eddington et al., 2010), and students are also transitioning to more independent management of their medical condition and treatments (traino et al., 2021). it is also common for individuals with cmcs to have comorbid depressive symptoms, and depressive symptoms among these individuals are associated with poorer health outcomes (egede, 2007; ferro et al., 2015; katon, 2011). furthermore, adults with a cmc (45.5%) are more likely use cannabis compared to those without a cmc (21.8%; dai & richter, 2019). it seems plausible that individuals who experience both risk factors for cannabis use (i.e., depressive symptoms and having a cmc) may be at higher risk for cannabis vaping given the self-medication hypothesis. furthermore, there are important associations among mental health, cmcs, and substance use (gandhi et al., 2022). gandhi and colleagues (2022) examined the burdens of behavioral health concerns and cmcs in rural communities. overall, the authors found that mental health conditions were associated with suds and cmcs; however, suds and cmcs were not significantly related (gandhi et al., 2022). these findings, along with the self-medication hypothesis, further support the aims of the current study: to examine associations between depressive symptoms, cmc status, and cannabis vaping, and whether cmc status would moderate the association between depressive symptoms and cannabis vaping. collectively, this study had three aims to enhance our understanding of the associations between depressive symptoms, cmc status, and cannabis vaping among college students. for all aims, four measures of cannabis vaping were evaluated: 1) lifetime use of cannabis vaporizers, 2) current use of cannabis vaporizers, 3) lifetime use of ends devices to use cannabis, and 4) current use of ends devices to use cannabis. the first aim assessed the associations between depressive symptoms and lifetime and pastmonth cannabis vaping. consistent with the selfmedication hypothesis (bolanis et al., 2020; crane et al., 2015; hooshmand et al., 2012; lazareck et al., 2012; rhew et al., 2017; weinberger et al., 2020; wilkinson et al., 2016; womack et al., 2016) and other recent, relevant literature (e.g., gandhi et al., 2022), it was hypothesized that experiencing greater depressive symptoms would be associated with an increased likelihood of vaping cannabis. the second aim assessed the associations between cmc status and lifetime and current cannabis vaping; it was hypothesized that college students with cmcs would be more likely to vape cannabis compared to those without cmcs. the final aim assessed the moderating role of cmc status on the association between depressive symptoms and cannabis vaping. it was hypothesized that the association between depressive symptoms and cannabis vaping would be stronger among those with a cmc compared to those without a cmc. methods participants and procedures participants (n = 3,742) were college students from a large midwestern university who completed a broader study of psychosocial functioning. this study was approved by the institutional review board and followed apa ethical guidelines. participants were recruited through an online survey system, consented to the study, and completed online questionnaires. like many universities, undergraduate psychology courses require a research component. students who completed this study were compensated with course credit. data collection for the larger study cannabis, a publication of the research society on marijuana 130 is still ongoing; the current study includes data from every semester from fall 2017 until spring 2021. the current study is cross-sectional because different participants enrolled each semester. sample size varied across analyses due to missing data on the dependent variables; however, missing data rates were minimal (cannabis vaporizing: missing =1.8%; using e-cigarette to vape cannabis: missing = 1.7%). measures demographic information. participants selfreported on age, sex (referent: male), family income, first generation college student status (referent: no), and education level (freshmen/ sophomores: 0; juniors/ seniors:1). race and ethnicity were conceptualized as sociocultural constructs that reflect differential exposure to systemic influences affecting power, oppression, and privilege among different populations (palermo et al., 2021). race and ethnicity were coded using dummy coding, with non-hispanic, white serving as the referent for: african american/black, hispanic/latinx, asian, american indian, multiracial, and “other background.” the date of survey completion was used to create a pandemic onset variable: data collected prior to spring 2020 were coded as prepandemic (0), and data collected during or after spring 2020 were coded as collected during the pandemic (1). depressive symptoms. past-week depressive symptoms were measured using the 20-item center for epidemiologic studies depression (cesd) scale (radloff, 1977). total scores were created by summing item responses, after rescaling necessary items by computing a total score. prior research has shown that this scale has good psychometric properties (radloff, 1977), and is a valid tool for screening depressive symptoms (vilagut et al., 2016). cronbach’s alpha for the current sample was .83, indicating good internal consistency. chronic medical conditions (cmc). participants self-reported on if they had a cmc and identified their diagnosis from a list of diagnoses (e.g., asthma, type 1 diabetes, type 2 diabetes, sickle cell disease). an overall cmc status variable was created for analyses. participants in the group without a cmc did not endorse a cmc (coded as 0); participants who did not endorse a cmc but endorsed a mental health diagnosis were also included in the group without a cmc. participants who endorsed a cmc were coded as 1; participants who endorsed a cmc and a mental health diagnosis were included in the cmc group. cannabis vaping. the questions used to assess cannabis vaping frequency were modeled after standardized assessments of cannabis use from the path study (hyland et al., 2017). prior research has documented the convergent, concurrent criterion and construct validity of selfreported brief assessments of cannabis use (similar to the present study’s assessment; ramo, hall, et al., 2012; shiplo et al., 2016). prior research also supports the use of self-reported assessments of cannabis vaporizer use (jones et al., 2016; shiplo et al., 2016). there are two modes of cannabis delivery that were assessed: cannabis vaporizers and ends devices to use cannabis. cannabis vaporizers can be used to vaporize products in the form of dry herbs, wax, and oil, and then turn these products into vapor; these devices are used to heat the cannabis to a point where thc is vaporized and then ingested/inhaled (cdc, 2019). in contrast, ends devices are used for the purposes of delivering nicotine, but they can be manipulated to deliver cannabis (cdc, 2019). cannabis vaporizer use. participants selfreported on their frequency of using cannabis vaporizers to deliver cannabis (“how often do you use cannabis electronic vaporizers to deliver thc?”). lifetime history of cannabis vaporizer use was coded as follows: no history (never tried, not even once; coded as 0) versus lifetime history (any level of use, including having tried cannabis vaporizers; coded as 1). as defined in prior literature (schulenberg et al., 2021), current use of cannabis vaporizer variable was coded as follows: no current use (never tried; only tried; used cannabis vaporizers only yearly; 0) versus current use (monthly, weekly, or daily use; 1). use of electronic nicotine devices to use cannabis. participants self-reported on their frequency of using ends devices to deliver cannabis (“how often do you use electronic nicotine devices to deliver thc?”). this question was modeled after prior research (morean et al., 2018). the same coding scheme as above was used health status, depressive symptoms, and cannabis vaping 131 to create a lifetime history of use of electronic nicotine devices to use cannabis variable and a current use of electronic nicotine devices to use cannabis variable. data analytic plan ibm spss statistics (version 24) was used for all analyses. prior literature and results from bivariate associations between the demographic variables (e.g., age, race/ethnicity, college level, ses, sex) and dependent variables were executed to identify covariates for primary analyses; covariates included: data collected during the pandemic, age, sex, income, and race/ethnicity. eight separate logistic regressions were performed. to examine aims 1 and 2, four main effects only models were used to identify the main effects of depressive symptoms (aim 1) and cmc status (aim 2) on the dependent variables (i.e., lifetime cannabis vaporizing, current cannabis vaporizing, lifetime use of ends devices to use cannabis, and current use of ends devices to use cannabis). to examine aim 3, four models were conducted to examine the main effects and the interaction between depressive symptoms and cmc status in predicting the dependent variables (aim 3). for aim 3, modprobe (spss macro) was used to estimate the logistic regression models and to probe significant two-way interactions (hayes & matthes, 2009). based on the provided macro output, betas rather than odds ratios were presented for aim 3 results. when a significant interaction was identified, the conditional effects of depressive symptoms on the dependent variables at each level of the moderator were identified (hayes, 2016). results participants predominantly identified as nonhispanic white (75.4%) and female (70.9%), with an average age of 19.4 years old (sd = 3.23); the most indicated annual family income category was $100,000 or more (41.6%). all participant demographics and descriptive statistics on variables of interest are presented in table 1. results of main effects regression models predicting lifetime and current cannabis vaping, and lifetime and current use of ends devices to deliver cannabis (aims 1 & 2), are presented in tables 2 and 3, respectively. table 1. descriptive statistics n = 3,742 demographic variables m (sd))/ n (%) data collected during the pandemic 947 (25.3%) female 2653 (70.9%%) age 19.4 (3.23) (17-24) family income a $0 9,999 64 (1.7%) $10,000 19,999 85 (2.3%) $20,000 29,000 172 (4.6%) $30,000 39,999 192 (5.2%) $40, 000 49,999 230 (6.2%) $50,000 59,999 262 (7.1%) $60,000 69,999 272 (7.3%) $70,000 79,999 288 (7.8%) $80,000 89,999 320 (8.6%) $90,000 99,999 279 (7.5%) $100,000 or more 1, 541 (41.6%) race/ethnicity white 2821(75.4%) cannabis, a publication of the research society on marijuana 132 african american 214 (5.7%) hispanic 134 (3.6%) asian 99 (2.6%) american indian 243 (6.5%) multi-racial 159 (4.2%) other 56 (1.5%) missing 16 independent variables depressive symptoms 16.32 (12.42) has chronic medical condition 550 (14.7%) dependent variables lifetime use of cannabis vaping lifetime history 850 (22.7%) current use of cannabis vaping current use 242 (6.5%) lifetime use of electronic nicotine devices lifetime history 666 (17.8%) current use of electronic nicotine devices current use 181 (4.8%) note. n’s ranged due to missing data. a income was treated as a continuous variable in the analyses, with coding ranging 1 to 11 (m = 8.39, sd = 2.93). table 2. main effects only model for lifetime and current cannabis vaping b se p or or 95% ci ll ul lifetime history of cannabis vaping independent variables depressive symptoms .026 .003 <.001 1.026 1.020 1.033 has a chronic medical condition .010 .116 .934 1.010 .805 1.266 demographic variables data collected during covid-19 pandemic a .730 .094 <.001 2.075 1.725 2.497 age .054 .032 .093 1.055 .991 1.124 female b -.118 .093 .207 .889 .741 1.067 income .041 .015 .008 1.041 1.010 1.073 race/ ethnicity c african american -.050 .196 .799 .951 .648 1.397 hispanic .049 .233 .833 1.050 .666 1.658 asian -.498 .303 .100 .608 .336 1.101 american indian .008 .168 .961 1.008 .725 1.402 multiracial .363 .193 .060 1.438 .985 2.099 other ethnicity -.377 .364 .300 .686 .336 1.400 health status, depressive symptoms, and cannabis vaping 133 current cannabis vaping independent variables depressive symptoms .034 .005 <.001 1.035 1.024 1.046 has a chronic medical condition -.035 .193 .856 .966 .661 1.410 demographic variables data collected during covid-19 pandemic a .763 .152 <.001 2.144 1.591 2.888 age -.017 0.42 .683 .983 .905 1.068 female b -.372 .154 .016 .689 .509 .933 income .023 .026 .384 1.023 .972 1.077 race/ ethnicity c african american -.635 .404 .116 .530 .240 1.171 hispanic .059 .406 .885 1.060 .479 2.349 asian -.224 .475 .637 .799 .315 2.029 american indian -.425 .325 .191 .654 .346 1.236 multiracial .218 .318 .493 1.244 .667 2.320 other ethnicity -1.528 1.01 .134 .217 .029 1.597 note. total n = 3,468. ci = confidence interval; ll = lower limit; ul = upper limit. control variables in the model included: pre/post covid, age, sex, income, race/ethnicity.a0=data collected pre-pandemic 1= during pandemic, b 0=female 1=male, 0c=non-hispanic, white. table 3. main effects only model for lifetime and current use of electronic nicotine devices to deliver cannabis b se p or or 95% ci ll ul lifetime history of using electronic nicotine devices to deliver cannabis independent variables depressive symptoms .023 .004 <.001 1.023 1.016 1.030 has a chronic medical condition -.195 .131 .135 .823 .637 1.063 demographic variables data collected during the covid-19 pandemica .681 .102 <.001 1.976 1.618 2.413 age .010 .011 .376 1.010 .988 1.033 femaleb .120 .104 .250 1.127 .919 1.382 income .050 .017 .003 1.051 1.017 1.087 race/ ethnicity african american -.271 .230 .239 .763 .486 1.197 hispanic .126 .249 .614 1.134 .696 1.849 asian -.418 .333 .209 .659 .343 1.264 american indian -.074 .188 .693 .929 .643 1.342 multiracial .256 .213 .230 1.292 .850 1.963 other ethnicity .019 .364 .959 1.019 .499 2.079 cannabis, a publication of the research society on marijuana 134 current use of electronic nicotine devices to deliver cannabis independent variables depressive symptoms .024 .006 <.001 1.024 1.011 1.037 has a chronic medical condition -.201 .240 .402 .818 .511 1.309 demographic variables data collected during the covid-19 pandemica .470 .181 .009 1.599 1.122 2.279 age -.063 .065 .332 .939 .826 1.067 femaleb -.331 .176 .059 .718 .509 1.013 income .056 .031 .073 1.058 .995 1.125 race/ ethnicity c african american -.066 .385 .865 .936 .440 1.993 hispanic -.582 .597 .330 .559 .173 1.802 asian -.053 .527 .920 .949 .338 2.663 american indian -1.049 .515 .042 .350 .128 .962 multiracial .500 .330 .130 1.649 .863 3.151 note. total n = 3,468. ci = confidence interval; ll = lower limit; ul = upper limit. control variables in the model included: pre/post covid, age, sex, income, race/ethnicity. a0=data collected pre-pandemic 1= during pandemic, b 0=female 1=male, 0 c=non-hispanic, white. moderation models lifetime history of cannabis vaporizing the overall model examining the main effects of depressive symptoms and cmc status and their interaction on lifetime cannabis vaporizing was significant, x2(1, n = 3433) = 8.38, p = .003; table 4. the depressive symptoms*cmc status interaction was significant, b = -0.023, p = .004, ci [-0.039, 0.008]. follow-up analyses examining the conditional effects of depressive symptoms on having a lifetime history of vaping cannabis were investigated at each level of cmc status. among individuals without a cmc, greater depressive symptoms were associated with an increased likelihood of having a history of cannabis vaporizing, b = 0.031, p < .001, ci [0.023, 0.038]. however, among individuals with a cmc, depressive symptoms were not related to having a lifetime history of cannabis vaporizing, b = 0.007, p = .303, ci [-0.007, 0.022]. the main effects were also significant: greater depressive symptoms were related to an increased likelihood of currently vaporizing, b = 0.031, p<.001, ci [0.023, 0.038]. individuals with a chronic medical condition had an increased likelihood of vaping cannabis. b = 0.52, p = .01, ci [0.118, 0.923]. significant covariates included: income, data collected during the pandemic, and identifying as asian. current cannabis vaporizing the overall model was significant, x2(1, n = 3,433) = 0.399, p < .001; table 4). the interaction was not significant, b = -.008, p = .527, ci [-.034, .018]. greater depressive symptoms were associated with an increased likelihood of cannabis vaporizing, b = 0.036, p < .001, ci [0.024, 0.048]. the cmc status main effect was nonsignificant. significant covariates included: being female and having data collected during the pandemic. table 4. moderation analyses for current and lifetime cannabis vaping b se p value sig. or 95% ci ll ul health status, depressive symptoms, and cannabis vaping 135 note. total n = 3,468. ci = confidence interval; ll = lower limit; ul = upper limit. dependent variable: 0= not current, 1 = current; 0=never, 1=ever. a0=female 1=male, b0=non-hispanic, white. c0=data collected pre-pandemic 1= during pandemic. control variables in the model included: pre/post covid, age, sex, income, race/ethnicity. lifetime history of using electronic nicotine devices to use cannabis the overall model was significant. x2(1, n = 3,435) = 0.285, p < .001; table 5). the interaction was not significant, b = -.005, p = .593, ci [-.023, .013]. greater depressive symptoms were associated with an increased likelihood of having a history of cannabis vaping, b = 0.024, p < .001, ci [0.016, 0.032]. the cmc status main effect was nonsignificant. significant covariates included: having data collected during the pandemic and family income. lifetime cannabis vaping depressive symptoms .031 .004 <.001 .0234 .0381 chronic medical condition status .520 .206 .011 .118 .923 depressive symptoms*cmc -.023 .008 .004 -.039 -.008 age .053 0.032 .098 -.010 .116 female a -.114 .093 .223 -.297 .069 income .041 .016 .008 .011 1.071 race/ ethnicity b african american -.058 .196 .769 -.443 .327 hispanic .039 .233 .867 -.419 .496 asian -.504 .304 .010 -1.010 .091 native american .013 .168 .940 -.317 .342 multiracial .376 .193 .051 -.002 .754 other ethnicity -.401 .365 .273 -1.116 .316 american indian -1.048 .515 .042 -2.058 -.038 multiracial .508 .331 .124 -.140 1.156 other -1.067 1.019 .295 -3.064 data collected during the covid19 pandemic c .735 .095 <.001 .549 .920 current cannabis vaping independent variables depressive symptoms .036 .006 <.001 .024 .048 chronic medical condition status (cmc) .177 .382 .642 -.570 .925 depressive symptoms*cmc -.008 .013 .527 -.034 .018 demographic variables age -.017 0.044 .692 -.103 .069 femalea -.370 .154 .016 -.673 -.069 income .023 .026 .383 -.028 .074 race/ ethnicity b african american -.636 .404 .116 -1.240 .157 hispanic .055 .406 .893 -.741 .850 asian -.223 .475 .639 -1.155 .709 american indian -.423 .325 .193 -1.060 .214 multiracial .227 .318 .476 -.397 .850 other ethnicity -1.535 1.019 .132 -3.532 .462 data collected during the covid19 pandemic c .763 .152 <.001 .465 1.061 cannabis, a publication of the research society on marijuana 136 current use of electronic nicotine devices to use cannabis the overall model was significant, x2(1, n = 3,435) = .276, p < .001; table 5). the interaction and cmc main effect were not significant, b = .009, p = .600, ci [-.041, .023]. greater depressive symptoms were associated with an increased likelihood of cannabis vaping, b = 0.025, p < .001, ci [0.011, 0.039]. having data collected during the pandemic was a risk factor; american indian individuals were less likely to use ends devices to use cannabis. table 5. moderation analyses for lifetime and current use of electronic nicotine devices to deliver cannabis b se p value sig. or 95% ci ll ul lifetime history of using electronic nicotine devices to deliver cannabis depressive symptoms .024 .004 <.001 .016 .032 chronic medical condition status -.084 .245 .732 -.563 .396 depressive symptoms*cmc -.005 .009 .593 -.023 0.013 age .011 .011 .352 -.012 .033 female a .121 .104 .246 .083 .325 income .050 .017 .004 .016 .083 race/ ethnicity b african american -.272 .230 .237 -.723 .179 hispanic .123 .249 .621 -.365 .612 asian -.419 .333 .208 -1.072 .234 american indian -.073 .188 .696 -.441 .295 multiracial .259 .213 .225 -.159 .677 other .015 .364 .968 -.699 .728 data collected during the covid19 pandemic c .682 .102 <.001 .482 .881 current electronic nicotine devices to deliver cannabis independent variables depressive symptoms .025 .007 <.001 .011 .039 chronic medical condition status (cmc) .004 .449 .994 -.877 .884 depressive symptoms*cmc -.009 .016 .600 -.041 .023 demographic variables age -.064 .065 .329 -.192 .064 femalea -.330 .176 .060 -.674 .014 income .057 .031 .072 -.005 .118 race/ethnicity b african american -.067 .386 .862 -.822 .689 hispanic -.586 .597 .327 -1.757 .585 asian -.052 .527 .922 -1.084 .981 american indian -1.048 .515 .042 -2.058 -.038 multiracial .508 .331 .124 -.140 1.156 other -1.067 1.019 .295 -3.064 .929 data collected during the covid19 pandemicc .470 .181 .009 .116 .825 health status, depressive symptoms, and cannabis vaping 137 note. total n = 3,468. ci = confidence interval; ll = lower limit; ul = upper limit. dependent variable: 0= not current, 1 = current; 0=never, 1=ever.a0=female 1=male, b0=non-hispanic, white c0=data collected pre-pandemic 1= during pandemic. control variables in the model included: pre/post covid, age, sex, income, race/ethnicity. discussion this study extended the limited research on predictors of cannabis vaping among college students by examining the moderating role of health status on the association between depressive symptoms and cannabis vaping. across analyses, the most consistent risk factors for cannabis vaping were having greater depressive symptoms and having data collected during the pandemic. cmc status only moderated the associations between depressive symptoms and cannabis vaping when examining lifetime cannabis vaporizing, suggesting that depressive symptoms were only a risk factor for cannabis vaporizing among young adults without a cmc but not those with a cmc. notably, greater depressive symptoms were related to an increased likelihood of lifetime and current cannabis vaporizing and use of ends devices to deliver cannabis. this finding is consistent with other literature demonstrating depressive symptoms are a risk factor for overall cannabis use (i.e., via methods other than vaping; crane et al., 2015; lazareck et al., 2012)rhew et al., 2017). however, the association between depressive symptoms and cannabis vaping was yet to be explored. most closely related, jones and colleagues (2016) investigated psychological distress – as defined as a composite of anxiety, depressive, and stress symptoms – in association with cannabis vaping specifically, but did not observe a relationship between psychological distress and cannabis vaping. these results contrast with the current findings of depressive symptoms predicting cannabis vaping; this discrepancy may be due to differences in the specific variables used (i.e., psychological distress vs. depression). taken together, it seems that depression in particular – versus other psychological distress variables, such as anxiety or stress – may have a unique association with cannabis vaping. the link between depression and cannabis vaping found in the present study is consistent with the self-medication hypothesis (bottorff et al., 2009; crane et al., 2015; lazareck et al., 2012; rhew et al., 2017; weinberger et al., 2020) and other relevant, recent literature (e.g., gandhi et al., 2022). the self-medication hypothesis posits that individuals with depressive symptoms use cannabis to reduce depressive symptoms (khantzian, 1985; 1997), and this has been supported for adolescents and young adults when examining overall cannabis use (wilkinson et al., 2016; womack et al., 2016) and across longitudinal studies that identified depression and suicidal ideation as risk factors for later, overall cannabis use (crane et al., 2015; lazareck et al., 2012; rhew et al., 2017; weinberger et al., 2020; wu, 2014). the current finding that depression predicted lifetime and current cannabis use via vaping methods is in line with this hypothesis and suggests that college students with depression may vape cannabis as a method of managing their depressive symptoms. collectively, the current cross-sectional findings coupled with the extant longitudinal literature support the self-medication hypothesis: certain individuals use cannabis via various delivery modes to alleviate depressive symptoms. these findings have important public health implications given the use of substances to cope with distress is associated with the poorest outcomes (cooper et al., 2015). the self-medication hypothesis would also predict that cmc status is associated with cannabis vaping; this hypothesis was only minimally supported. cmc status was only related to having a lifetime history of cannabis vaporizing, with those with a cmc being more likely to have a history of cannabis use; however, this was in a model with a significant interaction. cannabis, a publication of the research society on marijuana 138 this finding is consistent with prior research that demonstrated that overall cannabis use is more common among individuals with cmcs compared to those without cmcs during adolescence and adulthood (dai & richter, 2019; wisk & weitzman, 2016). several potential factors may have contributed to cmc status only being related to a lifetime history of cannabis vaporizing. for example, greater access and ease of using cannabis vaporizers relative to using ends devices to deliver cannabis may have supported greater use of cannabis vaporizers over other modalities. further, the publicized evali outbreak may have deterred use of ends devices to use cannabis, given their association with evali, but not use of cannabis vaporizers. cannabis use among individuals with cmcs is a public health problem, and prevention and intervention efforts are needed to address this modifiable risk for medically vulnerable young people. finally, consistent with the self-medication hypothesis, it was hypothesized that individuals with both depressive symptoms and a cmc would be more likely to vape cannabis because of the increased demands and stressors associated with having cmcs (brougham et al., 2009; compas et al., 1986; dusselier et al., 2005; eddington et al., 2010) that may be intersecting with depressive symptoms to contribute to greater cannabis use for coping.; this hypothesis was unsupported. cmc status only moderated the associations between depressive symptoms and cannabis vaping when examining lifetime cannabis vaporizing; depressive symptoms were only a risk factor for cannabis vaporizing among young adults without a cmc but were unrelated to lifetime cannabis vaporizing for those with a cmc. this finding was unexpected. this could be explained by other factors such as: 1) ends devices have gained popularity; thus, young adults without a cmc may have become curious about the product rather than using the product to self-medicate; 2) other motives for cannabis use such as social enhancement, relaxation, experimenting, and enjoyment/fun may be influencing cannabis use (lee et al., 2007); and/or 3) cannabis use has significantly increased across time among college students, which could impact patterns of cannabis use observed (odani et al., 2019; nida, 2020). overall, the current study’s investigation of substance use behaviors rather than substance use motives (coping or social enhancement, relaxation, experimenting, and enjoyment/fun) may have reduced the ability to draw firm conclusions regarding reasons for cannabis use among those with and without cmcs. however, this methodology is supported in the extant literature (bolanis et al., 2020; hooshmand et al., 2012; wilkinson et al., 2016; womack et al., 2016). among college students with a cmc, it is also possible that there are more influential predictors of cannabis vaping than depressive symptoms that were not examined and warrant attention, such as illness-related perceptions and/or management of physical symptoms of medical conditions. future research should assess cannabis use motives and/or other potential predictors to further elucidate risk factors for cannabis vaping among young adults with and without cmcs. the most consistent covariate that was related to cannabis vaping was data being collected during the pandemic. this is consistent with literature suggesting that cannabis use has increased during the covid-19 pandemic (bartel et al., 2020; sznitman et al., 2021). however, this finding may also be related to other contextual factors that somewhat coincided with the onset of the covid-19 pandemic, such as increased cannabis legalization across the united states (borodovosky et al., 2017) and the increase in vape shops following the medical legalization of cannabis in 2018 in the state where data were collected. the social construct of race and ethnicity also seems to be important in understanding cannabis vaping. american indian and asian individuals were less likely than non-hispanic, white individuals to vape cannabis. this is consistent with prior research that found that being white or latinx were risk factors for past-year cannabis vaping among college students (jones et al., 2016); this study expanded on jones and colleagues’ (2016) study and the literature on cannabis vaping by utilizing a sample with more representation of american indian college students (6.5% of the sample) and identifying that american indian individuals were less likely to vape cannabis. future research should examine promotive factors that may be supporting this reduced risk among american indian and asian health status, depressive symptoms, and cannabis vaping 139 students. like prior research, having a higher income and being male were also covariates associated with cannabis vaping among college students (jones et al., 2016). public health and clinical implications greater odds of cannabis vaping – across all outcomes – was associated with greater depressive symptoms, an important finding given prior research has documented that substance use coping is associated with the poorest outcomes (cooper et al., 2015). this indicates that both interventions for individuals experiencing depressive symptoms and for individuals experiencing comorbid depressive symptoms and cannabis use are warranted to enhance healthier coping and reduce cannabis use. unfortunately, there is inadequate access to treatment for college students with substance use or mental health difficulties (sun, 2020). cannabis use among young adults/college students could be addressed in primary care or university health settings by offering evidence based assessment, treatment, and harm reduction interventions for cannabis use (halladay et al., 2019; kansagara et al., 2019; montemayor et al., 2022). evidence-based interventions for individuals with comorbid cannabis use disorder and depressive symptoms include cognitive behavioral therapy, motivational interviewing, motivational enhancement therapy, and contingency management (lees et al., 2021; satre et al., 2018). limitations and future directions overall, data were collected from a predominately female college sample at a midwestern university with inadequate representation of diverse populations; thus, the generalizability of findings to other young adult populations (e.g., non-college students, more diverse young adults) may be limited. future research should utilize samples with more representation of racially minoritized college students. race and ethnicity were examined in the present study as proxy measures to reflect differential exposure to systemic influences affecting power, oppression, and privilege among different populations. future research should more directly examine sociocultural constructs (e.g., cultural factors, racism, social determinants of health) that may impact cannabis vaping. another limitation involves how we categorized individuals with a cmc versus those without a cmc based on self-reported physical health diagnoses, which excluded self-reported mental health diagnoses as a cmc. future research should recruit large samples of individuals with and without physical and mental health diagnoses to further parse apart important behavioral differences related to cannabis use. furthermore, the cross-sectional design limits the ability to draw causal conclusions; however, the crosssectional data provides important preliminary information on the associations between depressive symptoms, cmcs, and cannabis vaping. finally, this study did not include a measure of lifetime depression, which is a limitation. self-report of cannabis use may have led to underreporting of cannabis vaping (harrison et al., 2007). however, prior research has documented the convergent, concurrent, criterion, and construct validity of self-reported brief assessments of cannabis use (similar to the present study’s assessment; ramo, hall, et al., 2012; shiplo et al., 2016). research also supports the use of self-reported assessments of cannabis vaporizer use (jones et al., 2016; shiplo et al., 2016). yet, future research should consider using cannabis use biomarkers to reduce any possibility of underestimating current cannabis use; the current results may even be more pronounced when cannabis vaping is objectively measured. the current study did not assess cannabis use motives or if participants used cannabis recreationally or medicinally (and if medicinally, for what diagnosis). these omissions may limit conclusions that can be drawn about if participants were using cannabis to ameliorate depressive symptoms or distress associated with having a cmc. exploring whether cannabis use was recreational or medicinal is important to consider because medicinal use is legal in the state where data were collected. medical marijuana could have been prescribed to participants for a variety of mental and medical conditions, despite the fact that 1) there is only conclusive or substantial evidence suggesting a therapeutic effect for chemo-induced nausea and vomiting, chronic pain, and multiple sclerosis cannabis, a publication of the research society on marijuana 140 (cousijn et al., 2018) and 2) there is insufficient evidence to support a therapeutic effect for mental health symptoms (cousijn et al., 2018; hill, 2015; nasem, 2017; whiting et al., 2015). additionally, it is possible that individuals with a cmc may self-medicate via cannabis use to help manage their cmc or anxiety associated with their cmc. future research should further explore these associations by recruiting large samples of individuals with cmcs who use cannabis. while there is not current evidence suggesting a therapeutic benefit of medical marijuana for depression or the most common medical conditions reported in the present sample, there is substantial research supporting that depression is a risk factor for cannabis use. this study extends prior literature by identifying: that depressive symptoms were a consistent predictor of cannabis vaping among college students, consistent with prior selfmedication literature identifying young adults’ use of cannabis to reduce depressive symptoms (bolanis et al., 2020; hooshmand et al., 2012; khantzian, 1985; khantzian, 1997; wilkinson et al., 2016; womack et al., 2016), depressive symptoms may only be a risk factor for cannabis vaporizing among young adults without a cmc. these findings suggest the need for interventions to address depressive symptoms among college students with and without cmcs, and especially among those using cannabis use to cope with depression, to reduce overall cannabis vaping. cannabis use among college students could be addressed in primary care or university health settings by offering evidence-based assessment, treatment, and harm reduction interventions for cannabis use (halladay et al., 2019; 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(2016). bidirectional associations between cannabis use and depressive symptoms from adolescence through early adulthood among at-risk young men. journal of studies on alcohol and drugs, 77(2), 287– 297. https://doi.org/10.15288/jsad.2016.77.287 zvolensky, m. j., schmidt, n. b., antony, m. m., mccabe, r. e., forsyth, j. p., feldner, m. t., leen-feldner, e., karekla, m., & kahler, c. w. (2005). evaluating the role of panic disorder in emotional sensitivity processes involved with smoking. journal of anxiety disorders, 19(6), 673–686. https://doi.org/10.1016/j.janxdis.2004.07.001 funding and acknowledgements: dr. cole’s time was supported by p20ca253255 and r01mh126586. the authors report there are no competing interests to declare. data are available upon request from the corresponding author. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 40 internal ved abstract objective: increasingly, cannabis is being prescribed/used to help manage posttraumatic stress symptoms (ptss) or chronic pain, as cannabis has been argued to be beneficial for both types of symptoms. however, the evidence on efficacy is conflicting with evidence of risks mounting, leading some to caution against the use of cannabis for the management of ptss and/or chronic pain. we examined the main and interactive effects of ptss and chronic pain interference on adverse cannabis outcomes (a composite of cannabis use levels and cannabis use disorder, cud, symptoms). we hypothesized that chronic pain interference and ptss would each significantly predict adverse cannabis outcomes, and that chronic pain interference effects on adverse cannabis outcomes would be strongest among those with greater ptss. method: fortyseven current cannabis users with trauma histories and chronic pain (34% male; mean age = 32.45 years) were assessed for current ptss, daily chronic pain interference, past month cannabis use levels (grams), and cud symptom count. results: moderator regression analyses demonstrated chronic pain interference significantly predicted the adverse cannabis outcomes composite, but only at high levels of ptss. conclusions: cannabis users with trauma histories may be at greatest risk for heavier/more problematic cannabis use if they are experiencing both chronic pain interference and ptss. key words: = chronic pain; cannabis; ptsd; cannabis use disorder; trauma while some research suggests cannabis can be useful for alleviating chronic pain compared to treatment as usual (gruber et al., 2021; kansagara, 2017), a systematic review found only low strength evidence to support cannabis as effective for treating chronic pain (nugent et al., 2017). another review acknowledged a potential relationship between medicinal cannabis and cannabis-related problems, including cannabis dependence (yarnell, 2015). similarly, many trauma survivors are prescribed or use cannabis to manage posttraumatic stress symptoms (ptss1; metrik et al., 2016). some argue cannabis is beneficial in ptss treatment (walsh et al., 2017). however, a longitudinal study showed continued cannabis use was associated with worse posttraumatic stress disorder (ptsd) outcomes (wilkinson et al., 2015). moreover, high quality evidence (i.e., randomized controlled trials) on cannabis’ efficacy for treating ptsd is lacking (mckee et al., 2021). additionally, there are high rates of comorbidity between ptsd and cannabis use disorder (cud; walsh et al., 2014). sarah degrace1, pablo romero-sanchiz2, sean barrett1,3, philip tibbo1,3, tessa cosman1, pars atasoy3, & sherry stewart1,3 1department of psychiatry, dalhousie university 2school of psychology, university of sussex 3department of psychology and neuroscience, dalhousie university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000241 volume 8, issue 1 posttraumatic stress symptoms moderate the relationship between chronic pain and adverse cannabis outcomes: a pilot study corresponding author: sherry stewart, ph.d., dalhousie university, 5909 veterans' memorial lane, 8th floor, abbie j. lane memorial building, qeii health. halifax, nova scotia, canada, b3h 2e2. email: sstewart@dal.ca cannabis, a publication of the research society on marijuana 41 internal ptsd and chronic pain interference (i.e., the ways the presence of chronic pain interferes with one’s daily activities) commonly co-occur and are thought to exacerbate the symptoms of the other (asmundson & katz, 2009). indeed, one longitudinal study found that for injured veterans with ptsd (vs. non-injured veterans with ptsd), chronic pain interference mediated increases in ptss (lee et al., 2019). another study found a ptsd diagnosis predicted increased pain interference in active military members (li et al., 2021). a third (morasco et al., 2013) identified those with ptsd (vs. without ptsd) were more likely to have a substance use disorder and were experiencing greater pain interference. interestingly, depressive symptoms/coping strategies partially mediated this effect. evidently, pain interference is an important facet of chronic pain that has been empirically shown to be related to ptsd. for these reasons, cannabis interventions for alleviating either chronic pain or ptss remain controversial, particularly with cannabis legalization occurring in many jurisdictions. indeed, given observed associations between cannabis accessibility and increased cannabis use (cerdá et al., 2017), cannabis self-medication for ptss and/or chronic pain without the oversight of a prescriber is likely. while some research shows ptsd is comorbid with cud regardless of chronic pain (bilevicius et al., 2019), other work demonstrates ptsd-chronic pain comorbidity is more strongly associated than either disorder alone with substance dependence (kind & otis, 2019). additionally, chronic pain is more severe and intrusive among those with ptsd (siqveland et al., 2017); thus, chronic pain may be more likely to motivate cannabis use in the presence of greater ptss. ravn et al. (2018) found ptss positively moderated the relationship between chronic pain and distress, suggesting ptss may exacerbate the relationship between chronic pain and other health-relevant outcomes, including excessive/problematic cannabis use. more research is needed to test links between chronic pain, ptss, and cannabis outcomes. such research could help inform to whom preventative and early intervention resources should be targeted for minimizing adverse cannabis outcomes. we examined the main and interactive effects of ptss and chronic pain interference on adverse cannabis outcomes (a composite of past month cannabis use and cud symptom count) among trauma-exposed cannabis users with chronic pain. we hypothesized greater chronic pain interference and greater ptss (i.e., higher ptsd symptom count) would both independently predict greater adverse cannabis outcomes (h1). we further predicted an interaction where chronic pain interference effects on adverse cannabis outcomes would be strongest among those with greater ptss (h2). methods participants fifty participants (34% male; mage = 32.18 years, sd = 10.02; 20% current/previous military members) residing in halifax, nova scotia, canada, were recruited via social media (e.g., facebook, instagram) for an in-person study on trauma exposure and cannabis use (degrace et al., 2023a, b). participants were required to meet inclusion/exclusion criteria in a telephone prescreening: aged 19-65 years; no current diagnosis of serious mental illness2; exposure to >1 lifetime potentially traumatic event(s); and regular cannabis use (>1 g/week in the past month; gabrys & porath, 2019). for the current archival study, participants also had to report pain on most days in the past three months on the electronic chronic pain questionnaire (ecpq; coyne et al., 2017), leaving a final sample of n = 47 (34% male; mage = 32.45 years, sd = 10.28; 21.3% current/previous military members).3 1 throughout this manuscript, the acronym ptss refers to continuous measures of ptsd symptoms, whereas ptsd refers to the categorical diagnosis. 2 serious mental illness was defined s bipolar disorder, schizophrenia, or other psychotic disorder. 3 the ecpq allows for the screening out of those who did not report chronic pain. only those 47 who reported experiencing chronic pain on the first item of the ecpq were included in our primary analyses for the current archival study since only those acknowledging chronic pain went on to report on the degree of chronic pain interference. chronic pain and cannabis outcomes at high ptsd 42 internal procedure at in-person testing,4 participants were clinically assessed for current ptsd and cud via validated structured interviews conducted by a trained psychiatry graduate student supervised by a licenced clinical psychologist. only instruments relevant to the current archival substudy are described. measures demographics. participants reported demographic information (i.e., sex, age, military status). trauma exposure. the 17-item life events checklist (lec; gray et al., 2004) was used during pre-screening to assess criterion a of a dsm-5 (american psychiatric association; apa, 2013) ptsd diagnosis. ptss. past month ptss were assessed using the 20-item clinician-administered ptsd scale for dsm-5 (caps-5; weathers et al., 2018). if participants reported exposure to >1 lifetime traumas on the lec, they focused on their most distressing lifetime trauma for the caps-5. continuous caps-5 scores (i.e., ptsd symptom count; possible range = 0-20; e.g., tull et al., 2018) were used in hypotheses-testing regarding main and interactive effects of ptss on adverse cannabis outcomes. we used caps-5 scoring rules for establishing dsm-5 (apa, 2013) ptsd diagnoses, for sample description purposes.5 the caps-5 possesses excellent interrater reliability, test-retest reliability, and high internal consistency (α =.88; weathers et al., 2018; α = .82, present sample). chronic pain. the ecpq (coyne et al., 2017) is a brief measure tapping chronic pain and its characteristics. if participants indicated they had experienced pain on most days in the past three months, they continued with the remaining ecpq items. in our hypothesis-testing of the main and interactive effects of chronic pain on cannabis outcomes, we utilized the 5-item pain interference scale. participants rated how much their pain had interfered with functioning in the past week (0 = not at all to 10 = severe problem) in each of five life domains: usual activities, sleep, mood, cognitive functioning, and use of the senses. items were summed (possible range = 0-50). the pain interference scale has good internal consistency (α = .82, present sample) and good concurrent and discriminant validity (coyne et al., 2017). cannabis use. past month cannabis use levels were assessed using the cannabis timeline followback (c-tlfb; sobell & sobell, 1992). participants indicated on a calendar which days in the past month they had used cannabis, and how much cannabis (in grams) had been used each day. the c-tlfb has good test-retest reliability (robinson et al., 2012), excellent inter-rater reliability (norberg et al., 2012), and has shown validity in accurately depicting cannabis use (hjorthøj et al., 2012). total grams of cannabis (past month) were used as one component in our adverse cannabis outcomes composite. cud symptoms. cud symptoms were operationalized as past year cud symptom count on the 11-item structured clinical interview for dsm-5, research version (scid-5-rv; first et al., 2015). scid-5 cud symptom count scores (possible range = 0-11) were used as the second component in our adverse cannabis outcomes composite (pellegrino et al., 2020). we used established scid-5 scoring rules to determine dsm-5 (apa, 2013) cud diagnoses for sample description purposes.6 the scid-5 has excellent reliability and diagnostic sensitivity (osorio et al., 2019). data analysis andrew hayes’ (2013) process (v4.1) macro was used in hypothesis-testing. the two outcomes 4 participants were required to remain abstinent from cannabis, alcohol, and illicit drugs for 12 hours and from caffeine for 2 hours prior to their lab-based testing session for reasons related to the parent study (degrace et al., 2023a, b). abstinence was verified using a urine test, breathalyzer, and self-report. 5 the caps-5 scoring rules for establishing a dsm-5 (apa, 2013) ptsd diagnosis were: >1 symptom for each of criteria b and c, respectively; and >2 symptoms for each of criteria d and e, respectively. 6 the scid-5 scoring rules for establishing a dsm-5 (apa, 2013) diagnosis of cud are endorsement of >2 of 11 possible cud symptoms. those with a cud diagnosis were further classified as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6+ symptoms) using the dsm-5 (apa, 2013) categories for cud severity (see first et al., 2015). cannabis, a publication of the research society on marijuana 43 internal of interest, past month cannabis use and cud symptom count, were converted to z-scores and averaged to create a single composite. this composite, which we refer to as ‘adverse cannabis outcomes,’ was used as our primary outcome. our model regressed adverse cannabis outcomes on pain interference scores with ptss as the moderator. as all variables were continuous with meaningful values at zero, data were not centered for interpretation purposes (iacobucci et al., 2016; olvera-astivia & kroc, 2019). a significant interaction was probed using simple slopes analyses examining the effect of chronic pain interference on adverse cannabis outcomes at low (-1sd), mean, and high (+1sd) ptss levels. results descriptive statistics table 1 shows descriptive statistics and bivariate correlations. on the ecpq, participants reported mean chronic pain interference levels (m = 19.18, sd = 12.06, range = 0-50) comparable to those in patients with a clinical chronic pain condition (coyne et al., 2017). participants’ past month cannabis use levels (m = 54.4 grams, sd = 45.5, range = 4-206) were ~5 times higher than the monthly use levels of cannabis users in the canadian general population (statistics canada, 2020). the majority (70.2%) met criteria for pastyear cud (scid-5). amongst those with cud, 33.3% met criteria for mild, 15.2% for moderate, and 51.5% for severe cud. more than half (59.6%) met criteria for past-month ptsd (caps-5). see supplementary table 1 for further descriptive and clinical characteristics. chronic pain interference was significantly positively correlated with ptss (medium effect). cannabis use and cud symptoms were significantly positively intercorrelated (medium effect). the other inter-correlations among study measures were positive but small and not statistically significant.7 table 1. descriptive statistics and bivariate correlations. 1 2 3 4 1. chronic pain interference .494** .251 .242 2. ptss .109 .228 3. past month cannabis use (in grams) .333* 4. cud symptoms m 19.18 10.52 54.40 3.72 sd 12.06 4.87 45.55 2.84 range 0-50 2-19 4-206 0-9 note. * p < .05, ** p < .01 (two-tailed tests). chronic pain interference was assessed with a 5-item subscale of the ecpq (coyne et al., 2017); ptss was a ptsd symptom count on the caps-5 interview (weathers et al., 2018); past month cannabis use was assessed using the c-tlfb (sobell & sobell, 1992); and cud symptoms were a symptom count on the cud assessment from the scid-5 (first et al., 2015). 7 the following parameters were used to determine the magnitude of the correlations: .1-.3 small; .3-.5 medium; and .5-1.0 large (cohen, 1992). 8 values of the dependent variable at levels of the moderator are available in supplementary table 2. 9 a sensitivity analysis was conducted with the full sample of n = 50 from the larger study (degrace et al., 2023a, b). minimal possible values for chronic pain interference were given to the n = 3 participants who reported no chronic pain on the first question of the ecpq and the analyses were rerun. we also conducted another set of sensitivity analyses with the subsample reporting chronic pain (n = 47) where the analyses were repeated for past month cannabis use (on the c-tlfb) and cud symptom count (on the scid) separately (see supplementary tables 3 and 4, respectively). simple slopes analyses replicated the main results in all cases: the association between chronic pain interference and the adverse cannabis outcome in question was significant, but only at high (but not average or low) ptss levels. a final sensitivity analysis of our regression model without the interaction effect on the adverse cannabis outcomes composite score failed to produce main effects of ptsd (p = .693) or pain (p = .223). sensitivity analyses are available from the corresponding author on request. chronic pain and cannabis outcomes at high ptsd 44 internal regression inconsistent with h1, neither significant main effects of chronic pain interference nor ptss were observed on our adverse cannabis outcomes composite. however, a significant pain interference x ptss interaction was observed.8 consistent with h2, simple slopes analyses demonstrated greater chronic pain interference significantly predicted greater adverse cannabis outcomes only at high (but not average or low) ptss levels (see table 2, figure 1)9 table 2. regression analysis results with chronic pain interference, ptss, and their interaction predicting the adverse cannabis use outcomes composite (top panel); simple slopes across three levels of the moderator (bottom panel). effect b t p chronic pain interference -.035 -1.48 .144 ptss -.084 -1.74 .089 chronic pain interference x ptss .005 2.33 .024* simple slopes low (-1sd) ptss -.008 -.547 .587 mean ptss .015 1.36 .179 high (+1sd) ptss .037 2.53 .015* note. *p < .05; regression coefficients are unstandardized. figure 1. simple slopes analyses of chronic pain interference predicting the adverse cannabis use outcomes composite across three levels of ptss: low (-1 sd), mean, and high (+1 sd). note. significant simple slopes (p < .05) indicated via asterisk (*). discussion our pilot study is the first to examine the possible interactive effects of chronic pain and ptss on adverse cannabis outcomes (i.e., pastmonth cannabis use and cud symptom count). consistent with one of our two study hypotheses (h2), the chronic pain interference x ptss interaction predicted concurrent severity of adverse cannabis outcomes among traumaexposed cannabis users with chronic pain. specifically, a significant positive effect of chronic pain interference on levels of adverse cannabis outcomes (composite and each outcome individually) was observed only among those with a high ptss count. however, neither chronic pain -1 -0.5 0 0.5 1 low pain interference (-1sd) high pain interference (+1sd) a d v er se c a n n a b is o u tc o m es low ptss (-1sd) mean ptss high ptss (+1sd)* cannabis, a publication of the research society on marijuana 45 internal interference nor ptss alone was associated with adverse cannabis outcomes, in contrast to our other hypothesis (h1); just having life-interfering effects of chronic pain or just having high levels of ptss was not sufficient to elevate risk for concurrent adverse cannabis outcomes. thus, heavier/more problematic cannabis use is more likely when life-interfering levels of chronic pain are accompanied by high levels of ptss. results are consistent with research showing that veterans dealing with chronic pain and ptss are more likely to endorse maladaptive coping strategies compared to veterans experiencing chronic pain alone (alschuler & otis, 2012). given some limited evidence of efficacy of cannabis in managing chronic pain (nugent et al., 2017), greater cannabis use levels might be argued to be adaptive amongst those with elevated chronic pain and ptss. however, this pattern of moderation was observed not only for cannabis use levels but also for cud symptom count in our sensitivity analyses, suggesting greater cannabis use among those with both elevated chronic pain and ptss should be considered risky. previous research has been inconsistent as to whether chronic pain and ptss interact in the prediction of adverse cannabis outcomes. while one previous study found ptsd was associated with comorbid cud regardless of chronic pain (bilevicius et al., 2019), a literature review showed ptsd-chronic pain comorbidity was associated with greater substance dependence relative to either ptsd or chronic pain alone (kind & otis, 2019). our results are more consistent with the latter than the former result given our findings of interactive effects of chronic pain interference and ptss, but no main effects of ptss, on our adverse cannabis outcome composite (and its individual components in sensitivity analyses). prior research suggests a possible mechanism to explain our interactive effects of chronic pain and ptss on adverse cannabis outcomes. higher levels of distress (i.e., depression, anxiety) in those with both chronic pain and elevated ptss (rayn et al., 2018) may motivate greater cannabis use to cope, and thereby promote development of heavier and more problematic cannabis use. in future, research might explore a moderated mediation model, with ptss and chronic pain interacting to predict distress (the mediator), which in turn may contribute to heavy/problematic cannabis use. such work might identify a mechanism (i.e., heightened distress) to explain how ptss and chronic pain interact to contribute to adverse cannabis outcomes; this mechanism (i.e., distress) could be targeted in future interventions. indeed, clinicians working with trauma-exposed patients who experience concurrent chronic pain should adopt an integrated approach that targets both pain interference and ptss simultaneously. this involves comprehensive assessment, traumainformed therapies such as cognitive behavioral therapy (cbt), and effective pain management strategies such as physical therapy (weisfield & dunleavy, 2020). moreover, psychoeducation about the risks of heavy cannabis use, alongside regular monitoring and patient-centered care, help ensure the patient is responsive to treatment, ultimately reducing the risk of adverse cannabis outcomes and improving patient wellbeing (bell et al., 2024). given our sample used cannabis at 5x more grams per month compared to the general canadian population (statistics canada, 2020), the implications for clinical practice derived from this study might be most relevant to heavy cannabis users. potential limitations of this archival pilot study should be acknowledged. first, the data were cross-sectional, which precludes drawing causal conclusions from this moderation effect; longitudinal research is needed to determine if ptss and chronic pain interact in predicting escalations in adverse cannabis outcomes over time. second, we used symptom counts on structured clinical interviews to quantify ptss and cud symptoms. future studies may wish to use established measures assessing ptsd and cud symptom severity, as symptom counts may underestimate effects of interest. third, our quantification of cannabis use (in grams) did not consider cannabinoid (i.e., thc, cbd) dose or ratio and may not be easily estimated by those using concentrates or edibles. fourth, our pilot study sample size was relatively small and results should be replicated in a larger sample. our pilot findings may have important clinical implications if extended longitudinally. first, chronic pain interference and ptss were moderately positively correlated, pointing to the importance of clinicians regularly assessing for the other issue among patients presenting with chronic pain and cannabis outcomes at high ptsd 46 internal either problem. second, our modelling suggested individuals with both chronic pain and ptss are more likely to experience adverse cannabis outcomes. if replicated longitudinally, targeted interventions could be developed to intervene early or prevent adverse cannabis outcomes in this comorbid ptss-chronic pain group. third, individuals seeking treatment for chronic pain or ptss may not be aware of the elevated risks associated with using cannabis for pain or ptss management among individuals with both conditions. prescribers should discuss risks in addition to benefits of cannabis with their patients, prior to prescribing cannabis for those suffering chronic pain and ptss concurrently. moreover, for heavy cannabis users such as those in our sample, provision of psychoeducation on such risks (e.g., by family physicians) may be particularly important for patients using cannabis without a prescriber’s oversight. references alschuler, k.n., & otis, j.d. 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(2015). the use of medicinal marijuana for posttraumatic stress disorder. primary care companion for cns disorders, 17(3). doi:10.4088/pcc.15r01786 funding and acknowledgements: this work was supported through a cannabis and mental health catalyst grant (principal investigator: shs; #442109) from the mental health commission of canada and by a grant (principal investigator: sd; #893728) from the nova scotia health authority research fund. sd is supported by graduate studentships from the chronic pain centre of excellence for canadian veterans’ capacity building initiative, the l’oréal-unesco & france-canada research fund for women in science scholarship, and the dalhousie medical research foundation’s macquarrie neuroscience research graduate studentship. pt is supported through the dr paul janssen chair in psychotic disorders, dalhousie university. tc was funded through a summer studentship from the dalhousie university department of psychiatry research fund. shs is supported through a tier 1 canada research chair in addictions and mental health. the authors have no conflicts of interest to declare. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: degrace, s., romero-sanchiz, p., barrett., s., tibbo, p., cosman, t., atasoy, p., & stewart, s. (2025). posttraumatic stress symptoms moderate the relationship between chronic pain and adverse cannabis outcomes: a pilot study. cannabis, 8(1), 40-49. https://doi.org/10.26828/cannabis/2024/000241 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 51 ved abstract objective: recreational and medical cannabis use has increased, particularly among young adults, but little is known regarding who uses for these purposes or how purpose of use is associated with problematic use. method: we analyzed fall 2019 survey data among 1,083 us young adults (ages 18-34) reporting past 6month cannabis use. multivariable regression analyses examined: 1) characteristics of those using for only/primarily medical purposes, primarily recreationally, and only recreationally vs. equally for medical and recreational purposes (referent; multinomial logistic); and 2) reasons for use in relation to cannabis use disorder symptoms (linear) and driving under the influence of cannabis (duic; binary logistic). results: 37.1% used only recreationally, 23.5% primarily recreationally, 21.5% equally for both, and 17.8% medically. compared to those using equally for medical and recreational purposes, those using only/primarily medically had fewer friends who used cannabis; those using primarily recreationally were younger, more educated, less likely used tobacco, and reported fewer aces. those using only recreationally were younger, more likely male, less likely to report an adhd diagnosis or past-month alcohol or tobacco use, and reported fewer friends who used cannabis, aces, and depressive symptoms. using equally for medical and recreational purposes (vs. all other cannabis use subgroups) correlated with greater use disorder symptoms and duic. conclusions: using cannabis equally for medical and recreational purposes may pose particularly high-risk, given the association with greater mental health concerns and problematic use. understanding use profiles and how young adults interpret and distinguish medical and recreational use is critical. key words: = cannabis use; medical and recreational cannabis; cannabis use characteristics; risk factors; young adults cannabis is the most commonly used federally illicit drug in the us. in 2021, past-year cannabis use prevalence was 18.7% among us individuals ages 12 or older, which was highest among those ages 18-25 (35.4%), 26 and older (17.2%), and 1217 (10.5%) (samhsa, 2021). although cannabis is federally prohibited, as of november 2022, 21 states and 3 territories (including the district of priyanka sridharan1, katelyn f. romm2,3, & carla j. berg4,5 1department of epidemiology, milken institute school of public health, george washington university 2tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center 3department of pediatrics, college of medicine, university of oklahoma health sciences center 4department of prevention and community health, milken institute school of public health, george washington university 5george washington cancer center, george washington university cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000216 use of cannabis for medical or recreational purposes among us young adults: correlates and implications for problematic use and interest in quitting corresponding author: katelyn romm, phd, tset health promotion research center, department of pediatrics, stephenson cancer center, university of oklahoma health sciences center, 655 research pkwy #400, oklahoma city, ok 73104. email: katelyn-romm@ouhsc.edu. cannabis, a publication of the research society on marijuana 52 columbia) have legalized recreational use, and ~40 states and 4 territories have legalized medical use (hansen et al., 2022). despite some potential medical benefits of cannabis use (e.g., epilepsy, multiple sclerosis, chronic pain; banerjee & mccormack, 2019; bilbao & spanagel, 2022), cannabis use poses potential negative consequences, especially for young people (hall & lynskey, 2020), including impaired memory and attention, decreased motivation and productivity, mental health problems (e.g., anxiety, depression, psychosis), increased risk of addiction (stuyt, 2018), and driving under the influence of cannabis (duic) and related motor vehicle accidents (azofeifa et al., 2019). as legalized recreational and medical cannabis has expanded in the us, the use of cannabis for both recreational and medical purposes has become increasingly prevalent among young adults (schauer, 2021). although cannabis is predominantly used recreationally, it is increasingly used for relief from various physical and mental health conditions (leung et al., 2022; lin et al., 2016; paul et al., 2020). for example, a 2016 analysis of data from a nationally-representative us sample found that, in states with medical cannabis legislation, 17% of individuals used cannabis for medical reasons, while 83% used it recreationally (lin et al., 2016). a 2018 analysis of nationally-representative data from adults in the us and canada indicated that 27% had ever used cannabis for medical purposes (leung et al., 2022). it is important to understand who uses cannabis for medical vs. recreational purposes and the potential profiles of use that might entail the highest risk, for example, in terms of addiction, long-term chronic use (vs. quitting), and high-risk behaviors like driving under the influence. in terms of correlates of use for medical or recreational purposes, the existing literature is limited. one prior study using nationallyrepresentative data indicated greater odds of medical use among men vs. women and those ages 26-35 vs. other age groups (leung et al., 2022). related to markers of addiction, although the majority of those using cannabis do not experience signs of addiction, recent epidemiological patterns indicate a growing population living with some form of cannabis use disorder (compton et al., 2019). one study found that, among us adults using cannabis in a nationally-representative sample, past-year prevalence of cannabis use disorder was ~10% (compton et al., 2019). interestingly, while one national study found that individuals who used cannabis for medical reasons had a higher prevalence of daily or almost daily use (33%) compared to those who used cannabis recreationally (11%; lin et al., 2016), other research has found that those using cannabis medically (vs. recreationally) have lower rates of problematic cannabis use and related harm (connor et al., 2021). a particular concern is duic, as cannabis use increases the risk of being involved in a motor vehicle crash (asbridge et al., 2012). in 2018, 12 million (4.7%) us adults reported duic in the past year, which was more prevalent among those ages 16-34 and men (azofeifa et al., 2019). relevant to the current study, prior analyses of nationally-representative data have documented that duic is more prevalent among those who use cannabis for medical vs. recreational purposes (27% vs. 9.7%; wickens et al., 2022) and among individuals with symptoms of cannabis use disorder (salas-wright et al., 2021). interest in quitting cannabis use is also an important area of investigation, as lack of interest may have implications for ongoing, chronic, and potentially escalating use. many people who use cannabis on a regular basis are interested in reducing or quitting their use (masters et al., 2018; mcclure et al., 2019; zvolensky et al., 2018). for example, one study of young adults using cannabis documented that 22% reported quit attempts in the past 4 months and 19% reported readiness to quit in the next month (masters et al., 2018). another study found that 16% of those co-using cannabis and tobacco had attempted to stop using cannabis in the previous year, and 11% intended to in the next month (mcclure et al., 2019). however, cannabis cessation-related outcomes have not been investigated in relation to primary purposes for use. notably, most of the prior literature has documented whether people have used medically or recreationally, with very little research examining how individuals describe the reasons for their current use in terms of how often they use medically vs. recreationally. further, there is limited research characterizing individuals who use cannabis medically vs. recreationally or how reasons for use are associated with indicators of problematic use. this study aims to advance the medical or recreational cannabis use in young adults 53 literature by addressing these gaps. specifically, this study examined: 1) correlates (i.e., sociodemographics, psychosocial factors, use characteristics) of young adults’ reasons for using cannabis (i.e., recreational, medical, or both); and 2) indicators of problematic use (i.e., levels of use, symptoms of dependence, duic, considering quitting) in relation to young adults’ reasons for use (i.e., recreational, medical, or both). methods study design the current study is an analysis of survey data among 3,006 young adults (aged 18-34) participating in a 2-year, 5-wave longitudinal cohort study, the vape shop advertising, place characteristics and effects surveillance (vapes) study. vapes examines the vape retail environment and its impact on substance use, drawing participants from 6 metropolitan statistical areas msas (atlanta, boston, minneapolis, oklahoma city, san diego, seattle), selected for their variation in state tobacco control and cannabis retail legislation. this study, detailed elsewhere (berg et al., 2020), involved survey data collection launched in fall 2018 with assessments every 6 months for 2 years during fall and spring. this study was approved by the george washington university institutional review board. participants & recruitment advertisements posted on facebook and reddit targeted eligible individuals (18-34 years old, living in one of the 6 msas, english speaking) using imagery, taglines, and interests that appeal to young adults. individuals who clicked on ads were directed to a webpage with a study description and consent form, screened for eligibility, and then administered the baseline survey. purposive sampling was used to ensure sufficient proportions of the sample represented those using e-cigarettes and cigarettes (roughly 1/3 each), both sexes, and racial/ethnic minorities. subgroup enrollment was capped by msa. participants received an email 7 days after completing the baseline survey asking them to confirm their participation by clicking a “confirm” button included in an email. after confirming, participants were enrolled and emailed their first incentive (a $10 e-gift card). the duration of recruitment ranged from 87 to 104 days across msas. overall, 65,843 facebook/reddit users viewed study ads, 10,433 clicked on ads, 9,847 consented, and 7,096 were eligible. additionally, 2,751 were not allowed to advance to the baseline survey, with 1,427 ineligible and 1,279 not enrolled in order to reach recruitment targets of other demographics. the baseline survey was completed by 3,460 (48.8%; 51.2% partial completes, n = 3,636); 3,006 (87%) confirmed participation. the current analyses focused on fall 2019 data (i.e., one year post baseline; n = 2,375, 79.0% response rate; compensation of a $20 e-gift card). attrition analyses indicated that participants who did not (vs. did) complete the follow-up survey were younger, more likely male, and more likely to report past-month cannabis use at baseline (berg et al., 2020). measures sociodemographic covariates. we coded msa of residence and whether it was in a state where cannabis retail was legal (california, massachusetts, washington) or was not (georgia, minnesota, oklahoma). other sociodemographics included age, sex, sexual orientation, race, ethnicity, and highest level of educational attainment. cannabis use characteristics. participants were asked to report the number of days used in the past 6 months; those reporting any use were asked to report the number of days used in the past 30 days. among those who reported any past 6-month use, we asked, “do you use marijuana for medical or recreational purposes – or both: only for medical purposes, primarily for medical purposes, equally for both, primarily for recreational purposes, only for recreational purposes, i’m not sure.” based on the distributions and limited variability, those reporting only or primarily for medical purposes were collapsed into a single category. among those reporting past 6-month use, we also assessed age of first use (to operationalize early onset use; i.e., before age 18), number of times used per day, and whether participants held a medical cannabis card. we also asked participants how they use cannabis most of the cannabis, a publication of the research society on marijuana 54 time: smoked (in a joint or bowl, rolled in cigar papers with or without tobacco); vaped (with a vaporizer with or without tobacco); pipe/bong (in a waterpipe or bong with our without tobacco); ingested (with or without food, drank); and other (including tinctures, dabs, etc.; fong et al., 2006). we also administered the cannabis use disorder identification test – revised (cudit-r), an 8-item scale assessing hazardous use, with scores ranging from 0-32 with higher scores indicating more hazardous use (adamson et al., 2010). one item from the cudit-r that assesses interest in quitting was also used separately (“have you ever thought about cutting down, or stopping your use of marijuana? never; yes, but not in the past 6 months; or yes, during the past 6 months”). we recategorized participants as considered quitting (or reducing) in the past 6 months vs. others. we also asked, “during the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been using marijuana? 0, 1, 2-3, 4-5, 6 or more, or prefer not to answer.” this item was categorized as 0 vs. ≥1 time. other substance use. participants were asked to report number of days in the past 30 days they used: alcohol, cigarettes, e-cigarettes, little cigars/cigarillos, large cigars, hookah/waterpipe, and smokeless tobacco (nih, 2020). alcohol use was used as a continuous variable; use status for each tobacco product was operationalized as any vs. no use in the past 30 days and as a single aggregate variable as any vs. no use of any tobacco product in the past 30 days. psychosocial factors. participants were asked if a parental figure uses/used cannabis (yes/no) and how many of their 5 closest friends use cannabis (berg et al., 2015). depressive symptoms were assessed using the patient health questionnaire – 2 item (phq-2; kroenke et al., 2003), which assesses feeling down/depressed and little interest in doing things in the past 2 weeks (0 = not at all to 3 = nearly every day; summed scores of 0-6; cronbach’s α = .87). the aces-10 item scale assessed maltreatment and household challenges before age 18 (0 = no, 1 = yes; range 0-10; α = .81; felitti et al., 1998). finally, participants were asked whether they had ever been diagnosed with adhd. data analysis the current study analyzed data from 1,083 participants who reported any cannabis use in the past 6 months (i.e., since the last assessment). participant characteristics were summarized using descriptive statistics. chi-square and oneway anova tests were used to explore differences in participant characteristics in relation to reasons for use. then multinomial logistic regression was used to examine correlates of reasons for use, using “equally both” as our referent group. we included other substance use and psychosocial factors, as well as sociodemographic covariates that were significant in bivariate analyses (i.e., age, sex, race/ethnicity, education level). finally, regression models were used to examine reasons for use in relation to: 1) number of days used (linear regression); 2) cudit scores (linear regression); 3) duic (binary logistic regression); and 4) recently considering quitting (binary logistic regression). in these models, we accounted for age, sex, race/ethnicity, and education level. regression analyses were also conducted using multilevel modeling to account for the hierarchical structure of the data (i.e., young adults at the individual level nested within msa; aveyard, markham, & cheng, 2004; aveyard, markham, lancashire, et al., 2004). however, all intra-class correlations were approximately .01, and findings were not significantly different. all analyses were conducted using spss (version 26.0) and alpha set at .05. results participant characteristics in this sample of 1,083 participants who reported past 6-month cannabis use, the average age was 24.46 (sd = 4.64), 57.1% lived in states with legalized recreational cannabis, 41.9% were male, 40.3% were sexual minorities, 24.1% were non-white, 12.7% were hispanic, and 72.9% possessed at least a bachelor’s degree. in this sample, 37.1% used only for recreational purposes, 23.5% for primarily recreational purposes, 21.5% equally for medical and recreational purposes, and 17.8% for only/primarily medical purposes. of the 1,083 young adults reporting past 6-month use, 79.3% (n = 859) also reported using in the past 30 days (m days of use = 10.59, sd = 11.38), and the average cudit score was 7.45 (sd = 5.68). overall, 24.3% reported past 30-day duic, and medical or recreational cannabis use in young adults 55 30.9% reported considering past 6-month quit attempts. correlates of reasons for use bivariate analyses (table 1) indicated that there were differences in the proportions of young adults using cannabis who reported different purposes of use in relation to msa, age, sex, race, ethnicity, and education level (p’s < .05; see table 1 for significant post-hoc differences). regarding cannabis use characteristics, those who used equally for medical and recreational purposes reported the greatest number of days used and times used per day; those using only for recreational purposes reported the least (p’s < .001). those using only for recreational purposes were also the least likely to report early onset use (p’s < .001) but the most likely to report never trying to quit (p < .001); they also reported the greatest number of days of alcohol use (p = .006). those using only for medical purposes were most likely to report having a medical cannabis card; those using only recreational were the least likely (p < .001). those using only for recreational purposes were the least likely to report using via pipe/bong, but were the most likely to report ingesting cannabis as their most common mode of use (p < .001). those using primarily for recreational purposes were the most likely to report parental use of cannabis and lifetime diagnosis of adhd (p’s < .001). multinomial logistic regression analyses (table 2) indicated that compared to those who used equally for medical and recreational purposes (referent group), those who reported using for only/primarily medical purposes were less likely to live in boston, minneapolis, seattle, or “other” msa (vs. oklahoma city, p’s < .05) and had fewer friends who used cannabis (p = .003). those who reported using primarily for recreational purposes (vs. equally for medical and recreational purposes) were more likely to live in any other of the msas (except boston) vs. oklahoma city (p’s < .05), were younger (p < .001), more likely to have at least a bachelor’s degree (p = .042), reported fewer aces (p = .011), and were less likely to report past-month tobacco use (p < .001). those who reported using only for recreational purposes (vs. equally for medical and recreational purposes) were more likely to live in atlanta, boston, or minneapolis (vs. oklahoma city, p’s < .05), were younger (p < .001), were more likely male (p = .018), had fewer friends who used cannabis (p < .001), reported fewer aces (p < .001) and fewer depressive symptoms (p = .008), were less likely to report an adhd diagnosis (p = .010), used alcohol on more days in the past month (p = .015), and were more likely to report pastmonth tobacco use (p < .001). reasons for use in relation to use frequency, dependency, duic and interest in quitting regression models examining reasons for cannabis use in relation to the number of days used, cudit scores, duic, and interest in quitting in the past 6 months among those reporting past 6-month cannabis use are shown in table 3. using equally for medical and recreational purposes (vs. all other subgroups of cannabis use) correlated with more days of use, greater cudit scores, and greater odds of duic (p’s < .011). additional correlates included: being male (p = .027) and lower education (p < .001) for days of use; living in any other of the msas except atlanta or boston (vs. oklahoma city, p’s < .05), being younger (p = .042), being male (p < .001), and lower education (p < .001) for cudit scores; and being male (p < .001) or white (vs. black; p = .027) for duic. correlates of considering quitting cannabis included living in san diego or seattle (vs. oklahoma city, p’s < .05), being younger (p < .001), female (p = .002), and using equally for medical and recreational purposes vs. only recreational purposes (p < .001). discussion in this sample of us young adults ages 18-34 reporting past 6-month cannabis use, over onethird (~37%) used only recreationally, while only about one-fifth used primarily recreationally (~23%), equally for both (~21%), and only/primarily medically (~18%). cannabis, a publication of the research society on marijuana 56 table 1. correlates of reasons for cannabis use among young adults using cannabis within the past 6 monthsin fall 2019, n=1,083 * total n=1,083 (100%) only/primarily medical n=193 (17.8%) equally both n=233 (21.5%) primarily recreational n=255 (23.5%) only recreational n=402 (37.1%) variable n (%) or m (sd) n (%) or m (sd) n (%) or m (sd) n (%) or m (sd) n (%) or m (sd) p msa, n (%) <.001 atlanta 163 (15.1) 33 (17.1) 25 (10.7) 39 (15.3) 66 (16.4) boston 227 (21.0) 32 (16.6) 46 (19.7) 51 (20.0) 98 (24.4) minneapolis-st. paul 191 (17.6) 17 (8.8)a 45 (19.3)b 46 (18.0)b 83 (20.6)b oklahoma city (ref) 90 (8.3) 42 (21.8)a 22 (9.4)b 8 (3.1)c 18 (4.5)c,d san diego 161 (14.9) 37 (19.2) 31 (13.3) 43 (16.9) 50 (12.4) seattle 213 (19.7) 25 (13.0)a 53 (22.7)a,b 61 (23.9)b 74 (18.4)a,b other 38 (3.5) 7 (3.6) 11 (4.7) 7 (2.7) 13 (3.2) cannabis retail law, n (%) .155 legalized 617 (57.1) 99 (51.3) 134 (57.5) 157 (62.1) 227 (56.6) not legalized 463 (42.9) 94 (48.7) 99 (42.5) 96 (37.9) 174 (43.4) sociodemographics age, m (sd) 24.46 (4.64) 26.51 (4.82)a 25.35 (4.82)b 23.67 (4.38)c 23.45 (4.18)c <.001 male, n (%)** 439 (41.9) 62 (34.1)a 91 (41.4)a,b 96 (38.6)a,b 190 (47.9)b .009 sexual minority, n (%) 436 (40.3) 80 (41.5) 97 (41.6) 113 (44.3) 146 (36.3) .201 race, n (%) .048 white 813 (75.1) 144 (74.6) 185 (79.4) 189 (74.1) 295 (73.4) black 39 (3.6) 7 (3.6) 8 (3.4) 7 (2.7) 17 (4.2) asian 98 (9.0) 13 (6.7)a,b 9 (3.9)b 28 (11)a 48 (11.9)a other 133 (12.3) 29 (15.0) 31 (13.3) 31 (12.2) 42 (10.4) hispanic, n (%) 138 (12.7) 26 (13.5) 34 (14.6) 32 (12.5) 46 (11.4) .699 ≥bachelor’s degree, n (%) 789 (72.9) 121 (62.7)a 153 (65.7)a,b 195 (76.5)b,c 320 (79.6)c <.001 cannabis use characteristics number of days used, past 30 days, m (sd) 10.59 (11.38) 12.36 (11.88)a 17.15 (11.78)b 11.79 (10.97)a,c 5.19 (8.30)d <.001 early onset use (<18), n (%) 555 (55.7) 104 (59.8)a 147 (69.0)a 142 (58.2)a 162 (44.4)b <.001 times used per day, m (sd) 2.43 (2.69) 2.87 (3.21)a 3.90 (3.84)b 2.13 (1.91)c 1.57 (1.31)d <.001 has medical card, n (%) 122 (11.7) 57 (32.6)a 46 (20.5)b 13 (5.2)c 6 (1.5)d <.001 most common mode of use, n (%) <.001 smoked 456 (42.3) 67 (35.1) 108 (46.4) 103 (40.4) 178 (44.7) vaped 242 (22.5) 48 (25.1) 52 (22.3) 57 (22.4) 85 (21.4) pipe/bong 173 (16.1) 34 (17.8)a 47 (20.2)a 57 (22.4)a 35 (8.8)b ingested 182 (16.9) 36 (18.8)a,b 20 (8.6)c 35 (13.7)b,c 91 (22.9)a other 24 (2.2) 6 (3.1) 6 (2.6) 3 (1.2) 9 (2.3) cudit score, m (sd) 7.45 (5.68) 7.33 (5.45)a 10.03 (5.72)b 8.68 (5.73)c 5.24 (4.86)d <.001 medical or recreational cannabis use in young adults 57 drove under influence, n (%) 255 (24.3) 45 (24.3)a 95 (43.8)b 74 (29.7)a 41 (10.3)c <.001 considered cutting down or quitting, past 6 months, n (%) <.001 never 559 (53.2) 99 (52.7)a 100 (44.6)a,b 97 (38.8)b 263 (67.6)c yes, but not in the past 6 months 167 (15.9) 45 (23.9)a 40 (17.9)a 45 (18.0)a 37 (9.5)b yes, in the past 6 months 325 (30.9) 44 (23.4)a 84 (37.5)b 108 (43.2)b 89 (22.9)a other substance use number of days of alcohol use, past 30 days, m (sd) 6.83 (6.54) 5.60 (6.72)a 6.65 (7.03)a,b 6.72 (6.13)a,b 7.59 (6.33)b .006 past-month tobacco use, n (%) cigarettes 363 (33.5) 80 (41.5)a,b 106 (45.5)b 79 (31.0)a,c 98 (24.4)c <.001 e-cigarettes 506 (46.7) 110 (57.0)a,b 138 (59.2)b 114 (44.7)a,c 144 (35.8)c <.001 little cigars/cigarillos 152 (14.0) 44 (22.8)a 48 (20.6)a 42 (16.5)a 18 (4.5)b <.001 large cigars 98 (9.0) 25 (13.0) 24 (10.3) 16 (6.3) 33 (8.2) .080 hookah 125 (11.5) 31 (16.1) 26 (11.2) 32 (12.5) 36 (9.0) .079 smokeless tobacco 40 (3.7) 10 (5.2) 12 (5.2) 7 (2.7) 11 (2.7) .234 any tobacco 664 (61.3) 136 (70.5)a 175 (75.1)a 147 (57.6)b 206 (51.2)b <.001 psychosocial factors parental use of cannabis, n (%) 264 (24.4) 60 (31.1)a 72 (30.9)a 74 (29.0)a 58 (14.4)b <.001 number of friends using cannabis, m (sd) 3.20 (1.49) 3.06 (1.58)a 3.60 (1.41)b 3.46 (1.34)b,c 2.86 (1.49)a,d <.001 depressive symptoms, m (sd) 1.78 (1.74) 1.96 (1.85) a 2.15 (1.98)a 1.92 (1.65) a 1.40 (1.50)b <.001 aces, m (sd) 2.50 (2.48) 3.60 (2.77)a 3.24 (2.53)a 2.37 (2.34)b 1.62 (2.01)c <.001 lifetime diagnosis of adhd, n (%) 144 (13.3) 30 (15.5)a 39 (16.7)a 43 (16.9)a 32 (8.0)b .001 note. p-values indicate omnibus tests (per anova and chi-square) across modes of use. bolded and italicized values indicate statistical significance at p < .05. different superscripts denote statistically significant differences between groups at p < .05. * excluding those who report “not sure” for purpose of use (n = 15). ** 87 reported “other” sex. cannabis, a publication of the research society on marijuana 58 table 2. multinomial logistic regression examining correlates of reasons for cannabis use among young adults using cannabis in the past 6 months (referrent: use cannabis equally for medical and recreational purposes) * only or primarily medical primarily recreational only recreational variable aor ci p aor ci p aor ci p msa (ref: oklahoma city) atlanta 0.73 0.34-1.60 .435 3.35 1.23-9.07 .018 2.64 1.11-6.24 .027 boston 0.39 0.19-0.81 .012 2.58 1.00-6.63 .050 2.50 1.12-5.58 .025 minneapolis 0.22 0.10-0.50 <.001 2.63 1.02-6.81 .046 2.31 1.02-5.21 .044 san diego 0.70 0.33-1.48 .346 3.43 1.29-9.16 .014 1.69 0.71-4.02 .233 seattle 0.24 0.11-0.51 <.001 3.12 1.23-7.95 .017 1.92 0.85-4.30 .115 other 0.29 0.09-0.98 .046 1.43 0.39-5.23 .587 1.14 0.36-3.61 .824 sociodemographics age 1.04 0.99-1.09 .057 0.90 0.87-0.94 <.001 0.88 0.84-0.91 <.001 female (ref: male)** 1.48 0.95-2.31 .081 1.00 0.67-1.50 .995 0.63 0.43-0.92 .018 race (ref: white) black 0.97 0.31-2.99 .955 1.15 0.36-3.70 .812 2.04 0.75-5.59 .164 asian 2.21 0.87-5.61 .097 2.15 0.95-4.89 .067 2.07 0.93-4.58 .074 another race 1.13 0.61-2.09 .710 1.01 0.56-1.81 .976 0.90 0.50-1.60 .715 hispanic (ref: non-hispanic) 0.87 0.47-1.63 .670 0.82 0.46-1.48 .512 0.90 0.51-1.60 .721 ≥bachelor’s degree (ref: <bachelor’s degree) 0.81 0.51-1.29 .370 1.60 1.02-2.53 .042 1.43 0.92-2.22 .116 other substance use number of days of alcohol use 0.99 0.96-1.03 .674 1.01 0.98-1.04 .643 1.04 1.01-1.07 .015 any past 30-day tobacco use (ref: no) 0.97 0.60-1.57 .909 0.47 0.31-0.72 <.001 0.36 0.24-0.54 <.001 psychosocial factors parental cannabis use (ref: no) 1.09 0.69-1.73 .720 1.19 0.77-1.83 .436 0.57 0.36-0.89 .014 number of friends using cannabis 0.81 0.70-0.93 .003 0.92 0.80-1.06 .234 0.72 0.63-0.82 <.001 aces 1.08 0.99-1.18 .078 0.90 0.82-0.98 .011 0.83 0.76-0.91 <.001 depressive symptoms 0.94 0.83-1.05 .268 1.00 0.90-1.12 .989 0.86 0.76-0.96 .008 adhd (ref: no) 1.06 0.60-1.87 .855 1.13 0.67-1.90 .656 0.47 0.27-0.84 .010 nagelkerke r2 .349 note. italicized values indicate statistical significance at p < .05. * excluding those who report “other” most frequent modes of use, n = 19. ** 87 reported “other” sex. medical or recreational cannabis use in young adults 59 table 3. regression models examining reason(s) for use in relation to number of days used, cudit scores, driving under the influence of cannabis (duic), and considered cutting down or quitting in the past 6 months among young adults using cannabis in the past 6 months * days of use cudit duic considered cutting down/quitting variable b ci p b ci p aor ci p aor ci p msa (ref: oklahoma city) atlanta -2.40 -5.16-0.36 .088 0.71 -0.70-2.13 .322 1.05 0.53-2.07 .886 1.92 0.99-3.73 .054 boston 0.60 -2.02-3.23 .652 1.31 -0.04-2.65 .058 1.25 0.66-2.36 .495 1.19 0.62-2.28 .603 minneapolis 0.90 -1.82-3.62 .515 1.43 0.03-2.83 .045 1.23 0.63-2.38 .549 1.63 0.84-3.13 .146 san diego 0.19 -2.58-2.95 .895 1.56 0.15-2.98 .031 1.13 0.58-2.20 .731 2.11 1.15-4.28 .018 seattle 2.46 -0.20-5.11 .070 2.71 1.34-4.07 <.001 1.00 0.52-1.91 .993 2.35 1.24-4.45 .009 other -0.32 -4.34-3.71 .877 1.67 -0.40-3.74 .113 0.77 0.28-2.17 .624 1.58 0.61-4.06 .344 sociodemographics age 0.07 -0.08-0.21 .361 -0.08 -0.15-0.00 .042 0.99 0.96-1.03 .746 0.92 0.89-0.95 <.001 female (ref: male)** -1.44 -2.71 -0.16 .027 -1.53 -2.18 -0.88 <.001 0.45 0.33-0.62 <.001 0.63 0.48-0.84 .002 race (ref: white) black 1.92 -1.48-5.33 .268 1.04 -0.71-2.79 .243 2.41 1.11-5.27 .027 1.23 0.55-2.71 .616 asian -1.09 -3.30-1.12 .334 -0.33 -1.47-0.81 .571 0.87 0.48-1.59 .653 0.91 0.56-1.37 .715 another race 1.06 -0.91-3.03 .292 -0.38 -1.39-0.64 .466 1.09 0.67-1.76 .739 0.88 0.56-1.37 .570 hispanic (ref: non-hispanic) -0.26 -2.23-1.72 .799 0.95 -0.07-1.96 .067 0.94 0.58-1.52 .797 0.88 0.57-1.37 .571 ≥bachelor’s degree (ref: <bachelor’s degree) -3.44 -4.90 -1.99 <.001 -1.78 -2.53 -1.02 <.001 0.76 0.54-1.08 .123 1.12 0.81-1.55 .498 reason(s) for use (ref: equally) primarily or only medical -4.81 -6.87 -2.76 <.001 -2.09 -3.14 -1.03 <.001 0.44 0.28-0.70 <.001 0.66 0.41-1.04 .073 primarily recreational -4.82 -6.71 -2.93 <.001 -1.26 -2.23 -0.28 .011 0.54 0.36-0.82 .003 1.06 0.72-1.58 .759 only recreational -11.22 -12.96 -9.48 <.001 -4.67 -5.57 -3.78 <.001 0.13 0.08-0.20 <.001 0.40 0.27-0.60 <.001 r-square .195 a .161 a .176 b .169 b note. italicized values indicate statistical significance at p < .05. * excluding those who report “not sure” for purpose of use (n =15). ** 87 reported “other” sex. a adjusted r-square; b nagelkerke r-square. cannabis, a publication of the research society on marijuana 60 the rate of any current use for medical purposes was higher than the rate of ever use for medical purposes among us and canadian adults from a 2018 study (27%) (leung et al., 2022), which likely reflects the continued evolving sociopolitical context of cannabis and the younger age range of the current sample (who are more likely to use for medical purposes; leung et al., 2022). one notable finding is that a sizable proportion of young adults reported using cannabis for both medical and recreational purposes, which is an important contribution to the literature given that most studies on cannabis use have disregarded the potentially important differences across these distinct segments of young adults who use only recreationally, primarily recreationally, only/primarily medically, or equally for both. consistent with prior literature (johnson et al., 2016; kumar et al., 2019; swan et al., 2021), the largest portion of participants reported their most common mode of cannabis use as smoked, followed by vaped relative to using via pipe/bong or edibles. moreover, a larger proportion of those who reported using recreationally only vs. other reasons for use reported most commonly ingesting cannabis, whereas a smaller portion reported most commonly using cannabis via pipe or bong, also consistent with some prior work (azcarate et al., 2020). other novel findings in this study suggest that using cannabis equally for medical and recreational purposes was associated with various mental health risks. for example, those using equally for medical and recreational purposes reported more aces and depressive symptoms, as well as greater likelihood of an adhd diagnosis and past-month tobacco and alcohol use, compared to those using only (or primarily) recreationally. furthermore, using equally for medical and recreational purposes (vs. all other subgroups of cannabis use) was associated with more days of use, greater cudit scores, and duic. these findings underscore concerns for those who use cannabis equally for both purposes and may explain mixed findings documented in the literature: some research has found that individuals who use cannabis for medical (vs. recreational) purposes may use more frequently (lin et al., 2016) and be more likely to duic (wickens et al., 2022); other research suggests medical use is associated with lower rates of problematic cannabis use (connor et al., 2021). specifically, these mixed findings may be partially attributable to assessments of reasons for use that do not account for the possibility of using equally for both medical and recreational purposes. interestingly, using equally for medical and recreational purposes vs. only recreational purposes was associated with having considered quitting cannabis in the past 6 months, which could be an indicator of potential positive outcomes in the future (i.e., potentially quitting or reducing). however, this item is also conceptualized as a marker of dependency in the cudit (adamson et al., 2010). thus, the implications of this finding are difficult to interpret and may require longitudinal research to determine if quit intentions in fact do predict quitting or in what use subgroups it may predict quitting. with regard to other findings, using only/primarily medically or only recreationally was associated with having fewer friends who used cannabis, compared to using equally for medical and recreational purposes, which might relate to the significant role that social influences play in one’s use and motives for use (denson et al., 2023). in terms of sociodemographic findings, in this sample of young adults, younger age was associated with using primarily or only recreationally (vs. equally for medical and recreational purposes), which may align with prior findings that adults in the 26-35 age range are most likely to have used for medical purposes (leung et al., 2022). other novel findings were that, compared to using equally for medical and recreational purposes, using primarily recreationally was associated with higher education, and using only recreationally was associated with being male. reporting more markers of problematic use (e.g., greater days of use, cudit scores, duic) was also associated with being younger, being male, or lower education (azofeifa et al., 2019; carliner et al., 2017). those who were younger and female were more likely to have considered quitting cannabis, findings not previously documented in relation to cannabis but shown to be associated with intentions to quit tobacco (henley et al., 2016; silfen et al., 2015); these findings warrant additional investigation. current findings have implications for research and practice. first, more detailed medical or recreational cannabis use in young adults 61 assessments of cannabis use motives and related factors are needed to better understand how and why young adults use cannabis and to identify potentially high-risk profiles of use. given current findings that those who use equally for medical and recreational purposes reported more negative mental health indicators (e.g., aces, depressive symptoms) and markers of problematic use (e.g., dependence, duic), it is crucial to understand how these individuals interpret and distinguish medical and recreational use and for what medical purposes they use cannabis. furthermore, these results suggest that interventions to reduce cannabis use and related negative consequences among young adults should be tailored to the specific reasons for use, as different subgroups of young adults using cannabis may have different needs, engage in distinct risk behaviors, and require different strategies to alter their behaviors. finally, practitioners, especially those working with young adult populations, should not only assess cannabis use among those they serve, but also assess why they use, how they distinguish medical vs. recreational use, and any high-risk outcomes, like signs of dependency or duic. limitations this study is limited in generalizability to other young adults in the included msas or across the us, given the purposive sampling design to recruit targeted proportions of young adults using e-cigarettes and cigarettes and racial and ethnic minority groups, the use of social media-based recruitment, and the focus on 6 msas. relatedly, rates of tobacco and cannabis use should not be interpreted as use prevalence rates. in addition, the cross-sectional nature of these analyses and the use of self-report assessments limits our ability to infer causation and introduces the possibility of biased reporting. future research should use longitudinal data to better understand the directionality of associations between sociodemographics, psychosocial factors, and other substance use with reasons for cannabis use and associations between reasons for use with problematic cannabis use outcomes. conclusions current findings suggest that using equally for medical and recreational purposes, relative to the other cannabis use profiles, was associated with greater mental health concerns (e.g., aces, other substance use) and problematic use outcomes (e.g., 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(2018). perceived barriers for cannabis cessation: relations to cannabis use problems, withdrawal symptoms, and self-efficacy for quitting. addictive behaviors, 76, 45-51. https://doi.org/10.1016/j.addbeh.2017.07.011 funding and acknowledgements: this work was supported by the us national cancer institute (r01ca215155-01a1; pi: berg). dr. romm is supported by the american cancer society (134128-irg-19-142; pi: romm), the oklahoma tobacco settlement endowment trust (tset) contract #r22-03, and the national cancer institute grant awarded to the stephenson cancer center (p30ca225520). dr. berg is also supported by other us national institutes of health funding, including the national cancer institute (r01ca275066, mpis: berg, yang; r01ca278229, mpis: berg, kegler; r21ca261884, mpis: berg, arem), the national institute on drug abuse (r01da054751, mpis: berg, cavazos-rehg), the fogarty international center (r01tw012456, mpis: berg, paichadze, petrosyan), and the national institute of environmental health sciences/fogarty (d43es030927, mpis: berg, caudle, sturua).the authors have no conflicts of interest to declare. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 61 ved abstract objective: trauma survivors are more likely than others to use cannabis, and post-traumatic stress disorder (ptsd) commonly co-occurs with cannabis use disorder (cud). automatic memory associations between trauma reminders and cannabis use have been suggested as contributing mechanisms. these associations can be studied experimentally by manipulating trauma cue exposure in a cue-reactivity paradigm (crp) and examining effects on the accessibility of cannabis information in memory in trauma survivors with and without ptsd. method: cannabis users with trauma histories (n = 202) completed a ptsd measure (ptsd checklist-5) and were randomized to a trauma or neutral expressive writing task as an online crp. next, participants completed a cue-behavior word association task, which involved presentation of a series of ambiguous cue words to which participants provided the first word that came to mind. some of these ambiguous cues pertained to cannabis (e.g., weed, pot) and some to other substances (e.g., blow, shot). this task was scored by two independent raters. linear regression models tested the hypothesized main and interactive effects of crp condition (trauma, neutral) and ptsd group (probable ptsd, no ptsd) on the number of cannabis and other substance responses generated. results: main effects of crp condition were found for cannabis responses (b = 0.41, p = .048; trauma > neutral) but not other substance responses. unexpectedly, no main effects or interactions of ptsd group were observed for either outcome. conclusions: in cannabis users with trauma histories, writing about one’s trauma specifically activates greater accessibility of cannabis-related information in memory, regardless of ptsd. key words: = ptsd; cue-reactivity paradigm; cannabis; automatic cognitions; word associations since cannabis was legalized for recreational use in 2018, canada has seen an increase in the use of cannabis: past three-month use rose from 22% to 27% of those aged 16 and older from 2017 to 2022 (government of canada, 2023). currently, 25% of canadians aged 16 or older who use cannabisengage in daily or near daily use (government of canada, 2021). one risk factor for cannabis use is having experienced a traumatic event, defined in the dsm-5-tr (apa, 2022) as sarah degrace1, philip g. tibbo1, maya a. pilin2, marvin d. krank2, roisin m. o’connor3, jeffrey wardell4, matthew t. keough4, thomas snooks1, sarah-jeanne trottier1, sherry h. stewart1, 5 1department of psychiatry, dalhousie university 2psychology department, university of british columbia 3department of psychology, concordia university 4department of psychology, york university 5department of psychology and neuroscience, dalhousie university cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000262 volume 7, special issue 3 expressive writing about one's trauma increases accessibility of cannabis information in memory among trauma-exposed individuals who use cannabis corresponding author: sarah degrace, ph.d., dalhousie university department of psychology and neuroscience dalhousie university 6287 alumni crescent, rm 3263 3rd floor life sciences centre (psychology wing) p.o. box 15000 halifax, nova scotia, canada b3h 4r2. email: sarah.degrace@dal.ca cannabis, a publication of the research society on marijuana 62 exposure to actual or threatened death, serious injury, or sexual violence. indeed, those with trauma histories have a significantly increased odds of cannabis use (kevorkian et al., 2016) and of regular cannabis use (bassir nai et al., 2023). use of cannabis is in turn linked with increased risk of several physical and mental health conditions in the shorterand longer-term such as high blood pressure, risks to lung health, cognitive impairments, cud, psychosis, and anxiety (connor et al., 2021; cougle et al., 2016; hasin et al., 2016) and expensive emergency department visits (crocker et al., 2023). one potential reason that those with trauma histories have an increased cannabis use risk is that they may use cannabis to cope with the negative affect resulting from exposure to reminders of their traumatic experience (see review by degrace et al., 2022). some of this cannabis use may be deliberate, such as when an individual intentionally decides to use cannabis when they are feeling particularly hypervigilant. other use may be reflexive; for example, someone may automatically reach for cannabis without forethought as soon as they encounter a traumarelated trigger, as a habitual response to their distress. indeed, while specific, fully conscious, and deliberate coping motives may initially drive cannabis use in traumatized populations, automatic memory associations may form over time between the context in which substance use occurs (e.g., trauma-related contextual cues) and substance use behavior (van der vorst et al., 2013). thus, a person with a sexual assault history, for example, who uses cannabis to manage negative affect in response to trauma reminders (e.g., hearing about a sexual assault in the media) is thought to form strong memory associations over time between trauma cues, negative affect, cannabis use, and relief outcomes (edalati & krank, 2015; romero-sanchiz et al., 2022). these automatic cognitive associations are quick, spontaneous, and require little conscious awareness or reflection (cousjin et al., 2011; krank & robinson, 2017; stacy & wiers, 2010). they can be tapped using tasks that capture automatic processes measured in various ways, including but not limited to reaction time (e.g., degrace et al., 2023b; read et al., 2017) or word association tasks (ames et al., 2007; pilin et al., 2022). performance on such automatic cognition measures have been positively associated with substance use behavior (e.g., ames et al., 2007). theoretically, among trauma-exposed individuals who use cannabis, exposure to trauma reminders should activate the previously-formed memory associations between trauma cues and cannabis-related information (e.g., stimuli associated with cannabis use in the past like rolling papers). because of this activation, trauma cue exposure should increase accessibility in memory of cannabis-related information which should, in turn, give rise to reflexive cannabis use behavior. this would be consistent with individuals who use substances’ accounts of often finding themselves using their substance without deliberation (stacy & wiers, 2010). researchers can study the effect of trauma (vs. neutral) cue exposure on these automatic cognitions experimentally using cue reactivity paradigms (crps; sinha & tuit, 2012): lab-based exposure to relevant stimuli to elicit reactivity, or a relevant change in state (e.g., emotional [affect], physiological [salivation], cognitive [craving]). inlab exposure to a personalized trauma cue is intended to simulate the context of encountering a trauma reminder in everyday life. findings from prior studies using trauma crps among individuals with trauma histories who use substances have consistently demonstrated heightened physiological and subjective responses to trauma cues compared to neutral cues including increased self-report craving and stress reactivity (see review by degrace et al., 2022). additionally, studies have shown that trauma cue exposure can influence automatic cognitive processes. for example, participants with ptsd exposed to a personalized trauma cue showed a general response slowing on the stroop task that was associated with self-reported urge to drink (read et al., 2017). a well-established crp entails a two-session approach (coffey et al., 2002). during the initial session, a semi-structured interview (sinha & tuit, 2012), developed to elicit emotional imagery (lang et al., 1979), guides participants through describing their most traumatic experience. this material is later condensed into a brief, personalized audiovisual cue used in the second crp session (romero-sanchiz et al., 2022). an equivalent procedure is followed in developing and presenting the neutral control cue. attrition rates are high between the initial semi-structured cannabis cognitions 63 interview session and the second crp exposure session within this two-session protocol (e.g., coffey et al., 2006). we addressed this issue in a prior study, where we used the semi-structured interview alone, expecting it would itself elicit similar emotional and cognitive responses seen with the two-session protocol. however, while some controlled processes (e.g., cannabis craving) were successfully elicited by the single-session crp (degrace et al., 2023a), the semi-structured interview alone did not evoke increased automatic cannabis-related cognitions using a reaction time task (degrace et al., 2023b). this points to a need to explore alternative crps that not only mitigate study attrition, but also demonstrate sensitivity to the effects of trauma cue exposure on cannabisrelevant automatic cognitive processes. thus, the present study utilized a novel standalone expressive writing task (trauma vs. neutral) as a single-session method of administering a crp remotely. prior work in our lab has found this task to be efficacious in eliciting negative affect and positive cannabis outcome expectancies (including relief expectancies) in a sample of recent traumaexposed individuals who use cannabis (degrace et al., 2024). the expressive writing task was developed in accordance with two-session crps that incorporate brief expressive writing tasks into the protocol (read et al., 2017; rodrigeuz & read, 2020) and in accordance with the work of pennebaker (1997) on the therapeutic benefits of expressive writing about one’s trauma. however, our prior work (degrace et al., 2024) and the present study are novel in using the expressive writing task as a stand-alone crp in eliciting cognitions relevant to understanding cannabis use among trauma-exposed individuals who use cannabis. we studied trauma cue-elicited controlled cognitive processes (i.e., self-reported craving) in our prior expressive writing study (degrace et al., 2024) and trauma cue-elicited automatic cognitive processes (i.e., cue-behavior memory associations) in the present expressive writing study. theoretically, for those with ptsd, the effects of trauma cue exposure in activating automatic accessibility of cannabis-related information in memory should be particularly strong. this is because those with ptsd show greater coping motivated cannabis use (atasoy et al., 2023) providing greater opportunity for strong memory associations to develop between trauma cues and cannabis use. indeed, ptsd co-occurs at high rates with cannabis use and cud (cougle et al., 2011; kevorkian et al., 2016; metrik et al., 2022; walsh et al., 2014). for example, in a study of trauma-exposed individuals who use cannabis, lifetime ptsd was associated with increased odds of lifetime cud even after controlling potential confounds (e.g., depression, anxiety, alcohol dependence; kevorkian et al., 2016). importantly, longitudinal work shows that continued cannabis use is associated with worse ptsd outcomes (wilkinson et al., 2015). trauma cue-elicited increases in automatic accessibility of cannabis information in memory might be an underlying mechanism to help explain this high co-occurrence of ptsd with cannabis use and cud. specifically, cue condition (trauma vs. neutral) effects on relevant automatic association measures should be strongest among those with ptsd (i.e., an interaction). we tested this possibility in a recent study using a reaction time task – specifically, a cannabis approachavoidance task (degrace et al., 2023b). however, we showed only that those with greater ptsd symptoms displayed a greater cannabis approach bias than those with lesser ptsd symptoms; we failed to show that this automatic cognitive bias was enhanced among those exposed to a trauma (vs. neutral) crp in an n = 50 lab study. this suggested that automatic cannabis approach bias may be chronically activated among those with higher ptsd symptom severity. however, cue condition x ptsd symptoms interactions have been detected in other studies of deliberative, controlled cognitive processes, such as selfreported craving (e.g., romero-sanchiz et al., 2022). this suggests that such interactions may be observable for automatic cognition measures as well, provided a study is adequately powered to detect an (often smaller magnitude) interaction effect. thus, we utilized our expressive writing task remotely in an online study to acquire a sufficiently large sample to detect such theorized cue condition x ptsd interactions in a single session.a a using r (r v. 4.2.1; pwr package; champely, 2020), we calculated the number of participants needed to detect a small to medium (d = .3) effect for a 2x2 design, with power set at .80 and 12 total targets (i.e., cannabis and substance-primed cwat items). this analysis determined that we would need n = 44 participants per cell to detect this effect size (i.e., a minimum of n = 176). thus, we aimed to recruit ~200 participants to allow for some potential incomplete responding. cannabis, a publication of the research society on marijuana 64 we hypothesized those trauma-exposed individuals who use cannabis randomly assigned to the trauma (vs. neutral) expressive writing task would display greater accessibility of cannabisrelated information in memory (h1). we also expected that individuals with (vs. without) probable ptsd would show increased accessibility of cannabis-related information in memory (h2). further, we hypothesized a cue condition by ptsd group interaction, with the trauma (vs. neutral) cue-elicited accessibility of cannabis-related information in memory being greater among those with (vs. without) probable ptsd (h3). finally, we hypothesized specificity of the above expected effects to the ambiguous cannabis items on the cannabis word association task (cwat; pilin et al., 2022) that would not generalize to the other substance items on the cwat (h4). methods participants qualtrics survey panels were used to recruit trauma-exposed individuals who use cannabis. to participate, participants must have been residing in canada; aged 19-65 years old; exposed to 1 or more lifetime traumatic event(s) (gray et al., 2004); and have used at least one gramb of cannabis in the past month.c our final sample, after data scrubbing,d was n = 202 participants (43.6% male; m age = 42.94 years, sd = 14.71). this is the same sample used in our prior expressive writing study (degrace et al., 2024). tasks and measures demographics. participants reported their sex and age. trauma exposure. the life events checklist (lec-5; gray et al., 2004) was used to assess exposure to one or more dsm-5 (apa, 2013) ptsd criterion a traumatic event(s) (e.g., sexual assault, environmental disater) to ensure study eligibility. if respondents indicated more than one lifetime traumatic event exposure, they answered all further questions about trauma (e.g., ptsd assessment; expressive writing task) in relation to the trauma that had affected them the most profoundly (i.e., index event). cannabis use. past month cannabis use (frequency and quantity) was assessed with an online version of the cannabis timeline followback (c-tlfb; sobell & sobell, 1992). scores were used to ensure eligibility and were analyzed as potential covariates for use in sensitivity analyses. the c-tlfb has excellent inter-rater reliability and test-retest reliability (norberg et al., 2012) and self-reported online versions of the tlfb have been shown to be psychometrically sound (rueger et al., 2012). cud symptom severity. to assess cud symptom severity, we used the 8-item cannabis use disorder identification test-revised (cuditr; adamson et al., 2010). participants rated the frequency of experiencing various cannabisrelated problems over the past six months on a scale from 0 to 4 (ranging from never to daily or almost daily). the scores were then totaled. our sample demonstrated satisfactory internal consistency with an alpha coefficient of .75, indicating the cudit-r's robust psychometric properties. ptsd group. the ptsd checklist for dsm-5 (pcl-5; bovin et al., 2016) was used to describe sample ptsd symptom severity and to categorizee b participants could consume cannabis using any method, but were provided with conversion rates to ensure the amount they used was equivalent to at least one gram of cannabis (flower). c this minimum cannabis use threshold was set lower than that used in degrace et al. (2023a,b) (i.e., at least 1 gram per week over last month; see gabrys & porath, 2019) in order to feasibly recruit a sufficiently large sample to detect ptsd group x cue condition interactions if they were present. d in order to ensure data quality, 597 respondents were excluded for failure to follow writing task instructions (e.g., did not write about the assigned topic; wrote the same word repeatedly), 98 respondents were removed for duplicate ip addresses, and 47 respondents were excluded due to failed speeder checks (performed by qualtrics) and/or failed attention checks (e.g., “select ‘3’ for this item”). e we chose a categorical (vs. dimensional) measure of ptsd in order to best establish clinical relevance. f while a number of cut-offs on the pcl-5 have been suggested for identifying probable ptsd (e.g., 31-33; bovin et al., 2016) we chose a relatively high categorical cut-off for probable (i.e., 38; cohen et al., 2015) as our predictor to minimize false positives which are more likely when using a self-report questionnaire vs. clinical interview for case identification. additionally, this cut-off has undergone validation in evaluating probable ptsd in civilian samples, distinguishing it from other commonly used thresholds (e.g., bovin et al., 2016) which have been validated in military, clinical, and mostly male populations (cohen et al., 2015). cannabis cognitions 65 participants into two ptsd groups: probable ptsd (>38f; cohen et al., 2015) or probable no ptsd (<38). the pcl-5 has good reliability and validity and good sensitivity and specificity in detecting clinically-diagnosed ptsd (blevins et al., 2015). in our sample, internal consistency was excellent (α = .95). expressive writing task. participants were randomly assigned to complete a trauma-related (i.e., describing their worst lifetime trauma) or a neutral expressive writing task (i.e., describing their morning routine). programmed prompts queried for details on what happened, and bodily sensations, thoughts, and feelings that occurred during the event (sinha & tuit, 2012). participants were required to write for two minutes minimum and then to continue imagining the event as if it were happening now (read et al., 2017; rodriguez & read, 2020) for another two minutes. these were enforced through task-programming, meaning participants were not able to continue the survey until the 2minute minima had elapsed. length of the written passage was recorded (total word count) and later analyzed. cannabis-related automatic cognitions. the cannabis word association task (cwat; pilin et al., 2022), a cue-behavior association test (ames et al., 2007), assessed degree of accessibility of cannabis-related information in memory. this was estimated by the likelihood of generating a cannabis-related word associate to an ambiguous cannabis word. participants were shown a list of 35 ambiguous words, five of which could be associated with cannabis use (e.g., pipe, joint). to examine specificity to cannabis associations in memory, an additional seven items on the cwat were ambiguous words which could be associated with other substance use (e.g., blow, shot). participants filled in a blank next to each word in the list with the first word that came to mind. two independent raters, both blind to ptsd group and cue condition, coded each response as cannabisrelated, other substance-related, or neither.g summed totals to each category were calculated (e.g., if a participant responded with 4 cannabisrelated responses to the 5 ambigous cannabis words, their cwat cannabis score was a 4). these coded responses to the cwat’s ambiguous cannabis (possible range = 0-5; κ = 0.84) and other substance-related words (possible range=0-7; κ = 0.86) were used as cwat outcomes in analyses. procedure if trauma exposure (lec-5; gray et al., 2004), and cannabis use (c-tlfb; sobell & sobell, 1992) eligibility requirements were met, participants were redirected to complete other measures (see degrace et al, 2024) including assessment of ptsd symptoms (pcl-5; boivin et al., 2016). participants were then automatically randomized to complete either the trauma (n = 96) or neutral (n = 106) expressive writing task, which served as our remote crp. following expressive writing, participants completed the cwat (pilin et al., 2022). analysis strategy. we ran two separate linear regression models (r v. 4.2.1; lme4 package) with cue condition, ptsd group, and the condition by ptsd interaction term, predicting accessibility of cannabis and other substance-related information in memory (i.e., count of cannabis-related and other substance-related words generated to the appropriate ambiguous prompts on the cwat, respectively). we also tested for potential covariates (i.e., age, sex, cannabis use quantity and frequency, self-reported cannabis use problems, expressive writing word count) that were theoretically and empirically related to both the predictors and cwat outcomes that might need to be controlled in our main analyses. results sample characteristics. demographic and clinical characteristics are reported in table 1 for the overall sample and by cue condition. over onethird of the sample (36%; n = 73) scored 38 or higher on the pcl-5 indicating probable ptsd (cohen et al., 2015). this sample average cuditr score was just below the cutoff of 12 (43.6% scored 12 or greater) for probable cud and above the cutoff of 8 (61.8% scored 8 or more) for hazardous use (adamson et al., 2010). sample demographic and clinical characteristics are reported elsewhere further broken down by cue condition x ptsd group (degrace et al., 2024). g the coding of the first rater (sjt), who was naïve to study hypotheses and objectives, was used in analyses, as we reasoned this rater would be less prone to biases. cannabis, a publication of the research society on marijuana 66 table 1. descriptive statistics n (%)/ mean (sd) cue condition trauma n = 96 neutral n = 106 overall sample n = 202 age (in years) 43.25 (14.89) 42.55 (14.61) 42.94 (14.71) sex male 43 (44.8%) 45 (42.5%) 88 (43.6%) female 53 (55.2%) 61 (57.5%) 114 (56.4%) cudit-r score 11.80 (6.62) 10.97 (5.89) 11.37 (6.25) tlfb past month cannabis use (days used) 14.24 (10.68) 13.84 (10.18) 14.03 (10.40) pcl-5 score 32.02 (18.44) 31.05 (19.03) 31.51 (18.71) % with probable ptsd 36 (37.5%) 37 (34.9%) 73 (36.1%) expressive writing task word count 93.86 (95.94) 58.06 (50.39) 75.08 (77.45) note. cudit-r score: cannabis use disorder identification test-revised (adamson et al., 2010). tlfb = timeline follow-back (sobell & sobell, 1992). pcl-5 = ptsd checklist for dsm-5 (bovin et al., 2016). cannabis accessibility. consistent with h1, a significant main effect of cue condition emerged for cwat cannabis responses (t[198] = 1.99, 95%ci [0.00-0.81], p = .048), with more cannabis responses generated to the ambiguous cannabisrelated words in the trauma than the neutral condition (see figure 1, table 2). contrary to h2 and h3, there was no ptsd group main effect or interaction with cue condition for cwat cannabis responses (see table 2). consistent with h4, the significant main effect of cue condition seen for cwat cannabis responses (see h1 above) did not extend to a significant main effect of cue condition for other substance-related responses (t[198] = 0.17, 95%ci [-0.25-0.59], p = .424) on the cwat, and neither ptsd group nor its interaction with cue condition predicted other substance-related responses on the cwat. table 2. linear mixed models’ omnibus results for cannabis and substance-related automatic cognitions estimate (b) ci (95%) p cannabis words generated marginal r2 = 0.034 / conditional r2 = 0.019 condition (neutral = 0) 0.41 0.00 – 0.81 .048* ptsd status (ptsd= 0) -0.15 -0.62 – 0.32 .534 condition*ptsd status 0.01 -0.66 – 0.69 .966 substance words generated marginal r2 = 0.018 / conditional r2 = 0.003 condition (neutral = 0) 0.17 -0.25 – 0.59 .424 ptsd status (ptsd= 0) -0.28 -0.77 – 0.20 .251 condition*ptsd status 0.25 -0.44 – 0.95 .472 note. * p < .05, ** p < .01, *** p <.001. cannabis cognitions 67 figure 1. mean number of cannabis-related responses on the cannabis word assocation task (cwat) by cue type (trauma vs. neutral expressive writing task). tests for potential covariates. to identify potential covariates possibly needing to be controlled for in sensitivity analyses, we used a set of 2 (ptsd group) x 2 (writing condition) linear mixed models to examine if any writing condition effects emerged that might need to be controlled as covariates in the hypothesis tests. a separate analysis was run for each potential covariate: age, sex, cannabis use quantity and frequency, selfreported cannabis use problems, number of past traumatic events experienced, and writing task word count. results indicated a statistically significant effect of cue condition only on writing task word count (t[198] = 30.16, 95%ci [3.7756.55], p = .025) with more words written by those randomized to the trauma expressive writing than those randomized to the neutral expressive writing condition. we then assessed if writing task word count was related to our outcome (cannabis-related responses on the cwat) by running a correlational analysis. writing task word count and cannabis related cwat responses were not significantly correlated (r = .10, p = .149). thus, with no potential covariates differing by cue condition influencing our outcome, we did not conduct sensitivity analyses including covariates. discussion the present study served two primary purposes. first, our single session online trauma expressive writing crp had a methodological purpose, as it could help mitigate the attrition common to crp studies conducted in person across two sessions (coffey et al., 2006) and permitted acquisition of a larger sample to increase power to detect potential interactions. second, our trauma expressive writing task allowed us to examine trauma cue-elicited activation of relevant automatic cognitions that might help us understand why individuals with trauma histories are more likely than others to use cannabis (kevorkian et al., 2016; bassir nia et al., 2023). specifically, this study provided preliminary evidence for the stand-alone trauma expressive writing crp to successfully elicit greater accessibility to cannabis-related information in memory relative to the neutral expressive writing crp, consistent with h1. this finding is partially consistent with prior work: a study on automatic attention allocation found a slowing of automatic responses among drinkers with ptsd assigned to the trauma relative to the neutral crp condition, with the crp including (but not specific to) an expressive writing task (read et al., 2017). while cue condition was a significant predictor of the accessibility of cannabis related information 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 expressive writing task condition cannabis-related words on cwat neutral trauma cannabis, a publication of the research society on marijuana 68 in memory, the crp manipulation had no impact on responses to other substance-related ambiguous cues on the cwat, consistent with our cannabis-specificity hypothesis (h4). at first glance, this pattern of findings suggests that among a broad sample of recent trauma-exposed individuals who use cannabis, the activation of substance-related information in memory in response to personalized trauma cue exposure (via expressive writing) may be specific to cannabis rather than generalizable to a variety of other substances (i.e., substance-related responses on the cwat to other substance-related ambiguous prompts [e.g., blow, shot]). in a previous study using a semi-structured interview (sinha & tuit, 2012) as the crp, in a sample of regular traumaexposed individuals who use cannabis, trauma (vs. neutral) cue exposure elicited not only increased cannabis craving but also increased craving for alcohol (degrace et al., 2024). this difference may indicate cannabis specificity for automatic cognitive processes and generalizability to other substances for more controlled, deliberative cognitive processes like craving (tiffany, 1999). alternatively, the discrepancy may be due to methodological differences: in degrace et al. (2023a), we only examined alcohol craving in the subset of individuals who use cannabis who also reported drinking alcohol while we did not obtain information on other substance use in the present study. thus, it remains possible that expressive writing about a personal traumatic experience may indeed activate increased accessibility to other substance-related information in memory for those who use cannabis and other substances. contrary to expectations and prior work, probable ptsd status did not predict greater cannabis-related cognitions (h2; cf., degrace et al., 2023b), nor did probable ptsd status interact with the trauma cue to predict such cognitions (h3; cf., romero-sanchiz et al., 2022). while we had a larger sample than our previous study using the single session crp interview (degrace et al., 2023a), like that previous study, we were unable to detect an interaction between ptsd and randomly assigned cue condition (trauma vs neutral) on cannabis cue-behavior associations. this absence of a ptsd by cue condition interaction is also consistent with our recent study using the same expressive writing task in this same sample (see degrace et al., 2024) showing a main effect of cue condition on negative affect and expectancy craving (a controlled cognitive process; tiffany, 1999) but no interaction with ptsd. other work from our group has, however, shown a significant interaction between ptsd and crp cue condition for compulsivity cannabis craving – a controlled cognitive process (romero-sanchiz et al., 2022). since these prior studies have not systematically varied crp (singlevs. two-session; audiovisual cue vs. structured interview vs. expressive writing), cognitive outcome (automatic vs. controlled process; word association vs. reaction time task), or ptsd conceptualization (categorical vs. continuous; self-reported vs. clinical interview), more work is needed in identifying the conditions under which cue condition and ptsd interact in predicting cognitive outcomes relevant to understanding ptsd-cud comorbidity (e.g., cougle et al., 2011; kevorkian et al., 2016). another possible explanation for the lack of ptsd effects in the present study could be that the automatic substance-related cognitions tapped by the cwat may be relevant for all trauma-exposed individuals who use cannabis rather than being particularly relevant to those with ptsd. indeed, the type of automatic cognitions assessed may be worth noting in interpreting the results of this study. for example, we found an effect of ptsd status, but no cue condition effects, on cannabis approach bias in degrace et al. (2023b), whereas we found an effect of trauma cue assignment, but no effect of ptsd, on the accessibility of cannabis information in memory in the present study. this suggests we cannot assume results with one automatic cannabis-related cognitive bias will extend to another measure tapping another type of cognitive bias. future work may aim to directly compare, in a single study, trauma crp and ptsd main and interactive effects on different automatic cognition outcomes using word association (e.g., cue-behavior; behavior-outcome; ames et al., 2007) and reaction time tasks (e.g., selective attention to cannabis; automatic cannabis approach bias; e.g., read et al., 2017; degrace et al., 2023b) in this population. our study presents limitations which should be considered when interpreting our results. firstly, while steps were taken to ensure data quality in this online study (e.g., attention and speeder checks; replacement of participants who cannabis cognitions 69 clearly did not follow expressive writing instructions), the lack of experimenter presence in the online environment may have enabled participants to escape from the crp (e.g., stopping writing about trauma if anxiety became too intense), potentially minimizing the magnitude of cue condition effects. given that avoidance of trauma reminders is a symptom of ptsd (apa, 2013), escape from the writing task specifically among those with probable ptsd may have worked against the ptsd group x cue condition interaction hypothesized in h3. second, while we coded ptsd categorically for greater clinical relevance to understanding ptsd-cud comorbidity, and for consistency with the results of latent class analysis studies suggesting ptsd is better conceptualized as categorical than as dimensional (ayer et al., 2011; breslau et al., 2005; steenkamp et al., 2012), this choice may have reduced power to detect ptsd main or interactive effects relative to studies that have examined ptsd symptoms continuously (e.g., romero-sanchiz et al., 2022). third, our categorizing participants into probable ptsd and probable no ptsd groups based on a cutoff on a self-report measure (although a high cutpoint relative to other suggested cutoffs; e.g., bovin et al., 2016) likely resulted in some misclassification relative to if we had used a diagnostic interview like the clinician administered ptsd scale (caps-5; weathers et al., 2018) – the gold standard for officially diagnosing ptsd. use of a self-report measure may result in a participant scoring above the ‘clinical’ cutoff for ptsd without aligning with the full dsm-5 diagnostic criteria by scoring high on intrusion and hyperarousal items, for example, without meeting the avoidance or negative alterations in cognitions and mood criteria. in contrast, the caps-5 ensures a comprehensive assessment aligned with the dsm-5 criteria. the resultant potential misclassification could explain the absence of the hypothesized main and interactive ptsd group effects, highlighting a limitation in our study and emphasizing the importance of using the caps-5 in future research when possible. despite limitations, the present study provided preliminary evidence for the use of a remote, self-administered expressive writing task as a crp, in eliciting specific automatic cannabisrelated cognitions – namely increased accessibility of cannabis-related information in memory. however, the presence of likely ptsd did not intensify this trauma vs. neutral crp effect on cannabis accessibility in memory. thus, in-person crp administration (with an in-person experimenter to monitor participant engagement) may be needed to successfully intensify these automatic cannabis-related cognitions in individuals with ptsd, given their tendency to avoid trauma reminders (apa, 2013). while the absence of ptsd group effects or an interaction of ptsd group with cue condition suggests cuebehavior associations are an unlikely candidate for an automatic cognitive process to explain the high comorbidity of ptsd and cud (cougle et al., 2011), the main effects of cue condition may well be useful in understanding why those with trauma histories are at increased risk of cannabis use (bassir nia et al., 2023; kevorkian et al., 2015). indeed, the tendency of trauma cue exposure to increase accessibility of cannabis information in memory among trauma-exposed individuals who use cannabis may promote increased cannabis use, even without the individual’s conscious awareness or reflection (ames et al., 2007). this trauma cue-elicited reflexive cannabis use among those with trauma histories may be particularly likely in an environment where cannabis is readily accessible, such as in canada’s legalized context. references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2015). the use of medicinal marijuana for posttraumatic stress disorder. primary care companion for cns disorders, 17(3). https://doi.org/10.4088/pcc.15r01786 funding and acknowledgements: this work was supported through a cannabis and mental health catalyst grant (application #442109; principal investigator: shs) from the mental health commission of canada and by a grant (grant #893728; principal investigator: sd) from the nova scotia health authority research fund. sd is supported by graduate studentships from the chronic pain centre of excellence for canadian veterans’ capacity building initiative, the l’oréal-unesco & france-canada research fund for women in science scholarship, and the dalhousie medical research foundation’s macquarrie neuroscience research graduate studentship. pt is supported through the dr paul janssen chair in psychotic disorders, dalhousie university. shs is supported through a tier 1 canada research chair in addictions and mental health. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: degrace, s., tibbo, p. g., pilin, m. a., krank, m. d., o’connor, r. m., wardell, j., keough, m. t., snooks, t., trottier, s-j., & stewart, s. h. (2024). expressive writing about one's trauma increases accessibility of cannabis information in memory among trauma-exposed individuals who use cannabis. cannabis, 7(3), 61–73. https://doi.org/10.26828/cannabis/2024/000262 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 65 ved abstract objective: due to little knowledge regarding the contextual factors related to cannabis use, we aimed to provide descriptive statistics regarding contextual factors related to use and examine the predictive ability of contextual factors. method: we included college student participants (n = 5700; male = 2893, female = 3702, other gender identity = 48, missing = 57) from three multi-site studies in our analyses. we examined the means and standard deviations of contextual factors related to cannabis use (social context/setting, form of cannabis, route of administration, source of purchase, and proxies of use). additionally, we tested the predictive ability of the contextual factors on cannabis use consequences, protective behavioral strategies, and severity of cannabis use disorder, via an exploratory machine learning model (random forest). results: descriptive statistics and the correlations between the contextual factors and the three outcomes are provided. exploratory random forests indicated that contextual factors may be helpful in predicting consequences and protective behavioral strategies and especially useful in predicting the severity of cannabis use disorder. conclusions: contextual factors of cannabis use warrants further exploration, especially considering the difficulty in assessing dosage when individuals are likely to consume in a group context. we propose considering measuring contextual factors along with use in the past 30 days and consequences of use. key words: = cannabis use; cannabis-related consequences; social context; route of administration; college students; cannabis protective behavioral strategies in the context of a massively growing legal cannabis market throughout the united states, a harm reduction approach to understanding cannabis necessitates the consideration of any relevant characteristic of one’s cannabis use that may contribute to cannabis-related harms. in a meta-analysis, pearson (2019) found a mediumsized association between cannabis use indicators and consequences (rw=.367), demonstrating that most of the variance in cannabis-related negative consequences are not explained by any single indicator of cannabis use. this finding suggests that additional characteristics of cannabis use are needed to account for the likelihood of experiencing cannabis-related harms beyond frequency and quantity of use. social contexts of use, or the temporal, motivational, and situational factors surrounding use, are additional characteristics of cannabis use that predict cannabis use outcomes (beck et al., 2009). matison w. mccool1, matthew r. pearson1, the marijuana outcomes study team*, the protective strategies study team**, & the addictions research team*** 1center on alcohol, substance use, and addictions, university of new mexico cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000225 volume 8, issue 1 beyond frequency and quantity of cannabis consumption among college students: context of using cannabis relates to cannabisrelated outcomes corresponding author: matison mccool, ph.d., university of new mexico, 2650 yale blvd se msc 11-6280. albuquerque, new mexico 87106. phone: (505) 925-2322. e-mail: mwmccool@unm.edu. cannabis, a publication of the research society on marijuana 66 contextual factors of cannabis use the operationalization of contextual factors of cannabis use in prior work has included categories related to social facilitation, peer acceptance, sexseeking, emotional pain (beck et al., 2009), location of use, using companions (spinella et al., 2019), place of purchase, route of administration (parnes et al., 2018), environmental, emotional, and interpersonal contexts related to use (gray et al., 2024). recalling that cannabis use indicators such as quantity and frequency are moderately associated with consequences (pearson, 2019), contextual factors are associated with cannabis use disorder (beck et al., 2009), consequences, and protective behavioral strategy use (gray et al., 2024) even when controlling for direct cannabis use indicators. however, much of the previous literature has limited the examination of contextual factors to a few behaviors (e.g., solitary use; spinella et al., 2019), creating constructs out of specific behaviors (beck et al., 2009), or using latent profile analyses to find patterns of contextual factors (gray et al., 2024). contextual factors of cannabis use are significantly correlated (beck et al., 2009) which may lead to issues of multicollinearity when attempting to examine many individual contexts in a predictive model. given the broad operational definition of cannabis use contextual factors and many distinct situations in which cannabis use can occur, we focused our study on the following contexts of cannabis use: social situations and settings of use, form of cannabis and route of administration, and the source of purchase. situational and setting contexts most of the research on social context of cannabis use has focused on solitary use vs. social use. compared to social users, solitary cannabis users have reported higher levels of drinking to cope, higher levels of cannabis use, and greater endorsement of cannabis abuse/dependence (spinella et al., 2019). solitary cannabis use by adolescents has been shown to relate to cannabis use disorder symptoms during adolescence, but also prospectively predicts cannabis use disorder symptoms in young adulthood (creswell et al., 2015). solitary cannabis use frequency has been shown to mediate (i.e., account for) the effects of social anxiety on cannabis use and negative cannabis-related consequences (buckner et al., 2016). thus, solitary use of cannabis has been identified as a risk factor for negative cannabisrelated consequences. beck et al., (2019) included settings of cannabis use (i.e., in a car, in a dorm room) as part of a social facilitation construct. results assessing the relationship between social facilitation and dsm-iv cannabis use disorder criteria found that increased social facilitation was significantly associated with cannabis use disorder symptom severity. overall, where and with whom individuals use cannabis are associated with cannabis use outcomes above and beyond direct use indicators. context of cannabis form and route of administration with the rapid proliferation of legal cannabis markets, cannabis preparations have diversified to include a wide range of edible products and high-concentration products, which have unique routes of administration that are relevant to cannabis-related harms (parnes et al., 2018). for example, oral ingestion of cannabis is associated with higher concentrations of 11-hydroxy-∆9tetrahydrocannabinol (11-hydroxy-thc), which may be more potent than ∆9-tetrahydrocannabinol (thc) (lemberger et al., 1973; schwilke et al., 2009), and may lead to delayed onset of psychoactive effects, which leads to unintentional overintoxication (we avoid using the term overdose given that the primary intoxicating chemical in cannabis is non-toxic and non-lethal). high concentration products can be smoked with an assortment of essential equipment but can also be vaped in a concealable vape pen. use of concentrates is associated with rapid and higher levels of intoxication compared to flower products (bidwell et al., 2020). source of purchase context an outer situational context of one’s cannabis use includes how one obtains cannabis products. in the early days of recreational cannabis legalization in los angeles (i.e., 2016-2017), young adults who purchased products from cannabis dispensaries (compared to obtaining from family or friends) reported spending more money on cannabis, using more distinct cannabis products, using more frequently, using higher cannabis use context 67 quantities, using alone more often, and experienced higher negative cannabis-related consequences and cannabis use disorder symptoms (d’amico et al., 2020). brief machine learning overview machine learning approaches differ from traditional statistical approaches in several ways. first, traditional statistical approaches have focused on questions of inference, or using probabilities to test hypotheses describing how and why variables are related. machine learning algorithms largely focus on answering questions related to prediction, or using existing data to find patterns that predict a precise outcome (bzdok et al., 2018). while statistical models rely on parametric assumptions about the relationship between predictors and an outcome, machine learning algorithms do not and look for complex interactions to make the best prediction (lantz, 2019; witten & frank, 2002). for example, multiple regressions use independent variables, as the predictors need to be independent from each other to not affect the standard errors of other predictors. as such, multicollinearity occurs when an independent variable is highly correlated with other independent variables resulting in unstable coefficients and problems with model convergence (allen, 1997). machine learning models such as random forests are less affected by correlated variables, as they do not attempt to isolate the effects of a single variable on an outcome when looking for complex interactions to make predictions. though, multi-collinearity can slightly affect the selection of important variables (strobl et al., 2008). machine learning models offer unique advantages in examining outcomes, specifically regarding their ability to make precise predictions. however, a trade-off exists such that improved prediction is balanced by a loss in explaining outcomes (inference) as no coefficients are provided examining direct relationships between predictors and outcomes. machine learning algorithms have been used to examine cannabis-related outcomes such as consequences from use (schwebel et al., 2022), cannabis use in daily life (yu et al., 2023), and to examine the risk and protective factors of cannabis use (henry et al., 2024). the present study prior research has established relationships between constructs or latent profiles of cannabis contextual factors and cannabis protective behavioral strategy use, cannabis use consequences, and cannabis use disorder severity (beck et al., 2009; dyar et al., 2021; gray et al., 2024; parnes et al., 2018). however, grouping contextual factors together through variable or person-centered approaches limits the ability to identify specific contexts that may be of importance to predicting cannabis use outcomes. we aimed to extend prior research by using specific contextual indicators as predictors of cannabis use outcomes within three large samples of college student cannabis users. we sought to broadly characterize the social context of cannabis use among college students. we report descriptive statistics across each sample, and then used an exploratory modeling technique (random forest) to identify salient contextual predictors related to cannabis outcomes. therefore, we examined contextual factors as separate indicators of cannabis protective behavioral strategies (pedersen et al., 2017), negative cannabis-related consequences, and cannabis use disorder symptoms. methods participants and procedure the marijuana outcomes study team (most) participants included college students recruited from the psychology department participant pools at 9 universities in 9 states throughout the united states who participated for research participation credit according to procedures approved by the institutional review boards at each participating university (for methodological details regarding most please see: richards et al., 2021). of 7,000 total participants, our analyses are focused on 2,077 who reported past month cannabis use. data were collected between fall 2016 and spring 2017 such that at the time of data collection two states permitted recreational cannabis use (co and wa), 3 states permitted medical cannabis use (nm, ny, and ca), and 4 states did not permit cannabis use (va, tx, tn, and fl). cannabis, a publication of the research society on marijuana 68 the protective strategies study team (psst) participants included college students recruited using similar procedures from 10 universities in 10 states throughout the united states (for details regarding psst please see: pearson et al., 2019). of 7,303 total participants, our analyses are focused on 2,222 who reported past month cannabis use. data were collected between spring 2017 and fall 2017 such that at the time of data collection 3 states permitted recreational cannabis use (ak, co, and wa), 1 state permitted medical cannabis use (nm), and 6 states did not permit cannabis use (id, mo, ms, ne, va, and wy). the addiction research team study (art) participants included college students recruited using similar procedures from 10 universities in 8 states throughout the united states (for details regarding the method including participants and recruitment please see: richards et al., 2022, 2023). of 5,594 total participants, our analyses are focused on 1,397 who reported past month cannabis use. data were collected between spring 2020 and fall 2020 such that at the time of data collection 4 states permitted recreational cannabis use (ak, ca, co, and wa), 1 state permitted medical cannabis use (nm), and 3 states did not permit cannabis use (id, va, tx). participants in all studies provided informed consent to participate. in total, our analyses focused on 5700 participants (male = 2893, female = 3702, other gender identity = 48, missing = 57). the average age of the sample was 20.17 years (sd = 3.36). most of the participants identified as white (white = 4110, american indian/alaska native= 161, asian = 568, black/african american= 861, native hawaiian/pacific islander = 88, and other = 432) non-hispanic (n = 4487). measures context of cannabis use. most investigators developed a broad assessment of contextual variables related to one’s cannabis use to serve various purposes. this assessment characterizes the amount of money spent on cannabis; frequency, level, and length of intoxication; social and physical contexts of use; form of cannabis and route of administration; level of unplanned use; and source of cannabis (see table 1 for the items, scales of measurement, and descriptive statistics for these items). items in the context measure focused on proxies for direct use (e.g., money spent, subjective intoxication questions), social and setting places of use (e.g., with friends, at home), form of cannabis and route of administration (e.g., flower, concentrate, using a bong, vaporizer), and source of purchase (e.g., dispensary, black market). to focus our analyses on the predictive ability of contextual factors only, we excluded proxies of direct use. most scale items asked participants to rate the percent of time they engaged in each contextual factor (0% 100%). for example, participants were asked to report the percentage of time they used each form of cannabis, and totals had to equal 100%. again, please see table 1 for the specific items and scales of measurement regarding the context factors. table 1. cannabis use contexts across datasets most psst art total [variable labels are underlined] m sd m sd m sd m sd money spent (please estimate how much money you have spent on marijuana in the past month ($).) 42.44 69.57 45.20 70.95 53.38 76.02 46.19 71.84 typical intoxication (on a typical marijuana use day in the past 30 days, please indicate how high you get from using marijuana (0 – 100%).) 60.77 24.41 61.64 25.14 64.09 23.13 61.84 24.41 peak intoxication (please indicate the highest you have been from marijuana in the past month (0 – 100%).) 71.81 26.78 73.44 26.96 75.07 23.94 73.15 26.21 peak frequency (what percentage of the time do you get this high from using marijuana (0 – 100%)?) 57.75 32.09 59.27 32.10 62.48 30.59 59.49 31.77 length of intoxication (on a typical marijuana use day in the past 30 days, how long do you stay high from using marijuana (hours)?) 3.83 13.86 3.27 5.09 2.87 2.02 3.39 8.99 cannabis use context 69 most psst art total [variable labels are underlined] m sd m sd m sd m sd form of cannabis (in the past month, please report the percentage of marijuana you consumed in each of the following ways (must total to 100%)) plant (i.e., bud, flower) 78.65 32.52 73.94 34.46 53.27 40.48 70.38 36.93 edibles (i.e., brownie, chocolate) 10.79 23.97 12.97 26.54 17.21 30.72 13.26 26.96 concentrates (i.e., hash, dabs) 8.62 21.46 11.38 23.84 26.07 35.90 14.07 27.60 other [other form] 2.15 13.35 1.87 12.68 3.45 16.98 2.44 14.38 route of administration (in the past month, please report the percentage of marijuana you consumed in each of the following ways (must total to 100%)) smoked in joint/blunt without tobacco 32.68 36.57 31.25 35.62 22.21 32.79 29.49 35.62 smoked in joint/blunt with tobacco 5.94 18.96 4.67 16.69 4.13 15.96 5.06 17.60 smoked in bong/water pipe without tobacco 20.93 30.53 21.02 29.93 18.73 31.09 20.35 30.47 smoked in bong/water pipe with tobacco 2.74 12.93 3.21 13.44 2.02 11.34 2.67 12.58 smoked in bowl/pipe without tobacco 19.76 31.10 20.08 30.36 12.63 26.95 18.13 30.07 smoked in bowl/pipe with tobacco 2.38 11.61 1.81 10.40 1.13 8.36 1.85 10.42 eaten/cooked 10.73 24.87 10.83 25.88 15.26 30.42 11.88 26.77 used in a vaporizer 5.79 18.67 8.07 21.61 23.90 35.83 11.11 26.03 setting of use (in the past month, please report the percentage of times that you used marijuana in each of the following ways (must total to 100%)) at my home 32.88 38.49 38.09 39.99 53.18 40.97 40.11 40.58 at a friend’s home 32.94 37.12 35.11 37.16 24.54 33.98 31.36 36.55 at a stranger’s home 1.46 8.78 1.06 6.35 0.66 6.01 1.11 7.23 outside 13.28 26.63 8.75 20.95 9.58 21.93 10.72 23.70 in a car 10.56 22.10 9.24 21.75 6.74 17.78 9.28 21.26 at a party 8.18 19.34 6.49 17.27 4.31 14.74 6.46 17.37 other 1.46 10.55 0.36 3.55 0.98 8.79 1.23 9.64 social context of use (in the past month, please report the percentage of times that you used marijuana in each of the following ways (must total to 100%)) alone 15.88 27.01 17.40 28.11 30.42 36.00 20.03 30.44 with friends 76.28 33.09 75.53 33.34 58.84 40.08 71.73 35.77 with family 5.09 17.49 4.85 17.36 8.13 22.38 5.74 18.80 with people i don’t know [strangers] 1.68 8.51 1.29 7.13 0.75 5.80 1.30 7.39 other [with others] 1.25 10.19 1.06 9.63 1.86 12.62 1.33 10.64 unplanned use (in the past month, please report the percentage of marijuana that you used in the following way i did not make a plan to use marijuana (0% to 100%)) 44.60 42.31 38.00 41.50 40.17 41.77 40.94 41.96 source of cannabis (in the past month, please report the percentage ofmarijuana that you used from the following sources (must total 100%):) i bought it from a dispensary in the state where i live [dispensary1] 6.56 22.05 14.13 31.56 24.07 40.09 13.92 31.80 i bought it from a dispensary in the state where i do not live [dispensary2] 1.88 11.01 2.76 13.62 3.69 16.27 2.67 13.55 i bought it, but not from a dispensary [black market] 33.51 41.32 29.90 39.50 23.98 37.87 29.82 39.96 i did not buy it [did not purchase] 58.84 43.83 53.77 44.60 48.26 45.83 54.12 44.80 note. most = marijuana outcomes study team, psst = protective strategies study team, art = addictions research team cannabis, a publication of the research society on marijuana 70 cannabis protective behavioral strategies (pbs). we used the mean of the 17-item version (pedersen et al., 2017) of the pbsm (pedersen et al., 2016) to assess cannabis pbs use. internal consistency was high in each sample (α = .903, .925, .902). the pbsm has been shown to be a robust protective factor associated with lower cannabis use (severity) and consequences (pearson et al., 2017; pedersen et al., 2018). negative cannabis-related consequences. we used the sum of the 21-item version of the marijuana consequences questionnaire (simons et al., 2012) to measure negative cannabis-related consequences. internal consistency was high in each sample (α = .859, .886, .879). cannabis use severity. we used the sum of the 8item cannabis use disorder identification test— revised (cudit-r) (adamson et al., 2010) to measure cud symptoms. internal consistency was adequate in each sample (α = .816, .833, .837). analysis plan we examined the context of use variables with means and standard deviations across the three datasets individually and joined as one dataset. additionally, we wanted to examine potential predictive ability of contextual factors of use on cannabis use outcomes (i.e., cannabis pbs, negative cannabis-related consequences, and cannabis use disorder severity). we used machine learning, specifically random forests, to examine the potential for contextual factors to predict outcomes. random forests are an extension of regression trees (breiman, 2001). regression trees use a nonparametric algorithm to create a split, or a point in a predictor that best separate the outcome variable (strobl et al., 2009). in traditional regression trees, the output provides a single tree, or a visual representation of the algorithm’s classification of the outcome. in random forests, hundreds of trees are created by randomly subsampling predictor variables at each split, and then averaging the predictions of each tree to find what variables are most important in predicting the outcome (breiman, 2001). the same random forests procedures can also be used to impute missing data (tang & ishwaran, 2017). first, we used the missforest (stekhoven, 2022) package to impute all of the missing data via random forest imputation. then, we separated the data into a training dataset (80% of the available data) that we used to run the initial random forest model and a testing dataset (20% of the available data) reserved to test the predictive ability of the model. splitting the data in this way reduces the chances of the algorithm finding random variance and overfitting the model, as well as improves generalizability (ho et al., 2020). we used the randomforest package (liaw & wiener, 2002) in r (r core team, 2023) to find the optimal number of random predictors (i.e., tuning) for the model to subsample at each split (mtry). then, we ran a random forest model for each outcome variable (three models) with their respective tuning parameters with the training dataset. finally, we used the random forest model to make predictions on the testing dataset. we report the mean absolute error (mae; average distance between predicted and actual values), the mean squared error (average squared difference between predicted and actual values), the root mean squared error (root squared mse), and the proportion of variance in the outcome explained by the model (r2). each model consisted of only contextual factors as predictors. the mae and rmse are dependent upon the scale (range) of the outcome variable, and therefore there are no general guidelines for what constitutes “acceptable” fit. however, lower values of the mae and rmse indicate a more accurate prediction. results the means and standard deviations of the percentages of endorsement across all contexts of use are reported in table 1. in the results presented below, we report noticeable trends in all three datasets. we also include bivariate correlations between all contextual indicators and the three outcome variables to determine the directional relationship between the contextual factors and outcomes (table 2). money spent and intoxication overall, participants reported they spent an average of $46.19 on cannabis in the 30 days prior to study participation. the amount of money spent increased slightly between project most to project psst and again from project psst to project art. cannabis use context 71 table 2. raw correlations between cannabis use context variables and cannabis-related outcomes across each dataset most psst art 1 2 3 1 2 3 1 2 3 1. cudit-r 2. macq .629** .609** .649** 3. pbsm -.424** -.363** -.397** -.291** -.489** -.363** 4. source of cannabis (dispensary1) .108** .086** -.078** .165** .097** -.068** .162** .098** -.120** 5 source of cannabis (dispensary2) .067 .035 -.055* .014 .000 -.027 .037 .046 -.055* 6. source of cannabis (black market) .355** .292** -.318** .362** .257** -.287** .266** .198** -.236** 7 source of cannabis (did not purchase) -.401** -.328** .344** -.437** -.290** .306** -.376** -.266** .319** 8. money spenta .483** .408** -.448** .526** .352** -.405** .505** .365** -.428** 9. typical intoxa .217** .155** -.191** .255** .137** -.175** .182** .130** -.143** 10. peak intoxa .322** .218** -.255** .364** .223** -.251** .310** .224** -.227** 11. peak frequencya .049 .010 -.069** .067** .001 -.070** -.056* -.053* .021 12. length of intoxa .008 .003 -.044* .072** .026 -.056* .028 .046 -.013 13. form of cannabis (plant) .050 .010 .016 .071** .055* -.013 .070* .023 -.079** 14. form of cannabis (edibles) -.110** -.085** .099** -.167** -.134** .160** -.211** -.154** .148** 15. form of cannabis (concentrates) .041 .080** -.132** .133** .088** -.149** .139** .123** -.026 16. form of cannabis (other form) .016 -.004 .006 -.102** -.037 -.011 -.084** -.037 -.023 17. route of administration (joint) -.039 -.009 .003 -.057* -.026 -.006 .004 -.055* .012 18. route of administration (joint tobacco) .094* .067** -.025 .053* .049* -.034 .045 -.013 -.044 19. route of administration (bong) .134** .073** -.090** .159** .129** -.096** .167** .154** -.141** 20. route of administration (bong tobacco) .107** .084** -.039 .119** .112** -.090** .109** .103** -.097** 21. route of administration (bowl) -.065 -.054* .054* .000 -.048* .034 -.040 -.014 .027 22. route of administration (bowl tobacco) -.018 -.007 -.008 -.005 .025 -.023 -.016 .030 -.002 23. route of administration (eaten) -.161** -.072** .072** -.181** -.136** .175** -.210** -.162** .128** 24. route of administration (vaporizer) .035 -.036 .002 -.015 -.021 -.023 .007 .030 .034 25. setting of use (at home) .211** .141** -.152** .199** .123** -.121** .206** .140** -.184** 26. setting of use (at friend's) -.163** -.101** .155** -.190** -.119** .138** -.218** -.162** .177** 27. setting of use (at stranger's) -.035 .010 -.010 .006 .006 -.087** -.006 .021 .002 28. setting of use (outside) -.023 -.036 -.010 -.014 -.007 -.025 -.059* -.034 .064* 29. setting of use (car) .012 .042 -.030 .014 .030 .009 .101** .054* -.068* 30. setting of use (party) -.090* -.072** .055* -.049* -.070** .046* -.051 -.024 .070** 31. setting of use (other place) .014 -.028 -.009 -.023 .005 -.010 -.091** -.025 .030 32. social context of use (alone) .300** .238** -.261** .332** .224** -.272** .278** .185** -.297** 33. social context of use (with friends) -.304** -.217** .265** -.281** -.182** .257** -.249** -.166** .287** 34. social context of use (with family) .022 -.005 -.056* -.015 -.035 -.017 .032 .016 -.007 35. social context of use (with strangers) .074 .067** -.042 .046* .080** -.091** -.025 .002 -.014 36. social context of use (with others) .058 .019 -.039 -.009 -.002 -.005 -.048 -.030 -.044 37. unplanned usea -.348** -.200** .206** -.280** -.141** .125** -.175** -.105** .067* note. * p < .05, ** p < .01, a proxy of direct use or not a social context and removed from analyses. cannabis, a publication of the research society on marijuana 72 participants were asked to rate on a 0 – 100 scale how high they typically get when they use cannabis. in each of the three studies, participants reported percentages in the 60-65 range with an overall average of 61.835. participants were also asked to rate their highest level of intoxication on the same scale. in all three studies, participants reported the highest level of intoxication in the 70s (overall m = 73.151) and that they achieve this peak intoxication over half of the times they use cannabis (overall m = 59.487%). on days participants used cannabis in the past month they reported feeling high for an average of 3.392 hours. cannabis form in all three studies, participants reported using cannabis flower most of the time (overall m = 70.384%). however, a notable drop in cannabis flower use occurred between project most (m = 78.646%) and project art (m = 53.265%). the drop in the use of flower corresponded with a similar increase in the use of concentrates (most m = 8.621%; art m = 26.073%). route of administration the most prominent route of administration in projects most and psst was smoking a joint or blunt without tobacco. participants in project art endorsed using a joint or blunt without tobacco (m = 22.205%) and using a vaporizer (m = 23.902%) at similar rates. reported vaporizer use in project art was much higher than reported vaporizer use in projects most (m = 5.787%) and psst (m = 8.072%). use settings overall, using cannabis at home was the most endorsed setting. however, in project most and psst, participants tended to use at home or at a friend’s house at about the same frequencies. compared to most and psst, participants in project art appeared to make a trade-off between using cannabis at their own house (m = 53.180%) and their friend’s house (24.540%). social context of use overall, participants reported mostly using cannabis with their friends in all three studies. one notable difference between the three studies is that participants in project art reported using alone (m = 30.418%) more often than participants in most (m = 15.884%) and psst (m = 17.396%). source of cannabis and money spent across all three projects, participants mostly endorsed not sourcing cannabis themselves. in projects most and psst, the second most endorsed source was sourcing cannabis from a place other than a dispensary. in project art, the second most endorsed source was obtaining cannabis from a dispensary. in all studies, below 5% of cannabis sourcing involved crossing state lines to purchase at a dispensary in another state. random forest models first, we combined all three datasets and imputed missing values using the missforest package (stekhoven, 2022). the number of missing values for the macq (most = 1.97%; psst = 1.89%, art = 1.58%) and pbsm (most = 2.27%; psst = 1.75%, art = 1.58%) was acceptable in all three datasets. regarding the cudit-r, participants in project most were randomly assigned to complete one of four measures of cannabis use disorder symptoms, one of which was the cudit-r. thus, missingness for the cudit-r in project most was high (69.57%). missingness for the cudit-r in projects psst and art were acceptable (psst = 1.80%, art = 4.94%). the missforest package subsets the data into complete cases and variables with missing data. the package then runs a random forest algorithm based on the observed values to impute a value for missing data (stekhoven, 2022). after data imputation, we split the dataset into a training dataset and a testing dataset. for each outcome (pbsm, macq, cudit-r) we conducted a tuning model that examined the optimal number of variables randomly sampled at each split of the decision trees. the optimal number of variables randomly sampled for the cudit-r, pbsm, and macq models was 5. finally, we conducted random forest models for all three variables using the selected number of splits, 500 cannabis use context 73 decision trees, in the randomforest package (liaw & wiener, 2002) in r (r core team, 2022). below, we report the variable importance, or predictive utility of a variable across all the decision trees in a random forest, from the training dataset and model fit from using the training datasets on the testing datasets. for the pbsm, our rank-ordered variable importance plot can be viewed in figure 1. using alone, using with friends, obtaining cannabis on the black market, using concentrate, and using at home were the most important variables in predicting the pbsm. however, when using the random forest model to predict values in the testing dataset, the random forest predictions had room for improvement (table 3). on average, our model’s predicted values deviated from the true values (mae) by 0.74 units of the pbsm (range 1 – 6). the squared differences between the predicted and actual values (mse) was 0.94, and our model accounted for 16% of the variance in pbsm scores. for the macq, our rank ordered variable importance plot can be viewed in figure 2. using alone, obtaining cannabis on the black market, using with friends, primarily using a bong, and using at home were the most important predictors for the macq. we used the training model to predict macq scores in the portion of data set aside for predictions (table 3). on average, our model’s predicted values deviated from the true values (mae) by 2.68 units of the macq (range 0 – 21). the squared differences between the predicted and actual values (mse) was 13.02. overall, our random forest model of contextual factors accounted for 17% of the variance in the macq. the rank ordered variable importance plot for our random forest model predicting the cudit-r can be viewed in figure 3. the most important variables in predicting the cudit-r were using alone, obtaining cannabis on the black market, using with friends, using at home, and using a bong. on average, the model’s predicted values deviated from the true values (mae) by 3.12 units of the cudit-r sum (range = 0 – 32). the squared differences between the predicted and actual values was 18.79 and the model accounted for 38% of the variance in the cudit-r sum. figure 1. plot of variable importance for the pbsm in order from least important (top) to most important (bottom) note. the (+) and (-) after each contextual variable indicates the directional relationship to the pbsm. cannabis, a publication of the research society on marijuana 74 figure 2. plot of variable importance for the macq in order from least important (top) to most important (bottom) note. the (+) and (-) after each contextual variable indicates the directional relationship to the macq. figure 3. plot of variable importance for the cudit-r in order from least important (top) to most important (bottom) note. the (+) and (-) after each contextual variable indicates the directional relationship to the cudit-r. cannabis use context 75 table 3. random forest fit statistics outcome mtry r2 mae mse rmse protective behavioral strategies (pbsm) 5 0.16 0.75 0.94 0.97 negative consequences (macq) 5 0.17 2.68 13.02 3.46 cannabis use severity (cudit-r) 5 0.46 2.89 16.59 4.07 note. pbsm= protective behavioral strategies for marijuana, macq = marijuana consequences questionnaire, cudit-r = cannabis use disorder identification test-revised, mtry= the optimal number of random predictors (i.e., tuning) for the model to subsample at each split, mae = mean absolute error, mse = mean squared error, rmse = root mean squared error. discussion overall, the present study extends the previous literature, which has largely focused on using a few contextual variables to determine factor structures or latent profiles (beck et al., 2009; gray et al., 2024; spinella et al., 2019), by providing descriptive statistics across a broad array of social contexts of cannabis use. regarding the form of cannabis used, college students appear to predominately use flower cannabis, though the use of edibles and concentrates was not minimal. bivariate correlations between cannabis form and cannabis outcomes (table 2) indicated that edible usage was most consistently correlated (compared to other forms of cannabis) with less use disorder severity and consequences, and more pbs use. though, the use of concentrates was significantly correlated with less pbs use. of note regarding cannabis form, the use of concentrate was the most important cannabis form predictor in all three random forest models. this in part could be due to the greater exposure to thc when using concentrates versus flower (bidwell et al., 2020). regarding different routes of administration, the use of a bong was most consistently correlated with increased consequences and disorder severity and decreased use of pbs, and similar to form results, eating cannabis appeared to be the most protective route of administration (table 2). additionally, using a bong tended to be the most important route of administration in the random forest models, other than for pbs, where using a joint was slightly more important. bongs tend to be relatively indiscreet and would likely be owned by individuals that consume cannabis regularly, though more work is needed to determine why bong use specifically may be associated with worse outcomes. college students predominately consume using joints without tobacco and co-use with tobacco was not highly endorsed. regarding direct social contexts of use (who participants used with), participants tended to use with friends, and using with friends was the most consistent social context correlated with fewer consequences and disorder severity and more pbs use. in contrast, using alone was the most consistent social context correlated with negative cannabis outcomes, consistent with previous literature (table 2; buckner et al., 2016; creswell et al., 2015). using alone was the most important contextual factor in all of the random forest models. considering that solitary use accounts for much of the relationship between social anxiety and poor cannabis use outcomes (buckner et al ., 2016), it may be that solitary use is more associated with negative reinforcement, or using to remove unwanted emotional states. given the fact that using alone was the most important predictor in all models, this may highlight the need for preventative and clinical treatments to focus on decreasing the amount of time individuals use cannabis alone. regarding where individuals used, using at a friend’s house was consistently correlated with positive cannabis outcomes, while using at home was associated with negative outcomes (table 2). additionally, using cannabis at home was the most important social setting in all three random forest models. using at home and using alone are potentially conflated and our models cannot differentiate whether participants used at home alone or with friends. future work should focus on examining social networks of individuals that often use at home and whether including others may have protective effects on cannabis outcomes. cannabis, a publication of the research society on marijuana 76 regarding source of cannabis purchase, the most protective source of purchase was not purchasing cannabis, and purchasing on the black market was the source most strongly correlated with negative outcomes (table 2). in fact, sourcing cannabis on the black market was the most important source context in all of the random forest models. this likely indicates individuals that often purchase cannabis or go out of their way to source cannabis in places that do not have the same tax burden as a legalized market. one important note is that crossing state lines to source cannabis was not highly endorsed in any of the studies. lastly, the predictive models accounted for varying proportions of the cannabis outcomes’ variances. specifically, contextual factors accounted for 16% and 17% of the variance in pbs and cannabis use consequences respectively and 38% of variance in the cudit-r. considering our models removed proxies of use (i.e., level of intoxication, money spent), our results indicate that contextual factors likely account for additional variance in cannabis-related outcomes beyond direct use. additionally, the random forest models were able to predict outcomes relatively well. recalling that the mae is the average error of the model’s prediction in the same scale as the outcome, the model's relative errors were all within 9%-13% of the outcome variables’ range and may provide a benchmark for future studies using machine learning with cannabis contexts. limitations our study has several limitations. first, we created our contextual measurement tool, and said tool has not been validated for real-time use. second, our models do not account for the legal status of cannabis in the participant’s state of residence. as such, we do not know the status of how participants sourced cannabis. while the rates of crossing state lines to obtain cannabis were low in all three studies, the rates may change depending on the legal status of each state, and how far away the participants were from a dispensary. lastly, while the studies were conducted over a span of 4 years, we do not make any assumptions regarding the trends of cannabis use as state-level legalization has become more widespread over time. this is especially relevant as the covid-19 pandemic had not occurred during psst and most data collection but had already occurred during the art data collection. future work should focus on changes in these contextual trends and determine how potential changes may affect outcomes. future directions much work needs to be done regarding the contexts surrounding cannabis use. specifically, participants in our study tended to report using cannabis with friends. under the assumption that friends using cannabis together are not using their own pipes, bongs, or joints, it is likely difficult to accurately measure the amount of cannabis consumed by everyone, even if the weight and potency are known prior to group consumption. for example, even if study participants are asked to report the potency and to pre-measure the weight of each joint/bowl in real time, there is no way to know what percentage of that weight in combusted thc that everyone in a group session is consuming. this predicament contrasts with alcohol use, where more accurate measurements can be assumed by standard drink conversions. it may be that measuring additional contexts such as subjective intoxication, money spent, and form of cannabis use can be appropriate proxies for precise dosage and weights. the incorporation of assessing contexts of use could also provide pertinent information regarding environmental factors related to use. implementing contextual measures from a theoretical framework could help improve existing models predicting cannabis use outcomes. that is, what are the effects of core predictors of cannabis use outcomes when incorporating environmental factors into existing models? much of the modeling on cannabis use outcomes examine outcomes as functions of use, emotions, or urges. however, it is likely the predictors fluctuate between different contexts of use. references adamson, s. j., kay-lambkin, f. j., baker, a. l., 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(2017). random forest missing data algorithms. statistical analysis and data mining: the asa data science journal, 10(6), 363–377. https://doi.org/10.1002/sam.11348 funding and acknowledgements: matison mccool was supported in part by the national institute on alcohol abuse and alcoholism, t32aa018108 (pi: witkiewitz). conflict of interest statement: we have no conflict of interest to declare. we would like to acknowledge the efforts of sarah l. simons with conducting literature searches and contributing to an early version of this manuscript. data were collected by three research teams: marijuana outcomes study team (most), protective strategies study team (psst), and the addictions research team (art). *most includes the following investigators (in alphabetical order): amber m. anthenien, university of houston; adrian j. bravo, university of new mexico; bradley t. conner, colorado state university; christopher j. correia, auburn university; robert d. dvorak, university of central florida; gregory a. egerton, university at buffalo; john t. p. hustad, pennsylvania state university college of medicine; tatyana kholodkov, university of wyoming; kevin m. king, university of washington; bruce s. liese, university of kansas; bryan g. messina, auburn university; james g. murphy, the university of memphis; clayton neighbors, university of houston; xuanthanh nguyen, university of california, los angeles; jamie e. parnes, colorado state university; matthew r. pearson, university of new mexico; eric r. pedersen, rand; mark a. prince, colorado state university; sharon a. radomski, university at buffalo; lara a. ray, university of california, los angeles; jennifer p. read, university at buffalo. **psst includes the following investigators: matthew r. pearson, university of new mexico (coordinating pi); adrian j. bravo, university of new mexico (co-pi); mark a. prince, colorado state university (site pi); michael b. madson, university of southern mississippi (site pi); james m. henson, old dominion university (site pi); alison looby, university of wyoming (site pi); vivian m. gonzalez, university of alaskaanchorage (site pi); amber m. henslee, missouri science & technology (site pi); carrie cuttler, washington state university (site pi), maria m. wong, idaho state university (site pi), dennis e. mcchargue, university of nebraska-lincoln (site pi). ***art includes the following investigators: matthew r. pearson, university of new mexico (coordinating pi); adrian j. bravo, william & mary (site pi); bradley t. conner, colorado state university – fort collins (site pi); carrie cuttler, washington state university (site pi); craig a. field, university of texas at el paso (site pi); vivian gonzalez, university of alaska anchorage (site pi); james m. henson, old dominion university (site pi); jon m. houck, mind research network; kevin m. king, university of washington (site pi); benjamin o. ladd, washington state university (site pi); kevin s. montes, california state university – dominguez hills (site pi); mark a. prince, colorado state university – fort collins (site pi); maria m. wong, idaho state university (site pi). copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: mccool, m. w., pearson, m. r., the marijuana outcomes study team, the protective strategies study team, & the addictions research team. (2025). beyond frequency and quantity of cannabis consumption among college students: context of using cannabis relates to cannabis-related outcomes. cannabis, 8(1), 6580. https://doi.org/10.26828/cannabis/2024/000225 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 80 research article 135 ved abstract objective: an increasing number of canadians are registering as authorized users of medical cannabis. older patients comprise a growing subset of this population; however, relatively little information exists around age-related patterns of medical cannabis use. methods: the canadian cannabis patient survey (ccps) is a large cross-sectional survey of authorized medical cannabis patients in canada. this publication summarizes the results of the ccps 2021, with a focus on age-related outcomes and the elderly sub-population. results: the survey was completed by 2,697 patients. the mean age of participants was 54.3 years of age and the proportion of female respondents was 49.1%. among older patients, pain was the most common symptom, while anxiety was the most common symptom reported by younger patients. older patients exhibited a significant preference for oral administration over inhalation of medical cannabis when compared to younger patients, respectively (p>0.05). among patients taking prescription opioids, most of whom were older patients, 54% reported a decrease in use concurrent with medical cannabis. conclusions: older patients comprise a growing subset of medical cannabis patients, which is also reflected in ccps participants over time. this patient population exhibits different patterns of use compared to their younger counterparts, preferring high cbd orally ingested formulations, which they use primarily to treat painrelated illnesses/symptoms. overall, study participants reported that cannabis had a high degree of efficacy in alleviating their illness/symptoms, and many reported a reduction in their use of prescription opioids, alcohol, tobacco, and other substances. key words: = cannabis; medical cannabis; gender differences; age differences; survey medical cannabis was first made legally available in canada in 2001. as of march 2021, there were approximately 300,000 active client registrations with federal license holders, representing almost 1% of the canadian population (health canada, 2023). however, due to the availability of recreational cannabis in canada both before and after the legalization of adult recreational use in 2018, a substantial number of patients obtain and use cannabis for medical purposes without federal registration (hamilton et al., 2017; statistics canada, 2019). thus, these numbers are likely an underestimate mariah walker1, stephanie lake2, josé tempero3, kaye ong4, & philippe lucas4,5 1tilray canada leamington, ontario 2ucla center for cannabis and cannabinoids, jane and terry semel institute for neuroscience and human behavior, department of psychiatry and biobehavioral sciences, university of california, los angeles 3tilray deutschland gmbh cologne, germany 4tilray canada nanaimo, british columbia 5social dimensions of health, university of victoria cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000208 age-related patterns of medical cannabis use: a survey of authorized patients in canada corresponding author: josé tempero, pharmd, msc, tilray deutschland gmbh, cologne, 50668, germany. email: jose.tempero@tilray.com. cannabis, a publication of the research society on marijuana 136 of the prevalence of medical cannabis use in canada. despite the growing number of medical cannabis users around the globe, there is relatively little data to describe medical patterns of use overall, and among distinct demographic groups defined by gender, age, or medical condition. importantly, the number of older patients and female patients among medical cannabis users is increasing (bruce et al., 2020; han & palamar, 2020; vacaflor et al., 2020; yang et al., 2021) and these populations may exhibit different patterns of use compared to younger or male cohorts. older consumers are more likely to use cannabis for medicinal purposes rather than recreational purposes, to favour oral formulations, and to use medical cannabis to treat chronic health conditions (kaufmann et al., 2020; yang et al., 2021). understanding age-related differences in medical cannabis use can help inform healthcare decisionmakers about specific therapeutic patterns of use and the associated potential harms and benefits and of medical cannabis among various user populations. examinations of real-world medical cannabis use can provide valuable self-reported data about patient health, use of other medications, and the perceived effectiveness of medical cannabis. the canadian cannabis patient survey (ccps) is a large cross-sectional survey that was developed to collect data from canadian authorized medical cannabis patients registered with tilray, a federally authorized licensed producer with production facilities in british columbia and ontario and patients and distribution in all canadian provinces and territories. the survey has been administered every two years using a similar methodology since 2015, and includes questions on participant demographics, patterns of cannabis use, and self-reported use of prescription drugs and other substances before and after medical cannabis initiation. results from previous ccps have described the conditions for which medical cannabis is used, the preferred formulations and modes of administration, and the preferred ratios of active ingredients cannabidiol (cbd) and tetrahydrocannabinol (thc) (baron et al., 2018; lucas et al., 2020). subsequent publications stemming from latter iterations of ccps have focused on the relationship between medical cannabis use and reductions in substance use, including prescription medications (opioids and non-opioids), unregulated drugs, alcohol, and tobacco (lucas et al., 2019; lucas et al., 2020; lucas et al., 2021). earlier versions of ccps also noted an under-represented but growing female patient population, as well a steady increase in the age of respondents (lucas et al., 2019; lucas & walsh, 2017; lucas et al., 2021). in regard to gender, 27% of respondents identified as female in 2015, 37% in 2017, and 45% in 2019 (lucas et al., 2019; lucas & walsh, 2017; lucas et al., 2021). regarding age, 40 was the mean age of respondents in 2015 and 2017, increasing to 48 in 2019 (lucas et al., 2019; lucas & walsh, 2017; lucas et al., 2021). the present report summarizes results from ccps 2021 with a focus on age-related differences in primary illnesses and patterns of medical cannabis use, including primary modes of administration and preferred major cannabinoid profiles (i.e., thc vs. cbd). we hypothesized that the respondent population would continue to trend older than previous iterations of this survey and that medical conditions and patterns of use would differ by age, as would changes in the use of other substances including prescription drugs, alcohol, tobacco, and unregulated drugs. methods study sample invitations to participate in the survey were sent by email to medical cannabis patients registered with tilray, a federally authorized licensed producer (lp) in canada. recipients were informed that patients who completed the survey would be entered into a draw for 3 prizes of a $1000 credit to their medical account with tilray. clicking on the link in the email invitation led to a digital informed consent form. clicking “yes” to proceed with the survey was interpreted to mean that participants had provided consent to participate; clicking “no” immediately ended the survey. inclusion criteria included being age 18 or older, capable of reading and understanding english, and capable of legally consenting to the informed consent form. authorization to use medical cannabis was also included and confirmed by verifying the patient identification number. age-related patterns of medical cannabis use 137 measures the survey consisted of multiple choice, ranking, likert-type, and open-ended questions regarding demographic information, healthrelated information, details on medical cannabis use, and questions around use of other substances such as prescription drugs, unregulated drugs, alcohol, and tobacco. the survey gathered self-reported demographic data, including gender, age, current relationship status, highest education level completed, annual household income, and canadian province/ territory of residence. we also assessed the primary symptoms and illness for which participants used medical cannabis by providing a list of common symptoms and illnesses associated with medical cannabis use that included an option of clicking “other,” prompting a textual response. for primary illness, respondents could only select a single response, but the question on primary symptoms allowed for multiple responses. we gathered cannabis use information via multiple choice questions. primary method of use was assessed by providing a list of common methods of use (i.e., vaporizer/flower, oral oil/drops, oral capsules, oral edibles, oral tincture, joint, pipe, waterpipe/bong, vape pen, concentrates, topical, juicing, and “other”) limited to a single response. those who endorsed flower use were asked about days per week of use, as well as typical amount used per day (on days used) in dry weight, from “0.25 grams or less” to “4 grams or more”. participants were also asked to identify preferred flower types (i.e., high thc/low cbd, high cbd/low thc, 1:1 thc/cbd, or no preference). those who endorsed oral extract use (i.e., drops or capsules) answered questions specific to these products, including what type of extract they used most (i.e., high thc/ low cbd, high cbd/low thc, and 1:1 thc/cbd). those who endorsed liquid vape product use (i.e., vape pens or cartridges) answered questions specific to these products, including their preferred vape product (i.e., high thc/ low cbd, high cbd/low thc, and 1:1 thc/cbd, no preference) the use of prescription medications (opioids and non-opioids to treat a medical condition), alcohol, tobacco, and other substances was assessed by asking participants about lifetime regular use (defined as ≥10 days in a year). those who endorsed current or past regular use of prescription opioids, non-opioid prescription drugs, and illicit drugs were asked to identify up to five specific drugs within that category that they use(d). for opioids, up to five specific generic types of prescription opioid medications and associated dosages could be selected via drop down menu. we also asked participants to indicate which of the following statements best matched their experience using cannabis and prescribed opioids: (1) “i was surprised to find that my use of opioids changed after i began to use medical cannabis;” (2) “i deliberately used medical cannabis to reduce my use of opioids;” (3) “my md recommended medical cannabis in order to reduce my use of opioids;” (4) “my md recommended medical cannabis and then worked with me to develop a specific tapering program to help reduce my use of opioids;” or (5) “none of the above.” to understand potential differences in selfvs. clinician-guided use of medical cannabis to reduce prescription opioid use, we pooled the above responses into categories for intentional selfguided management (i.e., response 2), clinicianguided (i.e., responses 3 or 4), and no/nonintentional management of opioids with cannabis (i.e., responses 1 or 5). for prescription nonopioids, up to five drugs could be identified through an autofill list connected to the national drug data file (nddf), a us-based national prescription drug database. this ensured that consistent generic prescription drug names were used across participants to facilitate the analysis. however, a free-text option was also provided. for illicit drugs, up to five drugs could be indicated through a free-text option. for all substance categories (prescription opioids, prescription nonopioids, illicit drugs, alcohol, tobacco), participants were asked about perceived changes in use of that substance over the past-year, with options for increase, decrease, and no change. participants were asked to include their unique patient identification number to confirm eligibility and to assign credits to those who won a prize for participation. accordingly, the survey was not completely anonymous. however, all data was collected and examined at the group level, and patient identifier numbers were de-linked from the specific survey data provided by the patient during analysis. the survey received approval from advarra (pro00050772), an independent ethics review service provider. data cannabis, a publication of the research society on marijuana 138 collection was done using redcap software (vanderbilt university, nashville, tn, usa), a hipaa and pipeda compliant, password protected, electronic data capture program. data will be stored for seven years. statistical analysis we used descriptive statistics to summarize the socio-demographic characteristics of survey sample. we then stratified the sample by age group (≤40 years, 41-60 years, >60 years) and used pearson’s chi-square test or kruskal-wallis test, as appropriate, to examine age-related differences in primary illnesses and symptoms treated with medical cannabis, perceived effectiveness of cannabis for symptom relief, primary mode of administration, frequency of use, preferred major cannabinoid profiles of currently used formulations, and perceived past-year changes in other substance use. we followed up significant age-related differences with post hoc tests for pairwise comparisons (≤40 vs. 41-60 years; 41-60 years vs. >60 years; ≤40 vs. >60 years). we used the bonferroni methods to adjust p-values from post hoc tests. all analyses were conducted in r using rstudio. results in total, 27,431 survey invitations were issued by email, and 2,697 respondents met the inclusion criteria and completed the survey. at the time of the survey, health canada data indicates there were 272,690 federally registered patients, so those registered with tilray accounted for approximately 10% of all patients, and therefore survey respondents represent nearly 1% of all federally registered medical cannabis patients in canada (health canada, 2023). participant characteristics table 1 highlights participant characteristics. there was an almost even distribution of males (n = 1352, 50.1%) and females (n = 1325, 49.1%), and 10 respondents (0.4%) identified as a third gender. the mean age of study participants was 54.3 years (standard deviation = 14.0), and mean age did not differ significantly between males (54.6 years) and females (54.2 years; p = 0.429). most were married, and almost half identified as female. the survey provided the option to select multiple ethnicities, and there was an over-representation of white/caucasian respondents (91.3%) compared to the general canadian population, and an under-representation of all other ethnic groups. participants were highly educated, with over 95% (n=2583) having at least a high school degree, and 30.6% (n=827) reporting a university degree. with respect to employment, 44.6% (n = 1202) of patients worked full or part time, 32.9% (n = 887) were retired, and 16% (n = 431) did not work due to disability. table 1. characteristics of the sample (n = 2697) overall and by age group. variable overall age ≤40 age 41-60 age >60 2697 (100.0) 535 (19.8) 1150 (42.6) 1012 (37.5) age mean (sd) 54.3 (14.0) 33.8 (4.7) 51.2 (5.9) 68.6 (5.9) median (iqr) 56 (43 65) 35 (31-38) 52 (46-57) 67 (64-72) range (20 94) --- gender male 1352 (50.1) 269 (50.3) 575 (50.0) 508 (50.2) female 1325 (49.1) 250 (46.7) 572 (49.7) 503 (49.7) not indicated 10 (0.4) 8 (1.5) 2 (0.2) 0 (0.0) other gender 10 (0.4) 8 (1.5) 1 (0.1) 1 (0.1) relationship status married 1541 (57.1) 209 (39.1) 667 (58.0) 665 (65.7) widowed 109 (4.0) 4 (0.7) 21 (1.8) 84 (8.3) divorced 262 (9.7) 10 (1.9) 111 (9.7) 141 (13.9) separated 86 (3.2) 12 (2.2) 59 (5.1) 15 (1.5) age-related patterns of medical cannabis use 139 in a domestic partnership or civil union 262 (9.7) 95 (17.8) 115 (10.0) 52 (5.1) single, but cohabiting with a significant other 106 (3.9) 50 (9.3) 35 (3.0) 21 (2.1) single, never married 331 (12.3) 155 (29.0) 142 (12.3) 34 (3.4) race/ethnicity1 white 2463 (91.3) 467 (87.3) 1048 (91.1) 948 (93.7) hispanic 27 (1.0) 9 (1.7) 11 (1.0) 7 (0.7) asian 29 (1.1) 10 (1.9) 16 (1.4) 3 (0.3) south asian 37 (1.4) 19 (3.6) 13 (1.1) 5 (0.5) black 36 (1.3) 14 (2.6) 13 (1.1) 9 (0.9) aboriginal/first nation 67 (2.5) 21 (3.9) 30 (2.6) 16 (1.6) metis 64 (2.4) 12 (2.2) 29 (2.5) 23 (2.3) other 70 (2.6) 23 (4.3) 28 (2.4) 19 (1.9) highest degree completed less than high school degree 114 (4.2) 49 (4.7) 39 (3.4) 50 (4.9) high school degree or equivalent 638 (23.7) 115 (21.5) 258 (22.4) 265 (26.2) technical and non-university degree 1118 (41.5) 220 (41.1) 527 (45.8) 371 (36.7) university degree 593 (22.2) 142 (26.5) 240 (20.9) 211 (20.8) graduate degree 182 (6.7) 26 (4.9) 68 (5.9) 88 (8.7) doctorate or professional degree 52 (1.9) 142 (26.5) 240 (20.9) 211 (20.8) employment status employed, working full-time 952 (35.3) 325 (60.7) 540 (47.0) 87 (8.6) employed, working part-time 250 (9.3) 61 (11.4) 125 (10.9) 64 (6.3) not employed, looking for work 112 (4.2) 39 (7.3) 54 (4.7) 19 (1.9) not employed, not looking for work 65 (2.4) 28 (5.2) 32 (2.8) 5 (0.5) retired 887 (32.9) 7 (1.3) 120 (10.4) 760 (75.1) disabled, no able to work 431 (16.0) 75 (14.0) 279 (24.3) 77 (7.6) annual household income less than $10,000 66 (2.4) 20 (3.7) 34 (3.0) 12 (1.2) $10,000 $39,999 541 (20.1) 121 (22.6) 171 (14.9) 249 (24.6) $40,000 $69,999 717 (26.6) 130 (24.3) 273 (23.7) 314 (31.0) $70,000 $99,999 564 (20.9) 102 (19.1) 248 (21.6) 214 (21.1) $100,000 $129,999 387 (14.3) 83 (15.5) 184 (16.0) 120 (11.9) $130,000 $159,999 212 (7.9) 43 (8.0) 108 (9.4) 61 (6.0) over $160,000 210 (7.8) 36 (6.7) 132 (11.5) 42 (4.2) financial assistance for medical cannabis not applicable 2424 (89.9) 494 (92.3) 1028 (89.4) 902 (89.1) veterans affairs canada 147 (5.5) 17 (3.2) 67 (5.8) 63 (6.2) private insurance provider 21 (0.8) 5 (0.9) 7 (0.6) 9 (0.8) other 105 (3.9) 19 (3.6) 48 (4.2) 38 (3.8) note. 1does not sum up to 100% as participants could check off multiple race/ethnicity categories. reasons for medical cannabis use the primary illnesses and symptoms, stratified by age, for which medical cannabis was used are reported in supplementary table s1. chronic pain (27.8%; n = 750) and arthritis (14.9%; n = 402) were the two most common primary illnesses, and pain was the most common primary symptom (66.6%; n = 1796). anxiety was the third most common primary illness (9%; n = 242) and the second most common primary symptom (35.7%; n = 964). insomnia/sleep disorder was also a common condition, and this symptom, which is often co-morbid with chronic pain and other illnesses, was reported by 34.6% (n = 933) regarding perceived effectiveness, 87.1% of respondents (n = 2348) reported that medical cannabis helped alleviate primary symptoms “often” or “always,” ranking the effectiveness of medical cannabis at achieving symptom relief at 75.2 out of 100 (sd 16.4; table s1). statistically cannabis, a publication of the research society on marijuana 140 significant differences are observed in terms of perceived effectiveness between age groups, with the oldest age groups reporting a worst perceived effectiveness compared to the youngest one. to assess age-related patterns of use, patients were divided into three age categories: 40 years and under (n = 535; 19.8%), 41 to 60 years (n = 1150; 42.6%), and over 60 years (n = 1012; 37.5%). table 2 displays the top five reported primary illnesses and symptoms treated with medical cannabis, stratified by age group. reasons for medical cannabis use stratified by gender are presented in supplementary table s2. table 2. reasons for medical cannabis use by age group. age group, n (%) p-value2 ≤40 535 (19.8) 41-60 1150 (42.6) >60 1012 (37.5) primary illness currently treated with medical cannabis chronic pain 120 (22.4) 349 (30.3) 281 (27.8) .003a arthritis 20 (3.7) 115 (10.0) 267 (26.4) <.00a,b,c anxiety 105 (19.6) 100 (8.7) 37 (3.7) <.00a,b,c insomnia/sleep disorder 51 (9.5) 93 (8.1) 94 (9.3) .501 fibromyalgia 25 (4.7) 87 (7.6) 60 (5.9) .059 primary symptoms currently treated with medical cannabis1 pain 267 (49.9) 782 (68.0) 747 (73.8) <.00a,b,c anxiety 324 (60.6) 439 (38.2) 201 (19.9) <.00a,b,c insomnia/sleep disorder 237 (44.3) 428 (37.2) 268 (26.5) <.00a,b,c stress 225 (42.1) 309 (26.9) 112 (11.1) <.00a,b,c depression/low mood 213 (39.8) 254 (22.1) 135 (13.3) <.00a,b,c cannabis perceived to help with primary symptom relief (how often)3 ≤ sometimes 45 (8.4) 139 (12.1) 165 (16.3) <.001b,c ≥ often 490 (91.6) 1011 (87.9) 847 (83.7) perceived level of cannabis effectiveness for symptom relief (0-100% effective) median (iqr) 80 (73-90) 78 (70-87) 75 (60-84) <.001a,b,c note. 1patients could indicate >1 primary symptom 2displayed p-value is from omnibus pearson chi-square test (categorical variables) or kruskal-wallis test (numeric variables); bonferroni-adjusted p-values for post hoc pairwise tests between age groups indicated by superscript letters: aadj. p<.05 for ≤40 vs. 41-60 years; badj. p<.05 for 41-60 vs. >60 years; cadj. p<.05 for ≤40 vs. >60 years. 3respondents selected from categories “never”, “rarely”, “sometimes” (pooled into ≤sometimes) and “often”, “always” (pooled into ≥often) preferred formulations and modes of use tilray produces a wide range of cannabisbased products, including flower/bud, which can be smoked or vaporized, oil-based vaporizer cartridges, and extracts and capsules which can be taken orally. participants identified the formulation/mode of administration they use most often for medical purposes, and results are summarized in supplementary table s3. the majority (n = 1468; 54.4%) used extracts/drops via oral administration. the second most common primary formulation/mode of administration combination reported by substantially fewer respondents (n = 334; 12.4%) was dried flower via vaporizer. altogether, the primary mode of administration was oral for most respondents (n = 1722; 63.3%), but a substantial number (n = 939; 34.8%) reported inhalation (supplementary table s3). figures 1 shows primary mode of administration (oral, inhalation) by age group. as shown, oral administration increased significantly with age (figure 1). age-related patterns of medical cannabis use 141 figure 1. inhalation and oral modes of administration by age group. proportion of respondents in each age group who reported using cannabis through inhalation and oral modes of administration. inhalation modes of administration includes concentrates (dabs, shatter, etc.), joints, pipes, plant vaporizer, oil vaporizer, and bong; oral modes of administration include juicing, capsules, edibles, oils/drops, and tinctures. distribution of mode of administration differed significantly by age (x2=269.99, p<.001), with significant differences for pairwise age group comparison (bonferroni-adjusted p<.001). as shown in table 3, a substantial majority (n = 2218; 82.2%) used medical cannabis at least once per day, with significantly higher prevalence recorded for the oldest age group: 86.0% vs. 81.0% in the 41-60 group and 77.8% in the ≤40 group. however, the youngest age group was more likely to report using more than one form of cannabis (flower, oral product, vape product). of respondents who used dried flower (n = 1399), most (n = 752; 54.2%) used <1g per day. there was a significant age-related difference in the distribution of daily amount of flower used, with <1 g/day more often reported in the oldest group (60.1%) relative to the youngest group (49.3%), but we note that this pairwise difference was just shy of surviving bonferroni correction (p = 0.052). table 3. cannabis use patterns and preferences by age group. variable n (%) age group p-value ≤ 40 41-60 >60 overall (n = 2697) frequency of use < daily 479 (17.8) 119 (22.2) 218 (19.0) 142 (14.0) <.001b,c ≥ daily 2218 (82.2) 416 (77.8) 932 (81.0) 870 (86.0) form(s) of cannabis consumed cannabis, a publication of the research society on marijuana 142 flower 1399 (51.9) 424 (79.3) 669 (58.2) 306 (30.2) <.001a,b,c oral preparation 2298 (85.2) 398 (74.4) 977 (85.0) 923 (91.2) <.001a,b,c vape pen / cartridge 709 (26.3) 226 (42.2) 335 (29.1) 148 (14.6) <.001a,b,c > 1 form 1271 (47.1) 372 (69.5) 616 (53.6) 283 (28.0) <.001a,b,c flower products (n = 1399) average daily dose per use (dried weight) <1 gram 758 (54.2) 210 (49.3) 364 (54.4) 184 (60.1) .021d 1-2 grams 422 (30.2) 149 (35.1) 190 (28.4) 83 (27.1) ≥ 3 grams 219 (15.7) 65 (15.3) 115 (17.2) 39 (12.7) cannabinoid constituents of preferred flower high thc, low cbd 821 (58.7) 227 (53.5) 386 (57.7) 208 (68.0) .003c 1:1 ratio (thc:cbd) 257 (18.4) 98 (23.1) 119 (17.8) 40 (13.1) low thc, high cbd 134 (9.6) 44 (10.4) 68 (10.2) 23 (7.5) no preference 186 (13.3) 55 (13.0) 96 (14.3) 35 (11.4) oral products (n = 2298) cannabinoid constituents of most used oral product high thc, low cbd 532 (23.2) 84 (21.1) 255 (26.1) 193 (20.9) .010b 1:1 ratio (thc:cbd) 434 (18.9) 80 (20.1) 194 (19.9) 160 (17.3) low thc, high cbd 1332 (58.0) 234 (58.8) 528 (54.0) 570 (61.8) vape products (n = 709) preferred vape product cannabinoid constituents high thc, low cbd 373 (52.6) 109 (48.2) 168 (50.1) 96 (64.9) .011b,c 1:1 ratio (thc:cbd) 176 (24.8) 66 (29.2) 88 (26.2) 22 (14.9) low thc, high cbd 70 (9.9) 18 (8.0) 36 (10.7) 16 (10.8) no preference 90 (12.7) 33 (14.6) 43 (12.8) 14 (9.5) note. 1sample is reduced by n = 20 for gender abonferroni-adjusted p-value <.05 for <40 vs. 41-60 years bbonferroni-adjusted p-value <.05 for 41-60 vs. >60 years cbonferroni-adjusted p-value <.05 for <40 vs. >60 years d≤40 vs. >60 no longer significant after bonferroni correction (p = .052) the majority of those who used flower (n = 821; 58.7%) preferred high thc/low cbd cannabinoid profiles. significantly fewer people in the youngest group preferred high thc flower relative to the oldest group, (table 3). the youngest group favored dried flower with a similar ratio of thc to cbd relative to the older group. similar age-related preferences for high thc/low cbd (oldest group) and equal amounts thc to cbd (youngest group) were recorded for vape products (table 3). in contrast to preferred flower and vape product major cannabinoid ratios, the most used oral products had high cbd/low thc cannabinoid profiles, reported by 58.0% of eligible respondents (n = 2298). here, preference for high cbd/low thc products was lowest in the middle age group (54.0%) and highest in the oldest group (61.8%). cannabis use patterns and preferences by gender are presented in supplementary table s4. prescription drug use among all patients who reported past-year prescribed opioid use (n = 452), the most common opioid was oxycodone (42.9%). more than half of these patients (n = 270; 59.7%) reported attempting to use cannabis to reduce prescription opioid use, either self-guided (45.1%) or under the guidance of their healthcare provider (14.6%), with no age-related differences (data not shown). overall, 53.8% (n = 243) reported a decrease in prescription opioid use over the past year. selfreported changes in prescription opioid use (increase, decrease, stable) over the past year did not differ by age group (table 4). among all patients who reported past-year prescribed non-opioid pharmaceutical use (n = 1182), the most common drugs were naproxen (7.2%), acetaminophen (7.0%) and gabapentin (6.9%). overall, 32.4% (n = 383) reported decreasing their use over the last 12 months, 5.8% age-related patterns of medical cannabis use 143 (n = 69) reported an increase in use, and 61.8% (n = 730) reported no change in use. self-reported changes in prescription non-opioid use (increase, decrease, stable) over the past year did not differ by age group (table 4). past-year change in prescription opioids and non-opioids by gender are presented in supplementary table s5. table 4. past-year change in prescription opioids and non-opioids by age group. past-year perceived change in use n (%) age group p-value ≤ 40 41-60 >60 opioids1 (n = 452) increased 27 (6.0) 7 (9.7) 11 (4.8) 9 (6.0) .563 decreased 243 (53.8) 40 (55.5) 123 (53.5) 80 (53.3) no change 182 (40.3) 25 (34.7) 96 (41.7) 61 (40.7) non-opioids2 (n =1182) increased 69 (5.8) 16 (8.1) 30 (5.9) 23 (4.9) .323 decreased 383 (32.4) 69 (34.8) 169 (33.1) 145 (30.7) no change 730 (61.8) 113 (57.1) 312 (61.1) 305 (64.5) illicit substances3 (n = 110) increased 6 (5.5) 2 (4.7) 3 (6.4) 1 (5.0) .8964 decreased 54 (49.1) 23 (53.5) 23 (48.9) 8 (40.0) no change 50 (45.5) 18 (41.9) 21 (44.7) 11 (55.0) alcohol (n = 1451) increased 132 (9.1) 26 (9.5) 67 (11.0) 39 (6.9) <.001a,b,c decreased 551 (38.0) 135 (49.1) 234 (38.3) 182 (32.2) no change 768 (52.9) 114 (41.5) 310 (50.7) 344 (60.9) tobacco (n = 850) increased 36 (4.2) 6 (4.2) 22 (5.6) 8 (2.6) <.001a,c decreased 202 (23.8) 52 (36.1) 93 (23.7) 57 (18.2) no change 612 (72.0) 86 (59.7) 278 (70.7) 248 (79.2) note. 1most common prescribed opioids: (1) oxycodone, n = 194 (42.9%), (2) hydromorphone, n = 114 (25.2%), (3) tramadol, n = 94 (20.8%), (4) codeine, n = 85 (18.4%), (5) morphine, n = 44 (9.7%) 2most common prescribed non-opioids: (1) naproxen/naproxen-containing, n = 85 (7.2%), (2) acetaminophen/acetaminophen-containing, n = 83 (7.0%), (3) gabapentin, n = 81 (6.9%), (4) ibuprofen/ibuprofen-containing, n = 63 (5.3%), (5) pregabalin, n = 56 (4.7 %) 3most common illicit substances: (1) psilocybin, n = 57 (51.8%), (2) cocaine/crack, n = 53 (48.2%), (3) lsd, n = 31 (28.2%), (4) mdma, n = 23 (20.9%), (5) amphetamines, n = 12 (10.9%) alcohol, tobacco, and unregulated substances alcohol use was prevalent in this population, with 53.8% (n = 1451) respondents reporting lifetime use of alcohol. of these, 38% (n = 551) reported a reduction in alcohol use in the past year, 9.1% (n = 132) reported increased use, and 52.9% (n = 768) reported no change. the proportion of respondents reporting a reduction in alcohol use decreased significantly with age (≤40: 49.1%; 41-60: 38.3%; >60: 32.2%; table 4). additionally, 31.5% (n = 850) respondents reported lifetime use of tobacco or nicotine, with 23.8% (n = 202) reporting a decrease in use in the past year. similar to alcohol, the proportion of respondents reporting a reduction in use decreased significantly with age (≤40: 36.1%; 4160: 23.7%; >60: 18.2%). only 4.1% (n = 110) respondents reported lifetime use of unregulated substances, of whom 49% (n = 54) reported a reduction in use over the past year. no age-related differences in past-year changes in unregulated substance use were apparent. discussion the present report summarizes results of the 2021 ccps, which is the fourth such survey since 2015. compared to previous ccps years, we report a higher proportion of female respondents, reflecting a trend of increasing female cannabis, a publication of the research society on marijuana 144 participation in this biannual survey, from 27% in 2015 (lucas & walsh, 2017), 37% in 2017 (baron et al., 2018), and 45% in 2019 (data not published) to 49% in the present report. nevertheless, males still comprised a slight majority of respondents, despite a slight majority of females in the overall canadian population (statistics canada, 2022). health canada does not publish data on gender distribution in the federal medical cannabis program, so we were not able to compare the representation of female participants in ccps since 2015 to representation in the federal program, but we have found that underrepresentation of women among cannabis survey participants is consistent with other published study publications examining a similar cohort, including a 2020 survey of patients from another canadian licensed producer (42% females) (cahill et al., 2021), a 2014 survey of patients in ontario (43.8% females) (hamilton et al., 2017), and a 2016 survey of cannabis users in the us, uk, and canada (45.4% females) (sexton et al., 2016). the observed trend of increasing age of ccps survey respondents since 2015 is consistent with other studies of medical cannabis populations in canada and other jurisdictions in the published literature. for example, in a 2013-2016 survey of 1,429 subjects in the us, uk, and canada who had used cannabis within the last 90 days, the average age was 36.3 years (sexton et al., 2016), while in a more recent survey of 214 canadian authorized patients registered with a licensed producer, the average age was 50.7 years (cahill et al., 2021). we would expect this aging trend in medical cannabis patients in canada and around the world to continue as the stigma around medical cannabis diminishes and its therapeutic use is increasingly normalized. in the present study, chronic pain, arthritis, and anxiety were the top three primary illnesses for which medical cannabis was sought, consistent with previous studies (kaufmann et al., 2020; kosiba et al., 2019; yang et al., 2021). chronic pain is associated with sleep disturbances (ostovar-kermani et al., 2020) and mood disorders (meints & edwards, 2018), and pain, anxiety, and insomnia were the top three symptoms for which medical cannabis was used. thus, our findings are consistent with an older population of medical cannabis users who are primarily dealing with pain-related illnesses. this is further supported by age-related analyses. compared to other age categories, more patients aged 41 to 60 reported using medical cannabis to treat chronic pain, and more patients aged over 60 reported using medical cannabis to treat arthritis. on the other hand, more patients aged 40 and under reported using medical cannabis to treat anxiety as a primary illness, and insomnia, stress, and depression/low mood as primary symptoms. older age groups reported a lower perceived effectiveness of medical cannabis. the observed difference may be attributed to variations in the primary illness and symptoms treated or their severity status. for example, among patientreported primary illnesses, medical cannabis use for arthritis showed a significant increase with age, whereas usage for anxiety notably decreased. moreover, there was a significant difference in the primary symptoms treated with medical cannabis among all age groups: pain emerged as the most frequently treated symptom among the oldest age group, while anxiety, insomnia/sleep disorders, stress, and depression/mood disorders were the most commonly treated symptoms among the youngest age group. preferred routes of administration for medical cannabis also reflected additional age-related patterns of use. for example, 81.6% of patients over 60 years preferred oral formulations compared to 40.6% of patients 40 years and under. interestingly, the preferred ratio of active ingredients thc and cbd showed clear distinctions between oral versus inhalational routes of administration that were independent of age. patients using oral formulations tended to prefer high cbd and low thc concentrations for these formulations, while those using inhalational formulations (flower and vape products) tended to prefer low cbd and high thc concentrations for these products. inhalation causes a more rapid onset of effects and shorter duration time, while orally ingested cannabis products cause a slower onset of effects, but these effects last much longer than inhalation (huestis, 2007). patients favouring an inhaled high thc product may be seeking a faster onset and offset of action— perhaps for acute conditions needing rapid relief like an anxiety attack, insomnia, or flare-up of symptoms associated with their primary illness (e.g., pain, inflammation, muscle spasms)—while those preferring oral cbd-dominant products may want a longer symptom relief, as is the case age-related patterns of medical cannabis use 145 with many chronic pain treatments and the respective age group prevalence. the increased preference for oral methods of administration and, by extension, high cbd formulations among older patients reflects a pattern observed in the general population of cannabis-consuming canadians (statistics canada, 2019) and may be due to several factors. older individuals are more likely to suffer from health conditions for which cbd has received increased attention as a potential therapeutic agent that does not cause the impairing effects of thc (bhaskar et al., 2021; yang et al., 2021). this may be particularly attractive to older individuals that have traditionally reported a higher risk perception of cannabis compared to younger consumers (pacek et al., 2015). another interesting finding is that older patients had the highest preference in high thc / low cbd products for flower and vape. some possible reasons may be related to the type of illness being treated or more severe symptoms that require a higher dose of thc, when the inhalation route if chosen. also, since the oldest age group is least likely to use inhalation products and those that use oral products don't seem to prefer high thc more than the other age groups, this might actually indicate that there is an unmeasured difference between older adults who do choose to use inhalation products and other older adults that comprise the rest of the sample. it's possible that the use of inhalation products despite their older age indicates a higher risk population that may require particular attention. among respondents who reported using prescription opioids (most of whom were older patients), a majority reported an intention on their part to reduce opioid use, which is consistent with previous ccps results (baron et al., 2018; lucas & walsh, 2017). shi et al. found evidence for reduced use of schedule iii prescription opioids following legalization of recreational cannabis in a number of us states, suggesting the possibility that increased access to legal cannabis facilitates uptake of cannabis in favor of prescription opioids (shi et al., 2019). using medical cannabis as a substitute for opioids has been documented previously in survey-based research. for example, in a 2013-2014 crosssectional survey of 244 medical cannabis patients who patronized a dispensary in michigan, boehnke et al. reported a 64% decrease in opioid use (boehnke et al., 2016). because most evidence for reductions in opioid use with cannabis use comes from observational studies and surveys, evidence of a causal association is lacking. nevertheless, findings of reductions in opioid overdose fatalities (livingston et al., 2017) and dispensing of pharmaceuticals (liang et al., 2018) associated with increased access to regulated cannabis has generated a promising signal of possible public health impacts of medical cannabis legalization on opioid use, possibly influencing healthcare providers seeking alternatives to opioids in the treatment of pain-causing conditions. indeed, about 15% of respondents reported that their healthcare provider had recommended and/or supported tapering prescription opioids with medical cannabis. previous studies have reported reductions in the use of prescription non-opioid pain medications (baron et al., 2018; lucas & walsh, 2017), unregulated drugs (socías et al., 2017), alcohol (lucas et al., 2019), and tobacco (lucas et al., 2021) concurrent with cannabis use. in the present study, 32.4% of patients taking prescription non-opioid pain medications reported a decrease in use of these medications concurrent with medical cannabis use, and age-related patterns were similar to those for prescription opioids. in regards to non-pharmaceutical substance use, over half of respondents reported using alcohol concurrent with medical cannabis, and 38% of these reported a decrease in alcohol consumption, which is consistent with the results of ccps 2019, in which 44% (n=419) of those that identified past alcohol use saw a reduction following medical cannabis initiation (lucas et al., 2020). approximately one-third of patients reported using tobacco and/or nicotine, and 24% of those saw decreases in use, while 72% of these reported no change in their use. in contrast, lucas et al. found that 49% of medical cannabis patients who used tobacco and/or nicotine reported reductions in use concurrent with medical cannabis use (lucas et al., 2021). it is notable that decreases in both alcohol and tobacco/nicotine use were significantly more prominent in the youngest group of patients, which may have resulted from reduced opportunities to socialize in person due to covid-19, a phenomenon that cannabis, a publication of the research society on marijuana 146 would likely have the highest impact on younger respondents. given the significant rates of morbidity and mortality associated with both alcohol and/or tobacco/nicotine use in canada and around the globe, the 38% of respondents that reported declines in alcohol use and the nearly one-quarter of patients using tobacco/nicotine that reported a reduction in use in the present study may represent a significant public health impact. only a small percentage of survey participants reported using unregulated substances; however, among these patients almost half reported a reduction in the use of unregulated substances post medical cannabis initiation, while another 48% reported no change, and only 3% reported an increase in use. with so few patients reporting increases or initiation of use, our data suggests that transitions towards higher risk substance use patterns are unlikely to be exacerbated by the use of medical cannabis. overall, our results highlight that older patients represent an increasingly important subset of the medical cannabis population whose unique needs and patterns of use warrant further investigation. limitations of this study include restricting the population to patients registered with tilray as their provider of medical cannabis. while this was a national sample, it may have yielded data not representative of the broader population of medical cannabis patients in canada. however, tilray is a national licensed producer, and the geographic distribution of survey respondents closely corresponds with health canada’s national medical cannabis patient database for the same period (health canada, 2023; data on cannabis for medical purposes canada.ca, n.d.). since this sample was drawn from patients registered with a medical cannabis company, participants may be more likely to report positive effects related to the medical use of cannabis. additionally, all health information and substance use data was self-reported, and did not benefit from biological confirmation of medical conditions, symptoms, or substance use or abstinence, this data is vulnerable to recall bias, socially desirable responding, and other biases associated with self-report retrospective surveys. social policy changes and the covid-19 pandemic may have also impacted patient patterns of use as well as some of the outcomes of this study. since the non-medical adult use of cannabis was legalized in canada prior to this survey, and as there are many regulated and unregulated sources of cannabis available to canadian patients, it is possible that some participants used sources of cannabis other than those accounted for in this study. finally, the study was not completely anonymous, as the voluntary provision of a patient number at the end of the survey was needed for respondents wishing to be entered into a draw. however, this information was collected separately from the actual survey responses, and never associated with other survey data, and was therefore not expected to compromise confidentiality/anonymity, bias recruitment, or impact the results of the study. these limitations are counterbalanced by the large sample size and confirmation that respondents were federally authorized cannabis patients using under the guidance and/or oversight of a health care practitioner. conclusion in conclusion, the results of this crosssectional survey of canadian authorized medical cannabis patients indicate that older patients represent a growing subset of this population, with patterns of use that differ from those of younger patients. older patients were more likely to use medical cannabis to treat conditions related to chronic pain, while younger patients were more likely to use it to treat mood disorders and symptoms such as anxiety and depression. older patients preferred oral routes of administration with high cbd and low thc concentrations, while younger patients preferred inhalational formulations with high thc and low cbd concentrations. use of medical cannabis was associated with symptom improvement and meaningful reductions in the use of prescription opioids and non-opioids, unregulated drugs, alcohol, and tobacco. as cannabis becomes more normalized as a treatment option, it will be important to track changes in primary patient characteristics and associated patterns of use. the present findings may help inform potential treatment decisions by patients and health care providers in regards to medical cannabis use, and suggest that patient characteristics such as gender and age may impact patterns of use, and associated treatment adherence and outcomes. in age-related patterns of medical cannabis use 147 light of our findings and other observational studies suggesting that older patients are increasingly using cannabis for therapeutic purposes, further research is warranted to assess the therapeutic potential of various cannabisbased treatments in participants of 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(2021), cannabis: an emerging treatment for common symptoms age-related patterns of medical cannabis use 149 in older adults. journal of the american geriatrics society, 69, 9197. https://doi.org/10.1111/jgs.16833 funding and acknowledgements: tilray brands, inc. is the sponsor of this study and has provided funding for this study, including study design, data collection, and some of the data analysis and writing the manuscript. mw, pl, and jt own stock in tilray brands, inc. which may serve to gain financially, now or in the future, from publication of the manuscript. mw and jt receive salary from tilray brands, inc., which may serve to gain financially, now or in the future, from publication of the manuscript. sl has no conflict to declare. the authors would like to sincerely thank the thousands of patients who shared their experiences with medical cannabis with us by filling out this survey. additionally, we dedicate this paper to lead author mariah walker phd, who unfortunately did not live to see this paper published, but whose profound commitment to helping patients and contributing to academic research forms the foundation of this publication. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 105 ved abstract introduction: we examined whether the dualistic model of passion (dmp; i.e., obsessive passion [op] and harmonious passion [hp]) for cannabis use was prospectively associated with cannabis use and use-related outcomes, and with academic performance, relationship attachment style, and social connectedness among college students. we also explored whether the dmp was associated with outcomes when included in a model using established constructs (e.g., coping motives, refusal self-efficacy, cannabis use disorder [cud] symptoms) as predictors of cannabis use and outcomes. methods: using a longitudinal cohort design (baseline, 5-month, 10-month [timepoints chosen to better correspond to 9-month academic year]), 513 undergraduate students from two universities who reported using cannabis at least four times in the past month completed a baseline survey (308 meeting criteria for cud). we used generalized estimating equations to assess longitudinal associations between op/hp and cannabis use and academic/social outcomes at 5-month and 10-month. results: at baseline, participants were young adults (mean age = 20.57, sd = 2.51), 78.8% non-hispanic, 83.8% white, 55.0% female, and 72.3% heterosexual. greater hp was not associated with greater past month cannabis use or cannabis-related problems. greater op was associated with greater past month cannabis use and more cannabis-related problems. there were no significant passion by time interactions. greater hp was associated with more anxious attachment. op was associated with less social connection. conclusion: this research suggests that the dmp provides novel information about factors associated with cannabis use and use-related consequences, which can aid in our understanding of cannabis use, misuse, and cud among college students. key words: = cannabis; harmonious passion; obsessive passion; cannabis use disorder; college students cannabis is the most frequently consumed federally illicit substance in the united states (u.s.) and other countries (johnston et al., 2022; united nations office on drugs and crime, 2022). alan k. davis1,2, brooke j. arterberry2,3, yitong xin1, sterling m. hubbard3, corrine m. schwarting3, and erin e. bonar4,5,6 1 center for psychedelic drug research and education, college of social work, the ohio state university. columbus, oh usa 2 institute for population research, university of michigan, ann arbor, mi usa 3 department of psychology, iowa state university, ames, ia usa 4 university of michigan – department of psychiatry; ann arbor, mi, usa. 5 university of michigan – addiction center; ann arbor, mi, usa 6 university of michigan – injury prevention center; ann arbor, mi, usa. cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000180 incremental predictive validity of the dualistic model of passion for cannabis use among college undergraduate students with and without a cannabis use disorder corresponding author: alan k davis, ph.d. college of social work, the ohio state university. 1947 college road, columbus ohio, 43210. telephone: 614-292-5251. email: davis.5996@osu.edu. cannabis, a publication of the research society on marijuana 106 although cannabis use has benefits for several health conditions (e.g., chronic pain, multiple sclerosis; national academies of sciences, engineering, and medicine, 2017), frequent use is also associated with consequences (volkow et al., 2016) including increased risk the development of cannabis use disorder (cud; american psychiatric association, 2013; connor et al., 2021). as of 2020, cannabis use prevalence was 42% of young adults in the last 12 months, 27% in the last 30 days, and 9.8% using daily or neardaily use in the u.s. (schulenberg, 2021). among college students in the u.s., lifetime prevalence of cud is 9%; for those who report past-year consumption of cannabis, lifetime cud prevalence rises to 25% (arterberry et al., 2019; caldeira et al., 2008). symptoms of cud include craving, difficulty controlling use, tolerance, withdrawal, interference with everyday life, and continued use despite physical or psychosocial impairments (american psychiatric association, 2013). short and long-term consequences associated with cud include psychosocial and physical consequences such as memory loss, interpersonal conflict, academic and occupational interference, reduced self-care, anxious/depressed mood, impaired driving ability, myocardial infarction, impaired brain connectivity, and chronic bronchitis (patel & marwaha, 2022; pearson, 2019; simmons et al., 2022; simons et al., 2012; volkow et al., 2016). college students also are at risk for experiencing academic disruptions such as missing more classes and gradual gpa decline over time (arria et al.,2015; pritschmann, et al., 2022). therefore, understanding ways to engage college students in preventative interventions could help decrease the risk of problematic cannabis use and associated problems (e.g., academic performance), but there is little evidence for reduction in frequency of cannabis use or cud symptoms among young adults despite intervention (halladay et al., 2019; o’connor et al., 2020). for example, a review conducted by o’connor et al. (2020) found that interventions were not significantly associated with cannabis use outcomes in this population (standeven et al., 2020). therefore, there is a critical need for more research to better understand how to engage college students in addressing their cannabis misuse and cud. given the limited efficacy and adherence to current cud preventative interventions (halladay et al., 2019; o’connor et al., 2020), it is likely that several barriers exist that may limit students’ cud treatment initiation and engagement (e.g., access/availability of treatment, stigma). for example, a key barrier could be stigma associated with the pathological language that professionals or programs have used to describe cannabis misuse (e.g., words like “abuse” and “addiction”). moreover, this language may not reflect students’ typical language when describing their own cannabis use or associated behaviors, values, and perspectives. this discrepancy could hinder students’ willingness to seek out treatment, engage in meaningful recovery efforts, or achieve an abstinence or reduction goal. therefore, a deeper understanding of how best to approach the language of cannabis use and associated consequences among college students could improve preventative interventions designed to meet students’ needs, attract them into cud care, and increase treatment retention. the dualistic model of passion (dmp) of cannabis use is a conceptual model that could help address this goal because it can elucidate key components in understanding one’s relationship with cannabis use. according to the dmp (vallerand et al., 2003), it is more likely for individuals to develop passion for an activity when they devote more time and energy to engaging in it. there are two types of passion hypothesized in the dmp, harmonious passion (hp) and obsessive passion (op). hp refers to a relationship with an activity that enhances and is well integrated in one’s life. conversely, op refers to a relationship with an activity that has become so compelling that it causes conflicts with other activities or creates dissonance between the activity and one’s values. the dmp was first applied to behaviors such as gambling (ratelle et al., 2004; rousseau et al., 2002), gaming (lafreniere et al., 2009; stoeber et al., 2011; wang & chu, 2007), and pornography (rosenberg & kraus, 2014). in this prior research, greater hp was typically associated with positive outcomes (e.g., positive affect, life satisfaction) and sometimes positively related to frequency of addictive behaviors. in contrast, greater op was typically associated with negative outcomes (e.g., frequency and duration of behavioral engagement, negative affect, behavior-related passion for cannabis use among college students 107 consequences) and unrelated to life satisfaction (lafreniere et al., 2009; ratelle et al., 2004; rosenberg & kraus, 2014; rousseau et al., 2002; stoeber et al., 2011; wang & chu, 2007). in terms of cannabis use, prior studies have shown differential associations between cannabis use and related consequences and op (e.g., greater cannabis use, more consequences) and hp (e.g., greater cannabis use, fewer consequences; davis, 2017; davis et al., 2018; steers et al., 2015). additionally, findings have shown op for cannabis use had a stronger relationship with frequency of cannabis use and associated consequences compared to cannabis use motives (refers to reasons or motivations for an individual's decision to use cannabis) and refusal self-efficacy (refers to participants’ confidence in their ability to refuse offers of cannabis in various contexts; davis, 2017; davis & arterberry, 2019). given limited evidence in support of current treatments in this population (halladay et al., 2019; o’connor et al., 2020), it is possible that these treatments may be more acceptable if the dmp were incorporated into them, because it uses language about cannabis use that avoids pathologizing words (e.g., risky, abuse, addict, addiction), and instead discusses cannabis use in terms of how well one’s relationship with cannabis fits into their lives. however, research examining the dmp is limited by cross-sectional retrospective survey designs. therefore, prospective research is needed to understand the predictive validity of the dmp on cannabis use to inform treatment development. prospective research might also be able to explore whether passion for cannabis use changes over time, which could occur with repeated exposure to the drug and exposure to potential consequences of use, which has yet to be explored. college students who misuse cannabis might also have other characteristics such as relationship style and social connections that related to their ability or desire to engage in preventative interventions. for example, one’s attachment style (e.g., anxious or avoidant) has been associated with substance misuse and use disorder (dassa et al., 2013; kpelly et al., 2022) and cannabis use (schindler et al., 2009). because passion could be described as a relationship to cannabis use and how well that relationship fits into one’s life, it is possible that college students with more anxious forms of attachment and less social connection may be more at risk for developing op compared to those with more secure connections. however, there has been no research examining attachment style and social connection in relation to passion for cannabis use, which could advance understanding of the construct validity of the dmp. we designed the current study to explore the predictive validity of dmp by using a longitudinal cohort of undergraduate college students who completed assessments at three timepoints. we address three main aims in this paper: aim 1) we evaluate the dmp as a predictor of future cannabis use and use-related consequences, aim 2) we examine whether passion for cannabis use is prospectively associated with academic performance, relationship attachment style, and social connectedness, and aim 3) we examine whether the dmp is associated with cannabis use and related consequences while accounting for other use-related variables, such as coping motives and cannabis refusal self-efficacy. because of the associations between cannabis use and demographics, such as sex, gender, race, ethnicity, and socioeconomic status (greaves & hemsing, 2020; mccabe et al., 2007; patrick et al., 2012), we included these as control variables in this study. methods participants and procedure using a longitudinal cohort design, we collected data separately from two midwestern institutions. neither institution was in a state with recreational cannabis laws, while site 1 was located in a state with medical cannabis laws. this study was approved by irbs at the two sites, and both received a certificate of confidentiality from the national institutes of health. baseline assessments were administered from november 2020 through january 2021; 5-month follow-up occurred from march 2021 to june 2021; and 10month follow-up occurred from august 2021 to november 2021. the university registrar either provided email addresses from a random sample of undergraduate students (site 1), or sent emails to all undergraduates for recruitment (site 2). the email invited students to the study and provided a link to an informed consent page and eligible screening survey. inclusion criteria for the study were to 1) be 18 years or older, 2) be able to read, cannabis, a publication of the research society on marijuana 108 write, and speak english fluently, 3) be a college undergraduate student, 4) have used cannabis flower at least 4 times in the past month, and 5) ~50% of participants at each institution who met criteria for cud and 50% of participants who did not meet criteria for cud. after completing the screening questionnaire, we invited eligible participants to participate in the follow-up phase of the study via email with a secure web-based survey link. at baseline, 5-month, and 10-month followups, participants were asked to complete a series of online questionnaires. participants received a $25 incentive for completing the baseline questionnaires, another $25 for the 5-month assessment, and $40 for the 10-month assessment. the target enrollment for this study was 300 participants from site 1 and 300 participants from site 2. in total, 47,726 undergraduate students at the two study sites were emailed the screening link and 2,174 viewed the email, clicked a link to the online study, and completed the screening survey. there were 617 students that did not meet inclusion criteria. a total of 1,220 (930 that met criteria for cud and 290 that did not meet criteria for cud) were sent the baseline survey, with 578 who subsequently enrolled in the study (96.3% of the target enrollment). a total of 513 students completed the entire baseline survey (cud=308; non-cud=205). of the 513 who enrolled, 431 participants completed the 5-month follow-up survey, and 434 participants completed the 10month follow-up survey. the retention rate was 84.0% at 5-month and 84.6% at 10-month. participants that were enrolled in college at baseline were included in these analyses. bivariate analyses indicated there were no significant differences in sociodemographic characteristics between those lost to follow-up vs. those who stayed in the study with one exception, baseline gpa was lower among those that were lost at follow-up (p=.02). those that were lost at follow-up had greater baseline obsessive passion (p = .02) and lower baseline social connectedness (p = .01) than those that remained in the study. participants were young adults, mean age = 20.57 (sd = 2.51), 78.8% were non-hispanic white (see table 1), 55.0% reported their biological sex was female, 52.2% self-identified their gender identity as female, 72.3% self-identified as heterosexual, 51.8% reported a family household income greater than $100,000, 89.9% participants were enrolled in college full-time, and 80.7% reported a gpa higher than 3.0. measures cannabis use frequency. cannabis use frequency was measured by asking participants “how many times in the past month have you used cannabis flower?” responses were openended. cannabis harmonious and obsessive passion scale. this 13-item measure assessed the dmp, which differentiates hp (well-integrated with lifestyle) and op (conflicted with lifestyle) as it relates to recreational cannabis use (davis, 2017). the original measure was modified by changing the term “marijuana” to “cannabis”. participants reported how much they agree or disagree with each statement about their cannabis use (e.g., “using cannabis allows me to live memorable experiences” “i have almost an obsessive feeling for using cannabis”) on a 5-point likert scale ranging from 0 (strongly disagree) to 4 (completely agree). mean hp subscale (item 16) and mean op subscale (item 7-13) were calculated. internal consistency for each scale score was good. (hp: α’s range = .82-.86; op: α’s range = .90-.92; see supplemental table 1). brief marijuana consequences questionnaire (b-macq). the 21-item b-macq was included in this study to measure cannabis-related consequences (simons et al., 2012). participants were asked to select whether they experienced any consequences (e.g., “the quality of my work or schoolwork has suffered because of my cannabis use”) related to their cannabis use in the past 5months by indicating either yes (1) or no (0). internal consistency reliability of the total scale was good (α’s range= .85-.86; see supplemental table 1). experiences in close relationships relationship structure (ecr-rs). the 9-item ecr-rs assessed participants’ attachment style including anxious and avoidant dimensions. we used a general version of the scale as opposed to romantic, peer, or parental versions (fraley et al., 2011). participants were asked to rate the extent to which they believe each statement best described their feelings about close relationships (e.g., “it helps to turn to people in times of need,” “i often worry that other people do not really care for me”) on a 7-point likert scale ranging from 1 passion for cannabis use among college students 109 (strongly disagree) to 7 (strongly agree). internal consistency was adequate for both subscales (avoidance: α’s range = .78-.80; anxiety: α’s range = .87-.88; see supplemental table 1). cannabis use disorder (cud). based on the dsm-5, we included an 11-item list of symptoms to assess likely presence of a cud (american psychiatric association, 2013). participants were asked to report their cannabis use behaviors and related experiences in the past 12 months by answering yes (1) or no (0) through questions such as “in the last 12 months, i often used larger amounts of cannabis or used over a longer period than intended.” internal consistency was good: α = .81. modified cannabis refusal self-efficacy questionnaire (modified-crseq). the modified 3-item crseq was included in this study to measure participants’ confidence in their ability to refuse offers of cannabis in various contexts. modification included combining items from the original crseq measure (young et al., 2012) to assess how confident participants were they could resists offers of cannabis for emotional relief (e.g., “…you are feeling negative emotions [e.g., worried, sad, down, upset, restless]”), when they have the opportunity to use (e.g., “…you are around your friends [e.g., at a party, at a friend’s house, or hanging out]”), and for social facilitation (“…you are in new social situations [e.g., meeting people for the first time, wanting to feel confident or accepted in social situations]”). participants were asked to rate their confidence in refusing cannabis use on a 10-point scale ranging from 1 (not at all) to 10 (very). the social connectedness scale (scs). the 8item scs was measured participants’ degree of feeling connected to others in the social environment (lee & robbins, 1995). participants were asked to rate how much they agree or disagree with each statement (e.g., “i feel disconnected from the world around me”) on a 6point scale ranging from 0 (never true) to 5 (almost always true). internal consistency reliability was excellent (α’s range=.94-.95; see supplemental table 1). demographic information: participants were asked to report their age, gender identity, biological sex assigned at birth, race/ethnicity, family income (i.e., used as a proxy for socioeconomic status: ses), relationship status, education, gpa, college enrollment status, sexual orientation (identity, attraction, and behavior). table 1. demographic information of the sample at baseline, 5-months, and 10-months. baseline 5 months 10 months n % n % n % total sample size 513 431 434 site site 1 275 53.6% 241 55.9% 238 54.8% site 2 238 46.4% 190 44.1% 196 45.2% race/ethnicity non-hispanic, white 404 78.8% 344 79.8% 344 79.3% hispanic 36 7.0% 32 7.4% 30 6.9% other (includes other racial identities and multiple racial identities) 73 14.2% 55 12.8% 60 13.8% biological sex male 231 45.0% 187 43.4% 196 45.2% female 282 55.0% 244 56.6% 238 54.8% gender identity male 228 44.4% 183 42.5% 191 44.0% female 268 52.2% 230 53.4% 226 52.1% trans male 2 0.4% 1 0.2% 0 trans female 1 0.2% 0 0 0 non-binary 10 1.9% 11 2.6% 13 3.0% other 4 0.8% 6 1.4% 4 0.9% sexual orientation heterosexual 371 72.3% 304 70.5% 303 69.8% lesbian 15 2.9% 15 3.5% 14 3.2% cannabis, a publication of the research society on marijuana 110 gay 15 2.9% 14 3.2% 17 3.9% bisexual 94 18.3% 77 17.9% 80 18.4% pansexual 13 2.5% 16 3.7% 14 3.2% asexual 1 0.2% 2 0.5% 2 0.5% other 4 0.8% 3 0.7% 4 0.9% family income <$10,000-$99,999 247 48.2% 203 47.2% 215 49.4% $100,000 $149,999 138 27.0% 118 27.4% 116 26.7% >$150,000 126 24.7% 109 25.3% 103 23.7% college enrollment full-time 461 89.9% 376 87.2% 348 80.2% part-time 21 4.1% 26 6.0% 18 4.1% on break (e.g., summer) 30 5.8% 11 2.6% 1 0.2% graduated 1 0.2% 15 3.5% 58 13.4% dropped out 0 0 3 0.7% 9 2.1% grade point average 3.5 to 4.0 234 45.6% 209 48.6% 219 50.7% 3.0 to 3.4 180 35.1% 150 34.9% 146 33.8% 2.5 to 2.9 76 14.8% 55 12.8% 58 13.4% 2.0 to 2.4 17 3.3% 9 2.1% 7 1.6% 1.5 to 1.9 5 1.0% 6 1.4% 2 0.5% 1.0 to 1.4 1 0.2% 1 0.2% 0 0 note: participants’ age was on average 20.57(sd = 2.5) at baseline, 20.97(sd = 2.5) at five months, and 21.35(sd = 2.4) at ten months. ses=socioeconomic status. analytic strategy we calculated descriptive analyses of demographic and background characteristics (e.g., age, sex, race, gender identity, sexual orientation, school enrollment, gpa, family income; see table 1) and primary study variables (e.g., past month cannabis use, cud symptoms, cannabis use-related consequences, hp, op, social connectedness, attachment; see supplemental table 2). we compared demographic information differences between two sites and different timepoints using chi-square, see details in supplemental table 3. bivariate correlations with pearson correlation coefficients between primary study variables are presented in supplemental tables 4 and 5. we estimated generalized estimating equation (gee) models using sas 9.4 with a normal distribution, identity link, and first-degree autoregressive covariance structure to account for repeated measures within individuals. gee was used to account for autocorrelation and varying observations across individuals (zeger et al., 1988). gee models, unlike repeated measures anova, can utilize all available data and the population-average parameters are relatively robust to overdispersion that may occur (wang, 2014). we fit two models that included either hp or op as predictors for each outcome (frequency of cannabis use, cannabis problems, gpa, social connectedness, and attachment) controlling for site, cud symptoms at baseline, biological sex, race/ethnicity (e.g., non-hispanic white, hispanic, other), ses (e.g., <$10,000-$99,999; $100,000-$150,000, >$150,000), and past month cannabis use (i.e., cannabis problems models only). each model entered time (5-month and 10month follow-up) as a predictor to examine timevarying associations with outcomes. to do this, we centered and included baseline hp and op in the model as an interaction with time to examine these time-varying associations with outcomes (aim 1 and aim 2). for aim 3, we entered passion and the coping motives scale or crseq items (i.e., emotional relief, opportunistic, and social facilitation) into gee models separately to determine whether passion constructs would predict cannabis outcomes after controlling for site, past month cannabis use, cud symptoms at passion for cannabis use among college students 111 baseline, biological sex, race/ethnicity, and socioeconomic status after including coping motives/crseq scales in the model. we used a bonferroni correction p-value of .005 to determine significance due to multiple comparisons. results as supplemental table 2 shows, past month cannabis use frequency stayed relatively stable across time points, with the most frequent use reported at baseline (m = 19.97, sd = 20.18), 5month (m = 19.24, sd = 20.68), and 10-month (m = 18.69, sd = 20.93). the mean number of cannabis use-related consequences were also stable across time: baseline (m = 4.49; sd = 4.0), 5-month (m = 4.39, sd = 4.03), and 10-month (m = 4.24, sd = 4.07). aim 1: dmp as a predictor of cannabis outcomes all models controlled for biological sex, race/ethnicity, site, cud symptoms at baseline, and socioeconomic status (see table 2). greater baseline hp was not significantly associated with greater past month cannabis use or cannabisrelated problems. greater baseline op was associated with greater past month cannabis use overall (β = 9.01, se = 1.52, p < .001) and more cannabis-related problems overall (β = 2.53, se = 0.27, p < .001). there were no significant passion by time interactions. aim 2: dmp as predictor of gpa, social connectedness, and attachment all models controlled for biological sex, race/ethnicity, site, past month cannabis use, cud symptoms at baseline, and socioeconomic status (see table 3). greater hp was not significantly associated with more anxious attachment. op was associated with less social connection overall (β = -2.34, se = 0.51, p < .001), but not with anxious attachment. there were no significant time interactions. aim 3: passion, coping motives, and crseq associations with cannabis outcomes after controlling for biological sex, race/ethnicity, site, past month cannabis use, cud symptoms at baseline, and socioeconomic status, after including coping motives, hp was not associated with cannabis use overall (β = 1.72, se = 0.90, p = .055) or related consequences overall (β = .001, se = 0.23, p = .997; see table 4); however, coping motives were associated with more cannabis-related problems overall (β = 1.10, se = 0.24, p < .001). greater baseline op was associated with greater cannabis use overall (β = 9.09, se = 1.92, p < .001), but coping motives were not associated with overall cannabis use frequency (β = -0.03, se = 1.26, p = .979). although both greater op and coping motives were associated with more cannabis-related problems overall, op was associated with overall cannabisrelated problems at a greater magnitude than coping motives (op: β = 2.12, se = 0.29, p < .001; coping: β = 0.58, se = 0.24, p < .015). there were no significant time interactions. after controlling for biological sex, race/ethnicity, site, past month cannabis use, cud symptoms at baseline, and socioeconomic status, and after including the emotional relief item from the crseq, hp was not associated with cannabis outcomes (β = 2.01, se = 0.84, p = .017) see table 5); however, the emotional relief item was associated with fewer cannabis-related problems (β = -0.39, se = 0.07, p < .001). even after including the crseq emotional relief item, op was associated with greater cannabis use frequency (β = 9.11, se = 1.75, p < .001) and more cannabis-related problems (β = 2.07, se = 0.29, p < .001), while the emotional relief item was associated with fewer cannabis-related problems (β = -0.23, se = 0.07, p = 0.001). there were no significant time interactions. in table 6, after including the opportunistic item from the crseq, hp was not significantly associated with greater cannabis use frequency. although the opportunistic item was associated with fewer cannabis-related problems (β = -0.20, se = 0.06, p = .002), hp was not significantly associated with cannabis-related problems (β = 0.23, se = 0.21, p = .278). even after including the opportunistic item, op was associated with greater cannabis use frequency (β = 9.22, se = 1.79, p < .001) and more cannabis-related problems (β = 2.42, se = 0.27, p < .001). there were no significant time interactions. in table 7, after including the social facilitation item from the crseq, hp was not significantly associated with greater cannabis use frequency or cannabis-related problems. cannabis, a publication of the research society on marijuana 112 table 2. gee for relation between passion and cannabis outcomes at 5and 10-months. past month cannabis use cannabis-related problems β se 95% ci p-value β se 95% ci p-value harmonious passion hp 2.11 0.82 0.51 3.71 0.01 0.21 0.21 -0.19 0.62 0.297 time -0.53 0.44 -1.39 0.33 0.228 -0.10 0.09 -0.27 0.07 0.248 hp x time 0.44 0.35 -0.26 1.13 0.218 0.02 0.09 -0.16 0.19 0.860 past month cannabis use 0.03 0.01 0.02 0.04 <.001 site -5.68 1.55 -8.73 -2.64 <.001 0.89 0.28 0.34 1.44 0.002 baseline cud symptoms 8.35 1.44 5.52 11.18 <.001 2.96 0.28 2.42 3.50 <.001 sex -3.32 1.54 -6.35 -0.30 0.031 0.16 0.28 -0.38 0.70 0.564 race/ethnicity 1.69 1.74 -1.72 5.09 0.333 0.14 0.35 -0.55 0.84 0.684 ses -6.78 2.55 -11.78 -1.79 0.008 -0.25 0.42 -1.07 0.58 0.557 obsessive passion op 9.01 1.52 6.02 11.99 <.001 2.53 0.27 2.00 3.07 <.001 time -0.60 0.41 -1.40 0.21 0.147 -0.14 0.08 -0.29 0.02 0.086 op x time 0.17 0.64 -1.08 1.41 0.794 -0.19 0.11 -0.40 0.02 0.081 past month cannabis use 0.00 0.01 -0.01 0.01 0.971 site -6.45 1.38 -9.16 -3.74 <.001 0.55 0.22 0.11 0.99 0.014 baseline cud symptoms 2.61 1.28 0.11 5.12 0.041 1.73 0.24 1.26 2.21 <.001 sex -4.08 1.35 -6.73 -1.43 0.003 -0.06 0.22 -0.50 0.38 0.798 race/ethnicity 0.84 1.61 -2.32 4.00 0.601 -0.06 0.27 -0.60 0.47 0.812 ses -6.27 2.56 -11.30 -1.25 0.014 -0.19 0.42 -1.01 0.63 0.648 note. bold denotes significance at p<.005; cud = cannabis use disorder; ses=socioeconomic status; hp=harmonious passion; op = obsessive passion. race/ ethnicity coded as non-hispanic white vs. hispanic. socioeconomic staus coded as <$10,000-$99,000; $100,000-$150,000, >$150,000. passion for cannabis use among college students 113 table 3. gee for the relation between passion and gpa, social connectedness, and attachment at 5and 10-months. gpa social connectedness avoidant attachment anxious attachment β se 95% ci β se 95% ci β se 95% ci β se 95% ci harmonious passion hp 0.04 0.04 -0.04, 0.11 -1.08 0.54 -2.14, -0.02 0.48 0.41 -0.33, 1.29 0.77 0.28 0.22, 1.32 time -0.04 0.01 -0.07, -0.01 -0.20 0.18 -0.55, 0.14 -0.34 0.15 -0.62, -0.05 -0.15 0.11 -0.36, 0.06 hp x time -0.001 0.02 -0.03, 0.03 0.15 0.22 -0.27, 0.57 -0.27 0.17 -0.60, 0.07 -0.16 0.12 -0.40, 0.07 past month cannabis use 0.001 0.00 0.00, 0.00 0.01 0.01 -0.01, 0.04 0.01 0.01 -0.01, 0.02 0.00 0.01 -0.01, 0.01 site 0.29 0.07 0.15, 0.43 0.38 0.74 -1.08, 1.84 2.14 0.55 1.07, 3.21 -2.85 0.38 -3.61, -2.10 baseline cud symptoms 0.13 0.07 0.00, 0.26 -3.51 0.69 -4.87, -2.15 0.44 0.57 -0.67, 1.55 0.75 0.40 -0.03, 1.53 sex -0.02 0.08 -0.18, 0.14 -3.05 0.74 -4.50, -1.60 -0.22 0.55 -1.31, 0.86 2.86 0.38 2.12, 3.60 race/ethnicity -0.02 0.08 -0.18, 0.14 1.30 0.84 -0.34, 2.94 -0.29 0.66 -1.59, 1.00 0.72 0.39 -0.05, 1.49 ses -0.16 0.09 -0.34, 0.02 1.04 1.12 -1.15, 3.23 0.39 0.75 -1.08, 1.86 0.05 0.62 -1.16, 1.27 obsessive passion op 0.07 0.05 -0.02, 0.16 -2.34 0.51 -3.34, -1.34 0.69 0.43 -0.15, 1.52 0.72 0.31 0.11, 1.33 time -0.04 0.01 -0.07, -0.01 -0.17 0.17 -0.51, 0.17 -0.35 0.15 -0.63, -0.06 -0.16 0.11 -0.37, 0.05 op x time -0.004 0.02 -0.04, 0.03 0.29 0.19 -0.09, 0.66 -0.03 0.16 -0.33, 0.28 -0.05 0.12 -0.28, 0.18 past month cannabis use 0.001 0.00 0.00, 0.00 0.03 0.01 0.00, 0.06 0.00 0.01 -0.03, 0.02 -0.01 0.01 -0.02, 0.01 site 0.28 0.07 0.14, 0.42 0.65 0.73 -0.77, 2.08 2.05 0.54 0.99, 3.12 -2.94 0.38 -3.69, -2.19 baseline cud symptoms 0.11 0.07 -0.02, 0.23 -2.71 0.71 -4.10, -1.32 0.04 0.59 -1.12, 1.19 0.53 0.41 -0.27, 1.33 sex -0.03 0.08 -0.19, 0.13 -2.82 0.73 -4.24, -1.40 -0.29 0.55 -1.36, 0.78 2.77 0.38 2.03, 3.51 race/ethnicity -0.02 0.08 -0.18, 0.14 1.43 0.84 -0.21, 3.07 -0.37 0.65 -1.65, 0.91 0.68 0.40 -0.10, 1.46 ses -0.17 0.09 -0.35, 0.01 1.14 1.15 -1.12, 3.39 0.41 0.74 -1.03, 1.85 0.03 0.62 -1.18, 1.25 note: bold denotes significance at p<.005; hp=harmonious passion; op=obsessive passion, cud=cannabis use disorder; ses=socioeconomic status. race/ethnicity coded as non-hispanic white vs hispanic. socioeconomic status coded as <$10,000-$99,999; $100,000-$150,000, >$150,000. cannabis, a publication of the research society on marijuana 114 table 4. gee for the relation between passion, coping motives, and cannabis outcomes at 5and 10-months. past month cannabis use cannabis-related problems β se 95% ci p-value β se 95% ci p-value harmonious passion hp 1.72 0.90 -0.04 3.47 0.055 0.001 0.23 -0.45 0.45 0.997 time -0.56 0.44 -1.42 0.31 0.209 -0.07 0.08 -0.23 0.09 0.386 hp x time 0.40 0.40 -0.39 1.18 0.320 -0.03 0.10 -0.22 0.17 0.789 coping motives 1.80 1.17 -0.50 4.10 0.126 1.10 0.24 0.62 1.58 <.001 coping motives x time 0.11 0.53 -0.93 1.15 0.834 0.11 0.10 -0.09 0.31 0.277 past month cannabis use 0.02 0.01 0.01 0.04 <.001 site -5.70 1.56 -8.75 -2.64 <.001 0.79 0.26 0.29 1.29 0.002 baseline cud symptoms 7.07 1.49 4.16 9.99 <.001 2.21 0.27 1.69 2.73 <.001 sex -3.76 1.56 -6.82 -0.69 0.016 -0.16 0.26 -0.67 0.35 0.540 race/ethnicity 1.52 1.77 -1.95 4.99 0.390 0.09 0.33 -0.56 0.73 0.788 ses -6.54 2.63 -11.69 -1.38 0.013 0.07 0.34 -0.60 0.74 0.838 obsessive passion op 9.09 1.92 5.32 12.86 <.001 2.12 0.29 1.54 2.69 <.001 time -0.64 0.42 -1.47 0.19 0.130 -0.10 0.08 -0.25 0.05 0.183 op x time 0.32 0.83 -1.30 1.95 0.698 -0.21 0.12 -0.44 0.02 0.079 coping motives -0.03 1.26 -2.51 2.45 0.979 0.58 0.24 0.11 1.05 0.015 coping motives x time -0.31 0.58 -1.44 0.82 0.592 0.11 0.11 -0.10 0.32 0.292 past month cannabis use 0.00 0.01 -0.01 0.01 0.675 site -6.39 1.38 -9.10 -3.68 <.001 0.56 0.22 0.12 0.99 0.012 baseline cud symptoms 2.73 1.30 0.19 5.27 0.035 1.48 0.24 1.00 1.96 <.001 sex -3.95 1.35 -6.59 -1.31 0.003 -0.20 0.23 -0.64 0.24 0.380 race/ethnicity 0.79 1.61 -2.37 3.95 0.623 -0.05 0.28 -0.60 0.50 0.852 ses -6.51 2.62 -11.64 -1.37 0.013 0.03 0.35 -0.66 0.72 0.930 note.bold denotes significance at p<.005; cud = cannabis use disorder; ses=socioeconomic status; hp=harmonious passion; op=obsessive passion. race/ethnicity coded as non-hispanic white vs hispanic. socioeconomic status coded as <$10,000-$99,999; $100,000-$150,000, >$150,000. passion for cannabis use among college students 115 table 5. gee for the relation between passion, cannabis-refusal self-efficacy-emotional relief, and cannabis outcomes at 5and 10-months. past month cannabis use cannabis-related problems β se 95% ci p-value β se 95% ci p-value harmonious passion hp 2.01 0.84 0.36 3.66 0.017 0.10 0.21 -0.31 0.52 0.626 time -0.62 0.45 -1.50 0.25 0.163 -0.08 0.09 -0.25 0.09 0.352 hp x time 0.32 0.38 -0.43 1.06 0.407 0.03 0.09 -0.16 0.21 0.765 emotional relief -0.78 0.40 -1.57 0.01 0.052 -0.39 0.07 -0.53 -0.26 <.001 emotional relief x time -0.04 0.18 -0.39 0.32 0.845 0.05 0.03 -0.01 0.11 0.129 past month cannabis use 0.02 0.01 0.01 0.04 <.001 site -5.65 1.55 -8.68 -2.61 <.001 0.82 0.26 0.31 1.34 0.002 baseline cud symptoms 6.82 1.45 3.98 9.66 <.001 2.47 0.27 1.95 2.99 <.001 sex -3.59 1.53 -6.58 -0.59 0.019 0.05 0.26 -0.46 0.56 0.842 race/ethnicity 1.60 1.74 -1.82 5.02 0.359 0.13 0.34 -0.54 0.81 0.697 ses -6.87 2.60 -11.97 -1.77 0.008 -0.16 0.42 -0.99 0.67 0.699 obsessive passion op 9.11 1.75 5.69 12.54 <.001 2.07 0.29 1.50 2.63 <.001 time -0.67 0.42 -1.50 0.15 0.110 -0.11 0.08 -0.26 0.05 0.176 op x time 0.02 0.74 -1.43 1.47 0.979 -0.07 0.12 -0.30 0.16 0.526 emotional relief -0.01 0.40 -0.80 0.78 0.976 -0.23 0.07 -0.37 -0.09 0.001 emotional relief x time -0.08 0.18 -0.43 0.28 0.673 0.03 0.03 -0.03 0.10 0.348 past month cannabis use 0.00 0.01 -0.01 0.01 0.951 site -6.36 1.39 -9.09 -3.64 <.001 0.55 0.22 0.11 0.98 0.014 baseline cud symptoms 2.42 1.29 -0.11 4.95 0.061 1.59 0.24 1.12 2.06 <.001 sex -4.11 1.35 -6.76 -1.47 0.002 -0.09 0.22 -0.53 0.35 0.684 race/ethnicity 0.80 1.63 -2.38 3.99 0.622 -0.05 0.28 -0.60 0.50 0.866 ses -6.38 2.62 -11.51 -1.25 0.015 -0.09 0.41 -0.90 0.72 0.831 note. bold denotes significance at p<.005; cud=cannabis use disorder; ses=socioeconomic status; hp=harmonious passion; op=obsessive passion. race/ethnicity coded as non-hispanic white vs. hispanic. socioeconomic status coded as <$10,000-$99,999; $100,000-$150,000, >$150,000. cannabis, a publication of the research society on marijuana 116 table 6. gee for the relation between passion, cannabis-refusal self-efficacy-opportunistic, and cannabis outcomes at 5and 10-month. past month cannabis use cannabis-related problems β se 95% ci p-value β se 95% ci p-value harmonious passion hp 2.20 0.83 0.58 3.82 0.008 0.23 0.21 -0.18 0.63 0.278 time -0.61 0.45 -1.49 0.27 0.174 -0.07 0.08 -0.24 0.10 0.404 hp x time 0.22 0.38 -0.54 0.97 0.571 -0.02 0.09 -0.19 0.16 0.841 opportunistic -0.67 0.38 -1.41 0.07 0.074 -0.20 0.06 -0.33 -0.07 0.002 opportunistic x time -0.11 0.17 -0.44 0.23 0.538 -0.01 0.03 -0.07 0.05 0.669 past month cannabis use 0.03 0.01 0.01 0.04 <.001 site -5.58 1.54 -8.61 -2.56 <.001 0.85 0.27 0.32 1.38 0.002 baseline cud symptoms 6.71 1.44 3.90 9.53 <.001 2.58 0.27 2.05 3.11 <.001 sex -3.17 1.53 -6.17 -0.17 0.038 0.18 0.26 -0.34 0.70 0.492 race/ethnicity 1.65 1.74 -1.75 5.06 0.341 0.15 0.34 -0.53 0.82 0.668 ses -6.83 2.64 -12.02 -1.65 0.01 -0.15 0.41 -0.96 0.66 0.715 obsessive passion op 9.22 1.79 5.70 12.73 <.001 2.42 0.27 1.88 2.95 <.001 time -0.68 0.42 -1.51 0.15 0.110 -0.10 0.08 -0.26 0.05 0.178 op x time -0.13 0.78 -1.65 1.39 0.868 -0.21 0.11 -0.42 0.01 0.059 opportunistic -0.02 0.42 -0.84 0.79 0.955 -0.05 0.06 -0.16 0.07 0.444 opportunistic x time -0.16 0.19 -0.53 0.20 0.378 -0.04 0.03 -0.10 0.02 0.158 past month cannabis use 0.00 0.01 -0.01 0.01 0.913 site -6.33 1.39 -9.05 -3.61 <.001 0.55 0.22 0.11 0.98 0.013 baseline cud symptoms 2.15 1.30 -0.39 4.69 0.097 1.59 0.24 1.12 2.06 <.001 sex -3.99 1.36 -6.66 -1.31 0.004 -0.03 0.22 -0.47 0.41 0.903 race/ethnicity 0.84 1.62 -2.34 4.02 0.605 -0.05 0.27 -0.58 0.49 0.865 ses -6.40 2.66 -11.61 -1.19 0.016 -0.10 0.42 -0.91 0.72 0.817 note: bold denotes significance at p<.01; cud=cannabis use disorder; ses=socioeconomic status; hp=harmonious passion; op=obsessive passion. race/ethnicity coded as non-hispanic white vs hispanic. socioeconomic status coded as <10,000-99,999; 100,000-150,000, >150,000. passion for cannabis use among college students 117 table 7. gee for the relation between passion, cannabis-refusal self-efficacy-social facilitation, and cannabis outcomes at 5and 10-month. past month cannabis use cannabis-related problems β se 95% ci p-value β se 95% ci pvalue harmonious passion hp 2.22 0.85 0.56 3.89 0.009 0.19 0.21 -0.22 0.60 0.371 time -0.60 0.45 -1.47 0.28 0.181 -0.07 0.09 -0.23 0.10 0.441 hp x time 0.24 0.38 -0.50 0.98 0.528 -0.01 0.09 -0.19 0.17 0.933 social facilitation -0.37 0.42 -1.19 0.45 0.375 -0.22 0.07 -0.36 -0.08 0.003 social facilitation x time -0.16 0.18 -0.51 0.19 0.378 -0.01 0.03 -0.07 0.06 0.808 past month cannabis use 0.03 0.01 0.02 0.04 <.001 site -5.56 1.54 -8.58 -2.55 <.001 0.86 0.27 0.34 1.39 0.001 baseline cud symptoms 7.38 1.43 4.57 10.18 <.001 2.65 0.27 2.12 3.18 <.001 sex -3.28 1.53 -6.29 -0.28 0.032 0.16 0.26 -0.36 0.68 0.540 race/ethnicity 1.66 1.72 -1.71 5.02 0.334 0.16 0.34 -0.50 0.83 0.631 ses -6.88 2.60 -11.97 -1.79 0.008 -0.15 0.43 -0.99 0.70 0.735 obsessive passion op 9.31 1.67 6.03 12.59 <.001 2.35 0.28 1.80 2.90 <.001 time -0.67 0.42 -1.50 0.16 0.113 -0.10 0.08 -0.25 0.05 0.194 op x time -0.05 0.72 -1.47 1.37 0.946 -0.17 0.11 -0.40 0.05 0.125 social facilitation 0.13 0.39 -0.63 0.89 0.734 -0.07 0.07 -0.20 0.07 0.341 social facilitation x time -0.14 0.17 -0.47 0.20 0.422 -0.03 0.03 -0.10 0.04 0.422 past month cannabis use 0.00 0.01 -0.01 0.01 0.972 site -6.34 1.39 -9.06 -3.63 <.001 0.56 0.22 0.12 0.99 0.012 baseline cud symptoms 2.47 1.29 -0.06 5.01 0.055 1.65 0.24 1.19 2.12 <.001 sex -4.06 1.37 -6.73 -1.38 0.003 -0.04 0.22 -0.48 0.40 0.865 race/ethnicity 0.80 1.62 -2.38 3.97 0.623 -0.04 0.27 -0.57 0.49 0.880 ses -6.40 2.63 -11.56 -1.24 0.015 -0.09 0.42 -0.90 0.73 0.837 note: bold denotes significance at p<.005; cud=cannabis use disorder; ses=socioeconomic status; hp=harmonious passion; op=obsessive passion. race/ethnicity coded as non-hispanic white vs. hispanic. socioeconomic status coded as <$10,000-99,999; $100,000-$150,000, >$150,000. cannabis, a publication of the research society on marijuana 118 the social facilitation item, however, was associated with fewer cannabis-related problems (β = -0.22, se = 0.07, p = .003). after including the social facilitation item, op was still associated with greater cannabis frequency (β = 9.31, se = 1.67, p < .001) and more cannabis-related problems (β = 2.35, se = 0.28, p < .001). there were no significant time interactions. discussion in this prospective college student cohort study of cannabis use and use-related problems among those with and without a cud, the results from this study support the growing body of evidence that shows the dmp is not a substitute for other measures of problematic cannabis use (davis, 2017; davis & arterberry, 2019; steers et al., 2015). indeed, in this study, we found that hp and op are differentially associated with recent cannabis use and use-related consequences. additionally, we discovered that when hp and op were included as predictors along with coping motives, refusal self-efficacy, and cud symptoms, that op was either predictive of cannabis use and use-related consequences at a higher magnitude compared to these other constructs, or these other constructs were not significant predictors in the models. these data extend the currently available literature on this topic in several ways outlined below. the findings that greater hp was not associated with greater past month cannabis use or cannabis-related problems among college students with minimal cannabis use history are consistent with one study investigating this topic using retrospective and cross-sectional designs (steers et al., 2015). however, these findings are inconsistent with two studies among people who use cannabis regularly (e.g., davis, 2017; davis & arterberry, 2019). findings are also consistent with a study investigating the dmp model among young risky drinkers enrolled in a clinical trial (davis et al., 2019), wherein hp was not associated with binge drinking or alcohol userelated consequences. that hp has consistently been shown unrelated to use-related consequences among those engaging in risky cannabis use further supports this construct in these populations, and the hypothesis that hp may not be associated with increased consequences. we also found that greater baseline op was associated with greater past month cannabis use and more cannabis-related problems, and that op was associated with cannabis-related problems at a greater magnitude than coping motives. these results are consistent with retrospective and cross-sectional studies among frequent cannabis users (davis, 2017; davis & arterberry, 2019; davis et al., 2018) and among college students who use cannabis infrequently (steers et al., 2015). furthermore, because op was associated with cannabis use-related consequences at a greater magnitude than coping motives, future research should continue to explore whether op is a better predictor of cannabis use outcomes compared to other psychological and behavioral characteristics (e.g., motives, refusal self-efficacy) among young adults. nevertheless, that op has consistently been shown to be associated with cannabis use and use-related consequences establishes the importance of using this measure of passion for cannabis use in future studies in this population. to date, no studies have evaluated whether levels of op or hp for cannabis use vary over time. in this study, there were no significant passion by time interactions, which could be explained in multiple ways. this could mean that passion may vary at the within-person level on a daily or momentary basis, thus more frequent assessment techniques such as ecological momentary assessments could determine variations in passion. alternatively, it could also be that passion may change more slowly and that we were not able to detect such variations in a study designed to examine only 5and 10-month outcomes. alternatively, it is also possible that passion is stable over time once it develops. that said, these hypotheses await future research to assess whether passion fluctuates over time using methodology that addresses these measurement challenges. to our knowledge, this is the first study to assess elements of relational functioning as correlates of hp and op. notably, several studies have found a relationship between dysfunctional or less secure forms of attachment and behavioral addictions (tas, 2019), substance misuse and use disorder (dassa et al., 2013; kpelly et al., 2022), alcohol use-related consequences (molnar et al., 2010), and cannabis use (schindler et al., 2009). conversely, stronger family attachment and passion for cannabis use among college students 119 social support have been associated with less risky substance use (hamme et al., 2010). interestingly, although we expected that those college students with more anxious forms of attachment and less social connection may be more at risk for developing op compared to those with more social support, we found that op was only associated with less social support in this sample. that we found an association between op and less social connection suggests that for those high in op, relational functioning may already be a source of concern, and possibly contributing to their problematic cannabis use. if addressing op could be facilitated by addressing other relational aspects of one’s functioning (e.g., increasing positive social connections), then it is possible that one’s level of hp for cannabis use might increase while levels of op decrease. thus, we might expect that although cannabis use may continue, the function of cannabis use may change, and one might experience fewer, if any, use-related consequences, even if they experience anxious forms of attachment. additionally, that the passion measure appears to be more strongly related to cannabis use and use-related problems compared to other assessment tools (e.g., coping motives; refusal self-efficacy), suggests that this measure should be included in clinical settings in order to best determine for whom further screening or intervention may be useful. however, more research is needed to elucidate the ways in which attachment style, social connection, and passion for cannabis use are related. study findings should be considered in light of limitations. for example, although we recruited students from two campuses, the sample is not necessarily representative of students at all campuses (e.g., historically black campuses, private colleges, community colleges) across geographic regions; however, this investigation sets the stage for future, more generalizable studies. next, all data are self-reported, thus are subject to potential recall biases and demand characteristics; however, self-report of substance use is reliable and valid (simons et al., 2015) and our study’s procedures to promote valid reporting via confidentiality assurances and private, webbased administration. the full measure for the crseq was not used in this study to reduce participant burden in completing the survey; thus, the single item representations of the crseq scales may not capture fully the dimensions measured and findings should be interpreted with caution. further, we did not examine types and methods of cannabis use in this study, but future studies would benefit from examining whether differing cannabis use methods are associated with passion constructs. additionally, the recruitment strategy did not allow for assessment of the number of emails that were opened or read, nor did it allow for examination of who did not click a link to screen for the study, which limits our ability to examine to what extent response bias affected findings. finally, although cud symptoms were assessed and the number of symptoms are associated with a diagnosis, we did not conduct formal diagnostic evaluations. this body of research suggests that the dmp should be considered important in understanding why and to what extent young people consume cannabis or experience use-related consequences. one area of future research would be to examine the bidirectional relationships between passion constructs and cannabis-related outcomes, as passion constructs may be more stable or be better understood as trait-like instead of individual states. future research should also explore whether addressing constructs of the dmp in existing evidenced-based interventions for cannabis misuse and cud is feasible, acceptable, and effective. one promising area of inquiry could involve adapting a brief motivational interviewing intervention (e.g., miller and rollnick, 1991) to include discussion of hp and op and to assess whether this improves cannabis use-related outcomes among college students. furthermore, research could explore whether one’s level of hp and op differentially predicts response to evidence-based treatments, perhaps highlighting for whom an emphasis on passion could be beneficial in psychotherapy. studies could also assess whether levels of hp and op could be used as a screener to identify those more likely to need brief intervention and/or referral to treatment. in the meantime, clinicians working with college students or other young people with cannabis use, misuse, and/or use-related problems might consider whether integrating a discussion and measurement of passion into counseling activities could be beneficial in helping to ascertain the ways in which cannabis use is experienced by college students. indeed, the language of passion may be more acceptable to cannabis, a publication of the research society on marijuana 120 college students by reducing stigma associated with identifying as having cannabis use-related problems. for example, college students may be less likely to identify as having a problem with cannabis but may instead be more likely to think about their cannabis use in relational terms. if cannabis misuse is conceptualized as a relational problem consistent with the dmp, individuals may be more open to exploring and changing their cannabis use (consistent with hps), as opposed to current treatment approaches that frame cannabis as primarily a behavioral problem. this new way of thinking could also move the field in the direction of more acceptability for a recovery oriented systems of care (rosc) model (sheedy & whitter, 2009), which supports that recovery from any kind of substance use disorder should include improvement in functioning, whether or not that improvement in functioning includes reduction or cessation of substance use. regardless, decreasing the stigma associated with acknowledging problems associated with cannabis use among college students, even if limited to changes in the language we use to describe functional and dysfunctional use, may help to engage college students in important conversations about the role cannabis use plays in their day-to-day lives. this alone might facilitate more connection to care with these high-risk individuals and help decrease the likelihood of negative long-term cannabis misuse and cud trajectories. references arterberry, b. j., boyd, c. j., west, b. t., schepis, t. s., & mccabe, s. e. 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(1988). models for longitudinal data: a generalized estimating equation approach. biometrics, 1049-1060. https://doi.org/10.2307/2531734 funding and acknowledgements: funding for this study came from a competitive seed grant from the college of social work at ohio state university and by a seed grant from the iowa state university college of liberal arts. akd, yx, and smh were supported by the center for psychedelic drug research and education at ohio state university. the funding sources had no role in the study, data analysis, interpretation, or communication of findings. akd and bja are board members at source research foundation. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://doi.org/10.1080/07448480209595713 https://www.who.int/substance_abuse/publications/global_alcohol_report/gsr_2018/en/ https://creativecommons.org/licenses/by/4.0/ research article 1 ved abstract objective: since the federal canadian government legalized cannabis in 2018, cannabis use in the general population has slightly increased. however, little is known about the impact of cannabis legalization on pattens of cannabis use in psychiatric populations. method: we studied changes in daily/almost daily and average 30-day cannabis use amongst individuals currently using cannabis who reported past 12-month experiences of specific mental health disorders and among those without past 12-month experiences of any mental health disorder before and after canadian legalization of recreational cannabis use (n = 13,527). data came from canadian respondents in wave 1 (august–october 2018), wave 2 (september–october 2019), and wave 3 (september–november 2020) of the international cannabis policy study (icps). results: after adjustment for covariates, among individuals currently using cannabis, the odds of using cannabis daily/almost daily increased only in individuals with schizophrenia between wave 1 and waves 3 (aor = 9.19, 95% ci: 2.46 – 34.37). similarly, significant increases in average 30-day cannabis use between wave 1 (m = 12.80, se = 1.65) and wave 3 (m = 18.07, se = 1.03) were observed only among individuals with schizophrenia, f (1,2) = 4.58, p < .05. no significant changes in daily/almost daily or average past 30day cannabis use were observed in those without mental health problems or those reporting anxiety, depression, ptsd, bipolar disorder, or substance use disorders. conclusions: since legalization, cannabis use has significantly increased only among people with schizophrenia, highlighting the need for targeted public health prevention programs. key words: cannabis; legalization; canada; psychiatric disorders; psychosis; schizophrenia maryam sorkhou1,2, samantha johnstone1, andrea h. weinberger3, ziva d. cooper4, marcos sanches1, david j. castle5, wayne hall6, rachel a. rabin7, david hammond8, & tony p. george1,2 1institute for mental health and policy research, centre for addiction and mental health 2institute of medical sciences, university of toronto 3ferkauf graduate school of psychology, yeshiva university 4ucla center for cannabis and cannabinoids, jane and terry semel institute for neuroscience and human behavior, department of psychiatry and biobehavioral sciences and anesthesiology, david geffen school of medicine, university of california, los angeles 5tasmania centre for mental health service innovation, university of tasmania 6the national centre for youth substance use research, queensland university 7department of psychiatry, mcgill university 8school of public health sciences, university of waterloo cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000238 volume 7, special issue 3 changes in cannabis use patterns in psychiatric populations preand postlegalization of recreational cannabis use in canada: a repeated cross-sectional survey corresponding author: tony p. george, m.d., frcpc, university of toronto, centre for addiction and mental health (camh). 60 white squirrel way, room 312, toronto, ontario canada, m6j 1h4. phone: +1(416)535-8501 x32662. e-mail: tony.george@camh.ca. cannabis, a publication of the research society on marijuana 2 on october 17, 2018, canada became the second nation after uruguay to legalize recreational cannabis use with bill c-45. under this bill, the production, cultivation, processing, testing, licensing, medical sales, advertising and marketing regulations, labeling, health warnings, and shared taxation of cannabis products falls under the jurisdiction of the federal government. in contrast, provinces and territories are primarily responsible for regulating retail sales, both online and in physical stores. provincial and territorial governments also have the ability to adjust the minimum age limit, the possession amounts, and add further regulations on personal cultivation of cannabis (hall et al., 2022). initially, bill c-45 authorized the production, distribution, and sale, both wholesale and retail, of a limited range of cannabis products, which included dried cannabis, fresh cannabis, cannabis plants, cannabis plant seeds, and cannabis oil. however, one year later, amendments were made, which permitted the manufacture, distribution, and sale of three additional classes of cannabis products, including edibles, extracts, and topicals. the primary goals of legalization were to limit underage access, reduce criminal justice system resources spent on cannabis possession and trafficking, ensure quality control of cannabis consumed to protect public health, reduce stigma associated with illegal cannabis use, and increase consumer awareness of health risks associated with cannabis use (government of canada, 2018). despite these proposed benefits of legalization, the health impacts of this significant policy change in canada, including the effects of legalization on cannabis use patterns in psychiatric populations, remain unknown. there is a multifaceted relationship between cannabis use and psychiatric disorders. crosssectional and longitudinal effects of cannabis use on schizophrenia are consistently documented (d’souza et al., 2022; sorkhou et al., 2021), with strong evidence suggesting that frequent use of cannabis increases the risk of developing psychotic symptoms (murray et al., 2016; zammit et al., 2002). comparatively, prospective studies exploring the relationship between frequency of cannabis use and other psychiatric disorders including mood (feingold et al., 2015; van laar et al., 2007) and anxiety disorders (hayatbakhsh et al., 2007), yield less consistent results. specifically, while some studies find worsening of mood and depressive symptoms, other have failed to replicate such findings (for a review, see sorkhou et al., 2024). nonetheless, there is considerable evidence that frequent, non-medical cannabis use may impede treatment recovery and treatment engagement in people with psychiatric disorders, constituting a negative effect of cannabis use on mental health. in patients with major depressive disorder, for example, frequent cannabis use may lead to a worsening of symptoms, more frequent depressive episodes, and poorer psychosocial functioning (bahorik et al., 2017; bricker et al., 2007). similar findings are demonstrated in bipolar disorder (lev-ran et al., 2013), post-traumatic stress disorder (ptsd) (johnson et al., 2016; rodas et al., 2024), anxiety (buckner et al., 2017; tepe et al., 2012), substance use disorders (subbaraman et al., 2017), and psychotic-spectrum disorders (schoeler et al., 2016), where those using cannabis report more severe symptoms, longer duration of active illness, poorer functional ability, and higher rates of hospitalization. despite potential adverse effects of cannabis use in psychiatric populations, the perception of risks related to its use may be lower in individuals with a mental health disorder compared to those without a mental illness (pacek et al., 2020). for example, in a recent nationally representative american study examining trends in the prevalence and risk perceptions of cannabis use between 2005 and 2017, individuals with depression experienced a greater decline in perception of risk than nondepressed controls (pacek et al., 2020). coinciding with these changes in risk perceptions, cannabis use rates were twice as high among participants with depression than those without depression. as the legal landscape surrounding cannabis use continues to change globally, concerns have been raised that if not properly implemented, cannabis decriminalization and legalization may impact the general population’s perceptions regarding the health risks of cannabis use, potentially increasing consumption (zvonarev et al., 2019). this is of significant concern in individuals with a mental health disorder, as a growing body of literature indicates potential harms of frequent cannabis use in this vulnerable population (george et al., 2018). thus, the goal of this investigation is to examine changes in daily or almost daily and average 30-day cannabis use cannabis legalization and mental health disorders 3 after canadian cannabis legalization (october, 2018) specifically among individuals reporting past 12-month experiences of specific mental health disorders and reporting a 12-month history of current cannabis use. the current study is based on data from annual large, cross-sectional surveys conducted among respondents aged 16 – 65 across canada and the united states since 2018 (international cannabis policy study; icps). here, we focus on canadian data between 2018 and 2020 which provides a unique opportunity to study national-level changes in recreational cannabis use among psychiatric populations preand post-legalization. we tested two primary hypotheses: following the legalization of cannabis in canada in october 2018, individuals with any mental health disorder who reported a history of cannabis use in the past 12 months will demonstrate a significant increase in their (1) daily/almost daily and, (2) average 30day cannabis use rates. methods we analyzed repeated cross-sectional data from waves 1, 2, and 3 of the icps conducted in canada. data were collected via self-completed web-based surveys conducted in august 27 october 7, 2018 (immediately before cannabis legalization in canada), september 13 – october 31, 2019 (1 year post-legalization), and september 3 – november 2, 2020 (2 years post-legalization). respondents aged 16–65 were recruited through the nielsen consumer insights global panel and their partners’ panels, which consist of nonprobability based commercial panels. email invitations with a unique link were sent to a random sample of panellists (after targeting for age and country criteria); panellists known to be ineligible were not invited. the survey had a response rate of 1.3% in 2018, 3.7% in 2019, and 1.5% in 2020. surveys were conducted in english or french in canada. median survey times were 20, 25, and 21 minutes, in 2018, 2019, and 2020, respectively. respondents provided consent prior to completing the survey and received remuneration in accordance with their panel’s usual incentive structure (e.g., points-based or monetary rewards, chances to win prizes). the study was reviewed by and received ethics clearance through the university of waterloo research ethics committee (ore#31330). the final cross-sectional canadian sample comprised 41,093 respondents (n = 10,057 in 2018, 15,256 in 2019, 15,780 in 2020). the current analyses were based on the subsample of 13,527 respondents who had reported that they had consumed cannabis within the past 12-months (n = 2,768 in 2018, n = 5,381 in 2019, n = 5,378 in 2020). post-stratification sample weights were constructed using population estimates from statistics canada. respondents from canada were classified into age-by-sex-by-province, education, and, except in 2018, age-by-smoking status groups. these sample weights were used throughout the analyses to mitigate the effects of non-response and selection bias and return the sample to population representativeness. a full description of the icps methods, sample, and comparisons with national benchmark surveys are available in the icps methodology paper (hammond et al., 2020) and technical reports – wave 1 (2018), wave 2 (2019), and wave 3 (2020) (goodman et al., 2018; 2019; 2020). measures sociodemographic variables. gender identity, age, ethnicity/race, education, perceived income adequacy, and province of residence were collected. briefly, perceived income adequacy was assessed with a measure that is associated with objective measures of income and wealth (litwin & sapir, 2009). ethnicity/race was assessed with country-specific measures drawn from the canadian census. past 12-month experience of a mental health condition. participants were asked “have you experienced this/these mental health problem(s) in the past 12 months?” and were asked to select yes or no from the following list: anxiety (including phobia, obsessive–compulsive disorder or panic disorder); depression (including dysthymia); ptsd; bipolar disorder or mania; psychotic disorder (including schizophrenia); and an alcohol or substance use disorder. individuals selecting “no” for every mental health condition were recoded to individuals without any mental health problems. frequency of cannabis use. dependent variables included daily/almost daily cannabis use and average number of days of cannabis use in the past month (i.e., average 30-day cannabis use). daily/almost daily cannabis use was obtained cannabis, a publication of the research society on marijuana 4 using the following measure: “how often do you use marijuana?”. potential responses included, never, more than 12 months ago, less than once per month, one or two times per month, one or more times per week, every day or almost every day. afterwards, this original variable was recalculated into a binary variable where respondents who reported “every day or almost every day” for cannabis use were coded as 1 (e.g., daily/almost daily cannabis use), and respondents who reported one or more times per week, one or two times per month, less than once per month, more than 12 months ago, or never were coded as 0 (e.g., non-daily/almost daily cannabis use). similarly, average 30-day cannabis use was obtained using the following measure: “how often do you use marijuana?”. potential responses included, never, more than 12 months ago, less than once per month, one or two times per month, one or more times per week, every day or almost every day. respondents who had used cannabis at least once within the previous 12 months were subsequently asked to freely report their frequency of use per week, month, or year, depending on their initial response. using the numerical free-text responses provided, we calculated a latent variable representing participants' average 30-day cannabis use. stastisical analysis first, descriptive statistics were used to describe the prevalence of individuals without mental health problems, each of the 12-month mental health conditions, average 30-day cannabis use, and frequency of cannabis use. to measure the changes in risk of using cannabis daily/almost daily for each psychiatric condition and among individuals without mental health problems between waves 1 (reference group), 2, and 3, binary logistic odds ratios were computed where individuals reporting either “(1) less than monthly use,” “(2) one or two times per month,” “(3) one or two times per week,” and “(4) daily or almost daily use” were dichotomized to (1)-(2)-(3) versus (4). unless otherwise indicated, adjusted odds ratios (aors) are reported with 95% confidence intervals. to measure changes in average 30-day cannabis use between 2018 – 2020, univariate analyses of covariance (ancovas) were performed for each psychiatric condition. when significant main effects were observed, bonferroni‐corrected post‐hoc testing was performed to identify between which time‐ points a significant change in average 30-day cannabis use occurred. the level of significance for all statistical tests was set at p <.05. all models were run in spss v.26, and adjusted for the following covariates: age group, gender identity, education, ethnicity/race, region, and income adequacy. results demographics table 1 presents the weighted sample characteristics included in the current analyses from waves 1, 2, and 3 of the icps survey. on average, 34.7% of respondents who used cannabis did so daily at wave 3, as compared to 32.2% at wave 1. the most frequent 12-month experience of a psychiatric condition in waves 1, 2, and 3, was anxiety, with 36.1%, 38.9%, and 40.1% of respondents reporting this condition, respectively. table 1. weighted sample characteristics of individuals reporting past 12-month cannabis use by year characteristic wave 1 (n = 2,768) weighted % (n) wave 2 (n = 5,381) weighted % (n) wave 3 (n = 5,378) weighted % (n) gender identity female 44.7 (1237) 45.0 (2419) 46.2 (2484) male 53.8 (1489) 53.0 (2854) 51.5 (2768) transgender/other 1.5 (33) 2.1 (108) 2.3 (126) age group 16 – 25 20.5 (567) 19.8 (1063) 18.1 (975) 26 – 35 29.2 (809) 28.3 (1525) 28.3 (1523) 36 – 45 20.5 (567) 20.9 (1126) 21.4 (1152) cannabis legalization and mental health disorders 5 46 – 55 15.9 (441) 17.1 (920) 17.1 (922) 56 – 65 13.9 (384) 13.9 (747) 15.0 (805) ethnicity white 80.3 (2223) 74.8 (4023) 75.5 (4060) black 1.9 (52) 4.0 (214) 4.0 (215) asian 4.3 (110) 8.0 (487) 8.8 (471) indigenous 7.0 (193) 3.9 (209) 2.7 (146) other/mixed 6.5 (181) 8.3 (408) 9.0 (484) education less than high school 17.7 (490) 15.6 (840) 14.5 (778) high school diploma 27.9 (772) 27.8 (1495) 29.3 (1576) some college or technical vocation 35.5 (983) 34.2 (1841) 33.5 (1803) bachelor’s degree or higher 18.3 (507) 21.3 (1145) 21.8 (1172) not stated .6 (15) .11 (50) .9 (49) income adequacy very difficult 9.1 (253) 10.6 (569) 8.9 (480) difficult 22.2 (615) 24.5 (1319) 20.5 (1105) neither easy nor difficult 36.0 (996) 33.6 (1807) 36.4 (1959) easy 19.4 (538) 18.6 (1002) 21.5 (1154) very easy 11.1 (307) 9.4 (508) 9.4 (504) not stated 2.1 (59) 3.3 (176) 3.3 (176) province of residence british columbia 16.7 (464) 14.3 (770) 14.5 (781) alberta 12.5 (347) 12.5 (675) 12.0 (643) saskatchewan 3.0 (84) 3.1 (165) 3.4 (180) manitoba 3.3 (91) 3.7 (198) 3.4 (184) ontario 37.6 (1040) 41.7 (2243) 41.4 (2227) quebec 19.5 (541) 17.7 (951) 18.3 (984) new brunswick 2.4 (66) 2.3 (122) 2.3 (121) nova scotia 3.0 (83) 3.0 (160) 2.9 (158) prince edward island .5 (13) .4 (21) .4 (20) newfoundland & labrador 1.5 (40) 1.4 (74) 1.5 (79) cannabis use frequency past-year but less than monthly 31.2 (863) 32.1 (1729) 29.9 (1610) monthly 17.7 (491) 19.8 (1064) 18.7 (1008) weekly 18.8 (522) 16.0 (863) 16.7 (896) daily/almost daily 32.2 (893) 32.0 (1724) 34.7 (1863) past 12-month experience of a psychiatric conditions anxiety 36.1 (1000) 38.9 (2094) 40.1 (2159) bipolar 3.7 (103) 4.8 (259) 5.3 (285) depression 29.3 (812) 32.1 (1727) 32.7 (1760) individuals without mental health problems 53.5 (1481) 51.4 (2767) 49.4 (2655) ptsd 8.3 (229) 10.4 (558) 10.7 (575) scz 2.3 (64) 1.8 (97) 2.7 (147) sud 8.1 (225) 6.7 (363) 6.4 (345) note. ptsd: post-traumatic stress disorder; scz: schizophrenia; sud: substance use disorder. changes in daily/almost daily cannabis use. after adjusting for covariates, between waves 1 and 3, among those currently using cannabis, the odds of using cannabis daily/almost daily increased only among individuals with a 12-month experience of schizophrenia from wave 1 to waves 2 (aor = 8.18, 95% ci: 2.65 – 25.71) and 3 (aor = 9.19, cannabis, a publication of the research society on marijuana 6 95% ci: 2.46 – 34.37; tables 2 and 3). the prevalence of daily/almost daily cannabis use in individuals reporting 12-month schizophrenia was 43.8% in wave 1, 55.7% in wave 2, and 48.3% in wave 3. among other current cannabis users, the change in risk of using cannabis daily/almost daily from waves 1 to waves 2 and 3 did not significantly change for all other mental health groups or among individuals without a mental health disorder. table 2. prevalence of daily/almost daily cannabis use between 2018 (pre-legalization) – 2020 (post-legalization) in canadians reporting a mental health condition in the past 12 months mental health disorder 2018 (wave 1) % (n) 2019 (wave 2) % (n) 2020 (wave 3) % (n) anxiety 39.8 (398) 38.1 (797) 39.9 (861) bipolar disorder 51.5 (53) 49.8 (129) 43.9 (125) depression 41.6 (338) 40.2 (694) 42.7 (751) individuals without mental health problems 26.7 (395) 27.1 (750) 28.7 (763) ptsd 49.8 (114) 49.3 (275) 45.6 (262) scz 43.8 (28) 55.7 (54) 48.3 (71) sud 45.3 (102) 49.3 (179) 47.5 (164) note. ptsd: post-traumatic stress disorder; scz: schizophrenia; sud: substance use disorder. table 3. binary logistic regression model of adjusted odds of using cannabis daily/almost daily between 2018 (pre-legalization) – 2020 (post-legalization) in canadians reporting a mental health condition in the past 12 months note. all models have been adjusted for age group, gender identity, education, ethnicity/race, region, and income adequacy. abbreviations; aor, adjusted odds ratio; ci, confidence interval. ptsd: post-traumatic stress disorder; scz: schizophrenia; sud: substance use disorder. mental health disorder year daily use aor (95% ci) p-value anxiety 2018 reference 2019 .92 (.79 – 1.08) .32 2020 1.02 (.87 – 1.19) .84 bipolar disorder 2018 reference 2019 1.08 (.67 – 1.74) .76 2020 .86 (.53 – 1.39) .54 depression 2018 reference 2019 .93 (.78 – 1.10) .40 2020 1.06 (.89 – 1.26) .50 individuals without mental health problems 2018 reference 2019 .95 (.82 – 1.09) .44 2020 1.11 (.96 1.27) .16 ptsd 2018 reference 2019 .99 (.72 – 1.36) .94 2020 .89 (.65 – 1.22) .47 scz 2018 reference 2019 8.18 (2.6 – 25.71) <.01 2020 9.19 (2.46 – 34.37) <.01 sud 2018 reference 2019 1.13 (.80 – 1.60) .48 2020 1.17 (.83 – 1.66) .37 cannabis legalization and mental health disorders 7 changes in average 30-day cannabis use frequency. after adjusting for covariates, we observed a significant increase in average frequency of 30-day cannabis use among individuals currently using cannabis between wave 1 (m = 12.80, se = 1.65) and wave 3 (m = 18.07, se = 1.03) in individuals with a 12-month experience of schizophrenia (table 4; f (1,2)=4.58, p =.01). post-hoc analyses revealed that an increase in frequency of 30-day cannabis use occurred between 2018 and 2019 (p = .01) and this was sustained in 2020 (p = .01), with no further significant increases between 2019 and 2020. there was no significant change in average 30-day cannabis use among other psychiatric groups or individuals without a mental health disorder. table 4. changes in average 30-day cannabis use frequency between 2018 – 2020 in canadians reporting a mental health condition in the past 12-months diagnostic group 2018 30-day cannabis use mean (se) 2019 30-day cannabis use mean (se) 2020 30-day cannabis use mean (se) f p-value anxiety 14.11 (.42) 14.35 (.29) 15.11 (.28) 2.69 .07 bipolar disorder 16.73 (1.29) 16.83 (.82) 16.71 (.76) .01 .99 depression 14.83 (.47) 15.07 (.32) 15.57 (.31) 1.09 .34 individuals without mental health problems 11.07 (.32) 10.85 (.23) 11.53 (.24) 2.19 .11 ptsd 17.40 (.89) 17.18 (.56) 16.77 (.54) .24 .79 schizophrenia 12.80 (1.65)ab 18.83 (1.3)a 18.07 (1.03)b 4.58 .01 sud 17.01 (.87) 16.74 (.69) 16.67 (.70) .05 .95 note. all models have been adjusted for age group, gender identity, education, ethnicity/race, region, and income adequacy. post-hoc comparisons: a significant difference between 2018 and 2019 (p <.05) b significant difference between 2018 and 2020 (p <.05). se: standard error; ptsd: post-traumatic stress disorder; scz: schizophrenia; sud: substance use disorder. discussion using nationally representative data from the icps, we investigated changes in cannabis use patterns following cannabis legalization in canada amongst individuals with a 12-month history of cannabis who are reporting a mental health condition in comparison to those without any mental health problems. results indicated that changes in cannabis use patterns only occurred amongst individuals reporting symptoms of schizophrenia, with increases occurring in both rates of daily/almost daily cannabis use and average frequency of cannabis use in the past 30 days. there are several hypotheses that may explain the selective increase in cannabis use amongst people with a past year experience of psychotic symptoms or schizophrenia. one possibility is that these persons had poorer access to the series of health warnings and public education campaigns regarding safe cannabis use and risks of use implemented after cannabis legalization (hammond et al., 2020). these campaigns include warnings about the health risks of prolonged cannabis use, knowledge of δ-9tetrahydrocannabinol (thc) or cannabidiol (cbd) content, along with recommended limits on dosing (hammond et al., 2020). individuals with schizophrenia or psychotic disorders may not have ready access to this public health information. for example, public health campaigns may not be sufficiently: 1) outlining specific risks associated with using cannabis for individuals at high risk for schizophrenia or who have a psychotic disorder; 2) presenting information in a manner that it appears relevant and interesting; 3) appearing in places (e.g., social media versus television) that target populations are likely to see and attend to it; 4) employing fear-based tactics, which may paradoxically reduce campaign efficacy (atkin, 2001). a comparable example is canadian public health messaging related to tobacco use, which coincided with a significant cannabis, a publication of the research society on marijuana 8 decrease in tobacco consumption in the general population (31% in 1989 versus 11.9% in 2019; east et al., 2021; eliany & courtemanche, 1989). comparatively, in individuals with schizophrenia, tobacco prevalence has remained staggeringly high at approximately 60-70%, with studies showing no significant changes from 1991 (dickerson et al., 2013; tidey & miller, 2015). these findings suggest that the approaches employed by regulatory frameworks to reduce tobacco use may not have been as effective among individuals with schizophrenia in comparison to the general population. if similar challenges exist in reaching and resonating with individuals with schizophrenia regarding tobacco use, it is conceivable that analogous barriers could hinder the impact of public health campaigns about cannabis use. our findings underscore the need for targeted and innovative approaches in developing public health campaigns that can effectively communicate the risks associated with cannabis use to individuals with schizophrenia and psychotic disorders. second, cannabis legalization has made cannabis easier to access by adults and notably, it has substantially reduced the price of cannabis products (mahamad et al., 2020). this has made daily/almost daily cannabis much more affordable to persons with schizophrenia, many of whom have incomes that are much lower than their peers because of lower rates of paid employment and greater reliance on social welfare for income (aro et al., 1995). given the increased affordability and accessibility of cannabis following legalization, individuals with schizophrenia may find it more financially feasible to engage in frequent cannabis use. this may lead to a disproportionate impact on this population of cannabis users, underscoring the importance of closely evaluating the implications of cannabis legalization on individuals with schizophrenia. a third possible explanation for the selective increase in daily/almost daily and average 30-day cannabis use rates preand post-legalization amongst individuals experiencing schizophrenia or psychotic-related symptoms is that cannabis has been used for self-medication purposes. legalization has increased access to cannabis, thus people with psychosis may now increasingly use cannabis to self-medicate, including remediation of feelings of boredom, isolation, and negative affect (lowe et al., 2019). however, the specificity of the finding in individuals with psychotic disorders is unclear because selfmedication using cannabis has also been proposed to occur for other disorders, including depression and anxiety (wallis et al., 2022). further, there are few empirical findings that support the selfmedication hypothesis (mustonen et al., 2018; sideli et al., 2020). longitudinal studies evaluating clinical outcomes in individuals with psychotic-spectrum disorders who reduce or abstain from cannabis after receiving a diagnosis have inconsistent findings with respect to perceived benefits in cannabis use. in a recent meta-analysis examining outcomes of patients with schizophrenia who either continued or discontinued cannabis use after receiving a diagnosis, schoeler et al. (2016) found that individuals who discontinued cannabis use were significantly more likely than continuing users to experience decreases in positive symptoms and demonstrate improvements in psychosocial functioning. specific increases in cannabis use amongst individuals with psychotic-spectrum disorders is an important public health concern. relative to other mental health disorders, including mood and anxiety disorders, there is consistent observational evidence demonstrating that regular cannabis use is associated with an elevated risk of developing psychotic symptoms or disorders, in those who are at risk. recently, di forti and colleagues observed a significant increase in the incidence of psychotic disorders among five european countries, which was positively correlated with an increase in the prevalence of daily cannabis use (di forti et al., 2019). namely, the odds of developing a psychotic disorder among those using cannabis daily were 3.2 times higher than those not using cannabis. moreover, the authors found that availability of high-potency cannabis corresponded with a higher incidence for psychotic disorders across the five countries. other research has similarly indicated that adults who use cannabis daily or almost daily are significantly more likely than infrequentand non-users to be later diagnosed with a psychotic-spectrum disorder (giordano et al., 2015; van os et al., 2002). thus, increasing use of cannabis in individuals at risk for psychosis or with early psychosis may have serious adverse effects on disease progression and prognosis. cannabis legalization and mental health disorders 9 the current study’s findings need to be interpreted in light of several limitations. first, due to the cross-sectional nature of our repeated surveys, causal inferences between cannabis use and mental health conditions cannot be made. therefore, while our findings indicate an increase in daily/almost daily and average 30-day cannabis use amongst individuals with schizophrenia, it remains unknown whether frequent cannabis use precipitates the development of such symptoms or increases the severity of such symptoms. moreover, the study is limited in determining whether an increase in cannabis use prevalence amongst mental health populations increased overall, as we only examined usage patterns among individuals reporting current cannabis use. thus, it remains unknown whether legalization has increased cannabis use prevalence amongst individuals with mental health conditions. a third limitation concerns the tool employed to evaluate mental health status, which composed of a single-item self-report question for each diagnostic group. the categorization of mental health conditions in the icps measure may have impacted the responses. for example, the option for past 12-month experience of anxiety included generalized anxiety, phobia, obsessive-compulsive disorder, or a panic disorder. moreover, the icps estimates for prevalence of mental health diagnoses are higher in comparison to nationally representative surveys (smetanin et al., 2015), which may have arisen due to self-report bias. compared to inperson surveys or telephone interviews, the online survey mode of the icps may offer greater anonymity and promote more truthful reporting on sensitive subjects such as cannabis and mental health. however, the icps sample exhibits comparable rates of cannabis use to those found in national benchmark surveys conducted in canada (hammond et al., 2020). for instance, the 2018 icps reported a prevalence of 11.3% for daily/almost daily cannabis use, closely aligned with the national cannabis survey’s (ncs) estimate of 7.9% (rotermann, 2019). furthermore, respondents were recruited using non-probability-based sampling. as such, the findings do not provide nationally representative estimates, and were subsequently weighted by age group, gender identity, education, ethnicity/race, region, and income adequacy in canada. while our study detected statistically significant increases in cannabis use following legalization amongst individuals diagnosed with schizophrenia, it is crucial to recognize the limited representation of this particular psychiatric population within our study sample. this limitation necessitates caution in interpreting and generalizing these findings. larger, more inclusive studies are needed to validate these results and better understand the complex relationship between cannabis use patterns and legalization in individuals with schizophrenia. furthermore, although our study sought to control for age in our analyses, it is important to note that the youngest age range included in our study spans from 16 to 25 years old. this range does not differentiate the legal age for purchasing cannabis. additionally, these age groups encompass a significant period of brain developmental and behavioral changes, during which substance use is commonly initiated and mental disorders may emerge years later. in addition, the covid-19 pandemic arose during wave 3 of the study, which may have confounded our observed findings. the covid-19 pandemic and associated public health measures implemented to reduce transmission of the virus has yielded both direct and indirect effects on cannabis use patterns (imtiaz et al., 2021; mackillop et al., 2021). during the initial lockdowns triggered by the pandemic, most regions classified non-medical cannabis retail as essential or treated it as such (ccsa, 2022). across canada, cannabis retail stores experienced a surge in sales, except for prince edward island after the initial pandemic waves (myran et al., 2020). in the early stages of the pandemic, one study observed that cannabis consumption in canada remained steady (imtiaz et al., 2021), while another revealed that among canadians using cannabis, more than one third of the sample reported that their cannabis consumption had increased during the pandemic (statistics canada, 2021). consistent with previous findings, we observed that in our total sample, daily/almost daily cannabis use and average 30-day cannabis use slightly increased between 2019 – 2020, with significant increases occurring amongst individuals with schizophrenia. a final limitation is that the true depiction of the consequences of cannabis legalization may require many years to develop (hall et al., 2019). in canada, only dried flower and some cannabis oils were available for cannabis, a publication of the research society on marijuana 10 legal purchase during the first year of legalization (health canada, 2019). additionally, the legal cannabis market in canada exhibits disparities across provinces in key domains, including the structure of retail operations, the minimum age for purchasing cannabis (e.g., 18 in quebec and alberta, 19 in the rest of canada), pricing dynamics, and product standards (government of canada, 2018; hall et al., 2022; mahamad et al., 2020). considering these factors, a two-year follow-up period post-legalization in canada may not capture the full spectrum of effects associated with changes in cannabis use patterns among individuals with mental health disorders. in conclusion, our findings are the first to suggest that since the legalization of recreational cannabis use in canada in 2018, the frequency of cannabis use has selectively increased amongst individuals with schizophrenia and psychotic symptoms. these results clearly necessitate further investigation in subsequent waves of the icps, including explorations of reasons for cannabis use, potency of thc, and concurrent substance use. these findings may have notable adverse public health consequences, as this population is vulnerable to significant harms associated with frequent cannabis use, including more severe symptom profiles, more frequent psychotic relapse rates and reduced psychosocial functioning (athanassiou et al., 2021; murray et al., 2016). as other nations and american states consider legalizing cannabis, prioritizing effective public health interventions for at-risk populations, including those with mental health disorders, is crucial. tailored prevention programs should offer early education and accurate information concerning the potential risks associated with cannabis use. moreover, regulatory frameworks can be designed with a focus on safeguarding individuals with mental health disorders by enforcing clearer product labels and considering stricter potency limits. finally, better collaboration between mental health and addictions professionals, along with enhanced screening of cannabis use in mental health settings, are essential to address the intricate interplay between cannabis use and mental health. moving forward, future longitudinal research collecting similar population-based cannabis use patterns and mental health-outcome data over longer periods will be necessary to draw firmer conclusions regarding the potential consequences of cannabis legalization on mental health outcomes. references aro, s., aro, h., & keskimäki, i. 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(2019). the public health concerns of marijuana legalization: an overview of current trends. cureus, 11(9). https://doi.org/10.7759%2fcureus.5806. funding and acknowledgements: this work was supported by a canadian institutes of health research (cihr) project bridge grant (pjt153342) and a cihr project grant (dh). additional support was provided by a cihr grant pjt-190053 (tg). the authors would like to thank robin burkhalter, christian boudreau and vicki rynard for their help in creating the survey weights for the larger study. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: sorkhou, m., johnstone, s., weinberger, a. h., cooper, z. d., sanches, m., castle, d. j., hall, w., rabin., r. a., hammond, d., & george, t. p. (2024). changes in cannabis use patterns in psychiatric populations preand post-legalization of recreational cannabis use in canada: a repeated cross-sectional survey. cannabis, 7(3), 1–13. https://doi.org/10.26828/cannabis/2024/000238 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 146 ved abstract introduction: college students demonstrated changes in levels of mental wellbeing as they and the world experienced new levels of stress and anxiety due to the covid-19 pandemic. as access to healthcare became limited, students turned to alternative methods of coping, which included cannabis use. objective: to determine if an association between cannabis use and self-perceived mental wellbeing during the pandemic among college students exists. method: a paired samples t-test was used to compare self-reported mental wellbeing at different times during the pandemic, a one-way anova to compare self-reported mental health between respondents' cannabis use status, and a tukey-kramer post-hoc analysis was used to determine between group significance. all data collected were from participants at a single time point (retrospective self-report during april 2022). results: of 103 self-reported college students, the most significant differences in mental wellbeing were reported prior to and during the pandemic. consistent significant differences were observed between each of the college student groups derived from those students who entirely avoided cannabis use or cessation of use (highest rating), p = .018, as compared to those who initiated cannabis use prior to and during the pandemic (lowest rating) p = .045. post pandemic mental wellbeing demonstrated a higher level of mental wellbeing among those who had some exposure to cannabis compared to those who avoided cannabis entirely. conclusions: it cannot be concluded that mental wellbeing was lower due to cannabis use. however, it is possible those with lower self-perceived mental wellbeing turned to cannabis use. key words: = college students; pandemic; covid-19; cannabis; mental health by mid-april 2020, the covid-19 virus had spread to over 185 countries around the world (varghese et al., 2020). the public health response to this outbreak was to take maximal precautions to prevent a strain on limited resources and equipment. this led to the global adaptation of social distancing protocols (glogowsky et al., 2021) in order to “flatten the curve” and contain the spread of the virus around the world. one group specifically impacted by the protocols of lockdown and isolation was college-aged students. though the impact of social distancing and isolation was found to be helpful in reducing the spread of covid-19, the forced isolation, lack of social interaction, and disruptions to daily life led to a “secondary pandemic” of reduced mental wellbeing. (ganesan et al., 2021). in a longitudinal study from 2017, a common link was found between physical and mental wellbeing relating specifically to isolation and a lack of social interaction (ohrnberger et al., 2017). their findings suggest that social isolation is a leading cause of decline in physical and mental wellbeing, with a direct overlap between the two (ohrnberger et al., 2017). this is substantiated by the findings of kandola and stubbs (2020) who identified that anxiety disorders increase the risk of cardiovascular disease and premature mortality. sean himebaugh1, deanna romero1, & thomas a. clobes1 1california state university channel islands cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000186 cannabis and college students: self-perceived mental health prior to, during, and after the pandemic corresponding author: thomas clobes, phd, california state university channel islands, 1 university drive. camarillo, ca, 93012. phone: (805) 437-2619. email: thomas.clobes@csuci.edu. cannabis, a publication of the research society on marijuana 147 these studies inform us that the methods used by the governments of the world in dealing with covid-19 all combined to create a secondary series of health problems due to isolation. the primary stressors focused on in this review center around isolation and self-treatment of college students occurring around the pandemic. we strived for our research to differ from others, as we focused specifically on college students and looked at a period of time that was particularly stressful. isolation and loneliness even before the pandemic, a primary contributing factor to the increased usage of substances was isolation (bartel et al., 2020). it has been found that those who used cannabis prior to the pandemic experienced an average 20% increase in usage during lockdown (bartel et al., 2020). those who used cannabis the least frequently prior to the pandemic were most likely to increase their consumption during the height of the pandemic (assaf et al., 2020; jurkowitz, 2020). there were increases in usage from those studied by lake et al. (2022), which indicate that daily and weekly consumption rose, with the majority of users claiming that the escalation in usage was due to increased feelings of anxiety. college students tend to have a more adverse reaction to loneliness and isolation (hager et al., 2022). according to hager et al., younger demographics have been found to have higher risks of negative mental wellbeing due to isolation since that time alone tends to get filled with things like repetitive negative thinking (rnt). rnt is described as pervasive negative thoughts that take hold during periods of strife, manifesting as chronic worry. research suggests that rnt may be the link between loneliness and depression (hager et al., 2022; spinhoven et al., 2018). self-medication for mental wellbeing self-perceived mental health and/or wellbeing is one’s perception of their mental wellbeing from a general standpoint. this self-perceived mental health/wellbeing affords a generalization of populations suffering from a form of mental health disorders, mental health or emotional distress that is not usually apparent in perceived health according to a canadian health survey conducted by the government of northwest territories (2014). according to sources that include quantitative (gaviria-mendoza et al., 2022; makowska et al., 2020) and qualitative studies (kaggwa et al., 2021), self-medication became a major factor in the immediate response of the general public to the pandemic lockdown. the lack of coherent information from leadership (algara et al., 2022) led to many people around the world turning to alternative sources for information about selftreatment. it has been found that people turned to social media for information about self-treating for covid-19, and gravitated towards things such as over-the-counter pain medications, as well as cannabis for self-treatment of other chronic neurological and self-perceived mental health conditions, while hospitals and clinics focused on providing treatment and resources exclusively to those in immediate need (brenneke et al., 2022). research by norton et al., revealed a 20% usage of alternative medicines by people under 50 years old to treat covid-19. this suggests a prevalence among college students and other younger adults to seek non-traditional methods, such as cannabis, rather than therapy or prescription medications. alternative methods for coping literature has unveiled how people react when faced with stressful situations and times of uncertainty, which include alternative coping strategies such as seeking social support, providing acts of compassion, engagement in exercising, and employment of positive thinking (ogueji et al., 2021). it was also found that the mental wellbeing of college students should consider promotion of physical activity (vankim & nelson, 2013). other health behavior changes related to sex, parental status, job status, depression, and having more time available during the pandemic were the most cited reasons for these successful coping outcomes (knell et al., 2020). while these approaches proved helpful for some, there were still many others who turned to alternative medicines as methods for treatment during the pandemic lockdown; this includes the use of cannabis according to the data collected from this project. cannabis and college students 148 cannabis living situations of younger users, especially those away at college, whether dependent or independent, correlated a decrease in cannabis prevalence during the lockdowns, but not frequency (merrill et al., 2022). in a similar study, younger users reduced their cannabis consumption due to a change in accessibility of cannabis (boehnke et al., 2021). this evidence demonstrates the effectiveness of cannabis as a coping strategy for self-perceived anxiety and mental distresses for many people. complementary and alternative medicine approaches for various ailments remain underexplored. these methods include a vast range from neurological conditions to physical conditions, as compared to traditional approaches, cannabis may pose some beneficial mechanisms. much of the literature cited found anxiety to be a reoccurring theme for cannabis consumption and use. cannabis does afford some potential side effects, which are often mild to moderate. medical practitioners are encouraged to advise their patients of the probable ill-effects of cannabis use (hall & solowij, 1998), as well as its beneficial properties as an alternative and complementary based medication, prior to consideration of use (weisman & rodríguez, 2021). in some users, cannabis is utilized as a relief system for panic and anxiety, and frequent cannabis users have a higher prevalence of selfperceived anxiety, according to data by crippa et al. (2009). it was found in a study conducted by rup et al. (2021) that individuals with lower levels of self-perceived mental health statuses report more frequent use. in her report, rotermann (2020) discusses an association between utilization of cannabis and self-perceived lower levels of mental wellbeing. additionally, those with lower levels of self-perceived mental wellbeing were twice as likely to use cannabis as compared to those with higher levels of selfperceived mental wellbeing (rotermann, 2020). however, it cannot be determined if those with lower levels of self-perceived mental wellbeing are more prone to using cannabis, or if cannabis is the cause of lower levels of self-perceived mental wellbeing. the present study aims to use retrospective, self-report, cross-sectional data to identify relationships between self-perceived mental wellbeing and cannabis consumption among college students and other young adults before the pandemic, during the first year of the lockdown, and at present (as of april 2022) to determine commonalities and/or disparities. an extensive study by liu et al. (2014) lends credence to the claims that education is a key determinant of alternative self-care methods utilized and that college students have a high appetite for further complementary and alternative medicine knowledge. methods recruitment this project was part of an undergraduate course on medical cannabis. the project was constrained to a timeline within the traditional semester calendar of the university. this research was independently conducted by a group of undergraduate students. recruitment for this study was conducted via various social media platforms (facebook, instagram, twitter, snapchat, discord, and groupme). student researchers shared the link on their individual social medial accounts and requested their personal network to complete the survey and share it. no paid advertising was utilized. participants were provided an anonymous survey created on qualtrics. snowball sampling was utilized as an additional method for recruitment as well. no incentives were provided for study participation. the study was made available beginning on april 8, 2022, and closed on april 29, 2022. due to the constraints of the traditional semester, an ideal sample size was not the goal but, rather, as many respondents as possible during the permitted timeframe. data analysis ibm spss statistics (version 27.0) was used to complete the data analysis. a paired samples ttest was used to compare self-reported mental health at the beginning of the pandemic in march of 2020, during, and when lockdown requirements had been lifted after march 2021. a one-way anova was utilized for evaluation of significant differences between participants' cannabis use status (did not use, started using, continued using, and stopped using). differences in selfcannabis, a publication of the research society on marijuana 149 reported mental health by cannabis use status was determined using a tukey-kramer post-hoc analysis. statistical significance was set at p < .05. mental health measure approval for this project was granted by the california state university channel islands institutional review board in accordance with university standards. the participants utilized a 5-point likert scale answering the questions “how would you rate your emotional/mental health prior to the covid-19 pandemic?”, “how would you rate your emotional/mental health during the covid-19 pandemic?”, and “how would you rate your current emotional/mental health?” participants could select “very poor,” “poor,” “good,” “very good,” or “extremely good,” where (1) was very poor and (5) was extremely good. cannabis use measure for this portion of the survey, participants continued to utilize a 5-point likert scale answering the following questions, “did you initiate, continue, or stop using cannabis during the first year of the pandemic for any reason?”, “did your use of cannabis increase, decrease, or stay the same from when you initiated use during the first year of the pandemic to now?”, and “did your use of cannabis increase, decrease, or stay the same prior to the pandemic to now?” participants could select “very poor,” “poor,” “good,” “very good,” or “extremely good,” where (1) was very poor and (5) was extremely good. results when the study was concluded, 122 individuals responded to the survey invitation. however, 19 did not complete the entire survey, and their data was not included in the analysis. most of the participants were between the ages of 18-24, identified as female, and were hispanic (table 1). the final analysis included 103 participants, which can be seen in table 1. table 1. participant demographics (n = 103) n % gender female 74 71.84% male 25 24.27% non-binary / third gender 4 0.04% average age 23 years race undisclosed 1 0.01% other 23 22.33% black or african american 4 0.04% asian 23 23.33% american indian or alaska native 4 0.04% white 48 46.60% ethnicity non-hispanic 50 48.54% hispanic 53 51.46% cannabis and college students 150 figure 1. average college students’ mental wellbeing values note. * = significance between prior to and during the pandemic; † = significance between during and after the pandemic. mental wellness referring to figure 1, the mean self-reported mental wellness was 2.85 (sd = 0.9) prior to the pandemic, 2.38 (sd = 1.0) during the pandemic, and 2.97 (sd = 1.0) after the covid-19 related mandates were lifted. the mean self-reported mental wellness during the pandemic was significantly lower than the mean reported prior to the pandemic, m = 0.476, 95% ci [0.286, 0.665], t(102) = 4.985, p < .001. the mean from after the lifting of mandates was significantly higher than the mean during the pandemic, m = 0.592, 95% ci [0.374, 0.810], t(102) = 5.389, p < .001. the mean self-reported mental wellness after the lifting of mandates was comparable to the mean from before the pandemic, m = 0.177, 95% ci [0.106, 0.339], t(102) = 1.037, p = .302, a non-significant difference. there were no others between groups that were statistically significant. table 2 denotes the non-significant differences found during the analysis of the data. table 2. non-signficant differences prior to, during, and after covid-19 pandemic lockdown stopped using started using continued use did not use highest self-perceived mental n = 10 14 58 21 wellness values m = 3.5 2.43 2.84 2.86 prior to march of 2020 sd = 0.97 0.76 0.91 0.73 stopped using started using continued use did not use highest self-perceived mental n = 10 14 58 21 wellness values during m = 2.7 1.93 2.28 2.81 pandemic sd = 1.2 0.7 1 1 cannabis, a publication of the research society on marijuana 151 stopped using started using continued use did not use highest self-perceived mental n = 10 14 58 21 wellness values after m = 3.1 3.07 2.95 2.9 march of 2021 sd = 0.74 0.92 1 0.83 significant variations there was a significant variation in selfreported mental wellness prior to the pandemic between the different levels of cannabis use, f(3, 99) = 2.99, p = .035. there was a significant difference in self-reported mental wellness from those who stopped using cannabis (n = 10, m = 3.50, sd = 0.97) compared to those who started using cannabis (n = 14, m = 2.43, sd = 0.76; p = .018). there were no other pre-pandemic groups that were statistically significant. there was a significant variation in selfreported mental wellness during the pandemic between the different levels of cannabis use, f(3, 99) = 3.01, p = .034. there was a significant difference in self-reported mental wellness from those who did not use cannabis (n = 21, m = 2.81, sd = 1.0) compared to those who started using cannabis (n = 14, m = 1.93, sd = 0.73; p = .045). there were no other groups that were statistically significant. the differences in self-reported mental wellness after the pandemic between different cannabis use levels was not significant, f(3, 99) = 0.160, p = .923. discussion this study used retrospective self-report data from a convenience sample of college students to examine cannabis use and self-perceived mental wellbeing during the covid-19 pandemic. it cannot be definitely concluded from this data that cannabis is associated with lower levels of selfperceived mental wellbeing. while the data showed those who recently stopped using cannabis reported higher levels of self-perceived mental wellbeing during the pandemic, and those who continued using cannabis had worse selfreported mental wellbeing, perhaps those struggling with mental wellbeing turned to cannabis, rather than cannabis being the cause of poor mental wellbeing outcomes. in similar research, rotermann (2020) was unable to demonstrate the causal relationship between worsening self-perceived mental wellbeing and cannabis use. prior to the pandemic, in march 2020, those who stopped using cannabis for the duration of the pandemic had significantly higher levels of selfperceived mental wellbeing compared to those who started using cannabis at the beginning of the pandemic. the individuals whose cannabis use stayed the same, and who did not use, had comparable levels of self-perceived mental wellbeing. our data suggests that it cannot be concluded that cannabis was the cause of lower levels of mental wellbeing, or that lower levels of self-perceived mental wellbeing encouraged the use of cannabis during this perilous time. during the pandemic, between march 2020 – march 2021, it was discovered that those who started using cannabis had the lowest levels of self-perceived mental wellbeing, and this was significantly different from those who did not use cannabis. individuals who stopped using cannabis during the pandemic, or whose use stayed the same, had comparable self-perceived mental wellbeing scores. it appears once the pandemic lockdown restrictions had been lifted by march of 2021, all self-perceived mental wellbeing levels returned to near baseline. for study participants, when thinking about their mental wellbeing, and cannabis use prior to the pandemic, it was those who did not start using that resulted in higher levels of self-perceived mental wellbeing, as compared to those who initiated use or continued use throughout the course of the pandemic. limitations this study was limited with a small sample size, however, due to the limitation of the academic calendar, it was not possible to have the survey available for more than four weeks. unfortunately for the current study, the sample size was limited to 103 respondents with viable data. furthermore, if the survey had been cannabis and college students 152 available for longer, it is probable more respondents would have provided additional data. the federal status of cannabis adds additional challenges to recruiting respondents to a survey due to advertising restrictions with various outlets. this resulted in more reliance on snowball sampling, as defined in methods, which increased issues of anonymity and confidentiality and further discouraged participation in the survey. this recruitment technique also potentially limited diversity in the sample, and therefore, is not representative of the population. an example of this is the relatively high number of cannabis users in our sample (sandler et al., 2019; facebook terms of service, 2022). the respondents were asked to report their own status of mental wellbeing according to questions that were not validated instruments. as this project was taken on as a part of an undergraduate class, time and depth were both limited. this is reflected in the relatively crude and vague instruments used to collect our data, such as asking people to rate their self-perceived “mental wellbeing,” versus asking them to consider different aspects of mental wellbeing when answering the unvalidated questions. the survey required the subjects to report their self-perceived mental wellbeing retrospectively some time after the pandemic lockdown restrictions had been lifted. the questions specifically asked for answers related to “after march 2021,” and the survey that collected this data was implemented in april of 2022. conclusion students who started using cannabis at the beginning of the pandemic had lower levels of selfperceived mental wellbeing. it is unknown whether or not it is related to cannabis use. significant differences were discovered in selfperceived mental wellbeing between those who did not use compared to those who either started using or continued cannabis use during the pandemic. while during the pandemic, there was a significant difference between those who did not use cannabis and those who began using. it cannot be concluded that their self-perceived mental wellbeing was lower due to cannabis use. however, it is possible their lower self-perceived mental wellbeing states promoted cannabis use. the associations between cannabis use and selfperceived mental wellbeing are relevant to science and should remain at the forefront of ongoing research to better understand these correlations. references algara, c., amlani, s., collitt, s., hale, i., & kazemian, s. 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(2021). a systematic review of medical students’ and professionals’ attitudes and knowledge regarding medical cannabis. journal of cannabis research, 3(1). https://doi.org/10.1186/s42238-021-00100-1 funding and acknowledgements: no funding was utilized in this research. all authors declare that they have no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 139 ved abstract objective: despite increasing use of medical cannabis to manage cancer-related symptoms, u.s. payers do not reimburse medical cannabis, leaving patients responsible for all associated costs. we assessed how selfreported financial well-being is associated with patterns of cannabis consumption, out-of-pocket costs, and impact on symptoms in patients with cancer. method: from december 2021 to january 2022, we surveyed patients with cancer enrolled in the minnesota medical cannabis program. the mailed survey included cancer history, cannabis use history, symptom changes and sociodemographic questions including income and perceived financial wellness. we conducted descriptive analyses. results: of 797 eligible adults, 220 (28%) responded to the survey. two hundred eleven answered a question about current household income as living comfortably (lc, 45%; n = 95) or not living comfortably (nlc, 55%; n = 116). the nlc group reported lower incomes (47% vs 8% with annual incomes <$50,000) and were typically younger, unmarried, unemployed, or disabled. nlc group purchased more vaporizers (48% vs 27%), used products high in thc (92% vs 82%), and reported higher cannabis costs (40% vs 21% spending $200+/month). the nlc group more often stopped or used cannabis less frequently than they would like (54% versus 32%), frequently citing costs as a reason (85% vs 39%). both nlc and lc groups typically used cannabis daily and reported a high degree of symptom improvement. conclusions: patients with cancer using cannabis report significant improvements in cancer-related symptoms. high out-of-pocket costs for cannabis may be especially burdensome among those already financially struggling, raising questions about affordability of and equitable access to this therapy. key words: = cannabis; marijuana; cancer; financial toxicity; patient-reported outcome; symptoms in the united states (us), 37 states have legalized cannabis for medical and/or recreational purposes as of february 2023 with a growing number of patients with cancer using cannabis (ncsl, 2024). in recent surveys, nearly 20-25% of all patients undergoing cancer care reported current use of cannabis (martell et al., 2018; pergam et al., 2017), with similar prevalence rates for patients with early-stage and advancedstage (palliative intent) disease (saadeh & rustem, 2018; zylla, 2022). most patients report use of cannabis to alleviate symptoms of pain, nausea, insomnia and appetite loss that are related to the cancer or its treatment (steele et al., 2019). most cannabis research relies on observational data using patient-reported outcomes, with only a few, small-scale dylan zylla1, helen parsons2, jeanette ziegenfuss3, bruce lindgren2, susan park4, patricia jewett2, arjun gupta2, anne blaes2 1 healthpartners institute cancer research center 2 department of hematology, oncology and transplantation, university of minnesota 3 healthpartners institute 4 minnesota department of health cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000243 volume 8, issue 1 association of financial wellness with patterns of medical cannabis use and patient-reported outcomes in adults with cancer corresponding author: dylan zylla, md, ms, health partners cancer research center, 3800 park nicollet blvd, minneapolis, minnesota 55416. phone: (952)993-3248. email: dylan.zylla@parknicollet.com. financial wellness and cannabis use in cancer 140 randomized controlled trials on cannabis outcomes in patients with cancer completed to date (abrams, 2018; fallon et al., 2017; good et al., 2019; lichtman et al., 2017; steele et al., 2019; zylla et al., 2021). in two large observational studies, patients reported significant symptom improvement in the first 4-6 months after starting cannabis use with low rates of adverse events (anderson et al., 2019; bar-lev schleider et al., 2018). generalizing results from cannabis studies is challenging given the myriad of cannabinoidbased products with varying amounts of delta-9tetrahydrocannabinol (thc): cannabidiol (cbd) and different delivery mechanisms (anderson et al., 2019; bar-lev schleider et al., 2018; kim et al., 2019). furthermore, only 29% of oncologists report having sufficient knowledge of cannabis to provide recommendations to patients on its use (braun et al., 2018). as a result, patients may create their own cannabis treatment plans, experimenting with different products which can lead to higher overall out-of-pocket costs. the cost of cannabis is not covered by health insurance. cancer and its treatments are associated with high costs, some of which patients must cover themselves. growing cancer costs have given rise to sometimes dramatic financial burdens (“financial toxicity”) incurred by cancer (sedhom et al., 2021). costs for medical cannabis programs could further add to these financial burdens. in the highly regulated minnesota cannabis program (mcp), patients with cancerrelated symptoms report spending an average of $236 each month in addition to the yearly $200 registration fee, and patients using long-term cannabis for chronic, non-cancer pain may spend close to $4000 per year (mdh, n.d.). states with recreational programs may have lower monthly cannabis costs, but data are lacking (chino, 2022). the cost of cannabis is listed by both patients and clinicians as a barrier to more widespread cannabis utilization (olson et al., 2023; zylla et al., 2018; zylla et al., 2021) and differential affordability of medical cannabis programs could create new health inequities. despite increasing use of cannabis in patients with cancer to manage symptoms, data on the effectiveness of cannabis products for specific cancer symptoms remain sparse. further, little is known about if and how income is associated with the patterns of use of cannabis products and outof-pocket costs. we examined how financial wellness was associated with patterns of cannabis use and self-reported change in cancer symptoms (pain, anorexia, insomnia, stress, digestive issues, fatigue, and neuropathy) among cancer patients registered with the mcp. methods study setting in minnesota, legislation was passed in 2014 that allows seriously ill minnesotans to use medical cannabis to treat certain conditions. patients with cancer, coupled with a diagnosis of cancer-related pain, nausea or anorexia/cachexia are eligible to enroll in a patient registry maintained by the state. patients on this registry can get medical cannabis directly from one of fourteen dispensaries set up across the state. in december 2021, just under 1,400 individuals aged 18+ with a cancer-related indication were enrolled in the mcp. data collection central irb approval was obtained from the university of minnesota (protocol number 2020ls161). of the approximate 1,400 mcp registrants, 796 made a cannabis purchase in the prior three months and were invited to participate in a one-time survey. the survey was mailed december 2021-january 2022, accompanied by a letter signed by the mcp, and a postage-paid envelope to return the paper survey. returned surveys were scanned centrally using the teleform verification process and using a priori defined rules for data capture including treatment of out-of-range values, missed skip patterns and/or multiple responses. in total, 220 (28%) individuals completed the survey. for this analysis, we excluded participants who had not answered the question of whether they were living comfortably on their income, resulting in a total sample size of 211. the mcp provided a comprehensive report of all cannabis purchases from state-approved dispensaries for any survey respondent that was used to validate patientreported cannabis use and monthly costs. measures and statistical analysis cannabis, a publication of the research society on marijuana 141 the study survey was developed under the direction of dr. zylla in partnership with the healthpartners center for evaluation and survey research (cesr) and the study team using survey items with known psychometric properties where available, and with best practices for reducing measurement error and reducing burden when not (fowler, 1995). the survey was reviewed by content experts and patient advocates for face validity and iteratively modified as indicated. survey questions focused on a) current and past use of cannabis, b) frequency and duration of use, c) mode of use, d) therapeutic reasons for use, e) perceptions of benefit or risk/harm, f) discussion of use with clinical providers, g) recommendations received from clinical providers and h) costs. the survey questions used for this analysis are displayed in supplemental figure 1. the primary exposure of interest (taken from the national cancer institute’s health information national trends survey) was whether participants reported ‘living comfortably’ (lc) on their present income versus ‘not living comfortably’ (nlc; e.g., ‘getting by,’ ‘finding it difficult,’ or ‘finding it very difficult’) on their present income (national cancer institute, n.d.) . we chose subjective income perception over income dollar ranges because the same objective income may mean different things subjectively depending on one’s circumstances (e.g., dependents, assets, debts, fixed monthly expenses, etc.). the primary outcomes of interest in this analysis were 1) self-reported changes in symptoms (“how much do you think cannabis has worsened or improved your [pain; loss of appetite; insomnia or difficulty sleeping; stress (including anxiety or depression); digestive problems (including nausea, vomiting, diarrhea, constipation); fatigue or lack of energy; neuropathy]”, with answers ranging from “worsened quite a bit” to “improved quite a bit,” and with one answer option “i do not have this symptom.” second, we assessed patterns of cannabis use and cost: cannabis use before and since one’s cancer diagnosis, frequency of use, product type, average costs from cannabis use per month, whether cannabis use was stopped or frequency was reduced, and if yes, whether cost was a reason. a full list of these questionnaire items is provided in supplemental figure 1. we used descriptive statistics (frequencies, and chisquared, fisher, or wilcoxon rank sum tests as appropriate) to describe the study characteristics. results of 211 total respondents, 95 (45%) reported lc on their present income, and 116 (55%) reported nlc on their present income. respondents had diverse cancer diagnoses as seen in table 1 (breast 25.4%, lung 15.1%, colorectal 9.8%, prostate 8.8%). approximately 61% were 60 years old or older (with a median age of 62 years), 52% were female, 95% were white, and 40% were retired. most respondents (57%) had stage iv disease. some characteristics differed between the lc and the nlc group: those nlc were less likely to be married or partnered (60% vs. 88%), less likely to be 60 years old or older (53% vs. 71%), less likely to be retired (28% vs. 54%), more likely to be unemployed (7% vs. 0%) or disabled (35% vs. 7%), and to have lower incomes (47% vs. 8% with annual incomes <$50,000). table 1. characteristics of the study population characteristic everyone (n = 211) not living comfortably (n = 116) living comfortably (n = 95) p b n (%) n (%) n (%) age group: .007 <40 years 13 (6.2) 6 (5.3) 7 (7.4) 40-49 25 (12) 19 (16.7) 6 (6.3) 50-59 44 (21.1) 29 (25.4) 15 (15.8) 60-69 84 (40.2) 45 (39.5) 39 (41.1) > 70 43 (20.6) 15 (13.2) 28 (29.5) financial wellness and cannabis use in cancer 142 gender: .48 male 100 (47.6) 53 (46.1) 47 (49.5) female 109 (51.9) 62 (53.9) 47 (49.5) other 1 (0.5) 0 (0) 1 (1.1) race: .46 white 202 (96.7) 109 (95.6) 93 (97.9) other 7 (3.4) 5 (4.4) 2 (2.1) hispanic ethnicity: >.99 no 202 (98.1) 111 (98.2) 91 (97.9) yes 4 (1.9) 2 (1.8) 2 (2.2) education: less than hs 4 (1.9) 3 (2.6) 1 (1.1) hs graduate 19 (9.1) 14 (12.3) 5 (5.3) post hs training 23 (11) 11 (9.7) 12 (12.6) some college 57 (27.3) 38 (33.3) 19 (20) college graduate 68 (32.5) 34 (29.8) 34 (35.8) postgraduate 38 (18.2) 14 (12.3) 24 (25.3) marital status: <.0001 married or partnered 152 (72.7) 68 (59.7) 84 (88.4) divorced / separated 29 (13.9) 25 (21.9) 4 (4.2) widowed 13 (6.2) 8 (7.0) 5 (5.3) single, never married 15 (7.2) 13 (11.4) 2 (2.1) occupation status: <.0001 employed 61 (29.3) 26 (23) 35 (36.8) unemployed 8 (3.9) 8 (7.1) 0 (0) homemaker 3 (1.4) 2 (1.8) 1 (1.1) student 1 (0.5) 0 (0) 1 (1.1) retired 83 (39.9) 32 (28.3) 51 (53.7) disabled 47 (22.6) 40 (35.4) 7 (7.4) other 5 (2.4) 5 (4.4) 0 (0) annual household income: <.0001 <20k 20 (9.9) 20 (17.9) 0 (0) 20k-35k 21 (10.4) 18 (16.1) 3 (3.3) 35k-50k 18 (8.9) 14 (12.5) 4 (4.4) 50k-75k 43 (21.3) 24 (21.4) 19 (21.1) 75k-100k 35 (17.3) 19 (17) 16 (17.8) 100k-200k 49 (24.3) 16 (14.3) 33 (36.7) >200k 16 (7.9) 1 (0.9) 15 (16.7) health care coverage: >.99 yes 198 (96.6) 108 (96.4) 90 (96.8) no 7 (3.4) 4 (3.6) 3 (3.2) cancer type:a breast 52 (25.4) 30 (27) 22 (23.4) .55 prostate 18 (8.8) 9 (8.1) 9 (9.6) .71 lung 31 (15.1) 14 (12.6) 17 (18.1) .28 colon 20 (9.8) 12 (10.8) 8 (8.5) .58 cannabis, a publication of the research society on marijuana 143 other 115 (56.1) 60 (54.1) 55 (58.5) .52 cancer stage: .90c i 15 (9.1) 8 (8.9) 7 (9.3) ii 26 (15.8) 13 (14.4) 13 (17.3) iii 30 (18.2) 18 (20) 12 (16) iv 94 (57.0) 51 (56.7) 43 (57.3) don’t know 39 23 16 note. a more than one response may be selected; total n does not sum up to total sample size. b the p-value was derived from the chi-square or fisher’s exact tests for categorical factors and the non-parametric wilcoxon rank sum test for ordinal variables. c p calculated without the “don’t know” category. cannabis use patterns approximately 70% of all respondents reported using cannabis at least once prior to cancer diagnosis (table 2). nearly all respondents (94%) were currently using cannabis with 75% of those using cannabis reporting daily use. there was no evidence for differences in frequency of use between the lc and nlc groups. oral products (tablets, oral solutions and/or tinctures) were used more commonly than vaporizers (88% vs. 53%). the nlc group more often ingested cannabis via foods such as brownies, cookies, cake, or candy (35% vs. 18%, p = .01) and used vaporizers more often than the lc group (64% vs. 40%, p = .001). about one third of patients used topical products. eighty-eight percent of all respondents purchased at least one thc dominant product with nlc group having slightly higher purchase rates of thc-dominant products (92% vs. 82%, p = .05) and lower rates of using thc:cbd equivalent products (29% vs. 44%, p = .03). whole plant/smokeable products were not available in mcp during the period of the survey. table 2. patterns of cannabis use patterns of cannabis use everyone (n = 211) not living comfortably (n = 116) living comfortably (n = 95) p n (%) n (%) n (%) used prior to cancer diagnosis: .08 no 63 (30.3) 29 (25.2) 34 (36.6) yes 145 (69.7) 86 (74.8) 59 (63.4) used since cancer diagnosis: .63 no 4 (1.9) 3 (2.6) 1 (1.1) yes 204 (98.1) 112 (97.4) 92 (98.9) current user: >.99 no 11 (6) 6 (6) 5 (6) yes 172 (94) 94 (94) 78 (94) number of days used in past 30 days: .31 1-15 39 (20.7) 20 (19.4) 19 (22.4) 16-29 45 (23.9) 21 (20.4) 24 (28.2) 30 104 (55.3) 62 (60.2) 42 (49.4) product type:a high thc:cbd 149 (87.7) 84 (92.3) 65 (82.3) .05 equal thc:cbd 61 (35.9) 26 (28.6) 35 (44.3) .03 high cbd:thc 27 (15.9) 12 (13.2) 15 (19.0) .3 financial wellness and cannabis use in cancer 144 product route of admin:a oral 173 (87.8) 96 (87.3) 77 (88.5) .79 oral via food 54 (27.4) 38 (34.6) 16 (18.4) .01 oral via drink 10 (5.1) 6 (5.5) 4 (4.6) >.99 oral via pills, tinctures, sublingually 160 (81.2) 85 (77.3) 75 (86.2) .11 vaporizer 105 (53.3) 70 (63.6) 35 (40.2) .001 topical 71 (36.0) 42 (38.2) 29 (33.3) .48 smoking 47 (23.9) 31 (28.2) 16 (18.4) .11 frequency of use during cancer treatment: .64 more than once a day 56 (34.6) 34 (39.5) 22 (29) once a day or almost every day 66 (40.7) 33 (38.4) 33 (43.4) few times a week 28 (17.3) 13 (15.1) 15 (19.7) few times a month 9 (5.6) 4 (4.7) 5 (6.6) once a month or less 0 (0) 0 (0) 0 (0) only tried it once or twice 3 (1.9) 2 (2.3) 1 (1.3) average cannabis costs per month: .04 <$50 31 (15.6) 15 (13.5) 16 (18.2) $50-$99 51 (25.6) 24 (21.6) 27 (30.7) $100-$199 55 (27.6) 28 (25.2) 27 (30.7) ≥$200 62 (31.2) 44 (39.6) 18 (20.5) stopped / used less than you would like: .002 no 108 (55.7) 49 (45.8) 59 (67.8) yes 86 (44.3) 58 (54.2) 28 (32.2) cost was a reason for stopping or using less than you would like?b <.0001 no 26 (30.2) 9 (15.5) 17 (60.7) yes 60 (69.8) 49 (84.5) 11 (39.3) note. a more than one answer may be selected. b among those who answered ‘yes’ to previous question. the nlc group more often reported stopping cannabis use or using cannabis less frequently than they would like to (54% versus 32%, p = .002). among those reporting they had stopped using cannabis or were using it less frequently than they would like to, nlc respondents were more likely than lc respondents to cite costs as a reason (85% versus 39%, p < .001). the nlc group also reported higher cannabis costs than the lc group (40% versus 21% having $200 or more in monthly cannabis costs, p = .04). comprehensive cannabis purchase data provided by the mcp linked to survey respondents helped support self-reported data on cannabis use (results not shown). nlc respondents showed a trend towards longer duration enrolled in the mcp program (12.5 vs. 8.1 months (median), p = .27), higher total number of cannabis purchases (16 vs 12 total purchases (median), p = .10), and greater use of high thc products (58% vs. 50% high thc>cbd purchases, p = .035). patient-reported symptom burden most respondents gave favorable judgements as to how cannabis impacted their cancer symptoms (table 3). there was no evidence for significant differences in any of the selfreported effects on symptom burden between the lc and nlc groups. patients with pain, insomnia, and stress (anxiety/depression) had the largest benefit from cannabis use, with patient proportions reporting improvements in these symptoms ranging from 83-91%. the proportion of patients reporting improvements in anorexia and cannabis, a publication of the research society on marijuana 145 digestive symptoms was 69-80%, and about half of respondents reported improvements in fatigue and neuropathy. almost no respondents reported that any of these symptoms got worse after cannabis use. table 3. self-reported changes in symptoms after cannabis use symptom everyone (n = 211) not living comfortably (n = 116) living comfortably (n = 95) p c n (%) n (%) n (%) pain: .44 worsened 1 (0.5) 1 (1) 0 (0) no change 18 (9.8) 8 (7.8) 10 (12.3) improved 165 (89.7) 94 (91.3) 71 (87.7) do not have symptom 13 6 7 anorexia: .05 worsened 1 (0.6) 1 (1.1) 0(0) no change 41 (26.1) 17 (19.3) 24 (34.8) improved 115 (73.2) 70 (79.5) 45 (65.2) do not have symptom 40 21 19 insomnia: .44 worsened 0 (0) 0 (0) 0 (0) no change 20 (10.8) 13 (12.3) 7 (8.8) improved 166 (89.2) 93 (87.7) 73 (91.3) do not have symptom 12 4 8 stress a: .93 worsened 0 (0) 0 (0) 0 (0) no change 31 (17.5) 18 (17.3) 13 (17.8) improved 146 (82.5) 86 (82.7) 60 (82.2) do not have symptom 21 6 15 digestive b: .47 worsened 2 (1.4) 0 (0) 2 (3.4) no change 47 (32) 28 (31.5) 19 (32.8) improved 98 (66.7) 61 (68.5) 37 (63.8) do not have symptom 50 20 30 fatigue: .12 worsened 7 (4) 5 (5) 2 (2.7) no change 91 (52) 45 (45) 46 (61.3) improved 77 (44) 50 (50) 27 (36) do not have symptom 21 9 12 neuropathy: .72 worsened 1 (0.7) 1 (1.2) 0 (0) no change 65 (46.4) 39 (47) 26 (45.6) improved 74 (52.9) 43 (51.8) 31 (54.4) do not have symptom 58 27 31 note.a includes anxiety and depression b includes nausea, vomiting, diarrhea and constipation c the p-value was derived from the wilcoxon rank sum test excluding those not reporting the respective symptom. financial wellness and cannabis use in cancer 146 discussion in this survey study of patients with cancer registered in a state medical cannabis program, we found that individuals not living comfortably on their present income had higher monthly out-of-pocket costs for cannabis and were more likely to stop using cannabis or use it less than they would like; and this group more often cited cost as a reason for cannabis use disruptions. the overwhelming majority of patients reported improvements across a range of cancer symptoms and over half had used cannabis daily during their cancer treatments. virtually no respondents reported worsening symptoms from cannabis use. our study adds to a growing body of literature suggesting that medical cannabis may be a promising intervention to alleviate cancer symptoms (abrams, 2018; anderson et al., 2019; bar-lev schleider et al., 2018; steele et al., 2019). our study is one of the first to highlight financial challenges that come along with cannabis use: in our study population, those not living comfortably on their income reported higher costs related to cannabis, more often reported use disruptions (about half of nlc respondents), and more often cited costs as a reason for those disruptions. these findings are even more concerning as we also found that those not living comfortably on their income were younger, more likely to be disabled or unemployed, and less likely to be partnered – i.e., those not living comfortably on their income included some vulnerable patient subgroups. the annual enrollment fee of up to $200 for the state program may further add to the financial burden. however, while all patients in our survey paid the $200 annual fee, this fee was discontinued by the mcp in july 2023 when minnesota passed a recreational cannabis law and shows that costs for cannabis may drop when cannabis becomes recreationally legal. together, our findings raise questions around health equity with regards to access to medical cannabis among those with cancer. if cannabis is indeed effective to reduce cancer symptoms, all patient groups, and especially those most vulnerable, should have access to cannabis if they wish to, calling for interventions to make medical cannabis more affordable. for example, uncontrolled pain remains a large challenge for patients with cancer, with many seeking out alternative/integrative therapies suggested in national comprehensive cancer network guidelines (nahin et al., 2016; sedhom et al., 2021). like cannabis, many of these therapies often lack insurance coverage and lead to more financial toxicity. for instance, acupuncture costs over $100 per session and requires weekly visits, leading to similar monthly costs for patients using daily cannabis (fan et al., 2019). despite nearly 20% of patients with cancer use cannabis (martell et al., 2018; pergam et al., 2017), little is known about the type of products purchased and financial implications for patients. state medical programs generally require more regulatory oversight including comprehensive product testing for purity and potency, leading to higher overall costs for patients. thc-dominant products and those administered via a vaporizer typically have higher costs. research conducted in the mcp and other programs showed a wide variety of products and routes being utilized by patients (anderson et al., 2019; bar-lev schleider et al., 2018; pergam et al., 2017; zylla et al., 2021). patients in our survey also use various products and routes and generally appear to utilize oral products with a high thc:cbd ratio. vaporizer administration is faster acting compared to the oral route but has a shorter duration of control (grotenhermen, 2003). therefore, given the shorter duration of effect, there is concern there would be less of a sustained benefit for chronic symptom control among patients using an inhalation route of administration. as such, the increased rate of vaporizer use in nlc patients may lead to more frequent use and higher overall monthly costs. more research and clinical education are needed to show patients, providers, and policymakers how cannabis impacts overall symptom burden. specific dosing regimens for various symptoms would help patients obtain optimal dosing earlier on and lead to less trial and error. most patients desire cannabis education and guidance from their cancer care team, yet often end up relying on family, friends, and online sources (pergam et al., 2017) given great variability in medical cannabis knowledge and training for cannabis dispensary staff workers (braun et al., 2022). these gaps in professional knowledge may result in patients resorting to a “trial and error” approach that requires purchase of products that are ultimately unnecessary. for example, cannabis monthly costs depend largely cannabis, a publication of the research society on marijuana 147 on the total amount of thc purchased and frequency of use. having safe, cost-effective cannabis dosing guidelines may also entice a larger pool of patients to try cannabis. lowering the overall cost of medical cannabis through improved insurance coverage or discounted fees/rates for patients with cancer (especially those at lower income levels) could improve accessibility and reduce potential economic barriers that make cannabis unobtainable for many patients. our study has limitations. this was a cross-sectional study with a limited sample size that was 95% white in one geographic area and state program; our findings should be replicated in larger studies of diverse samples. this lack of racial diversity makes generalizing results difficult. we were unable to address the added economic challenges and potential legal fears that minorities may face when considering a purchase of cannabis. there is a possibility of selection bias in that cannabis users who were more enthusiastic about the effects of cannabis on their symptoms may have been more likely to participate in the study. further, continuing controversies around the legal status of medical cannabis may have made some potential respondents hesitant to participate, even though we ensured confidentiality in our consent form. we cannot rule out reverse causality in that it is possible that those who report more use or unmet need for cannabis perceive lower levels of living comfortably as a result. our survey did not explore decision making on how patients selected products/doses, or how much experimentation they needed to reach a cannabis regimen that worked for them. respondents had a median time in the state program off over 8 months suggesting that the reported cannabis products and monthly costs likely indicated their final “ideal” regimen. future studies should attempt to track cannabis use from the time of initial purchase to the most recent purchase to determine how product type, route of administration and total thc/cbd dose evolves over time. as stated earlier, the survey did not address other important social determinants of health that could impact overall financial wellness. as this survey took place during the covid-19 pandemic, it is possible one’s comfort of living (especially amongst those with a cancer diagnosis) may have been significantly altered further impacting their interest or ability to purchase cannabis. conclusion patients with 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(2017). cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use. cancer, 123(22), 4488-4497. https://doi.org/10.1002/cncr.30879 cannabis, a publication of the research society on marijuana 149 saadeh, c. e., & rustem, d. r. (2018). medical marijuana use in a community cancer center. jco oncology practice, 14(9), e566-e578. https://doi.org/10.1200/jop.18.00057 sedhom, r., gupta, a., wang, l., paller, c., & bao, t. (2021). payer coverage of integrative medicine interventions for symptom control in patients with cancer. jco oncology practice, 17(10), 587-590. https://doi.org/10.1200/op.21.00361 steele, g., arneson, t., & zylla, d. (2019). a comprehensive review of cannabis in patients with cancer: availability in the usa, general efficacy, and safety. current oncology reports, 21(1), 10. https://doi.org/10.1007/s11912-019-0757-7 zylla, d., jax, s, schmiechen, k, jelle, k, gilmore, g. (2022). a novel cannabis education clinic for patients with cancer: patient characteristics from initial visit. journal of clinical oncology 40, no. 28_suppl (october 01, 2022) 298-298. zylla, d., steele, g., eklund, j., mettner, j., & arneson, t. (2018). oncology clinicians and the minnesota medical cannabis program: a survey on medical cannabis practice patterns, barriers to enrollment, and educational needs. cannabis and cannabinoid research, 3(1), 195-202. https://doi.org/10.1089/can.2018.0029 zylla, d. m., eklund, j., gilmore, g., gavenda, a., guggisberg, j., vazquezbenitez, g., pawloski, p. a., arneson, t., richter, s., birnbaum, a. k., dahmer, s., tracy, m., & dudek, a. (2021). a randomized trial of medical cannabis in patients with stage iv cancers to assess feasibility, dose requirements, impact on pain and opioid use, safety, and overall patient satisfaction. supportive care in cancer, 29(12), 7471-7478. https://doi.org/10.1007/s00520-021-06301-x funding and acknowledgements: this study was supported by the national cancer institute p30 supplement – grant #3p30ca077598-22s2. the authors have no conflicts of interest to disclose. this work was presented in abstract and poster sessions at the 2022 american society of clinical oncology annual meeting june 3-7, 2022, in chicago, il. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: zylla, d., parsons, h., ziegenfuss, j., lindgren, b., park, s., jewett, p., gupta, a., & blaes, a. (2025). association of financial wellness with patterns of medical cannabis use and patient-reported outcomes in adults with cancer. cannabis, 8(1), 139-149. https://doi.org/10.26828/cannabis/2024/000243 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 108 ved abstract objective: the current study investigated procrastination as a potential moderator of the association between cannabis use and college grade point average (gpa). participants: 220 college students (ages 1824; 71.8% female) in the northwestern u.s. who were registered for classes in fall 2021. methods: demographic questions, substance use history, the beck anxiety inventory, the center for epidemiologic studies depression scale, and a procrastination scale were completed via an online survey. official term and cumulative gpa records were also collected. results: a regression model indicated that procrastination moderated the association between lifetime cannabis use and cumulative college gpa, whereas this moderation was not present when examining the relationship between past month cannabis use and term gpa. conclusion: the current study identifies a putatively modifiable factor that may be related to academic performance for students who use cannabis. these results may help inform future interventions designed to help students using cannabis succeed academically. key words: = cannabis; marijuana; procrastination; academic performance the nationwide prevalence of cannabis use among young adults (ages 19-30) reached new heights in 2021, with 42.6% reporting cannabis use in the past 12 months and 28.5% reporting use in the past 30 days, representing the highest levels recorded since the late 1980s (patrick et al., 2022). additionally, an increasing number of states have recently voted to legalize and regulate the recreational use of cannabis, potentially normalizing cannabis use among young adults residing in those areas. research suggests that cannabis use rates increased more among college students in oregon following recreational cannabis legalization than in states where recreational cannabis use remains prohibited (bae & kerr, 2020; kerr et al., 2018). in fact, a recent study in oregon found 51% of young adults (ages 22-24) reported cannabis use in the past 30 days, whereas only 33% of respondents reported past 30-day use in a sample taken from the same schools 10 years prior, when recreational cannabis use was illegal (stormshak et al., 2019). cannabis use among young adults on this scale is even more troubling in light of research suggesting a link between cannabis use and lower college grade point average (gpa), while also underscoring that the mechanisms behind this association are not well understood (martinez et al., 2015). as attitudes and behaviors surrounding cannabis use continue to evolve, so too must our understanding of the association between cannabis use and academic performance. furthermore, given the widespread prevalence of cannabis use among young adults, investigations need to be conducted to identify potential moderating factors in the association between cannabis use and academic performance that can be used to inform the creation of novel interventions. christopher j. mullin and anita cservenka 1 school of psychological science, oregon state university, corvallis, united states cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000215 cannabis use and academic performance in college students: the role of procrastination corresponding author: anita cservenka, ph.d., school of psychological science, oregon state university, 2950 sw jefferson way, corvallis, or 97331. phone: (541) 737-1366, email: anita.cservenka@oregonstate.edu cannabis, a publication of the research society on marijuana 109 cannabis and academic performance laboratory studies have repeatedly found that cannabis negatively impacts brain development, cognition, memory, and executive functioning in adolescent and young adult populations (ashtari et al., 2009; broyd et al., 2016; burggren et al., 2019; fontes et al., 2011). however, the evidence for cannabis use negatively impacting academic performance is more equivocal. for example, studies have shown that only certain patterns of cannabis use, such as younger age of initial cannabis use or increasingly frequent use, are associated with reduced educational attainment, higher dropout rates, and lower gpa among college students and young adults in general (suerken et al., 2016; thompson et al., 2019). furthermore, a systematic review of 16 longitudinal studies examining the associations among cannabis use and psychosocial outcomes (including educational attainment) revealed a consistent association between cannabis use and reduced educational attainment, but the strength of the association varied considerably between studies and was substantially reduced after adjusting for potential confounds (macleod et al., 2004). evidence for a direct effect of cannabis use on academic performance is scarce. rather, extant literature is replete with studies reporting indirect associations and stressing the role of additional covariates. for example, prior research suggests that academic performance is negatively affected by a culture surrounding cannabis use that includes delinquency and educational disengagement, rather than actual cognitive deficits (fergusson et al., 2003; lynskey & hall, 2000). however, as cannabis use continues to become more normalized, it seems increasingly unlikely that it would necessitate membership in a specific cannabis-based subculture. more recent research has identified additional factors to consider in the association between cannabis use and lower gpa in both high school and college students. for instance, several studies have concluded that cannabis use is related to increased rates of absenteeism, which then negatively impacts gpa (arria et al., 2015; caldeira et al., 2008). other studies have produced contradictory evidence for the effects of covariates. decamp and daly (2019) found that cannabis use was not related to test performance at a high-school level, and instead suggest that socioeconomic inequity was a much better predictor of academic performance. conversely, meier et al. (2015) examined the association between cannabis use and academic performance in a high socioeconomic status population and found that cannabis use was associated with lower test scores and gpa. importantly, the researchers found that the impact of cannabis use on academic performance was absent when controlling for alcohol and tobacco use (meier et al., 2015). on the contrary, páramo et al. (2020) found that coconsumption of alcohol and cannabis together had a greater negative impact on college gpa than binge-drinking alone, suggesting cannabis use may impact academic performance above and beyond alcohol use. other researchers have also found an association between the simultaneous use of cannabis with alcohol/tobacco and lower gpa, indicating that subsequent research into the effects of cannabis use must also account for polysubstance use (heradstveit et al., 2017; hernandez-serrano et al., 2018). lastly, college is a stressful time and students have been known to report elevated levels of depression and anxiety. a recent survey of college students indicates that 48% report moderate-tosevere levels of depression and 38% report moderate-to-severe levels of anxiety (wang et al., 2020). as increased levels of anxiety and depression have also been linked to lower gpas among college students (asher blackdeer et al., 2023), investigations of the association between cannabis use and academic performance also need to account for these internalizing symptoms. crucially, in order to identify the unique impact of cannabis use on academic performance, research must first control for the potentially confounding effects of important covariates related to academic performance. procrastination procrastination is another potential factor that may moderate the association between cannabis use and poor academic performance. procrastination is quite common in college, with some studies reporting that up to 70% of college students are procrastinators (schouwenburg et al., 2004). furthermore, procrastination appears to be associated with cannabis use. buckner et al. (2010) found that over 67% of frequent cannabis users identified as procrastinators, and that over cannabis and academic performance 110 80% of cannabis users seeking treatment endorse procrastination as a problem. in addition, a recent meta-analysis indicates that a statistically significant negative correlation exists between procrastination and multiple measures of academic performance, including gpa (kim & seo, 2015). while there is some debate over whether procrastination always represents dysfunctional behavior or if there are contexts where delaying tasks can be adaptive, as well as whether procrastination is a trait or a behavioral response to certain task-specific antecedents (kim & seo, 2015), most researchers regard it as a relatively stable personality trait strongly related to low conscientiousness (schouwenburg, 2004). it seems likely, therefore, that high levels of procrastination behavior can occur independent of cannabis use history, and that a person can be high in trait procrastination without being a cannabis user (and vice versa). accordingly, the present study explores procrastination as a factor that may modify the relationship between cannabis use and academic performance (i.e., as a moderator), rather than as a theoretical causal mechanism (i.e., as a mediator). specifically, it is possible that students who use cannabis and frequently engage in procrastination are more likely to turn in assignments late and delay studying for exams longer, resulting in lower gpas, relative to non-procrastinating cannabis users. the present study the purpose of the present study was to investigate the potential moderating role of procrastination in the association between cannabis use and academic performance, assessed via college gpa. previous research has largely focused on controlling for confounding variables in this association, but there is a need to examine potential moderators that could be related to the strength of the relationship between cannabis use and academic performance. this study was designed to determine if these moderations would be evident above and beyond the potentially confounding effects of sex, race/ethnicity, parent education level, polysubstance use, anxiety, and depression. accordingly, this study was designed to address whether procrastination moderates the association between cannabis use and academic performance, and whether there are unique effects of lifetime cannabis use relative to more recent cannabis use on cumulative vs. term gpa, respectively. for each model, it was hypothesized that there would be a main effect of cannabis use, such that students who use cannabis more frequently would have lower gpas than students who use cannabis less frequently. additionally, a hypothesized main effect of procrastination behavior predicted that students with higher procrastination scores would have lower gpas than participants with lower procrastination scores. furthermore, a hypothesized interaction between cannabis use and procrastination predicted that students who use cannabis more frequently and have higher procrastination scores would have lower gpas than participants who use cannabis more frequently and have lower procrastination scores. methods participants participants were 18-24 year old college students at a university in the pacific northwest united states, and were registered for classes in the fall 2021 term. in addition, participants were required to be us citizens, fluent in english, and not currently pregnant. after screening and data cleaning (see the data screening and cleaning section of the methods), a final sample of n = 220 was obtained. this sample was primarily female (71.8%), white (79.1%) and reported an average age of 19.48 (sd = 1.63). descriptive statistics for demographic variables, covariate measures, and scores on primary variables of interest can be found in table 1. study recruitment was primarily conducted through the university’s psychology department research pool website (sona), with some additional participant recruitment via community flyers (only three participants, or 1.4% of the final sample, were recruited via flyers). participants in the study were awarded research pool credits that could be used to satisfy course requirements, or they could take part in the study on a voluntary basis. this study was approved by oregon state university’s institutional review board (irb), study # 2021-1132, and was conducted in accordance with all ethical guidelines of the irb. cannabis, a publication of the research society on marijuana 111 table 1. demographics, covariates, and scores on primary variables total (n=220) demographics m(sd) or % range age 19.48 (1.63) 6.0 sex (% female) 71.8% race american indian/alaskan native 0.9% asian 9.5% native hawaiian/pacific islander 0.9% middle eastern 0.5% white 79.1% black/african american 0.9% more than one race 4.5% other 3.6% hispanic/latinx yes 13.2% no 85.9% unknown 0.9% parent education level some high school 2.3% high school graduate/ged 10.9% some college 7.7% associate degree/trade certificate 6.4% bachelor’s degree 36.4% graduate degree 36.4% year in school freshman 50.0% sophomore 17.7% junior 20.9% senior 9.5% other 1.8% past month cannabis use no days 61.4% 1-5 days 18.2% 6-10 days 5.5% 11-15 days 3.2% 16-20 days 0.9% 21-25 days 1.8% more than 25 days 9.1% lifetime cannabis use none 33.6% 1-5 uses 13.6% 6-10 uses 9.5% 11-50 uses 15.9% 51-100 uses 9.5% 101-500 uses 7.3% 501-1000 uses 2.7% 1001-2000 uses 4.5% 2001-5000 uses 1.8% 5001-10000 uses 1.4% term gpa less than 0.99 0.5% 1.00-1.49 1.8% 1.50-1.99 3.6% 2.00-2.49 6.8% 2.50-2.99 7.7% cannabis and academic performance 112 3.00-3.49 23.2% 3.50-3.99 35.5% 4.0 20.9% cumulative gpa 1.00-1.49 0.9% 1.50-1.99 4.1% 2.00-2.49 7.3% 2.50-2.99 8.6% 3.00-3.49 27.3% 3.50-3.99 37.7% 4.0 14.1% covariates past 30-day alcohol use (days) 4.62 (4.82) 22.0 past 30-day nicotine use (days) 3.69 (9.11) 30.0 past 30-day illicit drug use (days) 0.36 (2.85) 30.0 anxiety 16.11 (12.31) 57.0 depression 20.15 (11.43) 55.0 predictor/outcome variables past month cannabis use (days) 4.48 (9.02) 31.0 lifetime cannabis use (uses) 267.53 (947.36) 8000.0 procrastination 30.47 (6.33) 32.0 term gpa 3.37 (0.70) 3.15 cumulative gpa 3.36 (0.63) 2.99 measures demographics & substance use history participants completed a brief demographics questionnaire indicating their age, sex, race/ethnicity, and their parents’ education levels. prior to analysis, sex, race, and ethnicity were converted into dichotomous variables. specifically, these covariates were recoded so that: sex (0 = male, 1 = female), race (0 = non-white, 1 = white), and ethnicity (0 = not hispanic/unknown, 1 = hispanic). parent education level was coded as the highest education level attained by either parent on a scale from 1-6, from lowest (some high school) to highest (graduate degree). the questionnaire also measured polysubstance use by asking participants to indicate their past 30-day use of alcohol, nicotine, and illicit drugs. past 30-day alcohol use was collected with a single item: out of the past 30 days, how many days did you consume alcohol? past 30-day nicotine use was also collected with a single item: out of the past 30 days, how many days did you use any nicotine products? (e.g. – cigarettes, cigars, chewing tobacco, e-cigs, vapes), as was past 30-day illicit drug use: out of the past 30 days, how many days did you recreationally use illicit drugs other than alcohol, nicotine, or cannabis? anxiety & depression participants completed the 21-item beck anxiety inventory (bai) (beck et al., 1988). this scale has shown high internal consistency (α = 0.92) and testretest reliability over one week, r(81) = 0.75, and was developed to avoid confounding with depression (beck et al., 1988). the bai has been found reliable in college samples in the past (osman et al., 1997), as well as in the current sample (α = 0.93). additionally, participants completed the 20-item center for epidemiologic studies depression scale (ces-d) (radloff, 1977). this measure has been found to be a reliable (α = 0.87) and valid measure of depression in college samples in the past (radloff, 1991), and was also found reliable in the current sample (α = 0.91). total scores on these two measures were used to control for the potential effects of anxiety and depression on academic performance. cannabis use cannabis use is often assessed by frequency measures (how often cannabis was used) or cannabis, a publication of the research society on marijuana 113 quantity measures (how much cannabis was used). research suggests that participants have difficulty estimating the quantity of cannabis they are using and consistently overestimate quantities, even when the estimation is done immediately after preparation (prince et al., 2018). quantity measures are further complicated by the use of multiple forms of cannabis (flower, concentrates, edibles, etc.), and diverse methods of consumption (pipes, joints, vaporizers, foods, topical solutions, etc.), which often use different scales for quantity (e.g., grams of flower vs milligrams of thc in an edible). more recent surveys are being developed to improve quantity estimates, but have mostly been examined in samples with a high percentage of daily cannabis consumers (borodovsky et al., 2022). since we were interested in retrospective cannabis use over a long period and across a variety of forms and methods of consumption in a range of low to frequent cannabis users, we chose to focus on frequency of cannabis use rather than quantity. in the current study, cannabis use was operationalized in two ways: past month cannabis use and lifetime cannabis use. past month cannabis use was measured using a single continuous item, (approximately how many days of the past month did you use cannabis?). lifetime cannabis use was assessed using two items: (which of the following best captures the number of times you have used cannabis in your entire life?) with 10 ordinal categories estimating the number of lifetime cannabis uses: (1–5; 6–10; 11– 50; 51–100; 101–500; 501–1000; 1001–2000; 2001–5000; 5001–10,000; 10,000+), which was selected from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu) (cuttler & spradlin, 2017). a followup question was used to verify participants’ responses, and obtain a continuous estimation of cannabis use (within the range you indicated in the previous question, please estimate the exact number of lifetime cannabis uses). similar items querying estimates of lifetime number of cannabis use occasions (o'donnell et al., 2021), lifetime number of joints (gonzalez et al., 2012; verdejogarcia et al., 2013), and lifetime number of cannabis use days (pacheco-colón et al., 2019) have been used to estimate lifetime cannabis consumption in young adult samples. thus, the continuous estimation of lifetime cannabis use occasions was used as the lifetime cannabis use variable. while the primary form of cannabis used was not considered a variable of interest in the current study, it is worth noting that for participants who reported cannabis use, 42.1% used primarily marijuana (flower), 21.4% used primarily concentrates (e.g., oil, wax, shatter, butane hash oil, dabs), 19.3% used primarily edibles, and 17.2% selected “none” on the dfaqcu, indicating that they had no preference. procrastination participants completed a 10-item procrastination scale (chow, 2011). this measure’s reliability has been found acceptable in college samples in the past (α = 0.69; chow, 2011), as well as in the current sample (α = 0.74). this measure uses a 5-point likert scale (1 = not at all true, 5 = very true) to assess the extent to which participants agree with statements about their procrastination behavior, with higher scores indicating greater levels of procrastination. a sample item is: i frequently complete tasks earlier than is required (reverse coded). the total score on this measure was used to assess the tendency to exhibit procrastination behavior. academic performance participants provided their consent to release their official academic records as part of study participation. specifically, the study collected the participants’ term and cumulative gpa records for the fall 2021 quarter from the registrar’s office. these gpa records served as the primary dependent variables. each analysis was performed with term gpa and cumulative gpa. this provided the opportunity to examine the effect of past month cannabis use on term gpa, as well as an overall effect of lifetime cannabis use on cumulative gpa (although the predicted direction of the associations for both term and cumulative gpa were identical). while selfreported gpa was not considered in the current study, participants were asked to self-report their most recent college cumulative gpa for the purpose of comparison. for the 159 students who reported their cumulative gpa, their responses showed a moderate to strong correlation (r = 0.67, p < .001) with official gpa records. while the strength of the correlation is encouraging, this suggests that there may still be significant cannabis and academic performance 114 variation between self-reported and official gpa records. procedure participants who signed up for the study were directed to a qualtrics online survey. after participants provided consent, they were asked to enter their student identification number. this number was used to request official gpa records from the registrar’s office at the end of the fall 2021 term. the survey then generated a random id number to protect confidentiality, and a second survey was automatically opened to record the participants’ responses to survey measures, including the demographics/substance use history questionnaires, the procrastination scale, the bai, and the ces-d. data screening and cleaning prior to analysis, several participants’ data were excluded from analysis. a total of 310 participants completed the survey, but 27 participants were removed because they were duplicates (the same student id number being used for multiple responses). to remove a duplicate response, survey completion percentage was considered first (with more complete responses being retained over less complete responses), and if completion was comparable between duplicates, then the chronological first survey response was retained (with subsequent duplicate responses excluded). one participant was excluded due to an invalid student id number. next, data were screened for missingness on measures assessing primary variables and covariates. one participant was excluded because they were the only participant who reported “other” as their biological sex, and four participants were excluded because they reported “unknown/not applicable” for both parents’ education levels. an additional 51 participants were excluded for missing data, either for skipping entire measures or missing key items (the cannabis use items, the bai, the ces-d, or the procrastination scale). finally, wood et al. (2017) recommend excluding participants from online samples if they respond faster than a rate of 1 second per item. based on research assistants’ average completion time (20-40 minutes), a more conservative threshold was used, and an additional six participants were excluded for completion times less than 5 minutes. data analysis after verifying that statistical assumptions were met, data from the experiment were analyzed using ibm spss statistical software version 28.0 and the process macro (hayes, 2022). hypothesis testing was conducted using a series of hierarchical multiple linear regressions to examine the association between substance use and gpa. for each regression analysis, sex, race/ethnicity, parent education level, past month alcohol, nicotine, and illicit drug use, anxiety, and depression were entered as covariates in the first step, with main effects and interaction terms entered in the second step. for the moderation analyses, the continuous predictors were all mean-centered before computing interaction terms, and the mean-centered predictors and their interactions were then entered into the models after first controlling for covariates. the process macro was used to conduct simple slopes analyses, which produce unstandardized coefficients (hayes, 2022). correlations (pearson’s r) between primary variables for the final sample can be found in supplementary table 1. results procrastination & term gpa a hierarchical multiple linear regression tested past month cannabis use, procrastination, and their interaction as predictors of term gpa after controlling for covariates. as table 2 indicates, model 1 was significant, f(9,210) = 5.56, p < .001, and the covariates explained 19.2% of the variance in term gpa. sex and parent education level emerged as significant positive predictors of term gpa, suggesting females and students whose parents have greater levels of education earned higher grades on average in the fall 2021 term. in addition, past 30-day alcohol use and depression scores both emerged as significant negative predictors of term gpa, suggesting that students with more frequent alcohol use and/or greater depression levels earned lower grades that term. in model 2, adding past month cannabis use, procrastination, and their interaction improved cannabis, a publication of the research society on marijuana 115 the model, δf(3,207) = 7.34, p < .001, and it explained an additional 7.8% of the variance in term gpa. the analysis showed a main effect for procrastination, β = -0.29, t = -4.41, p < .001, such that greater procrastination scores predicted lower term gpa. however, neither past month cannabis use (β = -0.04, p = .549) nor the interaction term (β = -0.09, p = .152) were significant predictors of term gpa. table 2. hierarchical multiple linear regression of past month cannabis use, procrastination, and their interaction on term gpa model r2 (δr2) b (se) β t p step 1: covariates 0.192* < .001* constant 2.61 (0.22) sex 0.26 (0.12) 0.17* 2.48 .014* race 0.06 (0.11) 0.03 0.51 .613 ethnicity 0.05 (0.13) 0.03 0.38 .704 parent education level 0.15 (0.03) 0.31* 4.78 < .001* alcohol use 0.02 (0.01) 0.14 2.12 .035* nicotine use -0.01 (0.01) -0.11 -1.67 .096 illicit drug use 0.00 (0.02) -0.01 -0.18 .859 anxiety 0.00 (0.01) 0.03 0.31 .755 depression -0.01 (0.01) -0.23* -2.63 .009* model 2: main effects & interaction 0.270 (0.078)* < .001* constant 2.39 (0.21) sex 0.26 (0.10) 0.17* 2.53 .012* race 0.07 (0.12) 0.04 0.64 .523 ethnicity 0.05 (0.13) 0.03 0.40 .690 parent education level 0.17 (0.03) 0.34* 5.38 < .001* alcohol use 0.02 (0.01) 0.12 1.78 .076 nicotine use -0.01 (0.01) -0.09 -1.36 .175 illicit drug use 0.00 (0.02) -0.01 -0.08 .933 anxiety 0.00 (0.01) -0.03 -0.36 .718 depression 0.00 (0.01) -0.06 -0.68 .498 past month cannabis use 0.00 (0.01) -0.04 -0.60 .549 procrastination -0.03 (0.01) -0.29* -4.41 < .001* cannabis use x procrastination 0.00 (0.00) -0.09 -1.44 .152 note. asterisks (*) indicate significant models/predictors (p < .05). procrastination & cumulative gpa a second hierarchical multiple linear regression examined whether lifetime cannabis use, procrastination, and their interaction predicted cumulative gpa after controlling for covariates. as table 3 shows, model 1 was significant, f(9,210) = 3.87, p < .001, and the covariates explained 14.2% of the variance in cumulative gpa, with sex and parent education level emerging as positive predictors of cumulative gpa, and past 30-day nicotine use emerging as a negative predictor of cumulative gpa. in model 2, adding lifetime cannabis use, procrastination, and their interaction improved the model, δf(3,207) = 9.98, p < .001, and it explained an additional 10.8% of the variance in cumulative gpa. the analysis indicated significant main effects for lifetime cannabis use, β = -0.26, t = -3.20, p = .002, and procrastination, β = -0.31, t = -4.57, p < .001. in addition, the interaction term was significant, β = -0.19, t = -2.55, p = .012, indicating that the association between lifetime cannabis use and cumulative gpa varied with the level of procrastination. a simple slopes analysis (figure 1) showed that lifetime cannabis use predicted lower cumulative gpa when procrastination scores were high (+1 sd), b = -0.0003, p = .002, or procrastination scores were average, b = -0.0002, p = .002, but not when procrastination scores were low (-1 sd), b = 0.0000, p = .995. in other words, cannabis and academic performance 116 the association between lifetime cannabis use and cumulative gpa strengthened as procrastination scores increased, and greater cannabis use predicted lower grades for students with higher levels of procrastination, but not for students with lower levels of procrastination. table 3. hierarchical multiple linear regression of lifetime cannabis use, procrastination, and their interaction on cumulative gpa model r2 (δr2) b (se) β t p step 1: covariates 0.142* < .001* constant 2.78 (0.20) sex 0.21 (0.10) 0.15* 2.10 .037* race 0.09 (0.10) 0.06 0.87 .384 ethnicity 0.01 (0.13) 0.01 0.53 .959 parent education level 0.11 (0.03) 0.24* 3.57 < .001* alcohol use 0.02 (0.01) 0.12 1.74 .083 nicotine use -0.01 (0.01) -0.16 -2.21 .028* illicit drug use -0.02 (0.01) -0.08 -1.27 .204 anxiety 0.00 (0.01) -0.04 -0.42 .678 depression -0.01 (0.01) -0.13 -1.41 .160 model 2: main effects & interaction 0.251 (0.108)* < .001* constant 2.62 (0.19) sex 0.17 (0.09) 0.12* 1.81 .071 race 0.11 (0.10) 0.07 1.15 .250 ethnicity -0.02 (0.12) -0.01 -0.13 .893 parent education level 0.11 (0.03) 0.26* 4.00 < .001* alcohol use 0.02 (0.01) 0.13 1.90 .059 nicotine use -0.01 (0.01) -0.08 -1.20 .232 illicit drug use -0.01 (0.01) -0.06 -0.89 .376 anxiety -0.01 (0.01) -0.08 -0.88 .379 depression 0.00 (0.01) 0.01 0.39 .969 lifetime cannabis use 0.00 (0.00) -0.26* -3.20 .002* procrastination -0.03 (0.01) -0.31* -4.57 < .001* cannabis use x procrastination 0.00 (0.00) -0.19* -2.55 .012* note. asterisks (*) indicate significant models/predictors (p < .05). discussion in the present study, there was a main effect of procrastination, but no significant effects of recent cannabis use or interaction between recent cannabis use and procrastination on term gpa. there was also a main effect of lifetime cannabis use, a main effect of procrastination, as well as a significant interaction between lifetime cannabis use and procrastination on cumulative gpa. as hypothesized, more frequent cannabis use was related to lower gpa for students with higher levels of procrastination, but not for students with lower levels of procrastination. these results provide partial support for the hypothesized role of procrastination as a moderator between cannabis use and academic performance, and suggest that the strength of the association between lifetime cannabis use and cumulative gpa varies with the level of procrastination, and that students with higher levels of procrastination may be particularly vulnerable to poorer academic performance at higher levels of lifetime cannabis, relative to students with lower levels of procrastination. accordingly, it is possible that interventions designed to address procrastination behavior (e.g., time-management strategies, keeping a daily schedule, etc.) may be particularly beneficial for students who frequently use cannabis. helpful interventions for procrastination generally focus on training selfregulatory skills, building self-esteem, and increasing social support (schouwenburg, 2004). research suggests that cognitive behavioral therapy can be particularly effective for reducing procrastination behavior (van eerde & klingsieck, 2018). these interventions can help patients recognize patterns in their cannabis, a publication of the research society on marijuana 117 figure 1. procrastination moderates the association between lifetime cannabis use and cumulative grade point average note. greater lifetime cannabis use was associated with lower grades at high and average levels of procrastination, but not at low levels of procrastination. high and low procrastination scores were tested at one standard deviation above and below the mean, respectively. procrastination behavior and the irrational thoughts that may be contributing to their procrastination, then focus on correcting those irrational thoughts and changing subsequent behavior by enhancing self-regulation (e.g., setting goals, self-monitoring, managing priorities, time-management, etc.). however, therapeutic interventions can be prohibitively expensive, are often time-consuming, and are typically reactive in nature – treatment is often sought only after problematic behavior becomes apparent. a different approach is to incorporate procrastination intervention/prevention into the curriculum itself with the help of instructors/teachers. classroom techniques that have been shown to reduce academic procrastination include incorporating pop quizzes to encourage regular study habits, meeting with students who have late or missing assignments to develop a written plan for completing the work, assigning larger projects in more manageable chunks with frequent check-ins, and regular communications reminding students what they should be working on (zacks & hen, 2018). nevertheless, classroom-based interventions for procrastination remain understudied and further research is needed to identify any potential academic benefits of these strategies for students who procrastinate and frequently use cannabis. the present study also found negative associations between procrastination and both term and cumulative gpa. these findings are in line with previous research suggesting a negative association exists between procrastination and multiple indices of academic performance in college, including quiz and exam scores, course grades, and gpa (kim & seo, 2015). however, it is unclear why a significant interaction was found between cannabis use and procrastination when examining lifetime cannabis use and cumulative cannabis and academic performance 118 gpa, but not when examining past month cannabis use and term gpa. for example, it is possible that the term gpa collected could have been influenced by history effects. after all, the fall 2021 term marked the return to in-person instruction for many students after more than a year of remote learning during the height of the covid-19 pandemic. however, the term and cumulative gpa scores collected in the present study were very strongly correlated (r = 0.90, p < .001), whereas the correlation between past month and lifetime cannabis use was more moderate (r = 0.48, p < .001). therefore, it is more likely that lifetime cannabis use exhibits an association with cumulative academic performance because it reflects the residual and chronic effects of cannabis use on academic achievement. however, past month cannabis use may only provide a limited assessment of cannabis use characteristics that may change over the course of adolescence and young adulthood. indeed, research suggests that long-term cannabis users perform significantly worse on tests of memory and attention compared to shortterm users, and long-term use is also associated with impaired learning, retention, and retrieval on learning tasks (solowij et al., 2002). it is interesting to note that in the current study lifetime cannabis use was associated with lower cumulative gpa at both high and average levels of procrastination, but not at low levels of procrastination. thus, the current findings suggest that being low on this trait may be interpreted as protective for cannabis users in the long run. given more variance in the measure of lifetime cannabis use vs. past 30-day cannabis use, as indicated in table 1, it is possible that this relatively stable personality trait is more likely to moderate the relationship between a variable measuring a longer history of cannabis use and cumulative gpa. future investigations into the impact of cannabis use on academic performance should employ measures that can capture longterm cannabis use patterns, such as lifetime cannabis use, as opposed to only examining cannabis use in the past month. strengths and limitations the present study has several strengths to consider. for instance, all analyses were performed using actual gpa records obtained from the university registrar rather than via selfreport, increasing confidence in the current findings. furthermore, the study controlled for several potential confounding variables, and the associations reported here were found above and beyond important covariates related to academic performance. the present findings also underscore the importance of investigating how interactions between cannabis use and additional factors are related to academic performance rather than limiting investigations to the direct effects of cannabis use alone. conversely, the present study has some limitations that must be considered as well. for example, the participant sample represented primarily white and female students. this limits the generalizability of the present findings. while some evidence suggests the gender gap has been closing in recent years, historically cannabis use has been more prevalent in males than females (chapman et al., 2017), and the results of the current study also indicated that sex was a significant predictor of college gpa, with males earning lower gpas than females. in addition, the sample contained a large proportion (50%) of firstyear college students. for these students, lifetime cannabis use may be measuring predominantly adolescent cannabis use, as opposed to cannabis use in college. moreover, if first-year participants were in their first term during data collection, their term and cumulative gpas would be identical. accordingly, future studies should strive to replicate these results in more diverse samples of college students with more male participants and upper-level students. additionally, the models in this study only explained about 24-26% of the variance in gpa, suggesting that unexplored factors related to personality, motivations, and other individual differences need to be examined to understand how they may contribute to academic achievement. for example, some students may use cannabis to self-medicate symptoms of psychological distress (and may also be low procrastinators). although speculative, this reduction in negative affect may confer academic benefits for this sub-group of cannabis users. while the current study did not examine motivations for cannabis use, future investigations could consider how different motives for cannabis use (coping, social, enhancement, etc.) may differentially relate to cannabis, a publication of the research society on marijuana 119 academic outcomes. it is also noteworthy that parental education was significantly related to student gpa in the current study and should be controlled for in future investigations related to substance use and academic performance. furthermore, as this study is cross-sectional, causality cannot be determined. the directionality of potential associations among cannabis use, procrastination, and college gpa remains unclear. future research employing longitudinal designs could better address the question of causality, as well as explore how dynamic patterns of cannabis use interact with factors such as procrastination to affect grades over time. additionally, the measurement of cannabis use could have been affected by response bias. although participants were informed that their confidentiality would be protected by deidentification procedures, the potential for identification could have resulted in underreporting of cannabis use. moreover, even though similar assessments of cannabis use have been used in prior studies, accurately reporting the number of lifetime cannabis uses may have been more difficult for participants with more frequent cannabis use. future investigations may benefit from more comprehensive, multi-item measures of cannabis use frequency. finally, there are limitations inherent in using gpa as a dependent variable. for example, students who are struggling academically in a certain class often have options they can exercise (withdraw, pass/fail options, incomplete status, etc.) that may not be reflected on their term or cumulative gpa records. future investigations could also attempt to unpack gpa into separate components of performance. for example, future studies could examine the associations between cannabis use, procrastination, and scores on tests, quizzes, assignments, term papers, and participation/attendance grades. this may provide a more fine-grained measurement of academic performance that is able to distinguish between students with the same letter grades, as well as identify specific components of academic performance that could be disproportionately affected by cannabis use. conclusion in summary, the current study found that 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cannabinoids; medical cannabis; mobile application; mood disorders; thc a recent poll found that 91% of u.s. adults believe that marijuana should be legal in some form – either for medical and recreational use (60%) or medical use only (31%; green, 2021). this shift in public opinion is buoyed by rapid scientific advancement. a pubmed keyword search shows that between 1990-1999, researchers published fewer than 4,000 papers on cannabis/marijuana; since 2010, they’ve authored over 30,000. as public and scientific interest grows, the present paper turns its focus to an intersection with one of the most pressing issues of our time: mental health. over 31% of americans will suffer from an anxiety disorder at some point in their lives; close to 17% will suffer from major depressive disorder (kessler et al., 2012). yet, while antidepressants remain one of the three most frequently prescribed therapeutic drug classes in the country – currently used by over 40 million adults (cdc, 2018; brody & quiping, 2020) – multiple metaanalyses have demonstrated only modest benefits over placebo (kirsch et al., 2002; 2008), with a recent analysis co-authored by the food & drug administration suggesting only 15% of participants experience a substantial r. nathan pipitone1, benjamin banai2, jessica walters3, tyler dautrich4, kelly schuller1, & martha rosenthal5 1department of psychology, florida gulf coast university 2banai analitika, josipa jurja strossmayera 341, 31000 osijek, croatia 3cannamd, 7932 west sand lake road, suite 205, orlando, fl 32819 4morebetter (releaf app), po box 382, hyattsville, md 20781-0382 5department of biology, florida gulf coast university cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000223 using smartphone technology to track real-time changes in anxiety/depression symptomatology among florida cannabis users corresponding author: nathan pipitone, ph.d., florida gulf coast university, 10501 fgcu blvd. fort myers, florida, 33965. email: npipitone@fgcu.edu. cannabis, a publication of the research society on marijuana 124 antidepressant effect beyond a placebo effect in clinical trials (stone et al., 2022). pharmaceutical options, particularly anxiolytic medications (such as benzodiazepines), are also weighted by troubling side effects, including an addictive potential that can lead to severe psychological and physical dependence (edinoff et al., 2021). in the past few years, researchers have increasingly warned that benzodiazepine abuse is reaching “epidemic levels” (schmitz, 2016; sarangi, 2021). conversely, cannabis – now legal in some form in over 70% of u.s. states and territories – has attracted interest due to its ability to alleviate symptoms of both conditions with minimal, nonserious side effects such as drowsiness, dry mouth, tachycardia, and short-term impairment of memory, concentration, and motor performance (prashad & filbey, 2017; stith et al., 2018; wang et al., 2008). surveys of medical cannabis users across the country have shown that relief from symptoms of anxiety and depression are among the most commonly cited reasons for using medical cannabis (rosenthal & pipitone, 2021; reinarman et al., 2011). likewise, corroon et al. (2017) found that the odds of reporting substituting cannabis for prescription drugs were more than one and a half times greater among those reporting the use of cannabis to manage anxiety and depression. and yet, while cannabinoids have been shown to dosedependently induce antidepressant-like effects (sales et al., 2019) and significantly reduce ratings of anxiety and stress (cuttler et al., 2018), far less is known about the specific cannabinoid profiles that are most effective for patient use. cannabinoids may have both a direct and indirect role in depression and anxiety, and their effects are dose-dependent. the endocannabinoid system helps to ensure an appropriate response to stressful events and plays a role in extinction of aversive memories (jurkus et al., 2016; marsicano et al., 2002; stern et al., 2015). when antidepressant medications such as selective serotonin reuptake inhibitors (ssris) are effective, recent data suggest that their antidepressant actions may not be directly related to increasing allegedly low serotonin levels, but rather by encouraging neurogenesis in the hippocampus (santarelli et al., 2003). preliminary studies suggest that cannabinoids may play a role in regulating hippocampal neurogenesis (jiang et al., 2005; zhang et al., 2014), which may be one mechanism by which they regulate depression. additionally, thc is a partial agonist of cb1 receptors, which are involved in the regulation of mood (ashton & moore, 2011; valverde & torrens, 2012). anxiety may be associated with decreased levels of endocannabinoids and an upregulation of cb1 receptors, especially in the amygdala, hippocampus, and anterior cingulate gyrus (ligresti et al., 2016). a double-blind study of patients with social anxiety disorder found that those who received a dose of cbd before a public speaking task had significantly reduced anxiety, cognitive impairment, discomfort during speech, and lower blood pressure and heart rate compared to controls (beramaschi et al., 2011). cuttler et al. (2018) also examined the relationship between cannabinoid ratios and symptom relief, finding that low thc/high cbd cannabis was best for reducing perceived symptoms of depression, while high thc/high cbd cannabis was best for reducing perceived symptoms of stress. while cannabis is widely recognized for its ability to reduce acute symptoms of anxiety and depression (sexton et al., 2016), variations in cannabinoid profiles can produce significantly different effects. for instance, unlike cbd, human clinical studies demonstrate a common anxiogenic response to thc (lafrance et al., 2020b), especially at higher doses (sharpe et al., 2020). as cbd may attenuate the acute effects of thc (freeman et al., 2019), identifying ratio recommendations for these two particular cannabinoids in the treatment of anxiety and depression is important. recently, smartphone technology has facilitated the collection of large amounts of data from cannabis users. one popular smartphone app – releaf app™ – has been used worldwide by researchers, healthcare professionals, and cannabis product manufacturers to collect realworld data on the effects of consuming legal cannabis and hemp-derived cbd products. data collected in the patented releaf app have been published in more than 12 peer-reviewed articles in journals such as yale journal of biology & medicine, scientific reports, and frontiers in pharmacology. tracking patient-reported symptoms through smartphone technology, the present paper seeks to add to existing literature by assessing self-reported experiences of cannabis users in the state of florida, with a focus on how tracking anxiety/depression changes when using cannabis 125 cannabis alters symptoms of anxiety and depression along with its relationship to doses per session, consumption method, cannabinoid profile (thc/cbd), gender, and age. this approach builds on earlier research that has used smartphone technology to explore the role of cannabis in treating fatigue, insomnia, migraine and headache-related pain, obsessive-compulsive disorder, and post-traumatic stress disorder (kuhathasan et al., 2022; lafrance et al., 2020a; li et al., 2020; 2022; stith et al., 2020; mauzay et al., 2021). this approach also provides researchers with a more natural and authentic perspective on an individual’s use and perceived outcomes with cannabinoid products. using a smartphone application such as the releaf app allows individuals to anonymously track their real-time use of cannabinoid products from the comfort of their home while collecting their perspective before, during, and after cannabis consumption. using a mobile application in this way thus provides a more ecologically valid setting than what most clinical settings offer. this change in environment could result in participants experiencing different levels of anxiety than what their baseline is while in their regular daily routine. methods procedure this dataset was observational and was provided to us by releaf app after the data had been collected, making it archival in nature. all data came from the state of florida between march 30, 2018 and december 19, 2021. all data provided were stripped of any identifying characteristics and made anonymous. the releaf app was designed to help patients monitor the variable effects of cannabinoid-based products and records the types, routes of administration, and labeled cannabis phenotypes and cannabinoid contents of the products consumed. users indicate the medical conditions for which they are consuming cannabis, real-time symptom intensity levels prior to and following consumption, and any possible side effects experienced, under otherwise naturalistic conditions. prior to consuming cannabis, users are directed by the app to enter information about the product they intend to consume based on information provided on product labels. upon starting a treatment session, the user specifies the symptoms to be treated, reports a starting symptom intensity level (on a visual analog scale from 0 to 10), consumes the cannabis product, updates the symptom level, records side effects, and ends the session. the user can update the symptom intensity level as frequently as they want and can select multiple side effects (side effects were not included in this dataset). our dataset consisted of participants only reporting using cannabis for anxiety and/or depression. in total, we obtained data on 418 users, who recorded 9,966 sessions, in which 13,063 symptoms were treated (patients could report treating both anxiety and depression in a single session). users recorded different number of sessions that had a range of 1 – 2,844. mean value of number of sessions is 31.25 (sd = 172.7), and median number of sessions is 6 (q0.25 = 3, q0.75 = 12). anxiety was treated 7.752 (59.3%) times and depression was treated 5,311 (40.7%) times. participants out of 418 users, 240 (57.4%) were female, 164 (39.2%) were male, and 14 (3.4%) reported nonbinary gender. the average age of users was 36.53 years (sd = 11.39). symptom level analysis all symptom level analyses were conducted in r v.4.0.3. (r core team, 2021), using packages lme4 (bates et al., 2014) and lmertest (kuznetsova et al., 2017) for calculating p-values. furthermore, data were collected for one or more sessions per user. to reflect this hierarchical order of these data (ratings nested within sessions, which were further nested within user), we analyzed data using linear mixed-effects modeling and specified a three-level random intercept model, which estimates random effects of sessions and users and also estimates fixed effects of each predictor variable used in the study. significance of predictors was obtained using lmertest package via satterthwaite's degrees of freedom method. analyzing these data using linear mixed-effects approach allowed us to model specifics of the dataset: there were potentially multiple recordings for the same user representing repeated measurements, and each user could have one or more recordings of their sessions, meaning that the design of this study was cannabis, a publication of the research society on marijuana 126 imbalanced. compared to more traditional approaches such as linear regression or repeated measures anova, linear mixed-effects models do not have these conditions as an assumption and can handle this data structure well (snijders & bosker, 2012). first, we entered symptom relief changes, which refers to the amount of relief reported before versus after using cannabis (which is represented by the model intercept). since symptom severity start levels correlated with symptom relief, multilevel r(13061) = 0.36, p < .001, following other work (li et al., 2020; stith et al., 2018), we include symptom start level in the model where appropriate as a control. we then estimated fixed effects of symptom type (depression or anxiety), doses per session (the number of inhalations taken in a session), and consumption method (vaping versus smokable flower – joint or pipe). gender and age variables were then entered to assess their impact, followed by the two most reported cannabinoids in the user's product, thc and cbd levels. it should be noted that values of thc and cbd were self-entered by releaf app users; thus many failed to provide these data. among joint and pipe users, 611 cases had missing values, and 267 cases included values that seemed improbable for flower cannabinoid profiles (e.g., >50% of thc and/or cbd). furthermore, among vape users, 3,608 cases had missing values, and 46 cases had improbable values for thc and/or cbd (e.g., >100% thc/cbd). after these cases were removed, the final sample size for the models that included fixed effects of thc and cbd levels were 180 users who recorded a total of 4295 sessions. user level analysis the goal for analyzing responses from participants at the user level was to investigate whether there were any differences among participants who ended up experiencing positive relief (averaged across sessions for each user) after consuming cannabis compared to those who experienced averaged negative or no relief outcomes (since there were only 5% of participants who had negative relief outcomes, no relief and negative relief individuals were grouped together and pitted against those who experienced positive relief). the data were averaged at the user level and analyzed separately for symptoms of anxiety and depression. variables of interest between the two relief outcome groups were total number of sessions, symptom start and end levels, doses per session, consumption method, age, and gender. results zero-order multilevel correlations between the amount of relief and all quantitative independent variables used in the study were analyzed first1 amount of relief was significantly correlated with symptom intensity at the start of the session, doses per session, and age, but not with thc and cbd levels, symptom start multilevel r(13061) = 0.36, p < .001; doses per session multilevel r(13061) = 0.08, p < .001; age multilevel r(13061) = 0.05, p < .001; thc multilevel r(4293) = 0.01, p = ns; cbd multilevel r(4293) = -0.03, p = ns). symptom level analysis findings from the linear mixed-effects models for predicting relief based on user demographics and characteristics of consumed cannabis are presented in table 1. results showed that depression/anxiety symptomatology was significantly reduced after cannabis sessions in general (model 1). since symptom severity start levels correlated with symptom relief, multilevel r(13061) = 0.36, p < .001, following other work (li et al., 2020; stith et al., 2018), we included symptom start levels and found it to be a significant predictor of relief (model 2). after entering symptom type, doses per session, and consumption method into the model, all three predictors were found to be significantly related to relief, although each effect size was relatively small (standardized beta weights smaller than .1; nieminen, 2022; model 3). gender and age variables were entered next, with both variables failing to significantly impact relief (model 4). last, thc and cbd levels were entered. thc did not significantly impact relief; however, cbd levels did (model 5). 1 the r package correlation (makowski et al., 2019) used in this study does not provide multilevel correlations for categorical variables (e.g., symptom type), as they are treated as random effects variables, hence no correlation coefficients are provided in those contexts. tracking anxiety/depression changes when using cannabis 127 table 1. results of the mixed-effects modeling analysis of relief after cannabis consumption, results at the symptom level of analysis. model 1 model 2 model 3 model 4 model 5 predictors b β p b β p b β p b β p b β p intercept 2.17 <.001 -0.13 .241 -0.36 .002 -0.55 .114 -0.33 .078 symptom start 0.44 0.39 <.001 0.44 0.39 <.001 0.42 0.45 <.001 0.48 .48 <.001 symptom type 0.04 0.01 .026 0.03 0.01 .112 -0.01 -.00 .657 doses per session 0.02 0.05 <.001 0.04 0.08 <.001 0.02 .05 <.001 consumption method 0.16 0.05 .007 0.20 0.08 .001 0.09 .03 .538 age 0.00 0.02 .655 gender 0.12 0.05 .572 thc 0.00 .00 .864 cbd -0.01 -.05 .022 random effects σ2 0.84 0.66 0.66 0.70 0.52 τ00 sess_id:user 2.18 1.95 1.94 1.80 2.12 τ00 user 4.60 3.34 3.30 3.32 3.49 icc 0.89 0.89 0.89 0.88 0.92 n sess_id 9966 9966 9966 8356 4295 n user 418 418 418 390 180 observations 13063 13063 13063 11085 5705 marginal r2 / conditional r2 0.000 / 0.889 0.217 / 0.913 0.224 / 0.913 0.166 / 0.899 0.241 / 0.936 note. symptom type reference category is ‘anxiety’; consumption method reference category is ‘smokable flower (joint or pipe)’; gender reference category is ‘female’; bunstandardized regression coefficient; βstandardized regression coefficient; σ2residual variance; τ00 sess_id:userintercept variance at session level; τ00 userintercept variance at user level. user level analysis anxiety for continuous ivs, welch’s independent samples t-tests were used to assess differences between users who were in the positive (68%, or 257 users) or negative/no relief group (32%, or 121 users), and a chi square test of independence was used to inspect any differences in gender. individuals who had positive relief outcomes had significantly more sessions, t(361.15) = 2.18, p = .03, d = .21, and consumed more doses per session, t(327.5) = 3.35, p < .001, d = .34, than those in the negative/no relief group. age, t(214.47) = -1.04, p = .3, d = -.12, and gender, χ2 (1, n = 365) = .01, p = .91, were not significantly different among the two relief groups. in order to investigate consumption method differences between those in the two relief outcome groups, we calculated the proportion of each consumption method used (smokable flower [joint, pipe] or vape) for each user across all sessions. there were no differences in consumption methods (vape vs. smokable flower) between the positive relief and negative/no relief groups, t(224.08) = 1.09, p = .28, d = .12. see supplementary table 1 for all descriptive and inferential statistics for this analysis. depression the same tests described above for anxiety were used to detect differences among the different relief outcome groups for depression. see figure 1 for a graphical depiction of all users’ depression relief amount. individuals who had positive relief outcomes (74%, or 159 users) had significantly more sessions, t(168.58) = 2.03, p = .044, d = .23, than those in the negative/no relief group (26%, or 55 users). doses per session, t(85.05) = 1.48, p = .14, d = .24, age, t(100.7) = .24, p = .81, d = .04, and gender, χ2 (1, n = 204) = .05, cannabis, a publication of the research society on marijuana 128 p = .82, were not significantly different among the two relief outcome groups. see supplementary table 2 for all descriptive and inferential statistics for this analysis. the calculation of each consumption method proportion used within the two relief outcome groups was the same as described above for anxiety. there were no differences in consumption methods (vape vs. smokable flower) between the positive relief and negative / no relief groups, t(87.85) = .95, p = .34, d = .15. figure 1. average relief for anxiety and depression symptomatology before and after cannabis use sessions for users in the study (n=418). lines shown above 0 on the y-axis indicate positive relief outcomes (68% and 74% of users respectively). no lines present represent no change in relief (27% and 23% respectively). lines shown below 0 on the y-axis indicate negative relief outcomes (5% and 3%, respectively). discussion the present study explored real-time changes in florida cannabis users’ depression and anxiety symptomatology immediately before and after using cannabis. analyzing the data using linear mixed-effects modeling allowed us to investigate effects not only between participants, but also across multiple sessions for the same user. compared to more traditional approaches such as linear regression or repeated measures anova, these models handle the data structure particularly well (snijders & bosker, 2012); other work has used similar analytical techniques (e.g., stith et al., 2018). first, multilevel zero-order correlations between the symptom intensity at the start of the tracking anxiety/depression changes when using cannabis 129 session, doses per session, and age showed significant correlations with amount of relief. however, aside from symptom intensity at the start of the session, only the variable doses per session approached an effect size considered practically meaningful (cohen, 1988). thc and cbd levels were not significantly correlated with amount of relief. results from the symptom level analysis showed that both depression and anxiety symptoms significantly decreased after cannabis use in general; results at the user level of analysis showed that the majority of users experienced positive relief outcomes. this replicates previous work which has shown decreases in depression (cuttler et al., 2018; li et al., 2020; sachedina et al., 2022; stith et al, 2018) and anxiety (cuttler et al., 2018; sachedina et al., 2022; sharpe, 2020; stith et al., 2018) symptomatology following realtime cannabis consumption. gender and age also did not play a significant role in affecting symptom relief. similarly, cuttler and colleagues (2018) found no significant gender differences with regards to alleviation of depression symptoms, although, in their study, women perceived a greater decrease in anxiety symptoms than men. factoring in symptom type, doses per session, and consumption method revealed significant effects, although interpreting each predictor's standardized beta coefficient showed very small effect sizes and should be interpreted with caution (see below for a discussion). therefore, the effect of consumption method (or lack thereof), at least for depression, is similar to findings from li et al (2020). while thc levels did not significantly impact symptom relief, cbd levels did. but, like doses per session and consumption method, cbd’s effect size was small; thus, caution is warranted when interpreting any practical significance based on the presented model. what is more, not all users reported thc and/or cbd levels in their product, making the results difficult to generalize to all users in the study. while emerging research suggests that cannabis may significantly reduce ratings of depression (li et al., 2020) and anxiety (e.g., cuttler et al., 2018), far less is known about the specific cannabinoid profiles that may be most useful to patients. for instance, unlike cbd, human clinical studies demonstrate a common anxiogenic response to thc (lafrance et al., 2020b), especially at higher doses (sharpe et al., 2020). as cbd may attenuate the acute effects of thc (freeman et al., 2019), identifying ratio recommendations for these two particular cannabinoids in the treatment of anxiety and depression is of immediate importance. in addition, the terpenes found in specific chemovars may play a role in relieving symptoms of anxiety and depression (kamal et al., 2018; weston-green et al., 2021). as with any medication, results vary from person to person. in some, cannabis may increase anxiety. but analyzing the data at the user level revealed that the majority of users experienced positive relief from their cannabis use sessions (68% anxiety, 74% depression) compared to users who experienced no relief (27% anxiety, 23% depression) or negative relief (5% anxiety, 3% depression); see figure 1. for those experiencing anxiety, users in the positive relief group reported significantly more cannabis user sessions and more doses than those who experienced no or negative relief outcomes. although in the current study more user sessions and more doses were associated with an increase in symptom relief, more is not always better. cannabis has a biphasic dose response curve. lower doses of thc can decrease subjective reports of anxiety, whereas higher doses may be anxiogenic (andrade et al., 2019; sharpe et al., 2020). the challenge, of course, is that due to the individual differences in the endocannabinoid system, there is no universal standard as to what can be considered a “low” or “high” dose. in addition, this study does not include data on the extent of previous use of cannabis and potential tolerance that may have developed among different users. a previous study on florida medical cannabis users (rosenthal & pipitone, 2021) showed that fewer than one-quarter of medical cannabis patients reported needing more cannabis since beginning treatment to get the desired symptomatic effects. another recent study in pennsylvania found about 34% of medical cannabis patients reported needing more use over time (kimless et al., 2022), suggesting that tolerance may not be a primary factor in leading to more cannabis consumption, but may simply be a result of individual differences in how users in the current study consume their cannabis. last, consumption method, age, and gender did not significantly differ among the different anxiety relief groups. cannabis, a publication of the research society on marijuana 130 for those experiencing depression, those in the positive relief group reported significantly more sessions than those in the no relief/negative relief group. again, it would be shortsighted to conclude that simply using more cannabis will help treat symptoms of depression. these differences are most likely due to how cannabis users in the study have naturally titrated their consumption to meet their desired needs over time. future work should attempt to collect data on past cannabis use practices to better establish a connection between cannabis use amount and depression symptom relief. other variables considered in this analysis – doses per session, age, gender, and consumption method – were all found not to be significantly different between the two depression relief groups. incorporating smartphone technology to assess real-time user experiences when consuming cannabis gives researchers the ability to see important time-related changes in mental health following cannabis consumption. in addition, it gives researchers more accurate data on not only what products are being used, but the formulation of those products, their chemovar, and exactly how these products are being consumed. this allows researchers to get realworld data insights from an opt-in registry of the actual cannabis products available in state regulated dispensaries, while keeping everything anonymous, thus protecting patient and consumer privacy. this leads to more accurate studies rather than relying on patient feedback from review-like sites or effects of products not widely available to consumers in state regulated markets. our results, similar to earlier work (stith et al., 2018), speak to the potential of cannabis to combat acute depression and anxiety with a rapid onset of self-reported relief. for instance, li et al. (2020) found “widely experienced” relief from depression within two hours or less. this potential warrants particular focus, given that currently available antidepressants often take weeks, or even months, to achieve their full effect (machadovieira et al., 2010), and meta-analyses suggest their effectiveness is marginal or even negligible for patients experiencing mild to moderate depression (kirsch et al., 2002). the side effects and addictive potential of some anxiolytic drugs are disconcerting. cannabis users in this and other studies report experiencing symptom relief within a very short time span after drug administration. while caution must be exercised with cannabis use (as it is with all pharmaceutical approaches), cannabis administration to address acute symptoms of anxiety or depression is a treatment option that deserves further investigation. some may argue that intoxication due to cannabis use is the cause of what might be only temporary relief in symptoms of anxiety and depression. although our data cannot speak to the long-term impacts of medical cannabis use, recent research does shed light on this topic. martin et al. (2021) followed 368 patients with depression and anxiety for four years—some of whom used cannabis for relief, and others who used traditional ssri medications. they found that medicinal cannabis use was associated with lower self-reported depression, better sleep, less pain, and a higher quality of life. furthermore, researchers conducted follow-up assessments every three months throughout the study. those who used cannabis to control symptoms of anxiety and depression at baseline, as well as those who initiated use during the course of the study, showed improvement in symptoms over time, but those who did not use medicinal cannabis did not show improvement over the four-year trial. future work investigating the long-term impacts of medical cannabis use will undoubtedly help the scientific community better understand this area. while researchers are utilizing different and better statistical approaches (e.g., linear mixedeffects models) to better understand how cannabis can affect mental health outcomes, more interpretable data needs to be provided, namely estimates of effect size and/or the use of standardized statistics (nieminen, 2022). for example, it is difficult to interpret unstandardized regression coefficients across different research articles using bivariate or multiple regression, hence we cannot directly compare our work to other work in this area. specific to our data, since the linear mixed-effects modeling incorporates multiple sessions from each user and also across every participant, degrees of freedom for certain tests were large, leading to statistical significance occurring even though any practical movement of the data (as measured by the standardized regression coefficients) for some of the variables can be considered negligible. tracking anxiety/depression changes when using cannabis 131 limitations this study was based on self-reported archival data with no experimental intervention/ manipulation taking place. there was no control group to compare any effects to and, therefore, the study cannot take into account any expectancy effects towards positive affect. the study measured the acute effects on mood immediately before and after cannabis use rather than inbetween session effects. also, individuals who don’t find cannabis to be effective for reducing symptoms of anxiety and depression are likely underrepresented in this data, as such individuals are likely to decline participation and/or discontinue study involvement. no drug is “one size fits all,” and cannabis may be contraindicated in some users. those with cardiovascular issues or a genetic predisposition for schizophrenia or bipolar disorder may want to consider other treatment options. literature regarding longterm adverse events related to cannabinoid use is limited, with a 2015 meta-analysis failing to find any studies evaluating the topic specifically, even when searches were extended to lower levels of evidence (whiting et al., 2015). future studies warrant independent variable condition manipulation (random assignment to drug/control groups) and should also incorporate blind, placebo-controlled conditions. the present data was provided under anonymous circumstances, thus we do not have any reason to believe it was inherently biased in any major way. however, to understand the true impact of cannabis on depression/anxiety symptomatology, the above experimental procedures are needed. as we did not have specific details on patient cannabis consumer demographics, it was not possible to differentiate between individuals who were registered medical cannabis card holders and those who were purchasing cannabis from the unregulated black market. although users provided the route of administration and consumption method, we were not able to regulate the type or quality of cannabis product they used. the scientific community would benefit from the comparative study of specific medical cannabis products, the impact of thc and cbd ratios, as well as the influence of over 100 other cannabinoids and terpenes found in the cannabis plant. it was also not possible to clinically diagnose depression or anxiety in any person in the study; only the user's subjective interpretations of their own depression and/or anxiety was available. smartphones using application technology allows for convenient collection of otherwise difficult-to-obtain data such as real-time experiences following psychoactive drug use. future work should take the necessary steps to attempt to control for extraneous variables while utilizing this newer technology for a better understanding of the psychological impact of cannabis on symptoms of depression and anxiety. references andrade, a.k., renda, b., & murray, j.e. 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(2015). cannabinoids for medical use: a systematic review and meta-analysis. journal of the american medical association, 313(24), 2456-2473. https://doi.org/10.1001/jama.2015.6358. funding and acknowledgements: the authors received no funding considering any part of this research or manuscript. the authors declare no competing interests. this study protocol was reviewed and the need for approval and consent was waived by the institutional review board at florida gulf coast university. all authors agreed to the archival data analysis, td provided the data, bb and rnp performed data cleaning and analysis, rnp and jw initiated the writing of the manuscript, and all other authors contributed to the editing and final writing of the manuscript. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original source is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 38 ved abstract objective: alcohol is the most frequently depicted substance in the media, and adolescent exposure to alcohol in the media predicts alcohol use. there is relatively little research on exposure to cannabis in the media, but exposure to alcohol content may exert cross-substance effects on cannabis use. given the social and health risks associated with early cannabis use, the present study aims to assess the cross-substance effects of exposure to alcohol media content on age of cannabis initiation. method: a sample of 830 middle school students (53% female) reported on movie alcohol exposure and cannabis initiation longitudinally until high school completion. discrete-time survival models examined whether movie alcohol exposure predicted subsequent initiation among students who were cannabis-naïve at baseline, controlling for demographic, social, and behavioral covariates. the interaction between sex and movie alcohol exposure was also explored. results: one third (33%) of participants reported cannabis initiation with a mean of 5.57 estimated hours (sd = 4.29) of movie alcohol exposure. a 1-hour increase in movie exposure predicted a significant 16% increased probability of cannabis initiation in models adjusted for demographic variables and a significant 14% increase in models adjusted for demographic, behavioral, and social variables. no differences were observed across sex. conclusions: greater adolescent exposure to alcohol content in the media was associated with earlier cannabis initiation above and beyond other etiologically relevant demographic, behavioral, and social variables. the influence of cross-substance media exposures warrants further exploration and should be taken into consideration in the development of preventive interventions for youth substance use. key words: = media; alcohol; cannabis; adolescent; survival analysis cannabis initiation in youth is concerning due to its adverse impacts on brain development (usdhhs, 2016), educational and occupational attainment (beverly et al., 2019), and increased risk for cannabis use disorder in adulthood (rioux et al., 2018; leung et al., 2020). recent research has identified exposure to cannabis in the media as a risk factor for initiating or increasing cannabis use (primack et al., 2009; whitehill et al., 2020; trangenstein et al., 2019). less is known about how exposure to other substances, such as alcohol, may impact cannabis-related behaviors. given alcohol’s predominance in the media compared to other substances (castaldellimaia et al., 2021; sargent et al., 2006), the functional similarities between cannabis and alcohol, and the increasing availability and decreasing perceived risk of cannabis (garcia ramirez et al., 2020), this is an important gap in the literature. media is a prominent environmental influence on youth lives, including as a source of social erin corcoran1, tim janssen2, joy gabrielli1, & kristina jackson2* 1department of clinical and health psychology, university of florida 2center for alcohol and addiction studies, brown university cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000200 cross-substance effects of adolescent exposure to alcohol content in popular movies on cannabis initiation corresponding author: erin corcoran, m.s., department of clinical and health psychology, university of florida, 1225 center drive, gainesville, florida 32610-0165. email: erin.corcoran@ufl.edu. *kristina jackson is now at the rutgers addiction research center at rutgers university. cannabis, a publication of the research society on marijuana 39 learning (bandura, 1971), and there is consistent and strong evidence for the link between exposure to alcohol in the media and subsequent adolescent alcohol use (jackson et al., 2018; jernigan et al., 2016; hanewinkel et al., 2007; waylen et al., 2015; anderson et al., 2009). although adolescents are exposed to all substances in the media, they are exposed to alcohol content in the forms of both unbranded and branded content (i.e., product placements for marketing purposes; bergamini et al., 2013) more than any other substance. an analysis of oscar-nominated movies between 2008-2011 found that 50.1% featured alcohol, 13% featured alcohol alongside another substance, and 2.5% featured cannabis (castaldelli-maia et al., 2021). of the 50 most popular movies on netflix in 2020, 76% included alcohol use by secondary characters and 66% by primary characters (giannakodimos et al., 2022). these depictions are disproportionately positive, often displaying the benefits of alcohol use (e.g., fun, stress relief) more than the risks (sargent et al., 2002; russell et al., 2021; merrill et al, 2023; gosselt et al., 2017; bhatia et al., 2023). the message interpretation process model (mip) posits that the impact of exposure to media content is determined by one’s cognitive and emotional response to it (austin & johnson, 1997; austin & meili, 1994; austin et al., 2006; hoffman et al., 2014). as applied to alcohol media, adolescent exposure to frequent positive media depictions of alcohol has been shown to impact alcohol-related cognitions and emotions, such as expectancies about the positive effects of alcohol, perceived norms about approval of alcohol use, and attitudes favoring alcohol use (grube & waiters, 2005; janssen et al., 2018; nesi et al., 2017; brooks-russell et al., 2014; merrill et al., 2023). in a qualitative study with adolescents, exposure to alcohol online and in the media was described as promoting a sense of normalcy and as minimizing negative consequences, such as hangovers and addiction (merrill et al., 2023). one quoted adolescent linked alcohol depictions to cannabis, describing them in similar contexts and as reflective of similar personae (merrill et al., 2023). thus, it is possible that exposure to alcohol use in the media impacts adolescent cognitions and perspectives on other related behaviors, such as cannabis use. while there is growing evidence of similar impacts of exposure to cannabis in the media on adolescent cannabis use, alcohol in the media is an environmental risk worthy of further exploration given its relative frequency of appearance compared to cannabis. the social learning concept of generalization, whereby expectations about one form of substance use might translate to a functionally related behavior (bandura, 1986; andrews et al., 1993), provides theoretical justification for exploration of crosssubstance effects. the functional relationship between cannabis and alcohol is strong (e.g., metrik et al., 2018), with cannabis and alcohol commonly co-used (patrick et al., 2019; jackson et al., 2021; banks, rowe, mpofu, & zapolski, 2017) and found in the same physical contexts (jackson et al., 2021). there is evidence that use of one substance increases likelihood of future use of the other (wang et al., 2018). there is also overlap with characterological predictors of cannabis use and alcohol use, including impulsivity, sensation seeking, and parental monitoring (e.g., janssen et al., 2018; kaynak et al., 2013; rioux et al., 2019; vanderveen et al., 2016). thus, the same cognitive and affective mechanisms driving the impact of exposure to alcohol media on alcohol use may also extend to cannabis. crossor multi-substance effects have been illustrated in previous studies with different populations or modalities; young adults (18-24) exposed to peer alcohol content on social media were more likely to report both alcohol and cannabis use (stoddard et al., 2012) and younger adolescent (10-14) exposure to r-rated movies positively associates with early initiation and progression of both cannabis and alcohol use (stoolmiller et al., 2010). these findings, paired with increasing legalization of recreational and medical marijuana, increasing availability of cannabis, and decreasing perception of cannabisrelated risk, warrant exploration of other environmental risk factors for cannabis use. limiting analyses to within-substance effects (i.e., how exposure to alcohol impacts alcohol use) may paint an incomplete picture of the complex risk of media substance use. to address current gaps in the literature and given the high volume and low regulation of media alcohol depictions compared to other substances, the present investigation explores crosssubstance effects of exposure to alcohol in popular movies on subsequent cannabis initiation. analyses control for demographic, social, and movie alcohol exposure and cannabis initiation 40 behavioral factors shown to be associated with both alcohol and cannabis use. this study utilized a rigorous measure of movie alcohol exposure (sargent et al., 2002a; sargent et al., 2002b; sargent et al., 2006; stoolmiller et al., 2010) and a highly specific measure of cannabis initiation across time. we also examined whether sex at birth moderated the role of media exposure to alcohol, based on findings suggesting sex differences in associations between exposure to substances in the media and subsequent use (boyle et al., 2016; alsayyari & albuhairan, 2018). methods participants this study utilized secondary data analysis with a subset of data from a prospective study on alcohol use (jackson et al., 2021). participants were recruited from six rhode island middle schools from rural (n = 231), suburban (n = 508), and urban (n = 284) contexts and were relatively equally divided across sixth (33%), seventh (32%), and eighth grades (35%). we stopped school recruitment when we reached our sample goal of 1,000. all students were eligible for study participation, regardless of drinking status. our analytic subset was selected from those who completed movie alcohol exposure assessment (n = 882) and consists of those that did not yet use cannabis at that time (n = 830) to explore subsequent cannabis use among non-users. mean age at baseline for the analytic subset was 12.4 years (sd = 0.9), predominately female (53%) and white (78%). see table 1 for sample descriptives. the sample did not differ from the full sample on sex, socioeconomic status, or ethnicity, but were significantly more likely to be white, x2(6, n = 830) = 19.22, p < .01. for additional sample characteristics, see jackson et al., 2014, 2015, 2018, and 2021. procedures consent forms were both mailed and distributed in classrooms. once parent consent and adolescent assent was received, adolescent participants completed an in-person orientation session and both youth and their parents completed a baseline self-report paper-and-pencil table 1. sample descriptives m / n sd / % participants 830 - youth age at baseline (m/sd) -12.4 -0.91 youth sex at birth -- male 385 47 female 445 53 youth race -- white or caucasian 649 78 black or aa 35 4 american indian or alaskan native 13 2 asian 22 3 multiracial 56 7 native hawaiian or other pacific islander 4 1 don’t know / prefer not to answer 51 6 youth ethnicity -- hispanic/latino 101 12 not hispanic/latino 729 88 receipt of lunch subsidy -- yes 273 35 no 508 65 hours of movie alcohol exposure (m/sd) -5.57 -4.29 sensation seeking (m/sd) 2.24 0.84 baseline alcohol use -- yes 50 6 no 776 94 best friend cannabis use -- yes 35 4 no 780 96 parent audit (m/sd) -2.61 -2.4 survey. participants were then assessed over three years via five semi-annual surveys (every 6 months) and a sixth survey one year later. participants were then re-enrolled (82% retention) into a quarterly follow-up study that spanned enrollment through high school graduation (number of assessments varied as a function of grade at enrollment and school cohort). all study procedures were approved by brown university's institutional review board, and a certificate of confidentiality was obtained from the national institutes of health to protect participant confidentiality. measures demographics. youth sex (assigned at birth), race, ethnicity, and receipt of lunch subsidy (proxy cannabis, a publication of the research society on marijuana 41 for socioeconomic status) were assessed at baseline. participant responses to sex, race, and ethnicity items were re-coded into binary variables for analytic purposes (i.e., male and female, white and non-white, hispanic and nonhispanic, respectively). cannabis use. cannabis use behavior was assessed at each wave by asking participants “have you ever used marijuana (pot, hash, hash oil, etc.)?” age of cannabis initiation was determined by the age at which cannabis-naïve individuals at baseline first indicated having ever used cannabis. alcohol onset. alcohol use onset was assessed at each wave by asking participants “have you ever consumed alcohol?” responses were included in analyses as a binary yes or no variable indicating whether alcohol onset had occurred at each time point. movie alcohol exposure. media alcohol exposure was first assessed at a semi-annual follow-up timepoint that varied as a function of school cohort. exposure to alcohol in movies was calculated using a method that combines content analysis and random assignment of movie titles to youth surveys (sargent et al., 2002a; sargent et al., 2002b; sargent et al., 2006; stoolmiller et al., 2010). specifically, the top 100 box office hits from 2006-2010 were coded by 2 trained content coders for real or implied alcohol use, with an average krippendorf alpha of .76 for the 10% double coded. average alcohol time per movie was calculated. each participant was shown a random sample of 50 movies (the cover art and title) and asked whether they had seen the movie and how many times. a measure of scaled alcohol exposure was established by calculating the minutes from movies that participants reported seeing, divided by the total minutes possible within their set of 50 movies, and multiplying by total duration of all 100 movies. further details about this method with respect to the present sample are reported in jackson et al. (2018, 2021). sensation seeking. sensation seeking was assessed with six items from the upps-p impulsive behavior scale (α = .82; lynam et al., 2006). sample items include “i generally seek new and exciting experiences and sensations” and “i sometimes like doing things that are a bit frightening.” peer cannabis use. peer cannabis use was assessed by asking “think of your three best friends (the friends you feel closest to). in the past 6 months, have any of your friends used marijuana?” (arthur et al., 2000). participants responded yes or no to this prompt. parent alcohol use. parent alcohol use, behaviors, and related difficulties were assessed by asking the parent reporter to complete the alcohol use disorders identification test (audit; saunders et al., 1993) for themselves and their partner, if applicable. responses ranged from never/no (0) to four or more times a week/daily or almost daily/during the last year (4). a mean score of both caregiver responses was created for inclusion in analysis. analysis strategy we used discrete-time survival analysis (dtsa; singer & willett, 1993; willett & singer, 1993) in mplus 8.3 (muthén & muthén, 19982017) to examine whether the first assessment of movie alcohol exposure prospectively predicted subsequent cannabis initiation among students who were cannabis-naïve at the time of movie alcohol exposure assessment (n = 830). we tested an unadjusted model predicting the age of cannabis initiation based on exposure to alcohol in movies, as well as adjusted models to assess whether demographic, social, and behavioral variables increase or decrease the hazard of cannabis initiation over time. model 1 adjusted for demographic variables (sex, race, ethnicity, receipt of lunch subsidy), and model 2 adjusted for demographic variables as well as select behavioral (sensation seeking, time-varying alcohol onset) and social (peer cannabis use, parent alcohol use) variables. participant sex was tested as a moderator by creating a linear interaction variable representing the product of sex and media alcohol exposure. the effect of exposure to alcohol in movies was consistent across time, thus confirming the proportional hazards assumption. all models used full-information maximum likelihood estimation and handled missing data under assumption of missing at random. predictors with missing data (e.g., parent alcohol use, receipt of lunch subsidy) were made endogenous to the model by regressing them on other predictors without missing data (sex, race, ethnicity), which prevented cases with missing data on these predictors from being removed from the model in a listwise fashion. movie alcohol exposure and cannabis initiation 42 results across 15 time points (ages 11.5 to 18.5 years), 33% (n = 307/830) of previously cannabis-naïve participants reported cannabis initiation. among all who contributed movie exposure data, 35% (n = 309/882) of participants reported using both cannabis and alcohol at some point during the study, with 65% (n = 574/882) reporting initiation of either cannabis or alcohol and 9% (n = 78/882) of participants initiating both at the same time. seventeen percent (n = 152/882) of participants initiated cannabis use prior to alcohol use (including cases where alcohol was subsequently initiated and those where it was not), and 39% (n = 344/882) reported initiating alcohol use prior to cannabis use (including cases where cannabis was subsequently initiated and those where it was not). thirty-five percent (n = 307/882) of participants did not endorse initiating either cannabis or alcohol use during the study. based on a random sample of movies, participants reported a scaled average of 5.57 estimated hours (standard deviation [sd] = 4.29) of movie alcohol exposure (see table 1). a one sd increase in scaled movie exposure predicted a 19% [95% ci or: 1.05 – 1.33] increased probability of cannabis initiation in fully unadjusted models. in model 1, adjusting for demographic factors of sex, race, ethnicity, and lunch subsidy use, a one sd increase in scaled movie exposure predicted a 16% increased probability of cannabis initiation (95% ci or: 1.02 – 1.31; see figure 1). survival ratios were calculated for participant cannabis initiation, reflecting that those with lower (1-sd) exposure to alcohol in moves were less likely to report cannabis initiation by the age of 18.5 (or study completion), and those with higher movie alcohol exposure were more likely to have reported cannabis initiation by age 18.5 (or study completion). hispanic ethnicity (hr = 1.13; 95% ci or 1.06 – 1.21) and receipt of lunch subsidy (hr = 1.54; 95% ci or: 1.19 – 1.98) were significant predictors of age of cannabis initiation while sex and race were not (see table 2). in model 2, adjusting for demographic, behavioral (sensation seeking, time-varying alcohol onset) and social (peer cannabis use, parent audit) covariates, a one sd increase in scaled movie exposure resulted in a 14% increased probability in cannabis initiation (95% ci or: 1.01 – 1.29; see table 2). hispanic ethnicity (hr = 1.14; 95% ci or 1.06 – 1.21), receipt of lunch subsidy (hr = 1.51; 95% ci or: 1.17 – 1.95), timevarying alcohol onset (hr = 3.59; 95% ci or: 2.34 – 5.49) and peer cannabis use (hr = 2.59; 95% ci or 1.58 – 4.22) were significant predictors, while sex, race, parent audit score and sensation seeking were not (see table 2). a subsequent model examined whether the effect of movie alcohol exposure on cannabis initiation was dependent on participant sex, via moderation. the interaction term from this model (adjusted for sex, race, ethnicity, and receipt of lunch subsidy) was non-significant (hr = 1.01, p = .96), suggesting that the effect of movie exposure on cannabis initiation did not differ by sex at birth. figure 1. survival curve of cannabis initiation as a product of exposure to alcohol in movies from ages 11.5 to 18.5. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 su rv iv al r at io (1 -h az ar d) participant age mean +1 sd movie alcohol exposure -1 sd movie alcohol exposure cannabis, a publication of the research society on marijuana 43 table 2. estimates for the discrete-time survival model predicting cannabis initiation (n = 830). hr confidence interval hr 95% ll 95% ul p model 1 movie alcohol exposure 1.16 1.02 1.31 0.019 sex (1=male) 0.82 0.65 1.04 0.099 race (1=white) 0.88 0.63 1.23 0.452 ethnicity (1=hispanic) 1.13 1.06 1.21 <.001 receipt of lunch subsidy (y/n) 1.54 1.19 1.98 0.001 model 2 movie alcohol exposure 1.14 1.01 1.29 0.041 sex (1=male) 0.83 0.65 1.05 0.113 receipt of lunch subsidy (y/n) 1.51 1.17 1.95 0.002 race (1=white) 0.83 0.6 1.15 0.264 ethnicity (1=hispanic) 1.14 1.07 1.21 <.001 time-varying (t-1) alcohol onset (y/n) 3.59 2.34 5.49 <.001 note. hr=hazard ratio; y/n = response options yes or no; ll: lower limit; ul: upper limit. discussion the present study demonstrated that hours of exposure to alcohol in movies was associated with increased likelihood of cannabis initiation at a younger age. this was demonstrated even in rigorous analyses controlling for contemporaneous alcohol use as well as youth demographic variables (sex, lunch subsidy, race, ethnicity), alcohol onset, peer cannabis use, parent alcohol use, and sensation seeking. sex was not a significant moderator of the relationship between movie alcohol exposure and cannabis use, meaning that exposure to media substance use similarly impacted age of cannabis initiation across males and females. given the prominence of substances in the media and deleterious effects of early cannabis use (hawke et al., 2020), continued exploration of the nature of these associations and potential mitigating factors remains important for prevention efforts. approximately one third of previously cannabis-naïve participants reported initiating cannabis during the study, with almost all initiating alcohol use as well. it was more common for participants to initiate alcohol use prior to cannabis use rather than the reverse, although many initiated both substances at the same time. additionally, results suggest that adolescents were significantly more likely to initiate cannabis use earlier when they had initiated alcohol use, providing support for the shared context and frequent co-occurrence of alcohol and cannabis use (jackson et al., 2021). a valuable future direction would be exploration of these relationships and developmental substance use trajectories in an older, higher-risk sample. peer cannabis use also resulted in a hazard ratio notably higher than that of movie alcohol exposure, suggesting that, while exposure to substances in the media increases risk, peer behaviors remain one of the largest risk factors for youth substance use (stoolmiller et al., 2012). this is aligned with recent qualitative findings in which adolescents reported perceiving peer alcohol-related social media posts to be more influential for teen behaviors than influencer alcohol-related social media posts (corcoran et al., 2023). an important future direction may be an exploration of how peer influences and media exposure to substances interact to impact adolescent substance-related attitudes and behaviors. other significant covariates included prior year alcohol use, hispanic ethnicity, and lower socioeconomic status, somewhat consistent with earlier findings (e.g., wu et al., 2015). taken together, these findings contribute to a nuanced and complex understanding of youth cannabis onset, whereby media, individual, and social influences all contribute to risk. a consequence of cross-substance media effects is that youth with repeated exposure to multiple substances in the media may have greater risk for initiation of all substances. this is concerning given the extent of media substance exposures across media modalities, including television, streaming services, social media, online marketing. for example, alcohol depictions and marketing content are common and accessible to underaged youth on tiktok (russell, 2021), movie alcohol exposure and cannabis initiation 44 twitter (barry et al., 2016; cabrera-nguyen et al., 2016; litt et al., 2018), and youtube (barry et al., 2015). qualitatively, adolescents report seeing alcohol content on social media frequently, originating from both influencers and peers and including both branded and unbranded content (corcoran et al., 2023). even when educational and warning content is available on alcoholrelated posts, content with risk-taking and celebratory themes tend to elicit more likes and views (lim et al., 2021). cannabis content is also common on social media (cabrera-nyugen et al., 2016; whitehill et al., 2020). future research should aim to develop methodology for systematically quantifying these exposures across modalities to get a more comprehensive perspective on youth substance-related exposures and ascertain whether the cross-substance effects identified in the present study apply more broadly. across media modalities, the regulations and trends specific to any one substance likely implicate the others. for example, alcohol marketing (including product placements in movies) is self-regulated (noel et al., 2017), which is not effective in minimizing exposures to youth (noel et al., 2017). cannabis, on the other hand, is subject to more complicated regulations due to its status as a schedule i drug nationally and variable legal status across states, largely limiting marketing to specific conditions on social media or situations in which content will not cross state lines (whitehill et al., 2020; moreno et al., 2023; berg et al., 2023). this will almost certainly shift as states continue to legalize cannabis (borodovsky et al., 2016, 2017); as of august 2023, 24 states have legalized its use as compared to 4 in 2015 (disa, 2023; leins et al., 2021; laurence, 2023). legalization has been found to associate with a decrease in perceived risk of cannabis use among adolescents (maxwell & mendelson, 2016), which may further increase use and the cannabisrelated social media content youth are exposed to. another notable trend has been the proliferation of e-cigarettes and vape pens, which can be used to consume cannabis in a discrete way (e.g., not immediately identifiable as cannabis, vapor instead of smoke, subtle design). these characteristics hinder monitoring and prevention efforts (ramamurthi et al., 2019) and likely increase youth exposure to vaped substances. thus, the present study provides support for a more comprehensive consideration of media influences on youth substance behavior beyond exposure to one specific substance. from a preventive standpoint, media exposure to substance use, which is modifiable at a policy or family level, may be a promising environment risk factor on which to intervene. evidence exists for the protective effects of media parenting behaviors on youth risk behavior (cox et al., 2018), which would be expected to cut across multiple online risks (e.g., exposure to a range of different types of substances). parental media mediation involves the employment of mediaspecific parenting behaviors, such as talking to children about what they are seeing and doing online, educating children about online risks and safe media use, co-viewing or co-using media and technology, and house rules (gabrielli et al., 2018). present findings suggest media parenting approaches may be most effective for reduction of youth risk for substance use behavior if applied broadly across substance content. for example, if parents notice a child being exposed to alcohol advertising in the media, they may want to discuss how multiple substance use industries (including cannabis and tobacco industries) may underplay the risks involved with use of substances. study limitations include the study sample being drawn from one region of the us exclusively with overrepresentation of white participants and underrepresentation of black and hispanic participants. future studies may aim to replicate these findings with more nationally representative samples. additionally, it is possible that the identified relationship between media exposure to substances and cannabis use is, in part, a product of a general association between substance use and media use. however, studies on media exposure to substance use have controlled for general media use, with significant media substance effects enduring (gabrielli et al., 2021). thus, although media usage alone may have an effect, it appears that substance use in the media has an effect above and beyond that of general media use alone. we also did not control for cannabis exposures; some of the alcohol exposures coded may have also included cannabis. that said, given data on the relative frequency of substance depictions (e.g., castaldelli-maia, 2021), this is unlikely to have accounted for present associations. furthermore, cannabis content cannabis, a publication of the research society on marijuana 45 coding of media may be more complicated (e.g., a vape pen may or may not include cannabis) than alcohol content coding, which has a much stronger foundation of literature support. strengths of the present study include a robust measure of youth movie alcohol exposure, a longitudinal design with repeated measures of substance use behavior, and a substance-use naïve sample at baseline. cannabis initiation and use in youth, particularly at high volumes and frequencies, may result in detrimental health and social outcomes. gaining a greater understanding of modifiable environmental influences to substance use initiation and progression is important for prevention and intervention efforts. the present study identified an association between alcohol exposures in the media and subsequent cannabis initiation. future research should continue to explore non-specific media exposures as a potential influence on youth substance initiation. as it is unlikely that alcohol depictions will decrease in the media in the near future, and cannabis depictions may increase, an understanding of cross-substance and general substance media effects is important. references ajzen, i. 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(1993). investigating onset, cessation, relapse, and recovery: why you should, and how you can, use discrete-time survival analysis to examine event occurrence. journal of consulting and clinical psychology, 61(6), 952. https://psycnet.apa.org/doi/10.1037/0022006x.61.6.952 wu, l. t., swartz, m. s., brady, k. t., hoyle, r. h., & workgroup, n. a. (2015). perceived cannabis use norms and cannabis use among adolescents in the united states. journal of psychiatric research, 64, 79-87. https://doi.org/10.1016/j.jpsychires.2015.02.02 2 funding and acknowledgements: this manuscript was written with funding support through the national institute on alcohol abuse and alcoholism (r01 aa016838, jackson). the authors have no known conflicts of interest to disclose. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article ved abstract objective: scientific and medical sources continue to be outpaced by the burgeoning cannabis marketplace regarding emerging forms of cannabis, leaving consumers with a great deal of uncertainty about safety and efficacy that may be addressed in cannabis dispensary and online settings. the present study examines how cannabis dispensary staff (“budtenders”) use and evaluate the trustworthiness of online information about cannabis, especially social media content. method: qualitative semi-structured interviews were conducted with san francisco bay area budtenders (n = 18) and analyzed thematically. results: social media was not viewed as a reliable information source for dispensary-based social interactions. budtenders were skeptical of most commercially-oriented social media content and frustrated with inconsistent content moderation practices of social media platforms. budtenders instead preferred offline information sources and relationships, as well as information derived from first and secondhand experiences with cannabis products. when evaluating information on social media, online settings promoting privacy, community moderation, and accountability were seen as features of trustworthy environments. budtenders also expressed a range of confidence in medical, natural healing, and personal experience frameworks of health and cannabis knowledge production; concordance of social media content with these frameworks was an additional signal of trustworthy information. conclusions: this research highlights the role of budtenders in evaluating and triangulating emerging online cannabis information sources for consumers and the varied features and signals that cue budtenders to consider some online information as more trustworthy and credible for cannabis consumers. key words: = cannabis; budtender; social media; trustworthiness; online information legalization and decriminalization of cannabis in the united states (u.s.) and worldwide have coincided with an increase in novel types of cannabis products with varied potency, as well as interest in medicinal applications. california was the first state to legally allow medicinal cannabis access in 1996 and legalized adult (recreational) use in 2016 under proposition 64, which permitted sales in 2018. many states, including california, allow cannabis products to be sold in storefront dispensaries by staff known as “budtenders.” with meredith c. meacham1, maha n. mian1,2, danielle schell3, & coye cheshire4 1department of psychiatry and behavioral sciences, university of california san francisco 2department of psychology, suffolk university 3school of public health, university of california berkeley 4school of information, university of california berkeley cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000319 cannabis dispensary staff (“budtender”) perspectives on trustworthiness of social media information: a qualitative study corresponding author: meredith meacham, phd, mph, university of california san francisco, 675 18th street, san francisco, california, 94107. email: meredith.meacham@ucsf.edu cannabis, a publication of the research society on marijuana burgeoning marketplaces selling novel products and with uncertainty about the safety and efficacy of cannabis, consumers need trustworthy information on the risks and benefits of using cannabis products (madson, 2023). while governments, public health institutions, and healthcare providers may be the traditional communicators of risk regarding pharmaceutical, herbal, alcohol, and food products, cannabis use is illegal on the federal level as a schedule i substance and is not regulated by the u.s. food and drug administration. healthcare providers and scientists may address uncertainties, reduce decision complexity (larson et al., 2018), and engage in knowledge production about cannabis products, yet the scientific literature and clinical recommendations are far outpaced by novel products, indications, and claims (thrul & vandrey, 2024). much of this emerging information can be found online (khademi habibabadi et al., 2022), including on social media sites like youtube (etumuse et al., 2024; krauss et al., 2015; krauss et al., 2017; lim et al., 2021; yang et al., 2018), reddit (hu et al., 2021; meacham et al., 2018; meacham et al., 2019; sowles et al., 2017; thulin et al., 2024), twitter/x (cavazos-rehg et al., 2015; daniulaityte et al., 2015; lamy et al., 2016), meta-facebookinstagram (litvinova et al., 2024; moreno et al., 2022), and tiktok (rutherford et al., 2022). overall, these studies of social media content regarding cannabis have found few warning messages, predominantly personal experiences and pro-cannabis attitudes, and many unsupported therapeutic claims (madson, 2023; park & holody, 2018) that may be inaccurate or even harmful, particularly for youth and young adults (berg et al., 2023). in this sea of informational uncertainty and an abundance of unvetted online content, budtender dispensary staff can serve as significant arbiters of information to adult cannabis consumers. prior published research with cannabis dispensary or retail staff has primarily focused on medical cannabis settings and general budtender use of information or recommendation sources. a 2016 survey study of practices with 158 medical dispensary staff in california (peiper et al., 2017) found that “lack of information” was the most frequently reported barrier (70%) to medical decision-making and budtender-patient interactions. most dispensary staff in this sample (92%) reported daily internet use and 39% reported exchanging information with patients over social media. other budtender research has reported on attitudes and training practices (braun et al., 2022; bulls et al., 2023; carlini et al., 2022; haug et al., 2016; peiper et al., 2017) as well as medical recommendations and contraindications for specific conditions (barbosaleiker et al., 2022; dickson et al., 2018; merlin et al., 2021; slawek et al., 2023; weldy et al., 2020). less is known about how budtenders identify and integrate trustworthy online information sources into their interactions with customers in adult use or recreational cannabis point-of-sale settings. trustworthiness is a characteristic inferred about a person, technology, or system having incentive to act in our interest under conditions of uncertainty (hardin, 2001). trustworthiness is also linked to motivations (including moral commitments), consistency, and competence and is a fundamental component of social exchange theory, which focuses on the benefits people obtain from and contribute to social interaction with other people (cook et al., 2013; molm, 1995). although social exchange may be anchored in an economic transaction in a retail environment, these social relations occur and evolve over time within social structures like healthcare settings or online social networks. examples of social exchange relationships might include patients and physicians, budtenders and consumers, or budtenders and online information-sharing websites and communities. in each case, the various parties exchange valued resources of information. however, successful social exchange with others involves some assessment that one is receiving accurate, relevant, or trustworthy information. assessing this kind of trust can be especially difficult in online settings, as the social cues people use to assess trustworthiness in person may be absent, potentially increasing risk and uncertainty (cheshire, 2011). in light of a fractured information ecosystem and in order to inform the evolution of valuable and credible cannabis information in social exchange relationships that occur outside medical settings, the goal of the present study was to examine how budtenders in the san francisco bay area in california use and evaluate the trustworthiness of online cannabis information, especially social media content, as part of their social interactions with cannabis consumers. budtender perspectives on social media given the central role budtenders play in communicating risks and benefits of cannabis products to customers and the pervasiveness of social media in both budtenders’ and customers’ lives, we sought to more deeply understand how budtenders perceive online cannabis content through their own experiences, and how they evaluate the trustworthiness of that content when interacting with customers. in doing so, we can attain greater clarity about how budtenders navigate these information needs and identify gaps that could inform budtender training practices and public health communication strategies about the risks and benefits of cannabis. methods all study procedures were approved by the university of california san francisco institutional review board (#18-26906). recruitment customer-facing dispensary staff in the san francisco bay area were sampled purposively and approached via email, on social media, and by flyer for remote video semi-structured qualitative interviews conducted from march 2021 to february 2022. recruitment efforts included email invitations to six contacts with connections to cannabis businesses, posting of study information to three reddit communities and one linkedin group, and printed flyers left at six dispensaries in san francisco. invitations included brief study information and a link to an online eligibility survey. later, interview participants were also invited to share the study information with any coworkers or friends. potential participants completed an online qualtrics (provo, ut) survey assessing study eligibility, social media use, and demographics. eligibility criteria included (1) working in a customer-facing position at a san francisco bay area cannabis in the past year (including phonebased orders); (2) having a smartphone or computer with video and access to data or internet; and (3) being 18 or older. eligible participants were directed to share their preferred contact for scheduling (email or text/sms), preferred day of the week and time of day for the interview, and $60 e-gift card preference (to amazon, target, door dash, or safeway). of 56 people who completed the eligibility survey, 24 (42%) were eligible. of these 24, 18 completed the interview procedures and comprised the valid sample. primary reasons for ineligibility were location outside the san francisco bay area and not currently or recently working in a customer-facing dispensary position. the original target sample was 20 participants as is typical in health behavior research. interviews were conducted in batches of 4-5 participants based on recruitment pacing. after 14 interviews were completed, the first and senior author reviewed interview notes and discussed participant characteristics and data saturation, deciding to recruit and interview 4-6 additional participants, at which point the investigators decided that sufficient data had been collected. interview procedures eligible participants were contacted via email or text message from a study-specific google voice number to schedule the interview. a study information sheet, informed consent document, and zoom link were emailed and/or texted to participants, and an invitation to review and e-sign an informed consent document was sent via docusign. at the beginning of interview session, the interviewer (mcm) introduced herself and her background; reviewed the study objectives, format, and reminders of voluntariness and confidentiality; and asked for verbal consent to begin recording. the interviewer was a female assistant professor at an academic medical center, living in san francisco and with training and experience in social science and public health mixed methods research related to substance use and drug policy. none of the participants had an established relationship with the interviewer prior to study commencement. interview guide questions were informed by social psychology theories regarding social exchange and assessments of trustworthiness, and pilot tested with a volunteer research assistant who had worked at a dispensary. questions were grouped into four sections: opening, online settings, dispensary settings, and closing. the opening section prompted participants to describe their job, how they got started in the cannabis industry, and any job-related training that they had received. cannabis, a publication of the research society on marijuana next, in the online settings section, participants were asked about any cannabis-related websites, apps, or social media accounts they were aware of and their perceptions of the trustworthiness of these resources. in the dispensary section, participants were asked to describe their workplace and job tasks, as well as how they would respond to three hypothetical customers. the closing section prompted participants to reflect on changes to their job related to the covid-19 pandemic, general working conditions, knowledge and perceptions of bay area equity programs, and their favorite part of the job. interviews lasted from 45 minutes to 2 hours, with a median length of 90 minutes. only the interviewer and participant were present during the interview, and participants were only interviewed once. the interviewer took notes during the interview to capture key phrases, observations, and emerging themes. de-identified audio recording files were professionally transcribed by a hipaa-compliant transcription service. transcripts and findings were not shared with participants to minimize participant burden and given their limited interest when asked. coding and analysis interview transcripts were coded and analyzed in nvivo 12. first, the study team developed an initial set of a dozen codes based on the interview guide topics of the larger interview study. these initial codes were applied independently to two interview transcripts by two coders (mcm, dls). these codes and their applications were discussed by the study team (mcm, dls, cc) and grouped into seven larger code-group parent nodes: role identities, interactions with customers, trust and trustworthiness, online resources, social media, cannabis products, and desired effects. an expanded codebook with these seven code-group parent nodes, definitions, examples, and subcodes was compiled and applied independently by the two coders to the remaining interviews in batches of 2-4 interviews, with discrepancies identified and discussed until consensus was reached for the seven code-group nodes. the coders also drafted notes and memos throughout the coding process, capturing exemplar quotations and emerging themes. all 18 interviews were double-coded. for the present analysis, all quotations labelled with the online resources and social media codes were output from nvivo and reviewed, with a focus on co-occurring codes of trust and trustworthiness. labelled quotations were then grouped into major and minor themes and summarized and discussed by mcm and mnm. results sample description the 18 budtender participants ranged in age from 22 to 65, with a median age of 30. (table 1) the majority identified as female (n = 14, 78%) vs. male, and as people of color (n = 11, 61%) vs. white. racial and ethnic identities included black (n = 4), white (n = 7), latine or hispanic (n = 5), and asian/aapi (n = 4). almost all participants had some college (n = 9) or a college degree (n = 7). half of the budtenders (n = 9) were in their current or most recent position for over a year, compared to 7-12 months (n = 5), or 6 months or less (n = 4). as abstracted from interview transcripts, the most common training that people received was on-the-job shadowing (n = 7), followed by formal training or onboarding (n = 5), and reading or lecture materials (n = 2). participants worked at 13 unique dispensaries, primarily in alameda and san francisco counties. as abstracted from interview transcripts, most (7/13) dispensaries had products behind a counter, while in other dispensaries customers could browse products in the store (4/13). two dispensaries only had phone order and pick up or delivery service during covid-19 restrictions. in addition to social media platforms, websites mentioned in interviews as online sources included leafly.com and weedmaps.com, as well as cannabis business websites and newsletters, specific brand websites, pubmed.gov, and projectcbd.org. another website that came up several times was seedfinder.eu, which provided information on specific strain qualities and lineages. budtender perspectives on social media table 1. budtender participants characteristics (n = 18) participant # age gender time in position social media platforms used daily 1 30 female 8 months instagram, tiktok 2 39 female 1 year instagram, twitter/x 3 30 female 3 months instagram, tiktok 4 38 female 2 years facebook 5 29 male 2 years instagram, reddit 6 29 female 8 months instagram, twitter/x, tiktok 7 30 female 2 years facebook, instagram, snapchat, tiktok 8 31 female 4 months facebook, instagram 9 46 male 5 years facebook, instagram 10 37 female 4 years facebook, instagram 11 22 female 6 months twitter/x, reddit 12 38 female 3 years none (instagram weekly) 13 52 female 3 years facebook, instagram, twitter/x 14 65 male 1 year facebook, instagram, twitter/x, tiktok 15 28 female 3 months instagram, twitter/x, tiktok 16 37 female 2 years facebook, instagram 17 25 female 1 year instagram, tiktok 18 27 male 1 year instagram, reddit theme 1: social media content is abundant, but was not viewed as a reliable source of information all participants used social media at least weekly, reporting in the survey daily use of instagram (n = 15), facebook (n = 8), tiktok (n = 7), twitter (n = 6), and reddit (n = 3). the most mentioned social media platforms in interviews included instagram for brand and store promotion and youtube for instructional videos and product reviews. with respect to how often they saw cannabis content, some budtenders had separate accounts for personal use and for cannabis-related content and only saw cannabis content when they specifically followed cannabis content creators: “i guess i generate more [exposure to] cannabis influencers because that's what i'm seeking out on that profile, versus when i'm on let's just say [my personal account], it doesn't really show me as much advertisements for cannabis. … with that being said, i feel like it's almost like you have to seek it out for it to be thrown in your face.” participant #10, age 37 one budtender acknowledged how much more pervasive online engagement became for all aspects of life during covid-19: “now that we're gone through covid, everybody’s on all these different platforms…. like every single person on the planet has been forced to engage with technology at the highest level.” participant #9, age 46 budtenders who used multiple platforms also noted differences in what kind of cannabis content they saw on different platforms: “instagram is all pretty people smoking and we need to see something different, you know. and i get a little annoyed by that, but i think it's generational. but as far as facebook goes, there's budtender education. there's full spectrum. there're some groups on facebook that i have followed and i get articles, i get notices. and i compare them to linkedin because i've seen more serious articles from linkedin. participant #14, age 65 cannabis, a publication of the research society on marijuana the types of cannabis content that budtenders saw on social media often related to why they were using social media (e.g., business networking, educating themselves, staying in touch with friends). budtenders commented on the sheer amount of information online available to consumers, and how difficult it can be for consumers and budtenders to determine what is or is not reliably true: “i don't just, like, take the stuff at its word when i see it. i definitely have to, like, click into it, see what's going on, read through it.” participant #4, age 38 one participant described how they saw their role as a trusted partner when interpreting this online information for customers who may be new to cannabis: “so, i do hit a saturation point of not knowing – not wanting to know more. … yeah. again, it's going to confuse the customer. already especially a newbie. you know? and the relationship is about trust. …. it’s a partnership.” participant #14, age 65 several budtenders lamented that it was so difficult to parse the abundant content on the internet that identifying reliable information was a challenge: “so yeah, the internet, it's really hit or miss. like, i wish there was some sort of like weed-o-pedia that like everybody could just like agree [on].” participant #12, age 38 despite this general sense of overwhelm, some budtenders did use social media more intentionally and as a part of their job – to evaluate brands and producers on behalf of customers and to share personal recommendations with cannabis consumers: “a lot of us do share what we like. or a lot of us do recommend towards each other, ‘hey, i've tried that before. have you tried this?’ or, ‘oh, i like that. how does that make you feel?’ … actually, my social media network with more reliable sources. it's more credible. shows i'm a normal person, as well. also, builds a stronger connection between budtender and vendor, especially.” participant #5, age 29 theme 2: budtenders expressed skepticism when evaluating commercial content a key challenge expressed by many budtenders was tension in evaluating commercial vs. educational intents behind online cannabis content. their skepticism not only applied to the content itself, but to who created the content and the platform hosting it. some budtenders contrasted what they would like to see more of with the sales and commercial aspects of content that they usually see: “[i’d like to see] just more, like, knowledge on cannabis itself. it’s all just, like, buy, buy, buy, but it's not really, like, giving knowledge behind or background behind it.” participant #1, age 30 “i see a lot of … girls in bikini, and just selling products based on fun…. so, i think that's what social media sucks at, there's not more education being pushed. versus advertisement. so, i'd love to see that flip.” participant #10, age 37 in interactions with customers, addressing online information quality came up sometimes with consumers who were seeking specific products they had seen advertised online: “lots of people come in because they've read online that, yeah, cbd, cbd, cbd – it's just going to change everything. and like, bro, there's so much more to this. like talk to me about what you're trying to address first.” participant #4, age 38 theme 3: online cannabis content is inconsistently moderated by social media platforms budtenders also expressed concerns about the social media platforms themselves, reporting confusion and frustration with the inconsistency budtender perspectives on social media of content moderation of cannabis content and creators by the platforms: “i do not see eye to eye with the accounts that they choose to – to elevate and to sequester because it doesn't make any sense.” participant #3, age 30 this frustration was especially pronounced for budtenders at smaller businesses who were also managing their dispensary’s social media account: “so, for the most part, we're just trying to promote our dispensary. and it's really hard to try to get people to come in and build customer retention without being able to promote on instagram the way that other brands can. like food or alcohol or whatever…. there's definitely not clear rules on instagram on what you can post and what you can't. the same thing with tiktok. you just have to wing it and wonder, is it going to get taken down when it gets a certain amount of attention? or is it going to stay? you never know.” participant #7, age 30 while some budtenders lamented the commercial focus of cannabis-related social media content, others were actively involved in creating this content as part of their job. theme 4: accountability and community moderation were important social media features for a trustworthy social media information environment when considering features of different social media information sources, participants preferred private groups among known insiders, or wellmoderated public forums for sharing and relying on trustworthy information. regarding groups and forums, one budtender stated: “you can do the public ones, but the public ones get weird real fast .... so, i try to keep it to the private groups. so then if you belong to one, then someone will invite you to another, and then you get invited to another. so, it’s – it's definitely an insider kind of thing. and then if you act up, they're – you're out.” participant #13, age 52 moderation by community members or peers and accountability were important features of trustworthy forums for cannabis information: “[i find that information on reddit to be trustworthy] for the most part, because of the mods. there's literally someone to fact check you or listen to your complaint. they're responsible. i've been temporarily banned from certain subs for spreading misinformation. and literally, the accountability is – man, accountability goes a long way when it comes to information.” participant #18, age 27 when considering different platforms, this budtender preferred online group accountability on moderated sites like reddit compared with commercially oriented instagram content: “instagram is just everyone posting what they want to post, what they want you to see…. no one's being honest on their instagram because it's all tailored to their operations. you don't like it, you just delete the comment. but reddit, like i said, there's a whole lot more accountability and people speaking up. … i like that reddit is mostly people trying to be discreet. i haven't really seen anyone trying to sell things on reddit. and i don't know if that's even allowed. with certain subs, it's got to be a rule not to advertise.” participant #18, age 27 these community moderation and accountability features were noted as helpful for promoting trustworthiness of cannabis information by attempting to keep out commercial interests as well as flagging inconsistent or incompetent information or creators. theme 5: established histories, face-to-face relationships, and consistent values were more important than social media networks budtenders described several ways that they evaluate the intentions of content creators and quality of the content itself. first, trustworthiness of social media content was perceived to be greater with brands and content creators with known histories within the cannabis economy and relationships developed in face-to-face contexts. cannabis, a publication of the research society on marijuana when prompted to think about how they decide what to trust online, one budtender stated: “i have a lot of friends who are in the industry who are on instagram. so, i look at their stuff, and then, i like, see what they're tagging and see who's commenting and go through those profiles and see what seems legit, and then, do research on whether or not it is legit, and, you know … do some digging online to find out whether or not this person was a real individual and whether or not they're reputable and all that.” participant #4, age 38 the trustworthiness and competency of an inperson contact would sometimes be extended to their online presence: “it's just sort of the people that have worked at [my dispensary] and left that i know do good work that i'll follow like on instagram.” participant #12, age 38 many budtenders expressed the tendency to trust online content that comes from individuals or groups that have a longer history in producing or selling cannabis. for example, some explained that they preferred cannabis content creators that were in the industry since before prop 64 legalized recreational cannabis sales: “i seek out a lot more of the teachers…. i want to know that they've been in this industry for a while, too. i'm a little stuck up when it comes to that. i want to know that someone's been a part of this grassroots movement, and they didn't just jump in because they saw profit.” participant #10, age 37 the explicitly stated or inferred values of cannabis product companies or brands were also viewed as important in discerning trustworthiness. these values were inferred by online presence as well as word-of-mouth within the industry. “that’s the main thing, the main goal, is picking brands that at the core not only treat the plants with respect but treat their employees and their workers with respect.” participant #7, age 30 theme 6: budtenders evaluated online information by considering other knowledge finally, online information was seen as more trustworthy when it was concordant with preexisting knowledge held by the budtender or the consumer they were interacting with. in support of building trustworthy relationships with customers, some budtenders preferred content and knowledge based in scientific and medical research. this was especially the case when consumers had questions about using cannabis for medicinal purposes, and some budtenders noted that they would like to see more precise, medically oriented content: “i would like to see more concrete information in regard to ailments, you know? … [for example], back pain. oh, i have back pain. some people walk away and say okay, i'll put a cream on, and come back and say this didn't work. and some people say oh, i put it on my skin, and i was high all night. you know, so, it's a matter of getting information that i believe i could then recycle in my way.” participant #14, age 65 however, budtenders also contrasted western medicine with holistic and natural health knowledge and belief systems and firsthand accounts that they found more credible: “because, you know, people rely more on the medical system than they do in any other system. because it's a program that we're taught, that the medical system is the only system that knows the best. when that's not really the truth. … but there's more out there that is accessible. … so, you know, i'm a huge, like, person when it comes to naturally healing yourself." participant #16, age 37 “it's more green healing in a way, so i put up information about things that i use myself.” participant #10, age 37 for others, trustworthy information and recommendations derived from their personal experiences. one budtender shared how online product reviews on the website weedmaps budtender perspectives on social media affected what they tried themselves, which in turn affected what they recommend to consumers: “i do purchase a lot to experience it myself before i recommend. so, that [online reviews] also affects how i choose products, too.” participant #17, age 25 budtenders expressed a range of confidence in medical, natural healing, and personal experience frameworks of health and cannabis knowledge production; concordance of social media content with these frameworks was an additional signal of trustworthy information. discussion budtenders have the difficult task of making sense of an enormous and often inconsistent pool of online information about cannabis for customers during in-person social exchanges at dispensary storefronts, especially given the lack of consistent or centralized information from medical and scientific sources. as non-clinical arbiters of trust who reduce decision complexity for customers, budtenders distill vast amounts of cannabis information from a variety of personal, commercial, and medical sources. by interviewing california budtenders to examine how they use and evaluate the trustworthiness of online cannabis information, we were able to draw out several themes of trustworthy information cues and contexts: while abundant, social media itself was not a reliable source of information in dispensary-based interactions with customers. budtenders were skeptical of commercially oriented social media content and platforms and instead preferred to reference offline information sources and relationships, or online relationships grounded in trusted offline relationships or in well-moderated community forums. budtenders also expressed a range of confidence and beliefs in medical, natural healing, and personal or lived experience frameworks of knowledge generation. there are several implications from these themes for promoting trustworthiness in an evolving legal cannabis landscape. the first is that filtering abundant online information is part of the budtender’s role in a trustworthy social exchange relationship with a customer. regarding existing social media cannabis content, budtenders wanted to see more non-commercial knowledge-building content. when evaluating online information, accountability for its veracity, the reputation of who was sharing it, and a connection to an in-person trusted figure were features and signals that cued greater trust and credibility. the importance and usefulness of first and secondhand experience as strong reputational signals in assessing trustworthiness of information are consistent with other studies of budtender roles and practices. a focus group study with budtenders in washington state (carlini et al., 2022) found that budtenders “had long personal experience with consuming cannabis and wanted to share their knowledge.” having “firsthand knowledge” of the dispensary’s inventory and applying this knowledge to create a good cannabis experience for the customer were essential parts of the budtender role, in addition to educating customers around safer use and compliance with state law and regulations. a survey study with medical dispensary staff in the u.s. (merlin et al., 2021) also found that staff relied on a combination of personal and coworker experience when making recommendations to customers, along with the customer’s medical condition, the customer’s prior experience with cannabis, and occasionally apps and websites. in the present study, we note that not all budtenders reported using cannabis currently or frequently and would often refer on coworkers’ personal experiences and knowledge. efforts to communicate information and messaging about the risks and benefits of cannabis should acknowledge and incorporate this experiential knowledge. the commercial and profit-driven orientations of dominant social media platforms (based on advertising revenue) and the california adult use cannabis market (vs. prop 215 medical and legacy markets) were often-referenced challenges identified by budtenders. in response to legal liability and concerns about health misinformation and exposure of cannabis content to youth, many social media platforms have cannabis-promotion-specific policies; a 2022 review of policies found that all 11 platforms studied generally prohibited cannabis sales, but more specific policies about unpaid cannabis promotion were brief or ambiguous (berg et al., 2023). still, some of these restrictive and vague policies about cannabis content on social media cannabis, a publication of the research society on marijuana may contribute to situations where people are not able to consistently create or find non-commercial health and safety information about cannabis. efforts to improve digital health literacy (fitzpatrick, 2023) and social media self-efficacy (hocevar et al., 2014) are other means by which cannabis consumers and dispensary staff may be better able to evaluate the trustworthiness of online cannabis information. these efforts include the creation and dissemination of public health messages from multiple sources that are accessible, engaging, and credible to audiences. another potential target for facilitating transmission of trustworthy health and safety information to consumers via budtenders is the development and refinement of standardized training requirements for cannabis retail staff. given the largely informal training experiences reported by budtenders in this study, there was likely significant variation in the training they received. a review of requirements for nonmedical staff in 20 states found that 7 had statecertification training requirements and that 5 had employer-provided training requirements, but that details about requirements were minimal beyond compliance issues like minimum-age verification. the review authors also caution that large fees for trainings and prohibiting those with criminal records can hinder equitable employment (loparco et al., 2024). a prior interview study with cannabis dispensary staff regarding training specifically for therapeutic cannabis advice found that dispensaries tended to favor sales skills over therapeutic knowledge in hiring and that workplace training was unstandardized and weak (braun et al., 2022). as in the present study, dispensary staff were instead resourceful in learning about cannabis products outside of work, including sampling products and exchanging information with other staff and customers. other research on preferences for standardization of trainings for medical cannabis has identified product choice, dosing, route of administration, and drug interactions as key safety priorities (jean-jacques et al., 2021). budtender training implications from the present study point to a strong skepticism of commercialism and a need to acknowledge and incorporate the value of personal experiences and community histories with cannabis, as well as integrate more updated and robust medical evidence. the development of standardized training informed by multiple stakeholders to provide relevant and accurate informational resources would likely contribute to greater trustworthiness of transmitted information in dispensary settings. the findings of this study should be considered in the context of several limitations. as with qualitative research, these interviews may have limited transferability to budtenders in jurisdictions without legalized cannabis sales as regulations and stages of legalization vary between states, and even within states. additionally, there may be recall and socialdesirability biases with respect to how budtender participants report communicating to consumers. furthermore, how people evaluate trustworthiness may not be fully deliberate or cognitively describable. nevertheless, this study has captured perspectives from a wide sociodemographic range of individuals in an emerging professional role at a time of heightened online communication and expanding cannabis markets. future research will include explorations of how consumers evaluate cannabis information from budtenders and social media, especially when information conflicts with healthcare provider, public health authority, and legal information. this study highlights the role of budtenders in evaluating and triangulating emerging online cannabis information sources for consumers and the varied features and signals that cue budtenders to consider some online information as more trustworthy and credible for cannabis consumers. references barbosa-leiker, c., brooks, o., smith, c. l., burduli, e., & gartstein, m. a. 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(2020). perceptions of marijuana use for glaucoma from patients, cannabis retailers, and glaucoma specialists. ophthalmology glaucoma, 3(6), 453-459. https://doi.org/10.1016/j.ogla.2020.06.009 yang, q., sangalang, a., rooney, m., maloney, e., emery, s., & cappella, j. n. (2018). how is marijuana vaping portrayed on youtube? content, features, popularity and retransmission of vaping marijuana youtube videos. journal of health communication, 23(4), 360-369. https://doi.org/10.1080/10810730.2018.144848 8 funding and acknowledgements: this work was supported by u.s. national institutes of health grant k01 da046697. the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. the authors have no conflicts of interest to declare. the authors wish to acknowledge shim roh for feedback on the interview guide. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 24 ved abstract parent communication can be protective against cannabis use among young adults. however, changes in parent-student communication frequency naturally occur during the transition from high school to college. recent research suggests declines in parent-student communication frequency predict increased drinking and consequences during the first year of college, yet these effects on other risky behaviors are unknown. the current study investigated whether post-matriculation changes in frequency of texting/calling with parents predict cannabis use and simultaneous use of cannabis and alcohol, and whether pre-matriculation cannabis and simultaneous use predict changes in communication. first-year students (n = 287, 61.3% female, 50.9% white) reported cannabis and simultaneous use preand post-matriculation (t1 & t3) and changes in frequency of texting/calling their mother/father per day (t2). negative binomial hurdle models examined whether t2 changes in communication frequency predicted t3 cannabis and simultaneous use, and logistic regression models examined whether t1 cannabis and simultaneous use predicted t2 changes in communication frequency. results revealed that increasing (vs. decreasing) frequency of calling with mothers and texting with fathers was protective against cannabis use, whereas increasing frequency of calling with fathers was associated with greater risk of use. changes in communication did not significantly predict simultaneous use, nor did pre-matriculation cannabis or simultaneous use predict changes in either mode of communication with parents during the college transition. these findings highlight that changes in mother and father communication may be both beneficial and detrimental to cannabis use depending on the parent and mode of communication. implications for these findings are discussed. key words: = cannabis; college student; parent communication; text message; phone call cannabis use is prevalent among u.s. college students, with 43.9% reporting past year use and 24.5% reporting past 30-day use (schulenberg et al., 2021). using cannabis and alcohol simultaneously so that their effects overlap (simultaneous use) is also common, with approximately 20% of college students reporting simultaneous use in the past 30 days (looby et al., 2021). negative consequences associated with cannabis use include driving while high, decreased physical activity, and feeling in a fog the morning after use (bravo et al., 2019; pearson reed m. morgan1,2, bradley m. trager2, sarah c. boyle2, layla m. rainosek2, & joseph w. labrie2 1department of psychology, fordham university, bronx ny 2department of psychological science, loyola marymount university, los angeles ca cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000227 changes in parent-student text message and phone call communication during the transition to college as predictors of cannabis and simultaneous use during the first year corresponding author: bradley trager, ph.d., loyola marymount university, 1 lmu dr., los angeles, ca, 90045 phone: (310) 338-5238. email: bradley.trager@lmu.edu. cannabis, a publication of the research society on marijuana 25 et al., 2017). cannabis is also directly and indirectly associated with a range of academic outcomes including skipping class, achieving a lower gpa, and increased time to graduate from college (arria et al., 2015). simultaneous use may be more harmful, with studies indicating that combining cannabis and alcohol is associated with more consequences than using either substance separately (e.g., jackson et al., 2020; yurasek, aston, et al., 2017), perhaps accounted for by the amount of alcohol consumed on simultaneous use occasions (e.g., mallett et al., 2019). the transition into college is a critical period in which cannabis and alcohol use increase (fromme et al., 2008), riskier substance use trajectories can be established (arria et al., 2016; caldeira et al., 2012), and interventions targeting risky behaviors can be effectively implemented (e.g., parent-based interventions [pbis]; turrisi et al., 2001). thus, it is important to understand factors associated with increased risk for cannabis and simultaneous use that can be targeted in interventions delivered during the transition to college. parent-student communication and cannabis use general parent-student communication can be loosely defined as the exchange of any information, ideas, or feelings between parents and their children. this type of communication can be protective against cannabis use among young adults. cardenas et al. (2022) found that a low frequency of general parent-child communication was associated with being a heavy cannabis user (compared to being a low/non-user). however, over half of these participants were living with their parents and less than a quarter were enrolled in a 4-year college at baseline, and the situational differences between young adults and matriculating college students (e.g., moving away from home) prevent these findings from generalizing. cardenas et al.’s (2022) composite measure of communication included methods irrelevant to college students living outside their parents’ home (e.g., in-person contact), which further hinders the relevance of these findings to college students. while there are no published studies that have investigated the effects of general parent-student communication on simultaneous use, research has indicated drinking-related parenting variables can indirectly reduce simultaneous use (e.g., parental alcohol permissiveness; trager et al., 2021). thus, other parenting variables, such as general communication—which impacts both cannabis use (cardenas et al., 2022) and alcohol use (labrie & cali, 2011; small et al., 2011)—are also likely to reduce simultaneous use. text messages and phone calls are college students’ primary methods of communication with their parents (mccurdy et al., 2022), which is unsurprising given the ubiquity of smartphones among young adults (sidoti et al., 2024). despite this, there are no published studies that examine the impact of general parent-student communication specifically via texts and calls on cannabis or simultaneous use among incoming college students. most parents of college-aged individuals report communicating via text (73%) or phone (54%) with their young adult children several times per week (minkin et al., 2024). in line with this, a study by jensen and colleagues (2021) focusing on a racially diverse sample of college students, all of whom had previous experience with alcohol, found an average daily text exchange of 8 messages with mothers and 3 with fathers. further investigation into these communication patterns reveals that the frequency of text messaging between parents and students does not influence the students’ perceptions of parental autonomy support (brown et al., 2023). this suggests that texting offers parents a means to maintain contact with their college-aged children without compromising their sense of independence. while some research suggests this may not be the case for phone calls (racz et al., 2017; weisskirch, 2009), participants in these studies were younger adolescents, presumably living with their parents, and these data were collected over a decade ago, which calls into question the relevance of these findings today given the constantly evolving nature of technology. although the relationships between changes in parent-student digital communication and cannabis and simultaneous use have yet to be explored, research suggests that students whose frequency of texting/calling their parents increased or remained the same (vs. decreased) two months into college had lower odds of drinking and experiencing negative consequences 6 months later in their second semester of college changes in text and call communication 26 (trager et al., 2023a). this suggests that continued digital communication with one’s parents can be protective against alcohol-related risks in college (see turrisi & ray, 2010 for similar findings with other parenting constructs) and research is necessary to determine if these protective effects extend to cannabis and simultaneous use as well. trager and colleagues (2023a) also explored the inverse causal relationship—if pre-matriculation alcohol use predicted changes in communication frequency during the first semester—and found that heavy drinkers had lower odds of increasing or maintaining their frequency of texting their mothers (vs. decreasing) during their first semester of college. given trager et al’s (2023a) findings and the literature described above, we might expect that changes in parent-student digital communication could predict college students’ cannabis and simultaneous use, and that pre-matriculation cannabis and simultaneous use would affect collegebound young adults’ digital communication frequency with their parents. prior studies suggest that parenting style and communication can differ between mothers and fathers, and these differences might influence adolescent and young adult cannabis use. for instance, studies have revealed that mothers’ permissiveness toward cannabis use (but not fathers’) can be associated with greater odds of lifetime cannabis use among students between 14 and 21 years of age living with their parents (kokotovič et al., 2022). with respect to mothers’ and fathers’ communication in predicting adolescent cannabis use, research has revealed that adolescent boys who reported that talking to their fathers was easy (vs. difficult) had lower odds of past 30-day cannabis use (luk et al., 2010). however, this relationship was not significant among girls, nor were there any significant effects of mothers’ communication. taken together, these differences suggest that the nuances in mothers’ and fathers’ behaviors toward their children warrant separate examination in our current study. understanding these distinct influences could provide more precise insights into parental impacts on adolescent cannabis use, which are lacking in the literature. cannabis interventions for college students while there are several cannabis interventions in the college literature (e.g., elliott & carey, 2012; elliott et al., 2014; lee et al., 2010, 2013; palfai et al., 2014; riggs et al., 2018), all of which used personalized normative feedback in an attempt to correct overestimations of peers’ cannabis use, only one was designed for incoming students (lee et al., 2010) and it did not impact cannabis use. in contrast, pbis designed to prevent risky drinking that are administered during the transition into college can have secondary effects on cannabis use when given in combination with a brief motivational intervention (bmi; grossbard et al., 2010). however, alcohol bmis in isolation fail to influence cannabis use (white et al., 2015; yurasek, merrill, et al., 2017). this suggests the pbi component of grossbard et al.’s (2010) intervention may have been responsible for changes in students’ cannabis use. pbis promote general parent-student communication in addition to providing alcohol-focused resources, which may explain their influence on cannabis use. to test the idea that parent-student communication contributes to college students’ cannabis use, the current study explored the relationship between changes in students’ digital communication (via text messages and phone calls) with their parents and cannabis and simultaneous use during the transition to college. current study using data from trager et al. (2023a), the current study investigated whether changes in parent-student communication frequency via text messages and phone calls during the first month of college (t2) result in changes in cannabis and simultaneous use during the second semester of college (t3). we also explored whether prematriculation cannabis and simultaneous use (t1) predicted changes in parent-student communication following the transition to college (t2). the effects of an alcohol-specific pbi, fitstart+ (see labrie et al., 2024), on cannabis and simultaneous use and on changes in communication were also explored here. based on the research described thus far, we hypothesized that relative to students whose frequency of texting/calling their parent(s) decreased during the first month of the first semester of college, those whose communication frequency stayed the same or increased would have lower odds of cannabis and simultaneous use during their second semester. we also hypothesized that cannabis, a publication of the research society on marijuana 27 compared to those who had never engaged in cannabis or simultaneous use in the prematriculation summer months, those who had would have lower odds of increasing or maintaining their level of communication with their parents (vs. decreasing) during the first semester of college. although some research suggests parental communication with mothers vs. fathers may produce differing effects on cannabis use, differences in associations between mothers’ and fathers’ communication were exploratory. methods recruitment and procedures as part of a larger rct testing the effects of a college alcohol pbi (fitstart+; see labrie et al., 2024), incoming first-year students at a private university on the west coast of the united states were recruited to take part in a longitudinal survey study. participants were invited to participate in the study if they were an incoming first-year student under the age of 21 who had a parent email on file with admissions at the study institution. participants who completed the baseline survey in july 2021 (t1; n = 391) were invited to complete follow-up surveys in october 2021 (t2) and february 2022 (t3). following the t1 survey and prior to matriculation, participating students’ parents were invited to sign up for an online parenting program. approximately 70% of parents who were invited volunteered and signed up for the program that they were randomized into (either the intervention or control version of fitstart+). given that all students who participated at t1 were invited to complete the follow-up surveys, students were classified into one of three groups: (1) those with a parent who volunteered and was randomized to the intervention program (intervention group), (2) those with a parent who volunteered and was randomized to the control program (control group), and (3) those whose parent did not volunteer (no parent group). students received a $25 gift card for each survey they completed and a bonus $25 gift card if they completed all three surveys. participants included in the present study (analytic n = 287) were those who completed one of the four predictors (t2 items assessing changes in communication with their parents; see measures), one of the two outcome measures (t3 cannabis or simultaneous use), and all covariates (t1 & t2). students in the overall sample who did not meet these criteria (n = 104) were more likely to report having ever engaged in simultaneous use at t1 compared to those included in the current analyses (χ2 (1) = 5.22, p = .022); students did not significantly differ on any other variables included in the current analyses (ps > .05). participants participants (n = 287) were majority female at birth (birth sex; 61.3%), identified as female (gender identity; 61.0%; 38.3% male, 0.7% other) and were between the ages of 17 and 20 years (mage = 17.90; sdage = 0.41). the sample was racially (50.9% white; 19.2% multiracial; 14.3% black/african american; 12.5% asian; 0.3% native hawaiian/pacific islander; 0.3% american indian or alaska native; 2.4% missing) and ethnically (26.1% hispanic; 73.9% non-hispanic) representative of the research institution’s student body. most participants also reported that their parents were married (74.9%), and the majority of students did not live with a parent at t2 (97.7%). measures to determine which parent(s) participants had any sort of communication with, they were asked how often they see or communicate with their [mother/father] in person or online at t2. participants who indicated that they “never” communicated with a specific parent were not asked any subsequent questions about that parent, and their parent communication data were treated as missing. no participants indicated “never” communicating with both parents. descriptive statistics for all study variables can be found in table 1. changes in text and call communication 28 table 1. descriptive statistics for all study variables. m / n sd / % since you started college, has the amount you text your mother per day… (t2) decreased 46 16.1% stayed the same 97 34.0% increased 142 49.8% since you started college, has the amount you text your father per day… (t2) decreased 43 15.6% stayed the same 139 50.4% increased 94 34.1% since you started college, has the amount you call your mother per day… (t2) decreased 31 11.0% stayed the same 119 42.3% increased 131 46.6% since you started college, has the amount you call your father per day… (t2) decreased 40 14.7% stayed the same 137 50.2% increased 96 35.2% have you ever used marijuana/cannabis? (t1) yes 109 38.1% no 177 61.9% how many days have you used marijuana/cannabis to get high in the past 30 days? (t1) 1.47 4.60 how many days have you used marijuana/cannabis to get high in the past 30 days? (t3) 2.65 6.38 have you ever used marijuana/cannabis to get high at the same time as alcohol – that is, so that their effects overlapped? (t1) yes 51 17.8% no 236 82.2% how many days (in the past 30) did you use marijuana/cannabis at the same time as alcohol – that is, so that their effects overlapped? (t1) 0.19 0.66 how many days (in the past 30) did you use marijuana/cannabis at the same time as alcohol – that is, so that their effects overlapped? (t3) 0.59 1.59 drinker status (t1) tried alcohol 204 71.1% never tried alcohol 83 28.9% text messages exchanged with mother per day (t2) 6.50 5.08 text messages exchanged with father per day (t2) 3.90 4.07 phone calls exchanged with mother per day (t2) 2.07 2.11 phone calls exchanged with father per day (t2) 1.24 1.49 changes in frequency of texting & calling parents (t2) participants answered four questions to assess changes in their texting and calling behaviors with their parents: “since you started college, has the amount you [text/call] your [mother/father] per day...” “decreased,” “stayed the same,” or “increased.” cannabis use (t1 & t3) at baseline, participants were asked if they had ever used marijuana/cannabis (yes/no).1 at t1 and t3, they were asked “how many days have you used marijuana/cannabis to get high in the past 30 days?” answer options ranged from 0–30 days. simultaneous cannabis and alcohol use (t1 & t3) participants were asked at baseline, “have you ever used marijuana/cannabis to get high at the same time as alcohol – that is, so that their effects overlapped?” (yes/no). at t1 and t3, they were asked how many times in the past 30 days they used marijuana/cannabis at the same time as alcohol (0–30). drinker status (t1) students were asked to indicate which of the following six statements best described their 1although cannabis use in the current sample may seem low (38%), this is a higher percentage than what has been reported in a nationally representative sample of college students (24.5%; schulenberg et al., 2021). cannabis, a publication of the research society on marijuana 29 drinker status: “i have never tried alcohol”; “i am an abstainer (i do not drink at all but have tried before)”; “i am a [light/moderate/heavy/problem] drinker.” responses were dichotomized based on whether students reported never trying (0) or trying alcohol (1). frequency of daily texts & calls exchanged with parents (t2) to control for frequency of texts and phone calls between students and their parents in our models, participants were asked eight items assessing how many text messages and phone calls they sent to and received from their mother and father on average per day (e.g., texts sent to father per day; phone calls received from mother per day). response options for each item were 0– 10+. because texting and calling are reciprocal behaviors, the number of text messages/phone calls sent to and received from each parent were highly correlated (rs = .77–.92), and in line with previous research (brown et al., 2023; jensen et al., 2021), the number of text messages/phone calls sent to and received from each parent were summed to create measures of daily text message and phone call communication frequency with mothers and fathers (four items). analytic plan to examine whether decreases in mother/father-student phone calling and text messaging during the first few weeks of college influenced students’ subsequent cannabis and simultaneous use, we conducted two negative binomial hurdle models in mplus (version 8). the components of hurdle models include (a) a count component that models only the positive counts (count portion), and (b) a binary component to examine the probability of observing a zero versus a positive count (zero portion). models examined either t3 cannabis use or t3 simultaneous use as the outcome and focused on mother and father communication as predictors. texting and calling were included in the same models to understand the relative importance of each digital communication method. covariates in the models included demographic variables previously associated with cannabis use (i.e., birth sex, race, ethnicity; goodwin & silverman, 2024; hasin et al., 2019), whether students had ever tried cannabis (t1), cannabis use in the past 30 days (t1; cannabis model), simultaneous use in the past 30 days (t1; simultaneous model), whether students had ever tried alcohol (t1), and frequency of daily texts and calls exchanged with each parent (t2). additionally, study condition was dummy coded to serve as a covariate, with the intervention and no parent groups being compared to the control group in each model. four logistic regression models were then conducted to test whether pre-matriculation cannabis or simultaneous use predicted changes in communication with parents during the first semester. each model specified having used cannabis in the past 30 days (t1) and having engaged in simultaneous use in the past 30 days (t1) as the predictors and examined a different parent communication outcome (i.e., changes in mother texting, mother calling, father texting, and father calling). to assess the impact of the intervention and no parent groups relative to the control group, study condition variables were dummy coded and included in each model, alongside the demographic covariates included in the previous set of models. in all models, variance inflation factors (vifs) for non-categorical variables were < 5 (james et al., 2013). results changes in parent communication predicting cannabis use and simultaneous use for the count portion of the cannabis use model, among students who did use cannabis at t3, those whose communication via calling increased (vs. decreased) with their mothers since starting college (t2) demonstrated lower risk of cannabis use in the past 30 days at t3 (rr = 0.31, se = 0.50, p = .018). however, an increase in calling with the father since starting college (vs. decrease) was associated with a higher risk of cannabis use at t3 (rr = 4.03, se = 0.42, p = .001). students who reported having ever used cannabis at t1 were also at a higher risk for cannabis use in the past 30 days at t3 (rr = 3.26, se = 0.39, p = .002) (table 2). in the zero portion of the cannabis use model, students who reported greater daily calling with their mother had higher odds of remaining zero on cannabis use in the past 30 days at t3 (or = 1.47, se = 0.17, p = .027). those whose texting with changes in text and call communication 30 their father increased (vs. decreased) had higher odds of remaining zero on cannabis use in the past 30 days at t3 (or = 6.06, se = 0.72, p = .012). students who reported having ever used cannabis (or = 0.08, se = 0.50, p < .001), as well as those who reported having ever tried alcohol (or = 0.21, se = 0.68, p = .022), had lower odds of remaining zero on cannabis use in the past 30 days at t3. additionally, white students had higher odds of remaining zero on cannabis use in the past 30 days (or = 2.31, se = 0.42, p = .047) (table 2). in the simultaneous alcohol and cannabis use model, changes in calling or texting with mothers and fathers did not predict simultaneous use in either the count or zero inflated portions of the model. however, the count portion revealed that students who reported greater daily calling with their fathers at t2 had an increased risk for reporting simultaneous use at t3 (rr = 1.45, se = 0.16, p = .023). having a parent in the intervention group (vs. control) was also found to be associated with fewer simultaneous use days at t3 (rr = 0.52, se = 0.34, p = .050). in the zero portion of the model, students who reported greater daily calling with their mother had higher odds of remaining zero on simultaneous use at t3 (or = 1.47, se = 0.19, p = .047). those who had reported ever using cannabis at t1 also had lower odds of remaining zero on simultaneous use days at t3 (or = 0.11, se = 0.57, p < .001) (table 3). table 2. results from the hurdle model assessing the effects of changes in parent-student text and phone calling on student subsequent cannabis use. 95% ci 95% ci rr se p lb ub or se p lb ub count portion cannabis use days (t3) zero portion cannabis use days (t3) mother mother texting increased (t2) 1.20 0.54 .732 0.42 3.44 texting increased (t2) 0.56 0.67 .390 0.15 2.10 texting stayed the same (t2) 2.54 0.54 .082 0.89 7.24 texting stayed the same (t2) 1.26 0.57 .682 0.42 3.83 texting decreased (t2) ref. ref. ref. ref. ref. texting decreased (t2) ref. ref. ref. ref. ref. calling increased (t2) 0.31 0.50 .018 0.12 0.82 calling increased (t2) 3.42 0.75 .102 0.78 14.89 calling stayed the same (t2) 0.58 0.53 .302 0.20 1.64 calling stayed the same (t2) 1.75 0.72 .442 0.42 7.21 calling decreased (t2) ref. ref. ref. ref. ref. calling decreased (t2) ref. ref. ref. ref. ref. father father texting increased (t2) 0.47 0.46 .097 0.19 1.15 texting increased (t2) 6.06 0.72 .012 1.49 24.62 texting stayed the same (t2) 0.75 0.42 .488 0.33 1.71 texting stayed the same (t2) 2.07 0.56 .193 0.69 6.21 texting decreased (t2) ref. ref. ref. ref. ref. texting decreased (t2) ref. ref. ref. ref. ref. calling increased (t2) 4.03 0.42 .001 1.76 9.24 calling increased (t2) 1.13 0.75 .870 0.26 4.95 calling stayed the same (t2) 1.40 0.40 .404 0.63 3.09 calling stayed the same (t2) 0.78 0.66 .707 0.21 2.84 calling decreased (t2) ref. ref. ref. ref. ref. calling decreased (t2) ref. ref. ref. ref. ref. covariates covariates daily texting – mother (t2) 1.01 0.03 .843 0.94 1.08 daily texting – mother (t2) 0.99 0.05 .801 0.89 1.09 daily calling – mother (t2) 0.88 0.18 .448 0.62 1.24 daily calling – mother (t2) 1.47 0.17 .027 1.04 2.07 daily texting – father (t2) 1.03 0.05 .504 0.94 1.13 daily texting – father (t2) 0.89 0.06 .068 0.79 1.01 daily calling – father (t2) 1.06 0.23 .813 0.67 1.66 daily calling – father (t2) 0.91 0.18 .586 0.64 1.29 cannabis use days (t1) 1.03 0.02 .260 0.98 1.08 cannabis use days (t1) 0.92 0.07 .256 0.80 1.06 cannabis ever used (t1) 3.26 0.39 .002 1.53 6.94 cannabis ever used (t1) 0.08 0.50 < .001 0.03 0.22 tried alcohol (t1) 0.33 0.97 .253 0.05 2.20 tried alcohol (t1) 0.21 0.68 .022 0.06 0.80 birth sex (t1) 1.43 0.29 .225 0.80 2.54 birth sex (t1) 0.75 0.43 .504 0.33 1.73 white vs. other (t1) 1.07 0.35 .851 0.54 2.13 white vs. other (t1) 2.31 0.42 .047 1.01 5.30 hispanic/latinx (t1) 0.87 0.34 .687 0.45 1.70 hispanic/latinx (t1) 0.67 0.50 .417 0.25 1.77 intervention group 0.85 0.30 .597 0.48 1.53 intervention group 1.65 0.48 .300 0.64 4.27 no parent group 1.53 0.53 .417 0.55 4.31 no parent group 1.54 0.55 .433 0.53 4.50 control group ref. ref. ref. ref. ref. control group ref. ref. ref. ref. ref. note. bold denotes p < .05. demographic covariates are coded as follows: birth sex: 0 = female, 1 = male; race: 0 = other, 1 = white; ethnicity: 0 = not hispanic latinx, 1 = hispanic/latinx, intervention group = parent of student participated in rct and received the fitstart+ program, no parent group = parent of student did not volunteer to participate in rct, control group = parent of student participated in rct and received control program. cannabis, a publication of the research society on marijuana 31 table 3. results from the hurdle model assessing the effects of changes in parent-student text and phone calling on student simultaneous use. 95% ci 95% ci rr se p lb ub or se p lb ub count portion simultaneous use days (t3) zero portion simultaneous use days (t3) mother mother texting increased (t2) 0.80 0.38 .558 0.38 1.68 texting increased (t2) 0.88 0.74 .863 0.20 3.78 texting stayed the same (t2) 1.23 0.38 .588 0.59 2.57 texting stayed the same (t2) 1.23 0.75 .784 0.28 5.34 texting decreased (t2) ref. ref. ref. ref. ref. texting decreased (t2) ref. ref. ref. ref. ref. calling increased (t2) 1.42 0.45 .435 0.59 3.44 calling increased (t2) 1.60 0.98 .630 0.24 10.80 calling stayed the same (t2) 1.79 0.48 .225 0.70 4.55 calling stayed the same (t2) 1.23 1.04 .845 0.16 9.45 calling decreased (t2) ref. ref. ref. ref. ref. calling decreased (t2) ref. ref. ref. ref. ref. father father texting increased (t2) 0.41 0.53 .090 0.14 1.15 texting increased (t2) 1.91 0.78 .406 0.42 8.80 texting stayed the same (t2) 0.89 0.44 .790 0.38 2.10 texting stayed the same (t2) 2.30 0.70 .236 0.58 9.13 texting decreased (t2) ref. ref. ref. ref. ref. texting decreased (t2) ref. ref. ref. ref. ref. calling increased (t2) 1.18 0.54 .762 0.41 3.41 calling increased (t2) 2.30 0.95 .378 0.36 14.78 calling stayed the same (t2) 1.03 0.54 .956 0.36 2.98 calling stayed the same (t2) 2.37 0.94 .360 0.37 15.05 calling decreased (t2) ref. ref. ref. ref. ref. calling decreased (t2) ref. ref. ref. ref. ref. covariates covariates daily texting – mother (t2) 0.95 0.04 .139 0.88 1.02 daily texting – mother (t2) 1.01 0.05 .893 0.91 1.11 daily calling – mother (t2) 0.83 0.19 .310 0.57 1.20 daily calling – mother (t2) 1.47 0.19 .047 1.00 2.14 daily texting – father (t2) 1.01 0.06 .930 0.90 1.12 daily texting – father (t2) 0.91 0.06 .135 0.81 1.03 daily calling – father (t2) 1.45 0.16 .023 1.05 1.99 daily calling – father (t2) 1.01 0.21 .976 0.67 1.52 simultaneous use days (t1) 1.20 0.15 .244 0.88 1.62 simultaneous use days (t1) 0.72 0.23 .155 0.46 1.13 cannabis ever used (t1) 1.67 0.48 .287 0.65 4.26 cannabis ever used (t1) 0.11 0.57 < .001 0.04 0.34 tried alcohol (t1) 0.93 0.69 .915 0.24 3.59 tried alcohol (t1) 0.46 0.79 .321 0.10 2.14 birth sex (t1) 1.06 0.39 .883 0.49 2.27 birth sex (t1) 1.41 0.51 .498 0.52 3.79 white vs. other (t1) 0.82 0.40 .627 0.37 1.81 white vs. other (t1) 1.79 0.45 .192 0.75 4.29 hispanic/latinx (t1) 0.93 0.36 .832 0.46 1.86 hispanic/latinx (t1) 0.87 0.55 .798 0.29 2.56 intervention group 0.52 0.34 .050 0.27 0.99 intervention group 2.33 0.49 .086 0.89 6.14 no parent group 1.17 0.57 .786 0.38 3.57 no parent group 2.38 0.61 .156 0.72 7.93 control group ref. ref. ref. ref. ref. control group ref. ref. ref. ref. ref. note. bold denotes p < .05. demographic covariates are coded as follows: birth sex: 0 = female, 1 = male; race: 0 = other, 1 = white; ethnicity: 0 = not hispanic/latinx, 1 = hispanic/latinx, intervention group = parent of student participated in rct and received the fitstart+ program, no parent group = parent of student did not volunteer to participate in rct, control group = parent of student participated in rct and received control program. cannabis use and simultaneous use predicting changes in parent communication pre-matriculation cannabis and simultaneous alcohol and cannabis use did not predict changes in either text or phone call communication with mothers or fathers. however, if a student had tried alcohol, they were less likely to stay the same (vs. decrease) in their frequency of texting with their mother (or = 0.27, se = 0.51, p = .010). the same pattern was observed for fathers (or = 0.39, se = 0.48, p = .049). male students (vs. female) were less likely to increase their texting frequency (vs. decrease) with their mothers (or = 0.26, se = 0.38, p < .001). additionally, hispanic/latinx students were less likely to increase (vs. decrease) texting frequency with their mothers (or = 0.43, se = 0.39, p = .030).2 discussion the findings of this study highlight that adjustments in communication patterns between first-year college students and their parents through texting and calling can influence cannabis use and its concurrent use with alcohol into the second semester of their first year. notably, an increase in phone conversations with mothers was associated with a reduced likelihood of cannabis use at follow-up compared to students who reported a reduction in such interactions. importantly, this association was among students who had recently used cannabis, which suggests the protective effects are not limited to non-users. regular phone calls with mothers and an uptick in text messaging with fathers during the 2due to space constraints, results for the non-significant findings from these models are not included but will be provided upon request. changes in text and call communication 32 transition to college were also predictors of a higher probability of abstaining from cannabis use during the second semester. contrary to expectations, the study also revealed that an increase in phone calls with fathers during this transitional phase was linked to a heightened risk of cannabis consumption among recent cannabis users. greater daily phone calls with fathers were also associated with a greater risk of simultaneous substance use. these observations collectively suggest that reducing phone contact with mothers might increase the risk of cannabis use during the first college year, whereas an escalation in phone calls with fathers could indicate a higher risk of cannabis consumption and simultaneous use during the same timeframe. the underlying rationale for presuming that increased communication through text messages and phone calls with a parent could serve as a deterrent against cannabis use as students transition to college lies in the continuity of parental supervision. such communication channels are thought to extend the reach of parental monitoring beyond the confines of the home (jensen et al., 2021). indeed, parental monitoring has been empirically linked to a direct impact on college students’ cannabis consumption (napper et al., 2015; pinchevsky et al., 2012; white et al., 2006). however, the current study’s findings deviate from previous research by showing that increased phone communication with fathers—possibly interpreted as heightened paternal monitoring—during the college transition period can adversely affect first-year students’ cannabis use. a potential explanation for the differing outcomes associated with increased calling with mothers versus fathers might be attributed to the generally lower warmth found in fathers. prior work has revealed that greater father communication that captures warmth can have protective effects against cannabis use (luk et al., 2010). subsequent research has also revealed that greater monitoring by parents who are less warm, and who aim to deter their adolescents from cannabis use, can produce psychological reactance (brehm, 1966), leading to a stronger intention to use cannabis (donaldson et al., 2023). although the specific nature of the communication in our study remains unknown, it is recognized that fathers tend to exhibit less warmth than mothers (yaffe, 2023) and increased phone calls may symbolize more rigorous monitoring. hence, increases in phone communications with fathers in this study could have inadvertently exacerbated the risk of cannabis use among students, especially given that this risk was shown to be only found among recent cannabis users. additional evidence supporting the warmthmonitoring hypothesis described above can be derived from our finding that illustrates that increases in text messaging with fathers was protective against cannabis use. a reasonable explanation for this could be that the text messaging, which may be perceived by the students as a less intrusive and controlling form of communication (brown et al., 2023; jensen et al., 2021; racz et al., 2017), might mitigate the negative impact of the combination of low warmth and high monitoring that might be occurring with fathers’ calling. while these interpretations are conjectural, they underscore the need for future research to confirm the nuanced impacts of different forms of parent-child communication on college student cannabis use. one valuable approach could be the use of ecological momentary assessment (ema) as a method to gather realtime data on the nature and impact of these communications. future studies should aim to explore the specific content and context of text and phone communications, as well as the emotional quality of parent-child relationships, to better understand how they influence cannabis use behaviors. the findings from our study present a complex picture of parental communication’s impact on college students’ cannabis use, highlighting a protective effect of increased communication from mothers against cannabis use, while, conversely, noting that increased communication from fathers is associated with a higher risk of cannabis use and simultaneous use. this dichotomy underscores the importance of a nuanced examination of parental influence that goes beyond the aggregated data approach commonly found in the literature (e.g., cardenas et al., 2022; grossbard et al., 2010; small et al., 2011), which combines the effects of both parents without distinction. such aggregation may mask the distinct influences mothers and fathers have on their children’s substance use behaviors, potentially resulting in misleading conclusions about parental influences as a whole. the differential trends observed in our study— cannabis, a publication of the research society on marijuana 33 protective effects from increased maternal communication versus risk-enhancing effects from increased paternal communication—suggest that the roles and impacts of mothers and fathers on college students’ cannabis use are not interchangeable. future research should therefore prioritize separating the analysis of maternal and paternal influences to uncover the specific dynamics of how each parent’s communication style and frequency affect their child’s substance use. doing so will allow researchers to better identify and understand the nuanced mechanisms through which parental behavior influences college students’ decisions about cannabis use. this distinction is crucial for developing more effective, tailored interventions that consider the unique contributions of each parent to their child’s adjustment to college life and decision-making processes regarding substance use. this study builds upon the existing body of research surrounding the fitstart+ pbi by shedding light on its potential to prevent simultaneous alcohol and cannabis use during the first year of college. while prior studies have provided initial support for the program as a strategy to prevent heavy drinking (labrie et al., 2022, 2024), the current findings suggest an extension of these benefits to reducing concurrent substance use. however, the intervention does not appear to predict changes in parent-student communication through text or phone. this extension of the intervention’s impact is consistent with the notion that reducing parental permissiveness toward drinking—a primary focus of fistart+—may indirectly influence simultaneous substance use, as has been suggested in previous research (trager et al., 2021). consequently, these findings lend additional support to the idea that pbis, which target alcohol-specific parenting constructs, can also have a meaningful effect on limiting the simultaneous use of alcohol and cannabis. further, the study indicates that while fitstart+ is tailored towards modifying alcohol-related behaviors, it neither affects cannabis use independently—as observed with some alcohol-specific pbis (grossbard et al., 2010)—nor does it have any significant effects on changes in parent-student communications via text or phone during the transition into college. it is crucial to acknowledge that these results are preliminary, and more research is needed to fully understand the effectiveness and scope of fitstart+ before making any broad recommendations for its use in preventing substance use among college students. finally, results from this study also support previous findings on the reliability of certain predictors for cannabis use. this includes cannabis use being positively associated with past cannabis and alcohol use, and negatively associated with being white (goodwin & silverman, 2024; hasin et al., 2019). these effects, along with the prevalence of cannabis use in this study (~38%) being greater than the national average (~24%; schulenberg et al., 2021) offer some support for the notion that the findings from this study are likely to generalize beyond the current sample. however, future studies are needed to verify the current findings given that this study was conducted with underage students in a state where cannabis is legal for individuals who are 21 years of age and older. limitations and future directions the findings of our study are subject to several limitations. first, the sample originated from a single university within a state where recreational cannabis use is permitted, which may restrict the applicability of our results across different contexts. expanding this research to include a variety of universities and regions would likely broaden the relevance of our conclusions. our study was also limited by its sample size. given that cannabis use is endorsed by only about a quarter of college students (schulenberg et al., 2021), large samples are needed to verify the current findings. future work should investigate the observed associations in a large sample of individuals using cannabis and engaging in simultaneous use. another limitation is the lack of baseline measurements of parent-student text and phone communication, with assessments of changes during the initial month of college relying on student-reported perceptions. while perceptions can significantly influence behavior (e.g., trager et al., 2023b; varvil-weld et al., 2013), future studies should aim to corroborate these findings with objective measures of parentstudent communication changes, such as actual counts of texts and calls, to align subjective experiences with tangible events. another changes in text and call communication 34 limitation of this study was that we focused exclusively on communication with mothers and fathers, omitting other legal guardians/caregivers like aunts, uncles, or grandparents. future investigations should encompass a broader spectrum of caregivers to capture the diverse family dynamics of students. the absence of consequences of cannabis or simultaneous use is another limitation. incorporating a comprehensive view of how cannabisand simultaneous use-related consequences correlate with parent-student communication changes in future research is essential for a more complete understanding of the influence of parental communication on risky behaviors. finally, this study was a secondary analysis of existing data, which inherently restricted our ability to incorporate other potentially relevant parent and student variables into our examination (e.g., parental closeness, content of parental communication, parental cannabis use, socioeconomic status, student mental health, peer influences). this limitation may have prevented a more comprehensive understanding of the effects under scrutiny. future studies designed with the specific intent to explore these dynamics should aim to include a broader range of both parent and student variables that could influence the relationship between parent-student communication and cannabis use. expanding the scope of investigation in this manner would likely yield a richer, more nuanced understanding of the factors contributing to cannabis use among college students, thereby enhancing the development of targeted interventions and policies. conclusion to summarize, results from this study illustrate that increasing the frequency of calling with mothers and texting with fathers during the transition to college can be protective against cannabis use during the second semester of college. conversely, increasing phone calls with fathers may predict greater risk of cannabis use during the same period. these findings reveal that encouraging parent communication via these modes of communication may be both beneficial and detrimental for cannabis use depending on the parent. results also suggest that evaluating mothers and fathers separately can yield important insights that examining parents as a unit might not. future research is needed to better understand the content and context of parent-student text and phone call communications, as well as how these interactions influence students’ perceptions, attitudes, and behaviors towards cannabis use. references arria, a. m., caldeira, k. m., bugbee, b. a., vincent, k. b., & o’grady, k. e. 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(2017). marijuana use in the context of alcohol interventions for mandated college students. journal of substance abuse treatment, 79, 53–60. https://doi.org/10.1016/j.jsat.2017.05.015 funding and acknowledgements: support for this research was provided by the niaaa (grants r01 aa027168 and r34 aa026422). the niaaa had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. all authors declare that they have no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://doi.org/10.1080/10826084.2021.1981390 https://doi.org/10.1080/10826084.2021.1981390 https://doi.org/10.15288/jsad.22-00382 https://doi.org/10.15288/jsad.22-00002 https://doi.org/10.1037/0893-164x.15.4.366 https://doi.org/10.1037/0893-164x.15.4.366 https://doi.org/10.1002/dev.20434 https://doi.org/10.1016/j.addbeh.2012.09.017 https://doi.org/10.1007/s10964-008-9374-8 https://doi.org/10.15288/jsad.2015.76.367 https://doi.org/10.15288/jsa.2006.67.810 https://doi.org/10.1007/s12144-020-01014-6 https://doi.org/10.1007/s40429-017-0149-8 https://doi.org/10.1016/j.jsat.2017.05.015 https://creativecommons.org/licenses/by/4.0/ research article ved abstract objective: limited research examines the effect of stress on behavioral economic constructs among individuals using cannabis. this study examined whether the effects of acute stress on delay discounting differed in terms of cannabis use status and whether cannabis demand changed after stress induction. method: participants were two groups (n = 39 endorsing high-frequency cannabis use and n = 48 not endorsing cannabis use) of young adults (75.86% female, 67.82% white, mage = 21.64 years). during an online zoom session, participants completed a prestress assessment, the trier mental challenge test (tmct) stress induction, and then a poststress assessment. results: subjective stress increased significantly across groups after stress induction (p < .001, ƞp 2 = .23); no group x time interaction was observed. there were no differences in delay discounting across time or groups. for the use group only, cannabis demand intensity (p = .006, d = .50), but not other demand indices, significantly increased following the acute stress induction. coping motives did not moderate the association between the change in subjective stress and the change in delay discounting or the change in any cannabis demand indices among the use group. conclusions: cannabis demand might exert a more influential role than delay discounting in shaping decisions related to cannabis use while experiencing acute stress. however, the practical implications of this finding warrant further research due to the relatively small difference in hypothetical cannabis use observed. study design limitations that could impact the findings or lead to null results are discussed to inform future research. key words: = acute stress; delay discounting; cannabis demand; cannabis use; marijuana use cannabis is the most widely used federally illegal substance in the united states, with approximately 52.5 million people using cannabis and 16.3 million people meeting cannabis use disorder (cud) criteria in the past year. across age groups, young adults report the highest prevalence rates of use and cud, such that more than one-third of young adults used cannabis and 4.8 million young adults met cud criteria in the past year (substance abuse and mental health services administration, 2022). although curiosity, availability, and peer pressure are commonly reported reasons for initial cannabis use, stress relief is one of the most frequently reported benefits or reasons for sustaining cannabis use (copeland et al., 2001; glodosky et al., 2021; green et al., 2003; hyman & sinha, 2009). in addition, using cannabis to cope not only has a direct link to both cannabis use (bonnmiller et al., 2007; simons et al., 2005) and cannabis-related problems (lee et al., 2007; simons et al., 2005), it also serves as a mediator in the relationship between chronic stress and cannabis use and its associated problems (spradlin & cuttler, 2019). therefore, understanding how young adults use cannabis to deal with stress and how they make decisions under stress is critical to help interrupt the yi-chun chang1, robin l. rubey1, & benjamin o. ladd1 1department of psychology, washington state university vancouver, vancouver, wa cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000275 acute stress effect on delay discounting and cannabis demand among individuals endorsing high-frequency cannabis use corresponding author: yi-chun chang, m.s., department of psychology, washington state university, vancouver, 14204 northeast salmon creek ave, vancouver, wa 98686. email: yi-chun.chang@wsu.edu cannabis, a publication of the research society on marijuana connection between stress and problematic cannabis use, which in turn may serve to identify potential intervention targets to reduce the prevalence of cud among young adults. behavioral economics proposes a reinforcer pathology model to explain addiction as a behavioral pattern with two mechanisms jointly underlying decisions around initiating and maintaining substance use: delay discounting (i.e., the preference for the immediate acquisition of a commodity despite long-term adverse outcomes) and substance demand (i.e., the relative value of a reinforcer) (bickel et al., 2014; bickel & athamneh, 2020). several meta-analyses have demonstrated the association between addiction severity and substance use quantity/frequency with delay discounting (amlung et al., 2017; mackillop et al., 2011) as well as substance demand (kiselica et al., 2016; strickland et al., 2020). interestingly, the association between delay discounting and substance use outcomes seems more complex for cannabis specifically than for other substances. for example, unlike other substances, individuals with cud (johnson et al., 2010) or those using cannabis (jarmolowicz et al., 2020; strickland et al., 2017) did not significantly differ in monetary delay discounting compared to controls, even though individuals using cannabis demonstrated higher delay discounting rate in cannabis rewards than monetary rewards (foxx et al., 2023; johnson et al., 2010; patel et al., 2020). moreover, delay discounting was positively associated with cannabis problems but not consumption (aston et al., 2016; lopez-vergara et al., 2019; patel et al., 2020; strickland et al., 2017). although a recent meta-analysis showed a significant association between overall delay discounting across commodities and cannabisrelated outcomes, the authors noted that the effect was relatively smaller than other substances and called for future research exploring the theoretical rationales underlying this difference (strickland et al., 2021). thus, more research is required to determine the relationship between delay discounting and cannabis use outcomes. to our knowledge, those previous studies examining the relationship between delay discounting and cannabis-related outcomes utilized standard assessment conditions. as research suggests that individuals under stress might shift to a more short-sighted mindset to engage in health risk behaviors as coping behaviors to relieve stress immediately (fields et al., 2014, 2015) and that individuals tend to choose immediate rewards while experiencing undesired emotions (tice et al., 2001), one could expect that individuals who tend to use cannabis to cope with stress might increase the preference to choose immediate rewards when experiencing stress. therefore, examining how delay discounting changes among individuals who use cannabis under stress-induced experimental conditions could further understanding of delay discounting among individuals using cannabis. although several reviews demonstrated the association between cannabis demand and cannabis-related outcomes (aston & berey, 2022; aston & meshesha, 2020; gonzález-roz et al., 2023; strickland et al., 2020), most of them assessed trait demand while only a few examined state-dependent demand (hindocha et al., 2017; metrik et al., 2016) and none of them examined the effect of stress on state demand. a recent meta-analysis demonstrated state demand increased during stress/negative affect manipulations (acuff, amlung, et al., 2020), but this result was based on a limited number of studies on alcohol and cigarettes; none examined cannabis. thus, little is known about whether cannabis demand changes under stress manipulations. furthermore, cannabis demand is often indicated through five indices from a hypothetical marijuana purchase task: (a) intensity (i.e., the amount of cannabis consumed when the price is zero); (b) omax (i.e., maximum expenditure on cannabis across all prices); (c) pmax (i.e., the price at maximum expenditure); (d) breakpoint (i.e., the price at which no cannabis will be purchased); and (e) elasticity (i.e., the sensitivity of cannabis consumption to increases in cost) (aston et al., 2015; collins et al., 2014). across all indices, intensity and omax of substance demand demonstrate the most consistent and robust relations with substance use and problems (see meta-analyses gonzález-roz et al., 2023; martínez‐loredo et al., 2021; zvorsky et al., 2019). it is integral to investigate how these two cannabis demand indices change under acute stress among individuals using cannabis so that we can better understand how cannabis demand might affect motivations around cannabis use when individuals experience heightened momentary stress in daily life. stress, delay discounting, and cannabis demand the present study the present study planned to answer the question of how acute stress affects delay discounting and cannabis demand among young adults who use cannabis frequently. first, we aimed to compare delay discounting under acute stress among individuals who use and do not use cannabis. we hypothesized that individuals who use cannabis would have greater increases in delay discounting in response to acute stress, given previous research suggesting individuals tend to engage in health risk behaviors to acquire immediate stress relief when experiencing stress (fields et al., 2014, 2015; tice et al., 2001). secondly, we aimed to examine the effect of acute stress on cannabis demand among individuals who use cannabis. we hypothesized that cannabis demand indices intensity and omax would increase in response to acute stress based on the results from previous research examining alcohol demand (acuff, amlung, et al., 2020; amlung & mackillop, 2014; owens et al., 2015). lastly, we aimed to examine if coping motives serve as a moderator of acute stress effect on delay discounting and cannabis demand. we hypothesized stress would have a greater effect on increasing delay discounting and cannabis demand among individuals endorsing higher coping motives, based on previous research suggesting individuals reporting higher coping motives tended to show greater increases in alcohol demand during negative affect induction (rousseau et al., 2011). methods participants participants (mage = 21.64 years; 75.86% female; 67.82% white) were 87 young adults, with 39 endorsing cannabis use (i.e., cannabis use group) and 48 reporting not using cannabis (i.e., non-use group), recruited from advertisements posted in community and online social media sites as well as a psychology subject pool from a large public university in the pacific northwest united states. the recruited sample size was established based on a previous study examining the effect of stress on alcohol demand (owens et al., 2015). eligibility criteria included: 1) english speaking, 2) 18-29 years of age, and 3) able to participate in the study via zoom. further, eligible participants for the cannabis use group needed to endorse cannabis use at least five days per week in the past month and at least weekly use in the past six months, with no intent to quit or receive treatment; eligible participants for the non-cannabis use group needed to report no cannabis use in the past six months. exclusion criteria for all participants included illicit drug use other than cannabis in the past six months, using any tobacco products (including cigarettes and e-cigarettes) daily, and drinking more than four alcoholic beverages on more than four days of the week. the original recruited sample was 89, but two participants from the use group (one reporting age 39 and one reporting using cannabis once every 3-6 months and not using cannabis in the past month) were removed from the analyses due to ineligibility, resulting in the final sample size of 87. participants received a $30 gift card or research credit (college students could choose either) for their participation. this study was certified as exempt by the university institutional review board. procedure eligible participants were scheduled for an online zoom appointment with a trained research assistant due to covid-19 social distancing protocols (data collected from march 2021 to july 2022). participants were requested not to use alcohol, cigarettes, or cannabis 12 hours before the appointment to prevent acute intoxication. however, no biological verification was conducted, though all participants in the use group reported not currently feeling high. during the appointment, research assistants first obtained informed consent. then, participants were instructed to complete the demographics questionnaires, baseline assessments of subjective stress, and delay discounting. the cannabis use group also completed the baseline assessment of cannabis demand. then, all participants completed a stress induction task, after which they completed the poststress subjective stress and delay discounting assessments. the cannabis use group also completed the assessment of poststress cannabis demand as well as a cannabis use survey. participants were debriefed at the end of the study (figure 1). cannabis, a publication of the research society on marijuana informed consent demographics questionnaire per baseline stress assessment baseline marijuana purchase task poststress monetary choice questionnaire poststress marijuana purchase task cannabis use survey debriefing baseline monetary choice questionnaire stress induction & assessment figure 1. study procedure timeline note. only the use group completed the marijuana purchase task and cannabis use survey. stress induction. this study utilized the computerized trier mental challenge test (tmct), which resulted in significantly increased cortisol levels in previous research (kirschbaum et al., 1991; pruessner et al., 1999), as a stress induction task. during the task, participants were first instructed to share their screen with the researcher and told that the researcher would see their performance in this section. then, participants were asked to work on three trials of arithmetic problems for three minutes for each trial and told to solve as many problems as they could. when participants answered a problem incorrectly or did not answer it in time, the word “wrong” appeared on the screen in large font, and the computer would play a buzzing sound. at the end of each trial, participants were asked to report how many points they earned from each trial to indicate how many problems they solved correctly. measures demographic questionnaire. all participants were required to complete a demographic assessment, including age, gender, race, ethnicity, and income. perceived stress in daily life. as the data collection was conducted during the covid-19 pandemic, during which people were experiencing unprecedented stress, we used the 10-item perceived stress scale (pss; cohen & williamson, 1988) to measure participants’ overall perception of stress in their life during the last month to ensure that both non-use and use groups did not differ significantly. participants responded how often they experienced any stressful situations in their life from 0 (never) to 4 (very often) in the last month (α = .86 for the non-use group and α = .91 for the cannabis use group; α = .88 for the whole sample). subjective stress assessment. participants were required to rate how much stress they are currently experiencing using a 0 (no stress) to 10 (extreme stress) rating scale at the baseline and poststress assessments, which has been used in a previous study examining the acute stress effect among individuals using and not using cannabis (cuttler et al., 2017). delay discounting. the monetary choice questionnaire (mcq; kirby et al., 1999) was used to assess delay discounting at baseline and after the stress induction. it consisted of 27 hypothetical monetary choices between smaller immediate and larger delayed rewards. we used the approach kaplan et al. (2016) provided to calculate each participant's rate of discounting (k), which is the slope of the hyperbolic equation v = a/(1 + kd), where v is is the subjective value of the reward (a) of a given delay (d) with larger k indicating more likely to discount the values of delayed rewards (mazur, 1987). the mean overall consistency was 95.88% (sd = 3.99%) at baseline and 96.82% (sd = 3.44%) at poststress; no participants were below 75%, at which researchers suggest the need to examine further individual-level patterns of responding (kaplan et al., 2016). cannabis demand. the 22-item marijuana purchase task (mpt; aston et al., 2015) was used 0 min 10 min 25 min 14 min 13 min 50 min 45 min 55 min 70 min 75 min 20 min stress, delay discounting, and cannabis demand to assess cannabis demand. participants were asked how much cannabis they would use if it was of average quality at 22 ascending prices from $0 to $10 per hit when they had their typical amount of money to purchase cannabis. participants were also told they did not use marijuana or any other drugs before they made these decisions, and they could consume all the cannabis they requested and would not have an opportunity to use cannabis elsewhere. the mpt provides several indices of cannabis demand: intensity (consumption when there is no cost), omax (maximum expenditure), pmax (price at maximum expenditure); (d) breakpoint (price at which no consumption); and (e) elasticity (sensitivity of consumption to increase in cost). all indices were generated from the observed mpt responses except for elasticity (α). for those purchasing at least one hit across all prices, the breakpoint was set to the highest price (i.e., $10) (baseline: n = 16; poststress: n = 14) (yurasek et al., 2023). elasticity was derived from the demand exponentiated model: 𝑄 = 𝑄0 × 10𝑘(𝑒−𝛼𝑄0𝐶−1 ), where q is observed consumption at each unit price (i.e., c), q0 is consumption at price of zero, k represents the consumption range in logarithmic units, and α is the rate of the demand curve (koffarnus et al., 2015). in order to make elasticity (i.e., α) comparable across baseline and poststress, we examined three fixed k values (i.e., 2, 3, 4) to determine which constant provided the best model fit of the mean demand curve (mackillop et al., 2019; mcintyre-wood et al., 2022). a value of k = 4 was used across baseline and poststress to generate derivative elasticity as it provided the best model fit. the exponentiated model provided a good fit for participant-level data (baseline: mean r2 = .92, median r2 = .94; poststress: mean r2 = .93, median r2 = .95), as well as an excellent fit at the aggregate level (baseline: r2 = .98; poststress: r2 = .99). cannabis use. the 33-item daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017) was used to assess cannabis use patterns for the cannabis use group. cannabis use motives. the 36-item comprehensive marijuana motives questionnaire (cmmq; lee & grossbard, 2009) was used to assess 12 domains of motivations for cannabis use for the cannabis use group (α = .91). here, we only utilized the three items from the subscale of coping motives (α = .81). cannabis problems. the 19-item marijuana problems scale (mps; stephens et al., 2000) was used to assess the negative consequences related to cannabis use for the use group. participants responded to each problem with a response ranging from 0 (no problem) to 2 (serious problem); higher scores indicate higher problems (α = .85). analysis data preparation. before analysis, delay discounting rate k was log-transformed, a common way to process k in previous studies (e.g., chang & ladd, 2023; mellis et al., 2019; strickland et al., 2017) due to the lack of normality (skewness = 3.73, 3.21, kurtosis = 16.23, 12.02 for baseline and posttest, respectively). as a result, both skewness and kurtosis were reduced to within acceptable limits (skewness = -0.6, -0.69, kurtosis = 0.04, 0.02 for baseline and posttest, respectively). for the mpt, the r package “beezdemand” (kaplan et al., 2019) was used to pre-process cannabis demand data. participants with unsystematic responses (stein et al., 2015) were identified. overall, two participants violating the criterion of reversals from zero (i.e., no non-zero consumption should occur after two consecutive zero consumptions) at baseline and poststress were removed for demand-related analyses. outliers of demand indices (i.e., greater/less than 3.29 sds) were winsorized one unit higher than the greatest nonoutlying value (tabachnick & fidell, 2013) such that one participant was adjusted for intensity at baseline and posttest, and another one was adjusted for omax at poststress. all demand indices demonstrated skewness and kurtosis values within acceptable limits (-2 and 2) used by previous research (e.g., acuff, soltis, et al., 2020; copeland et al., 2023). analytic plan. first, a two-way (2 x 2) mixed anova was conducted with group (use vs. nonuse) and time (baseline vs. poststress) as ivs and stress as dv to examine if the stress induction led to change in subjective stress, as well as to compare if the stress levels differed between two groups at baseline and poststress, or the change of stress from baseline to poststress differed cannabis, a publication of the research society on marijuana between two groups. second, another similar twoway (2 x 2) mixed anova was conducted with delay discounting rate as dv to compare the effects of stress induction on delay discounting rate k between groups as well as examine if the delay discounting of two groups differed at baseline and poststress. third, paired t-tests were conducted to examine if all five cannabis demand indices significantly differed between baseline and poststress among the use group. fourth, moderation analyses were performed to investigate whether cannabis use motives moderated the relationships between changes in stress and changes in delay discounting, as well as changes in demand indices. the interaction term of change in stress and coping motives was entered into the regression model to predict change in outcomes (i.e., delay discounting, demand indices). lastly, to address the concern that observed changes might be attributable to repeated measurement, we examined the bivariate relationships between change in stress and change in delay discounting, as well as change in demand indices, from baseline to poststress to see if the increase in stress was correlated with the change in outcomes, which could further support that the stress induction contributed to the observed changes in outcomes. for demand-related analyses, we only had a priori hypotheses for intensity and omax as outcomes. however, we also analyzed other demand indices for exploratory purposes, as researchers have called for fully reporting all demand indices under the manipulation condition to better understand how the manipulation influences different aspects of motivation to use substances (acuff, amlung, et al., 2020). all analyses were done in r, version 4.3.1 (r core team, 2023), with packages stats (r core team, 2023) and afex (singmann et al., 2023) for the primary analyses. four participants (2 in the use group and 2 in the non-use group) did not complete the poststress assessment due to technical difficulties; thus, they were dropped from the related analyses. transparency and openness we reported how we determined our sample size, all data exclusions, manipulations, and measures in this study. this study’s design and its analysis were not pre-registered. materials, data with a codebook, and r codes for this study are available on the open science framework (https://doi.org/10.17605/osf.io/6kj2g). results descriptive characteristics there were no significant differences in age, gender, racial and ethnic composition, income, or perceived stress in daily life between groups (table 1). among the cannabis use group, baseline intensity and omax, but not other demand indices or delay discounting, were significantly correlated with cannabis use frequency and days using cannabis in the past month. cannabis problems were not associated with delay discounting or any demand indices (table 2). descriptive statistics of outcomes by time and group are presented in table 3 table 1. descriptive characteristics by group group use non-use p n 39 48 age 22.13 (3.2) 21.25 (2.96) .19 gender .51 man 7 (17.95%) 8 (16.67%) woman 28 (71.79%) 38 (79.17%) other 4 (10.26%) 2 (4.17%) race asian 6 (15.38%) 10 (20.83%) .71 american indian or alaska native 1 (2.56%) 0 (0%) .92 black 2 (5.13%) 1 (2.08%) .85 https://doi.org/10.17605/osf.io/6kj2g stress, delay discounting, and cannabis demand native hawaiian or other pacific islander 0 (0%) 1 (2.08%) 1.0 white 28 (71.79%) 31 (64.58%) .63 hispanic/latine 9 (23.08%) 8 (16.67%) .63 monthly income 1073.08 (1169.06) 1098.86 (1663.37) .93a perceived stress scale 19.31 (6.84) 19.08 (6.53) .88 cannabis coping motives 8.19 (3.12) marijuana problems scale 6.14 (5.16) cannabis use frequency 3 – 4 times a week 4 (10.26%) 5 – 6 times a week 9 (23.08%) once a day 5 (12.82%) more than once a day 19 (48.72%) age of onset of regular cannabis use 18.42 (2.18) age of onset of daily cannabis use 19.31 (2.42) # years used cannabis 4.53 (3.28) # days used cannabis last month 24.92 (5.27) # times/typical weekday 3.12 (2.2) # times/typical weekend day 4.01 (2.35) medical cannabis use 1 (2.56%) note: p-values represent pearson's chi-squared test or independent t-test for between-group comparisons. numbers in the parentheses indicate standard deviation or percentages. a log transformation was conducted due to the lack of normality. race and ethnicity were assessed within a single item, even though participants could select multiple options; this resulted in a number of participants indicating hispanic/latine ethnicity but not providing race. cannabis, a publication of the research society on marijuana table 2. correlations among study variables. variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1. age -.01 -.16 -.07 -.12 .01 .04 2. gendera -.02 .28 .13 .23 -.32* -.26 3. pss -.14 .49** .61** .43** -.09 .06 4. cannabis use frequency .42* .19 -.04 5. cannabis use days/month .41* .29 -.14 .73** 6. mps -.30 -.11 .30 -.06 -.26 7. coping motives .14 .34* .56** .17 .05 .45** 8. baseline stress -.19 .39* .65** .02 .03 .16 .26 .63** -.20 -.10 9. poststress stress .04 .18 .40* -.02 -.08 .15 .10 .65** -.04 .04 10. baseline log k -.23 .12 .12 -.02 -.11 .23 .02 .24 .09 .91** 11. poststress log k -.28 .04 .01 -.06 -.11 .25 -.06 .11 .02 .87** 12. baseline intensity .17 .25 .18 .35* .34* -.02 .24 .19 .36* .19 .13 13. poststress intensity .21 .21 .06 .34* .33 .02 .15 .17 .41* -.01 .03 .96** 14. baseline omax .08 .12 .05 .38* .36* .17 .28 -.13 -.21 -.10 -.25 .18 .16 15. poststress omax .16 .04 .04 .29 .21 .21 .23 -.10 .04 -.31 -.37* .16 .27 .80** 16. baseline pmax .33* -.10 .03 .19 .03 .30 .31 -.18 -.12 -.26 -.41* -.10 -.06 .60** .71** 17. poststress pmax .22 -.14 .09 .10 .01 .47** .46** -.16 -.18 -.24 -.30 -.11 -.09 .56** .56** .84** 18. baseline breakpoint .20 -.10 .12 .19 .10 .28 .20 -.04 -.07 -.17 -.31 .02 .01 .68** .67** .78** .77** 19. poststress breakpoint .23 -.10 .01 .22 .14 .29 .20 -.05 -.06 -.19 -.26 -.01 .04 .70** .70** .77** .78** .98** 20. baseline elasticity -.07 -.12 -.16 -.29 -.28 -.22 -.27 .04 .16 .04 .08 -.28 -.28 -.76** -.68** -.45** -.46** -.66** -.69** 21. poststress elasticity -.10 .005 .002 -.28 -.25 -.29 -.19 .08 .10 .07 .07 -.25 -.30 -.76** -.75** -.52** -.51** -.67** -.73** .93** note. correlations above and below the diagonal are non-use group (n = 48) and use group (n = 39), respectively. pss = perceived stress scale; mps = marijuana problems scale; log k = logarithmic-transformed delay discounting rate. agender coded as 1 = men, 2 = women, 3 = non-binary/other. * p < .05. ** p < .01. stress, delay discounting, and cannabis demand table 3. descriptive statistics of outcomes by time and group time baseline poststress group use group non-use group use group non-use group n 39 48 37 46 stress 5.41 (2.42)a 6.17 (2.15)a 6.16 (2.4)ab 7.39 (1.98)ab delay discounting (k)1 -1.98 (.61) -2.14 (.83) -1.96 (.65) -2.02 (.83) intensity 21.08 (15.37)a 22.66 (16.54)a omax 17.41 (12.6) 19.56 (16.17) pmax 4.29 (3.59) 3.81 (3.65) breakpoint 6.14 (3.68) 5.71 (3.84) elasticity .0060 (.005) .0057 (.0048) note. values presented as m (sd). two participants in the use group and two participants in the nonuse group did not complete the poststress assessmnts due to technical issues. elasticity is reported to four decimal places to show the distinction in values. 1logarithmic-transformed. asignificant withingroup differences were observed between baseline and poststress. bsignificant between-group difference was observed at poststress. effect of stress induction on subjective stress (manipulation check) the tmct resulted in increased subjective stress, as results of the two-way mixed anova showed a significant main effect of time on stress in the overall sample, f(1, 81) = 23.90, p < .001, ƞp 2 = .23. both groups significantly increased subjective stress after the stress induction (use group: t(36) = 2.42, p = .02, d = .40; non-use group: t(45) = 4.72, p < .001, d = .70). group also had a significant main effect on stress, f(1, 81) = 5.17, p = .026, ƞp 2 = .06. subjective stress between groups were not significant differently at baseline, t(85) = -1.54, p = .13, d = .33, but significant differently at poststress, t(69.64)1 = -2.50, p = .01, d = .56, such that the use group had significantly lower stress than the non-use group at poststress. however, the interaction effect of time and group was not significant, f(1, 81) = 1.04, p = .31, ƞp 2 = .01. effect of stress induction on delay discounting results of the two-way mixed anova showed a nonsignificant main effect of time on delay discounting, f(1, 80) = 3.42, p = .068, ƞp 2 = .04. delay discounting did not change from baseline to poststress among either group (use group: t(36) = .89, p = .38, d = .15; non-use group: t(44) = 1.75, p = .087, d = .26). group also had a nonsignificant main effect on delay discounting, f(1, 80) = .37, p = .54, ƞp 2 = .005. delay discounting between groups was not significantly different at either baseline, t(84) = 1.03, p = .31, d = .22, or poststress, t(81) = .35, p = .73, d = .08. also, the interaction effect of time and group was nonsignificant, f(1, 80) = .35, p = .56, ƞp 2 = .004. effect of stress induction on cannabis demand a paired t-test showed cannabis demand intensity significantly increased from baseline to after stress induction, t(34) = 2.96, p = .006, d = .50. however, other demand indices did not significantly change from baseline to poststress,omax: t(34) = 2.02, p = .051, d = .34; pmax: t(34) = -.97, p = .34, d = .16; breakpoint: t(34) = 1.73, p = .09, d = .29; elasticity: t(34) = -1.76, p = .09, d = .29 (see figure 2 for demand curves at baseline and poststress). moderation analyses moderation analyses showed coping motives did not significantly moderate the association between the change in stress and the change in any outcomes (delay discounting: b = .001, p = .25; intensity: b = -.06, p = .62; omax: b = .04, p = .87; pmax: b = .02, p = .67; breakpoint: b = .02, p = .22; elasticity: b = -.001, p = .20) among the use group. cannabis, a publication of the research society on marijuana figure 2. cannabis demand curves by baseline and poststress note. each data point represents average hypothetical consumption at a particular price on the marijuana purchase task. the x-axis is log-transformed, and zero values are replaced by trivial nonzero values (0.01) to permit logarithmic units. error bars represent the standard error of the mean (sem). relationship between change in stress and changes in delay discounting and cannabis demand we examined bivariate relationships between the change in stress and change in delay discounting from baseline to poststress for the control and cannabis use groups separately. the change in stress and change in delay discounting was not significantly correlated in either group (no-use group: r = .20, p = .19; use group: r = .05, p = .79). additionally, we explored the bivariate relationship between the change in stress and the changes in cannabis demand indices from baseline to poststress specifically within the use group. the change in stress was not significantly correlated with changes in intensity (r = .29, p = .09), omax (r = .31, p = .07), pmax (r = -.21, p = .23), breakpoint (r = -.11, p = .54), or elasticity (r = -.32, p = .06). discussion this study experimentally examined the effect of acute stress on delay discounting among individuals who use cannabis frequently compared to those who do not use cannabis, as well as cannabis demand among individuals who use cannabis. as expected, subjective stress increased after the acute stress induction in both groups. however, delay discounting did not significantly change from baseline to poststress in either group. moreover, neither groups differed significantly in delay discounting at baseline, poststress, or change from baseline to poststress. nevertheless, cannabis demand intensity, but not other demand indices, significantly increased after stress induction within the use group. 1t-test was adjusted due to unequal variances based on significant levene’s tests. stress, delay discounting, and cannabis demand finally, we did not see the moderating effect of coping motives on the associations between the change in stress and change in delay discounting as well as cannabis demand. in terms of our first aim to examine the effect of acute stress on delay discounting, contrary to our hypothesis, we did not see any differences across groups in change scores from baseline to poststress, nor did we observe differences at baseline or poststress. the observation that there was no significant difference in delay discounting between the groups at baseline is consistent with prior studies, which reported no distinct difference in delay discounting of monetary rewards between the cannabis use group and the non-use group under general conditions (johnson et al., 2010; strickland et al., 2017). interestingly, the effect size for the baseline group difference in delay discounting (d = .22) closely aligns with the omnibus effect size for the relationship between cannabis use and delay discounting in the recent meta-analysis (r = .08) (strickland et al., 2021). this raises the question of whether delay discounting serves the same function in reinforcer pathology for cannabis use as it does for other substance use. given that cannabis is frequently viewed in a positive light and is often considered less detrimental to health compared to other substances like cigarettes (berg et al., 2015; nguyen et al., 2023), this perception may result in a diminished trade-off between immediate and future rewards. consequently, this could explain the absence of any notable difference in delay discounting between individuals who use cannabis and those who do not. on the other hand, the lack of difference in delay discounting across groups at baseline might be due to the cannabis use group in this study being a sample of lower problem severity sample (i.e., average score of 6 on the mps out of potential range 0-38) despite engaging in relatively heavy cannabis use (i.e., 5+ days/week). as previous research has found that delay discounting was positively associated with the severity of cannabis problems but not cannabis use frequency or quantity (aston et al., 2016; lopez-vergara et al., 2019; patel et al., 2020; strickland et al., 2017), it is possible that the use group did not exhibit higher delay discounting than the non-use group under the standard assessment condition due to relatively lower severity of the cannabis use group in this study. surprisingly, neither groups significantly changed delay discounting in response to acute stress. this finding was contrary to the observed significant positive association between stress and delay discounting that a review found in the general population (fields et al., 2014). however, that review was primarily based on crosssectional data. several experimental studies further demonstrated the complexity of the effect of acute stress on delay discounting in general. for example, acute stress increased delay discounting only among cortisol responders, not in non-responders (kimura et al., 2013). a blunted cortisol response to stress has been observed among individuals using cannabis regularly (cuttler et al., 2017). although there was a significant change in subjective stress in the current study, perhaps the stress task/format was not strong enough to elicit a more pervasive stress response (e.g., cortisol) regardless of cannabis use status. an alternative explanation for why no significant increase in delay discounting was observed in either group could be the potential blunted stress response acquired due to covid19. data collection during covid-19 was likely influenced by prolonged stress exposure (goldfarb, 2020). we did not know if their reactivity to the acute stress was changed due to exposure to the prolonged multi-dimensional stressors (e.g., social, family, economic, employment, and education) that the covid-19 pandemic brought. under acute stress, individuals with higher perceived daily life stress tended to choose larger but delayed rewards (i.e., lower delay discounting); individuals with lower perceived daily life stress tended to choose smaller but immediate rewards (i.e., higher delay discounting) (lempert et al., 2012). since greater lifetime stress exposure was associated with blunted cortisol response to acute stress (lam et al., 2019) and acute stress did not alter delay discounting among those with blunted cortisol response (kimura et al., 2013), it is possible that both groups in this study experienced some levels of blunted stress response from the prolonging stress exposure during covid-19. this interpretation was also supported by the fact that the mean pss score in our sample was relatively higher than what was reported in a similar age cannabis, a publication of the research society on marijuana group in the general population (cohen & janickideverts, 2012). on the other hand, the lack of differences in delay discounting in response to acute stress across groups might be attributed to the mcq’s design, which features identical items. unlike tasks that adjust reward amounts based on responses (e.g., du et al., 2002), the mcq’s identical items could lead to a lack of sensitivity to change. given researchers have suggested utilizing alternative mcq in repeated measure design (kuang et al., 2018), futher research employing alternative mcq or other types tasks that adjust reward amounts is recommended. likely as a function of the lack of change in delay discounting in response to acute stress, no significant differences were observed in the cannabis use group’s response compared to the non-use group. however, this does suggest individuals using cannabis frequently do not prefer more immediate rewards than those who do not use cannabis when experiencing acute stress. this further reinforces the abovementioned question regarding the role of delay discounting in reinforcer pathology regarding cannabis use. perhaps delay discounting is not a critical mechanism in cannabis use choices while experiencing acute stress. in fact, while there is a lack of research examining the effect of acute stress on delay discounting in individuals using substances, the only other study we are aware of found delay discounting was not affected by acute stress in individuals endorsing heavy drinking either (amlung & mackillop, 2014). more studies are needed, but the current study contributes to this limited literature, suggesting that delay discounting may not be an important target to consider under conditions of acute stress despite being proposed as one of the joint mechanisms underlying substance use decision-making generally. regarding our second aim to examine the effect of acute stress on cannabis demand, results were partially consistent with our hypotheses, such that we found that demand intensity significantly increased after stress induction. however, omax did not significantly change as a function of stress induction, even though the statistical difference approached significance (p = .051). notably, the small to medium effect sizes of the changes in cannabis demand indices (intensity: d = .50; omax: d = 34; breakpoint: d = .29; elasticity: d = .29) observed in this study were larger than the effect sizes reported in the recent meta-analysis (intensity: d = .17; omax: d = 18; breakpoint: d = .14; elasticity: d = .16) by acuff and colleagues (2020). while our findings align in some aspects and diverge in others with the metaanalysis, which found that omax (but not other indices of demand indices) across substances significantly increased in response to stress/negative affect manipulations, it is important to note that the authors also highlighted the possibility of publication bias with a relatively small number of studies and predominantly with samples using alcohol or cigarette (acuff, amlung, et al., 2020). to our knowledge, this study is the first to examine the acute stress effect on cannabis demand. thus, while caution is warranted, demand intensity may play a more important role than omax in cannabis use than other substance use (e.g., alcohol or cigarette) under conditions of acute stress. as recent research found higher momentary alcohol demand intensity was associated with a higher likelihood of drinking and greater total alcohol consumption in the real world (motschman et al., 2022), one might expect that the observed effects could be applied to cannabis demand such that individuals might be more likely to use cannabis and use more when cannabis demand increases. accordingly, interventions targeting how to reduce cannabis demand intensity while experiencing momentary stress might be an avenue to reduce the frequency or quantity of cannabis use and to disconnect the relationship between stress and problematic cannabis use in the real world. however, despite observing a medium effect size related to increased intensity, it remains uncertain whether the magnitude of this increase (i.e., consuming an additional 1.5 hits in a typical day when cannabis is free) during acute stress holds any significant meaning or practical implications. it is also important to acknowledge that certain limitations in our study design (detailed in the following section) might impact the interpretation of our findings. as for the third aim of examining the moderating effect of coping motives on the association between the change in stress and change in delay discounting and cannabis demand, we did not see the expected moderating effect of coping motives. this finding diverges from previous research on alcohol demand, during stress, delay discounting, and cannabis demand which individuals reporting higher coping motives tended to increase the reinforcing value of alcohol under a negative mood induction (rousseau et al., 2011). the discrepancy might stem from the different methods of stress/negative mood induction employed. this study used a standardized math task to induce acute stress, whereas rousseau et al. (2011) utilized a personalized negative mood induction (i.e., utilizing participants’ personal life adverse events). furthermore, this result should be interpreted cautiously due to the small sample size of the cannabis use group in the current study. limitations and strengths the results of this study should be interpreted cautiously with the following limitations. first, the generalizability may be limited due to the fact that the current sample consisted of individuals identifying primarily as female and white. relatedly, we did not assess participants’ cigarette use status or frequency, except for screening out individuals endorsing daily cigarette or e-cigarette use. given the strong association between delay discounting and cigarette and e-cigarette use (amlung et al., 2017; mackillop et al., 2011; stein et al., 2018), the absence of this information hinders our ability to fully understand how tobacco use in our sample might confound the results. in addition, our results for the nonsignificant moderating effect might be an issue of a small sample size; future research utilizing a larger sample size to examine the moderating effect of coping motives on the association between stress and delay discounting as well as cannabis demand is recommended. moreover, this study's experiment was not done in a laboratory. instead, participants completed the tasks online from their homes. therefore, we could not control participants' home environments, which might potentially have affected the effect of stress induction. however, this might have increased some ecological validity as the experiment was done in the natural environment. in terms of research design specifically, we identified several limitations that warrant consideration for future similar studies. first, this study relied solely on the subjective stress assessment at the end of the stress induction task, without incorporating biological measures. it is possible that the effect of stress induction on subjective stress response might have begun to dissipate by the time behavioral measures were conducted. to address this concern, future research could assess stress at different time points during the stress induction task. additionally, the effects or the lack of effects we observed following stress induction might be confounded by repeated testing on the measures within a short timeframe. notably, this study lacked a neutral control condition (i.e., no stress condition), which makes it challenging to rule out the impact of repeated testing, nor could we rule out random error. however, the detection of small to medium effect sizes in the correlations between changes in stress and cannabis demand indices among the use group and between changes in stress and delay discounting among the non-use group might alleviate this concern, as it suggests the change in stress contributed to the changes in outcomes observed. nevertheless, we recommend similar future research consider implementing a neutral control condition to further address these factors. third, our use of mcq to assess monetary delay discounting may have limitations. the identical items in mcq might render it insensitive to detecting changes. the lack of sensitivity could be one reason why we did not observe significant differences. therefore, future research is recommended to explore tasks that dynamically adjust reward amounts based on responses (e.g., du et al., 2002). furthermore, given individuals using cannabis demonstrated higher delay discounting rates in cannabis rewards than monetary rewards, recent research calls for attention to non-monetary delay discounting as well as cross-commodity (i.e., money vs. cannabis) delay discounting in cannabis use (foxx et al., 2023; patel et al., 2020; strickland et al., 2017). future research using cannabis or cross-commodity discounting tasks is suggested to examine if results might differ due to the task reward type. lastly, our use of mpt with a trait vignette to assess cannabis demand might not fully capture state-level variations in cannabis demand, despite observing small differences in cannabis demand curves between baseline and poststress assessments. future research using state-specific vignettes to assess state demand is cannabis, a publication of the research society on marijuana recommended. in summary, addressing these limitations could enhance the interpretability of study findings and help rule out confounding factors related to study design. despite the above mentioned limitations, this study has several strengths. first, to our knowledge, this is the first study to examine the effect of acute stress on delay discounting and demand among individuals endorsing cannabis use. our findings regarding heightened cannabis demand intensity observed under acute stress could inform researchers and practitioners that cannabis demand could be used as an intervention target for preventing using cannabis to cope. second, to our knowledge, this study is the first to administer tmct online as a stress induction. this study demonstrated that the tmct could be administered online with a significant increase in subjective stress ratings. this effective online tmct administration provides an alternative approach for future research when facing barriers to administering in-person stress induction tasks. lastly, as we mentioned before, this study might have higher ecological validity, compared to the traditional experimental research, because the experiment was done in participants’ home environments. as people do not exist in a controlled laboratory, we believe our online experiment has a certain value in understanding how stress affects the tendency to choose immediate rewards and perceived cannabis value in the real-world context. conclusion the overall findings of this study highlight the importance of cannabis demand while experiencing acute stress among young adults endorsing high-frequency cannabis use. however, we approach these findings with some caution due to the limitations inherent in our study design. cannabis demand, especially intensity, may play a more influential role than delay discounting in choices around cannabis use decision-making while experiencing acute stress, although the relatively small difference raises questions regarding practical implications. furthermore, we acknowledge the importance of recognizing the study design limitations that could contribute to the study's observed findings or null results. we recommend that future research explore alternative approaches and methodologies to address these limitations while examining similar research questions, as such knowledge may have great potential to prevent using cannabis to cope with stress and further disconnect the association between stress and problematic cannabis use. references acuff, s. f., amlung, m., dennhardt, a. a., mackillop, j., & murphy, j. g. 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(2019). sensitivity of hypothetical purchase task indices when studying substance use: a systematic literature review. preventive medicine, 128, 105789. https://doi.org/10.1016/j.ypmed.2019.105789 funding and acknowledgements: this research was supported in part by funds provided for medical and biological research by the state of washington initiative measure no. 171. the funding source had no role other than financial support. all authors contributed to and were significantly involved in developing and writing this manuscript and have approved the final version of this manuscript. all authors declare no conflict of interest. we sincerely acknowledge and appreciate dr. james g. murphy's input on the initial research design/measure and the contributions of ashlin king, alexander mcallister, joseph box, and zacheria krocka to data collection. portions of this article were presented at the 2022 annual meeting of the research society on marijuana. this study was not preregistered. materials, data with a codebook, and r codes required to replicate the results of this study are available at: https://doi.org/10.17605/osf.io/6kj2g. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ table 2. correlations among study variables. research article 149 ved abstract objective: boredom is a common emotion associated with substance use in college students – a group already at risk for substance misuse. the purpose of this study is to understand how two types of trait boredom (susceptibility and proneness) in college students are associated with frequency of cannabis, alcohol, and tobacco use. method: data were collected from an online survey completed by a sample of undergraduate students (n = 414, mage = 19.55, 84.5% female; 64.3% white) enrolled at a large public university in the northwest. multivariate logistic regression was used to evaluate the association between trait boredom and frequency of cannabis, alcohol, and tobacco use after controlling for age, sex, and race. results: boredom susceptibility was a significant predictor of annual, monthly, and weekly cannabis and alcohol use, but only annual and monthly tobacco use. boredom proneness was only a significant predictor for monthly alcohol use. conclusions: findings were generally consistent across types of substances and frequency of use for boredom susceptibility, indicating students higher in susceptibility, rather than proneness, are a subgroup to target prevention interventions to alleviate boredom and subsequent maladaptive coping mechanisms. key words: = trait boredom; boredom proneness; boredom susceptibility; college students; substance use; prevention science boredom is characterized by feelings of dissatisfaction, restlessness, and weariness (elpidorou, 2014), and conceptualized as an unpleasant emotional state of “wanting, but being unable, to engage in satisfying activity” (eastwood et al., 2012, p. 482). it can result in disengagement from healthy pursuits, impacting development and growth (larson & richards, 1991; shaw et al., 1996). although boredom is a common emotion, individuals vary in their ability to effectively respond. much of the research has focused on trait boredom, or the general likelihood, or propensity, to experience boredom (elpidorou, 2014; mercer-lynn et al., 2014), versus state boredom, which is momentary and transitory (mikulas & vodanovich, 1993; weybright et al., 2015). trait boredom has been associated with negative outcomes such as substance use (weybright et al., 2015), which is illegal for adolescents and emerging adults under 21 years of age for most substances. further, cannabis, alcohol, and tobacco use have a potential for dependency, so delaying use until the legal age reduces the likelihood of dependency and substance use disorder (ali et al., 2020; hingson et al., 2006; le strat et al., 2015). from a developmental perspective, emerging adults may be more vulnerable to such negative outcomes, erica l. doering1, elizabeth weybright1, alana j. anderson2, kyle murphy1, linda caldwell3 1department of human development, washington state university 2 omni institute 3 department of recreation, park, and tourism management, the pennsylvania state university cannabis 2023, volume 6 (3) © author(s) 2023 researchmj.org 10.26828/cannabis/2023/000177 associations between trait boredom and frequency of cannabis, alcohol, and tobacco use in college students corresponding author: erica doering, m.s., 501 johnson tower, pullman, wa 99164. email: erica.doering@wsu.edu cannabis, a publication of the research society on marijuana 150 especially college students who are already at risk for substance misuse (e.g., binge drinking; hazardous substance use; mason et al., 2014; slutske et al., 2004). more specifically, boredom is implicated as a reason for college students use of cannabis, alcohol, and tobacco (cooper et al., 2017; lee et al., 2007; phillips et al., 2017; wong et al., 2018). therefore, it is important to investigate the role trait boredom plays in substance use among college students. although prior research repeatedly finds associations between trait boredom and substance use (csikszentmihalyi & larson, 2014; johnston & o’malley, 1986; sharp et al., 2011; vedelago et al., 2020), there is limited understanding of the association between differing types of trait boredom (i.e., proneness and susceptibility) and the frequency of substance use. there is much variability in cannabis and alcohol related negative outcomes (e.g., pearson, 2019; prince et al., 2018) and the factors contributing to substance use are complex resulting from the individual and the situation, research on boredom and substance use has included boredom as a motive for substance use (cooper et al., 2017; lee et al., 2007; phillips et al., 2017; wong et al., 2018) but often ignores the different types of boredom. therefore, the distinction between types of trait boredom (i.e., proneness and susceptibility) and the frequency of substance use is important as college student substance misuse (i.e., binge drinking or hazardous substance use) is concerning due to its association with negative outcomes (e.g., poor academic performance, unintentional injuries, mortality, etc.; arria et al., 2008; jones et al., 2001; skidmore et al., 2016). more specifically, cannabis use in college students is at a historic high (patrick et al., 2022) and college students are at an increased risk for frequent drinking episodes and binge drinking alcohol use (slutske et al., 2004). furthermore, although tobacco use has been on the decline, e-cigarette/vape use among college students is on the rise; these devices deliver more concentrated amounts of nicotine increasing the likelihood of nicotine addiction (roberts et al., 2022; welsh et al., 2019). as types of trait boredom may operate differently as motivation for use of cannabis, alcohol, and tobacco, it is important to understand the factors associated with each substance to inform prevention efforts. despite calls for efforts to directly address boredom (e.g., vogel-walcutt et al., 2012), few behavioral interventions exist which target boredom as a motive for engaging in substance use. given this, the current study aims to understand how trait boredom, specifically boredom proneness and susceptibility, is associated with frequency of cannabis, alcohol, and tobacco use in college students. boredom the definition of boredom is generally thought of as an unpleasant emotion resulting from a mismatch between the individual and the environment (eastwood et al., 2012). like other emotions, boredom conveys information such as how the current situation is not meeting expectations (clore et al., 2001). in other words, boredom serves as a signal that can lead to responses that are positive (e.g., refocusing attention, productivity, creativity; harris, 2000; mann & cadman, 2014; park et al., 2019) or negative (e.g., substance use; westgate, 2020; weybright et al., 2015). varying individual and situational factors contribute to experiences of boredom, including low and high arousal states (e.g., agitation, anger) and under and/or over-stimulation (eastwood et al., 2012; gerritsen et al., 2014; mikulas & vodanovich, 1993; vogel-walcutt et al., 2012). boredom is experienced on both a state and a trait level. almost everyone experiences state, or momentary, boredom from time to time, including college students (aldridge & delucia, 1989; danckert & allman, 2005; daniels et al., 2009; mann & robinson, 2009; pekrun et al., 2010). because state boredom is transitory and situational, individuals generally alleviate it by restructuring the situation (mikulas & vodanovich, 1993; weybright et al., 2015). however, individuals high in trait boredom struggle to effectively cope with these momentary experiences of boredom (mercer-lynn et al., 2014; weybright et al., 2015). given this, the current study focuses on trait boredom which is less frequently experienced among individuals than state boredom (~90% versus 10% respectively; chin et al., 2017; miller et al.,, 2014) but is more frequently associated with health risk behavior (biolcati et al., 2018; harris, 2000; lepera, 2011). trait boredom college student trait boredom and substance use 151 trait boredom is connected to individual internal factors resulting in a general likelihood, or propensity, to experience boredom (elpidorou, 2014; mercer-lynn et al., 2014). prior research suggests individuals experiencing trait boredom are less capable of alleviating boredom through restructuring activities when compared to individuals experiencing state boredom (farmer & sundberg, 1986; kass et al., 2001; weybright et al., 2015). two types of trait boredom, boredom proneness and boredom susceptibility, are each thought to be motivated by different underlying self-regulatory processes and are therefore differentially associated with risk behavior (mercer-lynn et al., 2011; mercer & eastwood, 2010). boredom proneness is the tendency to experience boredom (farmer & sundberg, 1986), while boredom susceptibility is the “aversion to repetition, routine, and dull people, and restlessness when things are unchanging” (zuckerman et al., 1978, p. 140). the approach-avoidance model suggests boredom proneness and susceptibility are related to avoidance and approach regulatory processes, respectively, which are different motivational systems involved in self-regulation (cornwell et al., 2014). for example, more boredom is experienced throughout the day in individuals high in boredom proneness, while individuals high in boredom susceptibility experience high sensation seeking (e.g., trait) in mundane situations (e.g., state). the avoidance regulatory process reflects the behavioral inhibition system (e.g., withdraw from unwelcome stimuli, sensitivity to punishment), which is associated with boredom proneness. boredom prone individuals often demonstrate lower levels of selfcontrol, likely caused by inability or failures to engage in goal-directed and meaningful behaviors (mugon et al., 2018; westgate & wilson, 2018). the approach regulatory process reflects engagement of the behavioral activation system (e.g., risk taking and impulsive behaviors, sensitivity to rewards and extreme novelty; gray, 1972, 1981; pickering & corr, 2008), which is associated with boredom susceptibility (mercerlynn et al., 2011; perone et al., 2019). boredom susceptible individuals seek novelty and stimulation through risk taking and engagement in risky behaviors to alleviate feelings of boredom (kılıç et al., 2019). further, individuals high in boredom susceptibility have a desire to escape boring situations and may use maladaptive boredom coping mechanisms (e.g., substance use; bieleke et al., 2022). due to the differential associations between boredom proneness and susceptibility in relation to negative outcomes, the current study focuses on understanding how trait boredom (susceptibility and proneness) influences the frequency of substance use. boredom and substance use the association between boredom and substance use in college students is a concern. boredom is associated with substance experimentation and has been found to be a consistent and strong predictor of cannabis, alcohol, and tobacco use (csikszentmihalyi & larson, 2014; johnston & o’malley, 1986; sharp et al., 2011). college students report boredom as motivation for engaging in cannabis (lee et al., 2007; phillips et al., 2017), alcohol (cooper et al., 2017), and tobacco use (wong et al., 2018). boredom is associated with increased likeliness to use alcohol and binge drink (biolcati et al., 2018; patrick & schulenberg, 2011; weybright et al., 2015). conversely, individuals who misuse substances are more likely to experience boredom (iso-ahola & crowley, 1991; lepera, 2011). several contextual factors also impact college student substance use and experiences of boredom including cannabis legalization and social norms. throughout the united states, including the northwest, 21 states or territories have measures regulating non-medical cannabis (national conference of state legislatures, 2022). this results in greater access to cannabis, reductions in perceived harms of use, and increases in perceptions of use, especially in college-aged students – all factors associated with increased use (gilson et al., 2022; rhew et al., 2022). these associations mirror those found in the alcohol use literature (slutske et al., 2016; wild et al., 2001). for individuals high in trait boredom, these same factors may result in a context which facilitates risk behavior engagement to alleviate boredom. both types of trait boredom, proneness and susceptibility, have been associated with risk behaviors in college students. specifically, boredom proneness is correlated with more substance use (weybright et al., 2015), substance cannabis, a publication of the research society on marijuana 152 misuse (lee et al., 2007; lepera, 2011), and binge drinking (biolcati et al., 2016). boredom susceptibility is correlated with alcohol use (kılıç et al., 2019; mercer-lynn et al., 2011), cigarette smoking (martínez-vispo et al., 2019), and opioid misuse (franques et al., 2003). despite these associations, the mechanisms by which trait boredom and substance use are associated are not well understood, including differing frequencies of substance use. further, there is limited research assessing boredom proneness and susceptibilities associations between cannabis, alcohol, and tobacco use. most research focuses on one specific substance versus the distinctions between multiple substances. therefore, the current study seeks to further the understanding of the associations between trait boredom and substance use to fill a gap in the literature pertaining the frequency of cannabis, alcohol, and tobacco use. aim of current study boredom is thought to arise in response to a mismatch between environmental conditions and personal predispositions, and substance use may be used to address boredom. despite prior research, there is a limited understanding of the association between trait boredom and the frequency of substance use. the purpose of the current study is to understand how types of trait boredom (susceptibility and proneness) are associated with frequency of cannabis, alcohol, and tobacco use in college students. the findings can be used to inform substance use prevention approaches. given the current literature on trait boredom and substance use among college students, the following research questions (rq) were explored: • rq1: how are boredom susceptibility and proneness associated with (a) past year and (b) past month substance use (i.e., cannabis, alcohol, and tobacco)? • rq2: how are boredom susceptibility and proneness associated with less than weekly versus greater than or equal to weekly substance use (i.e., cannabis, alcohol, and tobacco)? methods study design data were collected from undergraduate students enrolled in a large public university in the northwest united states. the large public university is located within a state with legalized recreational and medical cannabis use. students completed an online survey administered between october-december 2019 for extra course credit. the study was reviewed and approved by the university’s institutional review board. participants the sample consisted of 414 undergraduate students (mage = 19.55 years, sd = 1.48 years). approximately 84.5% identified as female for sex, 15.2% as male, and 0.2% preferred to not disclose their sex. the sample was predominantly white (64.3%; 13.5% hispanic or latino; 8.2% asian or asian american; 5.6% multi-racial; 5.3% black or african american; 1.2% native hawaiian or other pacific islander; 1.0% other; 0.7% preferred to not disclose; and 0.2% american indian or alaska native). additional details about the participants can be found in table 1. measures trait boredom boredom susceptibility. boredom susceptibility was measured with eight items from the brief sensation seeking scale (bsss-8; hoyle et al., 2002). responses were on a 5-point likert scale from ‘strongly disagree’ (1) to ‘strongly agree’ (5). high boredom susceptibility is associated with high sensation seeking in mundane situations (e.g., approach tendencies through risk taking and impulsive behaviors; gray, 1972, 1981; pickering & corr, 2008) and is typically measured with a subscale of a commonly used sensation seeking scale (zuckerman, 1994). an example prompt from the scale used to measure boredom susceptibility in the current study is “i get restless when i spend too much time at home.” internal consistency of the scale was good (α = 0.81), and the internal consistency is consistent with other scale applications among college students (hoyle et al., 2002). college student trait boredom and substance use 153 boredom proneness. boredom proneness was measured with 28 items from the boredom proneness scale (bps; farmer & sundberg, 1986). responses were on a 5-point likert scale from ‘strongly disagree’ (1) to ‘strongly agree’ (5). an example prompt from the scale is “i often find myself with nothing to do and time on my hands.” the internal consistency reliability of the scale with likert-scale options has been tested across multiple studies and samples and found to be good (α=0.79-0.91; vodanovich & watt, 2016; current study, α = 0.82). frequency of substance use past year substance use. past year substance use was measured for cannabis, alcohol, and tobacco with the item “within the last year how often have you used: marijuana (pot, hash, edibles, vape); alcohol (beer, wine, liquor); and tobacco (smoke, chew, snuff, vape; southern illinois university, 2021). response options included ‘did not use’, ‘once per year’, ‘six times per year’, ‘once per month’, ‘twice per month’, ‘once per week’, ‘three times per week’, ‘five times per week’, and ‘every day’. for analyses, response options were dichotomized to ‘did not use’ (0) and ‘did use’ (1). the response options were dichotomized because the skewness and kurtosis values for the scales were between +/-1, demonstrating normality for past year substance use for cannabis (skewness = 0.78; kurtosis = 0.81) and alcohol (skewness = -0.66; kurtosis = 0.77), but not tobacco (skewness = 1.25; kurtosis = 0.15). past month substance use. past month substance use was measured for cannabis, alcohol, and tobacco with the item “within the past 30 days on how many days did you have: marijuana (pot, hash, edibles, vape); alcohol (beer, wine, liquor); and tobacco (smoke, chew, snuff, vape; southern illinois university, 2021). response options included ‘0 days’, ‘1-2 days’, ‘3-5 days’, ‘6-9 days’, ’10-19 days’, ’20-29 days’, and ‘all 30 days’. for analyses, response options were dichotomized to ‘did not use’ (0) and ‘did use’ (1). the response options were dichotomized because the skewness and kurtosis values for the scales were not between +/-1, demonstrating a lack of normality for past month substance use for cannabis (skewness = 1.22; kurtosis = 0.06), alcohol (skewness = 0.25; kurtosis = -1.16), and tobacco (skewness = 1.84; kurtosis = 2.08). weekly substance use. to gain a better understanding of less than weekly versus greater than or equal to weekly substance use, a new variable was created for each substance (i.e., cannabis, alcohol, and tobacco) from the past year substance use variable. the ‘did not use’ students were treated as missing to allow for analysis of higher frequency use. the following response options: ‘once per year’, ‘six times per year’, ‘once per month’, and ‘twice per month’ were recoded as ‘less than weekly use’ (0), and the following response options: ‘once per week’, ‘three times per week’, ‘five times per week’, and ‘every day’ were recoded as ‘greater than or equal to weekly use’ (1). the literature does not have a single definition for what constitutes as regular and heavy substance use, but regular substance use usually follows a pattern of weekly or more frequent use of substances (i.e., cannabis, alcohol, and tobacco; gabrys & porath, 2019). therefore, the “greater than or equal to weekly use” variable follows this pattern of regular substance use. data analysis using ibm spss statistics (version 27), data were cleaned for coding errors, recoded reverse scored items, and evaluated for missingness. scales were created for boredom susceptibility and boredom proneness. both scatter plots and z scores were analyzed for outliers. the scatter plots were examined for boredom susceptibility and boredom proneness. there did not appear to be any data points falling far from the swarm, and the swarms appeared to be linear. to verify the scatter plots, the scales were standardized by creating z scores and examining the frequency distribution. there were no z scores greater than +/-3.29, demonstrating no outliers were present. the reliabilities of each scale were run and items decreasing reliability were evaluated for removal. descriptives including frequencies, means, and correlations were analyzed for issues of multicollinearity, and no issues of multicollinearity were found. bivariate correlations were examined for potential confounds and to check for issues of multicollinearity for boredom susceptibility and cannabis, a publication of the research society on marijuana 154 boredom proneness, r(414) = .19, p < .001. additional details about the frequencies and means can be found in table 1. there were no concerns for potential confounds. the variables are related but not redundant. table 1. descriptive statistics m (sd) boredom susceptibility 3.46 (0.73) boredom proneness 3.14 (0.40) age 19.55 (1.48) cannabis use % (n) yearly (did use; 1) 57.49 (238) monthly (did use; 1) 45.17 (187) weekly (greater than or equal to weekly use; 1) 25.36 (105) alcohol use yearly (did use; 1) 85.02 (352) monthly (did use; 1) 76.33 (316) weekly (greater than or equal to weekly use; 1) 47.10 (195) tobacco use yearly (did use; 1) 41.55 (172) monthly (did use; 1) 31.88 (132) weekly (greater than or equal to weekly use; 1) 19.32 (80) sex woman (1) 84.54 (350) man (0) 15.22 (63) prefer to not disclose (0) 0.24 (1) race/ethnic identity white (1) 64.25 (266) hispanic or latino (0) 13.53 (56) asian or asian american (0) 8.21 (34) multi-racial (0) 5.56 (23) back or african american (0) 5.31 (24) native hawaiian or other pacific islander (0) 1.21 (5) other (e.g., arab, basque, filipino, pakistani) (0) 0.97 (4) prefer not to disclose (0) 0.72 (3) american indian or alaska native (0) 0.24 (1) note. n = 414. participants age range = 18 – 25. analyses were conducted using mplus v.8.7 (muthén & muthén, 1998-2021), using the mlr estimator. three multivariate logistic regressions were used to evaluate the associations between trait boredom (susceptibility and proneness) and frequency (past year, past 30 days, weekly use) of substance use (i.e., cannabis, alcohol, and tobacco) controlling for age, sex, and race. for analyses, sex was recoded to ‘all else’ (0) and ‘female’ (1). ‘all else’ included response options ‘male’ and ‘prefer to not disclose.’ in addition, race was recoded to ‘all else’ (0) and ‘white’ (1). ‘all else’ included response options ’hispanic or latino’, ‘asian or asian american’, ‘black or african american’, ‘native hawaiian or other pacific islander’, ‘american indian or alaska native’, ‘multi-racial’, ‘other’, and ‘preferred to not disclose’. the first multivariate logistic regression to answer rq1a used boredom susceptibility and boredom proneness to predict annual cannabis, alcohol, and tobacco use. the second multivariate logistic regression to answer rq1b used boredom susceptibility and boredom proneness to predict monthly cannabis, alcohol, and tobacco use. the third multivariate logistic regression to answer rq2 used boredom susceptibility and boredom proneness to predict less than weekly versus greater than or equal to weekly cannabis, alcohol, and tobacco use. results rq1a – trait boredom and annual substance use college student trait boredom and substance use 155 a multivariate logistic regression was conducted using boredom susceptibility and boredom proneness to predict annual cannabis, alcohol, and tobacco use after controlling for age, sex, and race/ethnicity. cannabis, alcohol, and tobacco accounted for the 16.10%, 29.60%, and 15.90% of the total variance in the model, respectively. for annual cannabis use, boredom susceptibility (b = 0.97, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 2.64 (95% ci = 1.93, 3.62), which indicates that for every 1-unit increase in boredom susceptibility, the odds of annual cannabis use increase by 2.64 times. for annual alcohol use, boredom susceptibility (b = 1.30, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 3.68 (95% ci = 2.36, 5.73), which indicates that for every 1-unit increase in boredom susceptibility, the odds of annual alcohol use increase by 3.68 times. for annual tobacco use, boredom susceptibility (b = 0.89, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 2.42 (95% ci = 1.74, 3.37), which indicates that for every 1-unit increase in boredom susceptibility, the odds of annual tobacco use increase by 2.42 times. no significant association was observed between boredom proneness and the odds of annual substance use for cannabis, alcohol, and tobacco. in summary, boredom susceptibility was associated with greater annual use of cannabis, alcohol, and tobacco, while boredom proneness was not associated with annual substance use (see table 2 for full results for rq1a) table 2. rq1a – multivariate logistic regression for trait boredom and annual substance use substance predictor b p or 95% ci cannabis boredom susceptibility 0.97 < .001 2.64 1.93, 3.62 boredom proneness -0.18 .54 0.84 0.48, 1.47 age 0.19 .01 1.21 1.04, 1.41 race 0.09 .68 1.10 0.71, 1.71 sex 0.67 .03 1.95 1.06, 3.58 alcohol boredom susceptibility 1.30 < .001 3.68 2.36, 5.73 boredom proneness 0.79 .06 2.21 0.97, 5.03 age 0.34 .01 1.41 1.09, 1.81 race 0.60 .06 1.82 0.99, 3.36 sex 1.10 .004 3.00 1.42, 6.35 tobacco boredom susceptibility 0.89 < .001 2.42 1.74, 3.37 boredom proneness -0.13 .63 0.88 0.52, 1.49 age -0.02 .84 0.99 0.85, 1.14 race 0.83 < .001 2.29 1.44, 3.65 sex -0.52 .09 0.60 0.33, 1.08 note. the results are unstandardized effects. or = odds ratio; ci = confidence interval rq1b– trait boredom and monthly substance use a second multivariate logistic regression was conducted using boredom susceptibility and boredom proneness to predict monthly cannabis, alcohol, and tobacco use after controlling for age, sex, and race/ethnicity. cannabis, alcohol, and tobacco accounted for the 13.40%, 20.30%, and 11.60% of the total variance in the model, respectively. for monthly cannabis use, boredom susceptibility (b = 0.82, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 2.28 (95% ci = 1.70, 3.05), which indicates that for every 1-unit increase in boredom susceptibility, the odds of monthly cannabis use increase by 2.28 times. cannabis, a publication of the research society on marijuana 156 for monthly alcohol use, boredom susceptibility (b = 1.01, p < .001) and boredom proneness (b = 0.74, p = .03) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 2.75 (95% ci = 1.89, 4.01), which indicates that for every 1-unit increase in boredom susceptibility, the odds of monthly alcohol use increase by 2.75 times. the odds ratio for boredom proneness was 2.09 (95% ci = 1.09, 4.02), which indicates that for every 1-unit increase in boredom proneness, the odds of monthly alcohol use increase by 2.09 times. for monthly tobacco use, boredom susceptibility (b = 0.68, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 1.97 (95% ci = 1.45, 2.68), which indicates that for every 1-unit increase in boredom susceptibility, the odds of monthly tobacco use increase by 1.97 times. in summary, boredom susceptibility was associated with greater monthly use of cannabis, alcohol, and tobacco, while boredom proneness was only associated with greater monthly use of alcohol (see table 3 for full results for rq1b). table 3. rq1b – multivariate logistic regression for trait boredom and monthly substance use substance predictor b p or 95% ci cannabis boredom susceptibility 0.82 < .001 2.28 1.70, 3.05 boredom proneness -0.06 .83 0.95 0.56, 1.59 age 0.21 .01 1.23 1.07, 1.42 race -0.16 .49 0.86 0.55, 1.33 sex 0.84 .01 2.32 1.24, 4.33 alcohol boredom susceptibility 1.01 < .001 2.75 1.89, 4.01 boredom proneness 0.74 .03 2.09 1.09, 4.02 age 0.26 .01 1.29 1.07, 1.57 race 0.59 .02 1.81 1.10, 2.98 sex 0.55 .11 1.73 0.89, 3.34 tobacco boredom susceptibility 0.68 < .001 1.97 1.45, 2.68 boredom proneness -0.19 .48 0.83 0.49, 1.40 age 0.05 .49 1.05 0.91, 1.22 race 0.83 .001 2.30 1.40, 3.78 sex -0.26 .42 0.77 0.41, 1.44 note. the results are unstandardized effects. or = odds ratio; ci = confidence interval rq2 – trait boredom and less than weekly versus greater than or equal to weekly substance use a third multivariate logistic regression was conducted using boredom susceptibility and boredom proneness to predict less than weekly versus greater than or equal to weekly cannabis, alcohol, and tobacco use after controlling for age, sex, and race/ethnicity. cannabis, alcohol, and tobacco accounted for the 7.50%, 13.00%, and 9.40% of the total variance in the model, respectively. for less than weekly versus greater than or equal to weekly cannabis use, boredom susceptibility (b = 0.47, p = .03) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 1.59 (95% ci = 1.49, 3.07), which indicates that for every 1-unit increase in boredom susceptibility, the odds of weekly cannabis use increase by 1.59 times. for less than weekly versus greater than or equal to weekly alcohol use, boredom susceptibility (b = 0.76, p < .001) predicted a significant proportion of unique variance. the odds ratio for boredom susceptibility was 2.14 (95% ci = 1.49, 3.07), which indicates that for every 1-unit increase in boredom susceptibility, the odds of weekly alcohol use increase by 2.14 times. college student trait boredom and substance use 157 for less than weekly versus greater than or equal to weekly tobacco use, boredom susceptibility (b = 0.47, p = .06) did not predict a significant proportion of unique variance. no significant association was observed between boredom susceptibility and the odds of less than weekly versus greater than or equal to weekly substance use for tobacco. in addition, no significant association was observed between boredom proneness and the odds of less-thanweekly versus greater-thanor equal-to-weekly substance use for cannabis, alcohol, and tobacco. in summary, boredom susceptibility is associated with greater weekly use of cannabis and alcohol, while there were no associations for weekly substance use for boredom proneness (see table 4 for full results for rq2). post-hoc analyses were conducted using the two-item boredom susceptibility sub-scale of the bsss-8 (m = 2.55, range = 2.39 2.72, s2 = .06; hoyle et al., 2002) to measure boredom susceptibility. overall results remain the same for rq1a, rq1b, and rq2 and can be found in the supplementary tables. table 4. rq2 – multivariate logistic regression for trait boredom and less than weekly versus greater than or equal to weekly substance use substance predictor b p or 95% ci cannabis boredom susceptibility 0.47 .03 1.59 1.04, 2.45 boredom proneness -0.46 .19 0.63 0.32, 1.26 age 0.23 .02 1.26 1.04, 1.53 race 0.09 .76 1.09 0.62, 1.92 sex -0.24 .56 0.79 0.36, 1.75 alcohol boredom susceptibility 0.76 < .001 2.14 1.49, 3.07 boredom proneness -0.23 .43 0.80 0.45, 1.40 age 0.07 .39 1.07 0.92, 1.25 race 0.83 .001 2.29 1.41, 3.73 sex -0.75 .04 0.47 0.23, 0.97 tobacco boredom susceptibility 0.47 .06 1.61 0.98, 2.61 boredom proneness -0.80 .07 0.45 0.19, 1.08 age 0.22 .07 1.24 0.99, 1.57 race 0.37 .31 1.45 0.71, 2.97 sex -0.002 1.00 1.00 0.42, 2.36 note. the results are unstandardized effects. or = odds ratio; ci = confidence interval discussion although boredom is a normative experience among college students, understanding of the association between boredom susceptibility and proneness and the frequency of cannabis, alcohol, and tobacco use is limited. regarding substance use, our findings align with prior research finding boredom susceptibility is associated with alcohol (kılıç et al., 2019; mercer-lynn et al., 2011) and tobacco use (martínez-vispo et al., 2019), and boredom proneness with alcohol use (biolcati et al., 2016). the present study expands on this work by providing insights into how boredom susceptibility and proneness are associated with the frequency of cannabis, alcohol, and tobacco use. looking across levels of frequency, findings suggest boredom susceptibility is associated with annual and monthly use of cannabis, alcohol, and tobacco, as well as weekly use of cannabis and alcohol, but not tobacco. this suggests a different process at play for weekly tobacco users and points to differing motives based on frequency of substance use and substance class. in contrast, boredom proneness was only associated with monthly alcohol use. in addition, we controlled for age, race, and sex for each multivariate logistic regression, and there was not a consistent trend. for yearly substance use, age and sex were significant for cannabis and alcohol use, while race was significant for tobacco use. for monthly substance use, age and sex were significant for cannabis, age and race were significant for alcohol use, and race was significant for tobacco use. for weekly substance use, age was significant for cannabis, and race and sex were significant for cannabis, a publication of the research society on marijuana 158 alcohol use. there is not a grounding in empirical or theoretical literature to support looking at boredom and race/ethnicity differences. the findings for boredom and sex are mixed. data from the united states and other countries (e.g., australia, hong kong, lebanon) find male college students report higher levels of boredom than their female counterparts (sundberg et al., 1991; vodanovich & kass, 1990). however, other studies have found no sex differences (hickerson & beggs, 2007). the association of avoidance and approach regulatory processes (i.e., different motivational systems involved in self-regulation) with boredom proneness and susceptibility provides a deeper understanding of frequency of substance use (cornwell et al., 2014). individuals high in boredom proneness may engage in monthly use of alcohol to withdraw from their current environment. conversely, individuals high in boredom susceptibility are likely responding by engaging in sensation seeking desiring stimulation and novelty through engagement in risky behaviors to alleviate feelings of boredom. this may be why there is greater annual and monthly use of cannabis, alcohol, and tobacco, and especially greater weekly use of cannabis and alcohol. this greater frequency may be an attempt to bring such stimulation. individuals high in boredom susceptibility often experience high sensation seeking in mundane situations, and engage in substance use as a way cope with the boredom. the findings were consistent across types of substances and frequency of use. college students high in boredom susceptibility often respond by engaging in sensation seeking, because, theoretically, they desire stimulation to escape the boring situation which means they may use maladaptive boredom coping mechanisms (e.g., risky or harmful behaviors; bieleke et al., 2022). from a prevention perspective, this suggests college students higher in boredom susceptibility compared to those high in boredom proneness may need more support to alleviate the unpleasant emotion of boredom and subsequent maladaptive coping mechanisms such as substance abuse. researchers have called for interventions to address boredom, including clinical interventions to treat boredom proneness (gerritsen et al., 2014) and associated methods to better identify and support effective boredom coping (vogel-walcutt et al., 2012). these findings provide guidance in terms of moving prevention efforts forward in terms of what type of student to target and types of information or activities that might be successful. the results of this study show that there are different risks of substance use associated with boredom susceptibility compared to boredom proneness, which combined with our understanding of the different motivational systems involved in each type of trait boredom, suggests that the same intervention may not be effective. in other efforts, environmental campaigns targeting boredom to reduce college drinking have been released (e.g., washington state health care authority, 2020). this demonstrates an interest from university administrators in including boredom as a broader health promotion and life skill building approach to address substance use in college students. the findings from the current study point to the importance of college campuses in providing students with opportunities for positive risk taking (e.g., promotion of social activities with peers, rock climbing; dworkin, 2005) to provide better outcomes for college students higher in boredom susceptibility. limitations this study has contributed to understanding the association of boredom susceptibility and proneness with frequency of cannabis, alcohol, and tobacco use, however, there are several limitations to consider when interpreting these results. first, the measures are self-reported and cross-sectional. therefore, the data are vulnerable to issues of inherent bias, content validity, and sensitivity. second, our sample consists largely of female college aged students. the associations between trait boredom and substance use may differ for a college-attending men, and for collegeage non-students. future research should diversify the sample to increase generalizability of these findings. boredom susceptibility is measured using the bsss-8 (hoyle et al., 2002). the full bsss-8 measures the four primary dimensions of sensation seeking, which includes experience seeking, boredom susceptibility, thrill and college student trait boredom and substance use 159 adventure seeking, and disinhibition. three of the four dimensions of sensation seeking are not the constructs of interest. therefore, this could lead to concerns of content validity. despite this, high boredom susceptibility is associated with high sensation seeking in mundane situations (e.g., approach tendencies through risk taking and impulsive behaviors; gray, 1972, 1981; pickering & corr, 2008). therefore, we believed this measure was suitable for the current study. in addition, the same analyses were examined using the two-item boredom susceptibility sub-scale of the bsss-8 and similar results were found. an alternative measure of boredom susceptibility within the boredom coping survey is the sensation seeking scale form v – boredom susceptibility sub-scale (bss; zuckerman, 1994). bss consists of 10 items assessed using a forced choice format. the reliability of this scale has been found to be low in other studies (see gerritsen et al., 2014; perone et al., 2019; vodanovich & watt, 2016). a possible next step would be to find a more reliable measure of boredom susceptibility (e.g., converting bss from a forced choice scale to a likert scale using exploratory factor analysis and confirmatory factor analysis). conclusion and future directions in conclusion, the current study provides insights into how trait boredom in college students is associated with frequency of substance use and type of substance. the two types of trait boredom operate differently with the frequency of use and type of substance. findings were generally consistent across frequency of use and types of substances for boredom susceptibility, indicating college students higher in boredom susceptibility, rather than proneness, are a subgroup to target prevention interventions to alleviate boredom to address substance use. the focus of the current study was on trait boredom and substance use. our assumption is that individuals high in boredom susceptibility also report more substance use because they are reaching for substances to cope with boredom in the moment. one opportunity for future research to probe this assumption is to examine substance use in relation to state boredom using behavioral studies which induce boredom or ecological momentary assessments which would allow for states of boredom and subsequent coping to be caught in real time. another opportunity for future research is to assess the associations between mental health measures and trait boredom. prior research has found boredom to be a distinct negative emotion from depression (goldberg et al., 2011). a future study could look at profiles of boredom (see the meaning and attentional components (mac) model; 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(1978). sensation seeking in england and america: cross-cultural, age, and sex comparisons. journal of consulting and clinical psychology, 46(1), 139–149. https://doi.org/http://dx.doi.org/10.1037/0022006x.46.1.139 funding and acknowledgements: all authors have no competing financial interests to disclose. all authors report no conflict of interest, real or perceived. copyright: © 2023 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 150 internal ved abstract objective: this study investigated young adults’ (yas) experiences with tolerance breaks (temporary abstinence from cannabis; t-breaks). method: in study 1, 15 yas who used cannabis completed a qualitative interview. in study 2, 66 yas who used cannabis at least 2x/week completed online survey items assessing t-break familiarity, definitions, motivations, and experiences. data were analyzed using qualitative thematic analysis. results: in study 1, five themes were identified: (1) time frames for t-breaks were variable but brief and temporary, (2) t-breaks were motivated by tolerance reduction (3) and other motives, (4) withdrawal is an early barrier; positive outcomes occurred with longer breaks, (5) some yas viewed t-breaks as unnecessary/unachievable. study 2 findings demonstrated that yas were familiar with t-breaks and most had attempted a t-break in the past year; greater variability in t-break motivations was apparent in study 2. conclusions: results suggest that yas define t-breaks as an intentional and temporary period of abstinence from cannabis, regardless of motivation. key words: cannabis; young adults; tolerance breaks; temporary abstinence; qualitative among young adults (yas), rates of daily and near-daily cannabis use have nearly doubled in the past decade, and daily use is at historically high levels (patrick et al., 2022). among college students, 4.7% report cannabis use 20 or more days per month, and for their same age noncollege peers, this rate is tripled, with 14.5% using at this frequency (patrick et al., 2023). further, yas aged 18-25 have the highest rates of cannabis use disorder (cud) compared to other age groups (samhsa, 2020). regular cannabis use is associated with numerous harms, including poorer mental health (leadbeater et al., 2019), worse academic outcomes for those in school (arria et al., 2015, 2016; suerken et al., 2016), and worse occupational outcomes (thompson et al., 2019). although many people who use cannabis believe they can quit on their own without formal intervention (ellingstad et al., 2006; weiner et al., 1999), frequent and heavy cannabis use is a particularly difficult behavior to change. attempts to quit or reduce use tend to be shortlived (buckner et al., 2013; hughes et al., 2016; shrier et al., 2018), and the desire to quit cannabis katherine walukevich-dienst1, ella g. devries1, thomas j.k. fontana2, jessica a. blayney1, jason r. kilmer1, scott graupensperger1, & christine m. lee1 1center for the study of health and risk behaviors, department of psychiatry and behavioral sciences, university of washington 2center for health & wellbeing, university of vermont cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000289 volume 8, issue 1 what are tolerance breaks and why do young adults take them? a qualitative investigation of temporary abstinence breaks from cannabis corresponding author: katherine walukevich-dienst, phd, university of washington, 1959 ne pacific st, box 357238. seattle, washington 98195. email: kwd1@uw.edu. tolerance breaks 151 internal is typically low among yas (ramo et al., 2012). although yas tend not to seek or perceive a need for formal treatment (samhsa, 2020), many are turning to the internet to find other ways to reduce cannabis-related harms. tolerance breaks (“t-breaks”) may be one possible harm reduction strategy to help yas decrease cannabis-related harms. t-breaks are commonly referenced on the internet as a strategy to decrease cannabis use and tolerance by temporarily abstaining among people who engage in regular cannabis use, without the pressure or finality of a quit attempt (dugar, 2022; goldstein, 2023; hemraj, n.d.; weedmaps, 2020). specifically, major pro-cannabis websites have published articles encouraging t-breaks, claiming, for example, that t-breaks “offer plentiful benefits with little effort” and are “a good strategy for minimizing the risks of consuming too much [cannabis]” (weedmaps, 2020). some articles state t-breaks are effective in as little as 24 to 48 hours, while others recommend at least 21 days (dugar, 2022; goldstein, 2023; hemraj, n.d.; weedmaps, 2020). college health and wellness centers are also promoting the use of tbreak self-help guides, which use motivational interviewing and relapse prevention principles to provide psychoeducation and tips on how to manage common issues that can occur during a break, including craving, sleep disturbances, and boredom (fontana, n.d.; moore, n.d.). these approaches show promise as a harm reduction strategy, as initial pilot work testing one of these t-break guides indicates that yas are interested in and seriously committed to taking t-breaks and benefit from t-break-specific resources (fontana et al., 2023). temporary abstinence fits within harm reduction, relapse prevention, and transtheoretical frameworks of behavior change (marlatt et al., 2012; marlatt & donovan, 2005; prochaska & velicer, 1997) and there is an emerging literature supporting temporary abstinence as a reasonable harm reduction goal for other substances. for alcohol (e.g., “dry january”), individuals who participated in 30-day abstinence from alcohol challenges demonstrated decreases in drinking frequency post-break and endorsed other break-related benefits, such as improved sleep, regardless of whether abstinence was maintained for the full 30 days (de visser & nicholls, 2020; de visser & piper, 2020). tobacco/nicotine-focused “practice quit attempts” increased self-efficacy for change while also increasing motivation to change smoking behaviors among 30% of the sample (keizer et al., 2016, 2020). moreover, nearly 20% of individuals spontaneously decided to quit smoking during their practice quit attempt. thus, temporary abstinence could reduce acute harms associated with regular use and help people learn skills to practice and prepare for more permanent changes when ready (cox et al., 2022). yet, despite the popularity and initial support for guided t-breaks and temporary abstinence from other substances, there have been few empirical studies on temporary abstinence from cannabis specifically. in one study of temporary abstinence among yas, researchers used online website articles to develop the following definition of a t-break: “an intentional and temporary period of abstinence from cannabis with the primary goal of reducing tolerance levels so that a smaller amount of cannabis is needed to achieve the same high when use is resumed” (ansell et al., 2023). they found participants who took a tbreak with the sole motivation of reducing tolerance experienced increases in hazardous cannabis use and disorder symptoms 6 months later (ansell et al., 2023). however, among individuals who took breaks for other reasons (e.g., relationship reasons, starting a new job, upcoming drug test), longer breaks were associated with decreases in hazardous use and symptoms. yet, yas may conceptualize reasons for taking t-breaks more broadly or in a multifaceted way, as indicated in online forums and blog posts about t-breaks (see example reddit posts; krazecam, 2021; officialkfc, 2021; petewentzisgod, 2024). taken together, preliminary research suggests motives for breaks are differentially associated with outcomes, whereas online cannabis communities may have a broader conceptualization of t-breaks, beyond tolerance reduction alone. present study t-breaks are a well-known phenomenon online and among cannabis communities; however, the empirical literature assessing these experiences lags behind. as little is known about cannabis, a publication of the research society on marijuana 152 internal t-breaks at present, the primary goal of the current study was to conduct a secondary analysis of qualitative data to explore yas’ knowledge, motivations, and experiences related to t-breaks to develop a deeper, more nuanced understanding of this phenomenon. additionally, given a recent push for researchers to incorporate feedback from people with lived experience into substance use research, including the development and understanding of substance-related terminology (e.g., knopf, 2023), we explored yas’ personal definitions of t-breaks and used these definitions to inform and operationalize t-breaks. although the definition developed by ansell and colleagues (2023) was a critical first step toward understanding the initial risks and benefits of tbreaks, it remains unclear the extent to which this definition aligns with various ways in which yas conceptualize t-breaks, which is important for informing theory, future research, and prevention and intervention efforts. study 1 used qualitative data from individual interviews (n = 15 yas who engaged in cannabis use 2-3x/week in the past month) to assess yas’ knowledge of and experiences with t-breaks. given so little is known about ya experiences with t-breaks, the overall purpose of study 1 was to gain a general understanding of t-break experiences among yas. study 2 included qualitative and descriptive data from an online survey conducted with 66 yas who engaged in cannabis use 2-3x/week in the past month. study 2 expanded upon study 1 by using qualitative open-response data specifically to establish yas’ personal definition of t-breaks and identify common t-break motives. descriptive statistical analyses were conducted to assess the frequency/prevalence of cannabis use, familiarity with t-breaks, and the number of times participants took a t-break in the past year. . methods participants and procedures participants were recruited after completing all study procedures for another research study on regular cannabis use and cannabis behaviors among young adults. thirty individuals were invited via phone and email to participate in the current study. all participants were recruited from washington, a state in which both medical and recreational cannabis is legal for adults 21 years and older. study-specific procedures are described below. procedures were approved by the institution’s institutional review board. study 1: individual interviews. study 1 involved an individual interview about participants’ thoughts and experiences with completing the ema questionnaires (primary aim) and their cannabis use behaviors, including tbreaks (secondary aim). interested participants provided oral informed consent over the phone with study staff and scheduled a 60-minute audiorecorded virtual interview via zoom. interviews were conducted by the first author, a female clinical psychologist with experience in qualitative methods and substance use-related research and clinical work. participants were paid $20 for their time. data collection continued until saturation was reached for the primary aim of the present study (i.e., no new themes were identified in subsequent interviews). participants (n = 15) were 22.3 years old (sd = 3.5, range 18-27) and used cannabis at least 23x/week in the past month. on average, 53.3% (n = 8) reported using cannabis daily or more. the sample was 60.0% white (n = 9), 20.0% multi-racial (n = 3), 13.3% asian (n = 2), and 6.7% black or african american (n = 1); 20.0% identified as hispanic/latinx (n = 3). participants described their gender identity as woman/female (53.3%; n = 8), man/male (26.7%; n = 4), and transgender/gender non-conforming (20.0%; n = 3). over two-thirds (66.6%; n = 10) self-identified as sexual minoritized (e.g., asexual, bisexual, gay, queer). study 2: online survey open responses. study 2 involved a second 7-day ema study on affect and cannabis use behaviors. eligibility criteria for study 2 included being ages 18-29 and using cannabis at least 2-3x/week in the past month. participants who completed the qualitative interview for study 1 were not eligible for study 2. interested participants provided informed consent electronically before starting the ema protocol, which involved a baseline tolerance breaks 153 internal survey, ema surveys 4 times per day for 7 days (possible total of 28 ema surveys), and an immediate follow-up on day 8. four items assessing t-break familiarity, personal definitions (open-ended), experiences, and motives (open-ended) to take a t-break were included in the follow-up survey. all assessments were online. participants were compensated up to $170 for study 2. participants (n = 66) were 23.7 years old (sd = 3.1, range 19-29); 75.8% (n = 50) used cannabis four or more times a week in the past month. the sample was 62.1% white (n = 41), 16.7% asian (n = 11), 10.6% multi-racial (n = 7), 7.6% black/african american (n = 5), 1.5% american indian/alaskan native (n = 1), and 1.5% native hawaiian/other pacific islander (n = 1). participants described their gender identity as woman/female (54.5%; n = 36), man/male (39.4%; n = 26), or another way (6.1%; e.g., non-binary; n = 4). over half of the sample (60.6%; n = 40) selfidentified as sexual minoritized. data collection study 1: individual interviews. semi-structured interviews were conducted virtually from november to december 2022. the general question prompt about t-breaks was “what experience do you have taking tolerance breaks or t-breaks from cannabis, if any?” if participants endorsed experience with or awareness of t-breaks, they were asked additional follow-up questions, such as describing their knowledge about t-breaks and their personal experiences, reasons for taking a tbreak, and positive and negative consequences of t-breaks. follow-up questions varied across interviews. to encourage participants to speak openly and provide clarification on their thoughts, opinions, and experiences, reflections were used as well as probing with follow-up questions (corbin & strauss, 2008). interviews were audio recorded and transcribed by trained research staff. study 2: online survey open responses. in july 2023, 66 participants completed the follow-up survey, which included four t-break items. first, participants were rated “how familiar are you with the concept of tolerance breaks (or ‘t-breaks’) from cannabis?” from 0 = not at all to 4 = extremely scale. if participants endorsed familiarity with t-breaks, they were asked to indicate the number of times they have taken a t-break in the past year. response options were 0 = 0 times, 1 =1-3 times, 2 = 4-6 times, 3 = 7-9 times, 4 = 10-12 times, and 5 = more than 12 times. participants familiar with tbreaks were asked to write a few sentences in their own words discussing their personal definition of a tolerance break from cannabis and reasons why people might take a t-break. data analytic strategy for both studies, qualitative data were analyzed using braun and clarke’s six-step framework for thematic analysis: familiarization of data, generation of codes, combining codes into themes, reviewing themes, determining the significance of themes, and reporting of findings (braun & clarke, 2006). this approach was chosen because it is flexible, inductive, allows for iterative refinement of themes, and can be applied to the different types of qualitative data used in this study (i.e., interviews, brief open-response survey items). before reviewing the data, two primary reviewers (kwd and egd) discussed potential personal sources of bias to increase awareness and reduce the impact of personal perspectives on data analysis. identified sources of potential bias included engagement in cannabis-related research (kwd and egd) and clinical work (kwd), as well as exposure to ya cannabis behaviors such as t-breaks through peer and patient/client interactions and online articles (kwd and egd). additionally, we broadly anticipated that tolerance would be a commonly endorsed motive for taking a t-break, given that it is included in the name of the term, and tolerance was often discussed in online articles about this topic. the reviewers independently read and re-read the transcribed interviews (study 1) or openresponses (study 2) to become familiar with the data and generated the initial codes (i.e., a way to organize data into meaningful groups); given the limited empirical data on t-breaks, coding was cannabis, a publication of the research society on marijuana 154 internal data-driven rather than theory-driven. next, kwd and egd independently combined the codes into broader themes and met to review the themes, make changes as needed, and discuss theme significance. any discrepancies were resolved through majority consensus and discussion with other co-authors (cml, jab, jrk, sg, tjkf). for the quotes presented below, minor changes were made to improve readability (e.g., removed filler words such as “um”) without changing the content. we followed standard recommendations for reporting qualitative research (tong et al., 2007); see supplementary table 1 for the consolidated criteria for reporting qualitative research (coreq) checklist. . results study 1: individual interviews qualitative analyses revealed five broader themes; each theme is detailed below. theme 1: the time frame for t-breaks varied but was typically unplanned, brief, and temporary. participants described varying time frames for abstinence breaks from cannabis (i.e., a few hours to multiple weeks). shorter breaks that lasted for a few days were most common, and participants endorsed taking multiple t-breaks. for instance, one participant (21 years old, woman/female) described their t-break experience as variable, “i try to do at least a few days of not using it [cannabis] at all. and whenusually when i get on a roll of, like, a couple of days, it's easier to go longer without it. so, between, a couple of days, and a week or two.” another participant (25 years old, woman/female) described their t-break timeline as both variable and frequently occurring, “yeah, i do tend to take breaks. i--kind of depending on like the context, or how things have been going--switch between taking like a week to 2 weeks break every 6 weeks, or taking like 2 to 3 days off every 2 or 3 weeks…in the past year i have probably taken...jeez, probably 10 to 15 breaks, i would say.” a few participants reported no personal experience with t-breaks but had familiarity with the concept. the length of a t-break was determined by different situational factors (e.g., upcoming social plans, tests/exams) and was typically unplanned and flexible based on the circumstances. participants indicated intentions to return to using cannabis after the break, which differentiates t-breaks from quit attempts and other attempts to otherwise reduce their use. one participant (26 years old, man/male) explained, “i don't think i ever am like, ‘i'm done with the tbreak.’ …now, it's like, i'll choose not to smoke for a couple of weeks and try to be productive, and then one night i'll be like, ‘eh, f*** it,’ and then the next 3-4 days, i'll be smoking anyway, because why not?” theme 2: reducing tolerance was a common motivation for taking t-breaks. yas who engaged in heavy and frequent cannabis use reported wanting to take a t-break to reduce tolerance. many yas took t-breaks because they believed that temporarily abstaining would reduce tolerance so they could consume less post-break – “certainly tolerance [is a motivator to take a t-break], i noticed that when i do not take breaks it takes more cannabis to achieve the same result” (25 years old, woman/female) – and/or achieve “a better high” after the break – “honestly, something that motivates me for a tolerance break, is the day i smoke again, because then it's gonna hit stronger” (19 years old, woman/female). one participant who did not have personal experience with t-breaks described how friends take t-breaks to get a more intense high (19 years old, non-binary), “a lot of my friends will take t-breaks if they're waiting for a special event and then they're gonna get really high.” theme 3: yas also reported other concurrent motives for t-breaks, which varied widely. extrinsic motivators. in addition to reducing tolerance, participants described taking t-breaks for various extrinsic reasons. common extrinsic motivators included: 1. saving money. for instance, one participant (27 years old, male/man) explained taking a tbreak due to concerns that cannabis was interfering with their ability to pay for basic tolerance breaks 155 internal needs. “i feel like a lot of times when i take tolerance breaks, it wasn't necessarily because my tolerance had gotten so high but because i noticed i've been spending far too much money… i'm like, ‘okay, okay, i gotta chill, i’m cutting into how much money i have for rent now.’ i have to make sure i pay the bills. i can't be going that hard in it.” 2. physical health concerns (e.g., being sick, lung health). as an example, one participant (19 years old, non-binary) had no personal experience with t-breaks, but described that one motivation for a t-break would be to reduce concerns about negative physical impacts of smoking: “i know that there are negative health effects to inhaling smoke, and i'm doing that. but i guess more physical harm [would be a motivation for taking a tbreak]. physical health, i am really overly aware of.” 3. mental health concerns. for example, one participant (19 years old, man/male) was motivated to due to concerns about anxiety, “[i took a t-break] because i was feeling more anxious with smoking. so, i wanted to, you know, not smoke for a bit, and see if it helped.” 4. school or work responsibilities. several participants described stopping cannabis to help achieve practical goals, like passing a class before finals. one participant (26 years old, man/male) stated trying t-breaks around times of the school year of high importance, “i mean, definitely in the past, i've done that, like a very purposeful, zen t-break: ‘i'm gonna go work until this class is over, get my final done.’…[i took t-breaks] in school, just anytime i was taking an important class, or before finals.” 5. accessibility issues (e.g., being in a state or country where cannabis is illegal). numerous participants described taking circumstantial t-breaks based on physical location and accessibility (e.g., 19 years old, woman/female: “i actually am going to go on a tolerance break soon. i will be studying abroad...and weed is not allowed in japan. so, i will be on a break.”). another participant (26 years old, woman/female) described taking a break circumstantially based on location and who they are with, “[i take t-breaks] circumstantially. if i'm going to a work conference for multiple days, in different locations. it's more situational, or location based...i’ve taken pauses for weekends or a couple of days here and there, one: because mostly i just don’t think about it. or two: really circumstantially of what i have to do, and where i'm at, or i'm staying with my grandma for a week. i'm not gonna be taking a bong rip in the bathroom.” intrinsic motivators. participants also reported being intrinsically motivated to take tbreaks. participants reported wanting to be in control of their cannabis use, indicating that intrinsic motivation is an important factor in deciding to take t-breaks. a few participants used t-breaks as a time to reevaluate their “relationship with cannabis” and themselves. for instance, one participant (20 years old, trans man), described using a break to reconsider how their current cannabis use is impacting their life: “i think, with a break, especially from where i'm coming from right now from smoking every day, i think that it's a time to get information to assess yourself, and consider how you're using cannabis, and what that does. [one motivation for taking a t-break is] being more in touch with who i am without the effects of marijuana. and, i think, it's good to have control over it.” yas also indicated that they are motivated to modify or pause their cannabis use to “test” whether they are dependent on cannabis and viewed one’s ability to take a t-break as reassurance that they were not addicted. one person (25 years old, woman/female) stated concerns with addiction due to family history and took t-breaks in part to mitigate these concerns, “[i take t-breaks] because i have a genetic history of addiction in my family—that is something that i try to be cognizant of, my ability to stop using.” later in the interview, they explained that the ability to take breaks is an important personal indicator of a positive relationship with cannabis, “i do just value knowing that my relationship with it [cannabis] is such that i can sort of take those breaks and just assess where i'm at with it.” similarly, after describing a period of time when they were “severely abusing cannabis” and would take risks to use cannabis (e.g., transporting cannabis into non-legal states) another participant (26 years old, woman/female) stated cannabis, a publication of the research society on marijuana 156 internal that their “relationship with cannabis has changed as i’ve have gotten older and kind of mellowed out a little bit in other ways,” as indicated by their perceived ability to take tbreaks. theme 4: withdrawal symptoms were barriers to maintaining a break while positive consequences of t-breaks typically appeared later on. participant responses indicate that t-breaks are highly individualized experiences. various negative consequences were described, typically occurring during the beginning of a break. similar to other participants, one individual (26 years old, man/male) indicated craving, sleep, and physical issues can be challenges when starting a break, “i mean, everybody gets a craving every now and then, i don't think it's nearly as bad for me, as some of my friends, but it can still be hard…especially if you've been smoking for a while, starting a t-break can get a little wonky all sorts of stuff, sleep and acne, and who knows what else.” another (25 year old, woman/female) reported that t-breaks “made my nightmares a lot worse, and so i would have to take extra precautions before sleeping, like really trying to calm down my nervous system before falling asleep.” interestingly, despite participants often describing withdrawal symptoms, no participants ever used the term “withdrawal.” some participants saw the impact of mental health as a considerable barrier to initiating or maintaining a t-break, with many participants voicing concerns that temporarily abstaining could harm their mental health. one participant (26 years old, woman/female) described feeling like their mental health will never be as good when not using cannabis, “[during a t-break] i didn't ever really feel a sense of peace really, which is kind of sad. like accepting that i will never be as relaxed as when i'm able to use cannabis, just because my anxiety is so bad.” another (19 years old, woman/female) highlighted both irritability and anxiety as barriers, “so that can be frustrating, too, feeling like, ‘oh, if i don't smoke, i might be irritable today.’ so it can be hard relying on it every single day…because i know that if i don't smoke, i'm probably gonna be anxious or really irritable.” similarly, participants chose not to attempt or continue t-breaks during periods of high stress/anxiety as participants often used cannabis to cope with stress or poor mental health, and were unsure of other effective coping strategies to get through a difficult time, “if i go through a really bad moment, i might feel the need to use weed again, as a way to help me get through it, like get through things. i'd have to find something else that i can use as a crutch. it's definitely not healthy to make one thing a crutch for your emotions, i think. but, with weed, since it's just kind of there, and it works, it's just really easy to self-medicate with it. so, not being able to selfmedicate would be kind of like, ‘what do i do then?’” (19 years old, woman/female). after the initial discomfort of the t-break, participants described numerous perceived health benefits, including feeling more clear-headed, improved mood, improved ease with exercising, and overall physical health – e.g., “well once you get past all those things [participant mentioned perceived negative effects from a t-break, specifically increased anxiety, decreased motivation, low appetite] then probably you’d be back to being a normal, functioning human. and, probably betterunless i was taking edibles, if i was just smoking-probably better lung health, physical benefits like being able to breathe or just being able to do cardio better, more like physical stuff, i'd say, is a benefit. maybe saving money, since you're not buying weed. maybe, once you pass the negatives, the improvements in mood and maybe you get your motivation back, i'm not sure. mostly the mental stuff, i feel like, is negative when you go on a t-break, until you get past it. but physically, it improves. and it does the opposite when you smoke a lot” (18 years old, trans man). similarly, another participant (22 years old, woman/female) noticed longer breaks optimized benefits, “the longest break i’ve had was a couple of weeks and i kind of noticed that i was able to think better and feel more sure about how i was feeling. it didn't just feel muddled. in the shorter breaks, i don't think i notice that, but that long one that i tookor the longest one i tookfor sure, i could notice that.” although one individual (19 years old, woman/female) initially voiced concerns about negative impacts on mental health, they recognized that it would likely be temporary and tolerance breaks 157 internal improve, “i think at first, i would be a lot more irritable, a lot more anxious, but i think over time, i would actually have a lot less anxiety, just because i wouldn't have to kind of always have the anxiety of keeping up on my smoking habits to not have the anxiety, which helps a lot, so, i think i'd be a lot less anxious.” other participants, however, did not notice any improvements or benefits during their tbreaks. a particpant (26 years old, woman/female) voiced challenges to continuing a t-break, due to difficulty continuing the break when experiencing withdrawal, “even after those 11 days [of a tbreak], it was still pretty bad honestly. even with drinking water and exercising and doing all the other things to make myself feel better, i wasn’t craving it like, ‘i need it.’ but like man, this would be really good right about now.” theme 5: the main reasons for not taking a tbreak were believing t-breaks were unnecessary or unachievable several participants reported being unconcerned by their current cannabis use, and therefore viewed t-breaks as unnecessary. participants used several factors to gauge whether a t-break might be beneficial, including frequency of use, perceived personal relationship with cannabis, and whether cannabis use felt like a “choice” (i.e., indicative of having a positive relationship with cannabis) or a “need” (i.e., indicative of dependence/addiction). one participant (19 years old, man/male) expanded upon why t-breaks are unnecessary for him: “weed’s never been that much of an ‘i need to do it’ type of thing. i enjoy it, that's why i do it so often. but it is one thing that i feel pretty confident that i could just give up, if i wanted to. i couldn't say the same for nicotine, or probably even alcohol, but weed’s the one thing where i feel like i have a good relationship with it, at least for the past long while, you know. it's not the best relationship but…[participant trailed off].” another (26 years old, woman/female) echoed the sentiment of enjoying cannabis as part of their routine and confidence in her ability to take a break as reasons she thought a t-break was unnecessary, “but, for me, it’s [using cannabis] kind of became a part of my routine, and i really like it. i know that i could [take a break], if i didn’t want to continue using anymore, but, for me it’s just not a priority.” some participants indicated no current desire to change their current use patterns as their reason for not taking a break, “i’m just not trying to change or think about it [my use]. that’s just my personal current mindset” (19 years old, non-binary). certain psychosocial and contextual factors made t-breaks seem unachievable, such as having difficulty pausing cannabis use when their friends and partners are also using frequently, financial limitations to pursue other activities, because it is easily available, and perceived ability to take a break. one individual (19 years old, woman/female) captured many of the reasons yas did not want to take a t-break, despite desiring to do so – “i definitely have wanted to [take a tbreak], but it’s hard for me because all of my friends smoke, too, so it’s like, anytime i’m really hanging out with anyone, and there’s definitely the social aspect, too. i feel like any time i’m hanging out with people, we’re all smoking. so, it’s hard to kind of get out of that. especially where we live, too. there’s just kind of really easy access to weed here in washington, obviously, we just have a lot of it here. so, it can be hard because, even though i’ve wanted to take breaks, i don’t think i’ve ever really felt like i’ve been fully capable of taking a break…” this participant went on to describe the importance of cannabis in their current routine, and lack of other options due to financial limitations, “i know it's one thing that i know isn't going to change [using cannabis], and is one thing that's kind of always going to be there in my routineand i think of replacing that with something else is nice, because i need something that's gonna have the same normalcy, and give me the same expected relief from everything, where i know that i'm just gonna have it. like, something like a class, or some kind of extracurricular thing would do, but it's just really hard, feeling like i don't have the money.” study 2: online survey responses t-break familiarity and experience nearly all participants (93.9%; n = 62) reported familiarity with t-breaks (42.4% extremely familiar, 33.3% very, 12.1% moderately, 6.1% slightly). among those familiar cannabis, a publication of the research society on marijuana 158 internal with t-breaks (n = 62), 6.1% of participants (n = 10) reported not taking a t-break the past year, 56.5% reported taking a t-break 1-3 times, 15.1% 4-6 times, 8.1% 7-9 times, and 3.2% 10 or more times. themes based on open-text responses three major themes were identified using the open-text responses asking participants to reflect on their personal definitions of a t-break and reasons people might take a t-break. theme 1: yas define t-breaks as an intentional break from cannabis use, with the most common motivation being to reduce tolerance when asked to briefly define t-breaks, participants most commonly reported that tbreaks are temporary abstinence breaks from cannabis to lower tolerance (74.2%; n = 49). participants reported a desire to reduce tolerance for several reasons, including being able to smoke/consume less cannabis, achieve the original effects they got from when they first used cannabis, save money by using less cannabis, and/or get a “better high.” similar to study 1, participants gave varied responses for the amount of time that a t-break might last, with answers ranging from 1-2 days to a few weeks or months. “giving up weed to lower/reset your tolerance so you don’t need as much weed to get high.” “stopping using cannabis for a time specifically to reduce tolerance so less cannabis is more effective. usually takes a month or so for full effect (at least for heavy users like me)” “the longer you’ve used weed on consecutive days, the higher your tolerance becomes. to keep your tolerance on the lower side (and cheaper side) you need to take days off to stay balanced.” “people that smoke habitually, such as myself, often find themselves’ ‘smoking more and feeling less;' and a t-break is a good way to refresh and let your system clear out so that you can actually receive/process the molecules associated with ‘being high.’” theme 3: intrinsic motivations for t-breaks were less commonly endorsed participants also reported various intrinsic motivations for t-breaks (i.e., inherently satisfying or personally rewarding reasons and/or re-evaluating the role of cannabis in one’s life; 24.2%; n = 16). several participants reported that they take t-breaks to prove to themselves and others that they are capable of being in control of their cannabis use. others mentioned that they might take a t-break when they realize that cannabis is playing too much of a factor in their decision-making and other areas of their lives. “feeling bogged down by weed.” “don’t want to have to factor weed into all decision making and living life.” “realizing that your cannabis consumption is impacting other areas of your life.” “to show yourself/others your self-control.” “to focus more on my life” “when you start feeling bad about how much you use cannabis” theme 4: t-breaks are motivated by multiple reasons beyond reducing tolerance alone few participants (12.1%; n = 8) listed tolerance as the sole motivation for a t-break. approximately 16.6% (n = 11) of participants did not list tolerance as motivation for taking a tbreak. most participants (71.3%; n = 47) listed that they were motivated by tolerance plus some other intrinsic or extrinsic reason. one participant captures this sentiment in their personal p of a t-break: “intentionally going some set of time without using cannabis. some people do it so that when they start using again their high is better or it takes less cannabis to get high, but i think it could be for any reason.” discussion the present study adds to the limited literature on t-breaks from cannabis and is the first known study to qualitatively investigate ttolerance breaks 159 internal breaks among yas. the overall purpose of study 1 (qualitative interviews) was to gain a general understanding of t-break experiences among yas, whereas study 2 (online open-responses) expanded upon study 1 to establish yas’ personal definition of t-breaks and identify common tbreak motives. themes from both studies were used to inform an operational definition of tbreaks. we discuss our findings in each of these areas in more detail below. t-break experiences among yas are frequent, brief, and unplanned the vast majority of yas in both of our samples were familiar with the concept of tbreaks and took t-breaks in the past year often multiple times. across both studies, typical tbreaks ranged from a few hours to several weeks or months and breaks were variable, unplanned, and often brief. these themes are in line with prior work finding that individuals who use cannabis often make short, repeated, and unsuccessful reduction or quit attempts (hughes et al., 2016). withdrawal symptoms (e.g., craving, appetite and sleep disturbance, anxiety and mood changes) or fear of withdrawal symptoms may contribute to yas taking short, repeated, and unplanned breaks. in sample 1, feared or experienced withdrawal symptoms were reported as the main barriers to initiating or maintaining t-breaks. importantly, none of the yas used the word “withdrawal” to describe these experiences, which may indicate a general lack of knowledge about withdrawal or may be due in part to low perceived risk of experiencing withdrawal from cannabis (smith-lecavalier et al., 2024). psychoeducation and learning skills to manage withdrawal symptoms may help yas extend tbreaks for longer periods and increase the likelihood of experiencing benefits. setting breaks in advance and for a particular length of time could also help yas experience more benefits from breaks. in study 1, one of the themes that emerged was that experienced benefits of t-breaks tended to appear with longer breaks. this is in line with temporary abstinence findings from the alcohol literature (“dry january”), such that people who complete a month-long abstinence challenge from alcohol report significantly more abstinence-related benefits compared to individuals who lapse before 30 days (de visser & nicholls, 2020; de visser & piper, 2020). thus, yas may benefit from setting a specific goal that is at a minimum, beyond the typical peak of withdrawal from cannabis (i.e., 57 days) and could benefit from resources/intervention to support them in taking longer breaks. further research is needed to identify the optimal, evidence-informed length of a t-break to reach beneficial outcomes, which could vary based on an individual’s unique desired outcome (e.g., a few weeks to reduce tolerance versus a few months to “reset one’s relationship” with cannabis use). a proposed definition of a t-break, guided by people who take them in both studies, the primary motivation for tbreaks was to reduce tolerance. although reducing tolerance was a common reason for taking a t-break in both studies, findings from study 2, in particular, demonstrated that participants reported various other concurrent motives for t-breaks. this suggests that yas conceptualize t-breaks to include multiple motives and more broadly than prior research, which separated tolerance reduction motives from other types of motives (ansell et al., 2023). unlike quit attempts, permanent abstinence was not the goal for t-breaks, as most yas intended to return to using cannabis post-break. further, t-breaks were often viewed as a way for individuals to evaluate their relationship with cannabis use to reform their use practices in the future. unlike reduction attempts, during which an individual aims to reduce or moderate their use, the goal of a t-break was to stop using cannabis entirely (even if temporarily or for brief periods). in line with the broader findings from this qualitative analysis, we propose that a tbreak is “an intentional and temporary period of abstinence from cannabis, regardless of motivation.” furthermore, although “tolerance breaks” may occur without a desire to reduce tolerance as demonstrated in study 2, this seems to be a commonly accepted term to capture different types of use breaks for yas who use cannabis. motives for t-breaks are multifaceted cannabis, a publication of the research society on marijuana 160 internal other non-tolerance reasons for t-breaks were mostly extrinsic (e.g., saving money, reducing use around important school or work events, reducing negative physical effects, like difficulty breathing). interestingly, some participants used t-breaks as a “test” of addiction or dependence, with the ability to take a break serving as “proof” that someone is not addicted or dependent on cannabis. intrinsic reasons for temporary abstinence (e.g., self-control, wanting to avoid cannabis negatively impacting one’s life) were less commonly endorsed among this group of yas. ways to promote or increase intrinsic motivation may be one way to increase benefits from tbreaks, as research and theory suggest that greater intrinsic motivation is associated with a greater likelihood of considering, initiating, and maintaining changes in substance use behaviors (diclemente, 1999; downey et al., 2001). while we presented tolerance and other motives as separate themes, the motive of reducing tolerance was often enmeshed and discussed along with other motives for temporary abstinence. so, although tolerance was a common motive, it typically was not a standalone motive. this point is further supported by one participant’s response from study 2: “it is a conscious break of smoking weed to lower your tolerance. often coupled with some other reason for stopping smoking.” moreover, there was noticeable heterogeneity in people’s motivation for reducing tolerance (e.g., reducing tolerance will help them use less to save money, get more high, worried about tolerance). taking a t-break to reduce tolerance specifically to get more high or intoxicated may make it more likely that yas use more cannabis or become more intoxicated postbreak, but it is in accordance with their goal. therefore, broadly, reducing tolerance may not be concerning, but rather why someone wants to reduce their tolerance. clinical implications the present study highlights clear opportunities to correct misconceptions about cannabis use and related risks, including addiction potential, cannabis withdrawal, and cud. it is noteworthy that several participants reported using t-breaks as a “test” of addiction; of course, the presence of tolerance is one of the criteria associated with a diagnosis of cud. this highlights the possible need to provide prevention or intervention content about what it means to “be addicted” to cannabis and why tolerance could be a risk factor for cud. in fact, as noted above, a barrier to stopping cannabis use, even temporarily, was fear of unwanted symptoms emerging (including depressed mood, anxiety, sleep difficulty, headaches, etc.). these are symptoms associated with cannabis withdrawal (also one of the criteria associated with cannabis use disorder), yet this was not a term used by participants. legitimizing cud and its worthiness of recovery support or treatment could even boost help-seeking by those struggling with their cannabis use. even screening for cud can could be used as an opportunity for patient or client psychoeducation. some yas mentioned family history of addiction as a reason to take a t-break. it is possible that this represents contemplation of change and, within a motivational enhancement framework, an opportunity to elicit personally relevant reasons to change (e.g., not using cannabis to the degree that cud is a risk). lee and colleagues (2010) showed promising findings of a web-based personalized feedback intervention for those with a family history of addiction, so there are opportunities to “meet individuals where they are” in terms of their concern about substance use. despite interest in taking t-breaks, many yas were concerned about negative mental health impacts and struggled to cope with withdrawal symptoms. indeed, some viewed t-breaks as an unachievable goal. in combination with prior work demonstrating escalations in use post-tbreak (ansell et al., 2023), findings from the present study suggest that easily accessible and evidence-informed t-break interventions are needed to replace advice from online forums or websites. for instance, the publicly accessible 21day t-break guide (fontana et al., 2023), which aims to support yas taking a t-break by providing daily relapse prevention skills and psychoeducation, demonstrated feasibility and initial efficacy in a small pilot study (fontana et al., 2023). two-thirds of yas (64%) used the guide during the intervention period, and those who used the guide “a lot” were significantly more tolerance breaks 161 internal likely to complete a 21-day break compared to those who used the guide “some” or “not at all” (fontana et al., 2023). as participants in our study commonly reported that taking a t-break would be difficult due to withdrawal, social influence, or routine disruption, including skills to plan for and manage these concerns could be especially useful to support and encourage behavioral change among yas attempting a tbreak. limitations and future directions there were several limitations to the present study. questions about temporary abstinence were secondary to the primary aims of the overall study; thus, other important factors were not assessed, including the types of resources yas seek to support t-breaks, or ways in which tbreaks impact motivation or self-efficacy to change. these variables may be particularly important to understand, as temporary abstinence in the tobacco/nicotine “practice quit attempt” literature appears to increase motivation and self-effiacy, particularly for those who are in pre-contemplation or who are not interested or ready for more permanent change (keizer et al., 2016, 2020). study 2 used open responses collected online and thus may be limited in depth, given the inability to probe for clarity. further research is needed to more thoroughly understand t-break motivations. additionally, we did not assess whether participants primarily used cannabis for medical or recreational reasons. as such, it is possible that yas who use cannabis for medical purposes may have different motivations for and experiences with temporary abstinence. future prospective, daily-level, and intervention studies are needed to characterize ways in which psychosocial factors, like initial motivations, influence t-break initiation, time course, and outcomes, and how they change over time and through intervention. two-thirds of sample 1 and 60% of sample 2 identified as sexual minoritized, which is consistent with higher prevalence rates of cannabis use, including daily or near daily use, among sexual minoritized individuals compared to their heterosexual peers (e.g., dyar, 2022; mauro et al., 2022) as well as the study that served as our recruitment source. although we view the diverse representation of yas as a strength of the present study, future work may want to explore possible similarities and differences between sexual minoritized and heterosexual yas’ t-break experiences and motives. conclusions despite these limitations, this study is the first to our knowledge to use qualitative methods to gain a better understanding of t-breaks from cannabis among yas who engage in frequent, heavy use. even though yas tend to have a low desire to quit cannabis entirely, the prevalence of t-breaks among our sample indicates that yas are interested in changing or moderating their use, at least temporarily. further, yas were motivated to take breaks to reduce their tolerance and for various other extrinsic and intrinsic reasons. breaks tended to be short-lived, unplanned, and were often terminated prematurely due to difficulty managing withdrawal symptoms. not all participants believed that t-breaks were necessary given their content and satisfaction with current use patterns. much more research is needed to understand how temporary abstinence impacts cannabis use outcomes among yas. references ansell, e. b., bedillion, m. f., farris, s. r., gilbert, j. m., koch, m. m., & thureen, s. e. 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(1999). factors in marijuana cessation among high-risk youth. journal of drug education, 29(4), 337–357. https://doi.org/10.2190/pn5u-n5xb-f0vbr2v1 funding and acknowledgements: data collection was supported by a grant from the university of washington’s addictions, drug & alcohol institute (adai; pi: walukevich-dienst). manuscript preparation was supported by a grant from the national institute on alcohol abuse and alcoholism (k23aa031034; pi: walukevich-dienst). the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors would like to thank anne fairlie for assisting with recruitment (r21da050131; pi: fairlie). the authors declare no conflicts of interest. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: walukevich-dienst, k., devries, e. g., fontana, t. j. k., blayney, j. a., kilmer, j. r., graupensperger, s., & lee, c. m. (2025). what are tolerance breaks and why do young adults take them? a qualitative investigation of temporary abstinence breaks from cannabis. cannabis, 8(1), 150-164. https://doi.org/10.26828/cannabis/2025/000289 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 49 ved abstract college student cannabis use is at an all-time high. although frequent heavy cannabis use is related to cannabis problems, perceived risk of cannabis use is rapidly decreasing. yet, it is unknown whether specific domains of risk perceptions (general and domain-specific risk, risk to others and personal risk) are related to more cannabis use or related problems. thus, among 130 undergraduates who reported past-month cannabis use, the present study conducted secondary analyses to test whether, for both perceived risk to others and perceived personal risk: (1) general perceived risk was associated with cannabis-related outcomes (i.e., use, negative consequences, cannabis use disorder (cud) symptoms, motivation to change), (2) seven specific domains of perceived risk were related to cannabis outcomes, and (3) domain-specific perceived risk was related to cannabis use frequency. general perceived risk to others was negatively associated with cannabis use frequency whereas general perceived personal risk was positively associated with cannabis-related negative consequences, cud symptoms, and importance and readiness to change. greater legal and withdrawal/dependence risks were uniquely related to several outcomes (e.g., cud symptoms). participants who used cannabis frequently perceived more personal risk in most risk domains and less general risk to others than those who used infrequently. findings suggest personal risk is an important component to consider when assessing perceived risk of cannabis use and focusing on both general and domain-specific risks may provide valuable insight for future prevention and intervention efforts. key words: = perceived risk; undergraduates; cannabis; motivation to change; college students cannabis use among us undergraduate students is reaching some of the highest levels ever recorded. in 2021, 40.3% of undergraduates reported past-year and 24.2% past-month cannabis use (patrick et al., 2019). daily or near daily cannabis use rates also remain high (patrick et al., 2019), which is concerning given heavier use is associated with increased likelihood and severity of unwanted physical and psychosocial outcomes, including cannabis use disorder (cud; kirstyn n. smith-lecavalier1, paige m. morris2, mary e. larimer3, julia d. buckner2, katherine walukevich-dienst3 1university of washington, department of psychology 2louisiana state university, department of psychology 3university of washington, department of psychiatry and behavioral sciences cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000194 general and domain-specific perceived risk demonstrate unique associations with cannabis use, negative outcomes, and motivation to change among undergraduate students corresponding author: kirstyn n. smith-lecavalier, university of washington, department of psychology, 119a guthrie hall, box 351525, seattle, wa 98195, usa. email: kirstynl@uw.edu. cannabis, a publication of the research society on marijuana 50 caldeira et al., 2008; gunn et al., 2020), poorer mental health (keith et al., 2015), and worse academic outcomes (suerken et al., 2016). despite known risks of cannabis, perceived risk of regular use (i.e., one’s perceptions of the negative effects of using substances; danseco et al., 1999) has rapidly decreased over the past 20 years and is at some of the lowest levels ever recorded among undergraduates (lipari & jeanfrancois, 2016). this is particularly notable compared to trends in alcohol and tobacco risk perceptions, which remain relatively stable (waddell, 2022; lipari & jean-francois, 2016). rapid decrease in perceived risk of cannabis use is especially troubling, as perceived risk is a critical determinant of health-related behavior (janz & becker, 1984; kasten et al., 2019), contributes to motivation to change risky behaviors (kasten et al., 2019), and prospectively predicts changes in cannabis use (azofeifa et al., 2016; bachman et al., 1998; bachman et al., 1988; compton et al., 2016). among undergraduates, perceived risk may protect against initiating cannabis use (d’silva et al., 2020; hanauer et al., 2021). however, few undergraduates report believing regular cannabis use confers “great risk” of harm (lipari & jeanfrancois, 2016), and some evidence suggests more frequent cannabis use is associated with decreases in risk perception over time (grevenstein et al., 2015). students who experience negative consequences due to their cannabis use still report low perceived risk, with no difference in risk perception between those who had and had not experienced certain cannabisrelated negative consequences (kilmer et al., 2007). as such, a more detailed understanding of how undergraduates conceptualize risk of cannabis is needed, particularly among those using frequently. existing research has examined perceived risk to others (i.e., how much others risk harming themselves from using cannabis) and perceived personal risk (i.e., how much an individual risks harming themselves at their current rate of cannabis use). most population-based studies assess perceived risk to others (azofeifa et al., 2016; bachman et al., 1998; bachman et al., 1988; compton et al., 2016; grevenstein et al., 2015; lipari & jean-francois, 2016) whereas research on perceived personal risk is limited. some studies found perceived personal risk is higher among undergraduates who use more frequently compared to those who use less frequently (o'callaghan et al., 2006) and is cross-sectionally associated with cannabis-related negative consequences among adults who use cannabis (magnan & ladd, 2019). however, other studies did not find associations between perceived personal risk and use frequency (kilmer et al., 2007; magnan & ladd, 2019) or the experience of negative consequences (kilmer et al., 2007). given these inconsistencies, additional research is needed to better understand and explain discrepancies. this is particularly important when considering how perceived risk may be useful to inform cannabis prevention and intervention programs, and how perceived risk to others versus personal risk may maintain varying salience for individuals. there is also considerable variability in perceived risk across different domains of risk (e.g., physical harm, dependence, legal risks; o'callaghan et al., 2006). although only 30.4% of undergraduates reported believing regular cannabis use puts the user at great risk for harm generally, over 50% reported regular use puts the user at great risk for physical dependence, finding it hard to stop using, and performing worse at school/work. thus, undergraduates may perceive specific aspects of cannabis use as risky, which may obfuscate effects on use patterns when only examining general risk. the current study the current study sought to expand prior work (kilmer et al., 2007; magnan & ladd, 2019; o'callaghan et al., 2006) on general vs domainspecific perceived risk to self and others. first, we examined associations between general perceived risk to others and general perceived personal risk with cannabis outcomes (i.e., past 3-month cannabis use frequency, cannabis-related negative consequences, cud symptoms, motivation to change). we hypothesized general perceived risk to others would be negatively associated with cannabis use, negative consequences, and cud symptoms, general perceived personal risk would be positively associated with these outcomes, and both variables would be positively associated with motivation to change. second, we tested whether seven domains of perceived risk (i.e., productivity, perceived risk, cannabis use, and outcomes 51 lower energy, memory loss or cognitive impairment, problems at school/work, physical health problems, legal problems, dependence/withdrawal) to others and self were cross-sectionally associated with general perceived risk and outcomes. consistent with prior work (o'callaghan et al., 2006), we hypothesized dependence/withdrawal and problems at school/work would emerge as significant predictors of cannabis outcomes. third, as some prior work found differences in perceived risk by use frequency (e.g., okaneku et al., 2015), we tested whether domains of risk differed by use frequency. compared to students who use less than weekly, undergraduates who use cannabis weekly or more experience more negative consequences and cud symptoms (buckner et al., 2008; burdzovic andreas et al., 2021) and are more likely to meet criteria for cud (burdzovic andreas et al., 2021). thus, we hypothesized participants who engaged in cannabis use weekly or more (compared to less frequently) would rate perceived personal risk domains as higher, but risk to others as lower. the present aims were tested through secondary data analyses from a study that developed and tested problem-focused personalized feedback (pfi) against brief personalized normative feedback (pnf; morris & buckner, 2023; walukevich-dienst et al., 2021; walukevich-dienst et al., 2019). neither domains of risk nor baseline associations between risk domains and outcomes were examined as part of the parent study primary aims. participants who received an extended problem-focused intervention were asked to reflect on and rate their perceived risk of cannabis as part of the intervention.1 methods participants participants were from a sample of 268 undergraduates recruited for the parent intervention trial (morris & buckner, 2023; walukevich-dienst et al., 2021; walukevichdienst et al., 2019). for the parent study, eligible participants were current undergraduate students at louisiana state university who reported past-month cannabis use and at least one cannabis-related problem in the past three months. the current study utilized baseline data from 130 undergraduates (47.8% of total sample, 76.2% female, mage=19.8 years, sd=1.3) who completed questions about domains of perceived risk as part of their intervention and passed attention check questions (described in procedures below). of participants, 73.1% identified as non-hispanic/latin white, 14.6% black, 2.3% asian, and 3.1% multiracial; 6.9% hispanic/latin. procedures participants were recruited through the psychology department’s online research pool or on-campus flyers. the parent study was advertised as a two-part study on cannabis use rather than an intervention study to recruit participants with a range of motivation to change. interested participants first completed an online screening survey to determine eligibility. eligible participants were immediately directed to the online baseline survey and randomized to the online pfi condition or pnf-only condition. the analytic sample for the current study includes participants randomized to the pfi condition, as only pfi participants answered questions about domain-specific perceived risks. the pfi condition included pnf on cannabis use and related problems and brief psychoeducation modules on seven empirically informed domains of risk (see measures). upon starting each module, participants were asked to rate domainspecific perceived risk (see measures). participants also indicated which of 10 dsm-5 symptoms of cud they experienced in the past year during the dependence/withdrawal module.2 participants received personalized feedback on cud based on number of endorsed cud symptoms. intervention modules were presented in a randomized order to control for order presentation effects. more information about the intervention and procedures can be found in walukevich-dienst et al. (2019) and walukevichdienst et al. (2021). 1intervention findings indicated no main effect of condition on cannabis use frequency, consequences, or ratings of general perceived risk (walukevich-dienst, 2019). further information can be found in morris & buckner, 2023, walukevich-dienst et al., 2021, and walukevich-dienst et al., 2019. 2 continued use despite having persistent or recurrent social and interpersonal problems was not included due to a programming error. cannabis, a publication of the research society on marijuana 52 psychology pool participants received research credits and non-psychology pool participants were compensated $10 for baseline and $20 for follow-up. the study was approved by the university's institutional review board and we obtained a certificate of confidentiality from the national institute of mental health. informed consent was obtained prior to data collection and all procedures maintained adherence to apa ethical guidelines for research with human subjects (sales & folkman, 2000). measures marijuana use the marijuana use form (muf; buckner et al., 2007) is an 11-item measure used to assess past 3-month cannabis use frequency (0=none or less, 6=3 or 4 times a week, 10=21 times per week or more). in addition to the categorical muf outcome score, a categorical measure of use frequency was created to test whether perceived risk differed between participants who used frequently (i.e., once a week or more) or infrequently (i.e., less than once a week). marijuana problems the modified 30-item marijuana problems scale (stephens et al., 2000; walukevich-dienst et al., 2019) assessed past 3-month cannabisrelated problems. participants rated each problem from 0 (no problem) to 2 (serious problem) and items were converted to a count score of cannabis-related problems. the 30-item modified version demonstrated excellent internal consistency (α=0.96). perceived risk of cannabis use general perceived risk was measured using the perceived risk item from the monitoring the future project (schulenberg et al., 2021) which was modified to specify using “regularly” as using cannabis once a week or more per prior work (o'callaghan et al., 2006). participants were asked to rate general perceived risk to others (i.e., “how much do you think people risk harming themselves physically or in other ways if they use marijuana regularly [once a week or more]?”) and general perceived personal risk (i.e., “how much do you think you risk harming yourself physically or in other ways if you use marijuana at your current rate of use?”) from 1 (no risk) to 4 (great risk). additionally, using the same scale, participants rated domain-specific perceived risk to others (e.g., “how much do you think people risk having lower energy if they use marijuana regularly?”) and domain-specific perceived personal risk (e.g., how much do you think you risk having lower energy if you use marijuana at your current rate of use?”) for all seven domains (i.e., productivity, lower energy, cognitive impairment, problems at school/work, physical health problems, legal problems, dependence and withdrawal). domains were empirically informed through prior work identifying areas of low perceived risk (o'callaghan et al., 2006) and frequent cannabis-related problems among undergraduates (buckner et al., 2010). cannabis use disorder (cud) symptoms cud symptoms were measured by asking participants whether they had experienced (0=no, 1=yes) 10 different symptoms of cud in the past year.2 responses were converted to a count score of the ten items (α=0.77). symptoms were derived from dsm-5 criteria of cud (e.g., “in the past year, have you used marijuana in larger amounts or for longer periods of time than you meant to?”). number of cud symptoms was significantly, positively associated with past 3-month cannabis use frequency (r=.44, p<.001) and negative consequences (r=.52, p<.001). motivation to change cannabis use motivation to change rulers (buckner et al., 2016) were used to assess readiness (0=not ready to change to 10=trying to change), importance (0=not important to 10=very important), and confidence (0=not at all confident to 10=most confident) to change. rulers were based on work by miller and rollnick (2013) and shown to be associated with changes in cannabis use in prior work (gates et al., 2012; walukevich-dienst et al., 2021). to detect careless responding, three attention check questions were included in both perceived risk, cannabis use, and outcomes 53 baseline and follow-up surveys (e.g., “please select ‘strongly agree’ as your answer to this question”). participants (n=2) were excluded from data analysis if they failed attention check by answering two or more attention check questions incorrectly (meade & craig, 2012). data analyses analyses were conducted using spss version 29. first, we examined descriptive statistics and bivariate correlations among measures. second, we conducted 14 two-step hierarchical multiple regression analyses for each independent variable (iv): (1) perceived risk to others domains and (2) perceived personal risk domains on the following dependent variables (dv): general perceived risk to others, general perceived personal risk, cannabis use frequency, cannabis-related negative consequences, cud symptoms, and readiness, importance, and confidence to change. notably, both independent variables were only examined as predictors of their respective general perceived risk dvs. in step one, sex assigned at birth and age were entered as covariates. use frequency was also entered as a covariate in step one for all models except the use frequency model. in step two, the seven risk domains were entered simultaneously as ivs. we conducted separate models for each dv and computed squared semi-partial correlations (sr2) as effect size indices. third, we used a oneway analysis of covariance (ancova) model to test differences in perceived risk by use frequency, controlling for age and sex assigned at birth, using a bonferoni-corrected p-value (<.003) to correct for multiple comparisons. results descriptive statistics and bivariate correlations on average, participants used cannabis approximately twice per week and experienced 8.00 negative consequences (sd=5.08) in the past 3-months. average use was comparable to the defined “regular use” frequency (i.e., once or more a week) specified for perceived risk to others. importance (m=4.6, sd=3.03) and readiness (m=3.25, sd=3.12) to change were low, whereas confidence to change was high (m=8.18, ds=2.42). nearly 85% of participants reported no-to-slight perceived risk of regular use to others, whereas nearly 94% reported noto-slight perceived personal risk. risk to others and self was highest for legal problems and lowest for physical health problems. on average, participants rated risk to others as having slight-to-moderate risk across domains, whereas personal risk was rated as no-to-slight risk across domains. descriptive statistics are provided in table 1. correlations between use frequency, negative consequences, cud symptoms, and general and domain-specific perceived risk are displayed in table 2. both general perceived personal risk and the majority of perceived personal risk domains were significantly, positively associated with use frequency, negative consequences, and cud symptoms. perceived personal risk variables were not associated with most risk to others variables, with a few exceptions. only a few perceived risk to others variables were associated with use frequency, consequences, and cud symptoms. for example, use frequency was significantly, negatively associated with legal and dependence/withdrawal risk to others domains. for motivation to change variables, general perceived personal risk was significantly, positively associated with readiness (r=.23, p=.007) and importance (r=.24, p=.005) to change. cognitive risk to others was significantly, positively associated with readiness (r=.22, p=.013) and importance (r=.23, p=.008) to change. personal risk of lower productivity was positively related to importance (r=.23, p=.030), whereas confidence to change was negatively associated with five risk domains for both personal risk and risk to others (i.e., low energy, cognitive, school/work problems, physical health, dependence/withdrawal; rs= -.17 to -.28, ps<.05). cannabis, a publication of the research society on marijuana 54 table 1. means, standard deviations, and frequencies of general perceived risk and risk domains item mean sd no risk (%) slight risk (%) moderate risk (%) great risk (%) perceived risk to others general perceived risk 1.73 0.81 46.2 38.5 11.5 3.8 less productive 2.52 0.78 9.4 37.5 44.5 8.6 lower energy 2.44 0.80 11.7 40.6 39.8 7.8 cognitive impairment 2.25 0.78 15.6 49.2 29.7 5.5 problems at school or work 2.35 0.84 17.1 37.2 39.5 6.2 physical health problems 2.05 0.91 33.3 34.1 27.1 5.4 legal problems 2.64 0.92 13.2 27.1 42.6 17.1 dependence and withdrawal 2.30 0.9 21.3 36.2 33.9 8.7 perceived personal risk general perceived risk 1.37 0.65 70.8 23.1 4.6 1.5 less productive 1.84 0.85 38.8 44.2 10.9 6.2 lower energy 1.77 0.83 43.4 41.9 9.3 5.4 cognitive impairment 1.71 0.75 45.7 39.5 13.2 1.6 problems at school or work 1.60 0.75 55.0 30.2 14.0 0.8 physical health problems 1.54 0.71 56.6 34.1 7.8 1.6 legal problems 1.82 0.92 45.0 35.7 11.6 7.8 dependence and withdrawal 1.59 0.78 55.8 32.6 8.5 3.1 table 2. correlations between use frequency, negative consequences, cud symptoms, and general and domain-specific perceived risk 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1. use frequency 1 2. consequences -.01 1 3. cud symptoms .44** .52** 1 4. general riskp .11 .31** .27* 1 5. general risko -.28* .18 .01 .50** 1 6. productivityp .33** .24* .42** .26* -.001 1 7. low energyp .42** .21 .40** .27* -.04 .78** 1 8. cognitivep .51** 0.2 .45** .30** -.01 .59** .67** 1 9. school/workp .31** .22 .39** .23* .05 .68** .73** .60** 1 10. physical healthp .27* .24* .31** .38** .18 .64** .63** .62** .65** 1 11. legalp .32** -.01 .19 .13 -.13 .59** .55** .50** .47** .46** 1 12. dependencep .39** .29** .42** .30** .02 .61** .58** .67** .59** .66** .58** 1 13. productivityo .01 .17 .11 .15 .15 .26* .21 .22 .12 .18 .09 .19 1 14. low energyo -.17 .16 -.04 .17 .26* .11 .20 .07 .04 .15 -.10 .04 .61** 1 15. cognitiveo -.09 .28* .06 .22 .32** .14 .20 .28* .17 .28* .03 .20 .54** .45** 1 16. school/worko -.21* .28* .04 .17 .26* -.01 .11 .09 .19 .12 -.16 .08 .42** .50** .54** 1 17. physical healtho -.18 .20 .04 .25* .43** .08 .14 .11 .20 .40** .01 .21 .31** .41** .55** .50** 1 18. legalo -.10 -.08 -.18 .12 .13 .11 .09 .08 .04 .05 .44** .16 .30** .27 .33** .21 .27* 1 19. dependenceo -.29** .16 -.13 .19 .30** -.03 .00 .01 .01 .10 -.12 .06 .34** .39** .38** .56** .48** .33** 1 note. bolded p<.05, * p<.01, ** p<.001, o risk to others, p personal risk, cud = cannabis use disorder perceived risk, cannabis use, and outcomes 55 regression results predictors of general perceived risk (table 3) model 1. risk to others domains predicting general perceived risk to others. the general perceived risk to others model examined which domains of perceived risk to others predicted general perceived risk to others. step one of the model accounted for significant variance in general perceived risk, f(3,122)=5.75, p <.001, r2=0.12. in step two, the model remained significant, f(10,115)=4.48, p <.001, r2=0.28, and accounted for a significant increase in r2 , δf(7,115)=3.58, p=.002, δr2=0.16. perceived risk of physical health problems was significantly, positively associated with general perceived risk (sr2=0.065), whereas past 3-month use frequency was significantly, negatively associated with general perceived risk (sr2=0.063). model 2. personal risk domains predicting general perceived personal risk. the perceived personal risk model examined which domains of perceived personal risk predicted general perceived personal risk. step one did not account for significant variance in general perceived personal risk, f(3,125)=1.00, p =.406, r2=0.02. at step two, the model was significant, f(10, 118) )=2.44, p =.011, r2=0.17, and accounted for a significant increase in r2 , δf(7,118)=3.02, p=.006, δr2=0.15. perceived risk of physical problems was significantly, positively associated with general perceived risk (sr2=0.041). table 3. hierarchical regression results: general perceived risk effect estimate se 95% ci p ll ul model 1: general perceived risk to others step 1 sex assigned at birth -0.05 0.16 -0.38 0.27 .751 age 0.03 0.05 -0.08 0.13 .58 past 3-month use frequency -0.11 0.03 -0.16 -0.06 <.001 step 2 sex assigned at birth -0.09 0.16 -0.40 0.22 .572 age 0.03 0.05 -0.07 0.13 .527 past 3-month use frequency -0.08 0.03 -0.13 -0.03 .002 less productive 0.01 0.12 -0.22 0.24 .951 lower energy 0.02 0.11 -0.21 0.25 .869 cognitive impairment 0.11 0.12 -0.12 0.34 .353 problems at school or work -0.08 0.11 -0.29 0.13 .455 physical health problems 0.30 0.09 0.11 0.48 .002 legal problems -0.02 0.08 -0.17 0.14 .828 dependence/withdrawal 0.07 0.10 -0.12 0.25 .481 model 2: general perceived personal risk step 1 sex assigned at birth -0.10 0.14 -0.37 0.18 .485 age -0.03 0.04 -0.12 0.06 .498 past 3-month use frequency 0.03 0.02 -0.01 0.07 .188 step 2 sex assigned at birth -0.06 0.13 -0.33 0.20 .644 age -0.07 0.04 -0.15 0.02 .131 past 3-month use frequency -0.01 0.02 -0.06 0.04 .708 less productive 0.04 0.12 -0.19 0.27 .709 lower energy 0.09 0.13 -0.16 0.34 .476 cognitive impairment 0.14 0.12 -0.09 0.38 .227 problems at school or work -0.13 0.12 -0.37 0.11 .273 physical health problems 0.29 0.12 0.05 0.53 .017 legal problems -0.06 0.08 -0.22 0.10 .427 dependence/withdrawal -0.01 0.12 -0.24 0.22 .95 note. ci = confidence interval; ll = lower limit; ul = upper limit, cud = cannabis use disorder, p <.05 bolded in significant models. cannabis, a publication of the research society on marijuana 56 perceived risk to others of regular cannabis use (table 4) model 3. risk to others domains predicting use frequency. step one including covariates only did not account for significant variance in past 3-month use frequency, f(2,123)=0.97, p=.381, r2=0.02. in step two including perceived risk domains, the model was significant, f(9, 116)=2.22, p=.026, r2=0.15, and accounted for significant change in r2 , δf(7,116)=2.55, p=.026, δr2=0.13. perceived risk of dependence/withdrawal was significantly, negatively associated with use frequency (sr2=0.034). model 4. risk to others domains predicting negative consequences. step one did not account for significant variance in past 3-month negative consequences, f(3,122)=1.97, p=.122, r2=0.05. in step two, the model was significant, f(10,115)=2.48, p .010, r2=0.18, and accounted for significant change in r2 , δf(7,115)=2.66, p=.015, δr2=0.13. perceived risk of legal problems was significantly, negatively associated with negative consequences (sr2=0.031). model 5. risk to others domains predicting cud symptoms. step one accounted for significant variance in cud symptoms, f(3,122)=13.26, p <.001, r2=0.50. in step 2, the model remained significant, f(10,115)=5.39, p <.001, r2=0.57, although the change in the model was not, δf(7,118)=1.77, p=<.001, δr2=0.07. perceived risk of legal problems (sr2=0.031) and age (sr2=0.030) were significantly, negatively associated with cud symptoms. however, use frequency (sr2=0.159) was significantly, positively associated with cud symptoms. models 6, 7, and 8. risk to others domains predicting motivation to change. the readiness, importance, and confidence to change models were not statistically significant. table 4. hierarchical regression results: perceived risk to others domains effect estimate se 95% ci p ll ul model 3: past 3-month use step 1 sex assigned at birth -0.71 0.57 -1.84 0.42 .216 age 0.15 0.19 -0.22 0.51 .431 step 2 sex assigned at birth -0.32 0.56 -1.43 0.79 .572 age 0.05 0.18 -0.31 0.41 .793 less productive 0.78 0.41 -0.03 1.60 .060 lower energy -0.65 0.41 -1.45 0.15 .112 cognitive impairment 0.15 0.43 -0.70 0.99 .731 problems at school or work -0.26 0.39 -1.02 0.51 .506 physical health problems -0.17 0.33 -0.83 0.49 .604 legal problems -0.07 0.28 -0.62 0.48 .790 dependence/withdrawal -0.72 0.33 -1.38 -0.06 .033 model 4: past 3-month negative consequences step 1 sex assigned at birth -2.32 1.07 -4.44 -0.21 .032 age -0.27 0.35 -0.95 0.42 .442 past 3-month use frequency -0.05 0.17 -0.38 0.28 .772 step 2 sex assigned at birth -2.24 1.04 -4.31 -0.18 .033 age -0.27 0.34 -0.94 0.39 .418 past 3-month use frequency 0.05 0.17 -0.29 0.39 .767 less productive 0.73 0.78 -0.81 2.26 .352 lower energy -0.30 0.76 -1.81 1.20 .692 cognitive impairment 0.97 0.79 -0.59 2.53 .219 problems at school or work 0.77 0.71 -0.64 2.19 .282 physical health problems 0.46 0.62 -0.77 1.68 .460 legal problems -1.08 0.51 -2.10 -0.06 .038 dependence/withdrawal 0.42 0.63 -0.83 1.66 .511 perceived risk, cannabis use, and outcomes 57 effect estimate se 95% ci p ll ul model 5: past-year cud symptoms step 1 sex assigned at birth -0.69 0.46 -1.60 0.22 .133 age -0.31 0.15 -0.61 -0.02 .037 past 3-month use frequency 0.40 0.07 0.26 0.54 <.001 step 2 sex assigned at birth -0.58 0.46 -1.49 0.33 .208 age -0.33 0.15 -0.62 -0.04 .027 past 3-month use frequency 0.39 0.08 0.24 0.54 <.001 less productive 0.48 0.34 -0.20 1.16 .162 lower energy -0.30 0.33 -0.96 0.36 .374 cognitive impairment 0.10 0.35 -0.59 0.78 .780 problems at school or work 0.31 0.31 -0.32 0.93 .332 physical health problems 0.39 0.27 -0.15 0.92 .160 legal problems -0.52 0.23 -0.97 -0.07 .023 dependence/withdrawal -0.26 0.28 -0.81 0.29 .356 model 6: readiness to change step 1 sex assigned at birth -1.63 0.63 -2.87 -0.38 .011 age 0.23 0.20 -0.18 0.63 .270 past 3-month use frequency -0.21 0.10 -0.40 -0.01 .038 step 2 sex assigned at birth -1.66 0.64 -2.93 -0.38 .011 age 0.20 0.21 -0.21 0.61 .344 past 3-month use frequency -0.15 0.11 -0.36 0.06 .153 less productive -0.53 0.48 -1.47 0.42 .274 lower energy 0.28 0.47 -0.65 1.21 0.550 cognitive impairment 0.96 0.49 -0.01 1.92 .051 problems at school or work -0.21 0.44 -1.08 0.67 .639 physical health problems 0.03 0.38 -0.73 0.78 .942 legal problems -0.21 0.32 -0.83 0.42 .518 dependence/withdrawal 0.31 0.39 -0.46 1.08 .420 model 7: importance to change step 1 sex assigned at birth -0.61 0.67 -1.93 0.72 .365 age -0.09 0.22 -0.52 0.34 .681 past 3-month use frequency -0.06 0.11 -0.26 0.15 .599 step 2 sex assigned at birth -0.62 0.68 -1.96 0.72 .360 age -0.13 0.22 -0.56 0.30 .559 past 3-month use frequency -0.01 0.11 -0.23 0.21 .927 less productive -0.38 0.50 -1.38 0.62 .453 lower energy 0.50 0.49 -0.48 1.47 .316 cognitive impairment 1.17 0.51 0.16 2.18 .023 problems at school or work -0.12 0.46 -1.04 0.80 .796 physical health problems -0.24 0.40 -1.03 0.56 .556 legal problems -0.42 0.33 -1.08 0.24 .214 dependence/withdrawal 0.24 0.41 -0.57 1.05 .564 model 8: confidence to change step 1 sex assigned at birth 0.19 0.51 -0.83 1.20 .361 age 0.06 0.17 -0.27 0.38 .344 past 3-month use frequency -0.02 0.08 -0.18 0.14 .278 step 2 sex assigned at birth 0.17 0.54 -0.89 1.23 .746 age 0.06 0.17 -0.28 0.40 .734 past 3-month use frequency -0.03 0.09 -0.21 0.14 .708 less productive 0.26 0.40 -0.53 1.05 .512 lower energy -0.08 0.39 -0.85 0.69 .838 cognitive impairment -0.09 0.40 -0.89 0.72 .832 problems at school or work -0.29 0.37 -1.02 0.44 .428 physical health problems 0.04 0.32 -0.59 0.67 .899 legal problems 0.06 0.26 -0.47 0.58 .832 dependence/withdrawal 0.11 0.32 -0.53 0.75 .733 note. ci = confidence interval; ll = lower limit; ul = upper limit, cud = cannabis use disorder, p <.05 bolded in significant models cannabis, a publication of the research society on marijuana 58 perceived personal risk (table 5) model 9. personal risk domains predicting use frequency. step one including only covariates did not account for significant variance in past 3month use frequency, f(2,12)=0.73, p =.484, r2=0.01. in step two with perceived risk domains, the model was significant, f(9,119)=31.78, p <.001, r2=0.29 and accounted for a significant increase in r2 , δf(7,119)=6.70, p=<.001, δr2=0.28. perceived personal risk of cognitive impairment was significantly, positively associated with use frequency (sr2=0.067). model 10. personal risk domains predicting negative consequences. step one did not account for significant variance in past 3-month negative consequences, f(3,125)=1.94, p =.127, r2=0.04. step two was significant, f(10,118)=2.57, p =.007, r2=0.18, and accounted for a significant increase in r2 , δf(7,113)=2.76, p=.011, δr2=0.14. perceived personal risk of legal problems was significantly, negatively associated with negative consequences (sr2=0.053). model 11. personal risk domains predicting cud symptoms. step one accounted for significant variance in cud symptoms, f(3,125)=15.04, p =<.001, r2=0.26. step two also accounted for significant variance, δf(7,118)=3.82, p <.001, δr2=0.14. perceived personal risk of legal problems (sr2=0.024) and age (sr2=0.032) were significantly, negatively associated with cud symptoms. perceived personal risk to productivity (sr2=0.031) and use frequency (sr2=0.069) were significantly, positively associated with cud symptoms. models 12, 13, and 14. personal risk domains predicting motivation to change. readiness (model 12) and importance (model 13) to change models were not statistically significant at step one or two. the confidence to change model (model 14) was not significant at step one, f(3,125)=0.17, p=.916, r2=0.00 but was significant at step two, f(10,118)=2.14, p=.026, r2=0.15, and accounted for a significant increase in r2 , δf(7,118)=3.00, p <.001, δr2=0.15. perceived personal risk of dependence/withdrawal was significantly, negatively associated with confidence to change (sr2=0.045). lower energy was also negatively associated with confidence to change, although not statistically significant (p=0.50, sr2 =0.028). table 5. hierarchical regression results: perceived personal risk domains effect estimate se 95% ci p ll ul model 9: past 3-month use step 1 sex assigned at birth 0.14 0.19 -0.23 0.51 .464 age -0.61 0.58 -1.76 0.55 .299 step 2 sex assigned at birth 0.00 0.17 -0.34 0.34 .990 age -0.28 0.53 -1.32 0.76 .598 less productive -0.22 0.45 -1.12 0.68 .626 lower energy 0.83 0.49 -0.15 1.81 .094 cognitive impairment 1.48 0.45 0.60 2.37 .001 problems at school or work -0.32 0.47 -1.25 0.60 .493 physical health problems -0.56 0.47 -1.50 0.37 .235 legal problems 0.16 0.31 -0.46 0.78 .607 dependence/withdrawal 0.44 0.45 -0.46 1.34 .331 model 10: past 3-month negative consequences step 1 sex assigned at birth -0.17 0.34 -0.85 0.51 .619 age -2.42 1.06 -4.52 -0.31 .025 past 3-month use frequency step 2 sex assigned at birth -0.19 0.34 -0.87 0.49 .578 age -2.01 1.05 -4.08 0.06 .057 past 3-month use frequency -0.30 0.18 -0.66 0.06 .105 less productive 1.26 0.90 -0.53 3.05 .166 lower energy 0.79 0.99 -1.18 2.76 .429 cognitive impairment 0.79 0.92 -1.04 2.62 .396 problems at school or work -0.17 0.93 -2.01 1.67 .856 physical health problems -0.26 0.94 -2.13 1.61 .786 legal problems -1.74 0.63 -2.98 -0.50 .006 dependence/withdrawal 1.32 0.90 -0.47 3.11 .147 perceived risk, cannabis use, and outcomes 59 effect estimate se 95% ci p ll ul model 11: past-year cud symptoms step 1 sex assigned at birth -0.68 0.45 -1.58 0.21 .134 age -0.32 0.15 -0.61 -0.03 .030 past 3-month use frequency 0.42 0.07 0.28 0.55 <.001 step 2 sex assigned at birth -0.36 0.43 -1.22 0.50 .415 age -0.36 0.14 -0.64 -0.08 .013 past 3-month use frequency 0.28 0.08 0.13 0.43 <.001 less productive 0.93 0.38 0.18 1.67 .015 lower energy -0.06 0.41 -0.87 0.76 .890 cognitive impairment 0.56 0.38 -0.20 1.32 .148 problems at school or work 0.20 0.39 -0.57 0.96 .609 physical health problems -0.27 0.39 -1.05 0.51 .494 legal problems -0.56 0.26 -1.08 -0.05 .033 dependence/withdrawal 0.38 0.38 -0.36 1.12 .314 model 12: readiness to changea step 1 sex assigned at birth 0.22 0.20 -0.17 0.62 .271 age -1.62 0.62 -2.85 -0.39 .011 past 3-month use frequency -0.18 0.10 -0.37 0.00 .054 step 2 sex assigned at birth 0.20 0.22 -0.23 0.62 .357 age -1.57 0.65 -2.86 -0.28 .018 past 3-month use frequency -0.19 0.11 -0.41 0.04 .104 less productive 0.02 0.57 -1.10 1.14 .973 lower energy -0.10 0.62 -1.32 1.13 .878 cognitive impairment -0.02 0.58 -1.17 1.12 .966 problems at school or work 0.11 0.58 -1.04 1.26 .848 physical health problems 0.74 0.59 -0.43 1.91 .210 legal problems -0.31 0.39 -1.09 0.46 .423 dependence/withdrawal -0.10 0.56 -1.22 1.02 .861 model 13: importance to changea step 1 sex assigned at birth -0.57 0.66 -1.88 0.74 .392 age -0.08 0.21 -0.50 0.34 .704 past 3-month use frequency -0.02 0.10 -0.22 0.18 .860 step 2 sex assigned at birth -0.34 0.67 -1.67 0.99 .618 age -0.12 0.22 -0.56 0.32 .591 past 3-month use frequency -0.10 0.12 -0.33 0.14 .417 less productive 1.12 0.58 -0.03 2.27 .057 lower energy -0.11 0.64 -1.38 1.15 .859 cognitive impairment 0.57 0.59 -0.61 1.74 .342 problems at school or work 0.17 0.60 -1.01 1.36 .771 physical health problems 0.05 0.61 -1.16 1.25 .940 legal problems -0.83 0.40 -1.63 -0.04 .041 dependence/withdrawal -0.21 0.58 -1.36 0.94 .721 model 14: confidence to change step 1 sex assigned at birth 0.11 0.51 -0.89 1.12 .826 age 0.09 0.16 -0.24 0.41 .593 past 3-month use frequency -0.03 0.08 -0.18 0.12 .703 step 2 sex assigned at birth 0.04 0.50 -0.95 1.02 .939 age 0.06 0.16 -0.26 0.38 .717 past 3-month use frequency 0.12 0.09 -0.06 0.29 .181 less productive 0.68 0.43 -0.17 1.53 .115 lower energy -0.94 0.47 -1.87 0.00 .050 cognitive impairment -0.21 0.44 -1.08 0.66 .629 problems at school or work -0.10 0.44 -0.98 0.77 .820 physical health problems 0.04 0.45 -0.84 0.93 .921 legal problems 0.55 0.30 -0.04 1.13 .069 dependence/withdrawal -1.07 0.43 -1.92 -0.22 .014 note. ci = confidence interval; ll = lower limit; ul = upper limit, cud = cannabis use disorder, p <.05 bolded in significant models, aoverall model not significant cannabis, a publication of the research society on marijuana 60 differences by cannabis use frequency (table 6) compared to individuals who used cannabis infrequently (n=64), individuals who used more frequently (n=65) reported significantly lower general perceived risk to others, but did not significantly differ on any risk to others domains. individuals who used infrequently did not differ from those who used more frequently on general personal risk but reported significantly higher ratings of personal risk domains (medium to large effects), except for personal physical and legal risk. table 6. means, standard deviations, and one-way analyses of variance by use frequency measure infrequent use (n=64) frequent use (n=65) f(4,123) p η2 m sd m sd perceived risk to others less productive 2.56 0.80 2.49 0.77 0.21 .652 0.002 lower energy 2.59 0.73 2.29 0.84 4.19 .043 0.033 cognitive impairment 2.36 0.8 2.14 0.75 2.44 .121 0.019 problems at school or work 2.53 0.84 2.17 0.80 6.28 .014 0.048 physical health problems 2.22 0.98 1.88 0.80 4.50 .036 0.035 legal problems 2.77 0.85 2.51 0.97 2.47 .119 0.019 dependence/withdrawal 3.06 1.02 2.78 1.01 2.55 .113 0.020 general risk to others 1.98 0.86 1.48 0.69 13.10 <.001 0.094 perceived personal risk less productive 1.56 0.77 2.12 0.84 16.21 <.001 0.115 lower energy 1.47 0.67 2.06 0.88 19.37 <.001 0.134 cognitive impairment 1.44 0.56 1.97 0.83 18.31 <.001 0.128 problems at school or work 1.39 0.63 1.82 0.81 10.58 .001 0.078 physical health problems 1.41 0.61 1.68 0.77 5.13 .025 0.039 legal problems 1.59 0.75 2.05 1.02 8.72 .004 0.065 dependence/withdrawal 1.34 0.54 1.83 0.89 13.46 <.001 0.097 general personal risk 1.28 0.58 1.45 0.71 2.08 .152 0.016 note. sex assigned at birth and age included as covariates (not shown), significant at bonferroni corrected p <.003 (bolded) discussion the present study tested how general and domain-specific perceived risks to others and oneself were cross-sectionally associated with cannabis use frequency, negative outcomes, and motivation to change among a sample of undergraduates who use cannabis. results partially supported hypotheses. for aim 1, general perceived risk to others was negatively correlated with use frequency, whereas general perceived personal risk was positively associated with consequences/cud symptoms and some facets of motivation to change (i.e., importance, readiness). for aim 2, after accounting for shared variance among risk domains, legal and dependence/withdrawal risk were uniquely associated with outcomes. for aim 3, undergraduates who used cannabis more frequently reported greater perceived personal risk in five of seven risk domains and less perceived general risk to others compared to those perceived risk, cannabis use, and outcomes 61 who used less frequently, despite no significant differences in general personal risk or domainspecific risk to others. findings suggest assessing both general and domain-specific risk, as well as risk to others and oneself, can provide a more nuanced understanding of perceived risk and its association with cannabis outcomes among undergraduates. perceived personal risk was rated in the no-toslight risk range, on average, whereas perceived risk to others was rated in the slight-to-moderate risk range, even though average use in the sample was higher than “regular use” as defined in risk to others items. thus, undergraduates may minimize their personal risk of cannabis use, despite acknowledging a similar level of use poses risk to their peers. although general perceived risk to others was negatively associated with use frequency, general perceived personal risk was not. rather, general perceived personal risk was positively related to negative consequences and cud symptoms. in contrast with prior work finding no association between perceived risk and the experience of negative consequences (i.e., academic, social) among undergraduates who use cannabis (kilmer et al., 2007), the present findings indicate individuals who experience problems related to their use may perceive greater personal risk, despite viewing their personal use as less risky than a similar level of use for others. findings also underscore the importance of considering domain-specific perceived risk. only the physical risk domain predicted general perceived risk to self and others. undergraduates may be focusing on the “physical risk” portion of the item when rating general perceived risk. importantly, although only the physical risk domain significantly predicted general risk, students rated physical risk as having the lowest risk of any domain. physical health problems are rarely reported by young adults who use cannabis (buckner et al., 2010; terry-mcelrath et al., 2022), and negative physical health effects of cannabis tend to be cumulative (volkow et al., 2014). the infrequency and lack of immediacy of these consequences may contribute to an inaccurate perception of actual physical risks associated with heavy, frequent cannabis use. second, given the increase in legalization of medical cannabis use in the past decade and attention toward prescribing cannabis to manage physical concerns (national academies of sciences & medicine, 2017), students may view cannabis as being less risky physically. this is supported in part by decreases in perceived risk post-legalization (mennis et al., 2023). several domains of risk emerged as important predictors of outcomes. consistent with hypotheses, dependence/withdrawal risk was a significant predictor of cannabis outcomes; however, cognitive, productivity, and legal risks also served as unique predictors. perceived dependence/withdrawal risk to others and perceived personal cognitive risk were negatively associated with use frequency, and perceived personal risk to productivity was positively associated with cud symptoms. similar to other work finding greater perceived risk is protective against cannabis use (e.g., d’silva et al., 2020), present findings indicate some domain-specific perceived risks might mitigate risk associated with certain cannabis use behaviors. additionally, perceived legal risk to self and others were negatively associated with consequences and cud symptoms. knowing perceived legal risk may mitigate harms associated with cannabis use, college campuses may consider maintaining strict cannabis policies with required intervention postviolation as evidence suggests undergraduates decrease their cannabis use post-sanction (buckner et al., 2018). in addition to decreasing use, strict campus policies and an associated intervention may result in higher-risk students experiencing fewer negative outcomes and maintaining more accurate perception of legal/systemic risk despite changes in state/federal policies. general perceived personal risk (but not general or domain-specific perceived risk to others) was positively associated with importance and readiness to change. thus, perceiving risk to others may be too distal an association to motivate individuals to change their own cannabis use. notably, even though the overall sample reported high confidence to change, greater personal risk of dependence/withdrawal was negatively associated with confidence to change. individuals who perceive themselves at risk of withdrawal/dependence may experience uncertainty about how to change use and/or manage withdrawal/dependence symptoms. as high confidence to change is an especially important predictor of changes in substance use among young adults (bertholet et al., 2012), it cannabis, a publication of the research society on marijuana 62 may be advantageous to emphasize personal risk, rather than risk to others, when working with individuals who use cannabis. further, as confidence to change increases early on in cannabis-related treatment (chung & maisto, 2016), continuing to provide psychoeducation, problem-solving, and skills around managing withdrawal/dependence to increase confidence remains important. consistent with hypotheses, participants who used frequently reported less general perceived risk to others than those who used infrequently. however, regarding domain-specific perceived personal risk, those who use more frequently perceived five out seven domains as riskier than those who use infrequently, consistent with prior research finding undergraduates who engage in more frequent cannabis use rate their personal risk higher (o'callaghan et al., 2006). notably, results could reflect differences in how personal risk vs risk to others items were framed. specifically, participants were asked to rate risk to others who used once a week or more, but rate personal risk based on one’s current frequency of use. if a participant’s personal use rate was much higher than once per week, they may view their use as inherently riskier given consequences they are currently or have previously experienced. it will be important to test whether results remain consistent if risk to others is assessed more similarly to personal risk (i.e., “if others use marijuana at your current rate of use”). clinicians may want to focus on increasing perceived personal risk among undergraduates who use cannabis rather than general risk, as perceived personal risk (but not perceived risk to others) was associated with negative consequences and cud symptoms. further, the current study suggests it may be particularly useful to emphasize psychoeducation on longterm risks and consequences of cannabis including physical, legal, and dependence risks for undergraduates who use cannabis more broadly. individuals may be reporting short-term perceived personal risks more accurately as they may have already experienced them; however, there may be a misperception of risks associated with long-term consequences due to their lack of immediacy. additionally, it may be beneficial to provide psychoeducation on domains individuals are most concerned about (e.g., dependence/withdrawal among individuals who use heavily, legal risk among individuals in states with illegal recreational cannabis). notably, as perceived risk appears to be a protective factor for undergraduates who do not use or use infrequently (e.g., hanauer et al., 2021; kilmer et al., 2007), targeting perceived risk to others may be particularly useful in prevention programs when paired with education on safer use to protect against potential negative consequences. results should be viewed in light of study limitations. first, data were collected crosssectionally. further examination of research questions longitudinally could provide critical information regarding temporal relations among study variables including how individuals’ risk perceptions change over time and how various risk perceptions may protect against or contribute to the onset or maintenance of problematic cannabis use. second, questions were administered as part of an intervention which may have impacted results. relatedly, participants rated general and domain-specific risk to others ‘if they use marijuana regularly [once a week or more]” and personal risk “if you use marijuana at your current rate of use.” future research would benefit from using a consistent use frequency anchor to assess risk to self and others. third, data was collected in a state where recreational cannabis was illegal which may contribute to findings associated with perceived legal risk. given previous research has shown a decrease in felony convictions, arrests, and police involvement related to cannabis following legalization in certain states (maxwell & mendelson, 2016), it is critical to assess perceived risk of cannabis use across states with varying legal status. further, the sample was relatively small and predominantly comprised of nonhispanic/latin, white, female participants; replication with larger and more diverse samples in terms of race/ethnicity, age, and sex assigned at birth will be important. notably, legal risk may differ unfairly among racial and ethnic minority groups due to bias-driven racial disparities in cannabis-related arrests and convictions (bunting et al., 2013). clinicians working with patients who use cannabis should consider the legal status and related legal risks in their state of practice, and potential impacts of legal disparities for their clients; exploring perceived legal risk and providing psychoeducation if indicated may be perceived risk, cannabis use, and outcomes 63 useful for patients expressing ambivalence about changing their use. fourth, although the present study provides important information on various domains of risk, domains were not comprehensive. measures of domain-specific perceived risk to self and others were developed specifically as part of the pfi for this study. although results suggest preliminary construct validity, future work testing other psychometric properties of these measures is necessary. further, although risk domains were empirically informed, there may be other risk domains (e.g., driving while intoxicated, financial challenges) not captured in the present study. future work could use qualitative interviews to further identify the most relevant domains to undergraduates and test whether results replicate in a larger, more diverse sample. taken together, future research should examine relations posed in this study longitudinally, utilize questions with consistent use rates for risk to others and oneself, in states with varying legal status of cannabis, in larger, more diverse samples, outside the context of an intervention study, and include a wider variety of risk domains. perceived risk of using cannabis is on a consistent decline despite known risks (lipari & jean-francois, 2016; waddell, 2022). results of the present study suggest future research could benefit from expanding current conceptualizations of 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(2019). online personalized feedback intervention for cannabis-using college students reduces cannabis-related problems among women. addictive behaviors, 98, 106040. https://doi.org/10.1016/j.addbeh.2019.106040 funding and acknowledgements: this research was supported by grants from the national institute on alcohol abuse and alcoholism (niaaa) and national institute on drug abuse (nida). data collection was supported by funding from louisiana state university's department of psychology awarded to dr. walukevich-dienst. data analysis and manuscript preparation were supported by f31da057796 (pi: smithlecavalier), t32aa007455 (pi: larimer), f32aa029589 (pi: walukevich-dienst), k23aa031034 (pi: walukevich-dienst), r21aa030071 (pi: buckner), and r21da056846 (buckner). the content is solely the responsibility of the authors and does not necessarily represent the official views of niaaa or nida. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 74 ved abstract objective: the present research evaluated the impact of legalizing recreational cannabis among individuals with substance use disorders (suds) who may already use cannabis at high rates. method: using an interrupted time series study design, we evaluated the potential impact of legalizing recreational cannabis among individuals seeking treatment for sud within a hospital-based treatment setting in guelph, ontario. we examined 2,925 individuals who entered an inpatient sud treatment program between april 2017 and december 2021. we performed segmented regression analyses using both the date of cannabis legalization and the date of edibles legalization as the interruption time point. we also performed stratified analyses to examine potential sex differences. results: we found no significant changes in the frequency of cannabis use using either of the interruption time points. however, among the subsample who had used cannabis, there was evidence of increasing cud severity post-legalization of edibles, as well as an overall decreasing trend in readiness to quit over time. stratified analyses also suggested possible sex differences in frequency of cannabis use, cud severity, and readiness to quit. conclusions: results point to some small but potentially important impacts of recreational cannabis legalization that may only continue with time. nevertheless, there is a need to continue to monitor cannabis use trends over time to understand any potential lagged effects. key words: = cannabis; health policy; substance use disorder; vulnerable populations emily m. britton1, radia taisir1, alysha cooper1, yao li1, sarah sousa1, yelena chorny2, james mackillop1,3-5, & mary jean costello1 1homewood research institute 2homewood health centre 3st. joseph’s healthcare 4michael g. degroote centre for medicinal cannabis research, mcmaster university 5peter boris centre for addiction research, st. joseph’s healthcare cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000260 volume 7, special issue 3 examining the potential impact of recreational cannabis legalization on individuals receiving treatment for substance use disorder: an interrupted time series study in guelph, ontario, canada corresponding author: mary jean costello, phd, homewood research institute. riverslea, 150 delhi st, guelph on, n1e 6k9. phone: (519) 838-8104, ext. 32320. email: jcostello@hriresearch.com cannabis, a publication of the research society on marijuana 75 on october 17, 2018, canada became the second country after uruguay to legalize recreational cannabis with the introduction of the federal cannabis act (2018). under this new legislation, adults could legally purchase, possess, and use non-medical cannabis (dried, fresh, and oil) in limited quantities based on provincial and territorial regulations that oversee retail distribution and sales (government of canada, 2018). one year later, on october 17, 2019, the federal government amended the cannabis act to include three new classes of cannabis: edibles, topicals, and concentrates. these policy changes aimed to minimize the harms posed by cannabis, including eliminating the illicit market, reducing youth access, ensuring quality control, and increasing awareness of the health risks (cannabis act, 2018; government of canada, 2022). nevertheless, scientists and practitioners raised concerns that legalization would lead to an increase in cannabis use and consequent harms (hajizadeh, 2016; svrakic et al., 2012; windle et al., 2019). thus, there became a pressing need to understand the impacts of this new legislation on cannabis use and associated health and wellbeing. over the past five years, several studies have examined the impact of recreational cannabis legalization among the canadian population. these studies generally indicate modest but significant increases in the prevalence of cannabis use following legalization (see athanassiou et al., 2023; hall et al., 2023 for review). for example, recent results from the 2023 canadian cannabis survey—a large-scale national survey conducted by health canada—indicated that 26% of people (aged 16+) reported using cannabis over the past 12 months, up from 22% in 2018 (health canada, 2024). in ontario, which is canada’s most populous province, studies have similarly reported small but significant increases in cannabis use over time following legalization (nigatu et al., 2020; turna et al., 2021). in addition to an increase in cannabis use, studies have also reported increased rates of cannabisattributable healthcare visits and cannabisrelated hospitalizations during both the initial and longer-term post-legalization phases (kim et al., 2023; walker et al., 2023). although research to date has provided important insights with respect to the general population, there remains a need to study the effect of legalization on specific at-risk populations, including individuals with substance use disorders (suds). research prior to legalization shows that people with psychiatric disorders, and in particular those with suds, tend to use cannabis at elevated rates and are more likely to have a cannabis use disorder (cud; lev-ran, le foll, et al., 2013; wittchen et al., 2007). additionally, cannabis use and cud are often elevated among those with concurrent disorders (i.e., people living with sud and another comorbid psychiatric condition; hango & larochelle-côté, 2018; lev-ran, le strat, et al., 2013). on the other hand, frequent and long-term use of cannabis is associated with increased use of other substances that may become problematic (hasin & walsh, 2021; secades-villa et al., 2015; subbaraman & kerr, 2015). given these complex relations, it may be particularly important to study the potential effects of legalization among individuals with suds. an increase in cannabis use or cud within this group may necessitate adaptations in the structure or delivery of treatment programs and services to meet changing substance use patterns and possibly cooccurring psychiatric symptoms. furthermore, as these settings include individuals with elevated pre-legalization cannabis use and cud, they may provide insights into trends that pertain only to individuals with high levels of use. in the present research, we used an interrupted time series (its) design to examine the impact of recreational cannabis legalization among individuals who entered an inpatient sud treatment program in guelph, ontario. in an its design, the outcome of interest is measured sequentially within a population at equal time intervals before and after an intervention, thereby permitting comparison of the level and slope of the outcome preand post-intervention (bernal et al., 2017). specifically, we examined changes in the frequency of cannabis use post-legalization among the full patient population, as well as changes in severity of cud symptoms, the proportion of those who screen positive for cud, and readiness to quit among a subsample who had used cannabis. given the known differences in cannabis use patterns among males and females (e.g., calakos et al., 2017; cuttler et al., 2016), we also explored potential sex differences as a secondary objective. although recreational cannabis legalization occurred on october 18, potential effects of cannabis legalization on sud 76 2018 in canada, the first in-person dispensaries did not open until april 2019 in ontario (owram, 2019). therefore, we considered two intervention breakpoints: the initial date of legalization (oct. 17, 2018) and the date of edibles legalization one year later (oct. 17, 2019), which also coincided with increasing access to cannabis and commercialization in ontario (myran, staykov, et al., 2022). methods participants and procedure participants were individuals who voluntarily entered a large inpatient sud treatment program located in guelph, ontario between april 17th, 2017 and december 16th, 2021. the program offered a 35-day, group-based treatment for adults aged 19+ with alcohol and/or other substance use disorders. data were collected using a selfadministered questionnaire completed as part of standard clinical practice upon admission to the program. the questionnaire included psychometrically validated measures and tools used to screen for sud and other psychiatric disorders. all patients were informed that these data may be used for research purposes and provided implicit consent. we accessed the data retrospectively via research protocols (#16-06, #1908) that received ethics approval from the regional centre for excellence research ethics board in guelph, ontario. over the study period, 2,925 individuals entered the treatment program and completed the clinical questionnaire. we excluded 27 cases that were missing data related to cannabis use or did not have a valid admission date (required to assign the case to a time period). in total, 2,898 individuals (mage = 41.41, sd = 11.73; 72% male) were included in the primary analysis. of the full sample, 1,416 people (48.8%) indicated they had used cannabis at some point within the past year. within this subsample, we excluded people who were missing data related severity of cannabis use or readiness to quit using cannabis, resulting in a final subsample of 1,384 individuals. table 1 presents the demographic and substance use characteristics for both the full sample and subsample who used cannabis. supplemental table s1 presents the demographic and substance use characteristics of individuals admitted pre versus post-cannabis legalization. some characteristics differed between the two groups with respect to age, education, most frequently used substance(s), and sud profile. table 1. socio-demographic and substance use characteristics for the full sample (n = 2898) and the subsample who used cannabis (n = 1384) characteristic full sample used cannabis n % n % sex male 2087 72.0 1053 76.1 age < 30 years 476 16.4 350 25.3 30 to 39 years 855 29.5 496 35.8 40 to 49 years 784 27.1 331 23.9 50 to 59 years 586 20.2 166 12.0 ≥ 60 years 197 6.8 41 3.0 education completed college/university 1155 39.9 462 33.4 employment employed 2152 74.3 1011 73.0 marital status married or partnered 1236 42.7 486 35.1 most frequently used substance(s) at admissiona alcohol 1901 65.6 760 54.9 cannabis 636 21.9 626 45.2 stimulants 598 20.6 333 24.1 cannabis, a publication of the research society on marijuana 77 opioids 357 12.3 189 13.7 sedatives 159 5.5 77 5.6 other 66 2.3 28 2.0 screened positive for sudb aud 2180 75.2 1004 72.5 cud 718 24.8 708 51.2 other dud (not incl. cud) 1438 49.6 865 62.5 screened positive for sudb aud only 1132 39.1 271 19.6 dud only (incl. cud) 611 21.1 345 24.9 both aud + dud (incl. cud) 1040 35.9 732 52.9 note. sud = substance use disorder; aud = alcohol use disorder; cud = cannabis use disorder; dud = drug use disorder. a most frequently used substance was identified as the substance(s) with the highest response score(s) on a hybridized version of the nida quick screen question (nida, 2012) and adapted nida-modified assist (apa, 2013). groups are not necessarily mutually exclusive. b positive screen defined as endorsing two or more criteria on the dsm-v sud checklist (apa, 2013). groups are not necessarily mutually exclusive. outcome measures cannabis use. the frequency of cannabis use was assessed using a hybridized version of the national institute on drug abuse (nida) quick screen question (nida, 2012) and adapted nidamodified assist v2.0 (american psychiatric association [apa] 2013). individuals rated on a scale from 0 (none) to 5 (multiple times per day) how frequently they had used cannabis over the reference period.. for data collected april 2017 to april 2018 (n = 780), cannabis use was assessed over the past year; for data collected may 2018 to december 2021 (n = 2118), cannabis use was assessed over the past 90 days. to justify combining these data, we conducted a segmented regression analysis using the level change impact model to examine whether there was a significant level change following the change in reference period. results showed that the change in reference period was not associated with the frequency of reported cannabis use (see supplemental table s2). severity of cannabis use. the dsm-5 suds checklist (apa, 2013; hasin et al., 2013) was used to assess the severity of cud symptoms. the checklist assesses 11 diagnostic criteria and was previously validated in relation to a structured clinical interview in the same treatment setting (levitt et al., 2021). response options were dichotomous (yes or no), indicating endorsement of each specific criterion. the total number of endorsed criteria was then calculated with responses ranging from 0 to 11. like cannabis use, cud symptoms were assessed over the past year for data collected april 2017 to april 2018 and over the past 90 days for data collected from may 2018 to december 2021. results from a segmented regression analysis again demonstrated that the change in reference period was not significantly associated with the severity of cannabis use (see supplemental table s2). proportion of patients screening positive for cud. a dichotomous variable was created using the total number of endorsed criteria for cud (described above) to indicate whether the patients screened positive for cud (total number of endorsed criteria ≥ 2 ) or not (total number of endorsed criteria < 2). readiness to quit using cannabis. a readiness ruler (chung et al., 2011; maisto et al., 2011) was used to assess patients’ readiness to change their cannabis use. using the ruler, patients were asked to indicate how ready they were to make a change (quit or reduce) their cannabis use. ratings ranged from 1 to 10, where 1 represented “not at all ready” and 10 represented “already trying to make a change.” design and data analysis we used an its design to examine whether recreational cannabis legalization was associated with changes in the frequency of cannabis use among the full sample, as well as changes in severity of cannabis use, proportion who screened positive for cud and readiness to quit among the subsample of patients who had used cannabis. to ensure substantive sample sizes at each time point, we examined each outcome in bi-monthly potential effects of cannabis legalization on sud 78 periods using the sample of individuals who were admitted to the treatment program within the respective period. we conducted two sets of analyses using two different intervention break points: (1) the date when recreational cannabis became legal in canada, october 17th, 2018, and (2) the date when edible cannabis products and concentrates were legal for sale in canada, october 17th, 2019 (one year following cannabis legalization). we analyzed the data using segmented regression analysis, modelling the association between legalization and each outcome using the level and slope change impact model (bernal et al., 2017). for ease of interpretation, we applied a logit transformation to the screened positive for cud outcome, since this was represented as a proportion. each model included: (1) an intercept, (2) the time elapsed since the start of the study (representing the underlying pre-intervention trend), (3) an intervention variable coded 0 for pre-intervention and 1 for post-intervention (representing the level change immediately following the intervention), and (4) the product of the intervention and the time elapsed since the beginning of the intervention (representing the slope change following the intervention). notably, following the recommendation of xiao and colleagues (2021), we calculated the slope change as the product of the intervention and the time elapsed since the start of the intervention (as opposed to the start of the study) to allow for proper interpretation of the level change. seasonality was tested using the ollech and webel’s combined seasonality test (ollech, 2021; ollech & webel, 2020) and was not detected for any of the outcomes understudy. extreme outliers were identified using the boxplot method for each outcome. serial autocorrelation of model residuals was examined through the durbin-watson test (durbin & watson, 1992) and accounted for with prais-winsten regression (prais & winsten, 1954) when necessary. normality was assessed using the shapiro-wilk test (shapiro & wilk, 1965). to check heteroscedasticity of the model, the breusch-pagan test (breusch & pagan, 1979) was used and weighted least squares (wls) regression was performed when necessary. we also explored potential sex differences using stratified analyses to compare results for males and females. finally, we calculated bayes factors to determine whether null findings indicated evidence in support of the null hypothesis or were a result of insensitive data. a bayes factor above 1 provides increasing evidence in support of the null hypothesis, whereas a bayes factor below 1 provides increasing evidence in support of the alternative hypothesis. a bayes factor of 1 indicates insensitive data. thresholds of bayes factors approximately >3 and <1/3 were used to indicate evidence in support of the null and alternative hypotheses, respectively (dienes, 2016). all statistical analyses were performed in the statistical software, r (v. 4.4.1; r core team, 2024). results segmented regression results using the date of cannabis legalization (october 17, 2018) and the date of edibles legalization (one year later; october 17, 2019) as the intervention breakpoint are presented in table 2. figure 1 presents the comparison of trends for each of the outcomes with and without legalization occurring. among the full sample, we found no significant level or slope changes in the frequency of cannabis use preand post-legalization using either of the intervention breakpoints. furthermore, the bayes factors provided evidence in favour of the null hypothesis (i.e., no change in the outcomes). among the subsample who used cannabis, there were no level or slope changes in the average number of endorsed cud symptoms using the date of cannabis legalization as the intervention breakpoint. however, results indicated a significant slope change using the date of edibles legalization (or one-year after cannabis legalization). as seen in figure 1 panel d, there is a trend of increasing cud severity over time following the intervention breakpoint (relative to the pre-intervention trend). the bayes factor provided some support for the alternative hypothesis in this case. however, there were no significant level or slope changes in the proportion of who screened positive for cud. the bayes factor provided some support for the slope change using the date one year after cannabis legalization, but it provided full support for the null hypothesis for the other level or slope changes. finally, there were also no level or slope changes in average readiness to quit using either of the intervention breakpoints, and the bayes factors provided strong evidence in favour of the null hypothesis. while we did not find any cannabis, a publication of the research society on marijuana 79 evidence of an intervention effect, the results did show an overall trend of decreasing readiness to quit over time when using the lagged intervention breakpoint. table 2. segmented regression results examining associations between recreational cannabis legalization and cannabis use outcomes cannabis legalization breakpoint (oct 17, 2018) edibles legalization breakpoint (oct 17, 2019) dw p b se t p bf dw p b se t p bf frequency of cannabis use 2.19 .921 2.26 .937 intercept 1.19 0.15 8.97 <.001 1.26 0.10 12.63 <.001 slope 0.03 0.02 1.38 .182 2.05 0.02 0.01 1.48 .151 1.76 level change -0.15 0.17 -0.97 .342 3.31 -0.02 0.14 -0.17 .863 5.21 slope change 0.00 0.03 -0.19 .853 5.20 0.02 0.02 0.96 .346 3.34 severity of cannabis use 2.14 . .823 2.14 .809 intercept 3.39 0.44 7.71 <.001 3.57 0.33 10.85 <.001 slope -0.02 0.08 -0.28 .786 5.10 -0.07 0.04 -1.80 .084 1.04 level change -0.62 0.52 -1.20 .243 2.59 0.26 0.46 0.57 .575 4.50 slope change 0.07 0.08 0.84 .407 3.71 0.12 0.06 2.14 .042 0.53 proportion of cud +ve 2.39 .639 2.43 .569 intercept 0.22 0.24 0.89 .380 0.33 0.18 1.84 .078 slope -0.01 0.04 -0.22 .831 5.17 -0.04 0.02 -1.82 .081 1.01 level change -0.28 0.28 -1.00 .328 3.21 0.25 0.25 1.00 .328 3.21 slope change 0.03 0.04 0.64 .527 4.31 0.05 0.03 1.63 .117 1.41 readiness to quit 2.79 .105 2.78 .116 intercept 7.49 0.36 20.67 <.001 7.62 0.27 28.39 <.001 slope -0.04 0.06 -0.59 .562 4.45 -0.07 0.03 -2.26 .033 0.41 level change -0.29 0.42 -0.69 .497 4.17 0.23 0.37 0.60 .552 4.41 slope change 0.03 0.07 0.43 .668 4.82 0.06 0.05 1.25 .223 2.42 note. dw = durbin-watson test; bf = bayes factor figure 1. trends for each outcome with and without legalization occurring potential effects of cannabis legalization on sud 80 note. *1-year lagged legalization break point coincides with the expanding commercialization of cannabis in ontario including legalization of edibles, concentrates and topicals. panel a-b: frequency of cannabis use; panel c-d: severity of cud symptoms; panel e-f: proportion of cud +ve screened; panel g-h: readiness to quit using cannabis. stratified analyses by sex table 3 presents segmented regression results for males and females separately, using both the date of recreational cannabis legalization and date of edibles legalization (one-year lagged date). figures 2 and 3 show the comparison of predicted trends for each of the outcomes with and without legalization for both males and females, respectively. there was no significant level change or slope change in the frequency of cannabis use when using either of the intervention breakpoints for either males or females. however, there was some evidence of an overall increasing trend in frequency of cannabis use among the males following cannabis legalization breakpoint. among the subsample who used cannabis, there were no level or slope changes in the average number of endorsed cud symptoms for either males or females using the date of cannabis legalization as the intervention breakpoint. however, results indicated a significant slope change in cud severity following the one-year lagged intervention breakpoint for males. this slope change was not significant for females, though the pattern was in the same direction. the bayes factor provided some evidence for the alternative hypothesis for the male subgroup, but indicated insensitive data for the female subgroup. for the proportion who screen positive for cud, there was no level change or slope change for either males or females following cannabis legalization. on contrary, following cannabis, a publication of the research society on marijuana 81 legalization of edibles, we found significant slope change (with marginal support indicated by the bayes factor) for females who used cannabis. for readiness to quit using cannabis, we found no significant level or slope change using either of the intervention breakpoints for either males or females. however, there was evidence of an overall trend of decreasing readiness to quit using cannabis over time among males, but not females, following the edibles legalization breakpoint. table 3. segmented regression results examining associations between recreational cannabis legalization and cannabis use outcomes stratified by sex cannabis legalization breakpoint (oct 17, 2018) edibles legalization breakpoint (oct 17, 2019) dw p b se t p bf dw p b se t p bf frequency of cannabis use males 2.45 .529 2.30 .846 intercept 1.21 0.13 9.04 <.001 1.37 0.11 12.99 <.001 slope 0.05 0.02 2.20 .038 0.47 0.02 0.01 1.36 .187 2.10 level change -0.27 0.16 -1.73 .097 1.19 0.04 0.15 0.27 .786 5.10 slope change -0.02 0.03 -0.93 .361 3.43 0.01 0.02 0.62 .542 4.37 females a 1.80 .243 1.94 .424 intercept 0.99 0.27 3.71 .001 0.89 0.20 4.52 <.001 slope 0.00 0.05 -0.05 .961 5.29 0.02 0.02 0.94 .358 3.41 level change 0.12 0.31 0.38 .711 4.93 -0.24 0.29 -0.85 .406 3.70 slope change 0.02 0.05 0.34 .740 5.00 0.02 0.04 0.53 .601 4.60 severity of cannabis use males 2.04 .614 2.07 .666 intercept 3.44 0.43 8.03 <.001 3.62 0.32 11.38 <.001 slope -0.02 0.08 -0.22 .826 5.16 -0.06 0.04 -1.77 .090 1.12 level change -0.60 0.50 -1.19 .246 2.61 0.12 0.44 0.28 .783 5.09 slope change 0.05 0.08 0.65 .520 4.28 0.12 0.06 2.08 .048 0.61 females 2.11 .761 2.11 .740 intercept 3.45 0.91 3.79 .001 3.68 0.68 5.39 <.001 slope -0.04 0.16 -0.23 .822 5.16 -0.10 0.08 -0.27 .218 2.38 level change -0.93 1.07 -0.87 .391 3.61 0.36 0.95 0.38 .707 4.92 slope change 0.12 0.17 0.70 .489 4.14 0.20 0.12 1.65 .111 1.35 proportion of cud +ve males 2.29 .866 2.32 .799 intercept 0.22 0.23 0.93 .361 0.39 0.17 2.21 .037 slope 0.01 0.04 0.23 .819 5.15 -0.03 0.02 -1.54 .138 1.63 level change -0.29 0.27 -1.06 .298 3.01 0.24 0.24 0.98 .337 3.28 slope change -0.01 0.04 -0.13 .901 5.25 0.02 0.03 0.69 .500 4.18 females b 2.29 .881 2.36 .734 intercept 0.14 0.40 0.34 .737 0.18 0.30 0.59 .558 slope -0.05 0.07 -0.69 .497 4.10 -0.06 0.03 -1.81 .083 1.01 level change -0.35 0.48 -0.73 .476 4.00 0.24 0.42 0.57 .572 4.41 slope change 0.10 0.08 1.25 .224 2.38 0.12 0.06 2.17 .041 0.50 potential effects of cannabis legalization on sud 82 readiness to quit males c 2.90 .050 2.88 .057 intercept 7.71 0.41 18.89 <.001 7.75 0.30 25.55 <.001 slope -0.09 0.07 -1.19 .245 2.60 -0.10 0.03 -2.96 .007 0.07 level change -0.29 0.48 -0.61 .549 4.40 0.53 0.42 1.24 .255 2.44 slope change 0.09 0.08 1.14 .267 2.77 0.08 0.05 1.53 .140 1.65 females 1.85 .310 1.86 .317 intercept 6.23 0.72 8.61 <.001 6.86 0.54 12.66 <.001 slope 0.19 0.13 1.46 .159 1.84 0.06 0.06 0.93 .362 3.43 level change -0.76 0.85 -0.90 .376 3.52 -1.08 0.75 -1.43 .166 1.90 slope change -0.20 0.14 -1.45 .161 1.86 0.02 0.10 0.25 .805 5.13 note. dw = durbin-watson test; bf = bayes factor. a since the breuch-pagan test for the ols regression model failed for homoscedasticity, we present the results using wls regression. b since the proportion of cud positive screened corresponding to time point 28 was an extreme outlier, the analyses were performed using the proportions of 1 to 27-time points. c since the p value of the durbin-watson test was exactly .05, we also ran this analysis using prais-winsten regression. results did not meaningfully differ across the two approaches, so here we present the results using ols regression. figure 2. trends for each outcome with and without legalization occurring among males cannabis, a publication of the research society on marijuana 83 note. *1-year lagged legalization break point coincides with the expanding commercialization of cannabis in ontario including legalization of edibles, concentrates and topicals. panel a-b: frequency of cannabis use; panel c-d: severity of cud symptoms; panle e-f: proportion of cud +ve screened; panel g-h: readiness to quit using cannabis. figure 3. trends for each outcome with and without legalization occurring among females potential effects of cannabis legalization on sud 84 note. *1-yr lagged legalization break point coincides with the expanding commercialization of cannabis in ontario including legalization of edibles, concentrates and topicals. panel a-b: frequency of cannabis use; panel c-d: severity of cud symptoms; panel e-f: proportion of cud +ve screened; panel g-h: readiness to quit using cannabis. discussion in contrast to research showing an increase in cannabis use following legalization in canada among the general population (e.g., athanassiou et al., 2023; fischer et al., 2021; hall et al., 2023; turna et al., 2021), our current investigation suggests this may not be the case among individuals entering treatment for sud. indeed, we found no evidence to suggest legalization was associated with either immediate or gradual increases in the frequency of cannabis use postcannabis or post-edibles legalization. these findings are consistent, however, with other work showing no change in cannabis use patterns following legalization in a sample of youth seeking substance use services (hawke & henderson, 2021) and a sample of patients treated for opioid use disorder (rosic et al., 2021). moreover, our findings are also consistent with research showing that increases in cannabis use, at least within a community sample, may be restricted to individuals who did not use cannabis prior to legalization (turna et al., 2021). together, these results suggest that the changes associated with legalization (e.g., increased access to and awareness of cannabis) may have less of an impact on subpopulations who were already using cannabis at elevated rates prior to legalization, such as individuals with sud. while there was no evidence of an overall increase in cannabis use, there was evidence of an increase in cud symptom severity post-edibles legalization among the subsample who used cannabis; however, this did not translate into an increase in the proportion of individuals who screened positive for cud. notably, the increasing cud severity trend only emerged using the edibles legalization date, one year after recreational cannabis legalization, as the intervention breakpoint, but not using the initial date of legalization. although the policy change took effect across canada on october 17, 2018, legalization was not necessarily a discrete event, but rather an unfolding process with substantial variability across different provincial and territorial jurisdictions (myran et al., 2019; myran, staykov, et al., 2022). in ontario, access to legal cannabis remained quite limited in the cannabis, a publication of the research society on marijuana 85 first year following legalization and was largely restricted to online sales. thus, this trend of increasing cud symptom severity post-edibles legalization may be due in part to the availability of more potent cannabis products, as well as to the expanding commercial landscape more broadly. our findings are consistent with other research showing that increases in cannabis-related harms tend to coincide more with cannabis commercialization, rather than legalization with strict retail controls (kim et al., 2023; myran, pugliese, et al., 2022). this suggests that greater access and availability of cannabis products is likely contributing to harmful effects, rather than the policy change itself. additionally, a clinical implication of our findings is the need to adapt programs and services to address increasing cud severity over time. among the subsample of patients who used cannabis, we found no evidence that legalization was associated with any changes in readiness to quit. however, there was evidence of a global decrease in motivation to quit over the entire study period, independent of legalization. research has demonstrated reduced perceptions of the harmfulness of cannabis use over time (hasin & walsh, 2021), and these shifting perceptions may make people less motivated to change their behaviour. furthermore, this decrease in motivation to reduce cannabis use may reflect changes in attitudes and increased social acceptance that were occurring even before the actual policy change took effect. finally, we found some evidence of sex differences in terms of trends in cud severity, the proportion of those who screened positive for cud, and readiness to quit using cannabis. results indicated a trend of increasing cud severity post-edibles legalization for males, mirroring the results of the total sample; however, this trend was not significant for females. examination of the pattern of results shows that these trends were similar for both males and females, but the comparatively small sample of females likely made it difficult to detect an effect. as a result, we are hesitant to conclude that these results reflect any kind of meaningful sex difference in the impacts of legalization on cud severity. we also found marginal evidence of an increase in the proportion of females who screened positive for cud following post-edibles legalization. with respect to readiness to quit, there was a significant overall decrease for males, like the total sample, but not for females. the female trend over time, while nonsignificant, was in the opposite direction, which suggests that this may reflect a true sex difference as opposed to simply a lack of statistical power. strengths and limitations this investigation included several strengths, including applying an its design with existing clinical data to study a natural experiment, a moderate sample size and time frame, and the examination of multiple outcomes. however, its limitations require consideration. first, the modest number of bi-monthly data points preand postlegalization meant the studies could likely only detect relatively large effects (bernal et al., 2017). therefore, it is important to stress, the absence of observing any early effects of legalization on the cannabis use outcomes understudy does not preclude the potential presence of longer-term effects that should be the focus of ongoing study. in addition, the sample sizes for the stratified analyses were relatively small, particularly for the female subgroup. as a result, analyses with the female subgroup may have been underpowered, contributing to the null findings. second, the reference period for reporting cannabis use and cud symptom severity changed from the past year to the past 90 days during the pre-legalization period and may have introduced variability in the responses that cannot be fully attributable to the legalization breakpoints. that said, we expect both reference periods are susceptible to the same recency bias, in that respondents are likely to rely heavily on recent events or behaviours to answer the questions. in this case, we would expect responses to be similar regardless of the reference period. in fact, our supplementary, segmented regression analyses indicated that there was no change in either of the outcomes following the change in reference period. although we cannot be sure the change in reference period did not affect the results, our supplementary results provide some reassurance. although time consuming, future research should employ a timeline follow back method (sobell & sobell, 1992), when feasible, to limit recency bias concerns. third, there were differences in the demographic and substance use characteristics of participants who entered the potential effects of cannabis legalization on sud 86 treatment program preand post-legalization, which also could have contributed to the null effects. finally, the study analyzed trends in a single clinical setting that is similar to many others, but whether these results are provincially or nationally generalizable is an open question. conclusion this study provides evidence that legalization has not (yet) affected the frequency of cannabis use, the proportion of those who screen positive for cud or readiness to change cannabis use within a sample of individuals entering treatment for sud. there was, however, evidence of increasing severity of cud symptoms post-edibles legalization among those who used cannabis, coinciding with increased commercialization. these early findings point to some potentially important changes that may only continue with time. thus, it will be important to continue to monitor trends in cannabis use, cud severity and readiness to quit cannabis within 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(2021). reflection on modern methods: a common error in the segmented regression parameterization of interrupted time-series analyses. international journal of epidemiology, 50(3), 1011–1015. https://doi.org/10.1093/ije/dyaa148 cannabis, a publication of the research society on marijuana 89 funding and acknowledgements: this research was funded in part by the canadian centre on substance use and addiction (ccsa) using funds provided by health canada in support of cannabis research. the views expressed herein do not necessarily represent the views of ccsa or its funders. jm's contributions were partially supported by the peter boris chair for addictions research. homewood research institute (hri) is an independent charitable organization funded through a variety of sources including homewood health, community stakeholders, corporations, and private foundations. homewood health provides unrestricted charitable donations to hri. jm is a senior scientist and principal in beam diagnostics, inc. and a consultant to clairvoyant therapeutics, inc. the authors declare no competing interests. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: britton, e. m., taisir, r., cooper, a., li, y., sousa, s., chorny, y., mackillop, j., & costello, m. j. (2024). examining the potential impact of recreational cannabis legalization on individuals receiving treatment for substance use disorder: an interrupted time series study in guelph, ontario, canada. cannabis, 7(3), 74–89. https://doi.org/10.26828/cannabis/2024/000260 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 67 ved justin matheson1, harseerat saini1,2, rebecca haines-saah3, marcos sanches4, matthew e. sloan1,5-10, adam zaweel1,7, ahmed hassan1,5-8,10,11, leslie buckley5,6, amy porathl2,13, james mackillop14-16, christian s. hendershot17, stefan kloiber6-8, & bernard le foll1,5-8,18, 19 1institute for mental health policy research, centre for addiction and mental health 2human biology program, faculty of arts and sciences, university of toronto 3cumming school of medicine, university of calgary 4biostatistics core, centre for addiction and mental health 5addictions division, centre for addiction and mental health 6department of psychiatry, university of toronto 7department of pharmacology & toxicology, university of toronto 8campbell family mental health research institute, centre for addiction and mental health 9department of psychological clinical science, university of toronto scarborough 10institute of medical science, university of toronto 11department of psychiatry, king abdulaziz university 12knowledge institute on child and youth mental health and addictions 13children’s hospital of eastern ontario research institute 14michael g. degroote centre for medicinal cannabis research, mcmaster university and st joseph’s healthcare hamilton 15peter boris centre for addictions research, mcmaster university and st joseph’s healthcare hamilton 16department of psychiatry and behavioural neurosciences, mcmaster university 17department of population and public health sciences and institute for addiction science, keck school of medicine, university of southern california 18department of family and community medicine, faculty of medicine, university of toronto 19waypoint research institute, waypoint centre for mental health care cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000309 volume 8, issue 2 cannabis use characteristics and reasons for product choices among patients accessing treatment for substance use disorders: a mixed-methods study corresponding author: justin matheson, phd, center for addiction and mental health, 100 stokes street. toronto, ontario, canada, m6j 1h4. email: justin.matheson@camh.ca cannabis, a publication of the research society on marijuana 68 abstract objective: the diversity and potency of cannabis products have increased in recent years, underscoring the importance of understanding which products are being used and why. patients with substance use disorders (suds) use have a high prevalence of risky cannabis use, making it especially important to understand use patterns in this group. we aimed to first describe cannabis product characteristics and then explore reasons for choosing products in our sample. method: in this mixed-methods study, 472 adults who self-reported accessing sud treatment and lifetime cannabis use completed an online survey. a subset of 22 participants completed in-depth interviews. quantitative results focused on describing cannabis use characteristics (e.g., product types) among participants reporting past-year cannabis use (current use group) or lifetime cannabis use but no use in past year (past use group), while qualitative descriptive analysis was used to describe reasons for choosing products among participants who were currently using cannabis. results: across medical and non-medical use of cannabis, dried flower and smoked cannabis formulations were most used (e.g., 89% of the current use group reported smoking cannabis for non-medical purposes), followed by edibles (e.g., 53% of the current use group used edible formulations of cannabis for non-medical purposes), though there was considerable use of higher-potency products such as concentrates and dabs (e.g., 11% of the current use group had used dabs for non-medical purposes). our qualitative analysis found that almost all participants were motivated by thc content when purchasing products, yet sometimes perceived medical benefits or harm reduction were reasons for using certain products (especially cbd-dominant products), while sometimes other factors (e.g., convenience, familiarity) were influential. conclusions: cannabis use characteristics (including motives for choosing products) are complex and nuanced in patients accessing sud treatment. more work is needed to understand longitudinal relationships between use of different cannabis products and both harms and potential benefits. key words: = cannabis; addiction treatment; substance use disorder; medical cannabis; harm reduction the legalization and commercial sale of nonmedical cannabis has been paralleled by increasing diversity and potency of cannabis products, especially in canada (matheson & le foll, 2020). according to the 2023 canadian cannabis survey, among individuals aged 16 years or older who reported past-year cannabis use, 60% had used dried flower or leaf, 54% had used edibles, and 34% had used vape pens or cartridges (health canada, 2023). use of dried flower or leaf decreased between 2018 and 2023, while use of edibles, vape pens or cartridges, and beverages increased over this period (health canada, 2023). similarly, in the canadian province of ontario, exclusive use of ingestionbased methods of cannabis use increased among adults aged 18 years or older between 2017 and 2022, while exclusive use of inhalation-based methods decreased (nigatu et al., 2024). these trends are concerning, as prior research characterizing the health effects of cannabis use has largely focused on smoking dried flower as the primary mode of cannabis use, while growing evidence suggests that cannabis-attributable harms vary by mode of use (gunn et al., 2020; russell et al., 2018; steeger et al., 2021). furthermore, the potency of cannabis products, typically quantified as the proportion of δ9tetrahydrocannabinol (thc), has been increasing in recent decades. for example, in the united states, mean thc potency increased from 9% in 2008 to 17% in 2017 (chandra et al., 2019). this is also concerning, as higher-potency products are associated with an increased risk of psychosis and cannabis use disorder (cud), and possibly anxiety and depression, according to a recent systematic review (petrilli et al., 2022). most of these data have been collected in general population or community samples, which reflect larger trends in cannabis use, potency, and impacts on mental health. however, little work to date has examined these relationships in clinical samples that are likely more vulnerable to the negative health effects of higher-potency cannabis use. cannabis use and cud frequently co-occur with other substance use disorders (suds) (hayley et al., 2017; obadeji et al., 2022; youngwolff et al., 2021), which are often comorbid with mood and anxiety disorders (lowe et al., 2019). cannabis in addiction treatment 69 people with suds may use cannabis for temporary relief of mood and anxiety symptoms, which is a commonly cited reason for medical use of cannabis (corroon et al., 2017; lucas & walsh, 2017). a recent study including a large sample of participants aged 16-65 years residing in canada (n = 10,057) or the united states (n = 17,112) found that prevalence of cannabis use was nearly twice as high among people with at least one mental health condition (not inclusive of sud) compared to those with no conditions (rup et al., 2021). furthermore, participants reporting at least one mental health condition were more likely than those with no conditions to report use of several cannabis product types, especially highpotency products such as vaped oils, orally ingested oils, and concentrates (rup et al., 2021). use of higher-potency cannabis products has been associated with increased risk of cud and selfreport of cannabis consequences (e.g., poor memory and paranoia; freeman & winstock, 2015; gunn et al., 2020). limited research has considered relationships between cannabis product choices and other substance use; for example, vaping cannabis (compared to other methods of cannabis use) has been associated with greater use of alcohol and tobacco among adolescents and adults (morean et al., 2021; sun et al., 2023). however, there is a lack of information about use of cannabis products in people seeking treatment for suds. the ongoing diversification of cannabis products on the market, coupled with the growing evidence that certain cannabis product types (including higher-potency products) are associated with greater risk of cannabisattributable harm, underscores the need to understand cannabis use characteristics among populations who may experience more harms than benefits. we used data from a mixedmethods project to describe cannabis use characteristics of a sample of adults accessing sud treatment in ontario, canada, with two specific goals in mind. first, using quantitative data from a cross-sectional survey, we sought to describe which cannabis products participants report using, where they purchase these products, and where they get information about products, for both self-reported medical and non-medical use. we chose to focus on both medical and nonmedical use of cannabis as there is substantial overlap in use (schauer et al., 2016). moreover, prior work has found a high prevalence of nonmedical (recreational) use among those who selfreport medical use of cannabis, which is even higher among individuals reporting at least one (broadly defined) mental health condition (morean & lederman, 2019). second, using qualitative data from in-depth, one-to-one interviews, we examined reasons for purchasing and using different cannabis products. we note that our focus was on understanding motives for using different cannabis products, not overall motives for using cannabis, which will be explored in a future manuscript. methods this mixed-methods study employed a convergent parallel design. the quantitative (survey) and qualitative (interview) phases of data collection occurred simultaneously; data were analyzed separately and then combined so that both data sources informed one another. participants participants accessing sud treatment in ontario, canada were invited to participate in an anonymous online survey using redcap (research electronic data capture; harris et al., 2009). recruitment flyers were distributed through several networks of hospitals and treatment centres offering addiction treatment services in ontario, canada (e.g., the centre for addiction and mental health [camh] in toronto and st. joseph’s healthcare in hamilton). participants interested in completing the survey were sent a link to view an electronic consent form. participants reviewed the consent form and selected a checkbox to indicate their consent to continue. eligibility criteria were self-reported and included: being 18 years or older, ever accessing services at an addiction-focused treatment center in ontario, and ever having been diagnosed with or treated for any sud. if participants were ineligible, the survey terminated and no data were collected; otherwise, eligible participants were routed to complete the survey. survey completers were directed to a separate redcap project to enter their email address to receive a $20 electronic gift card and to indicate if they were interested in participating in a virtual, in-depth, one-to-one interview (described more below). data collection began in april 2022 cannabis, a publication of the research society on marijuana 70 and concluded in january 2023. this study was reviewed and approved by camh research ethics board (protocol # 061/2021). quantitative measures and analysis demographic and sud information. all demographic and sud questions are available in the supplementary materials. gender identity, sexual identity, racial/ethnic group, income, and education were all recoded from their original values. information about sud treatment type is presented in etable 1. cannabis use characteristics. participants were first asked if they had ever used cannabis (no = never use) and then if they had used cannabis in the past year (no = past use, yes = current use). data from the never use group are not included here but are reported elsewhere. for most questions, the current use group was asked about past-year use (e.g., “in the past 12 months, have you used the following products…”) and the past use group about lifetime use (e.g., “in the past, did you ever use the following products…”). see supplementary materials for all cannabis use questions. data analysis. all quantitative data analysis was conducted in ibm spss statistics (version 27). there were 692 total records in the survey project; 90 records were excluded because they did not provide any data beyond answering the first few demographics questions, and an additional 57 records were excluded for completing the survey in an impractically short time (less than 10 minutes, suggesting poor data quality). one participant did not answer the question about cannabis use history and 72 participants had never used cannabis, leaving 472 for this analysis (363 current use and 109 past use). demographic and cannabis use characteristics are presented descriptively (count and percentages). note that some participants did not answer all survey questions, thus sample sizes differ between survey items. the exact sample sizes informing the descriptive results are included in tables 1 and 2. qualitative data collection and analysis interviews. participants who indicated interest in the interviews were sent an electronic consent form to review. scheduling of interviews was conducted on a first-come basis. all interviews were conducted by the first author (jm) using the webex platform and started with a virtual consent discussion. in addition to meeting the eligibility criteria to participate in the survey, participants were required to endorse current (past-year) cannabis use to participate in the interviews. interviews began once eligibility criteria were confirmed and once the participant signed the electronic consent form. an interview guide was developed and reviewed by the study team. in the first section, participants were asked about cannabis use motives, trajectories, and subjective experiences. in the second section, participants were asked about their cannabis product purchasing and information sources, as well as preferences. finally, the third section focused on cannabis expectancies. the full interview guide is provided in the supplementary materials. interviews were audio-recorded using webex software (no video recording) and transcribed verbatim by a professional transcriptionist. quantitative analysis. the goal of the qualitative data analysis was to better understand reasons for cannabis product choices and sources of information about cannabis, which led us to use a qualitative descriptive analysis approach (doyle et al., 2020). qualitative descriptive analysis is an ideal approach when studies do not need to be grounded in a deep theoretical context, when data coding and analysis are meant to stay close to participants’ experiences (with a focus on description, not interpretation), and when qualitative analysis is conducted in conjunction with quantitative data (i.e., mixed-methods). our coding was semantic and primarily deductive, as it was informed by our pre-existing knowledge of cannabis use and by the structure of the survey responses (i.e., where possible, we tried to align codes with specific response items in the surveys to facilitate comparisons between the quantitative and qualitative data). the entire interview transcript was considered for coding, though we did not engage in line-by-line coding, and coded only data relevant to our research question (which was primarily in the second section of the interview). our research question that guided coding had two parts: part one focused purely on description of which cannabis products participants reported purchasing, where they purchased these products, and where they obtained information about cannabis in addiction treatment 71 products; part two focused on understanding why participants had preferences for different cannabis products. the first two authors, a postdoctoral researcher (jm) and a senior undergraduate student (hs), coded the transcripts. to guide analysis, we followed the steps of thematic analysis as developed by braun and clarke (2006), though we did not follow braun and clarke’s more recent approach of reflexive thematic analysis (braun & clarke, 2019) given that our analysis was intended to be descriptive (not critical/interpretive). first, we read and reread interview transcripts (in their entirety), kept notes, and had regular meetings to discuss initial findings. next, we both independently coded a subsample of interviews, and then met to discuss and develop a working list of codes. hs then recoded all the interviews and jm reviewed all coding and made some minor adjustments (which were mutually agreed upon). codes related to the first part of our research question (i.e., those corresponding to survey items) were used to quantitate and tabulate cannabis use characteristics and facilitate comparison with the survey data. once this quantitation was completed, we focused our thematic analysis on the codes that described reasons for cannabis product preferences. to develop themes, we first created a table with our central research question written at the top: “what is guiding cannabis product selection and preferences?” we then added to the table all codes along with their frequency in the dataset and associated data extracts. next, we generated several additional blank tables and copied codes and their associated data extracts into these tables to organize data into tentative themes. to determine if the codes “fit” together and represented a coherent pattern across the entire dataset, we re-read all the data extracts within each code, wrote a new summary of each code, summarized each tentative theme, and then compared the code summaries to the theme summaries to ensure there was internal homogeneity. finally, we named the themes, selected compelling data extracts to support each theme, and further refined each theme as we wrote the initial version of this manuscript. in order to attribute quotes, we assigned each participant a random letter and included their age, gender (note that gender was an open-ended question and the language used to identify participants’ gender matches their verbatim response), and self-reported suds (aud: alcohol use disorder; bud: benzodiazepine use disorder; cud: cannabis use disorder; coud: cocaine use disorder; mud: methamphetamine use disorder; oud: opioid use disorder). table 1. demographic characteristics and self-reported suds, by cannabis use group (n = 472) characteristic current use (n = 363) past use (n = 109) sex assigned at birth (n, %) female male intersex/other 134 (37%) 228 (63%) 1 (0.3%) 44 (40%) 64 (59%) 1 (1%) gender identity (n, %) cisgender woman cisgender man gender minority 125 (34%) 222 (61%) 16 (4%) 45 (41%) 64 (59%) 0 sexual identity (n, %) heterosexual sexual minority 265 (73%) 98 (27%) 100 (92%) 9 (8%) age (mean, sd, range) 35.2 (10.0) [18-69] 35.4 (12.6) [19-73] racial/ethnic group asian black indigenous latin american 40 (11%) 58 (16%) 13 (4%) 20 (5.5%) 31 (28%) 24 (22%) 6 (6%) 5 (5%) cannabis, a publication of the research society on marijuana 72 middle eastern white mixed/other don’t know 7 (2%) 193 (53%) 29 (8%) 3 (0.8%) 2 (2%) 35 (32%) 5 (5%) 1 (1%) income $0 $14 999 $15 000 $29 999 $30 000 $59 999 $60 000 or more don’t know 78 (22%) 100 (28%) 74 (20%) 77 (21%) 34 (9%) 24 (22%) 47 (43%) 13 (12%) 19 (17%) 6 (6%) education less than high school diploma high school diploma some college college diploma some university university degree don’t know 50 (14%) 56 (15%) 43 (12%) 71 (20%) 40 (11%) 103 (28%) 0 17 (16%) 19 (17%) 15 (14%) 24 (22%) 14 (13%) 20 (18%) 0 housing1 own home renting boarding home correctional facility unhoused group home shelter/hostel supportive housing living with parents 58 (16%) 214 (59%) 5 (1%) 2 (0.6%) 12 (3%) 4 (1%) 14 (4%) 15 (4%) 46 (13%) 33 (30%) 52 (48%) 2 (2%) 0 3 (3%) 0 2 (2%) 7 (6%) 13 (12%) sud diagnosis1 (n, %) alcohol use disorder sedative use disorder cannabis use disorder stimulant use disorder cocaine use disorder opioid use disorder hallucinogen use disorder pcp use disorder (and related) inhalant use disorder 207 (57%) 21 (6%) 119 (33%) 51 (14%) 73 (20%) 79 (22%) 20 (6%) 11 (3%) 1 (0.3%) 50 (46%) 9 (8%) 19 (17%) 6 (6%) 25 (23%) 21 (19%) 7 (6%) 1 (1%) 1 (1%) note. 1participants could select multiple options, so column does not add to 100%. results demographic and sud characteristics in both cannabis use groups (current use and past use groups), over half of participants were cisgender men (current use, 61%; past use, 59%), the majority were heterosexual (current use, 73%; past use, 92%), and the mean age was 35 years. the largest percentage of participants selfidentified as white for both groups (current use, 53%; past use, 32%), followed by black (current use, 16%; past use, 22%) and asian (current use, 11%; past use, 28%). in both groups, the most common self-reported sud was alcohol use disorder (current use, 57%; past use, 46%), with similar proportions reporting cocaine use disorder (current use, 20%; past use, 23%) and opioid use disorder (current use, 22%; past use, 19%), and more cannabis use disorder in the current use group (33%) relative to the past use group (17%). see table 1. cannabis in addiction treatment 73 table 2. cannabis use characteristics, by cannabis use groups (n = 465) cannabis use characteristic1 current use (n = 356) past use (n = 109) reason for use (n, %) medical reasons recreational reasons both don’t know 35 (10%) 132 (37%) 177 (50%) 12 (3%) 9 (8%) 78 (72%) 15 (14%) 7 (6%) physician or np recommended medical cannabis (n, %) yes no n=338 104 (31%) 234 (69%) n=68 11 (16%) 57 (84%) authorization for medical cannabis (n, %) yes no n=337 82 (24%) 255 (76%) n=66 9 (14%) 57 (86%) products used for medical purpose2 (n, %) dried flower hashish liquid concentrate oil or disposable vape solid concentrate edible liquid other n=284 235 (83%) 67 (24%) 67 (24%) 110 (39%) 38 (13%) 129 (45%) 50 (18%) 29 (10%) n=39 26 (67%) 6 (15%) 7 (18%) 9 (23%) 4 (10%) 14 (36%) 5 (13%) 6 (15%) thc and cbd content for medical use2 (n, %) cbd only thc only high cbd/low thc high thc/low cbd balanced thc and cbd other n=298 53 (18%) 126 (42%) 56 (19%) 131 (44%) 90 (30%) 8 (3%) n=46 16 (35%) 17 (37%) 8 (17%) 9 (20%) 7 (15%) 5 (11%) source of cannabis product for medical use2 (n, %) self-grown grown by others shared with a group of friends from family or friend from an acquaintance from a dealer or storefront health canada licensed producer by mail order other don’t know n=298 24 (8%) 21 (7%) 34 (11%) 52 (17%) 33 (11%) 222 (74%) 63 (21%) 10 (3%) 8 (3%) n=45 2 (4%) 1 (2%) 15 (33%) 12 (27%) 10 (22%) 23 (51%) 4 (9%) 3 (7%) 0 source of information for medical cannabis use2 (n, %) from a friend from a physician/nurse practitioner from a newspaper article from social media from websites other n=260 99 (38%) 70 (27%) 29 (11%) 55 (21%) 108 (42%) 35 (14%) n=54 20 (37%) 31 (57%) 5 (9%) 10 (18%) 22 (41%) 1 (2%) method of non-medical cannabis use2 (n, %) smoking eating drinking n=350 313 (89%) 187 (53%) 83 (24%) n=105 90 (86%) 42 (41%) 12 (11%) cannabis, a publication of the research society on marijuana 74 vaporizing (non-portable) vaporizing (portable) dabbing other 50 (14%) 118 (34%) 39 (11%) 20 (6%) 11 (10%) 10 (10%) 11 (10%) 4 (4%) source of cannabis product for non-medical use2 (n, %) self-grown grown by others shared with a group of friends from family or friend from an acquaintance from a dealer or storefront health canada licensed producer by mail order other n=349 31 (9%) 26 (7%) 70 (20%) 79 (23%) 60 (17%) 263 (75%) 69 (20%) 4 (1%) n=108 5 (5%) 5 (5%) 60 (56%) 32 (30%) 21 (19%) 40 (37%) 4 (4%) 2 (2%) note. 1current users were asked about their cannabis use characteristics in the past 12 months, while past users were asked about their characteristics over their lifetime. 2participants were instructed to select no option if none applied, thus the total n for each question is different; participants could also select more than one option, so columns do not add up to 100%. cannabis use characteristics (survey) overall, the majority of participants reported recreational use (current use, 37%; past use, 72%) or mixed recreational/medical use (current use, 50%; past use, 14%). medical use only was rare in both groups (current use, 10%; past use, 8%). all participants were asked additional questions about both medical and non-medical use of cannabis, regardless of their endorsement of medical/non-medical use in this initial question. see table 2. medical use. a minority of participants had received a recommendation from a physician or a nurse practitioner to use cannabis for medical purposes (current use, 31%; past use, 16%) and a slightly lower percentage self-reported receiving an authorization to use medical cannabis (current use, 24%; past use, 14%). among both groups, the most common product used for medical purposes was dried flower (current use, 83%; past use, 67%), followed by edibles (current use, 45%; past use, 36%), and then oil or disposable vape (current use, 39%; past use, 23%). in the current use group, the most common cannabinoid profile of medical cannabis was high thc/low cbd (44%), followed closely by thc only (42%), and then balanced thc and cbd (30%). in the past use group, the most common profile was thc only (37%), followed by cbd only (35%), and then high thc/low cbd (20%). the current use group predominantly sourced cannabis products for medical purposes from a dealer (presumably illicit source) or storefront (74%), while the past use group reported more a range of sources, mixed between a dealer or storefront (51%), shared with a group of friends (33%), or from family/friends (27%). the most common source of information about cannabis for medical purposes among the current use group was websites (42%), followed by friends (38%), and then from a physician or nurse practitioner (27%). among the past use group, physician/nurse practitioner was the most common source (57%), followed by websites (41%), and then friends (37%). non-medical (recreational) use. for recreational purposes, the vast majority of both the current use group (89%) and the past use group (86%) reported smoking, while the second most common method was eating cannabis (current, 53%; past use, 41%). portable vaporizers and drinking cannabis were also relatively common in the current use group only (34% and 24%, respectively). the current use group predominantly sourced non-medical cannabis from a dealer or storefront (75%), while the past use group shared cannabis with friends or family (56%), obtained from a dealer or storefront (37%), or from a friend or family (30%). qualitative results (interviews) in terms of gender, age, and self-reported sud diagnosis, the interview sample was very similar to the survey sample. we provide in table 3 quantitation of the qualitative interview transcript coding. overall, the interview data triangulate with the survey data: purchasing from cannabis in addiction treatment 75 a legal storefront was the most common method of accessing cannabis (90.9%), smoking was the most common mode of use (72.7%), and dried flower was the most commonly reported product (86.4%). the only notable difference was source of information: in the interviews, most participants reported getting information about cannabis products from non-government websites (59.1%) or directly from legal storefronts (50.0%). in the survey (see table 2), 27% of participants in the current use group reported getting information about medical cannabis from a physician or nurse practitioner, yet no interviewed participants mentioned obtaining any information about cannabis from a healthcare provider. obtaining information directly from legal storefronts was not an option in the survey, though it could have been included in the “other” option reported by 14% of participants in the current use group. thus, it is likely that our survey missed capturing the high proportion of cannabis consumers obtaining cannabis information from storefront dispensaries, an important insight gained from the interviews. table 3. sociodemographic, clinical, and cannabis use characteristics of the interview sample (n = 22) pre-interview questions gender1 (n, %) female male genderfluid 9 (40.9%) 12 (54.5%) 1 (4.54%) age (mean, sd, range) 34 (7.0) [21-47] sud diagnosis2 (n, %) cannabis use disorder alcohol use disorder cocaine use disorder methamphetamine use disorder benzodiazepine use disorder mdma use disorder opioid use disorder ketamine use disorder 11 (50.0%) 13 (59.1%) 3 (13.6%) 2 (9.09%) 1 (4.54%) 1 (4.54%) 3 (13.6%) 1 (4.54%) quantitation of qualitative coding where do you access cannabis? (n, %) legal storefront government website illicit source friends or family grow at home 20 (90.9%) 2 (9.09%) 3 (13.6%) 5 (22.7%) 2 (9.09%) where do you get information about cannabis? (n, %) legal storefront friends or family government website non-government website other no info needed 11 (50.0%) 5 (22.7%) 1 (4.54%) 13 (59.1%) 1 (4.54%) 3 (13.6%) mode of cannabis use (n, %) dabbing oral smoking topical vaping 5 (22.7%) 14 (63.6%) 16 (72.7%) 1 (4.54%) 12 (54.5%) product type (n, %) cannabis, a publication of the research society on marijuana 76 capsules or oils cbd-dominant or cbd-only concentrates dried flower drinks edibles vape pen 4 (18.2%) 6 (27.3%) 4 (18.2%) 19 (86.4%) 1 (4.54%) 14 (63.6%) 13 (59.1%) note. 1“what is your gender?” was an open question; participants’ preferred/self-reported language is used here. 2participants could indicate multiple sud options. in addition to quantitation of the codes used to describe cannabis use characteristics, which was intended to complement the survey data, we used thematic analysis to determine what was guiding participants in making decisions about purchasing cannabis products. we developed three themes. our first theme, thc to feel high, describes how thc content was by far the most consistent factor guiding cannabis product decisions. nearly all participants (n = 19) were interested in knowing the thc content of cannabis products when making purchasing decisions. some participants wanted the highest possible thc content, such as participant a (31, female, cud), “i base mine on the highest percentage of thc,” and participant c (47, female, mud/oud), “i always look for a higher thc level.” other participants had specific preferences for thc content. six participants who primarily purchased dried flower explicitly stated their preferred thc content, which ranged from 16% to 30% thc. other participants were less specific, but wanted more thc than cbd or no cbd at all, such as participant f (31, female, cud), “i typically try to go for the strains that have more thc than cbd,” and participant v (40, male, aud/bud/cud), “i'm not looking for it [cbd]… because it takes away from the thc in the weed.” some participants noted changes in their thc preferences, e.g., participant e (33, male, cud): “if you would have asked me a month ago, i would have told you that i'm looking for the highest thc level. but now that i've been dealing with getting sick from smoking so much, i’m actually trying to keep it around, like, 20 at highest.” while most participants spoke about thc content independently of specific product types, product type and route of administration came up more often in relation to the speed or intensity of the thc high. using cannabis concentrates with a vape pen or by dabbing (which typically deliver very high doses of thc) were preferred for the immediate feeling of high and the intensity of the high. for example, participant n (28, female, aud/cud) noted, “i also have been, like, smoking dabs more recently” because “it’s a way faster high.” similarly, participant c (47, female, mud/oud) noted, “smoking, like, the distillate, or the pens, it's really intense. it gets me, like, it gives me an intense feeling, right?” she also noted that “oils, or, like, the shatter products…intensify the feeling of the other drugs.” she went on to explain that the choice to use “more intense products” was dependent on setting: “so, i'll smoke that [high-potency products] in, like, a social situation, if i'm having company over, you know, whereas i'll smoke the flower when i'm by myself. i'll take a hit off a bong, just to relax, chill out, you know. i'm by myself.” some participants reported disliking edibles because of the delayed onset of effects or because of a blunted or nonexistent high. for example, participant p (25, male, aud/cud/coud) explained that “just having to wait for an hour and having it last for longer periods of time than smoking flower is not as ideal for me.” one participant, however, did have a dissenting opinion on edibles: participant l (40, male, oud) noted, “for the longest time i was very apprehensive to getting edibles because my experience with them has been that they're way too strong, like they're uncomfortably strong.” in summary, our first theme identified thc content as the most consistently self-reported factor in determining cannabis product choices across our dataset. nearly all participants often looked for higher-thc products, and many preferred inhaled products with very high thc levels such as vape pens and dabs, which suggests that the speed and intensity of the thc high are major motives for choosing between products. however, is it important to note that not all participants were interested in high-thc cannabis in addiction treatment 77 products, and among those who were, preferences for products changed both in the short-term (e.g., when in a social setting compared to using alone) and the long-term (e.g., in response to experiencing physical or mental health challenges). in general, choosing cannabis products based on thc content was unrelated to other substance use or sud symptoms, with the exception of one participant who felt that higherpotency products intensified the effects of other drugs. our second theme, health and harm reduction, describes how participants are often concerned about their physical and mental health when choosing cannabis products, which leads to a focus on cbd content or avoiding certain products that have had negative effects in the past. under half of participants (n = 8) specifically mentioned cbd content as an important factor guiding cannabis product decisions. unlike with thc content, no participants had a numeric cbd content in mind when purchasing products, but rather looked for any “high-cbd” or “balanced” (cbd-thc equivalent) products. of the seven participants who mentioned potential medical benefits as a factor when deciding which cannabis products to purchase, five specifically mentioned cbd, which was perceived as being useful for pain management, anxiety reduction, and improved sleep. for example, participant r (29, female, mud) noted that “higher cbd is better for pain. so, i was smoking higher cbd in my weed, and it was helpful... and it was nicer than taking the percocets because i didn't like how they made me feel”. similarly, participant q (47, male, cud) noted, “it's all mainly cbd-based… i take it if i have anxiety or, you know, my back's killing me, and stuff like that.” other participants used different cannabis products (especially high-cbd products) as a harm reduction strategy, such as participant p (25, male, aud/cud/coud): “i sometimes use cbd if i'm just taking a break from smoking [cannabis], whether it's for, you know, a week or a month…it’s a good substitute because it doesn’t get me high. and it can also help with, like, the general withdrawal of not smoking weed, just the anxiety, the lack of sleep, all those things. cbd helps a lot with that.” participant k (34, male, aud) described gravitating towards higher-cbd products because “it gives me kinda something to do with my hands” during periods of reducing use of thc. he made an analogy with alcohol: “[cbd] is like, non-alcoholic beer or something like that, you know?” similarly, participant g (29, male, aud) noted, “i tend to go for higher cbd and then lower thc strains because i do not know my limits and i will smoke an entire joint to myself. and if i smoke something that's far too concentrated in thc, then i will be, like it will take my entire day away from me.” some participants felt that the use of specific cannabis products helped them avoid or reduce alcohol use. participant t (38, female, aud/coud) explained that, “i will buy the weed drinks just for the social aspect, if my friends are drinking beer or something.” she elaborated that consuming cannabis-infused beverages substituted for drinking alcohol in social situations because she “[felt] more involved” when others were drinking alcohol. similarly, participant j (39, male, aud) described using certain products to avoid drinking alcohol: “in my current moments when i feel like i would rather go binge drinking, to not be drinking, i use concentrates, like a lot, like maybe one gram of concentrate with, like, 80% of thc.” while he perceived this use of high-thc products as harmful to his health, it was still reduced harm compared to using alcohol: “i would rather relapse on using too much cannabis rather than using any amount of alcohol, which leads to painful abstinence syndrome later.” under half of participants (n = 9) were motivated by avoiding or reducing negative effects when purchasing cannabis products. choosing products based on their anxiolytic effects was common, which was sometimes linked to the distinction of indica or sativa products. for example, participant a (31, female, cud) explained, “so, if i smoke an indica, i know it's gonna come. the anxiety is, or the paranoia may set in more. when i'm smoking a sativa or a sativa hybrid profile, i don't feel as much anxiety and paranoia… versus if i'm smoking an indica, then i'm locked in my chair just sitting there, thinking, like, why did i do this to myself?” for other participants, more cbd and less thc was a strategy to avoid anxiety, as described by participant f (31, female, cud): “and then just in certain circumstances when i have experienced anxiety from strains that have maybe a little bit too much thc, i will try to do a little bit more of the cbd.” for some participants, edibles were cannabis, a publication of the research society on marijuana 78 preferred over dried flower products to avoid inhaling smoke, such as participant g (29, male, aud): “i got into edibles for a little bit, because i got sick, and i felt like it wasn't smart to be smoking. so, i started buying any kind of edible that i could find at the dispensary, and keeping my dosage to maybe, like, 50 milligrams max, because i know i'm super sensitive to edibles.” others preferred vaping for health reasons, such as participant e (33, male, cud): “um, vaping's kind of, like, the middleman. like, he's in-between to help with the cravings, or if i'm sick and would rather vape than smoke to, you know, not hurt my throat or lungs as much as much. like, it's just something to puff on through the day.” in contrast, two participants were concerned about potential harmful effects of vaping. for example, participant m (30, genderfluid, aud/cud) described an unpleasant experience with vaping: “it was a more intense kind of burning and kind of spasming that i felt, i felt in my lungs. and i had a way more severe kind of, very bronchial kind of chest cough that i hadn't had before.” in summary, our second theme demonstrates how participants perceive the relationship between cannabis products and their physical and mental health, which can influence product choices. for some participants, products with more cbd were perceived as having some direct medical benefits or as being useful for reducing thc intake. a few participants used specific cannabis products (beverages or high-potency concentrates) as a strategy to avoid or reduce use of alcohol. edibles and vaping were sometimes preferred over smoking cannabis to avoid some of the perceived physical health consequences of smoking. in some cases, participants had negative experiences with certain products, which led them to find alternative products. our third and final theme, convenience, familiarity, and price, describes how participants are not always concerned about the cannabinoid content or specific effects of cannabis products. under half of participants (n = 8) highlighted the convenience of either purchasing or using a product as an important factor guiding purchasing behaviour. for example, participant k (34, male, aud) noted the convenience of using vape pens: “if i’m out and about and i want a quick puff, i'll just have my vape pen in my bag.” similarly, participant g (29, male, aud) noted, “ah, if i'm lazy, [i’ll buy] pre-rolled joints.” a similar minority of participants (n = 7) noted that their choice of products was rooted in familiarity. for nearly all of these participants, smoking dried flower was their introduction to using cannabis and this remained their preferred mode of use. for example, when participant p (25, male, aud/cud/coud) was asked why he preferred purchasing dried flower, he explained: “just the way i've always been consuming weed is i prefer it that way.” similarly, participant m (30, genderfluid, aud/cud) explained (about smoking dried flower), “i think there's an aspect that that's kind of how i was introduced into weed. i don't really know any other way. i did, for a while, when i was trying to get off smoking and i was vaping for a while, i did vape some weed, and didn't really like the effect that i felt on it, on my lungs and stuff.” finally, some participants (n = 7) focused mostly on the price of products when deciding which to purchase. often, the price influenced where participants would purchase products, but sometimes price also influenced which types of products to purchase. for example, participant v (40, male, aud/bud/cud) noted that his continued purchase of one specific strain of dried flower was because “that's the biggest bang for your buck.” in summary, our third theme demonstrates that thc and cbd content and expected drug effects are not always guiding factors when choosing between products. sometimes, the convenience of purchasing or using certain products supersedes other factors, or the price is more salient. for some participants, familiarity with one mode of cannabis use (usually smoking dried flower) led to a consistent preference when making purchasing decisions. it is important to note that, across all three themes, most participants reported multiple (sometimes opposing) reasons for choosing certain products over others, which varied depending on factors such as social setting and changes in mental or physical health. discussion growing evidence suggests that risks associated with cannabis use vary by product type, yet little research has examined cannabis use characteristics of patients accessing sud cannabis in addiction treatment 79 treatment, who are likely at elevated risk of experiencing cannabis-attributable harms. using data from a mixed-methods project of patients accessing sud treatment, our goal was to use quantitative survey data to describe cannabis use characteristics and qualitative in-depth interview data to better understand why certain cannabis products are preferred. overall, we found that the most common mode of using cannabis was smoking dried flower, yet there was considerable use of edibles and higher-potency products such as concentrates. in our qualitative analysis, we found that nearly all participants looked to thc content when purchasing products and often favored products and modes of use that led to faster or more intense highs. yet, some participants were motivated by avoiding negative effects (e.g., titrating down thc content to avoid ill health) or by perceived medical effects when purchasing certain products (especially cbddominant products). further, other motives such as convenience, familiarity, and price were occasionally more salient when choosing cannabis products. most of the cannabis characteristics (based on both the survey and the interview data) followed expected patterns that mirror large population surveys such as the 2018-2023 canadian cannabis surveys (health canada, 2023). the most commonly reported cannabis products for medical purposes were dried flower and edibles, the most common method of recreational cannabis use was smoking (followed by eating), and most common source of cannabis was legal storefronts or dealers (though there was a higher proportion of the past use group that reported obtaining cannabis from friends and family). there were notable percentages of participants reporting using liquid concentrates (24% of the current use group), oils or disposable vapes (39%), and solid concentrates (13%) for self-reported medical purposes. this is concerning since these product categories are typically associated with increased harms (matheson & le foll, 2020), yet is in line with prior work. for example, results from the international cannabis policy study revealed a higher likelihood of using higher-potency cannabis products (including concentrates) in survey respondents reporting mental health conditions compared to those with no conditions (rup et al., 2021). in the 2023 canadian cannabis survey, 22% of respondents who had used cannabis for mixed (medical and non-medical) purposes reported use of concentrates or extracts, compared to just 9% of respondents reporting either medical or non-medical use only (health canada, 2023). the prevalent use of high-potency cannabis products in this sample of patients accessing sud treatment could present an important opportunity for better knowledge exchange between clinicians and patients. in the current cannabis use group, only 27% reported getting information about medical cannabis from a physician or nurse practitioner (while 42% reported getting information from websites and 38% from friends). this finding was corroborated in the qualitative interviews where not a single participant mentioned getting any kind of information about cannabis from their clinicians (most participants asked budtenders at legal storefronts or relied on websites like reddit for medical information). one potential reason patients are not discussing their cannabis use with clinicians and healthcare providers is stigma. in prior qualitative research from canada, people who used cannabis for medical purposes reported experiencing skepticism and dismissal from healthcare providers, which likely eroded trust in patient-provider relationships and may have led to increased covert use of cannabis (bottorff et al., 2013). relatedly, lack of sufficient training and education about cannabis use (including potential medical uses) could make clinicians hesitant to ask patients about cannabis, especially given the rapidly evolving cannabis landscape (fehr et al., 2024). more work is needed to overcome barriers related to cannabis knowledge exchange between patients and clinicians, which will hopefully present opportunities for clinicians to counsel patients to limit their use of high-potency products and other potentially risky or harmful cannabis use patterns. improved knowledge exchange will also be necessary if medical cannabis is to be considered in the context of sud treatment, given the complexity of evidence for balancing harms and potential medical benefits of cannabis in patients with suds (fehr et al., 2024). in our thematic analysis, we found that thc content was the most common deciding factor when choosing products, where a high thc content was preferred. modes of use that increase the speed or intensity of the cannabis high (e.g., cannabis, a publication of the research society on marijuana 80 dabbing or vaping concentrates) were often (but not always) preferred over modes with slow onset of effects (e.g., edibles). conversely, about half of participants were also motivated by avoiding negative effects or by perceived medical benefits of certain cannabis products, especially cbd products (e.g., effects on sleep, pain, or anxiety, or reduction of harms associated with thc use). a prior survey of adults self-reporting medical use of cannabis found that use of vaporized concentrates was significantly higher when participants reported mixed (recreational/medical) use of cannabis compared to medical use only (46% vs. 25%), which led the authors to suggest that use of concentrates might facilitate recreational use among individuals reporting primarily medical use of cannabis (morean & lederman, 2019). our data lend partial support to this interpretation; while none of our interviewed participants used cannabis exclusively for medical reasons, many reported using certain cannabis products (e.g., edibles, high-cbd products) for perceived medical effects, despite also using higher-thc products (including concentrates) for non-medical purposes, usually on different days or for different periods of time. use of different products for different reasons at different times presents a substantial challenge to interpreting data examining the health effects of cannabis, yet prior work has employed different methodologies to capture this level of nuance. for example, a study using ecological momentary assessment (ema) daily diary data found that individuals who reported mixed use of cannabis used less cannabis and alcohol on days when cannabis was used for medical reasons, while they reported greater use of both cannabis and alcohol on days when cannabis was used for exclusively non-medical reasons (coelho et al., 2023). furthermore, the reduction in both cannabis and alcohol use on days of medical reasons for using cannabis was not accompanied by a change in the number of different types of cannabis used, suggesting that decreased use of dried flower for medical reasons was not accompanied by an increase in use of other cannabis product types (coelho et al., 2023). the use of cannabis as harm reduction has received a lot of attention in the literature (adinoff & cooper, 2019; chaiton et al., 2022; fehr et al., 2024), which was echoed in a minority of participant interviews, where reducing harms was a major motivating factor for some participants when deciding which products to use. among participants who perceived specific cannabis products as potential harm reduction, the majority focused on cbd-containing products as a strategy for reducing harms associated with thc use. some participants perceived cbd as a substitute for thc, while some had the perception that cbd helped manage withdrawal symptoms when abstaining from or reducing use of thc. this is similar to the findings of a cross-sectional study in france, where a minority of participants who used cannabis (11%) reported that their primary motive for using cbd was to reduce cannabis consumption, and this was reportedly due to cbd reducing withdrawal symptoms (fortin et al., 2022). whether or not cbd is an effective treatment for sud symptoms is beyond the scope of our paper (readers are directed to recent reviews on this topic [elsaid et al., 2019; karimi-haghighi et al., 2022; kloiber et al., 2020; nona et al., 2019; paulus et al., 2022]), but our data suggest that cbd may have some value as a harm reduction approach for some patients with cud. relatedly, two participants shared experiences of using specific cannabis products to reduce or avoid alcohol use. one participant who was abstinent from alcohol used thc-infused beverages to feel “included” in social situations where friends were drinking alcohol, while another participant used high-potency cannabis concentrates during periods of strong alcohol cravings to reduce the chances of returning to alcohol use. these findings are not meant to be generalized to imply that cbd or other cannabis products are useful for harm reduction for all patients with suds, but rather provide examples of how individual patients in sud treatment who use cannabis may benefit from considering alternative cannabis products as part of their therapeutic journey in reducing substance-related harms. this work should be interpreted with certain limitations in mind. these data are crosssectional, and thus we cannot infer causality or direction of effects. due to the anonymous nature of the survey, we relied on self-report to identify individuals with suds, so we cannot be sure all participants meet dsm-5 criteria for a sud. while it was an intentional decision to recruit participants in sud treatment without specifying sud type, it is possible that our findings may differ by substance of choice (e.g., product motives cannabis in addiction treatment 81 might differ for patients with oud vs. aud). there were some differences in the cannabis use questions for medical and non-medical use (e.g., participants were asked about product types for medical use but modes of use for non-medical use), which limited some of the comparisons we could make. relatedly, the current cannabis use group was asked about past-year use of cannabis while the past cannabis use group was asked about lifetime use of cannabis, which precluded any statistical comparison between those two groups. in our survey questions about cannabis access, “from a dealer or storefront dispensary” was a single response option, so we unfortunately could not distinguish between legal and non-legal access of cannabis in the survey. since the survey was anonymous and we did not repeat the demographics questionnaire with interviewed participants, the interview sample is missing more comprehensive demographic information (e.g., we do not know the race/ethnicity of the participants we interviewed). further work is needed to extend our findings in different demographic groups and to characterize cannabis product choices from an intersectional perspective. finally, while our qualitative results give important insights into some potential factors that guide cannabis product decisions among people accessing sud treatment, our results are not meant to generalize beyond the interview sample and cannot speak to causal mechanisms underlying purchasing decisions. future work employing human experimental paradigms (e.g., placebo-controlled laboratory studies comparing addiction liability across cannabis product types) will serve as an important complement to our mixed-methods approach. conclusion we described cannabis use characteristics and reasons for choosing specific products among patients accessing sud treatment. in line with prior surveys, dried flower was the most commonly reported cannabis product type and smoking was the most common mode of use, though edibles were common as well, with highpotency products such as concentrates and disposable vapes reported by about a quarter of participants for self-reported medical use. importantly, only about a quarter of participants currently using cannabis reported obtaining information about medical use of cannabis from a clinician, which was corroborated in the in-depth interviews where not a single participant sought cannabis information from healthcare professionals. instead, storefront dispensaries and non-government websites seem to be predominant sources of information about cannabis products (including medical use). in thematic analysis of interviews, we found that thc content was a primary reason for choosing cannabis products, with many participants preferring cannabis products (e.g., dabs, concentrates) for faster or more intense high. yet, some participants’ product choices depended on perceived medical effects or harm reduction, while other participants were more concerned with convenience, familiarity, or price. these results contribute to an evolving cannabis literature 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(2021). nicotine and cannabis vaping among adolescents in treatment for substance use disorders. journal of substance use and addiction treatment, 125, 108304. https://doi.org/10.1016/j.jsat.2021.108304 funding and acknowledgements: funding was received from the mental health commission of canada (mhcc), through a canadian institutes of health research (cihr) grant (application number 454899). the views represented herein solely represent the views of the researchers and do not represent the views of mhcc. the funder was not involved in the design or conduct of the study or interpretation of study results. bernard le foll has obtained funding from pfizer (grand awards, including salary support) for investigator-initiated projects. dr. le foll has some in-kind donation of cannabis product from aurora and medication donation from pfizer and bioprojet and was provided a coil for tms study from brainsway. dr. le foll has obtained industry funding from canopy (through research grants handled by camh or the university of toronto), bioprojet, acs and alkermes. dr. le foll has received in kind donations of nabiximols from gw pharma for past studies funded by cihr and nih. he has been a consultant for shionogi. he is supported by camh and a clinician-scientist award from the department of family and community medicine of the university of toronto and an addiction psychiatry chair from the department of psychiatry of the university of toronto. he also participated in an advisory board meeting for indivior and got a grant from indivior for a clinical trial. james mackillop is a principal and senior scientist in beam diagnostics, inc. and has consulted to clairvoyant therapeutics, inc. dr. mackillop is supported by the peter boris chair in addictions research and a canada research chair in translational addiction research (crc-2020-00170). matthew sloan receives research funding from the canadian institutes of health research (cihr) and the centre for addiction and mental health discovery fund. dr. sloan is also supported in part by an academic scholar award from the department of psychiatry, university of toronto. stefan kloiber reports grants from the labatt family innovation fund in brain health (department of psychiatry, university of toronto), the max bell foundation, the canadian centre on substance use and addiction, the centre for addiction and mental health discovery fund, the ontario ministry of health and long-term care (mohltc), the canadian institutes of health research (cihr), and the international ocf foundation (iocdf). dr. kloiber received honorarium for consultation from empowerpharm. no other authors have relevant declarations. justin matheson would like to thank the centre for addiction and mental health (camh) womenmind community for salary support while conducting this study. the authors are grateful to the participants who took part in the study and to the clinical and research staff at camh, st. joseph’s healthcare hamilton, and other centres in ontario that helped with recruitment. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: matheson, j., saini, h., haines-saah, r., sanches, m., sloan, m. e., zaweel, a., hassan, a., buckley, l., porath, a., mackillop, j., hendershot, c. s., kloiber, s., & le foll, b. (2025). cannabis use characteristics and reasons for product choices among patients accessing treatment for substance use disorders: a mixedmethods study. cannabis, 8(2), 67 84. https://doi.org10.26828/cannabis/2025/000309 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ research article 9 ved abstract objective: u.s. cannabis policy has been shaped by racism and produced racist outcomes. the legalization of cannabis for adult use represents an opportunity to end harmful policies and repair some of the damage caused by the war on drugs. however, this opportunity may be slipping away. large corporations with histories of exploitation are steering cannabis policy to maximize profits. parabola center for law and policy created a media campaign to educate the public about these issues and promote cannabis policies that benefit regular people. we conducted an experiment in the context of an online survey to determine whether six videos from the campaign would resonate with u.s. adults and influence beliefs about cannabis policy. method: in september 2023, we conducted an online survey of 404 u.s. adults. participants were randomized to view six parabola campaign videos featuring cannabis policy experts before or after responding to survey questions. results: participants who saw the parabola campaign videos had greater agreement that cannabis legalization should not benefit the tobacco industry, the pharmaceutical industry, and alcohol companies (all p < .05). they also had greater agreement that legalization should create space for small businesses, create a sharing community, and benefit people from communities that have been harmed by the drug war (all p < .05). conclusions: public education can be a powerful tool to promote equity-focused cannabis policy, by raising awareness of corporate influence, promoting community-centered regulatory models, and building support for an equitable approach to federal legalization. key words: = cannabis; marijuana; policy; media u.s. cannabis policy has been shaped by racism. historically, cannabis messaging has exploited racially coded fears of criminality. this has been consistently documented, with an early example being the campaign for the marijuana tax act of 1937 (national academies of sciences engineering and medicine, 2024). during the mid-1960s, “public confusion, anger, and fear” about cannabis grew, as a behavior associated with “marginal citizens” became prevalent among “children of the dominant majority” (national commission on marihuana and drug abuse, 1972). within this social context, cannabis was classified in 1970 as a “schedule i” controlled substance, meaning it ostensibly had no accepted medical use and high potential for misuse (united states drug enforcement administration, 2024). president nixon appointed a commission to conduct a broad review of cannabis use in the united states, including the efficacy of existing cannabis laws (wgbh educational foundation, 2024). the national commission on marihuana and drug abuse—commonly referred to as the shafer commission—published its report in 1972 (wgbh educational foundation, 2024). the commission concluded that prohibition failed to jane appleyard allen1, shaleen title2, & brian bradfield1 1rti international 2parabola center for law and policy cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000299 volume 8, issue 3 same story, different seller: teaching the public how cannabis models driven by profit create the same injustices as prohibition corresponding author: jane appleyard allen, ma, rti international, 307 waverley oaks rd #101, waltham, massachusetts 02452. phone: (781) 370-4041. email: janeallen@rti.org cannabis, a publication of the research society on marijuana 10 prevent cannabis use, discouraged treatment seeking, undermined public education, and that, in general, existing cannabis law was “out of proportion to the individual and social harm engendered by the drug” (national commission on marihuana and drug abuse, 1972). nixon disregarded the report, pouring energy into a “war on drugs” that was later described by aide john ehrlichmann as an excuse to criminalize black people (equal justice initiative, 2016). today, u.s. cannabis policy produces racist outcomes in the united states and around the globe (acker j, 2019; alang, et al., 2017; alexander, 2012; cooper, 2015; daniels et al., 2021; drug policy alliance & harm reducation international, 2024; edwards et al., 2020; mueller, gebeloff, & chinoy 2018; stowe et al., 2024; substance abuse and mental health services administration, 2020; the public science project and drug policy alliance, 2021). in the united states, there are stark racial inequities in arrest rates for cannabis possession (edwards et al., 2020). although use of cannabis is similar by race, black people are arrested for possession at approximately four times the rate of white people (edwards et al., 2020; substance abuse and mental health services administration, 2020). studies also document disproportionate cannabis possession arrest rates for hispanic/latino/a and indigenous people (mueller, gebeloff, & chinoy, 2018; the public science project and drug policy alliance, 2021). arrests and other engagement with the u.s. legal system, including stops and detainments, produce negative health, financial, and social outcomes for individuals as well as for their families and communities (acker j, 2019; alang et al., 2017; alexander, 2012; cooper, 2015). the harm resulting from cannabis-related interactions with the u.s. legal system can be felt over generations (alexander, 2012). the u.s. government has used its global influence to export its prohibitionist approach to drugs to low and middle-income countries around the world (drug policy alliance & harm reducation international, 2024). specifically, it has used its economic and military power to pressure countries in the global south to adopt policies that criminalize drug use (stowe et al., 2024). this has led to the suppression of traditional and sacred use of cannabis, despite the plant’s significant role in rastafari, sufi, and hindu traditions, for example (daniels et al., 2021). and, as in the united states, these policies have led to the disproportionate criminalization of black, brown, and indigenous people (daniels et al., 2021; drug policy alliance & harm reducation international, 2024). the u.s. legalization of cannabis for adult use represents an opportunity to end harmful policies and repair some of the damage caused by the war on drugs. however, legalization in itself does not end or repair disproportionate harm. for example, although we see a marked decline in cannabisrelated arrests in u.s. states that legalize cannabis for adult use, racial inequities in arrest rates remain, or grow worse (firth et al., 2019; gunadi & shi, 2022). this is because the systemic racism that underlies u.s. cannabis policy persists as states create a new legal cannabis industry. cannabis legalization provides an opportunity, however, for people and communities to become educated about past and ongoing harm. as a result, communities can choose to envision and shape policy that rejects profit-driven corporate values in favor of other social and economic models. by way of example, we see state social equity programs providing assistance for people harmed by the war on drugs to enter the legal industry, and states committing a portion of their cannabis tax revenue to community reinvestment (commonwealth of massachusetts cannabis control commission, 2024; illinois department of commerce and economic opportunity, 2024; new york state office of cannabis management, 2024; the state of new jersey, 2021). although these programs have not been fully realized, they demonstrate an openness to different policy models. this opportunity may be slipping away. as states experiment with policies to center equity and repair harm, large corporations with histories of exploitation are steering federal cannabis policy toward the maximization of profits. organizations such as the coalition for cannabis policy, education, and regulation (cpear) lobby on behalf of members including altria (parent company of philip morris), reynolds american, and molson coors beverage company (coalition for cannabis policy education and regulation, 2022). during the 2022 and 2024 election cycles, organizations and individuals spent more than $10 million on cannabis lobbying. cpear lobbying expenditures account for about one-tenth of the total (open secrets, 2024). in short, the profit models create injustice 11 united states is poised to legalize cannabis at the national level with substantial input from large corporations and without meaningful consideration of systems to support equity. this will “lock us in” to cannabis policy that prioritizes profit to the exclusion of equity. small businesses will be unable to compete. state efforts to advance equity will erode. based on historical evidence, the federal government will pave the way for the tobacco industry to target black, brown, and lowincome communities and lowand middle-income countries, marketing novel cannabis products engineered to addict (barry, hiilamo, & glantz, 2014; centers for disease control and prevention, 2022; lee, ling, & glantz, 2012; unknown, 1983). tobacco companies and other large corporations will extract profit from the same neighborhoods that have been devastated by the racist war on drugs (barry et al., 2014; coalition for cannabis policy education and regulation, 2022). public education can play a role in averting this outcome. studies show that although most americans support legalization, many do not have fixed opinions about what cannabis policy should look like (allen et al, 2023; pew research center, 2022). moreover, findings from a recent study show that an educational message is associated with greater support for specific cannabis policies that can create a more equitable industry (allen et al., 2023). this study uses an online experiment to test the efficacy of six videos, in which cannabis policy experts invite viewers to consider policies that put regular people and small businesses first. methods theoretical underpinnings of the study design the design of this study is based in behavior change theory, with an emphasis on the theory of reasoned action and the theory of planned behavior (ajzen, 1991; fishbein, 1967). these theories posit that beliefs underpin attitudes and social norms, which in turn contribute to intention to engage in behavior and behavior change. the centers for disease control and prevention (cdc) advises that, to achieve sufficient awareness levels to generate population-level belief and behavior change, public education campaigns should reach at least 75% of the intended audience in each quarter of the first year of a campaign (centers for disease control and prevention, 2014). having achieved that, and when the campaign consists of messages that resonate with and are respectful of the intended audience and which address beliefs that have “room to move,” evaluators might expect to observe belief change within 6-12 months, and behavior change within 12-18 months (centers for disease control and prevention, 2014; hornik & woolf, 1999; zhao et al., 2020). large-scale campaign evaluations may conduct longitudinal baseline and follow-up data collections to document campaign awareness, campaign resonance, and belief and behavior change. however, these types of evaluations are often not feasible for campaigns with modest budgets, tight timelines, campaigns that have already launched, or campaigns designed for smaller, systematically underserved, and hard-toreach populations. an alternative evaluation design is an efficacy study. an efficacy study uses an online experiment to manipulate exposure within a study sample. by comparing the beliefs of those exposed to campaign media with the beliefs of those who were not exposed, it is possible to assess the immediate, short-term effects of campaign exposure. this type of study provides insight into whether a campaign has the potential to be effective if population-level awareness is great enough. study design and implementation we conducted an experiment in the context of an online survey to determine whether six videos featuring cannabis policy experts would 1) resonate with adults in the united states and 2) influence beliefs about the future of cannabis policy. from september 12 through 25, 2023, we recruited a nonprobability sample of 404 adults aged 21 and older who were members of a dynata panel. dynata is a company that has developed and maintains an online group of people who participate in surveys for rewards. individuals who were eligible and consented to participate were assigned using true randomization to one of two study conditions. respondents in condition one (“exposed” condition) watched six videos before answering questions about cannabis policy. respondents in condition two (“not exposed” condition) answered survey questions before watching the videos. the order in which respondents received the videos was randomized cannabis, a publication of the research society on marijuana 12 to preclude order effects. the videos were part of a larger media campaign—the parabola campaign—that only aired publicly after this study had ended, to ensure that study participants could not have seen the videos prior to study participation. the study protocol, consenting documents, and survey instrument were approved by rti’s irb. the 20-minute survey was optimized for use on mobile devices. the study design is summarized graphically in figure 1. figure 1. parabola campaign study design we used the survey screener to intentionally develop a nonprobability sample that was racially diverse and had good variation on political philosophy. we consider it a priority to emphasize the perspectives of black and latine people in research that may shape the future of cannabis policy, because black and latine people have been, and still are, disproportionately harmed by the war on drugs (edwards et al., 2020). we would have liked to screen on cannabis use to intentionally include a substantial proportion of cannabis consumers in the study. because cannabis consumers have been and continue to be stigmatized and criminalized for their cannabis use, we think it is important to include their perspectives in research that may shape cannabis policy. however, the data collection vendor we worked with, dynata, would not permit us to ask about cannabis use because it is illegal at the federal level. in response, we reviewed data from a 2021 study in which the sample was intentionally balanced by cannabis use status (33% current/past-30-day consumers, 32% noncurrent lifetime consumers, 35% never consumers) and noted that the natural fall of political philosophy was fairly well distributed (38% liberal, 36% moderate, 21% conservative, 8% another political philosophy; allen et al., 2023). thus, we theorized that ensuring good distribution on political philosophy would yield a range of cannabis use experiences. we operationalized our diversity priorities using data collection goals. our data collection goals for political philosophy were 33% “very” or “somewhat conservative,” 33% “moderate (neither conservative nor liberal),” and 33% “very” or “somewhat liberal.” our goals for race were “at least 20% black or african american,” and “no more than 40% white.” our goal for ethnicity was “at least 30% hispanic, latino/a, latinx, latine.” our goal for gender identity was “no more than 55% identifying as cisgender women.” we monitored data collection daily and amended the screener programming to close or open the survey to specific populations to meet these goals, as well as our overall goal of 400 completes. we were not able to meet all of our goals. sample characteristics are shown in table 1. table 1. unweighted study sample, overall and by condition profit models create injustice 13 overall (n = 404) not exposed condition (n = 203) exposed condition (n = 201) p-value age mean 48 years 44 years 52 years .0000 18-34 30.5% 27.5% 24.4% .1659 35-54 44.8% 36.4% 27.9% .0004 55+ 24.6% 36.1% 47.8% .0000 race* american indian/alaska native 12.4% 16.7% 8.0% .0071 asian 12.1% 14.3% 10.0% .1825 black or african american 29.5% 33.5% 25.4% .0735 native hawaiian 2.7% 3.9% 1.5% .1304 white 45.0% 31.5% 58.7% .0000 multiracial or another race 9.4% 13.8% 5.0% .0023 are you hispanic, latino/a, latinx, latine? yes 13.9% 16.7% 10.9% .0916 gender identity woman 49.5% 44.3% 54.7% .0368 man 49.0% 53.2% 44.8% .0907 transgender woman 0.5% 1.0% 0.0% .1570 transgender man 0.5% 1.0% 0.0% .1570 nonbinary 0.0% 0.0% 0.0% . genderqueer 0.0% 0.0% 0.0% . genderfluid 0.0% 0.0% 0.0% . questioning 0.2% 0.0% 0.5% .3179 an identity not listed here 0.2% 0.5% 0.0% .3179 i don’t know what this question is asking 0.0% 0.0% 0.0% . prefer not to answer 0.0% 0.0% 0.0% . how would you describe your political philosophy? very conservative 11.6% 10.8% 12.4% .6171 somewhat conservative 18.3% 17.7% 18.9% .7616 moderate 35.4% 37.9% 32.8% .2853 somewhat liberal 19.6% 17.2% 21.9% .2400 very liberal 12.9% 12.3% 13.4% .7382 none of the above 2.2% 3.9% 0.5% .0186 note. *percentages add to more than 100% because we provided a “select all that apply” option. the media campaign the parabola campaign is a media campaign created by parabola center for law and policy cannabis, a publication of the research society on marijuana 14 (parabola center). the goal of the campaign is to advance parabola center’s mission by providing everyone with the education, access, and expertise to support cannabis legalization policies that put people and small businesses first. the campaign consists of 22 videos featuring excerpts from interviews with cannabis policy experts. the interviews were conducted at the second expert forum on global justice in emerging cannabis markets, in prague, the czech republic, in may 2023, and the federal cannabis policy crash course, in boston, massachusetts, in june 2023. the interviews touch on themes related to international drug policy, including the undermining of indigenous knowledge, the harmful role of u.s. drug policy on drug laws across the globe, and the use of drug prohibition as a tool to oppress black and latine communities. they highlighted the role of corporations in targeting and exploiting historically marginalized people to further their own power and profit. this study evaluates receptivity to and efficacy of six of the videos from the parabola campaign. the experts featured in these videos are leaders of the organizations drug policy alliance (new york, u.s.a.); marijuana justice (virginia, u.s.a.); simply pure dispensary (colorado, u.s.a.); umzimvubu farmers support network (south africa); international center for ethnobotanical education, research, and service (iceers; catalonia, spain); and transform drug policy foundation (united kingdom). links to the videos used in the study can be found at https://www.youtube.com/@parabolacenter. full transcripts of the videos are provided in appendix 1. measures the survey included measures to assess participants’ reactions to the videos, beliefs and attitudes about cannabis, and participant demographics. the items in each domain are described below. reactions to campaign videos. we measured participants’ receptivity to the videos by asking how much participants agreed or disagreed with the following statements: “this video grabbed my attention”; “this video is informative”; “this video is powerful”; “this video is meaningful to me”; “this video is convincing”; and “this video is worth remembering.” response options took the form of a 5-point scale ranging from “strongly disagree” to “strongly agree.” this is an established measure of receptivity, also called advertising “perceived effectiveness” or “pe” which has been associated with subsequent belief and behavior change (davis et al., 2017; davis et al., 2012; duke et al., 2016). for each video, we asked study participants if they would like, share, or comment on it if they saw the video on social media. we also asked if they would watch a 30-minute version of each video. response options were “definitely yes,” “probably yes,” “probably not,” and “definitely not.” unless the participant indicated that they would “definitely not” share or comment on a video we followed up with open-ended questions asking, “if you shared this on social media, who would you share it with?” and “if you commented on this on social media, what would you say?” beliefs about cannabis policy. we measured participant endorsement of 34 campaign-related beliefs about cannabis policy. twelve beliefs corresponded to the main messages of the videos. twenty-two beliefs corresponded to other messages conveyed by the parabola campaign. these beliefs fell into three domains: “who should benefit from cannabis legalization?” (11 items); “what do people value in cannabis policy?” (5 items); and “who do people trust to create good cannabis policy?” (6 items). the individual belief measures can be found in tables 2 and 3. response options for all belief measures took the form of a five-point scale ranging from “strongly disagree” to “strongly agree.” respondents also had the option to respond, “i don’t know.” demographic variables. the first questions in the study screener were age and state. later in the screener, we asked individuals to provide their birthdate and zip code. we screened out individuals for whom age/birthdate and state/zip code data did not correspond. we measured race by asking, “what is your race? select all that apply.” response options were “american indian or alaska native”; “asian”; “black or african american”; “native hawaiian or other pacific islander”; “white”; and “another race, please specify.” we measured ethnicity by asking, “are you hispanic, latino/a, latinx, latine?” response options were “yes” and “no.” our measure of gender identity was, “which best describes your gender identity? select all that https://www.youtube.com/@parabolacenter profit models create injustice 15 apply.” response options were “woman”; “man”; “transgender woman”; “transgender man”; “nonbinary”; “genderqueer”; “genderfluid”; “questioning”; “an identity not listed here, please describe”; “i don’t know what this question is asking”; and “prefer not to answer.” we also asked, “how would you describe your political philosophy?” response options were “very conservative”; “somewhat conservative”; “moderate—neither conservative nor liberal”; “somewhat liberal”; “very liberal”; and “additional category, please specify.” table 2. mean agreement with the main messages of the parabola campaign videos, by condition not exposed condition (n = 203) exposed condition (n = 201) p-value i support a cannabis market that puts the public good first and private profit second. [steve] 79.9% 79.3% .8969 the united states and other countries have a lot to learn from one another on cannabis policy. [oscar] 77.3% 81.4% .3600 indigenous knowledge about cannabis deserves attention and respect. [philasande] 71.2% 75.4% .3905 i’d like to see a regenerative, sustainable, joyful econ around cannabis. [kassandra] 71.2% 73.2% .6814 it's important that cannabis legalization create space for small business and communities of color. [wanda] 61.0% 74.0% .0093 cannabis knowledge has been passed down over generations. [philasande] 65.9% 69.0% .5470 co-operative models based on community need and support are important for cannabis policy. [chelsea] 59.2% 72.3% .0107 i support a cannabis economy that emphasizes sharing. [kassandra] 62.8% 67.4% .3836 it's important to prevent alcohol and tobacco companies from moving into cannabis. [steve] 62.6% 66.5% .4415 everyone will benefit from including southern voices in cannabis policy. [chelsea] 46.2% 59.1% .0162 cannabis models driven by profit create the same injustices as prohibition. [oscar] 41.2% 58.9% .0010 cannabis companies should be led by communities harmed by drug war. [wanda] 28.0% 43.3% .0026 cannabis, a publication of the research society on marijuana 16 table 3. mean agreement* with supporting parabola campaign messages, by condition not exposed condition (n = 203) exposed condition (n = 201) p-value who should benefit from cannabis legalization? people who use marijuana as medicine 85.6% 88.1% .5056 workers in the cannabis industry 76.6% 73.7% .5538 people who use marijuana for pleasure 62.3% 65.7% .5031 locally-owned businesses 61.8% 65.8% .4453 people who have been harmed by past enforcement of marijuana laws 62.5% 63.1% .9133 small businesses 58.2% 63.8% .2939 everyday people 58.3% 63.3% .3466 the tobacco industry (disagree) 46.9% 58.0% .0403 alcohol companies (disagree) 48.2% 67.0% .0004 pharmaceutical companies (disagree) 28.5% 46.1% .0007 large corporations (disagree) 40.1% 55.7% .0039 who do people trust to create good cannabis policy? people with lived experience 68.3% 70.0% .7405 people who use marijuana 57.7% 62.1% .4102 people who are working for social equity 56.6% 62.4% .2709 tobacco industry executives (disagree) 63.6% 68.7% .3234 alcohol company executives (disagree) 64.6% 68.0% .5147 pharmaceutical company executives (disagree) 48.4% 52.4% .0392 what do people value in cannabis policy? social equity 71.4% 74.4% .5204 people having access to cannabis 69.6% 70.0% .9382 ending marijuana arrests 64.7% 67.1% .6406 creating a sharing community 53.1% 70.2% .0009 preserving marijuana culture 47.0% 51.8% .3764 note. *estimates reflect the combined proportion of respondents who “strongly agreed” or “agreed,” with the exception of the seven cases noted, which reflect the proportion who “strongly disagreed” or “disagreed.” analysis we weighted the data to force the distributions of the exposed condition sample and the not exposed condition sample to exactly equal the distribution of all respondents, and therefore, equal each other. weighting the study data was important because there were profit models create injustice 17 statistically significant differences by condition in three demographic variables known to be associated with study outcomes: age, gender identity, and race. this occurred because we used true randomization of assignment to condition and also screened out populations as they exceeded our data collection goals. the exposed condition sample was older and had a higher proportion of women and white people compared to the not exposed condition sample (shown in table 1). because these characteristics are associated with less support for legal retail cannabis (pew research center, 2015; schaeffer, 2023) and because the videos all build on the assumption of cannabis legalization, we theorized that the experiment may be biased toward a null finding. the weights control for differences between the two conditions on age category, race, and gender identity. we used imputation to replace 17 missing values on variables used in the calibration adjustment. we did this using a hot deck imputation procedure that randomizes the missing values to one of the categories with a probability proportional to each level of distribution in the corresponding sample. we used f-tests (adjusted wald tests) to conduct significance testing on mean agreement with each outcome, based on a 5-point scale. to streamline the presentation of our findings, we combined the “strongly agree” and “agree” responses, and the “strongly disagree” and “disagree” responses. we also combined the “neutral” and “i don’t know” responses on the principle that both responses represent an opportunity for public education. analyses were conducted using stata version 16 (statacorp, 2025). results sample characteristics we surveyed 404 adults aged 21 and older from across the united states. approximately half of the study participants (n = 201) were assigned to the exposed condition. the other half (n = 203) were assigned to the not exposed condition (table 1). the mean age of the overall sample was 48 years. the racial makeup of the overall sample was 12.4% american indian/alaska native, 12.1% asian, 29.5% black, 2.7% native hawaiian, 45.0% white, and 9.4% multiracial or another racial identity (table 1). in the overall sample, 13.9% identified as hispanic, latino/a, latinx, or latine. by gender identity, the overall sample was 49.5% women and 0.5% transgender women, 49.0% men and 0.5% transgender men, and 0.2% questioning or an identity not listed. no participants described themselves as nonbinary, genderqueer, or genderfluid. by political philosophy, the overall sample was 11.6% very conservative, 18.3% somewhat conservative, 35.4% moderate, 19.6% somewhat liberal, 12.9% very liberal, and 2.2% none of the above. as noted earlier, the demographic characteristics of the two conditions differed statistically significantly on variables known to be associated with opinions about cannabis legalization. specifically, the exposed condition sample was older (age 52 vs. 44), had a higher proportion of women (55% vs. 44%), and had a higher proportion of white people (59% vs. 32%), compared to the not exposed condition sample (all at least p < .05, as shown in table 1). reactions to campaign videos the mean pe score for the set of six parabola campaign videos was 3.53 (figure 2). the videos generated the highest pe scores among respondents who are black (3.91), liberal (3.80), and in the 18-34 age range (3.77). the lowest scores were among people who are white (3.21), conservative (3.36), and in the 55 and older age range (3.15). although a target level of advertising pe has not been established in the literature, studies show that pe scores of 3.47 or greater have been associated with actual advertising effectiveness among adults (davis et al., 2017). figure 2. parabola campaign video reactions by race, ethnicity, political philosophy, and age* cannabis, a publication of the research society on marijuana 18 l note. *the label black includes people who described themselves as black or african american. the label latine includes people who described themselves as hispanic, latino/a, latinx, or latine. the label multiracial includes people who described themselves multiracial or another race. the label ai/an signifies those who described themselves american indian or alaska native. the characteristic that best described the videos was “informative,” endorsed by 68% of study participants (data not shown). in addition, more than half of participants described the videos as “convincing” and “attention grabbing” (both 58%), “worth remembering” (57%), and “powerful” (54%). more than half (59%) described the videos as “meaningful to me” (data not shown). a substantial proportion of study participants reported that, if they saw the videos on social media, they would like them (63%), share them (49%), or comment on them (44%). nearly half of the participants (48%) said they would watch a 30-minute version of the video. overview of experimental findings about one-third of the beliefs we assessed (11 out of 34) differed statistically significantly at p < .05, or greater, across experimental conditions. in each case, we observed greater endorsement of beliefs promoted by parabola campaign videos in the exposed condition relative to the not exposed condition (tables 2 and 3). additionally, we observe a pattern of effects such that 32 of the 34 beliefs we evaluated were more greatly endorsed (though not always statistically significantly), consistent with parabola campaign messaging among those in the exposed condition relative to the not exposed condition (tables 2 and 3). statistically significant findings are described in greater detail below. endorsement of the main messages of the videos we measured endorsement of 12 beliefs that correspond to the main messages of the parabola campaign videos (table 3 and appendix 1). for five of these beliefs, we observed statistically significantly greater agreement in the exposed condition relative to the not exposed condition (figure 3). these beliefs are “it is important that cannabis legalization create space for small businesses and communities of color” (p < .01); “co-operative models based on community need and support are important for cannabis policy” (p < .05); “everyone will benefit from including southern voices in cannabis policy” (p < .05); “cannabis models driven by profit create the same injustices as prohibition” (p < .01); and “cannabis companies should be led by people from communities that the drug war has harmed” (p < .01). figure 3. endorsement of the main messages of parabola campaign videos profit models create injustice 19 who should benefit from cannabis legalization? we measured endorsement of 11 beliefs about which groups should benefit from cannabis legalization (table 3). parabola campaign messaging communicates that seven of the groups should benefit from legalization, including people who use marijuana, people who have been harmed by past enforcement of marijuana laws, and locally-owned businesses. the campaign communicates that the following groups should not benefit from legalization: the tobacco industry, alcohol companies, pharmaceutical companies, and large corporations. endorsement of parabola campaign messaging, therefore, took the form of agreement with the first seven items in table 3, and disagreement with the last four items. we document statistically significantly greater disagreement that the tobacco industry (p < .05), alcohol companies (p < .001), pharmaceutical companies (p < .001), and large corporations (p < .05) should benefit from cannabis legalization in the exposed condition, relative to the not exposed condition (figure 4). figure 4. “i think cannabis legalization should benefit…” by study condition cannabis, a publication of the research society on marijuana 20 who do people trust to create good cannabis policy? we measured endorsement of 6 beliefs about which entities study participants trust to create good cannabis policy (table 3). the parabola campaign advocates trust for three of the groups: people who use marijuana, people with lived experience, and people who are working for social equity. the campaign asserts that the following groups should not be trusted to create cannabis policy: tobacco industry executives, alcohol company executives, and pharmaceutical company executives. participants in the exposed condition reported statistically significantly greater disagreement that pharmaceutical company executives would create good cannabis policy relative to those in the not exposed condition (p < .05). what do people value in cannabis policy? we asked study participants five questions about what they value in cannabis policy (table 3). participants in the exposed condition reported statistically significantly greater agreement that they care about “creating a sharing community,” relative to participants in the not exposed condition (p < .001). discussion this study shows that public education can be used to promote equity-focused cannabis policy, by raising awareness of corporate influence, promoting community-centered regulatory models, and building support for an equitable approach to federal legalization. specifically, we find that after being exposed to brief videos featuring a diverse group of cannabis policy experts, study participants were more supportive of cannabis policies that create space for small businesses and communities of color; were more supportive of cannabis models like co-ops, that create a sharing community and are not profitdriven; and were less interested in seeing legalization benefit the tobacco industry, alcohol companies, pharmaceutical companies, and other large corporations. additionally, we found that receptivity to the videos exceeded the threshold associated with actual advertising effectiveness overall, and among people who identify as black; latine/hispanic; asian; native hawaiian or profit models create injustice 21 other pacific islander; liberal; or age 21 to 54. the videos were least well received among white people, conservatives, and people 55 years of age and older. it is worth noting that the pe score for people who identify as political moderates was more similar to that of conservatives than liberals. taken together, these findings indicate that the set of videos we tested in this study have the potential to change population-level beliefs about cannabis policy. translating that potential into reality is primarily a matter of funding. when public education campaigns are ineffective, a common reason is insufficient funding, resulting in too little population-level campaign exposure (hornik, 2002). as noted earlier, the best guidance on the amount of exposure needed for effective public education campaigns is from the cdc’s best practices for comprehensive tobacco control programs. best practices recommends that public education campaigns reach at least 75% of the intended audience in each quarter of the year (in other words, consistently) for three to six months to achieve campaign awareness and six to 12 months to achieve belief and attitude change (centers for disease control and prevention, 2014). these videos may achieve belief change more rapidly and with less funding than campaigns that seek to change more established beliefs. cannabis legalization is still an emerging issue in the united states, and many people do not have firm, preexisting beliefs about what cannabis policy should look like. for example, from 25% to 44% of participants in the unexposed study condition said they were “neutral” or “didn’t know” if they agreed with the policies promoted through the videos (figure 3). this represents an opportunity to provide education about models to shape equity-focused drug policy. studies show that a characteristic of “promising” public education messages is that the belief they seek to change has “room to move.”(zhao et al., 2024) in other words, the desired belief is not already widely held within the population of interest. that is the case with the beliefs measured as part of this study, and is consistent with findings from other cannabis policy studies (allen et al., 2023). among those who viewed the parabola campaign videos, a smaller proportion said they were neutral or didn’t know whether they supported the policies. indeed, we see that the proportion of those who are neutral or didn’t know is smaller for each of the messages shown in figures 3 and 4, with the exception of the message about the tobacco industry, which is about the same in the two conditions, perhaps because attitudes toward the tobacco industry are somewhat more established. limitations this study has a number of limitations. first, we observe statistically significant differences by condition in three demographic variables known to be associated with study outcomes: age, gender identity, and race. specifically, the exposed condition sample was older and had a higher proportion of women and white people compared to the not exposed condition sample (table 1). national data show that older people, women, and white people are less supportive of legal retail cannabis relative to their peers (pew research center, 2015; schaeffer, 2023). as a result, the exposed condition sample likely had more anticannabis attitudes and beliefs at the outset of the study relative to the not exposed condition sample. thus, it is possible that the experiment was biased toward a null finding. we addressed this limitation by weighting the data to force the distributions of the exposed condition sample and the not exposed condition sample to exactly equal the distribution of all respondents, and therefore, equal each other. second, this study is based on a nonrepresentative sample. we intentionally developed a sample that was 30% black and would have liked to include a larger sample of people who identify as hispanic/latine. we prioritize the perspectives of black and latine people in research that may shape the future of cannabis policy because black and latine people have been, and still are, disproportionately harmed by the war on drugs (edwards et al., 2020). as noted, the weights are designed to produce accurate results for the experiment. they are not designed to produce estimates that are representative of adults in the united states. a companion report to this study presents estimates based on data that are weighted to the adult u.s. population. that report can be found on the parabola center website. third, we would have liked to ensure that we had a substantial proportion of cannabis https://www.parabolacenter.com/pdf/american%20values%20and%20beliefs%20about%20legalization.pdf cannabis, a publication of the research society on marijuana 22 consumers in the study by screening on cannabis use. because cannabis consumers have been, and continue to be, stigmatized and criminalized for their cannabis use, we think it is important to include their perspectives in research that may influence cannabis policy. unfortunately, as noted earlier, the data collection vendor we worked with, dynata, would not permit us to ask about cannabis use, since it is illegal at the national level. this is one example of the many ways national cannabis laws discourage and diminish cannabis research. however, based on data from an earlier study, we theorized that ensuring good distribution on political philosophy would yield a range of cannabis use experiences, including a substantial proportion of cannabis consumers (allen et al., 2023). fourth, we were disappointed that the study sample did not include a meaningful number of people who identify as transgender, nonbinary, genderqueer, genderfluid, or questioning. in this regard, the sample differs from others we have recruited recently for other studies. however, we recruited for those studies using social media advertisements rather than using a panel vendor. in any case, failing to include people who identify as transgender, nonbinary, genderqueer, genderfluid, and questioning represents a loss of important insights for our work to examine possibilities for shaping drug policy. fifth, study participants were not permitted to skip the videos embedded in this survey. although we cannot be sure participants watched or attended to the videos, our methods almost certainly produced greater exposure than one would naturally find in response to a media campaign. additionally, we measured the effects of the media immediately following exposure to the videos. thus, we do not know whether the effects we have documented on beliefs are enduring. conclusion this study suggests that public education can be a powerful tool to promote equity-focused cannabis policy by raising awareness of corporate influence, promoting community-centered regulatory models, and building support for an equitable approach to federal legalization. this moment in time, in which federal cannabis policy is being shaped prior to legalization, presents a fleeting opportunity to reimagine the u.s. approach to cannabis and begin to redress the devastating impacts of the war on drugs. the opportunity is fleeting because corporate interests are already working to create cannabis policy that will maintain the inequitable and exploitative dynamics that have long characterized u.s. drug policy, with power simply shifting from government to corporations. the research presented here indicates that this is not what the people of the united states want, particularly when they learn about alternative cannabis legalization models from cannabis policy experts. references acker j, b. p., arkin e, leviton l, parsons j, hobor g. 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(2024). promising themes for electronic cigarette prevention campaigns for youth and young adults. nicotine & tobacco research, 26(8), 999–10006. https://doi.org/10.1093/ntr/ntae019 funding and acknowledgements: this study was funded by parabola center for law and policy, with support from a grant from the open society foundation. shaleen title is the founder and director of the parabola center for law and policy, a nonprofit think tank which has received funding from small businesses. we are deeply grateful to dr. megan lewis, dr. alex kral, dr. gary zarkin, dr. annice kim and burton levine for their support of this study. thank you to the international society for the study of drug policy (issdp) for the opportunity to present and receive feedback on an earlier version this work at the 2024 conference. thank you also to three anonymous peer reviewers: your suggestions made this a stronger paper. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: allen, a., title, s., & bradfield, b. (2025). same story, different seller: teaching the public how cannabis models driven by profit create the same injustices as prohibition. cannabis, 8(3), 9–25. https://doi.org/10.26828/cannabis/2025/000299 https://creativecommons.org/licenses/by/4.0/ research article 163 ved abstract introduction. despite cannabis use disparities among sexual minority (sm; vs. heterosexual) young adults (smyas), little research has explored social influences contributing to these disparities. this study examined sexual identity subgroup differences in parenting behaviors and associations among parenting behaviors and cannabis use behaviors among ya subgroups. methods. participants were female (n=416; 44.7% bisexual, 7.2% lesbian) and male (n=228; 11.0% bisexual, 13.2% gay) yas (ages 18-29) recruited via social media from 6 us cities. bivariate analyses examined differences in perceived parenting (psychological control, behavioral control, knowledge, autonomy support, warmth, communication, cannabis disapproval), any past-month (current) cannabis use, and current cannabis use frequency across sexual identity subgroups. multivariable regression examined associations among sexual identity and parenting behaviors with cannabis use outcomes. results. among female yas, bisexual (vs. heterosexual) yas had greater odds of cannabis use, reported more frequent use, and reported greater parental psychological control and less behavioral control, autonomy support, warmth, and communication; greater psychological control was associated with both outcomes; less autonomy support was associated with current use; and less warmth and communication were associated with use frequency. among male yas, gay and bisexual (vs. heterosexual) yas had greater odds of current use and reported more frequent use and greater psychological control; gay (vs. heterosexual) yas reported greater behavioral control and less autonomy support, warmth, and communication; and greater psychological control and less warmth and communication were associated with both outcomes. conclusions. cannabis prevention/cessation programs should target specific parenting behaviors that differentially impact cannabis use outcomes among specific smya subgroups. key words: = sexual identity; young adults; cannabis use; parenting behaviors katelyn f. romm1,2, sunny mcdonald1,3, emma dilissio4, craig dearfield5, & carla j. berg6,7 1tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center 2department of pediatrics, college of medicine, university of oklahoma health sciences center 3department of psychology, rose state college 4department of women’s health, university of pennsylvania 5department of epidemiology, milken institute school of public health, george washington university 6department of prevention and community health, milken institute school of public health, george washington university 7george washington cancer center, george washington university cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000236 disparities in cannabis use among female and male sexual minority young adults in the us: the role of parenting behaviors corresponding author: katelyn f. romm, ph.d., tset health promotion research center, stephenson cancer center, department of pediatrics, college of medicine, university of oklahoma health sciences center, 655 research pkwy #400, oklahoma city, ok 73104. phone: 405-271-1903. email: katelyn-romm@ouhsc.edu. cannabis, a publication of the research society on marijuana 164 cannabis is the most commonly used federally illicit substance within the us, particularly during young adulthood (nida, 2022), which involves significant life changes (e.g., increased independence) and increased risk for substance use initiation (arnett, 2005, 2015; barroso et al., 2019; schulenberg et al., 2021). past-month cannabis use rates have increased from 17% in 2011 to 29% in 2021 among those ages 19-30 (patrick et al., 2022), corresponding with expansion of medical and recreational cannabis legalization in the us (disa global solutions, 2022). despite cannabis’ potential medical utility (e.g., treating chronic pain; nasem, 2017), negative behavioral and health implications include motor vehicle crashes, mental health problems, and subsequent or current use of other substances, such as tobacco and alcohol (memedovich et al., 2018; nasem, 2017). certain groups of young adults (yas), including sexual minority (sm) yas (smyas; i.e., bisexual, gay/lesbian, or another nonheterosexual identity) report disproportionately high rates of cannabis use (dunbar et al., 2022; gonzales, 2020; kerr et al., 2015; liautaud et al., 2021; philbin et al., 2019; schuler & collins, 2020). recent national data suggest that 29.4% of sm adults reported past-month cannabis use relative to only 10.7% of heterosexual adults (nsduh, 2020). these disparities may be especially pronounced during young adulthood, a particularly vulnerable time for sm individuals who may be acknowledging, accepting, struggling with, or disclosing their sexual identity, which may be associated with greater coping-related cannabis use (meyer, 1995, 2003, 2013; pollitt et al., 2017; russell et al., 2014; tierney & ward, 2017). among yas, specifically, smyas are at greater risk for engaging in past-month cannabis use (dunbar et al., 2022; kerr et al., 2015; liautaud et al., 2021) and report more days of cannabis use (dunbar et al., 2022; gonzales, 2020; schofield et al., 2023) relative to heterosexual yas. moreover, important differences exist with regard to specific sexual identity and sex, with bisexual female yas displaying higher rates of (kerr et al., 2015) and more frequent (parnes et al., 2017) past-month cannabis use relative to both lesbian and heterosexual female yas. research among male smyas is less consistent, with some findings suggesting that gay and bisexual (vs. heterosexual) male yas are more likely to use cannabis (gonzales, 2020), some findings suggesting that bisexual (vs. gay and heterosexual) male yas report more frequent past-month use (parnes et al., 2017), and others suggesting no differences (liautaud et al., 2021). limited research has examined factors that contribute to cannabis use disparities among smya subgroups. greater cannabis-specific parenting behaviors (e.g., rules about use, parental disapproval of use) have been shown to reduce likelihood for cannabis use among yas generally (dorius et al., 2004; ramer et al., 2021; vermeulen-smit et al., 2015; yang et al., 2022). general parenting behaviors, such as autonomy support, which promotes yas’ independence in making their own decisions, or psychological control, in which parents use guilt and emotional manipulation (barber et al., 2011), also have known implications for cannabis use among yas. for instance, research has shown that positive parenting behaviors (i.e., behavioral control [graves et al., 2005; king et al., 2015; kokotovič et al., 2022; prins et al., 2021; ruybal & crano, 2020; vermeulen-smit et al., 2015], knowledge of adolescent/yas’ behaviors [cardenas et al., 2022; vermeulen-smit et al., 2015], autonomy support [liga et al., 2017; vermeulen-smit et al., 2015], warmth [king et al., 2015; kokotovič et al., 2022; ruybal & crano, 2020], communication [cardenas et al., 2022]) decrease risk for cannabis use, while negative behaviors (i.e., psychological control [liga et al., 2017; nelson & padillawalker, 2013; romm & metzger, 2018, 2021; romm et al., 2019]) increase risk for use, among adolescents and yas. according to minority stress theory, smyas face unique stressors (e.g., discrimination, social rejection) related to the stigmatization of their non-heterosexual identity (brooks, 1981; hatzenbuehler, 2009; meyer & frost, 2013). parents may be a source of this stress and discrimination for smyas, with over 70% of sm individuals reporting parental rejection after coming out to their parents (d'augelli et al., 2008). parents who are more rejecting of their ya children’s sexual identity may exhibit less positive (e.g., parental warmth) and greater negative (e.g., psychological control) parenting behaviors to minimize their interactions with their children, convey their disapproval, and attempt to control their children’s sexual identity (bebes et al., 2015; fish et al., 2020; mills-koonce et al., 2018; parenting and cannabis use among sm young adults 165 montano et al., 2018). these parenting behaviors may in turn promote coping-related cannabis use among smyas. thus, while all yas experience some level of both positive and negative parenting behaviors, smyas may experience lower levels of positive and higher levels of negative parenting behaviors, which may partially explain documented cannabis use disparities among sm (vs. heterosexual) yas. notably, existing research has focused primarily on sm-identifying adolescents and substance use broadly (i.e., cannabis, tobacco, alcohol, other illicit substance use aggregated). findings suggest that sm (vs. heterosexual) adolescents report lower levels of parental knowledge and parent-child communication (montano et al., 2018) along with greater parental rejection (padilla et al., 2010) and psychological control (kiekens et al., 2020), which were in turn, associated with greater substance use. our prior work suggests that female smyas, particularly those who are bisexual, reported greater psychological control and lower parental knowledge, autonomy support, warmth, and communication, which were associated with greater tobacco use among bisexual versus heterosexual female yas (romm et al., 2023). although male smyas, particularly gay yas, reported greater negative and fewer positive parenting behaviors relative to heterosexual yas, these parenting behaviors were not associated with tobacco use (romm et al., 2023). virtually nothing is known about parental behaviors in relation to smyas’ cannabis use. existing research has focused on parental rejection after coming out (typically during adolescence) and suggests that sm adolescents who experience greater parental rejection are at greater risk for substance use (i.e., alcohol, illicit substance use aggregated [fish et al., 2020; needham & austin, 2010; ryan et al., 2009]) and related cravings (i.e., cannabis, nicotine, alcohol [parnes et al., 2023]). in order to understand whether parenting behaviors may contribute to cannabis use disparities among smyas, the current study aimed to address gaps in previous research by examining associations between: 1) sexual identity (distinguishing bisexual, gay/lesbian, and heterosexual) and cannabis use outcomes (i.e., past-month [current] cannabis use, cannabis use frequency); 2) sexual identity and parenting behaviors (i.e., psychological control, behavioral control, knowledge, autonomy support, warmth, communication, cannabis-use disapproval); and 3) parenting behaviors and cannabis use outcomes among female and male yas, separately. methods study design this study analyzed spring 2022 crosssectional data among a subset of yas who participated in a 2-year longitudinal study, the vape shop advertising, place characteristics and effects surveillance (vapes) study, addressing the vape retail environment and its impact on substance use among yas (berg et al., 2021). participants were drawn from 6 metropolitan statistical areas (msas; atlanta, boston, minneapolis, oklahoma city, san diego, seattle) with varied cannabis legislative contexts (public health law center, 2020). the parent study aimed to examine multilevel determinants of ecigarette and other tobacco product use over time. this study was approved by the george washington university institutional review board. participants & recruitment in fall 2018, ads posted on facebook and reddit targeted eligible individuals: 1) residents of the 6 aforementioned msas (per home zip code); 2) english speaking; and 3) ages 18-34. ads used indicators reflecting those eligible and used social media groups/pages and ad imagery relevant to the target population. after clicking an ad, individuals were directed to the consent form, and completed an online eligibility screener. purposive, quota-based sampling ensured the sample represented sufficient numbers of individuals who used e-cigarettes and cigarettes, roughly equal numbers of female and male yas, and 40% racial/ethnic minorities. those eligible and allowed to advance to enrollment then completed the wave 1 (w1) survey. participants were prompted to confirm their participation via email 7 days later, and were officially enrolled and e-mailed their first incentive ($10 e-gift card). of the 10,433 individuals who clicked on ads, 9,847 consented, of which 2,751 (27.9%) were not allowed to advance because they were either: a) cannabis, a publication of the research society on marijuana 166 ineligible (n=1,472) and/or b) excluded to reach subgroup target enrollment (n=1,279). among the remaining 7,096 individuals, 48.8% (n=3,460) provided complete data, and 86.9% (n=3,006) confirmed participation. the current study analyzed survey data collected in spring 2022 among a subset of participants, selected to ensure representation across sexes, sexual identity, racial/ethnic backgrounds, and tobacco and cannabis use. additionally, we targeted yas under age 30 to capture those for whom parenting behaviors are most relevant (padilla-walker et al., 2013), as recent research suggests that parents continue to play a substantial role in yas’ lives (e.g., emotional, informational, tangible support) through age 29 (minkin et al., 2024). of the 1,147 participants targeted for this assessment, 942 (82.1%) provided complete data (and were compensated with a $10 amazon e-gift card). in order to examine differences in parenting behaviors by sexual identity and associations between parenting behaviors and cannabis use, the current study analyzed data among 644 participants under the age of 30. measures primary outcomes: any current cannabis use and frequency of past-month cannabis use participants reported the number of days they used cannabis in the past 30 days (0 to 30 days). any current (past month) use was defined as > 1 day of use; nonuse was defined as 0 days of use. primary predictor: sexual identity by sex subgroup participants were asked, “how would you describe your sexual orientation? (select all that apply)” (heterosexual, gay, lesbian, bisexual, or another sexual identity [specify]). participants were categorized as heterosexual (heterosexual only), gay/lesbian, or bisexual. some participants selected multiple responses and were recoded: n=9 reported gay/lesbian and other [queer] and were recoded to gay/lesbian; and n=13 reported bisexual and other [queer] and were recoded to bisexual. regarding sex, participants were asked, “what sex were you assigned at birth?” (female, male, other [specify], prefer not to answer). all participants reported either female or male sex. mechanisms of interest: parenting behaviors participants completed assessments of parental psychological control, using barber’s (1996) psychological control scale – youth selfreport (8 items; e.g., “my parent(s) changes the subject whenever i have something to say”; α=.92), behavioral control, using kerr and stattin’s (2000) parental monitoring scale (4 items; e.g., “my parent(s) tries to set rules about what i do with my free time”; α=.92), and knowledge, using barber’s regulation scale adapted for yas (4 items; e.g., “my parent(s) knows what i do in my free time”; α=.90 [padillawalker et al., 2008]); these scales used response options of 0=not at all like him/her to 4=a lot like him/her. participants also completed the perception of parents scale which assesses parental autonomy support (7 items; e.g., “my parent(s) helps me to choose my own direction”; α=.74; [robbins, 1995]) and warmth (6 items; e.g., “my parent(s) accepts me and likes me as i am”; α=.93; [robbins, 1995]); response options were 1=not at all true to 7=very true. finally, they reported on parental communication, assessed using the family communication subscale of the youth assets scale (4 items; e.g., “do you talk to your parent(s) about your problems?”; α=.85 [cheney et al., 2015]), with response options of 0=almost never to 3=almost always. mean scores were calculated for each measure of parenting behavior. yas also reported on their parents’ cannabisspecific parenting behaviors, including parental encouragement to not use cannabis (“how often have your parents encouraged you to not use cannabis or marijuana?”; 1=rarely or never to 7=frequently) and parental disapproval of cannabis use (“please rate the extent to which your parents disapprove of cannabis or marijuana use”; 1=completely approve to 5=completely disapprove). given high correlations among the 2 cannabis-specific parenting items (r=.77, p<.001), these items were aggregated by calculating a mean score to create an overall measure of parental disapproval of cannabis use. parenting and cannabis use among sm young adults 167 sociodemographic covariates participants reported their age (continuous variable), race (white, black, asian, other), ethnicity (hispanic vs. non-hispanic), and msa of residence. due to limited racial and ethnic variability among specific sex-by-sexual minority subgroups (see tables 1 and 2), participants were categorized as non-hispanic white versus racial/ethnic minority for primary analyses. msa of residence was used to code whether participants resided in a legalized (boston, san diego, seattle) versus not legalized (atlanta, minneapolis, oklahoma city) recreational cannabis context. participants who had moved since wave 1 were coded based on their current msa of residence (n=119). data analysis all analyses were conducted among female and male yas, separately, using mplus 8.8. bivariate analyses (i.e., chi-square tests, oneway anovas) examined associations between sexual identity and participant sociodemographic characteristics (i.e., age, race, ethnicity, legalized recreational cannabis context), parenting behaviors (psychological control, behavioral control, knowledge, autonomy support, warmth, communication, cannabis disapproval), current cannabis use, and frequency of current cannabis use (among those who report current use). multivariable logistic and multivariable zero-inflated poisson regression examined associations among sexual identity and parenting behaviors with odds of current cannabis use and frequency of cannabis use, respectively, controlling for participant age, racial/ethnic minority status, and legalized recreational cannabis context. results parenting behaviors and cannabis use among female yas among female yas (n=416), 44.7% identified as bisexual, 7.2% lesbian, and 48.1% heterosexual (table 1). regarding cannabis use, 40.1% reported current cannabis use; among those who reported current use, individuals reported using an average of 13.55 (sd=11.59) days of the past 30. a greater proportion of bisexual (53.8%) yas reported current cannabis use relative to heterosexual yas (27.0%). among those who reported current cannabis use, bisexual yas reported more days of cannabis use (m=14.40 [sd=11.79]) relative to heterosexual yas (m=11.08 [sd=11.35]). bivariate analyses indicated that bisexual and lesbian (vs. heterosexual) female yas reported less parental knowledge (table 1). bisexual (vs. heterosexual) yas also reported greater parental psychological control and less autonomy support, warmth, and communication. there were no differences in behavioral control or parental cannabis disapproval based on sexual identity. in multivariable regression analyses (table 3, upper panel), bisexual (vs. heterosexual) identity, residing in a legalized recreational cannabis context, greater parental psychological control, and lower autonomy support were associated with greater odds of current cannabis use. among those reporting current use, bisexual (vs. heterosexual) identity, residing in a legalized recreational cannabis context, greater parental psychological control, lower warmth, lower communication, and lower disapproval were associated with more frequent cannabis use. table 1. bivariate analyses characterizing heterosexual, lesbian, and bisexual female yas, n=416 variables total n=416 (100.0%) heterosexual n=200 (48.1%) lesbian n=30 (7.2%) bisexual n=186 (44.7%) p sociodemographics age, m (sd) 25.02 (2.39) 24.95 (2.45) 24.83 (2.29) 25.12 (2.37) .710 race, n (%) .036 white 296 (71.2) 132 (66.0) 26 (86.7) 138 (74.2) black 18 (4.3) 10 (5.0) 1 (3.3) 7 (3.8) asian 53 (12.7) 36 (18.0)a 2 (6.7) 15 (8.1)b other race 49 (11.8) 22 (11.0) 1 (3.3) 26 (14.0) cannabis, a publication of the research society on marijuana 168 hispanic, n (%)a 39 (9.4) 15 (7.7) 2 (6.9) 22 (11.8) .343 racial/ethnic minority, n (%) 152 (36.5) 82 (41.0) 7 (23.3) 63 (33.9) .103 legalized recreational context, n (%) .801 no 174 (41.8) 83 (41.5) 11 (36.7) 80 (43.0) yes 242 (58.2) 117 (58.5) 19 (63.3) 106 (57.0) parenting behaviors, m (sd) psychological controlb 1.47 (1.04) 1.24 (0.91)a 1.49 (1.08) 1.69 (1.11)b <.001 behavioral controlb 0.65 (0.98) 0.63 (0.94) 0.58 (0.89) 0.68 (1.03) .825 knowledgeb 2.22 (1.10) 2.54 (0.96)a 2.01 (1.23)b 1.93 (1.13)b <.001 autonomy supportc 4.62 (1.15) 4.84 (1.03)a 4.77 (1.10) 4.36 (1.23)b <.001 warmthc 5.34 (1.58) 5.74 (1.27)a 5.24 (1.53) 4.94 (1.78)b <.001 communicationd 1.57 (0.86) 1.75 (0.76)a 1.54 (0.97) 1.38 (0.90)b <.001 cannabis disapprovale 3.35 (1.56) 3.46 (1.49) 3.27 (1.47) 3.23 (1.65) .375 past-month cannabis use, n (%) 167 (40.1) 54 (27.0)a 13 (43.3) 100 (53.8)b <.001 days of past-month cannabis use, m (sd) 13.55 (11.59) 11.08 (11.35)a 13.70 (9.19) 14.40 (11.79)b <.001 note. bold values denote statistical significance at p<.05. m=mean, sd=standard deviation. a6 reported prefer not to answer for ethnicity. bassessed on a scale of 1=not at all like him/her to 4=a lot like him/her. cassessed on a scale of 1=not at all true to 7=very true. dassessed on a scale of 0=almost never to 3=almost always. eaggregate of 2 items: parental encouragement not to use cannabis (1=rarely or never, 7=frequently) and parental disapproval of cannabis use (1=completely approve, 5=completely disapprove). parenting behaviors and cannabis use among male yas among male yas (n=228), 11.0% identified as bisexual, 13.2% gay, and 75.9% heterosexual (table 2). regarding cannabis use, 32.9% reported current cannabis use; among those who reported current use, individuals reported using an average of 11.73 (sd=10.82) days of the past 30. a greater proportion of bisexual (52.0%) and gay yas (50.0%) reported current cannabis use relative to heterosexual yas (32.9%). among those who reported current cannabis use, bisexual (m=13.31 [sd=10.44]) and gay (m=13.93 [sd=10.60]) yas reported more days of cannabis use relative to heterosexual yas (m=10.31 [sd=10.91]). table 2. bivariate analyses characterizing heterosexual, gay, and bisexual male yas, n=228 variables total n=228 (100.0%) heterosexual n=173 (75.9%) gay n=30 (13.2%) bisexual n=25 (11.0%) p sociodemographics age, m (sd) 25.08 (2.40) 24.88 (2.31) 25.67 (2.58) 25.92 (2.60) .057 race, n (%) .128 white 160 (70.2) 115 (66.5) 22 (73.3) 22 (88.0) black 5 (2.2) 5 (2.9) 0 (0.0) 0 (0.0) asian 45 (19.7) 39 (22.5) 2 (10.0) 2 (8.0) other race 20 (8.8) 14 (8.1) 5 (16.7) 1 (4.0) hispanic, n (%)a 18 (7.9) 13 (7.6) 2 (6.7) 3 (12.0) .717 racial/ethnic minority, n (%) 83 (36.4) 68 (39.3) 9 (30.0) 5 (20.0) .141 legalized recreational context, n (%) .965 no 106 (46.5) 81 (46.8) 14 (46.7) 11 (44.0) yes 122 (53.5) 92 (53.2) 16 (53.3) 14 (56.0) parenting behaviors, m (sd) psychological controlb 1.01 (0.84) 0.88 (0.78)a 1.48 (0.92)b 1.37 (0.90)b <.001 behavioral controlb 0.53 (0.83) 0.44 (0.72)a 0.83 (1.04)b 0.77 (1.14) .021 knowledgeb 2.20 (0.99) 2.31 (0.97)a 1.76 (0.97)b 2.04 (0.99) .011 autonomy supportc 5.03 (0.94) 5.18 (0.85)a 4.43 (1.08)b 4.74 (1.01) <.001 warmthc 5.79 (1.24) 5.95 (1.15)a 5.17 (1.39)b 5.53 (1.40) .003 communicationd 1.63 (0.70) 1.71 (0.69)a 1.38 (0.69)b 1.41 (0.71) .013 cannabis disapprovale 3.55 (1.41) 3.52 (1.37) 3.52 (1.48) 3.74 (1.67) .768 parenting and cannabis use among sm young adults 169 past-month cannabis use, n (%) 75 (32.9) 47 (27.2)a 15 (50.0)b 13 (52.0)b .005 days of past-month cannabis use, m (sd) 11.73 (10.82) 10.31 (10.91)a 13.93 (10.60)b 13.31 (10.44)b .044 note. bold values denote statistical significance at p<.05. a1 reported prefer not to answer for ethnicity. bassessed on a scale of 1=not at all like him/her to 4=a lot like him/her. cassessed on a scale of 1=not at all true to 7=very true. dassessed on a scale of 0=almost never to 3=almost always. eaggregate of 2 items: parental encouragement not to use cannabis (1=rarely or never, 7=frequently) and parental disapproval of cannabis use (1=completely approve, 5=completely disapprove). table 3. multivariable logistic regression analyses predicting any past-month cannabis use among female (n=416) and male (n=228) yas and zero-inflated poisson regression predicting days of pastmonth cannabis use among female (n=167) and male (n=75) yas reporting any past-month cannabis use any cannabis use days of cannabis use variable aor 95% ci p b se p female sexual identity (ref: heterosexual) lesbian 1.74 0.77, 3.93 .185 -0.04 0.05 .419 bisexual 2.78 1.76, 4.38 <.001 0.30 0.09 .001 age 1.00 0.92, 1.10 .979 0.01 0.01 .297 racial/ethnic minority 0.74 0.47, 1.16 .735 -0.08 0.05 .09 legalized recreational context 1.66 1.08, 2.54 .021 0.20 0.05 <.001 parenting behaviors psychological control 1.55 1.10, 2.20 .013 0.33 0.03 .029 behavioral control 0.99 0.74, 1.33 .989 -0.09 0.03 .329 knowledge 0.93 0.70, 1.24 .628 -0.08 0.03 .09 autonomy support 0.87 0.76, 0.95 .027 -0.03 0.04 .458 warmth 1.06 0.80, 1.40 .679 -0.16 0.03 <.001 communication 0.95 0.65, 1.40 .810 -0.20 0.04 <.001 cannabis disapproval 0.92 0.80, 1.06 .257 -0.20 0.01 .019 nagelkerke/adjusted r2 .134 - male sexual identity (ref: heterosexual) gay 2.74 1.11, 6.80 .03 0.28 0.1 .016 bisexual 3.26 1.23, 8.61 .017 0.23 0.1 .019 age 0.84 0.73, 0.96 .013 -0.02 0.02 .118 racial/ethnic minority 1.08 0.55, 2.11 .824 -0.14 0.08 .787 legalized recreational context 2.49 1.31, 4.73 .006 0.33 0.08 <.001 parenting behaviors psychological control 1.69 1.03, 3.05 .033 0.18 0.07 <.001 behavioral control 0.82 0.50, 1.36 .824 0.04 0.06 .52 knowledge 0.87 0.60, 1.27 .478 -0.03 0.04 .503 autonomy support 0.97 0.55, 1.71 .909 -0.37 0.06 .052 warmth 0.47 0.29, 0.93 .047 -0.21 0.05 <.001 communication 0.61 0.34, 0.97 .027 -0.19 0.07 .004 cannabis disapproval 0.82 0.65, 0.94 .034 -0.16 0.03 .042 nagelkerke/adjusted r2 .192 - note. bold values denote statistical significance at p<.05. bivariate analyses indicated that bisexual and gay (vs. heterosexual) male yas reported greater parental psychological control (table 2). gay (vs. heterosexual) yas also reported greater behavioral control and less parental knowledge, autonomy support, warmth, and communication. in multivariable regression analyses (table 3, lower panel), bisexual and gay (vs. heterosexual) identity, residing in a legalized recreational cannabis context, greater parental psychological control, lower warmth, lower communication, and lower cannabis disapproval were associated with greater odds of current cannabis use and more frequent cannabis use among those who reported current use. cannabis, a publication of the research society on marijuana 170 discussion the current study expands upon research aimed at identifying mechanisms contributing to disparate patterns of cannabis use among specific sexual identity-by-sex subgroups of yas. among female yas, bisexual, but not lesbian, yas displayed greater odds of current cannabis use and reported more frequent use relative to heterosexual yas. this is consistent with previous research on cannabis use, as well as tobacco and other substance use (kerr et al., 2015; li et al., 2018, 2021; parnes et al., 2017; romm et al., 2022; schuler & collins, 2020). among male yas, both bisexual and gay yas displayed greater odds of past-month cannabis use and reported more frequent past-month use than heterosexual male yas, which is consistent with some prior work (gonzales, 2020). furthermore, findings indicated that smyas, particularly bisexual female and gay male yas, reported fewer positive and greater negative parenting behaviors, which were associated with adverse cannabis use outcomes. research has generally suggested that bisexual, relative to lesbian female yas, experience rejection from both the sm community and society at large, potentially contributing to elevated rates of substance use (movement advancement project, 2016). expanding upon this phenomenon, current findings suggest that bisexual (vs. heterosexual) female yas reported significantly higher levels of parental psychological control and lower levels of parental knowledge, autonomy support, warmth, and communication, whereas lesbian (vs. heterosexual) female yas reported lower levels of parental knowledge only. to interpret these findings, parents may be more likely to view bisexual versus lesbian identity as a phase (scherrer et al., 2015) and thus, may engage in psychological control and limit autonomy support in order to control bisexual female yas’ sexual attraction or behaviors. additionally, parents who disapprove of bisexual female yas’ sexual identity may withdraw and display less warmth, affection, and communication with their children (montano et al., 2018). among females, greater psychological control and less autonomy support were associated with greater odds of past-month cannabis use, and greater psychological control, less warmth, communication, and cannabis disapproval were associated with more frequent past-month cannabis use. bisexual female yas may engage in cannabis use as a means of reasserting their autonomy in response to less autonomy support and greater psychological control (barber et al., 2011). because warmth and communication promote emotional well-being and protect against health-risk behavior engagement (padilla-walker et al., 2008), bisexual female yas may use cannabis more frequently to cope with the absence of these relational behaviors. among male yas, those identifying as gay reported higher levels of parental behavioral control along with lower levels of parental knowledge, autonomy support, warmth, and communication relative to those identifying as heterosexual; both bisexual and gay (vs. heterosexual) male yas reported higher levels of psychological control. findings are consistent with prior work suggesting that gay male yas report lower levels of parental support relative to both heterosexual and bisexual male yas (needham & austin, 2010). further, findings suggest that greater psychological control, less warmth, communication, and cannabis disapproval were associated with greater odds of cannabis use and more frequent use among male yas. these findings vary from those related to tobacco, which suggest that these parenting behaviors were not associated with tobacco use among male yas (romm et al., 2023). thus, sm (vs. heterosexual) male yas, particularly gay yas, may be engaging in greater cannabis use, specifically, rather than substance use broadly, to cope with experiencing greater negative and fewer positive behaviors from their parents. notably, despite associations between parental cannabis disapproval and lower odds of current cannabis use among male yas and less frequent use among female and male yas, we found no evidence for sexual identity differences in perceived parental cannabis disapproval. findings might suggest that parents vary in their level of parenting behaviors that are more relational in nature, such as psychological control, autonomy support, warmth, and communication, based on their ya children’s sexual identity, as these parenting behaviors may be used to minimize their interactions with their children, convey their disapproval, and attempt to control their children’s sexual identity (bebes et al., 2015; parenting and cannabis use among sm young adults 171 fish et al., 2020; mills-koonce et al., 2018; montano et al., 2018). cannabis-related parenting behaviors, however, are less relational in nature and thus may be less impacted by parents’ reactions to sm children’s sexual identity. taken together, findings have important implications for future research and practice. parenting behaviors that might reflect parental reactions to yas’ sexual identity – such as psychological control, autonomy support, warmth, and communication – may have important implications for smyas’ cannabis use. cannabis prevention and cessation programs might benefit from focusing on reducing negative parenting behaviors and enhancing positive parenting behaviors among smyas, who experience greater levels of negative and lower levels of positive parenting behaviors. in particular, it may be beneficial to encourage autonomy promoting behaviors along with warmth and communication in efforts to prevent and reduce cannabis use among specific subgroups of smyas. moreover, to further our understanding of the role of parenting behaviors and to inform interventions, future research should examine the potential impact of sm-specific parenting behaviors, including those both positive (e.g., parental support of smyas’ sexual identity, parental education regarding sexual identity) and negative (e.g., parental heterosexism) as a factor promoting resilience or risk among smyas in response to other minority stress experiences (meyer, 2015). future research should also examine other minority stress factors, such as discrimination, lgbtq+ community connectedness, and peer rejection that are most strongly associated with cannabis use among specific subgroups of smyas to inform prevention and intervention efforts. limitations the current findings should be interpreted in light of several limitations. first, findings have limited generalizability to other us yas given targeted recruitment of individuals who use tobacco (who may also be more likely to use cannabis [dierker et al., 2018]) and thus, should not be interpreted as prevalence rates. second, current analyses do not focus on gender identity. given previously documented gender-related disparities in cannabis use (dyar, 2022), future research should explore parenting behaviors as mechanisms contributing to cannabis use disparities among gender minority (vs. cisgender) yas. third, data were cross-sectional and thus, we are unable to examine bidirectional associations among parenting behaviors and cannabis use. it is possible that parenting behaviors may be influenced by knowledge of yas’ cannabis use. fourth, we did not assess participants’ report of maternal and paternal parenting, separately, or whether participants used cannabis for medical and/or recreational reasons. finally, we had small sample sizes for certain sexual identity-by-sex subgroups (i.e., lesbian females, gay males, bisexual males), leading to limited analytic power. conclusions as public health authorities strive to reduce disparities in cannabis use among vulnerable populations, including smyas, it is imperative to understand potential mechanisms driving disparities in use. expanding upon previous research indicating that smyas display elevated rates of cannabis use and more frequent use, current findings suggest that bisexual relative to heterosexual female and both bisexual and gay relative to heterosexual male yas display greater odds of current cannabis use and report more frequent cannabis use. moreover, findings suggest that bisexual female and gay male yas reported lower levels of positive parenting behaviors (knowledge, autonomy support, warmth, communication) and higher levels of negative parenting behaviors (psychological control), which were associated with greater odds of current cannabis use and more frequent use. findings highlight potentially important targets for reducing cannabis-related disparities among smyas, while also emphasizing the need for large-scale interventions that can attend to the unjust social conditions that perpetuate stigma, likely related to negative parenting toward smyas. references arnett, j. j. 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(r01tw012456, mpis: berg, paichadze, petrosyan), and the national institute of environmental health sciences/fogarty (d43es030927, mpis: berg, caudle, sturua). this study was approved by the george washington university institutional review board. the authors declare no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 165 ved abstract objective: driving after cannabis use (dacu) has become an increasing public health concern nationwide. although previous research has linked perceived peer approval, perceptions of dangerousness, and negative effect expectancies to dacu, no previous work has examined whether these constructs can be successfully targeted in an intervention or whether changes in these variables lead to changes in dacu. the present study is a secondary data analysis to investigate within-subject change and potential mechanisms of change in a pilot trial for a mobile phone-based intervention shown to significantly reduce dacu over time. method: participants were 66 emerging adults who completed the mobile-based intervention and provided 3-month follow-up data. participants completed measures that assessed rates of dacu, negative cannabis expectancies, perceptions of dangerousness, and perceived peer-approval. results: results indicated that negative effect expectancies significantly increased from baseline to three-month follow-up, while perceived peer approval for dacu significantly decreased from baseline to three-month follow-up. though significant within-subject change was found for all variables of interest, none of the variables of interest significantly mediated changes in instances of dacu over time. the results of the current study suggest that key variables associated with dacu-perceived peer approval and negative cannabis expectancies can be successfully targeted in a mobile-based brief intervention. conclusions: continued research investigating moderators and mediators of intervention outcomes is warranted. key words: = driving after cannabis use; interventions; cognitions according to data from the national institute on drug abuse, 43.6% of young adults (ages 1930) reported past year cannabis use, which is the highest rate in the last 36 years (patrick et al., 2023). in the past ten years, there has been an approximately 2% increase in past-year cannabis use among college students and a 9% increase in past-year cannabis use among same aged noncollege peers. daily use of cannabis has also been on the rise among both college and non-college young adults, with 14.5% of non-college students reporting daily use vs. 4.7% of college students sarah n. elder1 & jenni b. teeters1 1department of psychological sciences, western kentucky university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000287 volume 8, issue 1 are changes in negative cannabis expectancies, peer approval, and perceptions of dangerousness of driving after cannabis use associated with changes in instances of driving after cannabis use following a mobile-phone based intervention? corresponding author: jenni b. teeters, phd, western kentucky university, kelly thompson hall, 1906 college heights blvd. bowling green, kentucky, 42101. phone: (270) 745-3918. email: jenni.teeters@wku.edu cannabis, a publication of the research society on marijuana 166 (14.5% vs. 4.7%; patrick et al., 2023). given the rise in both lifetime and daily cannabis use among young adults, increased research on the consequences of cannabis use is vital. of specific concern, more people are engaging in driving after cannabis use (dacu), such that in 2022, 4.7% of u.s. residents (11.7% aged 21-25; 6.3% aged 1620) reported driving while impaired by cannabis (center for behavioral health statistics and quality, 2023). previously identified dacurelated cognitions that may impact the likelihood of dacu are perceptions of dangerousness of dacu, perceptions of peer approval of dacu, and cannabis effect expectancies (arterberry et al., 2017; beaulieu-thibodeau et al., 2023; sterzer et al., 2022; wickens et al., 2019). this study aims to investigate the connection between perceptions of dangerousness, perceptions of peer approval, and cannabis effect expectancies and dacu among young adults. specifically, the present study aims to examine whether a brief dacu intervention resulted in changes in perceived peer-approved and negative effect expectancies and whether changes in dacu-related cognitions mediated changes in instances of dacu over time. rates of dacu are especially high among young adult cannabis users (ages 19-22). whitehill and colleagues (2014) found that undergraduate students who reported using cannabis had a higher prevalence of dacu (31.3%) compared to the reported frequency of alcohol using students driving after drinking (6.8%). additionally, cannabis users were also more likely to ride with a cannabis impaired driver (45.3%) compared to alcohol users riding with a drinking driver (15.6%). several other studies have shown a similar trend in rates of cannabis users engaging in dacu compared to alcohol users engaging in driving after drinking (center for behavioral health statistics and quality, 2023; nida, 2018; o’malley & johnston, 2013). given the high rates of dacu in this age group and the potential for fatal consequences, it is extremely important to identify risk factors for dacu that can be used as intervention targets. mccarthy and colleagues (2007) reported several cognitive predictors of dacu. these include perceptions of dangerousness of dacu and peer norms surrounding cannabis use. they found that among cannabis using individuals, perceptions of dangerousness and peer norms were associated with dacu. specifically, cannabis users were more likely to engage in dacu if they perceived their friends to be okay with it or if they perceived it as less dangerous. additionally, cannabis effect expectancies also play an important role in the decision to engage in dacu. cannabis expectancies include physiological and psychological effects one might expect to experience after using cannabis and can be both positive and negative. positive cannabis effect expectancies often can create positive feelings and associations with cannabis use. conversely, negative cannabis effect expectancies are effects that are associated with negative feelings or experiences (schafer & brown, 1991). several previous studies have found links between negative cannabis expectancies and likelihood of dacu (arterberry et al., 2013; king et al., 2020). many studies have utilized brief interventions (bis) containing personalized feedback to reduce cannabis use and related problems by identifying and correcting faulty normative beliefs to increase motivation to change a problematic substancerelated behavior (halladay et al., 2019). halladay and colleagues (2019) reviewed the literature on the effects of brief interventions for cannabis use among young adults and found that many brief interventions that included feedback specified for the individual (personalized feedback) were more successful than interventions that did not include this component. studies included in their review utilized brief interventions that were aimed at reducing cannabis use and associated problems. one of the features that was consistent among different brief interventions reviewed was giving personalized feedback to the individuals about their substance use patterns and how their beliefs compared to their peers’ beliefs. this personalized normative feedback is useful in helping the individual correct faulty normative beliefs. personalized feedback also typically informs the individual about their problematic patterns of use and provides strategies for low-risk substance use. although these types of brief interventions have shown some promise in reducing symptoms of cannabis use disorder, only one pilot study (using the present dataset) has examined whether a similar brief intervention approach could be used specifically to reduce dacu. teeters and colleagues (2022) found that the mobile-based brief intervention described in the method section below resulted in 1) increased perceptions of changes in driving after cannabis use cognitions 167 dangerousness of dacu (teeters et al., 2021) and 2) decreases in dacu and riding with a cannabisimpaired driver (teeters et al., 2022). results from the pilot study suggest that the intervention could increase perceptions of dangerousness related to dacu and reduce instances of dacu over time. however, teeters and colleagues (2021) did not examine whether changes in perceptions of dangerousness mediated changes in instances dacu over time. additionally, it is important to measure changes in other intervention targets, such as perceived peer approval and negative effect expectancies, and test these as potential mediators of intervention outcomes. the present study uses previously published data from the personalized feedback intervention conditions of the pilot trial to attempt to examine whether changes in instances of dacu were mediated by changes in perceptions of dangerousness, perceived peer approval, and negative effect expectancies. identifying mechanisms underlying effects found in brief cannabis intervention studies represents a major gap in the literature. many of the studies reviewed above include multiple components that target various mechanisms, and it is unclear which parts of the interventions led to behavior change. given the research reviewed above, it is clear that perceptions of dangerousness, perceived peer approval, and negative cannabis expectancies influence decisions to use cannabis and to drive after use, but it remains unclear whether targeting and changing these dacu-related cognitions would lead to reductions in instances of dacu over time. rationale for the current study given the gap in current literature on mechanisms underlying change in brief cannabis interventions and the increase in individuals using cannabis and engaging in dacu, creating and deploying feasible and effective interventions targeting dacu is critical to ensure that fewer people engage in risky cannabis-related behaviors. informing cannabis users about the impairing effects cannabis has on driving abilities is also an important step in changing the widespread belief that cannabis has little to no effect on driving ability. interventions that create personalized feedback can help individuals become more aware of their beliefs about cannabis and their cannabis use behaviors and can lead to increased motivation to change. research examining mechanisms of change in brief intervention studies is needed to ensure that individuals are receiving the most efficacious interventions and that resources are being used to fund the most effective interventions. therefore, the current study aims to address this by investigating 1) if a mobile based brief intervention can increase negative cannabis effect expectancies and lower perceived peer approval of dacu and 2) whether changes in dacu-related cognitions (perceptions of dangerousness, perceived peer approval, and negative cannabis expectancies) mediate changes in instances of dacu over time. this hypothesized mediation model can be seen in figure 1. figure 1. hypothesized mediation model of change in negative expectancies/perceptions of dangerousness/perceived peer norms mediating rates of driving after cannabis use from baseline to three-month follow-up. cannabis, a publication of the research society on marijuana 168 methods participants the sample for this study comes from a randomized pilot trial examining efficacy of a mobile based brief intervention aimed at reducing dacu (clinicaltrials.gov nct03496129). the primary specific aim of the pilot trial was to determine whether the intervention resulted in significantly greater reductions in instances of dacu compared to an educational control condition. for the present study, data comes from the personalized feedback + interactive text messaging condition (pf + mit; the condition that received an intervention including personalized feedback and interactive motivational interviewing style text messages; described below), and the personalized feedback only condition (pf; the condition that received only personal feedback regarding their substance impaired driving responses from the survey; described below). data from 66 participants were analyzed for this secondary data analysis. participants were 65.2% women, 30.3% men, and 4.5% identified as “other.” they were 78.8% caucasian, 4.5% black, 1.5% hispanic or latino, 1.5% asian, 9.1% multi-ethnic, and the remainder identified as “other.” the average age of participants was 21.80 (sd = 4.86). regarding academic class, 15.2% were freshman, 15.2% sophomores, 30.3% juniors, 22.7% seniors, 12.1% were in graduate school, and 4.5% were not currently enrolled. please see teeters et al. (2022) for additional descriptions of study flow, including participant enrollment and participants lost to follow-up. measures all measures were collected at baseline (prior to the intervention) and 3-month follow-up. demographics. participants completed a brief questionnaire regarding age, race/ethnicity, gender, and class status. driving after cannabis use. driving after cannabis use (dacu) was assessed at baseline and the 3-month follow up by asking, “in the past 3 months, how many times have you driven within 2 hrs. of using marijuana?” marijuana effect expectancy questionnairebrief. the marijuana effect expectancy questionnaire-brief (meeq-b; torrealday et al., 2008) consists of a positive expectancy subscale that generalizes global positive effects of cannabis use (relaxation, social facilitation, and global positive effects), and a negative expectancy subscale that represents global negative effects of cannabis use (physical and psychological impairment). the meeq-b consists of 6-items that measure participants’ level of agreement with assertions about marijuana’s positive expectancies and negative expectancies (derived from the mean composite score of the 3 corresponding items). participants rated items on a 5-point likert scale from 1 (disagree strongly) to 5 (agree strongly). an example of an item from the positive expectancy subscale is, “marijuana helps a person relax and feel less tense (helps you unwind and feel calm),” and an example of an item from the negative expectancy subscale is, “marijuana makes it harder to think and do things (harder to concentrate or understand; slows you down when you move).” greater scores on the positive subscale of the meeq-b indicate that the individual endorses a stronger belief that using cannabis will have positive effects, while greater scores on the negative subscale of the meeq-b indicate that the individual endorses a stronger belief that using cannabis will have overall negative effects. in the present study, the meeq-b scales demonstrated low internal consistency at both baseline (positive: α = .56; negative: α = .40) and the three-month follow-up (positive: α = .66; negative: α = .41), which is consistent with previously published studies that have used the meeq-b (aarons et al., 2001; brackenbury et al., 2016). perceptions of dangerousness. perceived dangerousness specific to dacu was measured using a 4-point likert scale that ranges from 1 (not at all dangerous) to 4 (very dangerous) and was assessed by asking, ““how dangerous do you believe it is to drive after marijuana use?” perceived peer approval (friend and typical college student). perceived peer approval was separated by perceived friend approval and perceived typical college student approval. both perceived peer approval items were measured using a 7-point likert scale that ranges from 1 (strongly disapprove) to 7 (strongly approve). perceived friend approval was assessed by asking, “how much do you think your closest friends approve of driving a car after using marijuana?” to assess perceived typical college student changes in driving after cannabis use cognitions 169 approval participants were asked, “how much do you think a typical student at your university approves of driving a car after using marijuana?” procedure prior to data collection, the pilot trial was reviewed and approved by the university institutional review board. participants were college students recruited at a mid-sized university in the southeastern united states. participants in the pilot trial were recruited through a mass university-wide email, the university subject pool, and flyers posted on campus. following an eligibility screener survey, eligible participants were contacted by phone by trained lab personnel and invited to participate. eligible participants who wished to participate were then sent a 30-minute baseline questionnaire via text-message to be completed remotely on their mobile phone via a secure web server. after completing the battery of online measurements, participants were randomly assigned to one of three intervention conditions: personalized feedback + interactive text messaging intervention (pf + mit), personalized feedback only (pf), and a substance use information intervention (ic), which served as the control group. given that the present study focuses on the sample that received the personalized feedback, the personalized feedback only (pf) and personalized feedback with interactive text messaging (pf +mit) conditions are described below. all data included in this manuscript come from the baseline assessment and 3-month follow-up assessments (collected between august 2018 and december 2019 and not impacted by the covid-19 pandemic). please see teeters et al. (2022) for additional methodological details of the pilot trial. substance impaired driving personalized feedback only (pf) the participants that were randomized to the pf condition were sent a link to a secure site that contained feedback that was specific to their personal cannabis use, dacu frequency, and information regarding social norms surrounding dacu. unlike the pf+mit condition (described below), this condition did not receive the interactive text messaging component of the intervention. substance impaired driving personalized feedback + interactive text messaging (pf + mit) the participants that were randomized to the pf +mit condition were texted a link to a secure site containing feedback that was specified to their personal cannabis use, dacu frequency, as well as information regarding social norms surrounding dacu and cannabis use. motivational interviewing style interactive text messaging was included in this condition to help participants think more critically about their attitudes, expectancies, and perceptions of dangerousness surrounding dacu. once the participants received the text message, they were instructed to respond back to the interventionist after they had completely read through their personalized feedback document. after receiving the confirmation text from the participant, the interventionist texted three open-ended questions that were (1) of the information you just viewed, what was most interesting? (2) how would receiving a dui impact your future career goals? (3) what is your plan for driving after substance use in the future? once those were sent, based on the participant’s response, the interventionist would engage in text messaging conversations with the participant to reflect and provide support and encouragement using motivational interviewing style. often the conversations would consist of having participants come up with their own reasons for decreasing their engagement in dacu and included goal setting. for both intervention conditions, negative effect expectancies, perceptions of dangerousness, and perceived peer approval surrounding dacu were targeted using the following feedback elements: feedback from the brief marijuana effect expectancies questionnaire that the participant endorsed during the survey (targeted negative expectancies), a percentile ranking of the individual’s impaired driving rates compared to peers (targeted peer norms), a dui information cost sheet, and a summary and infographic of research demonstrating driving related impairments associated with cannabis use (targeted perceptions of dangerousness). cannabis, a publication of the research society on marijuana 170 data analysis plan analyses were conducted using ibm spss statistics (version 28.0). these analyses represent a secondary data analysis of the previously published pilot trial (described above). only data from participants assigned to condition 1 & 2 (pf +mit, pf) were analyzed, given that the aim is to investigate whether the personalized feedback interventions resulted in changes in dacu-related cognitions. paired samples t-tests were used to evaluate whether the intervention resulted in significant increases in negative expectancies and significant decreases in perceived friend and typical student approval of dacu. mediation analyses using the memore macro (montoya, 2017) were conducted to examine whether changes in negative cannabis expectancies, perceptions of dangerousness, and perceived peer approval mediated intervention outcomes. memore is a macro that estimates mediation models for two-instance repeated measures designs. the macro estimates the total, direct, and indirect effects of x on y through the mediator m for mediation models. in order to determine if there is a mediation, the significance of the indirect effects is based on the confidence intervals (ci). memore uses bootstrapping, monte carlo, or normal theory approaches in order to generate confidence intervals for inference about the indirect effect. there is a significant mediation when the ci values do not cross zero. if the values of the ci do cross or include zero, it is a nonsignificant mediation (montoya, 2017). results descriptive statistics on average, participants at baseline reported driving after cannabis use 24.7 times in the past three months (sd = 24.4). at the three-month follow-up, participants reported driving an average of 18.6 times in the past three-months (sd = 24.4). means, standard deviations, and standard error means for the variables at baseline and three-month follow-up are shown below in table 1. table 1. means, standard deviations, and standard error means for rates of driving after cannabis use, marijuana effect expectancy questionnaire-brief negative effect expectancy subscale, perceptions of dangerousness, and perceived peer approval at baseline and three-month follow-up variable mean sd n se t1 driving after cannabis use 24.77 24.40 66 3.00 t2 driving after cannabis use 18.59 24.40 66 3.00 t1 negative expectancies 9.06 2.08 66 .256 t2 negative expectancies 9.65 1.97 66 .243 t1 dangerousness 1.59 .554 66 .068 t2 dangerousness 1.77 .675 66 .083 t1 friend approval 4.89 1.28 66 .159 t2 friend approval 4.42 1.25 65 .155 t1 student approval 4.02 1.35 66 .167 t2 student approval 3.30 1.28 66 .157 note. t1 = baseline, t2 = three-month follow-up changes in driving after cannabis use cognitions 171 paired samples t-test. table 2 reports the results of the paired samples t-test. the results of the paired-samples t-test demonstrate that between baseline and the three-month follow-up, negative effect expectancies were significantly increased (t = -2.313, p = .012, cohen’s d = -.285). in regards to perceptions of peer approval, both friend and typical western kentucky university (wku) student perceptions were significantly decreased from baseline to three-month follow-up (t = 3.237, p < .001, cohen’s d = .401 and t = 3.949, p < .001, cohen’s d = .486, respectively). table 2. paired samples t-test of negative effect expectancies, perceptions of dangerousness, and perceived peer approval from baseline to three-month follow-up mean sd se lower ci upper ci t df onesided p t1 negative expectancies – t2 negative expectancies -.591 2.08 .255 -1.10 -.081 -2.31 65 .012 t1 dangerousness – t2 dangerousness -.182 .654 .081 -.343 -.021 -2.26 65 .014 t1 friend approval – t2 friend approval .492 1.23 .152 .188 .796 3.24 64 <.001 t1 student approval – t2 student approval .712 1.47 .180 .352 1.07 3.95 65 <.001 note. ci = confidence interval, t1 = baseline, t2 = three-month follow-up mediation. the results of the indirect effect of the intervention on changes in times of dacu through changes in negative effect expectancies (standardized indirect effect = .22) had a confidence interval of [-2.06, 2.58]. the indirect effect of the intervention on changes of dacu frequency through changes in perceptions of dangerousness (standardized indirect effect = 1.22) had a confidence interval of [-.69, 4.43]. the results of the indirect effect of the intervention on changes in dacu through changes in perceived friend approval (standardized indirect effect = .49) had a confidence interval of [-3.18, 3.99]. lastly, the indirect effect of the intervention on rates of dacu through perceived typical wku student approval (standardized indirect effect = .24) had a confidence interval of [-3.10, 2.33]. all of these confidence intervals include zero, which indicates that negative effect expectancies, perceptions of dangerousness, and both perceived peer approval variables were not mediating this relationship. please see table 3 for the full mediation model. table 3. the indirect association of perceived dangerousness, negative expectancies, perceived friend approval and perceived typical student approval on driving after cannabis use over time b (se) p 95% c.i.: [ll, ul] outcome: change in dacu over time (t1 dacu – t2 dacu) intercept 4.30 (4.20) .31 [-4.10, 12.69] negative expectancies -0.43 (1.92) .83 [-4.28, 3.42] perceived dangerousness -7.90 (6.30) .21 [-20.52, 4.71] perceived peer approval 0.99 (3.09) .75 [-5.20, 7.19] perceived typical college student approval -0.35 (2.55) .89 [-5.46, 4.75] cannabis, a publication of the research society on marijuana 172 direct effect of t1 dacu on t2 dacu 5.98 (3.39) .31 [-4.10, 12.69] indirect effect of t1 dacu on t2 dacu via changes in negative expectancies .22 (1.10) [-2.06, 2.58] indirect effect of t1 dacu on t2 dacu via changes in perceived dangerousness 1.22 (1.33) [-69, 4.43] indirect effect of t1 dacu on t2 dacu via changes in perceived friend approval .49 (1.72) [-3.18, 3.99] indirect effect of t1 dacu on t2 dacu via changes in perceived peer typical student approval -.24 (2.65) [-3.10, 2.33] total effect of the model 5.98 (3.39) .08 [-.79, 12.76] note. b, unstandardized regression coefficient; se, standard error; confidence interval, 95%; ll, lower limit; ul, upper limit, dacu = driving after cannabis use, t1 = baseline, t2 = threemonth follow-up. discussion driving after cannabis use is a significant public health concern, and with the increasing legalization of cannabis for medical and recreational purposes, research on dacu is needed now more than ever. the present study used data from a previously published pilot trial (see teeters et al., 2022) of a mobile-phone based intervention with personalized feedback and interactive text-messages delivered in motivational interviewing style. results have shown that the pf + mit condition resulted in: 1) significant increases in perceptions of dangerousness of dacu (teeters et al., 2021) and 2) significant decreases in dacu and riding with a cannabis-impaired driver compared to the substance information control condition (teeters et al., 2022). though the results from these studies have added to the literature on brief cannabis interventions, it remains unclear what led to the cognitive and behavioral changes. said another way, it remains uncertain what components of the intervention contributed to successful intervention outcomes. the current study investigated negative effect expectancies, perceptions of dangerousness, and perceived peer approval as potential mediators given the previous literature showing a significant connection between these variables and dacu. our results showed that negative effect expectancies increased significantly following the personalized feedback interventions. additionally, both perceived peer approval variables (perceived friend approval and perceived typical college student approval) decreased in both conditions. these findings are encouraging because it demonstrates that the intervention was effective at changing these cognitive perceptions of dacu, and while they may not have mediated the changes in dacu over time, the significant changes are noteworthy. research is mixed on whether cognitive changes lead to behavior change (dijkstra & vries, 2001), but changing attitudes and cognitions represent a step in the right direction. the hypothesis that the changes in negative effect expectancies, perceptions of dangerousness, and perceived peer approval would mediate a dacu intervention outcome was not supported, as shown by the results from the memore mediation analysis. although negative effect expectancies and perceptions of dangerousness significantly increased, and perceived peer approval significantly decreased from baseline to the three-month follow-up, none of these variables independently mediated the intervention outcomes. the nonsignificant mediation results may be the result of the intervention and feedback including several different components geared towards several cognitive mediators, which might have come together to lead to the change in times driving after cannabis use. it may be that components of the intervention are not working in changes in driving after cannabis use cognitions 173 isolation to influence the reduction in dacu. the intervention targeted a combination of mechanisms that are interlinked. therefore, it may be the combination of elements that led to changes in dacu, rather than specific mechanisms in isolation. relatedly, different intervention components may have appealed to different individuals. while it is important to try to disentangle specific mechanisms underlying the effects in brief interventions, a paper conducted by o’donnell (2022) argues that brief interventions themselves are actually complex, and the combination of the multiple components may lead to successful intervention outcomes. the complexity of the brief interventions and feedback could be contributing to the effects in the current study because of the multiple cognitive and behavioral targets that are within the intervention. for the current study, it could have been that small changes in negative expectancies combined with small changes in perceptions of dangerousness and perceptions of norms that mediated the intervention outcomes. future research should examine the impact of the entire brief intervention targeting several cognitive mediators of dacu in comparison to interventions targeting only one cognitive mediator in order to isolate effective intervention components. limitations of the current study include that cannabis use, effect expectancies, perceptions of dangerousness, perceived peer approval, and rates of dacu were collected via retrospective self-report. the data may have been skewed due to biases from reporting sensitive substance use information. this could have negatively influenced accurate data reporting; however, the participants were reminded several times that their information was anonymous and that they could have refused to answer any questions they did not feel comfortable answering. nonetheless, future studies should use either daily diary report of substance use or ecological momentary assessment (ema) to track substance use in a way that is more frequent and does not require participants to report substance use from months ago that they may not accurately remember. these methods reduce bias and reporting error due to the increased frequency of having participants complete assessments and can be done via apps or text messaging for efficiency and accessibility. notably, the present study measured instances of driving after cannabis use in the past 3 months rather than driving impairment due to cannabis use. the measures used did not account for how much cannabis was used before driving, timeframe of use, type of product, potency of product used, or participant cannabis-use history (tolerance). it is extremely important that efforts are made in future research to include additional details related to cannabis use impairment in order to gain a more nuanced assessment of possible cognitive and behavioral changes that could impact driving behaviors. additionally, due to the covid-19 pandemic, six-month follow-up data were not collected as planned in the original pilot study (teeters et al., 2022). having data six-months after the intervention would have provided more informative data regarding the change in expectancies, perceptions of dangerousness, perceived peer approval as well as change in dacu. this would have also shown the impact and duration of the effects from the intervention outcome to examine if this trend lasts beyond the three-month follow-up. future studies would benefit greatly from collecting data at six months and a year post-intervention to examine the durability of the intervention effects. another potential explanation for the null mediation results in the present study is the sample size. although the original pilot study was adequately powered to detect medium effects, mediation analyses were not planned as part of the original data analysis plan and were undertaken as secondary data analyses in the present manuscript. this is important, as the mediation models tested in the present study were likely not adequately powered to detect mediation effects. in the future, power analyses including suspected mediating variables should be conducted during intervention planning in order to make sure the sample size is large enough to detect these effects. also, because the data were collected from a small sample of young adults in southwestern kentucky, it cannot be fully representative of all young adults in kentucky or other states, specifically where medical and recreational cannabis use is legal. future studies should replicate the current study from a population in a state where cannabis is legal to examine any differences in perceptions, attitudes, and behaviors surrounding dacu. additionally, this sample was not diverse in terms of racial and cannabis, a publication of the research society on marijuana 174 ethnic diversity, and future interventions should aim to include a more diverse sample to get a better generalization of all cannabis users. on a related note, future adequately powered studies should consider including other relevant variables that may influence results such as state of residence (legal to purchase recreational and medical cannabis versus not legal, legal driving limit set versus no legal limit) and location of residence (living on campus versus off, living with roommates versus alone, living in a rural area versus an urban area with rideshare resources). despite these limitations, this study has significant relevance, as it is one of the first to examine the mediating role of negative cannabis effect expectancies, perceptions of dangerousness, and perceived peer approval on a brief intervention targeting dacu. the current study fills a gap in the literature by longitudinally examining a potential mechanism of change. few studies have longitudinally assessed cannabis use and dacu, and none have assessed negative effect expectancies, perceptions of dangerousness, and perceived peer approval as mediators of this relationship. several pieces of information from this study can be used to inform improvement of this text-based intervention prior to future trials. because the intervention resulted in significant changes in dacu-related cognitions, it is clear that the intervention should be replicated in a larger, more diverse sample. based on our findings, it appears that including information related to negative effect expectancies, perceptions of dangerousness, and perceived peer approval was helpful in altering dacu-related cognitions over time. this is especially important given past research showing that many emerging adults and other members of the public do not view dacu as dangerous or believe that they can compensate for impairment if they are indeed driving while high, leading to a permissive attitude toward dacu (colonna et al., 2021). concerningly, some individuals report that they believe using cannabis improves their driving abilities (donnan et al., 2022). due to the potentially damaging consequences that can occur when an individual drives after using an impairing level of cannabis, it is extremely important to identify factors that can changes beliefs and attitudes related to dacu, such as those identified in the present study. additionally, many participants in this intervention also reported driving after using other substances, mainly alcohol. future studies should examine the effect of an intervention that targets polysubstance impaired driving and the role driving-related cognitions play in that 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(2019). exploring perceptions among people who drive after cannabis use: collision risk, comparative optimism and normative influence. drug and alcohol review, 38(4), 443-451. https://doi.org/10.1111/dar.12923 funding and acknowledgements: this project was supported by the national institute of general medical sciences (#8p20gm103436). declarations of interest: none. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: elder, s. n., & teeters, j. b. (2025). are changes in negative cannabis expectancies, peer approval, and perceptions of dangerousness of driving after cannabis use associated with changes in instances of driving after cannabis use following a mobile-phone based intervention? cannabis, 8(1), 166-176. https://doi.org/10.26828/cannabis/2025/000287 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ brief report 1 ved abstract objective: evidence regarding the efficacy of various forms of cannabis and cannabinoid concentrations is limited, and cannabis industry regulatory infrastructure is still in development. meanwhile, most us states have legalized medical or adult use cannabis. this study aimed to understand what advice cannabis budtenders in the san francisco bay area were providing to customers for pain and sleep trouble – two of the conditions most cited as reasons for using cannabis medicinally. method: we visited 35 of 42 cannabis dispensaries in alameda and san francisco counties in california, and using a “secret shopper” approach, asked the budtenders for recommendations on products, dosage, and strains to best alleviate pain and sleep trouble. results: for pain relief, budtenders showed a strong preference for topicals (77.1%), while edibles were most indicated for sleep trouble (60.0%). reasons provided included budtender personal experience and product effectiveness. cannabidiol (cbd) was endorsed most often for pain relief in high cbd:thc ratios (28.6%), 1:1 ratios (28.6%), and cbd alone (22.9%). for sleep relief, tetrahydrocannabidiol (thc) alone was most recommended (34.3%). when asked about cannabis strains for pain, 85.7% of budtenders did not express a preference, but for sleep, 57.1% of budtenders selected indica. conclusions: this study illustrates that budtenders in the bay area have specific ideas about cannabis uses, including types, concentrations, and strains, despite a lack of evidence for most recommendations. future research should prioritize study of topical preparations of cannabis for pain, edibles for sleep, and tinctures for both, which budtenders regularly recommended to customers. key words: = cannabis; marijuana; commercial determinants; substance use; health policy cannabis consumption is legal for medical or adult use in 38 states, seven territories and the district of columbia (norml, 2021). according to medical cannabis registries, nearly 240 million people in the us are eligible to access cannabis for medicinal purposes (marijuana policy project, 2021), and in the 24 states with adult use legalization, anyone over 21 may purchase cannabis. those aged 18-20 may also purchase cannabis in some of those states with a physician’s recommendation (e.g., california, louisiana), a medical recognition card (e.g., washington), or if they have a qualifying medical condition (e.g., illinois, maryland). qualifying conditions differ by state. cannabis purveyors, however, need not have specialized medical training to offer advice to customers on the best forms of cannabis for any ailment, ideal cannabinoid concentrations, or christine hoang,1 louisa m. holmes,2* & pamela m. ling1 1center for tobacco control research & education, university of california san francisco 2departments of geography and demography, and the consortium on substance use and addiction, the pennsylvania state university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000328 volume 8, issue 3 dispensing medical advice: san francisco bay area budtender recommendations for pain and sleep relief corresponding author: louisa m. holmes, phd, pennsylvania state university, 375 steam drive, university park, pennsylvania 16802. phone: (814) 865-3433. email: lmholmes@psu.edu cannabis, a publication of the research society on marijuana 2 efficacy for illness. prior studies have found that just over 50% of budtenders in states with adult use cannabis laws report having received any training, and training content tended to focus on the details of the cannabis laws themselves rather than the state of cannabis science (carlini et al., 2022; haug et al., 2014; loparco et al., 2024; peiper et al., 2017). yet prior research has also demonstrated that budtenders (cannabis dispensary sales associates) tend to offer advice freely despite lack of medical training or sufficient evidence supporting the effectiveness of cannabis for chronic conditions, such as sleep disorders or recurring pain (carlini et al., 2022; peiper et al., 2017). according to a recent report, only three conditions demonstrate “modest” evidence of benefit from cannabis treatment – chemotherapyinduced nausea, clinically-diagnosed chronic pain reduction, and reducing spasticity related to multiple sclerosis (national academies of sciences engineering & medicine, 2017). there is not yet sufficient evidence to determine the therapeutic effects of cannabis for other conditions, nor is there clear evidence on required dosage, mode of ingestion, cannabinoid concentration, or the necessary duration of consumption to achieve a therapeutic outcome (cannabis policy research workgroup, 2018; national academies of sciences engineering & medicine, 2017). in the absence of evidence or consistent regulation of the cannabis industry, budtenders have become the de facto providers of information regarding cannabis usage, dosage, and consumption. limited prior research with budtenders and dispensary customers has found that customers rely on budtender advice and deem the recommended products as largely effective, although the budtenders do not view health education as their responsibility (bachhuber et al., 2019; carlini et al., 2022). one survey of california budtenders found that those who had been formally trained for their positions actually viewed medical decision-making as less important than budtenders who had not received training and were also less likely to have a “patientcentered philosophy,” wherein patients were involved in the decision-making process about which cannabis products to use, compared to a “budtender-centered philosophy,” wherein the customer followed the budtender recommendations. this suggests that budtenders without formal training are more likely those engaging with customers on questions of medical efficacy, at least in california (peiper et al., 2017). california legalized medical cannabis in 1996 followed by adult use cannabis in 2016, operationalized in 2018. within california, 16.3% of adults reported using cannabis in the past 30 days, according to 2020 california health interview survey data, and among the highest risk group for cannabis use, youth and young adults, 27% of 18–26-year-old residents of alameda and san francisco counties (the study area) reported using cannabis in the prior month, and more than 50% of teens reported past month use (holmes et al., 2016; ucla center for health policy research, 2020). more than 40 dispensaries have opened in alameda and san francisco counties alone since the state began issuing adult use licenses in 2018, and the covid-19 pandemic corresponded to an uptick in dispensary sales (ling et al., 2022; vangst et al., 2020). for this study, we visited 35 dispensaries in alameda and san francisco counties using a “secret shopper” approach to gain understanding of how budtenders give medical advice and their reasons for doing so. methods we obtained a list of all cannabis dispensaries in san francisco and alameda counties using weedmaps and yelp and verified their current operation by calling dispensaries and accessing their websites. we developed a standardized data collection instrument informed by consultation with the alameda and san francisco county health departments and drawing on the cannabis literature and pilot visits to cannabis retailers in both counties wherein one of the study leaders observed retailer environments (supplementary material). we programmed the instrument into esri’s survey123 connect software (esri, 2024) and research staff used the survey123 app on their smart devices to enter data in the field. in 2020, using a “secret shopper” method, we trained eight research staff members to act as data collectors to visit all cannabis dispensaries located in the two counties. the research staff were young adults, some of whom were enrolled in university as undergraduate or graduate students and the others had recently graduated with bachelor’s or dispensing medical cannabis advice 3 master’s degrees. we were unable to complete data collection because california implemented covid19 shelter-in-place orders on march 15, 2020, before we visited all 42 dispensaries. this study therefore includes data from 35 dispensaries – 13 in alameda county and 22 in san francisco county. research staff attended an in-person training in which study authors (lmh, pml) presented on cannabis forms, strains, delivery modes, devices, and cannabinoid types and concentrations and trained the staff on taking field notes and engaging in participant observation. research staff also practiced alternating between interviewing each other and recording data with the data collection instrument. during the training they also made pilot visits to nearby dispensaries to practice using the instrument. researchers who visited a dispensary during training were not assigned to that dispensary for data collection. the study was exempt per the ucsf human research protections program. two research staff members visited each dispensary and spoke to one budtender in each dispensary, indicating that they were relatively new cannabis consumers and seeking advice. research staff asked a standard set of questions of each budtender, including the questions, “what do you recommend for pain relief?” and “what do you recommend for trouble sleeping?” standard follow up questions were “does thc concentration matter?” and “does product type or mode of ingestion matter?” field staff did not actually purchase cannabis products. since device recording and photos were generally prohibited by dispensary staff and ownership, data collectors wrote detailed field notes about the conversation with budtenders immediately after exiting each dispensary. at the conclusion of the conversation, study staff went outside and immediately completed the field note template, which prompted them to record the look and feel of the dispensary environment, presence of signage and promotions, and responses to the standard questions. the two research assistants visiting the dispensary then compared notes and resolved inconsistencies or disagreements through discussion. the authors of this study reviewed the specific recommendations regarding product type, strength, cannabinoid composition, and strains, and calculated the percentages of budtenders making certain recommendations across all the dispensaries visited. results table 1 shows the frequency with which budtenders recommended certain cannabis products for pain relief and trouble sleeping. budtenders overwhelmingly recommended topicals (77.1%) to treat pain, followed by edibles (22.9%) and tinctures (20.0%). for trouble sleeping, 60% of budtenders recommended edibles, followed by tinctures (28.6%) and flower (20.0%). the most common reason budtenders recommended topicals for pain relief was due to their own personal experiences with the product (25.9%), that it did not get the consumer “high” (18.5%), or that it was the most effective product to address pain (14.8%). edibles were deemed most effective for sleep (9.5%) and good for beginners (9.5%). however, many of the budtenders did not provide a particular reason for recommending edibles for sleep (85.7%) or for pain relief (25.0%). tinctures were also endorsed for pain relief (42.9%) and based on personal experience (28.6%), though budtenders did not agree on whether they would get the consumer high (14.9% yes vs. 14.9% no). flower was only suggested as a sleep remedy, and most budtenders did not specify a reason (43.0%). table 1. budtender product recommendations, 2019-2020 bay area young adult health study (n = 35 dispensaries) recommendations for: pain relief sleep trouble recommended type n % n % topicals 27 77.1 0 0.0 edibles (including beverages) 8 22.9 21 60.0 tinctures 7 20.0 10 28.6 flower 0 0.0 7 20.0 vape/pre-roll 0 0.0 2 5.7 none 7 20.0 6 17.1 cannabis, a publication of the research society on marijuana 4 reason for recommending n % n % topicals 27 0 budtender personal experience 7 25.9 0 0.0 does not get you high 5 18.5 0 0.0 most effective 4 14.8 0 0.0 does not show up on drug screen 1 3.7 0 0.0 no reason given 9 33.3 0 0.0 edibles (including beverages) 8 21 most effective 3 37.5 2 9.5 gets you high 2 25.0 0 0.0 budtender personal experience 1 12.5 2 9.5 does not get you high 0 0.0 1 4.8 good for beginners 0 0.0 2 9.5 no reason given 2 25.0 18 85.7 tinctures 7 10 most effective 3 42.9 2 20.0 budtender personal experience 2 28.6 1 10.0 does not get you high 1 14.3 0 0.0 gets you high 1 14.3 0 0.0 does not involve smoking 0 0.0 1 10.0 no reason given 2 28.6 6 60.0 flower 0 7 budtender personal experience 0 0.0 2 29.0 most effective 0 0.0 2 29.0 no reason given 0 0.0 3 43.0 vape/pre-roll 0 2 budtender personal experience 0 0.0 1 50.0 easy to use for beginners 0 0.0 1 50.0 table 2 shows the types and ratios of cannabinoids recommended for pain and sleep relief, as well as suggested strains. high cannabidiol (cbd) to tetrahydrocannabidiol (thc) and ratios of 1:1 cbd:thc were indicated as equally appropriate dosages for pain relief (28.6%) and were recommended for sleep in some cases (11.4% and 20.0%, respectively). alternatively, some budtenders recommended high ratios of thc:cbd for pain (14.3%) and sleep relief (8.6%). cbd alone was also advocated for pain 22.9% of the time and for sleep by 5.7% of budtenders. however, thc alone was most often endorsed for alleviating sleep trouble (34.3%). of those budtenders who offered a dosage indication, 26.7% and 30.0% suggested the products they recommended were the most effective for pain and sleep, respectively. cbd was also said to ease inflammation (16.7%). additionally, 16.7% of budtenders provided dosage advice that would prevent the consumer from getting high, which ranged from taking one gummy or using low-thc products to specific dosages between 5-10 milligrams of thc at most. most of the budtenders seemed to rely on personal experience when giving advice on cannabinoid concentrations and ratios for various products. for example, while several budtenders indicated that cbd-only products were effective for pain, in several cases they recommended higher doses of cbd as more effective. however, one budtender said that cbd can be ineffective for some people and steered the shoppers to thconly products. another advised that whether products included cbd or thc, all products induced sleep eventually. dosage advice relied in part on budtender’s experiences as well, with a couple of budtenders sharing personal stories of times that they had a “bad high.” however, more frequently budtenders directed shoppers to dispensing medical cannabis advice 5 patient safety materials or websites, and in one instance suggested the shoppers should come back and speak to the registered nurse who consulted at the dispensary several times a week. regarding cannabis strains, most budtenders (85.7%) did not have a specific recommendation when asked about pain relief. those that did all mentioned indica as the appropriate strain (14.3%), and for sleep, 57.1% suggested indica. two budtenders also identified hybrid strains for sleep trouble. no one mentioned sativa in either case. the only reasons given for selecting indica or hybrid strains were that they were considered the most effective for pain or sleep and were fast acting. table 2. budtender cannabinoid and strain recommendations, bay area young adult health study (n = 35) recommendations for: pain relief sleep trouble n % n % recommended cannabinoids high cbd:thc ratio 10 28.6 4 11.4 1:1 cbd:thc 10 28.6 7 20.0 cbd only 8 22.9 2 5.7 high thc:cbd ratio 5 14.3 3 8.6 3:1 thc:cbd 3 8.6 0 0.0 low cbd:thc ratio 1 2.9 0 0.0 thc only 1 2.9 12 34.3 cbn only 0 0.0 3 8.6 thca only 0 0.0 2 5.7 no recommendation 5 14.3 6 17.1 reason for cannabinoids recommendation (of those who provided recommendation) most effective 8 26.7 9 30.0 cbd helps alleviate inflammation 5 16.7 0 0.0 thc helps alleviate pain 3 10.0 0 0.0 gets you high 3 10.0 0 0.0 budtender personal experience 3 10.0 1 3.3 less psychoactive/does not get you high 0 0.0 5 16.7 thc is faster acting 0 0.0 1 3.3 cbd is calming 0 0.0 1 3.3 no reason provided 14 46.7 13 43.3 strain recommendation indica 5 14.3 20 57.1 hybrid 0 0.0 2 5.7 none 30 85.7 15 42.9 reason for strain recommendation (of those who provided recommendation) most effective/fast acting 3 60.0 7 35.0 no reason provided 2 40.0 13 65.0 discussion we saw clear patterns in budtenders’ recommendations for treating pain and sleep trouble. budtenders showed a strong preference for topicals in pain treatment and edibles for addressing trouble sleeping. they also strongly preferred indica strains for sleep trouble, and to a lesser degree, pain relief. most of the budtenders offered dosage advice, though this ranged across cannabis, a publication of the research society on marijuana 6 several cannabinoids and cannabinoid ratios. the most common reasons for providing specific advice were that the budtenders deemed a certain product to be the most effective for pain or sleep relief, or as a result of their own experiences with the products. chronic pain is the most common condition cited by patients for medical use of cannabis, and a 2015 systematic review of studies on cannabis for pain suggested modest efficacy (whiting et al., 2015). this study suggests that topical forms of cannabis may gain popularity as they were frequently suggested for pain treatment, followed by tinctures. there have been studies on the effects of cannabinoids for pain reduction, but human studies have focused exclusively on flower without attention to topical or tinctures (national academies of sciences engineering & medicine, 2017). additional research is needed, particularly on commercially available topical products and tinctures, to substantiate the broad therapeutic claims of pain relief that were found in this study. cannabis has been identified as a sleep aid for over a century, and there is evidence that cannabis use may decrease sleep latency and so might have a role in treating sleep disorders (kesner & lovinger, 2020). alternatively, a recent analysis of nationally representative nhanes data found that recent cannabis use was associated with less optimal sleep duration (diep et al., 2022). a systematic review of the evidence on sleep outcomes found small improvements in sleep among those using cannabinoids but significant risk of bias in the studies, and a 2019 systematic review of clinical trials on cannabis and sleep found small improvements but called for larger and more rigorous studies (whiting et al., 2015). in our study, 60% of budtenders recommended edibles for alleviating sleep trouble, but like topicals and tinctures, little evidence currently exists on efficacy, dosage, or potential side effects of using edibles (national academies of sciences engineering & medicine, 2017). the budtenders expressed a strong preference for indica forms of cannabis for sleep and, to a lesser extent, for pain. none of the budtenders cited sativa as a recommended strain for either condition despite the long historical use of sativa as an analgesic for pain (russo, 2019). however, more than 51% of the budtenders did indicate high cbd:thc ratios or cbd alone for pain relief, citing in some cases its use as an antiinflammatory agent, which does find support in the literature (russo, 2019; savage et al., 2016). the cannabinoids themselves provide another area ripe for additional research given the budtenders’ willingness to offer dosage information to customers and because the distinction between indica and sativa is not particularly useful from a therapeutic perspective (russo, 2019). this study suggests that budtenders have the potential to be an influential resource for public health education on cannabis and its health effects. our findings are consistent with prior research that found budtenders are committed to improving customer experience with cannabis and strive to help consumers avoid negative consequences (carlini et al., 2022), although in contrast to the prior study, we found that budtenders did make recommendations related to health conditions when asked. we found that budtenders’ recommendations for cannabis products were commonly made without specific reasons, and when reasons were given, they were most frequently based on general claims of superior efficacy or the budtender’s personal experience. given that budtenders are viewed as trusted sources of information who attend to customer needs as part of their work, this study suggests that efforts to educate budtenders about the state of the science and to establish professional guidelines for recommendations to consumers are needed. this study has several limitations: first, the sample was limited to a small census of cannabis dispensaries in san francisco and alameda counties, california, which are both locations with a longstanding history of cannabis use and decades of experience with medical marijuana legalization. findings may not generalize to other geographic locations, although they are consistent with prior literature. in addition, budtender recommendations were based on recall by trained research staff using a “secret shopper” protocol that did not allow for verbatim recording, so data are subject to recall bias. we attempted to mitigate this through careful training, field note recordings immediately following dispensary visits, and triangulation between multiple researchers. additionally, as our goal was for data collectors to engage budtenders in what might be a typical conversation held with a novice cannabis dispensing medical cannabis advice 7 customer and given our secret shopper approach, research staff did not pursue budtenders extensively on how they knew certain products were more effective than others beyond the reasons they provided, e.g., personal experience. finally, our data are limited to interpersonal communications taking place within cannabis dispensaries, and we did not formally include other sources of marketing messages or health claims, such as on cannabis dispensary websites, which have been analyzed separately (hoeper et al., 2022). conclusion this study provides novel insight into informal therapeutic claims and recommendations that budtenders communicate to customers in cannabis dispensaries. our findings suggest that research efforts on cannabis efficacy should prioritize the products most 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(2015). cannabinoids for medical use: a systematic review and meta-analysis. jama, 313(24), 2456–2473. https://doi.org/10.1001/jama.2015.6358 funding and acknowledgements: this work was supported by the california tobacco-related disease research program [trdrp 27ir-0042]. the authors have no conflicts of interest to declare. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: hoang, c., holmes, l. m., & ling, p. m. (2025). dispensing medical advice: san francisco bay area budtender recommendations for pain and sleep relief. cannabis, 8(3), 1–8. https://doi.org/10.26828/cannabis/2025/00032 8 issue date: november 03, 2025 https://creativecommons.org/licenses/by/4.0/ research article 111 ved abstract problematic cannabis use is highly prevalent among postsecondary students. consequently, there is a need to examine risk factors associated with problematic cannabis use in this population. the present study investigated whether emotion dysregulation mediates the relationship between adverse childhood experiences (aces) and problematic cannabis use, and whether affective impulsivity (negative and positive urgency) uniquely moderates this relationship. participants consisted of current cannabis users (n = 586) recruited from five universities across canada. participants completed an online survey containing selfreport measures of aces, emotion dysregulation, negative and positive urgency, and problematic cannabis use. among the sample of postsecondary students, 36% (n = 213) met the threshold for problematic cannabis use. moderated-mediation analyses revealed that aces were positively associated with emotion dysregulation and problematic cannabis use. there was also a significant indirect effect of emotion dysregulation on the association between aces and problematic cannabis use at moderate and high (but not low) levels of negative urgency, and at moderate and high (but not low) levels of positive urgency. the moderated-mediation models remained significant when controlling for other facets of impulsivity. results suggest that elevated levels of emotion dysregulation and urgency are important proximal risk factors for problematic cannabis use among postsecondary students with a history of aces. while aces cannot be modified given their occurrence in the past, interventions that aim to build mindfulness and adaptive emotion regulation skills may be beneficial for reducing the likelihood that these students will engage in impulsive behaviors, such as cannabis use, when experiencing emotional distress. key words: = adverse childhood experiences; problematic cannabis use; postsecondary students; affective impulsivity; emotion dysregulation cannabis use is highly prevalent in north america (conway, 2022; substance abuse and mental health services administration, 2023). data collected within the past five years has indicated that a greater number of north american emerging and young adults aged 16-25 years reported past-year cannabis use relative to adults aged 26 and older (statistics canada, 2021; substance abuse and mental health services administration, 2023). many postsecondary students fall within the age range wherein elevated rates of cannabis use have been identified and may comprise a key at-risk group for problematic cannabis use, as indicated by jenna l. vieira1, lindsey a. snaychuk1, jana milicevic1, david c. hodgins2, n. will shead3, matthew t. keough4, hyoun s. kim1,5 1department of psychology, toronto metropolitan university, toronto, ontario, canada 2department of psychology, university of calgary, calgary, ab, canada 3department of psychology, mount saint vincent university, halifax, ns, canada 4department of psychology, york university, toronto, on, canada 5university of ottawa institute of mental health research at the royal, ottawa, ontario, canada cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000190 adverse childhood experiences and problematic cannabis use: the role of emotion dysregulation and affective impulsivity corresponding author: hyoun kim, ph.d., department of psychology, toronto metropolitan university 350 victoria street, toronto, on, m5b 2k3. phone: 416-979-5000 ext. 552624, email: andrewhs.kim@torontomu.ca. cannabis, a publication of the research society on marijuana 112 persistent use despite negative impacts on social functioning and health (connor et al., 2021). indeed, elevated rates of problematic cannabis use and cannabis use disorder (cud) have been observed among postsecondary students (arterberry et al., 2020; caldeira et al., 2007). while emerging and young adults are collectively at heightened risk of problematic cannabis use (health canada, 2022; parekh et al., 2020), postsecondary students are confronted with various unique factors that may further increase this risk. postsecondary students frequently report elevated stress levels that are potentially attributable to high study demands and challenges with work-life balance, which can encourage increased cannabis use as a way to cope with such feelings (istasy et al., 2019). many postsecondary students also transition to living situations that involve cohabitation with peers during their studies, which are associated with increased prevalence of cannabis use (o’brien et al., 2017). such situational factors may underpin the increase in cannabis use that has been observed among students as they begin postsecondary education (cadigan et al., 2019). unfortunately, cannabis use has been linked to various harms, including increased risk of depression (gobbi et al., 2019), anxiety (stiles-shields et al., 2021), suicidal ideation and attempts (gobbi et al., 2019), and psychosis (hall & degenhardt, 2008). the risks associated with cannabis use may be especially heightened for postsecondary students, as emerging adulthood is recognized as a critical developmental period during which individuals may be particularly susceptible to the consequences of substance use (stone et al., 2012). moreover, individuals who used cannabis heavily in early adulthood have been found to endorse more physical, cognitive, and mental health conditions at 40 years of age relative to those who did not use cannabis heavily during this period (patrick et al., 2021). consequently, it is important to elucidate the risk factors and mechanisms of problematic cannabis use among postsecondary students to better understand the constructs that may contribute to this vulnerability. adverse childhood experiences and cannabis use adverse childhood experiences (aces) are defined as potentially traumatic events that occur in an individual’s life prior to 18 years of age (felitti et al., 1998). studies have consistently observed that young adults (shin et al., 2018) and postsecondary students (schwartz et al., 2022) with a history of aces are at greater risk of being diagnosed with a substance use disorder, including cud, later in life. for example, a longitudinal study found that the total number of aces endorsed by participants was significantly associated with the development of all severity levels of cud in young adulthood (moss et al., 2020). in another longitudinal study, young adults with a history of aces were significantly more likely to be classed as high-severity cannabis users relative to those without a history of aces (davis et al., 2021). among postsecondary students in particular, endorsing a greater number of aces has been linked to significantly higher likelihood of having used cannabis in the past 30 days (forster et al., 2018). as aces are events that take place before the age of 18 years, they may be conceptualized as a distal risk factor (nolen-hoeksema & watkins, 2011). in other words, aces represent a static underlying vulnerability for future cannabisrelated problems that unfortunately cannot be modified given their occurrence in the past. however, it is possible that aces increase an individual’s propensity for developing problematic cannabis use indirectly through proximal risk factors, which comprise vulnerabilities that are more immediate and receptive to modification (e.g., attentional biases, negative affectivity, emotion dysregulation; nolen-hoeksema & watkins, 2011). understanding the proximal mechanisms through which aces may heighten the risk of problematic cannabis use among postsecondary students can reveal potential constructs that can be targeted to reduce the negative impacts of these early life experiences. emotion dysregulation, aces, and cannabis use a proximal risk factor that may account for the association between aces and problematic cannabis use is emotion dysregulation. emotion dysregulation is a multidimensional construct that encompasses deficits in an individual’s ability to fully experience and manage emotions (gratz & roemer, 2004). according to gratz and roemer (2004), emotion dysregulation is specifically characterized by difficulties with emotional awareness, acceptance of emotions, controlling impulsive behaviors when trauma and affective impulsivity in cannabis use 113 experiencing negative emotion, behaving in goaloriented ways when experiencing negative emotion, and using adaptive strategies to regulate emotions. studies have consistently demonstrated a positive relationship between aces and emotion dysregulation (dvir et al., 2014; michopoulos et al., 2015; poole et al., 2017). one potential interpretation of this association is that aces may hinder emotion regulation development, potentially by depriving youth of emotional nurturance and other opportunities from caregivers that would allow them to learn the skills necessary for effectively recognizing and modulating their emotions (dvir et al., 2014). however, it is important to note that some aces do not involve caregivers, and thus their negative effects may occur through other pathways. indeed, aces may also impact emotion regulation development through their effects on the stress response system within the brain (clemens et al., 2020). consistent exposure to stressful life events in childhood may lead the brain to release excess amounts of stress hormones, which in turn trigger the hypothalamic-pituitary-adrenal (hpa) axis (responsible for the “fight or flight” response; sheng et al., 2021). hpa axis overactivation may lead other functions of the brain to be limited, including those controlled by the limbic system, which are responsible for emotional reactivity (clemens et al., 2020). consequently, aces and their resulting stress may impact the brain such that youth are left with less capacity to regulate their emotions. in turn, the heightened emotion dysregulation resulting from aces may increase risk for problematic cannabis use. for example, one study found that emotion dysregulation was particularly elevated among a group of cannabis users characterized by frequent, heavy use and many associated consequences (manning et al., 2019). in another study, the positive association between stressful life events and problematic cannabis use was found to be stronger among individuals who endorsed greater levels of emotion dysregulation (cavalli & cservenka, 2021). taken together, it is plausible that aces may precipitate the development of emotion dysregulation which could, in turn, lead to problematic levels of cannabis use. in support of this notion, there is a growing body of evidence that suggests emotion dysregulation mediates the association between aces and a variety of substance and behavioral addictions (lim et al., 2019; kim et al., 2023; poole et al., 2017; wolff et al., 2016). however, to our knowledge, no studies to date have investigated whether emotion dysregulation mediates the relationship between aces and problematic cannabis use specifically. given the robust associations that have been identified between aces, emotion dysregulation, and other addictions as noted above (lim et al., 2019; kim et al., 2023; poole et al., 2017; wolff et al., 2016), these relationships are also likely to exist in the context of problematic cannabis use, which the present study tests directly. the potential role of negative and positive urgency beyond emotion dysregulation, there are likely additional constructs implicated in the hypothesized pathway from aces to problematic cannabis use among postsecondary students. it is possible that the association between emotion dysregulation prompted by aces and problematic cannabis use may be stronger among some postsecondary students depending on the extent to which they endorse certain personality traits. two personality traits in particular, negative urgency and positive urgency (cyders & smith, 2008), may play such a role. negative and positive urgency comprise a dispositional tendency to behave impulsively when experiencing intense negative or positive emotion, respectively (cyders & smith, 2008) and therefore can be conceptualized as affective impulsivity. of importance to the present study, elevated levels of both negative and positive urgency have been identified among individuals with a history of aces (oshri et al., 2018; shin et al., 2018) and have also been linked to greater emotion dysregulation (benzerouk et al., 2022; reff & baschnagel, 2021) and problematic cannabis use (um et al., 2019; wardell et al., 2016). individuals high in positive or negative urgency as well as emotion dysregulation may be more prone to experiencing heightened emotional intensity and relying on maladaptive strategies, such as impulsive behaviors (e.g., substance use), to regulate their emotional distress. for example, negative urgency has been found to interact with emotion dysregulation to predict more positive cigarette smoking expectancies among youth (dir cannabis, a publication of the research society on marijuana 114 et al., 2016), suggesting that individuals with elevated levels of both of these constructs may be at greater risk of engaging in addictive behaviors. to our knowledge, the extent to which emotion dysregulation mediates the association between aces and problematic cannabis use depending on levels of negative and positive urgency has not been empirically examined in the existing literature. consequently, the present study aims to directly test this. the present study given that existing research has established emotion dysregulation as a mechanism of the relationship between aces and various addictive behaviours (lim et al., 2019; kim et al., 2023; poole et al., 2017; wolff et al., 2016), this multicenter study of canadian postsecondary students tested whether emotion dysregulation similarly mediates the relationship between aces and problematic cannabis use. as impulsivity is conceptualized as a personality and individual differences variable (birkley & smith, 2011; whiteside & lynam, 2001) and may thus inform our understanding of the conditions under which relationships between other psychosocial variables occur, the present research extends the models tested in previous studies by assessing whether emotion dysregulation mediates the relationship between aces and problematic cannabis use at high levels of negative or positive urgency, specifically. we hypothesized that i) aces would be positively associated with problematic cannabis use, ii) emotion dysregulation would be positively associated with problematic cannabis use, and iii) emotion dysregulation would mediate the association between aces and problematic cannabis use at high levels of both negative and positive urgency. methods participants and procedure the sample consisted of 592 undergraduate students recruited from five universities across four provinces in canada who reported having used cannabis in the past year. due to missing data within variables of interest, six participants were excluded from analyses; consequently, the final sample consisted of 586 participants (mage = 20.72, sd = 4.79, range = 17-62). full demographic characteristics of the sample are presented in table 1. data were collected between october and november 2021. all participants completed the self-report questionnaires of interest as part of a larger survey battery hosted by qualtrics. ethics approval was obtained from the research ethics board at the authors’ respective institutions and participants’ informed consent was obtained prior to data collection. participants were granted course credit for completing the online survey. three manuscripts resulting from the dataset used in the present study have been published previously (kim et al., 2023, coelho et al., 2023a/b). however, this is the first and only paper that has specifically examined problematic cannabis use. the data underlying the present manuscript is available on osf (https://osf.io/ajz7s). table 1. demographic characteristics of the sample. demographic variable n % gender man 119 20.3 woman 448 76.5 non-binary 7 1.2 transgender man 3 .5 genderqueer 3 .5 gender questioning 2 .3 agender 1 .2 prefer to specify 3 .5 transgender woman 0 0 trauma and affective impulsivity in cannabis use 115 ethnicity white 322 54.9 east asian 75 12.8 south asian 43 7.3 black 37 6.3 multiple ethnicities 45 7.7 middle eastern 24 4.1 latino 17 2.9 prefer to specify 7 1.2 indigenous 16 2.7 sexual orientation straight 414 70.8 gay or lesbian 20 3.4 bisexual 95 16.2 queer 25 4.3 questioning 19 3.2 asexual 2 .3 prefer to specify 2 .3 pansexual 0 0 two-spirit 0 0 education high school 256 43.7 some college/university 265 45.2 college/university degree 48 8.2 post-high school (not college) 9 1.5 professional school diploma 5 .9 post-graduate work 2 .3 post-graduate degree 1 .2 employment status not working 200 34.1 working part-time 350 59.7 working full-time 36 6.1 relationship status single – never married 390 66.6 single – divorced 3 .5 single – widowed 1 .2 married 17 2.9 living common law 43 7.3 in relationship – living separately 132 22.5 measures cannabis use descriptives participants were asked three questions regarding their engagement in, frequency, and quantity of cannabis use. the first, “have you consumed marijuana, tincture, hashish, hash oil, weed, grass, or pot in the past 12 months?”, was rated dichotomously (1 = yes, 0 = no), and was used to identify past-year cannabis users (i.e., the study sample). for the second, “in the past 30 days, on how many days did you consume marijuana, tincture, hashish, hash oil, weed, grass, or pot?”, participants were shown a dropdown menu and asked to select a number from 0 to 30. for the third, “in the past 30 days, how many grams of marijuana, tincture, hashish, hash oil, weed, grass, or pot did you consume?”, participants were also shown a drop-down menu and asked to select a number from 0-99. problematic cannabis use the screener for substance and behavioral addictions (ssba; schluter et al., 2018) is a selfcannabis, a publication of the research society on marijuana 116 report measure that assesses addiction problems in relation to four substances (alcohol, cannabis, nicotine, cocaine) and six behaviors (gambling, shopping, video gaming, overeating, sexual activity, overworking/overstudying) experienced in the past year. for the present study, only items related to problematic cannabis use were used. using a fivepoint likert scale ranging from 0 (“none of the time”) to 4 (“all of the time”), participants were asked to report on the following four self-report statements in relation to their cannabis use: “i did it too much”, “once i started, i couldn’t stop”, “i felt i had to do it in order to function”, and “i continued to do it, even though it caused problems” (schluter et al., 2018). total scores were calculated by summing the four items and ranged from 0 to 16, with higher scores reflecting greater problematic cannabis use. consistent with hodgins et al. (2022), a total score of 3 or greater was used to indicate problematic cannabis use. the ssba cannabis portion has demonstrated good convergent validity in relation to the cannabis abuse screening test (r = .74), a well-validated measure of problematic cannabis use (schluter et al., 2020). internal consistency of the ssba cannabis portion was α = 0.91 in the present sample. the adverse childhood experience questionnaire (ace) the adverse childhood experience questionnaire (ace; dong et al., 2004) is a 29-item self-report questionnaire that measures ten categories of aces that individuals may be exposed to during childhood including emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, household substance abuse, mental illness, parental separation or divorce, and household crime. participants are asked to rate the extent to which they experienced each item on a 5-point likert scale from “never” to “very often”. the 29 items were then coded to reflect a dichotomous score of either 0 = no or 1 = yes for each category of ace. consistent with dong et al. (2004), the scores were then combined to generate a total score (zero to 10) to determine the total number of ace categories an individual was exposed to. the internal consistency of the ace total score was α = 0.76 in the present sample. brief version of the difficulties in emotion regulation scale (ders-18) the brief version of the difficulties in emotion regulation scale (ders-18; victor & klonsky, 2016) is an 18-item self-report questionnaire that assesses facets of emotion dysregulation including awareness, clarity, non-acceptance, strategies, goals, and impulse. participants are asked to rate the extent to which each item applies to them using a five-point likert scale from 1 (“almost never”) to 5 (“almost always”). the ders-18 has demonstrated strong internal consistency, as well as convergent and concurrent validity (victor & klonsky, 2016). given our interest in the overall construct of emotion dysregulation, total scores calculated from all 18 items summed were used in the present study, whereby higher scores reflect greater emotion dysregulation. in the present sample, the internal consistency of ders-18 total score was α = 0.90. upps-p short form (supps-p) the short-form version of the upps-p impulsive behavior scale (supps-p; cyders et al., 2014) is a 20-item self-report measure designed to assess different facets of impulsivity including sensation seeking, lack of premeditation, lack of perseverance, negative urgency, and positive urgency. each facet is represented by a separate subscale consisting of 4 different items. for the present study, only the negative and positive urgency subscales were measured. participants were asked to rate each item on a four-point scale from 1 (“strongly agree”) to 4 (“strongly disagree”), and the 4 items that correspond to the negative and positive urgency subscales were averaged. the averages of each item were summed to produce scores for these subscales, whereby higher scores reflect greater negative and positive urgency, respectively. the supps-p has been supported as a valid and reliable alternative to the original 59-item upps-p measure (cyders et al., 2014). in the present sample, internal consistency of the negative urgency subscale was α = 0.72 and the internal consistency of the positive urgency subscale was α = 0.78. data analysis analyses were performed using ibm spss version 27. to examine between-variable associations, bivariate correlations were obtained trauma and affective impulsivity in cannabis use 117 for all variables. two moderated-mediation models were then run using process macro for spss (model 14; hayes, 2013). for the first model, aces was entered as the independent variable, ssba problematic cannabis use as the dependent variable, emotion dysregulation as the mediating variable, and negative urgency as the moderating variable. the second model was identical to the first, but with positive urgency entered as the moderating variable instead of negative urgency. the same two models were run a second time with the other supps-p subscales (i.e., sensation seeking, lack of premeditation, lack of perseverance, and the urgency construct that was not entered as a moderator in a particular model) entered as covariates. to control for the potential influence of demographic variables, age, gender, and ethnicity were also entered as covariates in each model. in all models, moderation effects were tested on the b path between emotion dysregulation (m) and cannabis use (y). interaction terms between emotion dysregulation and negative or positive urgency were produced by process macro (hayes, 2013) for all models, and significant interaction terms were probed at +1 and -1 sd from the mean. results data screening and assumption tests datapoints within the variables included in the moderated-mediation models were defined as outliers if they exceeded a cut-off score of z = 3.29 standard deviations from the mean (tabachnik & fidell, 2013). no outliers were identified, and consequently, all datapoints were included in analyses. assumptions for moderated-mediation were tested including independence of observations, linearity of relationships between variables, homoscedasticity of error values, multicollinearity between independent variables, and normal distribution of error values (hayes, 2018). all assumptions were met with the exception of normality, which was somewhat positively skewed. given that regression analysis is robust against minor violations of normality (hayes, 2018), we proceeded with moderatedmediation analyses. preliminary results on average, participants reported having consumed cannabis on 5.98 days (sd = 9.07) and having consumed a total of 5.11 grams of cannabis (sd = 10.64) in the past 30 days. scores on the cannabis subscale of the ssba ranged from 0-16, with 36% (n = 213) of the sample meeting the cutoff for problematic use. there were significant positive associations between all variables included in the main study analyses, with effect sizes ranging from small to medium. means, standard deviations, and correlation coefficients are presented in table 2. table 2. means, standard deviations, and bivariate correlations between problematic cannabis use, negative urgency, positive urgency, aces, and emotion dysregulation. measure m (sd) range 1 2 3 4 5 1. problematic cannabis use 3.13 (4.25) 0-16 2. negative urgency 2.47 (.68) 1-4 .29** 3. positive urgency 2.02 (.67) 1-4 .34** .55** 4. aces 2.89 (2.43) 0-10 .29** .18** .22** 5. emotion dysregulation 50.00 (13.47) 21-90 .30** .58** .38** .26** note. ** p < .01 cannabis, a publication of the research society on marijuana 118 moderated mediation (process model 14) negative urgency the index of moderated-mediation was significant (b = .04, se = .03, 95% bca ci [.01, .12]; see figure 1), suggesting that the mediation model between aces, problematic cannabis use, and emotion dysregulation depended on levels of negative urgency when controlling for age, gender, and ethnicity. in other words, there was a significant moderation effect on the b path between emotion dysregulation (m) and cannabis use (y). there was a significant direct effect of aces on problematic cannabis use (c’ = 36, se = .07, 95% ci [.22, 50], t = 5.11, p < .001) such that increased aces was associated with increased problematic cannabis use. further, there was a significant effect of aces on emotion dysregulation (m) (a = 1.42, se = .22, 95% ci [.99, 1.86), t = 6.42, p < .001), such that increased aces was associated with increased emotion dysregulation. there was no significant effect of emotion dysregulation (b = -.05, se = .05, 95% ci [-.14, .04], t = -.1.15, p = .207) nor negative urgency (b = -1.0, se = .87, 95% ci [-2.70, .70]) on problematic cannabis use. negative urgency moderated the relationship between aces, emotion dysregulation and problematic cannabis use (b = .04, se = .02, 95% ci [.01, .07], t = 2.43, p = .016) at moderate (2.50; b = .05, se = .02, 95% bca ci [.02, .08]) and high (3.25; b = .08, se = .02, 95% bca ci [.04, .11]) but not low (1.75; b = .02, se = .02, 95% bca ci [-.04, .06]) levels of negative urgency. the hypothesized moderated-mediation model remained significant when controlling for other facets of impulsivity (i.e., positive urgency, sensation seeking, premeditation, and perseverance) (b = .04, se = .02, 95% bca ci [.01, .08]). specifically, negative urgency moderated the relationship between aces, emotion dysregulation and problematic cannabis use at moderate (2.50; b = .04, se = .02, 95% bca ci [.01, .08]) and high (3.25; b = .07, se = .02, 95% bca ci [.03, .12]) but not low (1.75; b = .01, se = .02, 95% bca ci [-.02, .05]) levels of negative urgency. figure 1. moderated-mediation model testing the relationship between adverse childhood experiences, emotion dysregulation, negative urgency, problematic cannabis use. note. b = unstandardized coefficient; se = standard error, * = significant at the α = .05 level; *** = significant at the α = .01 level. trauma and affective impulsivity in cannabis use 119 positive urgency the index of moderated-mediation was significant (b = .07, se = .03, 95% bca ci [.01, .12]; see figure 2), suggesting that the mediation model between aces, problematic cannabis use, and emotion dysregulation depended on levels of positive urgency when controlling for age, gender, and ethnicity. in other words, there was a significant moderation effect on the b path between emotion dysregulation (m) and cannabis use (y). there was a significant direct effect of aces on problematic cannabis use (c’ = 30, se = .07, 95% ci [.22, 50], t = 4.37, p < .001) such that increased aces was associated with increased problematic cannabis use. further, there was a significant effect of aces on emotion dysregulation (m) (a = 1.42, se = .22, 95% ci [.99, 1.86), t = 6.42, p < .001), such that increased aces was associated with increased emotion dysregulation. there was no significant effect of emotion dysregulation (b = -.04, se = .04, 95% ci [-.11, .02], t = -.1.25, p = .210) nor positive urgency (b = -.81, se = .82, 95% ci [-2.43, .81]) on problematic cannabis use. positive urgency moderated the relationship between aces, emotion dysregulation, and problematic cannabis use (b = .05, se = .02, 95% ci [.02, .08], t = 3.01, p = .003) at moderate (2.00; b = .05, se = .01, 95% bca ci [.02, .08]) and high (2.75; b = .08, se = .02, 95% bca ci [.05, .11]) but not low (1.25; b = .01, se = .02, 95% bca ci [-.02, .05]) levels of positive urgency. the hypothesized moderated-mediation model remained significant when controlling for other facets of impulsivity (i.e., negative urgency, sensation seeking, premeditation, and perseverance) (b = .04, se = .02, 95% bca ci [.01, .08]). specifically, positive urgency moderated the relationship between aces, emotion dysregulation and problematic cannabis use at moderate (2.00; b = .03, se = .02, 95% bca ci [.01, .07]) and high (2.75; b = .07, se = .02, 95% bca ci [.03, .12]) but not low (1.25; b = -.002, se = .02, 95% bca ci [-.03, .04]) levels of positive urgency. figure 2. moderated-mediation model testing the relationship between adverse childhood experiences, emotion dysregulation, positive urgency, problematic cannabis use. note. b = unstandardized coefficient; se = standard error, * = significant at the α = .05 level; *** = significant at the α = .01 level. cannabis, a publication of the research society on marijuana 120 discussion aces have been strongly implicated in the etiology and maintenance of problematic cannabis use among postsecondary students (schwartz et al., 2022), highlighting the importance of identifying the mechanisms and moderators of this relationship that may be targeted to reduce negative impacts. consistent with this objective, the present study examined whether emotion dysregulation mediates the association between aces and problematic cannabis use at differing levels of affective impulsivity (negative and positive urgency) among postsecondary students. the hypothesized moderated-mediation models were supported. as predicted, aces were positively associated with problematic cannabis use in the present study. this finding is consistent with previous research that has demonstrated a robust link between aces and various addictions, including gambling (poole et al., 2017), alcohol use (loudermilk et al., 2018), and cannabis use (forster et al., 2018). also as predicted, emotion dysregulation was found to mediate the association between aces and problematic cannabis use at high levels of both negative and positive urgency in the present study. in other words, for people with greater affective impulsivity, the indirect effect of emotion dysregulation on the relationship between aces and problematic cannabis use is particularly powerful. aces expose youth to chronically elevated stress levels, which can lead to longstanding dysregulation of the immune and endocrine systems as well as parts of the brain such as the hippocampus, prefrontal cortex, and amygdala (boullier & blair, 2018). deficits in the functioning of such systems and brain regions are proposed to play a role in elevated emotion dysregulation (martin & ochsner, 2016) and impulsivity (mitchell & potenza, 2014), which have also been identified as risk factors for substance use (hildebrandt et al., 2021; weiss et al., 2015) and problematic cannabis use specifically (cavalli & cservenka, 2021; manning et al., 2019; wardell et al., 2016). given that emotion dysregulation is characterized in part by difficulty adaptively regulating emotions (gratz & roemer, 2004), individuals who endorse higher levels of affective impulsivity may experience greater frequency and duration of intense emotions (gross & jazaieri, 2014). in turn, experiencing intense emotions regularly may present individuals who also endorse higher levels of negative or positive urgency with an increased likelihood of engaging in risky and impulsive behaviors such as cannabis use, which can become problematic when used repeatedly. individuals with both a history of aces and elevated urgency may also be more prone to using cannabis to a problematic extent as a way to reduce distress. according to the selfmedication hypothesis (khantzian, 1997), individuals engage in substance use and addictive behaviors to regulate their emotions and specifically, to reduce distress. indeed, attending university can be a stressful experience involving challenging life transitions (e.g., moving out of the family home, seeking partor full-time work) and intense academic pressure, which can contribute to mental health difficulties including anxiety and depression (pedrelli et al., 2015). consequently, postsecondary students who endorse a history of aces and a greater tendency to behave rashly when experiencing intense emotion may represent a group that is particularly vulnerable to engaging in risky behaviors (e.g., excessive cannabis use) as a means of coping with distress, particularly given that aces may have impacted their ability to develop healthy ways of doing so (dvir et al., 2014). the interaction between emotion dysregulation and urgency among postsecondary students who have encountered aces is particularly concerning, as emerging adults are already generally prone to increased engagement in risk-taking behavior, a susceptibility that may be enhanced among students as they leave the family home and transition into postsecondary education (smith & cyders, 2016). emotion dysregulation and urgency are proximal risk factors for addictions that may be more receptive to modification (nolen-hoeksema & watkins, 2011) than the more distal aces. consequently, the findings of the present study may carry important implications for the prevention and treatment of problematic cannabis use among postsecondary students with a history of aces. interventions targeting both emotion dysregulation and affective impulsivity may be particularly beneficial for this subset of individuals. for example, dialectical behavior therapy skills training (dbt-st) is often used trauma and affective impulsivity in cannabis use 121 with substance use disorders to treat problems rooted in emotion dysregulation and specifically aims to increase an individual’s ability to tolerate and regulate distress (warner & murphy, 2021). further, mindfulness-based interventions (mbis) are also commonly used to target emotion dysregulation and reduce impulsivity through mindfulness, which involves maintaining nonjudgmental awareness of one’s thoughts and emotions in the present moment (kabat-zinn, 1994). mindfulness meditation encourages individuals to “sit with” uncomfortable emotions rather than attempt to suppress or act upon them rashly. this skill may, in turn, reduce their likelihood of engaging in maladaptive and impulsive behaviors, such as cannabis use, when experiencing heightened emotional intensity. moreover, developing greater emotional awareness, acceptance, and understanding, as well as replacing emotion-based impulsive behaviors with more adaptive regulation skills, may further decrease their propensity for developing problematic cannabis use. limitations and future directions while the findings of the present study supported the hypothesized moderated-mediation models, several limitations should be noted. first, a cross-sectional design was employed, which precludes conclusions regarding the causal nature of the relationships between aces, emotion dysregulation, negative and positive urgency, and problematic cannabis use among postsecondary students. future studies should consider examining these relationships longitudinally, such as by measuring emotion dysregulation and urgency at several time points and tracking the transition to problem cannabis use overtime among youth who have encountered aces. second, a self-report measure was used to assess problematic cannabis use. although the ssba (schluter et al., 2018) was administered in the present study given its brief length and minimal burden on participants, a structured diagnostic interview may be used in future studies to more comprehensively and accurately confirm the presence of cud. third, the present study was conducted in a canadian context wherein cannabis has been legalized since 2018 (rotermann, 2020). previous research has identified higher rates of cannabis use among individuals residing in regions where it is legal relative to those residing in regions where it is still criminalized (goodman et al., 2020), suggesting that postsecondary students with a history of aces may display different patterns of problematic cannabis use depending on their geographic location. another important contextual factor to note is the covid-19 pandemic, which was ongoing during data collection for the present study. there is evidence to suggest that rates of substance use significantly increased among emerging and young adults during the pandemic (marchand et al., 2022). as such, participants in the present study may have endorsed greater cannabis use severity than would typically be observed. future studies may consider testing the present moderated-mediation models among postsecondary students living in regions where cannabis is not legal, as well as outside of the context of the covid-19 pandemic, to determine whether results diverge. finally, it is important to note that the majority of participants were white, single, straight women pursuing post-secondary education. therefore, the homogeneity of the sample may limit the external validity, or in other words, generalizability of our findings (henrich et al., 2010). future studies should consider including a more diverse sample, particularly with regards to gender, ethnicity, and socioeconomic status. for instance, this may be achieved by using a prescreener to identify and selectively invite participants who both use cannabis and identify as members of underrepresented sociodemographic groups. conclusion in conclusion, the findings of the present study found support for the mediating role of emotion dysregulation in the relationship between aces and problematic cannabis use at high levels of both negative and positive urgency in a large sample of canadian postsecondary students. although aces represent a distal risk factor and their occurrence cannot be modified, emotion dysregulation and urgency may be promising proximal targets for decreasing the risk of problematic cannabis use among these individuals. interventions that aim to increase mindfulness and adaptive emotion regulation skills may reduce the likelihood that cannabis, a publication of the research society on marijuana 122 postsecondary students with a history of aces will resort to risky and impulsive behaviors, such as cannabis use, when experiencing heightened emotional distress. references arterberry, b. j., boyd, c. j., west, b. t., schepis, t. s., & mccabe, s. e. 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(2001). the five factor model and impulsivity: using a structural model of personality to understand impulsivity. personality and individual differences, 30(4), 669–689. https://doi.org/10.1016/s0191-8869(00)000647 wolff, s., holl, j., stopsack, m., arens, e. a., höcker, a., staben, k. a., hiller, p., klein, m., schäfer, i., barnow, s., & cansas study group (2016). does emotion dysregulation mediate the relationship between early maltreatment and later substance dependence? findings of the cansas study. european addiction research, 22(6), 292–300. https://doi.org/10.1159/000447397 funding and acknowledgements: funding for this study was provided by a ryerson university faculty of arts research grant. the ryerson university faculty of arts had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. the authors confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere. the present study has been submitted to present as a five-minute talk at the 2023 canadian psychological association conference. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 149 special section editor benjamin o. ladd, ph.d. keynote addresses expanding and improving public health regulations of cannabis rosalie l. pacula university of southern california thc-sparing effects of cannabis constituents: potential to reduce harms and improve outcomes? ziva d. cooper university of california – los angeles poster presentations all poster presentations and symposia were peerreviewed by (in alphabetical order): adrian bravo (william & mary), r. lorraine collins (suny buffalo), bradley t. conner (colorado state university), verlin joseph (university of new mexico), benjamin o. ladd (washington state university vancouver), eric pedersen (university of southern california), kristina t. phillips (kaiser permanente hawaii), emma smith (colorado state university), kirstyn smithlecavalier (university of washington). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. examining the chemical behavior of cannabinoids and terpenes in cannabis sativa l antonio junior, sadanand dhekney, michael foland (laboratory of plant biotechnology, department of agriculture, food and resource sciences, university of maryland eastern shore) the use of cannabis sativa derived cannabinoids and terpenes has increased in recent years. consumers demand cannabis flowers containing ideal levels of those compounds. this research aimed to perform chemical analysis of cannabinoids and terpenes to establish the appropriate harvest time to meet commercial standards. plants were grown for 8 weeks at 16h of light, and later, flowered at 8h of light for 14 weeks. after 6 weeks into flowering, flowers were tested biweekly using gc-ms. results demonstrated that terpenes such as b-myrcene, d-limonene and caryophyllene levels were the highest on week 6, then, they declined towards week 14. on the other hand, cannabinoids such as abstracts from the 2023 scientific meeting of the research society on marijuana july 21st-23rd, 2023 cannabis 2023, volume 6 (2) © author(s) 2023 researchmj.org doi: 10.26828/cannabis/2023.02.001 conference abstracts 150 cbd, δ-9-thc, cbg, and cbn increased from the sixth through the 10th week and started decreasing from week 12 through 14. if growers require high contents of terpenes, they should harvest their plants no later than 8 weeks into flowering, and if highest cannabinoids content is required, plants should be harvested from 8-10 weeks into flowering. blood and urinary metal levels among marijuana users in nhanes (2005-2018) katlyn e. mcgraw, anne e. nigra, joshua klett, marisa sobel (columbia university mailman school of public health) xin hu (emory university) elizabeth oelsner (columbia university) ana navas-acien, tiffany r. sanchez (columbia university mailman school of public health) "with the ongoing nationwide decriminalization of marijuana and rapid expansion of stakeholders including manufacturers, legislators, and consumers, there is an urgent need for epidemiological-relevant data on marijuana contaminants and their potential health risks. because the cannabis plant is a known heavy metal scavenger, we hypothesized that individuals who use marijuana will have higher metal biomarker levels as compared to those who do not use. to examine the relationship between marijuana use and metal exposures, we acquired and combined seven cycles of data from the national health and nutrition examination survey (2005-2018) for n= 7,254 participants, classified by use: non-marijuana/non-tobacco, marijuana-only, tobacco-only, and dual marijuana and tobacco use; and by recent marijuana use: in the last 7 days, 8-30 days, or 31-365 days. five metals were measured in blood and 16 in urine using inductively coupled plasma-mass spectrometry; urinary metals were adjusted for urinary creatinine. linear regression models were adjusted for age, sex, race, education, egfr, and nhanes cycle year. compared to participants who used neither tobacco nor marijuana, participants reporting dual marijuana and tobacco use, had statistically significantly higher mean blood cadmium levels (3.5 µg/l; 95%ci: 3.1, 3.9; p<0.001) and urine cadmium levels (0.69 µg/g; 95%ci: 0.56, 0.83; p<0.001). blood lead levels (0.64 µg/dl; 95%ci: 0.44, 0.87; p<0.001) and urine lead levels (0.54 µg/g; 95%ci: 0.31, 0.80; p<0.001) were also higher among dual users. participants reporting marijuana-only use had higher mean blood cadmium levels (0.22 µg/l; 95%ci: 0.11, 0.34; p<0.001) and urine cadmium levels (0.18 µg/g; 95%ci: 0.06, 0.31; p=0.004) and higher mean blood lead levels (0.27 µg/dl; 95%ci: 0.07, 0.50; p=0.006) and urine lead levels (0.21 µg/g; 95%ci: -0.006, 0.50; p=0.058). among marijuana-only users who had used marijuana in the last week, we found a 0.23 µg/l (0.12, 0.35) and a 0.20 µg/g (95%ci: 0.03, 0.39) higher cadmium levels and a 0.39 µg/dl (0.11, 0.75) and 0.31 µg/g (95%ci: 0.01, 0.70) higher lead levels in blood and urine, respectively, as compared to non-marijuana use. our results suggest marijuana is a significant source of cadmium and lead exposure. research regarding cannabis use and cannabis contaminants, particularly metals, should be conducted to address public health concerns related to the growing number of cannabis users. changes in blood pressure/heart rate after cannabis use and the relationship to selfreported drug effect and thc concentration sarah a. limbacher, julia wrobel, alexis krause, lauren turow, ashley brooks-russell (colorado school of public health) background: the relationship between acute cannabis use and change in blood pressure and heart rate (bp/hr) is well established. studies show cannabis use acutely significantly increases heart rate and mildly increases blood pressure in the minutes following smoked or inhaled use of cannabis. less is known about how frequency of use (i.e., tolerance) may affect the magnitude of the relationship, and how the physical effects of acute cannabis use relate to self-reported drug or intoxication effects, and the relationship to thc potency. aims: to analyze the relationship between changes in bp/hr (preto postcannabis use), subjective intoxication, thc concentration, and explore by frequency of cannabis use. methods: bp/hr was measured at baseline and mean of 2.4 minutes post-cannabis smoking (or rest period for non-use control group). the arcimarijuana scale and visual analog scale (vas) conference abstracts 151 were administered at both time points. linear regression models were used to measure change in bp/hr between the following groups; daily (n=45) and occasional cannabis use (n=18), and non-use (n=8). results: there was a significantly higher hr after smoking in occasional and daily use groups as compared to the control group (p<0.001). body tingling and feeling that the heart is beating faster were associated with higher hr (p<0.01). the difference in hr between occasional and daily use groups after smoking was not significant (p=0.42). neither thc concentration nor vas score was significantly associated with bp/hr. conclusions: these results indicate the cardiovascular physiological effects of cannabis consumption are not subject to tolerance or thc concentration in the product. therefore, bp/hr might be a reliable predictor of recent use. this is a departure from other effects, such as cognitive or subjective drug effects, where tolerance to cannabis is well established. accuracy of labeled thc potency across product types in colorado gregory r. giordano, angela d. bryan, marco ortiz torres (university of colorado boulder, boulder, colorado) colin brook, duncan mackie (medpharm holdings llc, denver, colorado) l. cinnamon bidwell (university of colorado boulder, boulder, colorado) accurate labeling of thc potency in cannabis products is important to inform consumer purchasing decisions and dose titration. the present study aimed to independently test the accuracy of labeled thc potency in flower, concentrate, and other (e.g., tinctures, drinks, pills, etc.) cannabis products in colorado. this study was a collaboration between medpharm, a licensed cannabis testing facility, and a research team at the university of colorado boulder. cannabis products were purchased from colorado dispensaries by a designated member of the research team, who also recorded product label information and transferred the product to a blinded container. triplicate analysis of cannabinoid potencies was then conducted by another member of the research team who was blinded to the label information. observed thc potency was calculated using the industry standard equation total thc = thc + (0.877 x thca). consistent with the state of colorado standards that allow a 15% deviation between labeled and actual potency, products were classified as accurately labeled if observed thc was within ±15% of the labeled value, over-labeled if observed thc was more than 15% above the labeled value, and under-labeled if observed thc was more than 15% below the labeled value. a chisquared test was used to evaluate the effects of product type on label accuracy, and independent samples t-tests were used to compare observed and labeled thc for each product type. onehundred twenty-eight cannabis products were purchased, including 57 flower products, 57 concentrate products, and 14 other products. mean observed thc potency was 20.6% (sd = 4.67) [range: 11.7-33.0] for flower products, 71.5% (sd = 4.33) [range: 58.3-80.0] for concentrate products, and 4.74mg (sd = 3.06) [range: 0.1910.31] for other products. mean labeled thc potency was 23.4% (sd = 5.23) [range: 8.92-39.0] for flower products, 73.6% (sd = 5.04) [range: 59.5-82.4] for concentrate products, and 6.29mg (sd = 3.06) [range: 1.25-10.0] for other products. mean absolute difference between observed and labeled thc potency was 4.11% (sd = 3.99) [range: 0.14-17.9] for flower products, 3.57% (sd = 2.81) [range: 0.04-11.5] for concentrate products, and 2.37mg (sd = 2.10) [range: 0.065.81] for other products. label accuracy depended on product type (x2(4, n = 128) = 39.04, p < .001), with 52.6% of flower products accurately labeled (over-labeled: 40.4%, under-labeled: 7.0%), 98.2% of concentrate products accurately labeled (overlabeled: 1.8%, under-labeled: 0.0%), and 35.7% of other products accurately labeled (over-labeled: 50.0%, under-labeled: 14.3%). observed thc potency was significantly lower than labeled potency in both flower (t(112) = 3.02, p = .003) and concentrate (t(112) = 2.41, p = .02) products, but no difference was observed in other products (t(26) = 1.36, p = .19). this study is ongoing, with additional cannabis products to be purchased and included in the analysis. these preliminary results found labeled thc to be higher than observed thc in both flower and concentrate products, but not in other products. observed thc in both flower and other products were frequently outside of ±15% of labeled thc, while conference abstracts 152 close to 100% of concentrate products were within ±15%. cannabis use frequency is linked to altered cardiac and vascular functioning neel muzumdar, kelsey piersol, antony p. pawlak, kelly sun, amanda colangelo, jennifer f. buckman (rutgers university) current efforts to federally legalize cannabis often aim to discredit the characterization of cannabis as a class i drug by citing its lack of lifethreatening health effects. while historically true, the physiological effects of cannabis, particularly of newer more potent strains and concentrates, are not yet fully elucidated. of particular interest is cannabis’ effects on the cardiovascular system. cannabis intoxication is known to acutely mobilize cardiovascular processes, increasing heart rate and blood pressure during intoxication. increased activation of the endocannabinoid system is linked to vascular disorders such as atherosclerosis. however, most of the research on how cannabis affects cardiovascular functioning comes from decades-only administration studies, static cardiovascular descriptive data, and emergency department samples. the present study contributes to the field by characterizing cardiovascular and substance use data obtained from 183 ostensibly healthy college students without a substance use disorder (sud) diagnosis. participants were part of an ongoing 2-year prospective study of how college lifestyle behaviors affect cardiovascular health. heart rate variability (hf hrv), an index that correlates with parasympathetic nervous system (i.e.,g vagal) activity, was calculated from an ecg and log-transformed. pulse wave velocity (pwv), an index of arterial stiffness, was calculated from the ecg and a continuous blood pressure finger cuff. generalized linear models analyzed relationships between past 30-day cannabis use frequency and cardiovascular indices. for hf hrv, an interaction between past 30-day cannabis use frequency and sex was found. higher hf hrv was significantly associated with more frequent use for females whereas lower hf hrv was associated with more frequent use in males (estimate+se=-0.0077+0.0036, p=0.0296). for pwv, a direct relationship with past 30-day cannabis use frequency was found (estimate+se=0.0134+0.004, p=0.0008) suggesting potentially more arterial stiffness in more frequent cannabis users compared to less frequent users. these initial results imply that the cardiovascular system may be altered with frequent use even in young, healthy samples. moreover, neuroendocrine influences, i.e., sex differences, may further modulate the effects of cannabis on cardiovascular functioning, possibly due to its effects on endocannabinoid activity. these data suggest that chronic cannabis use habits, even among individuals without sud, may alter resting cardiovascular set points. risks and therapeutic benefits of cannabis among college students amidst the covid-19 pandemic selina espinoza, melissa-ann lagunas, claudia rocha, jennifer l. lovell (california state university, monterey bay) more than half of the united states has legalized medicinal and/or recreational cannabis. the purpose of the study is to understand cannabis use and perceptions among college students – 21 years and older – in a legalized cannabis state. participants included 203 college students, the majority identified as female (61.1%, n = 124) and latinx/hispanic (46.8%, n = 95). the online survey included demographic questions and questionnaires measuring cannabis consumption, cannabis use disorder, and quality of life. participants answered open-ended questions about the negative, positive, and spiritual impact/s of cannabis on their life and health, and how the covid-19 pandemic impacted their cannabis use. a paired-sample t-test indicated participants significantly found more relief using cannabis compared to non-cannabis treatments or medications. there was no significant correlation between quality of life and cannabis use disorder symptoms. inductive content analysis of 112 written responses revealed perceived negative effects (e.g., anxiety/mental health issues) and positive effects (e.g., relaxation/stress reduction) from using cannabis. most participants reported no spiritual benefits; however, some participants discussed cannabis use improving connection to self and self-awareness. regarding the impact of the covid-19 pandemic on use, most participants (27.8%) reported increased cannabis use, while some reported decreased cannabis use. these conference abstracts 153 findings reflect the importance of understanding the wide-range of benefits and risks perceived by college students who consume cannabis and how these results can inform prevention and wellness efforts. cannabis and college students: self-perceived mental health prior to, during, and after the pandemic deanna l. romero, sean l. l. himebaugh, thomas a. clobes (california state university channel islands) iintroduction: college students demonstrated changes in levels of mental health as they and the world experienced new levels of stress and anxiety due to the covid-19 pandemic. as access to healthcare became limited, students turned to alternative methods of coping, which included cannabis use. objective: to determine if an association between cannabis use and self-perceived mental health during the pandemic among college students exists. methods: social media was utilized to invite respondents to the survey, as well as snowball recruitment. a paired samples t-test was used to compare self-reported mental health at different times during the pandemic, a one-way anova to compare self-reported mental health between respondents' cannabis use status, and a tukeykramer post-hoc analysis was used to determine between group significance. results: of 103 self-reported college students, the most significant differences in mental wellbeing were reported prior to and during the pandemic. it was discovered that the most significant differences between each of the college student groups derived from those students who entirely avoided cannabis use or cessation of use (highest rating), p=.018, as compared to those who initiated cannabis use prior to and during the pandemic (lowest rating) p=.045. post pandemic mental health demonstrated a higher level of mental wellness among those who had some exposure to cannabis compared to those who avoided cannabis entirely. conclusion: it cannot be concluded that mental health was lower due to cannabis use. however, it is possible those with lower self-perceived mental health turned to cannabinoid use. a cannabis beliefs scale andrew p. weinstein, clayton neighbors (university of houston) cannabis has routinely been identified as one of the most frequently used illicit substances among adolescents, young adults, and the general adult population in the united states by large epidemiological studies. recent policy changes in the legal status of cannabis have inspired calls for the replication of research and further exploration of the biopsychosocial relationships between cannabis use and outcomes. theoretical psychological perspectives of behavior, such as outcome expectancies, substance-related social norms, and motivation, have routinely found success in explaining portions of why substance use occurs. however, this literature has been limited by focusing primarily on either college students or those actively using cannabis. this study sought to identify a more general method of evaluating beliefs about cannabis that would possess utility across a broad range of group identities. two important types of validity for the new assessment measure(s) were their unique content area, distinguishing them from existing measures (i.e. discriminant validity) and the ability to predict scores on other assessment measures (i.e. predictive validity). we examined the relationships among cannabis-related beliefs in the context of social norms, expectancies, and motivation as well as the associations with indicators of cannabis use and related consequences. results indicated that the proposed cannabis belief scales possess discriminate and predictive validity. implications for future research opportunities were explored. differences in alcohol and cannabis motives among simultaneous, concurrent, alcohol-only, and cannabis-only users katherine a. berry, alison looby (university of wyoming) stimulant norms and prevalence (snap) study team substance use motives are strong predictors of alcohol and cannabis use and consequences among college students. both simultaneous alcohol and cannabis (i.e., marijuana; sam) and concurrent alcohol and cannabis (i.e., marijuana; cam) use are associated with higher endorsement conference abstracts 154 of certain types of motives compared to single drug-only use, which may explain heightened risks for experiencing negative consequences evidenced by co-users. understanding whether motives differ according to type of use could provide an important avenue for intervention efforts; however, research has not yet examined if motives differ between sam and cam users. thus, the purpose of this study was to examine how sam, cam, and single drug-only users differ on alcohol and cannabis motives. participants were 2295 college students (72.4% female, 50.6% white) from seven us universities who reported past-month alcohol and/or cannabis use (41.2% sam, 12.4% cam, 39.1% alcohol-only, 7.3% cannabis-only). participants completed measures of alcohol and cannabis motives and past-month substance use frequency via online survey. two multivariate analyses of covariance (mancova) models were conducted to examine differences on cannabis motives (i.e., enjoyment, celebration, conformity, and coping) and alcohol motives (i.e., social, coping, enhancement, and conformity) separately by past-month user status, controlling for sex and frequency of use. the overall cannabis model was significant, with between-group effects on conformity (f(2,1398)=3.90, p=.02), coping (f(2,1398)=6.96, p=.005), and celebration (f(2,1398)=5.83, p=.015) motives. pairwise comparisons utilizing a bonferonni-corrected alpha (p<.017) indicated that sam users endorsed greater coping (p=.002) and celebration (p=.004) motives than cam users. moreover, cannabisonly users held greater coping motives than cam users (p=.009). sam and cannabis-only users did not differ on any motives. the overall alcohol model was also significant, with between-group effects on all four alcohol motives. pairwise comparisons indicated that sam users endorsed greater social (p=.012), coping (p=.003), and enhancement (p<.001) motives than cam users. moreover, sam users were higher on all four motives (all ps<.01) than alcohol-only users, and cam users were higher on social motives (p=.013) than alcohol-only users. results indicate that sam and cam users can be importantly differentiated by alcohol and cannabis motives, with sam users reporting greater motives for use related to coping with negative mood and enhancing positive mood/celebrating for both substances. interestingly, sam users did not differ from single drug-only users on cannabis motives, though they uniformly reported greater alcohol motives. given that sam users reported stronger enhancement and coping motives than cam users across both drugs, it is possible that college students may opt to combine their substances when they are predominantly motivated to use for mood-related reasons. considering that sam users only differed from single-drug users with regard to alcohol, but not cannabis motives, it may be that simultaneous use particularly enhances alcohol-related desirable outcomes, though not necessarily desirable cannabis outcomes. as such, intervention efforts designed to reduce sam use may benefit from specifically targeting alcohol and mood-related motives. moreover, research is needed to examine the within-person effects that motives may have on type of use. sleep-related cannabis expectancy questionnaire (sr-ceq): factor analysis replication, reliability, and validity patricia a. goodhines, krutika rathod (university of maine) lisa r. larowe (massachusetts general hospital, harvard medical school) amelia v. wedel (syracuse university) introduction: cannabis is commonly used for sleep aid, despite mixed evidence for its sleeppromoting effects. expectancies for the sedative effects of cannabis could influence the degree to which cannabis confers acute sleep-promoting effects and may exacerbate propensity to respond to sleep problems with cannabis use. recently, the sleep-related cannabis expectancies questionnaire (sr-ceq; goodhines et al., 2020) was developed to assess expectancies that cannabis use will benefit or harm sleep, and initial evidence for its 2-factor structure was obtained in a general college sample. however, the sr-ceq’s associations with sleep and cannabis use behaviors remain unknown, precluding assumptions of construct validity. this study aimed to replicate the two-factor structure and excellent internal reliability of the sr-ceq, as well as provide incremental evaluation of construct validity among a sample of undergraduate college students. conference abstracts 155 method: cross-sectional online survey data was drawn from 287 college students (mage=19.07±1.44 years, range 18-25; 47% assigned male at birth; 84% non-hispanic white; 61% lifetime cannabis use) at a four-year university in the northeastern u.s. as longitudinal study of college health behaviors. of the original 332 participants, 6 were excluded for missing data and 39 were excluded as multivariate outliers on positive/negative subscales. a two-factor confirmatory factor analysis (cfa) was conducted with oblimin rotation and ml estimation to test the hypothesized measurement model’s fit to the data. bivariate correlations assessed construct validity via associations with demonstrated demographic, mood, sleep, and cannabis risk indices. independent sample t-tests explored whether srceq subscale scores differed as a function of sex, clinical insomnia severity, and/or hazardous cannabis use. results: cfa results demonstrated adequate fit of the two-factor measurement model to observed data (srmr=0.08), with excellent internal consistency within both positive (α=.94) and negative (α=.91) subscales. both subscales significantly correlated to the corresponding general expectancies subscale (rs=.59-.61, ps<.001). positive sleep-related cannabis expectancies were correlated with mood (depression/anxiety, distress intolerance; rs=.20.26, ps<.001), sleep (insomnia severity, pre-sleep arousal, diurnal impact; rs=.16-.28, ps=.001-.01), and cannabis use (frequency, hazardous use, sleep aid and solitary use, negative consequences; rs=.23-.48, ps=.001-.03). in contrast, negative sleep-related cannabis expectancies were not correlated with depression/anxiety, sleep, or hazardous cannabis use (ps<.05), but were associated with distress intolerance (r=.13, p=.04) and cannabis use (less frequency, sleep aid and solitary use, more consequences; r=-.18-.22, ps=.001-.03). positive sleep-related cannabis expectancies were greater among students with clinical insomnia severity (t[285]=2.71, p<.01; d=.33) and hazardous cannabis use (t[284]=6.63, p<.001; d=0.91). no group differences were observed by sex or for negative sleep-related cannabis expectances (ps<.05). conclusions: this study extends psychometric validation of the sr-ceq. results replicated the two-factor structure and highlight distinct psychosocial correlates for positive (sleep problems, depression/anxiety, and hazardous cannabis use) and negative sleep-related cannabis expectancies (general cannabis use, but not hazardous use, sleep problems, or depression/anxiety symptoms). findings further highlight positive sleep-related cannabis expectancies as a potential risk factor for insomnia and hazardous cannabis use. continued research is needed to (a) assess generalizability to varied populations and (b) clarify predictive validity and test-retest validity through longitudinal designs. factors related to riding with a drunk/drugged driver among us and israeli adults: cannabis, alcohol, both, or neither cassidy r. loparco, yuxian cui, zongshuan duan (george washington university) yael bar-zeev (the hebrew university of jerusalem and hadassah) yan wang (george washington university) hagai levine (the hebrew university of jerusalem and hadassah) lorien c. abroms (george washington university) amal khayat (the hebrew university of jerusalem and hadassah) carla j. berg (george washington university) background: driving under the influence (dui) of alcohol or cannabis is a public health concern. prevalence of dui in the us is over 4% for both alcohol and cannabis. dui is associated with increases in automobile crashes, fatalities, and has numerous economic consequences. despite prior research examining determinants of dui, relatively little is known about the passengers in vehicles in which the driver is dui. methods: data were obtained from a crosssectional online survey of us and israel participants ages 18-45 (n=2,222; us: n=1,128; israel: n=1,094) conducted in 2021. we used multinomial logistic regression to analyze the past 30-day odds of being a passenger in a vehicle after the driver had used: 1) alcohol only, cannabis conference abstracts 156 only, or both relative to neither alcohol or cannabis (referent); and 2) alcohol only or cannabis only relative to both, separately. results: overall, 17.6% had been passengers in vehicles with a driver dui of alcohol or cannabis in the past 30 days (4.2% alcohol only, 5.5% cannabis only, 7.9% both). most individuals had used alcohol (54.0%) but not cannabis (16.7% in the past 30 days. most people (36.6%) thought that driving after using cannabis was ‘much less’ or ‘somewhat less’ risky than alcohol; 33.9% thought there was no difference; and 29.6% thought that driving after using cannabis was “somewhat more” or “much more” risky than alcohol. compared to not being driven by anyone dui, statistically significant correlates of being alcohol only dui passengers were being from the us (aor=1.89), sexual minority (aor=2.59), and past-month alcohol use (aor=3.12); correlates of being cannabis only dui passengers were younger age (aor=1.03), less than a college degree (aor=1.92), and lower perceived risk of dui of cannabis versus alcohol (aor=1.82), and past-month cannabis use (aor=6.98); and correlates of being a dui passenger where the driver had used both alcohol and cannabis were being from israel (aor=1.82), older (aor=1.03), and past-month cannabis use (aor=15.65). compared to being driven by someone dui of both alcohol and cannabis, correlates of alcohol only dui passengers were being from the us and no past-month cannabis use; correlates of being a cannabis only dui passenger were being from the us, lower education, no past-month alcohol use, and lower perceived risk of cannabis versus alcohol. conclusions: country, age, perceived risk, and past-month substance use were associated with being a passenger in a vehicle while the driver was dui. prevention and intervention strategies to reducing dui prevalence and related risk should include approaches aimed at the passengers in a vehicle, in addition to the drivers themselves. comparing young adults’ perceptions of and strategies related to driving under the influence of alcohol, cannabis, and delta-8 thc: a mixed methods study loparco, c. r. (george washington university) olsson, s. (texas christian university) greene, k. m. (montana state university) berg, c. j. (george washington university) henry, d. (university of north texas) walters, s. t., zhou, z., rossheim, m. e. (university of north texas health science center) introduction: alcohol and cannabis are the most commonly used impairing substances in the u.s. in 2018, the u.s. federally legalized several psychoactive cannabis products, including delta8 thc. several thousand calls to poison control centers have been made related to delta-8 thc use. driving under the influence (dui) of alcohol and cannabis are serious public health concerns: automobile crashes are a leading cause of death. although the prevalence of dui of delta-8 thc has not been assessed, toxicology analyses of dui cases indicate that dui of delta-8 thc may be increasing. methods: data were from an online survey administered to a convenience sample of u.s. adults aged 18-25 (59% male, 59% nonhispanic white) using amazon mturk in july– august 2022 (n=189). the following were quantitatively assessed and compared related to dui of alcohol, cannabis, and delta-8 thc: pastmonth frequency, likelihood of future use, and perceived risk. participants were asked “please list all the ways that driving while under the influence of marijuana and delta-8 thc are [similar/different; two separate questions]” and “on the times you have driven while under the influence of a cannabis product (e.g., marijuana, delta-8 thc etc.), what techniques (if any) did you use to reduce the potential risk?” descriptive statistics and thematic analyses (qualitative) were conducted. results: regardless of the substance, most participants reported being ‘somewhat unlikely’ to dui and thought dui carried ‘moderate harm’. most individuals (58.78%) reported equal dui likelihoods for all three substances, 20.95% reported being more likely to dui of alcohol than cannabis and delta8 thc, and the remaining 20.28% were equally split in reporting higher likelihoods of dui of delta-8 thc (vs. alcohol and cannabis, 10.14%) or cannabis (vs. alcohol and delta-8 thc, 10.14%). additionally, 35.29% of participants reported dui conference abstracts 157 of alcohol to be riskier than cannabis or delta-8 thc, 33.99% had equal dui risk perceptions for all three substances, 16.99% believed dui of delta-8 thc was the riskiest, and 13.73% believed that dui of cannabis was the riskiest. among those reporting use of each substance, past-month dui occurred most frequently after using delta-8 thc (22.03%, n=13/59), followed by alcohol (18.13%, n=29/160), and cannabis (10.32%, n=13/126). qualitative results indicated that dui of delta-8 thc and cannabis were compared by discussing risk perceptions and potency, and most participants felt that dui of cannabis was safer than delta-8 thc. participants also discussed how these substances may impact driving risk (e.g., slower reaction time, less focused, sedation, anxiety, calming). strategies to reduce dui risk fell into two categories: before driving (reduce amount used, wait after using to drive, have a designated driver) and during driving (drive short distances, drive slowly, avoid highways, turn off phone/radio). discussion: this was the first study to examine and compare delta-8 thc dui perceptions alongside alcohol and ‘traditional’ cannabis. dui interventions that are broad and focus on impairment, rather than substancespecific information, may be efficacious. interventions should build upon existing strategies that individuals are already implementing to reduce their dui harm (e.g., reducing the amount used, reducing distractions). event-level associations among thc, cbd, social context, and subjective experience during cannabis use episodes yi-chun chang, renee e. magnan, benjamin o. ladd (washington state university vancouver) objective: limited research takes the quantity and potency of cannabis products, as well as social context, into consideration while examining subjective experience of real-world cannabis use. this study aimed to examine the subjective experience as a function of thc/cbd dosages (quantity x potency) and social context during cannabis use episodes in an intensive longitudinal study with individuals using cannabis recreationally. method: one hundred and two adults (55.4% female, 87.2% white, 90.2% nonhispanic, mage = 35.67) reporting weekly cannabis use were recruited from the community. participants completed a baseline self-report battery and then a 14-day ecological momentary assessment (ema) protocol using their smartphones, during which they self-initiated a brief survey after each cannabis use episode. participants reported the thc and cbd potency and quantity of the cannabis product, social context, and subjective experience (i.e., like, dislike, and high). a series of multilevel models with two levels were built with level 1 (event level: thc dosage, cbd dosage, social context, time since finishing use) and level 2 (person level: cannabis problems) predictors of subjective experience. thc and cbd dosages were personmean centered. results: at the within-person level, higher thc dosage (b = .15, p <.001; b = .35, p <.001) and cbd dosage than one’s average (b = .09, p =.04; b = .11, p =.03), and social use (b = .20, p =.01; b = .34, p <.001) significantly predicted greater liking and feeling high, respectively. the higher the thc dosage than one’s average predicted lower disliking (b = -.05, p =.03). a significant interaction effect of thc dosage and social context (b = .08, p = .02) was observed such that solitary use had a negative association between thc dosage and dislike (b = -0.05, p = .03) and social use had a null association (b = .02, p = .25). moreover, the quadratic effect of time since use was a significant predictor in all three outcomes, during which all three subjective experiences increased and then decreased with time since use. at the between-person level, individuals with greater cannabis problems reported lower liking (b = -.15, p =.04) and higher disliking (b = .08, p =.01), but not feeling high, on average, across the ema protocol. conclusion: social context plays an important role in the subjective reward at the within-person level, even when thc/cbd dosages are controlled for. future research could examine if social context is related to cannabis-related behaviors (i.e., use quantity, problems) to understand how it might be a risk/protective factor at the event level. moreover, individuals with greater cannabis problems might experience less like but more dislike in general across use episodes. interventions targeting cannabis problems could highlight this evidence to effectively challenge expectancies/motives of use. conference abstracts 158 characterizing cannabis use in rural college students: the novel role of belongingness and negative mood krutika rathod (university of maine) alexis wagner (husson university) taylor broadaway (university of maine) audrey tesi (university of akron) patricia a. goodhines (university of maine) introduction: rates of young adult cannabis use in rural areas are not only steadily increasing but approaching levels seen in urban communities (14.7% in non-metro; 18.5% in small and large metro areas; samhsa, 2020). despite comparable prevalence, rural youth may be at increased risk for cannabis-related harms such as driving while intoxicated. rural communities therefore represent a notable risk group for cannabis use and associated vulnerabilities, potentially attributable to social isolation characteristic of these environments. social isolation has been linked to serious health risks and higher rates of depression, anxiety, and suicide (national academies of sciences, 2020), which may confer risk for self-medication with cannabis. as such, community belongingness may be protective against affective sequelae of social isolation, and thus represent a critical modifiable intervention target for rural cannabis use. this study integrated distinct frameworks of substance use and belongingness to examine the novel interpersonal determinants of cannabis use in rural communities, specifically belongingness. method: cross-sectional online survey data was drawn from 332 college students (mage=19.03 years [sd=1.39, range 18-25]; 53% female; 84% white) at a four-year university in the northeastern u.s. as a longitudinal study of college health behaviors. of the original 332, 5 were excluded due to missing cannabis data, resulting in an analytical sample of 327. bivariate correlations of all study variables were examined to characterize rural college cannabis use and psychosocial correlates. a fully saturated crosssectional path model explored the association of university belongingness with past-month cannabis use via past-month depression/anxiety symptoms after controlling for male sex, white race, and first-year class. results: students endorsing past month cannabis use (57%; n=185) reported using 1-5 occasions in the past month, with 28% using at hazardous levels and 4 negative psychosocial consequences (m=4.25 [sd=4.34]) on average. students endorsed more social use (m=4.06 [sd=1.78]) than solitary use (m=1.97 [sd=2.01]) on average over the past month. past month cannabis use frequency was correlated with higher phq-4 mean scores (r=0.14,p=.01), but not university belonging (p>.05). path analyses suggest that belongingness was significantly associated with negative mood (a path; β=-.30, b=-0.11, se=0.02, p<.001, 95% ci [-0.15, -0.07]), which was in turn associated with cannabis use (b path; β=.18, b=0.44, se=0.12, p<.01, 95% ci [0.14, 0.73]). after accounting for this indirect pathway, the direct belongingness-cannabis relationship was nonsignificant (c’ path; β=.04, b=0.04, se=0.05, p=.45, 95% ci [-0.06, 0.14]). this suggests full mediation of the indirect pathway via depression and anxiety symptoms (b=-0.05, se=0.02, 95% ci [-0.09, -0.01]). conclusions: the significant indirect pathway of belongingness to cannabis use via depression and anxiety symptoms in this dataset suggests a novel cannabis risk mechanism in rural young adults. this study contributes to an unfortunate paucity of literature on rural cannabis use. future directions include continued characterization of rural cannabis use to assess replicability and generalizability across regions and time, as well as sociodemographic variability in perception and salience of belongingness. continued exploration of interpersonal protective and risk factors novel to the rural environment, such as belongingness, may help identify intervention targets to inform clinical recommendations. cannabis expectancies as moderators of the day-level association between cannabis quantity and driving under the influence of cannabis megan n. fleming, lindsey k. freeman, tayler j. vebares (university of missouri) andrea w. wycoff (brown university) timothy j. trull (university of missouri) conference abstracts 159 background: driving under the influence of cannabis (duic) may negatively impact driving performance (simmons et al., 2022) and increase risk of collision (up to 1.92 times that of unimpaired drivers; asbridge et al., 2012). therefore, understanding risk and protective factors is crucial. individuals’ expectations of cannabis’s effects act as protective or exacerbating factors in individuals’ risk of duic (arterberry et al., 2013; ewing et al., 2015; huynh et al., 2022; king et al., 2020). for example, individuals expecting cannabis to have global negative effects or lead to cognitive and behavioral impairment may be less likely to drive. in contrast, individuals who expect cannabis to induce perceptual and cognitive enhancement may be at increased risk of duic.  research also suggests that greater cannabis use quantity may increase the risk of duic (huynh et al., 2022). in the current study, we sought to further understand these factors by examining whether global negative effects, cognitive and behavioral impairment, and perceptual and cognitive effects expectancies moderate the within-person association between cannabis use quantity and participant reports of duic. methods: 31 individuals who reported smoking cannabis flower at least three days per week between the ages of 18 and 50 (m=24.32; sd=7.71) completed the marijuana effects expectancy questionnaire (schafer & brown, 1991) and reported daily cannabis use in grams and whether they engaged in duic over the past 21 days via timeline follow-back. logistic multilevel models tested the moderating role of global negative effects, cognitive and behavioral impairment, and perceptual and cognitive effects expectancies on the association between grams of cannabis consumed on a given day and participant reports of duic across 718 days. results: participants reported driving after smoking on 29.81% of days. on days when participants reported driving after smoking, they reported driving within two hours of smoking on 91.12% of days. cognitive and behavioral impairment and global negative effects expectancies significantly moderated the association between cannabis quantity and duic (or=4.22; 95% ci:[1.53, 11.67]; p=.006 and or=37.55; 95% ci:[4.53, 311.54]; p=.001, respectively). however, findings suggested that individuals reporting greater cognitive and behavioral impairment or global negative effects were more likely to report duic on days when they reported smoking a greater amount of cannabis than usual, while those reporting lower cognitive and behavioral impairment or global negative effects were less likely to report duic after greater consumption. the interaction between perceptual and cognitive effects expectancies and cannabis quantity was not significant (or=1.20; 95% ci:[0.35, 4.17]; p=.775). conclusions: cognitive and behavioral impairment and global negative effects significantly moderated the association between cannabis quantity and the likelihood of duic, but the pattern of results was inconsistent with our hypotheses. notably, our sample consisted of individuals reporting frequent cannabis use. it may be that individuals who frequently use cannabis accurately predict its effects. individuals in our sample who endorsed greater cognitive and behavioral impairment and global negative effects expectancies may have done so due to prior experience engaging in risky behaviors, including duic, following heavier use; however, further work is needed to explain this effect. the impact of personality risk factors on motives and cannabis consequences in emerging adulthood alexandra shifrin, jasmin l. katz, camara azubuike, abby l. goldstein (university of toronto) emerging adults (eas; ages 19-29) have the highest rates of cannabis consequences relative to other age groups. although motives (i.e., reasons for using cannabis) are an established predictor of cannabis consequences, less is known about how other factors (i.e., personality) interact with motives to further increase cannabis-related problems. two personality risk factors have emerged as potentially relevant for predicting problematic cannabis use: anxiety sensitivity (i.e., fear of anxiety-related sensations and their connection to potentially negative consequences) and sensation seeking (i.e., desire for novel and stimulating experiences). anxiety sensitivity has been linked to both cannabis consequences and motives, particularly negative reinforcement motives such as using cannabis for coping and conference abstracts 160 alleviation of social anxiety, however it is unclear how anxiety sensitivity impacts the relationship between these motives and cannabis consequences. in addition, where motives have been examined, they are typically explored at the trait level, despite motivational models highlighting motives as state-level constructs that impact cannabis use in real time. the purpose of the current study was to examine the moderating role of anxiety sensitivity on the relationship between coping and social anxiety motives and cannabis consequences using an ecological momentary assessment research design. participants were 81 eas who used cannabis regularly (mage = 21.99; 57.3% female; 41.5% caucasian; 72% enrolled in postsecondary education) and completed a short survey three times a day, reporting on their cannabis use, motives, and consequences over 14 days. anxiety sensitivity and sensation seeking were assessed at baseline. hierarchical linear modelling tested whether personality risk factors moderated the within-person relationship between motives and cannabis consequences. in general, eas experienced greater consequences when they were higher in anxiety sensitivity (β = .07; se = .03; p = .02). in addition, cannabis consequences were higher when they were linked to episodes of cannabis use that were more highly motivated by coping (β = .10; se = .04; p = .03), and social anxiety (β = .06; se = .03; p = .006). anxiety sensitivity moderated the within-person relationship between coping motives and cannabis consequences (β = -.02; se = .01; p = .003). the within-person relationship between social anxiety motives and cannabis consequences was consistently high for those who were higher on anxiety sensitivity. for those lower in anxiety sensitivity, the slope was positive; participants had greater consequences on episodes when they used cannabis for social anxiety reasons. these results offer insight into personality risk factors as important trait-level moderators of the statelevel relationship between motives and cannabis consequences. anxiety sensitivity emerged as an important risk factor to consider, especially at lower levels where the risk of experiencing cannabis consequence becomes greater when endorsing specific motives. treatment and intervention approaches may benefit from targeting this subpopulation of eas by addressing using cannabis to cope or for social anxiety reasons. comprehensive characterization of sexual and gender minority cannabis use disparities among emerging adults paul w. martines, junhan cho, adam m. leventhal (university of southern california) evan a. krueger (tulane university) dae-hee han, dayoung bae, alyssa f. harlow, melissa wong, jessica l. barrington-trimis (university of southern california) background: the proportion of emerging adults (aged 21-25) who identify as sexual and/or gender minority (sgm) has increased in the united states over the past decade. while sexual and gender minority (sgm) emerging adults use cannabis at disproportionately high rates, it is unclear if sgm cannabis use disparities generalize across various sgm identities, and across different cannabis products. the current study examined associations between diverse sgm identities and use of different cannabis products. methods: data were from a prospective cohort, originally recruited from los angeles county high schools, who have since been digitally surveyed four times as emerging adults (ages 18-23) from 2019-2022 (n=2706). past 30-day use frequency of five cannabis products (smoked flower, vaped, edibles, blunts, and concentrates, and number of polyuse products) were compared across four gender (cisgender female, cisgender male, nonbinary, transgender) and seven sexual orientation identities (heterosexual, asexual, bisexual, gay/lesbian, pansexual, queer or other identity, and questioning) using time-varying contemporaneous associations after adjusting for sociodemographic factors (e.g., age, race/ethnicity, education enrollment, working status, financial status). results: transgender (vs. cis-gender female) participants had higher past 30-day cannabis use frequency for combustible flower (relative risk (rr)=2.82, 95% ci=1.15-7.09), vaped (rr=2.96, ci=1.43-6.12), blunts (rr=2.92, ci=1.14-7.46), concentrates (rr=2.22, ci=1.16-4.25), and polyproduct (rr=2.30, ci=1.19, 4.45). non-binary (vs. cis-gender female) participants had higher conference abstracts 161 frequency of past 30-day use for 2 out of 5 cannabis products (rrs ranged from 2.32 to 2.59). gay/lesbian (vs. heterosexual) participants had greater frequency of past 30-day cannabis use for combustible flower (rr=1.93, ci=1.44-2.60), vaped (rr=1.95, ci=1.35-2.81), edible (rr=2.00, ci=1.24-3.22), blunts (rr=1.61, ci=1.04-2.48), concentrates (rr=2.28, ci=1.25-4.19), and polyproduct (rr=1.51, ci=1.24-1.85). bisexual (vs. heterosexual) participants reported a greater frequency of past 30-day use for 4 out of 5 cannabis products (rrs ranged from 1.32 to 1.66), while participants identifying as queer or another identity (vs. heterosexual) reported a greater frequency of past 30-day use for 3 out of 5 cannabis products (rrs ranged from 1.91 to 2.31). asexual vs. heterosexual respondents did not differ in cannabis use. conclusions: emerging adults who identify as most, but not all, sgm identities may be at greater risk of more frequent use of various cannabis products, especially those identifying as transgender or gay/lesbian. inclusive sgm measurement may aid in more precise identification of cannabis use disparities. does marijuana use impact other drug outcomes for sober living house residents? elizabeth mahoney, meena subbaraman, amy mericle, doug polcin (public health institute) background: sober living houses (slhs) offer an abstinence-based environment for people in recovery. increased legalization of marijuana for recreational use as well as use of marijuana for medical purposes has put slh operators and managers in a difficult position regarding how to handle marijuana use among residents. further complicating matters, harm reduction models highlight the potential for substituting marijuana for other drugs because people report less adverse side effects, a decreased likelihood of a relapse, and less concern about withdrawal. while a substitution strategy may work for some, research is needed on how this approach could impact the recovery of slh residents. methods: we used observational data from a longitudinal study conducted from 2018 to 2021 to look at 557 new slh residents at baseline, sixmonth follow-up, and 12-month follow-up. the sample was predominately male (71%), had a mean age of 39.8 years, and 49% self-identified as nonwhite. bivariate tests were conducted to examine differences between residents who had and had not used marijuana in the 6 months prior to baseline. mixed models examined the associations between any self-report of marijuana use the 6 months prior to entering the slh and other drug outcomes at 6and 12-month followup: any use of drugs other than marijuana during the past 6 months, total days of drug use other than marijuana, number of dsm-5 substance use disorder (sud) symptoms, and severity scores >0 on the addiction severity index (asi) drug scale. final models adjusted for age, sex, race/ethnicity, any substance use 30 days prior to baseline, pastmonth substance use treatment, and past sixmonth 12-step attendance. logistic regression was used for the dichotomized outcomes and negative binomial regression was used for count outcomes. all mixed models adjusted for clustering at the slh level with robust standard errors. results: bivariate tests for differences between residents who had and who had not used marijuana in the 6 months prior to baseline found significant differences (ps<0.05) for race/ethnicity, any substance use for 30 days prior, number of days used in past 6 months, and number of 12-step meetings attended in past 6 months. any past six-month cannabis use was related to significantly (ps<0.01) higher odds of any past-6-months drug use other than marijuana (or=28.74, 95% se: 15.64); more days of drug use other than marijuana in the past 6 months (irr=15.01, 95% se: 6.29); dsm-5 sud symptoms (irr=2.39, se: 0.41); and higher odds of any drug issues on the asi (or=90.55, se: 63.76). conclusions: marijuana does not appear to have a substitutional role for residents in slhs; marijuana use was instead associated with an increase in other drug use and greater drugrelated issues. these findings point to a higher overall risk to the recovery efforts of slh residents who use marijuana. development and initial validation of the safe cannabis consumption identity measure luke d. salomone, robert d. dvorak (university of central florida) conference abstracts 162 previous research has suggested that observed factors of cannabis use including use patterns, motives, and consequences are mirroring the same factors for alcohol use. as the prevalence of cannabis continues to grow, the ambiguous nature of a popularizing substance calls for more empirical approaches toward treating cannabisrelated problems. narrowing in on a flexible state of identity as opposed to inflexible states of behaviors show to promote long-lasting behavior change. while implementing this context with interventions, measures regarding a healthy identity with cannabis have yet to be explored. a measure that quantifies the extent of a healthy identity with consuming cannabis was created, entitled the safe cannabis consumption identity measure (sccim). a five-factor model based on previous literature was conceptualized. an exploratory factor analysis along with a confirmatory factor analysis was conducted on the baseline sample (n = 580), revealing a strong two-factor model. the two altering factors identified within the model were “congruent identity” and “counter identity”. the measure demonstrated moderate concurrent and discriminant validity. prospectively four weeks later, those that reported moderate cannabis use were recruited for a follow-up survey (n = 52), which was evaluated for test-retest reliability and predictive validity. the measure demonstrated sound test-retest reliability and predictive validity, predicting higher use of protective behavioral strategies and lower cannabis-related consequences and cannabis use altogether. by utilizing a psychometric model of identity toward cannabis use, the sccim aims to serve as a practical mechanism for cannabis use interventions. college adjustment, rumination, marijuana coping motivations, and problematic marijuana use: a path model among freshmen college students rebecca j. dunaief, adrian j. bravo (william & mary) cross-cultural addictions study team background: problematic marijuana use is prevalent, particularly in young adults, with marijuana use disorder affecting 5.8%, or 2.0 million, of young adults (ages 18 – 25) in the united states alone (samhsa, 2020). previous research has reported a significant association between poor college adjustment and later marijuana use (welsh, 2019). though existing research reports a significant association between poor college adjustment and marijuana use outcomes, the underlying mechanisms that could explain these associations are less clear. in support of negative affect regulation pathway models, prior research has found rumination (particularly problem-focused thoughts) and marijuana use coping motives to significantly mediate the relationship between poor negative affect and marijuana use problems (bravo et al., 2019). however, research examining whether rumination and marijuana coping motives mediate the relationship between poor college adjustment and problematic marijuana use is limited. objective: the present study aimed to expand prior research by exploring the associations between college adjustment, problem focused thoughts, marijuana use coping motives, negative marijuana-related consequences, and cannabis use disorder symptoms among freshmen college students. specifically, we hypothesized that poor college adjustment would relate to more negative marijuana-related consequences and cannabis use disorder symptoms via more problem focused thoughts and higher coping motives. method: participants were 285 (59.6% female) u.s. college student freshman who consumed marijuana in the past month and completed measures of marijuana use patterns (i.e., frequency of use in a typical week), marijuana use consequences (brief marijuana consequences questionnaire; simons et al., 2012), cannabis use disorder symptoms (cannabis use disorder identification test, adamson et al., 2010), marijuana use motivations (marijuana motives questionnaire, simons et al., 1998), college adjustment (college adjustment questionnaire, o’donnell et al., 2018), and problem-focused thoughts (ruminative thoughts style questionnaire, brinker & dozios, 2008). to address study aims, two path analyses were performed to test the serial unique associations between college adjustment → problem focused thoughts → coping motives → negative marijuana related consequences/cannabis use disorder symptoms. conference abstracts 163 results: within our path models, we found significant double-mediation effects for both negative marijuana-related consequences (indirect β = -.02, 95% cis = -0.04, -0.01) and cannabis use disorder symptoms (indirect β = -.02, 95% cis = -0.03, -0.01) as outcomes. specifically, we found that a higher endorsement of poor college adjustment was associated with more problem-focused thoughts, which in turn was associated with higher marijuana coping motives, which in turn was associated with more negative marijuana-related consequences and cannabis use disorder symptoms. conclusions: these findings provide support for the relevance of problem-focused thoughts and coping motives as potential factors in linking poor college adjustment to problematic marijuana use among freshmen college students. clinically, these results lend support to targeting problemfocused thoughts and marijuana coping motives among freshmen transitioning to college in order to mitigate harms stemming from poor college adjustment and its impact on problematic marijuana use. further, our preliminary findings encourage further exploration of these associations in longitudinal or experimental studies. risky family dynamics, rumination, marijuana coping motives, and problematic marijuana use: a cross-cultural examination isabela ortiz caso, adrian j. bravo (william & mary) cross-cultural addictions study team background: problematic marijuana use is prevalent, particularly in young adults, with marijuana use disorder affecting 5.8%, or 2.0 million, of young adults (ages 18 – 25) in the united states alone (samhsa, 2020). previous research has reported a significant association between poor family dynamics in childhood (i.e., family conflict) and development of substance use disorders (skeer et al., 2009; 2011). though existing research reports a significant association between childhood family conflict and substance use outcomes, limited research has examined the impact of childhood family conflict on marijuana use outcomes among college students, especially across differing cultures. moreover, the underlying mechanisms that could explain these associations are less clear. objective: the present study aimed to expand prior research by exploring the associations between childhood family conflict, rumination subfacets (i.e., anticipatory thinking, counterfactual thinking, problem-focused thoughts, and repetitive thinking), marijuana use coping motives, and negative marijuana-related consequences among college students from seven countries. specifically, we hypothesized that poor family dynamics (i.e., higher family conflict) would relate to more negative marijuana-related consequences via more ruminative thinking (specifically problem focused thoughts) and higher coping motives. method: college students from seven countries (u.s., argentina, canada, uruguay, spain, south africa, and england) completed an online survey examining mental health and substance use outcomes. to test study aims, the analytic sample comprised of 1,559 (68.3% female) college students who consumed marijuana in the past month and completed a measure of poor family dynamics. path analysis was performed within the whole sample testing the serial unique associations between poor family conflict → rumination subfacets → marijuana coping motives → negative marijuana-related consequences. multi-group analysis was performed to determine if the proposed model was invariant across gender and countries. results: within our comprehensive model we found that coping motives (indirect β = .04, 99% cis = 0.01, 0.07) and anticipatory thoughts (indirect β = .03, 99% cis = 0.01, 0.05) uniquely indirectly influenced the relationship between poor family conflict and negative marijuanarelated consequences. specifically, more family conflict was associated with more marijuana coping motives and anticipatory thoughts, which in turn were related to more negative consequences. moreover, we found one significant double-mediation effect for problem-focused thoughts and coping motives (indirect β = .01, 99% cis = 0.01, 0.03) illustrating that more family conflict was associated with more problemfocused thoughts, which in turn was associated with higher marijuana use coping motives, which in turn was associated with more negative marijuana-related consequences. this model was invariant across countries and gender groups suggesting replicability and generality. conference abstracts 164 conclusions: these findings provide support for the relevance of rumination and coping motives as potential factors in linking childhood family conflict to problematic marijuana use across nations. our preliminary findings encourage further exploration of these associations in longitudinal and experimental studies and lends support to the therapeutic targeting of rumination and marijuana coping motives to mitigate harms stemming from poor childhood family conflict. covid-19 stress, ruminative thinking, marijuana coping motivations, and problematic marijuana use: a path model among u.s. college students maya reddy, adrian j. bravo (william & mary) "background: covid-19 destabilized life for college students and researchers are continuing to gather data to understand the impact covid-19 has had on cannabis use among college students. in support of negative affect regulation pathway models, prior research has found rumination (particularly problem-focused thoughts) and marijuana use coping motives to significantly mediate the relationship between poor negative affect and marijuana use problems (bravo et al., 2019). focusing on covid-19, a recent study found that marijuana use coping motives significantly mediated the relationship between increases in poor mental health symptoms due to the impact of covid-19 and marijuana use problems among college students (dunaief et al., 2023). however, whether rumination and marijuana coping motives mediate the relationship between covid-19 related stress and problematic marijuana use is limited. objective: the present study aimed to expand prior research by exploring the associations between covid-19 related stress, problemfocused thoughts, marijuana use coping motives, and negative marijuana-related consequences among u.s. college students. specifically, we hypothesized that higher covid-19 related stress would relate to more negative marijuanarelated consequences via more problem-focused thoughts and higher coping motives. method: our sample consisted of 485 undergraduate students (58.1% cis woman) who consumed marijuana in the past month and completed measures of covid-19 related stress, rumination, marijuana coping motives, and negative marijuana-related consequences in the spring of 2022. to address study aims, a path model was conducted (covid-19 related stress → problem-focused thoughts → marijuana coping motives→ negative marijuana-related consequences) using process macro (hayes, 2013) in spss. results: within our path model, we found that coping motives (indirect β = .05, 99% cis = 0.004, 0.10) uniquely indirectly influenced the relationship between covid-19 related stress and negative marijuana-related consequences. specifically, higher covid-19 related stress was associated with more negative marijuana-related consequences via higher marijuana use coping motivation. moreover, a significant doublemediation effect for problem-focused thoughts and coping motives was found (indirect β = .01, 99% cis = 0.004, 0.03). specifically, we found that higher covid-19 related stress was associated with more problem-focused thoughts, which in turn was associated with higher marijuana use coping motives, which in turn was associated with more negative marijuana-related consequences. conclusions: our preliminary findings suggests that college students reporting high covid-19 related stress and who tend to engage in ruminative thinking (particularly problemfocused thoughts) are turning to marijuana to alleviate their struggles; however, this increased motivation to use marijuana to cope is associated with more experiences of negative marijuanarelated consequences. taken together, providing resources for substance-free coping strategies to manage the stress related to covid-19 may be extremely useful for this population (particularly those engaging in ruminative thinking). moreover, our preliminary findings encourage further exploration of these associations in longitudinal studies to examine the long-term effects of covid-19 on marijuana outcomes among this population. sensitivity to both reward and non-reward as predictive of subjective mood ratings to delta-9tetrahydrocannabinol (thc) among young adults julia brooks, zoa glab, shahd smadi, rebecca denson, natania crane (university of illinois at chicago) conference abstracts 165 background: rates of cannabis use have increased in young adults, an age group particularly susceptible to problematic use and developing cannabis use disorder. positive subjective response following drug use is an important indicator of substance use maintenance and potential problematic use. it is possible that differences in subjective response to single doses of delta-9-tetrahydrocannabinol (thc) predict future cannabis use, but little research has examined this question. further, it is not clear what factors predict differences in subjective response to thc. the current study examined sensitivity to reward and non-reward, known risk factors for problematic substance use, as predictors of subjective response to a single dose of thc in young adults who use cannabis. methods: in a within-subject, randomized, doubleblind, placebo-controlled design, 24 young adults ingested either placebo or 7.5mg oral thc (dronabinol) and completed subjective mood ratings of positive and negative affect at regular intervals throughout the visit. linear regression analyses examined whether measures of sensitivity to reward and non-reward (bis/bas scales) collected at study baseline were associated with positive and negative mood ratings during peak intoxication (120-180 minutes after drug administration). results: young adults with higher bas total scores demonstrated lower positive mood ratings to thc (versus placebo), β= -.54, p=.006, even after controlling for sex and lifetime cannabis use frequency. when bas subscales were examined in separate models, bas-drive was the only significant predictor of positive mood ratings, β= .48, p=.02, indicating higher bas-drive scores were related to lower positive thc mood ratings. bas-fun seeking and bas-reward responsiveness subscales were not significantly associated with positive mood ratings to thc (p-values < .05). for the bis scale, young adults with higher bis total scores showed greater positive mood ratings to thc (versus placebo), β= .42, p=.04, and this effect trended toward significance after controlling for sex and lifetime cannabis use frequency. in terms of negative mood, no bis or bas scores were related to negative mood ratings to thc (versus placebo; p-values < .05). conclusions: these findings revealed that both sensitivity to reward and non-reward were related to subjective positive mood, but not negative mood, ratings to thc among young adult cannabis users. our results suggest that those more sensitive to rewards more generally are likely to report lower subjective positive mood after thc, and those more sensitive to nonrewards are more likely to report higher subjective positive mood after thc. this pattern of findings supports evidence that general sensitivity to rewards and general sensitivity to non-reward in one’s environment may each be dissociable risk factors for substance use maintenance and problematic use. college marijuana beliefs, marijuana motives, protective behavioral strategies, and cannabis use disorder symptoms: a path model among u.s. college students zannie l. montgomery, adrian j. bravo (william & mary) background: marijuana is one of the most often used drugs among college students and excessive use is linked to numerous negative consequences. the degree to which marijuana use is ingrained in students' social life and sense of self may be reflected in their perception of how vital marijuana is to the college experience (pearson et al. 2017), which has the potential to be a significant predictor of symptoms of cannabis use disorder among college students (nielsen et al., 2019). in examining mechanisms linking the perceived importance of marijuana to the college experience (herein called college marijuana beliefs) to marijuana outcomes, one study found that higher college marijuana beliefs were associated with more negative consequences via lower use of marijuana protective behavioral strategies (bravo et al., 2019). however, limited research has investigated what factors link college marijuana beliefs to lower use of protective behavioral strategies (pbs) and in turn more negative marijuana-related consequences. objective: the present study aimed to examine the connections between college students' perceived value of marijuana to their college experience (i.e., college marijuana beliefs), their reasons for using marijuana (i.e., marijuana use motivations), marijuana pbs use, and their symptoms of cannabis use disorder. specifically, we hypothesized that higher college marijuana beliefs would relate to more cannabis use disorder symptoms via higher marijuana use motives conference abstracts 166 (specifically enhancement and coping motives) and less use of pbs. method: participants were 485 (58.1% cis woman) u.s. college students who consumed marijuana in the past month and completed measures of marijuana use patterns (i.e., frequency of use in a typical week), cannabis use disorder symptoms (cannabis use disorder identification test, adamson et al., 2010), marijuana use motivations (marijuana motives questionnaire, simons et al., 1998), marijuana pbs use (pedersen et al., 2017), and college marijuana beliefs (perceived importance of marijuana to the college experience scale, pearson et al., 2017). to address study aims, five path analysis models were performed (one for each marijuana motive; enhancement, social, coping, conformity, and expansion) to test the serial unique associations between college marijuana beliefs → marijuana use motives → pbs use → cannabis use disorder symptoms. results: within our path models, we found significant double-mediation effects for both enhancement motives (indirect β = .006, 95% cis = 0.002, 0.01) and coping motives (indirect β = .005, 95% cis = 0.001, 0.01). specifically, we found that higher college marijuana beliefs were associated with more enhancement and coping motives, which in turn was associated with fewer marijuana pbs use, which in turn was associated with more cannabis use disorder symptoms. conclusions: these findings provide support for the relevance of marijuana use motives (particularly enhancement and coping) and lower pbs use as potential factors in evaluating marijuana’s perceived importance to the college experience and cannabis use disorder symptoms. clinically, the results of this study may influence the development of targeted interventions that seek to reduce cannabis use disorder symptoms among college students by promoting pbs use and reducing cannabis use motivations, especially among students endorsing high college marijuana beliefs. predicting positive outcomes: an operant conditioning framework for cannabis use theodore j. fetterling (san francisco va health care system) jamie e. parnes (center for alcohol and addiction studies, brown university) concerns about negative impacts due to cannabis use are well documented on both individual and public health levels. extensive research has identified several indicators (i.e., age, male, use frequency) of cannabis-related negative outcomes. operant conditioning suggests positive outcomes serve as the reinforcing aspects of use; however, no studies have investigated if common predictors of negative outcomes are also associated with positive outcomes. moreover, research has identified different facets of positive consequences (i.e., social, mood, perceptual, and sexual enhancement). given the increasing availability of cannabis, there is a growing need to identify indicators of positive outcome facets and their salience, as these outcomes likely serve to promote use over time. since there is a dearth of research in this area, the present study examined exploratory associations between age, sex, and cannabis use frequency with different facets of positive outcomes. college students (n=615; 68.3% female; age m=19.98, sd=1.97) completed several self-report questionnaires, including participant demographic characteristics, cannabis use frequency, and positive outcomes of use. we used path analysis to examine unique associations between model predictors (i.e., age, sex, use frequency) and each positive outcome facet (i.e., social, mood, perceptual, sexual enhancement). use frequency was measured as the typical number of use periods each week (i.e., 12am-4am, 4am-8am, 8am-12pm, 12pm-4pm, 4pm-8pm, 8pm-12am; range=0-42) over the past three months. we evaluated two models: one predicting positive outcome frequencies and another predicting positive outcome valences. results indicated consistently significant, positive relationships between cannabis use and both frequency and valence of each positive outcome facet, the strongest of which was perceptual enhancement outcomes. both frequency and valence of social outcomes decreased significantly with age. findings further indicated the predictors accounted for the most variance in perceptual outcomes (14% frequency; 11% valence), followed by mood (11% frequency; 8% valence), social (6% frequency; 6% valence), and sexual enhancement (6% frequency, 3% valence). sex was not associated with any positive outcome facet. consistent with an operant conditioning framework, these findings suggest cannabis use conference abstracts 167 frequency is a strong indicator of positive outcome frequency and valence. notably, cannabis use frequency was the lone significant predictor of perceptual outcomes, which showed the largest amount of variance explained by predictors. thus, positive perceptual outcomes from use may serve as a particularly strong reinforcer toward ongoing cannabis use relative to other outcomes. regarding age, younger students in the sample reported greater positive social outcomes from use, which may reflect differences in the contexts or motives for use between younger and older individuals (e.g., use becoming more private for older individuals). taken together, these findings provide an initial step toward identifying salient indicators for reinforcing aspects of cannabis use. future research is needed to determine the extent of shared versus unique indicators between positive and negative outcomes. blunt smoking initiation, progression, and deescalation among youth and young adults: a 3state markov model of panel data dale s. mantey (university of texas health science center school of public health) latrice montgomery (university of cincinnati college of medicine) benjamin cristol, baojiang chen, melissa harrell (university of texas health science center school of public health) objective. to characterize and compare transitions in blunt smoking behavior among a diverse cohort of youth and young adults observed between spring 2019 and fall 2021. methods. we analyzed six (6) waves of panel data from n=2,608 youth and young adults, collected via the texas adolescent tobacco and marketing surveillance (tatams) system. data were collected from spring 2019 through fall 2021. we applied a three-state markov model to compare differences in the transition across three categories of blunt smoking: (a) never; (b) ever, non-current; and (c) current. our first markov model estimated differences in transitions across these three categories by race/ethnic category. next, we conducted a series of stratified markov models to identify common and unique predictors of blunt smoking transitions among each race/ethnic category. covariates were sex, age, language spoken at home, depression, alcohol use, tobacco cigar smoking. results. demographically, our sample was 37.5% latino, 31.7% non-hispanic white, 14.7% nonhispanic black, and 16.0% non-hispanic ""other."" our first markov model found that progression to ever (hr: 2.09; 95% ci: 1.15 – 3.81) and current (hr: 1.64; 95% ci:1.15-2.34), from never blunt smoking, was more likely among nonhispanic black youth, relative to non-hispanic white youth. among current blunt smokers, deescalation was less likely among nh-black (hr: 0.59; 95% ci: 0.43–0.81) and nh-""other""(hr: 0.53; 95% ci: 0.38–0.74), relative to nh-white youth. no differences were observed between nhwhites and latinos. the second markov model found that depression and alcohol use were each strong, consistent, longitudinal predictors of blunt smoking initiation, progression, and sustained use among all race/ethnic categories. conclusions. in this diverse cohort, blunt smoking initiation, progression, and de-escalation varied by race/ethnic category, though predictors of transitions did not. depression and alcohol are important, temporal risk factors for blunt smoking; consistent with cross-sectional findings from national, surveillance estimates. efforts to prevent and reduce blunt smoking will require extensive research to further understand the transitions of blunt smoking initiation and sustained use among youth. insomnia symptoms, cannabis protective behavioral strategies, cannabis-related problems and suicide ideation among u.s. college students maria m. wong (idaho state university) matthew r. pearson (university of new mexico) hannah k. lesnick (idaho state university) addictions research team both insomnia symptoms and cannabis use have been linked to suicide ideation and attempts. however, the mediators of this relationship are not fully understood. in this study, we investigated whether protective behavioral strategies for cannabis use (pbsc) and cannabis use related problems mediated the relationship between insomnia symptoms and suicide ideation conference abstracts 168 (si). specifically, we hypothesized that higher insomnia symptoms led to lower use of pbsc and more cannabis use related problems, which then increased si. study participants were 5044 college students recruited from 10 universities in the u.s. students participated in an online survey with assessments of insomnia symptoms, cannabis use, protective behavioral strategies, and si. insomnia symptoms refer to problems falling asleep, problems staying asleep, and early morning awakening. these symptoms were measured by the insomnia severity index (isi) (morin, belleville, bélanger, & ivers, 2011), sleep problems questionnaire (jenkins, stanton, niemcryk, & rose, 1988) and sleep disorders questionnaire (douglass et al., 1994). protective behavioral strategies for marijuana were measured by the protective behavioral strategies for marijuana scale (pbsm) (pedersen, huang, dvorak, prince, & hummer, 2017). cannabisrelated problems were measured by the brief marijuana consequences questionnaire (bmacq). si was measured the columbia suicide severity rating scale (posner et al., 2011). all analyses controlled for gender, age and race. data were analyzed by structural equation modeling. in the measurement model, isi, spq and sdq loaded significantly onto the latent variable, insomnia symptoms (standardized factor loadings of isi: .81, p<.001; spq: .92, p<.001; sdq: .85, p<.001). in the structural model, higher insomnia symptoms predicted lower pbsc (β=-.10(.04), p<.01) and higher cannabis related problems (β=.09(.03), p<.05). higher cannabis related problems significantly predicted increased si (β=.09(.02), p<.001). cannabis related problems significantly mediated the relationship between insomnia symptoms and si (95% asymmetric confidence interval: .002, .018, p<.05). higher insomnia symptoms also had a significant direct effect on cannabis related problems (β=.29(.02), p<.001). more frequent use of pbsc predicted fewer cannabis related problems (β=-.34(.02), p<.001). however, pbsc did not predict si. we will discuss the implications of these findings on understanding the variables that mediate the relationship between insomnia symptoms and si among college students. a major limitation of the study is its cross-sectional design, preventing us to drawing any conclusion about temporal or causal relationships among the variables. thus, the model presented here need to be replicated in other studies, especially studies that collects longitudinal and/or experimental data. characterizing prenatal cannabis use patterns in people's own words alexandria capolino (brown university) anastasia philippopoulos (stony brook university) rachel l. gunn, jacqueline nesi, elizabeth r. aston, lauren micalizzi (brown university) pregnant people rely on anonymous forums to educate themselves about prenatal cannabis use (pcu), some due to mistrust of healthcare providers and fear of negative repercussions. these resources contain misinformation that can lead individuals to make decisions about their pcu that are detrimental to their own health and to the health of their child. understanding the timing and patterns of pcu, as well as motivations for quitting, can inform health effects of pcu and windows for intervention. objective: this study evaluated statements about the duration/patterns of pcu (i.e., trimesters of use) and quitting that were posted to a public pcu form with >47,000 current members. methods: a qualitative analysis was conducted on a random sample of ten threads per month from june 2020 to may 2021 (n=120). posts were analyzed if they contained information about cannabis use during pregnancy or lactation and timing and/or quitting pcu. two independent coders used thematic analysis to codify information about pcu timing, such as the trimester(s) in which pcu occurred, and if/when people changed their pattern of use. coders then met to discuss and finalize consensus codes. results: most individuals reported using cannabis throughout their entire pregnancy. when quitting was referenced, it occurred during the second or third trimester, and quitting was often motivated by fears of child protective services involvement. conclusions: interventions should target early pcu, but should also be offered throughout pregnancy, as those who use cannabis in pregnancy tend to continue to use it for the duration of their pregnancy. further research is needed on the relationship between trimester(s) of pcu and trimester-specific effects on maternal-fetal health, and non-stigmatizing conference abstracts 169 pcu prevention and intervention efforts should be prioritized. protocol for sensitivity to cannabis effects and cue reactivity as markers of a developing disorder in adolescents hayley treloar padovano, robert miranda jr., jane metrik, elizabeth aston (brown university) cannabis use disorder (cud) is a significant public health concern with origins in adolescence. cannabis use escalates during the teenage years, and early cannabis use predicts the development of later problems. leading etiological theories suggest that repeated cannabis use as the brain develops produces changes in reward systems. over time, these instrumental brain changes alter cannabis effects and increase the incentive salience of cannabis cues, ultimately conferring risk for cud. this upcoming longitudinal study pairs ecological momentary assessment (ema) in the natural environment and a gold-standard human laboratory (hlab) paradigm to monitor changes in subjective cannabis effects, cue reactivity, and cud symptoms across the formative adolescent years. leveraging smartphone (ema) reports in natural settings allows for studying adolescents’ reactions to the typically higher potency thc products and varied formulations (e.g., oils, edibles) favored by teenagers. the use of an accelerated longitudinal design allows for charting development from ages 13 to 19 through multicohort assessments completed in a shorter timeframe. we aim to recruit 224 adolescents (ages 13 to 16 at study outset, n = 56 per age cohort) who endorse cannabis use in the past month. adolescents will complete a baseline hlab protocol with followups at 1, 2, and 3 years. each yearly assessment point will also include a 28-day measurement burst of ema in daily life. multiple domain latent growth curve modeling will: (aim 1) characterize age-related changes in sensitivity to rewarding cannabis effects over adolescence (ages 13 to 19); (aim 2) test prospective relations of cud symptom progression with change in sensitivity to rewarding cannabis effects; and (aim 3) test prospective relations of cud progression with responses to cannabis cues in the natural environment and hlab. the upcoming longitudinal study extends the investigative team’s prior research showing cross-sectional associations of cud severity with subjective cannabis effects and cue reactivity among adolescents. in this study, well-defined etiological cud constructs will be assessed across adolescence in real-world and laboratory settings. disaggregating individual differences in change from overall age trends through an accelerated longitudinal design is a sensitive approach that is distinctively innovative. this work aims to support efforts to prevent the progression of an incubating or emerging cud by enhancing scientific understanding of the trajectory to more severe harms. we aim to provide new empirical evidence of malleable processes that can serve as targets of preventative interventions. thc-o-acetate: understanding consumer experiences with a novel semi-synthetic cannabinoid daniel kruger (university of michigan) carlton ""cb"" bone, charles klein (portland state university) jessica kruger (university at buffalo) meredith meacham (university of california san francisco) introduction: there is a growing interest in and consumer demand for semi-synthetic cannabinoids. the addition of an acetate group to thc, the primary psychoactive component in cannabis, is thought to increase the potency of thc-o-acetate, colloquially known as thco. the need for understanding these substances and the consumers who chose to use them takes on new urgency, as thco will likely transition to the unregulated black market due to the u.s. drug enforcement agency’s february 2023 statement on the schedule i status of cannabinoid acetates. methods: researchers conducted the first known survey to examine consumer experiences with thco. a survey was posted to novel cannabinoidspecific online forums in mid-2022 and included measures from previous studies on the medical use of cannabis and cannabis products and addressed a broad range of issues, including administration methods, use frequency, experiential properties of thco, other cannabinoids used, health and medical conditions treated, drug substitution, adverse experiences, conference abstracts 170 and sources of information on thco. the survey content was also informed by comments in social media discussions of thco users. results: participants (n = 267) primarily consumed thco by vaping concentrates or extracts (71%) and edibles (49%), most (66%) used thco once a week or more frequently. most respondents (66%) used thc-o-acetate once a week or more, 88% inhaled heated/combusted thc-o-acetate, which may result in exposure to toxic ketene gas. experiential properties generally resembled those of thc, though with a greater latency of effects. most participants also used other novel cannabinoids such as hexahydrocannabidiol (hhc, 73%), cannabinol (cbn, 58%), and cannabigerol (cbg, 55%), some simultaneously with thco. about a third (36%) of participants used thco to treat a health or medical condition, most commonly for mental health issues such as anxiety or panic attacks (26%), depression or bipolar disorder (20%), and stress (15%). about a quarter (24%) of participants reported drug substitution, most commonly for sleep aids (11%), pain relievers (10%), alcohol (9%), and antidepressants (9%). only 4% of respondents received information on thc-o-acetate from their primary care provider, only 14% reported that their primary care provider knew they used thc-o-acetate, and 54% were not at all confident in their primary care provider’s ability to integrate medical cannabis into their treatment. internet discussion forums (85%) and websites (82%) were the predominant sources of information on thco, and a third (34%) of participants desired to receive information from their primary health/medical care provider. conclusions: all policies and practices should be informed by empirical evidence. people use thco-acetate users for recreational and medical use, reporting thc-like effects and effective substitution for other drugs. this use is generally separate from mainstream healthcare. although the legal environment is increasingly restrictive for thco, consumer demand and medicinal use may result in continued use, likely through unregulated markets. there is a continuing need for harm reduction efforts, such as lowering the risk of exposure to toxic ketene gas. thc-o-acetate: examining consumer attitudes and beliefs related to the risks of consuming the semi-synthetic cannabinoid thco carlton ""cb"" bone, charles klein (portland state university) jessica s. kruger (university at buffalo) meredith meacham (university of california san francisco) daniel kruger (university of michigan) introduction: semi-synthetic, or artificial, cannabinoids are a class of compounds that are typically manufactured with hemp derived concentrates, some of which have been found in the cannabis plant. semi-synthetic cannabinoids such as delta-8 or 9 thc-o-acetates, commonly known as thco, have gained attention for several reasons. consumer interest in the alleged increased potency of this substance; combined with researchers identifying a link heating these substances and ketene formation. as semisynthetic cannabinoids face increasing scrutiny the importance of identifying health antecedents and consequences of using semi-synthetic cannabinoids in comparison to medical marijuana and recreational cannabis becomes increasing important, given the recursive relationship of these markets. methods: as part of a structured questionnaire exploring consumer attitudes and experiences surrounding thco and other semi-synthetic cannabinoids administered across a variety of cannabinoid-related forums on the social media platform reddit, participants were asked a series of open-ended questions designed to elicit responses on a variety of topics from research design to health concerns. researchers reviewed each open-ended question answer to code responses for key themes that would help identify patterns surrounding research priorities and health concerns. results: respondents [n=209] were most interested in the active drug and health effects as well as the mechanisms of action associated with different types of thco products (35%) followed closely by product safety, quality, and testing reliability (30%) these types of posts had positive, negative, and neutral sentiments about thco and reflect the nascent status of market, science, and regulations surrounding these kinds of conference abstracts 171 substances. significantly, 16% of respondents were explicitly interested in the medical potential of thco, noting its potential benefit as an analgesic agent. when asked what health concerns were greatest, 36% of respondents (n=143) indicated lung related injuries including comments about evali and ketene formation as well as lipid pneumonia and cannabinoid hyperemesis. conclusions: consumers are increasingly relying on self-regulation to navigate the complex landscape of products and regulations that structure market access. this self-regulation has emerged most notable in a desire for research on the health effects and mechanisms of actions associated with the substance thco. awareness of risks associated with consuming thco, specifically the formation of ketene is a positive indication that online communities may be able to support harm reduction practices surrounding the use of emergent psychoactive substances like semi-synthetic cannabinoids. despite the clear schedule status of thco, it is imperative that researchers continue to explore the antecedents and consequences of the use of this substance. the moderating effect of campus climate on the relation between loneliness and cannabis use kira sturgess, bradley conner (colorado state university) cannabis use is highly prevalent on college campuses in the united states, second only to alcohol use and occurring at higher frequency than tobacco use (north & lukas, 2021). in a campus climate, cannabis misuse is associated with missing classes, lower grade point average, and other negative outcomes (shashwath et al., 20187). rankin defines campus climate as "the current attitudes, behaviors and standards of faculty, staff, administrators and students concerning the level of respect for individual needs, abilities and potential" (rankin, 2023). a number of studies have identified variables that are positively associated with cannabis use, including loneliness (rhew, et al., 2021). loneliness, typically defined as the perception of being alone and isolated, is associated with poorer mental and physical health outcomes (russell, 1996). furthermore, other studies have found that campus climate operates as a protective factor for college student physical and mental health (woodford et al., 2015). given this, it is important to identify both variables that predict cannabis use and those that buffer against it. to date, no published studies have examined relations between loneliness and campus client and their effect on cannabis use. the present study investigated whether loneliness predicted cannabis use frequency in a nationally representative dataset from college students, and whether campus climate moderated this relation. data come from the american college health association national college health assessment (acha-ncha) iii, a national sample of college students in undergraduate and graduate/professional programs. this project includes student data from the third iteration of the questionnaire that spans the spring semester of 2019 through the spring semester of 2022. during this time, 461 institutions and 301,183 students participated in the acha-ncha iii survey.  the acha-ncha iii questionnaire includes a series of questions on multiple aspects of campus climate as it relates to student wellbeing. responses were measured using a likert scale ranging from 1= “strongly disagree” to 6= “strongly agree”.  the acha-ncha iii survey includes the ucla 3-item loneliness scale as the measure of self-reported loneliness in college students (hughes et al., 2004). response options ranged from 1= “hardly ever” to 3= “often”. cannabis use frequency is measured as “when, if ever, was the last time you used cannabis/marijuana? please include medical and non-medical use” and was measured as within the last 2 weeks, ,more than 2 weeks ago but less than 30 days ago, more than 30 days ago but within the last 3 months, more than 3 months ago but within the last 12 months, more than 12 months ago, never. results indicated that loneliness significantly positively predicted cannabis use frequency (p < 0.001). further, the results confirmed that campus client significantly negatively predicted cannabis use (p < 0.001). finally, campus client moderated the relation between loneliness and cannabis use frequency (p < 0.001), indicating that campus climate acts as an intermediary factor against the effects of loneliness on cannabis use. these findings might offer an intervention point for individuals who are experiencing loneliness and who use cannabis, preventing misuse and subsequent negative outcomes. conference abstracts 172 preliminary psychometric testing of the treatment self-regulation questionnaire for assessing motivations for responsible cannabis use: an application of self-determination theory haydee andujo, joey c. mok (university of new mexico) jakub d. gren (institute of psychiatry and neurology) dylan k. richards, matthew r. pearson (university of new mexico) addictions research team cannabis use protective behavioral strategies (pbs) are cognitive–behavioral strategies used before, during, and/or after cannabis use to reduce cannabis use and related problems. selfdetermination theory (sdt) provides a potentially useful framework to understand motivations for responsible cannabis use, which is operationalized in the present study as cannabis pbs use. the treatment self-regulation questionnaire (tsrq) has been used previously to assess types of motivation per selfdetermination theory (sdt) for responsible drinking (richards et al., 2017, 2021). initial support for good psychometric properties of the tsrq has been found, including measurement invariance across subgroups of college student drinkers. in the present study, we examined the relation of motivations for responsible cannabis use, as assessed by the 15-item treatment selfregulation questionnaire (tsrq), with cannabis pbs use and other cannabis-related outcomes. participants (n = 408) were college students who reported past-month cannabis use recruited from a multisite study. consistent with sdt and previous studies of the tsrq for drinking responsibly, we found support for a 4-factor structure of the tsrq via exploratory structural equation modeling (cfi=.974, rmsea=.047). introjected regulation (“because i would feel guilty or ashamed of myself if i did not use cannabis responsibly”) was positively associated with cannabis pbs use (β=.37, p<.001). external regulation (“because others would be upset with me was negatively associated with cannabis use (β=-.26, p<.001). unexpectedly, autonomous motivation (“because i personally believe it is the best thing for my health,” β=.14, p=.092) and amotivation (“i really don't think about it,” β=-.01, p=.842) was not significantly related to cannabis pbs use. our overall model (motivation-pbs usecannabis use-consequences/severity) accounted for a substantial portion of the variance in cannabis-related outcomes including frequency of cannabis use (r-square=.301), negative cannabisrelated consequences (r-square=.189), and cannabis use disorder symptoms (r-square=.441). the present study provided initial psychometric support and validation of a version of the tsrq for assessing motivations for responsible cannabis use. consistent with sdt, more self-determined motivations (autonomous motivation and injected regulation) were protective factors (associated with higher pbs use and lower cannabis use/problems), whereas less self-determined motivations (external regulation and amotivation) were risk factors (associated with lower pbs use and higher cannabis use/problems. overall, our results partially support the predictions of sdt, suggesting the need for further development and refinement of the trsq. identifying profiles of cannabis users based on their motivations to use cannabis responsibly: an application of self-determination theory joey c. mok, haydee andujo (university of new mexico) jakub d. gren (institute of psychiatry and neurology) dylan k. richards, matthew r. pearson (university of new mexico) addictions research team self-determination theory (sdt; ryan & deci, 2000) provides a useful framework for understanding motivations for responsible cannabis use. research indicates college students’ motivation to use alcohol responsibly varies in the quality and quantity of motivation (richards et al., 2021). further, person-centered approaches like latent profile analysis has been used to identify subgroups of individuals based on their motivational profile (richards et al., 2020), including 3 classes: a high quantity class (i.e., self-determined), a high quantity class (relatively high on all types of motivation), and a low quantity class (amotivated). the objective of the present study is to identify unique subpopulations of college students based on motives to use cannabis responsibly per sdt using latent profile analysis. college students conference abstracts 173 from one of ten universities were recruited to participate in an online survey study (n=1856). our analyses are limited to past month cannabis users who also completed the required measures (n=386). the 5-class solution had high classification precision (relative entropy = .953). using the automatic bch method, we examined the differences between each of the 5 classes on cannabis-related variables including cannabis pbs use, cannabis use, negative cannabis-related consequences, and cannabis use severity. for the sake of parsimony, we focus on the differences between the self-determined class (i.e., expected to have the best outcomes based on sdt) and the amotivated class (i.e., expected to have the worst outcomes based on sdt). as expected, the amotivated class reported significantly lower cannabis pbs use (m=3.64) than the selfdetermined class (m=4.44), p<.001; significantly higher cannabis use (m=14.76) than the selfdetermined class (m=9.77), p=.008; and significantly higher cannabis use severity (m=12.31) than the self-determined class (m=9.10), p=.017. however, there were no significant differences in the experience of negative cannabis-related consequences (p=.25). previous research on motivations to drink (alcohol) responsibly has supported a 3-class solution, whereas our results supported a finergrained 5-class solution. as predicted by sdt, the amotivated class reported the lowest cannabis pbs use, highest cannabis use, highest consequences, and highest cannabis use severity. as expected, the self-determined class reported the highest cannabis pbs use, lowest cannabis use, lowest cannabis use disorder symptoms. given our limited sample size (n<400), our results should be considered preliminary, and replication of our class solution is needed. additional work is needed to examine how these classes may differ on other sdt-based constructs (e.g., satisfaction of psychological needs), and how profiles predict outcomes prospectively over time. profiles of ethnic experiences among a hispanic college students and cannabis-related outcomes verlin w joseph (university of new mexico) craig a field (university of texas-el paso) matthew r pearson (university of new mexico) cannabis is the most widely used substance among college students and is associated with several deleterious academic and developmental outcomes (volkow, 2014). of particular concern is the potential for college students to develop cannabis use disorder (cud); in fact, roughly 10% of first-year college students met the criteria for a cud in a previous sample (caldeira et al, 2008). one group at risk for developing cud are hispanic college students. historically, hispanics use substances including cannabis at lower rates than non-hispanic white individuals. however, cannabis use incidence rates among hispanic youth has significantly increased over the previous ten years (marzell et al, 2017). several factors including discrimination, identity, and acculturative stress were identified as correlates of cannabis use among hispanic young adults (yokey et al., 2020). yet, little is known regarding the outcomes associated with cannabis use among hispanic college students. therefore, our study sought to identify profiles of ethnic experiences and cannabis use outcomes among college hispanic college students reporting current cannabis use. the current study utilized data from a large multi-site study focused on substance use among college students (n=5494). the scale of ethnic experience (see) was utilized to assess domains of ethnicity-related cognitive constructs including ethnic identity, perceived discrimination, mainstream comfort, and social affiliation. cannabis use outcomes including cud symptoms (cudit-r), frequency of cannabis use (marijuana use grid), consequences of cannabis use (brief marijuana consequences questionnaire), and protective behavioral strategies (protective behavioral strategies for marijuana) were assessed using validated measures. we conducted a series of latent profile analyses modeling 1to 6-profile solutions using mplus. we considered the following to determine the optimal profile solution: goodness-of-fit indices (i.e., akaike information criterion [aic], bayesian information criterion [bic]), classification diagnostics (i.e., relative entropy), the lo-mendell rubin adjusted likelihood ratio test, substantive interpretation of profiles, and consistency of the profile solution across samples. the aic, bic, and sample-adjusted bic continued to improve for each k+1 solution, conference abstracts 174 however the 4-profile solution was the only solution with an entropy greater than 0.8 (entropy=0.805). based on fit statistics and interpretability, we selected a 4-profile solution as optimal: profile 1 (low mainstream conflict; 49.1%), profile 2 (high mainstream conflict/low social affiliation; 5.0%), profile 3 (low ethnic identity/low social affiliation; 4.0%), profile 4 (high ethic identity/high social affiliation; 41.9%). profile 1 reported the greatest number of cud symptoms (m=5.38, se=0.3), marijuana use frequency (m=7.00, se=0.8), and marijuana use consequences (m=4.21, se=1.2). profile 2 reported using the highest use of protective behavioral strategies (m=4.49, se=0.3) and the least amount of consequences (m=0.76, se=0.5). preliminary findings may suggest that targeting factors including mainstream conflict and social affiliation may serve as key points for developing interventions to reduce cud and cannabis consequences among this population. examining associations between cannabis hangover symptoms and protective behavioral strategies used sarah elder, benjamin o. ladd (washington state university vancouver) background: past research has been mixed or inconclusive involving the next day residual effects of cannabis making research on it even more critical. limited survey studies indicate some endorsement of hangover symptoms such as “brain fog” or fatigue and the acute and residual effects of cannabis use often are reported as mild to moderate impairments in learning, memory, processing speed, and executive functioning. these are promising targets for measuring postacute impairment and may suggest mechanisms by which cannabis use leads to decreased performance and overall well-being. importantly, little to no research has examined the correlation between hangover symptoms endorsed and how they relate to protective behavioral strategies toward marijuana (pbsm). thus, the present study aimed to examine whether there were any correlations between pbsm and cannabis hangover symptoms endorsed in a sample of college student reporting cannabis use. we hypothesized that endorsement of more cannabis hangover symptoms would be positively correlated with the pbsm endorsement. method: participants were 292 college students from a large public university in the united states who reported using cannabis more than 10 times in their lifetime and reported experiencing some next day residual effects from cannabis, or a cannabis “hangover”. participants completed an online survey that assessed several factors such as current cannabis use patterns, cannabis hangover symptoms experienced (17 items, yes/no lifetime experience), pbsm (36 items, 1 = never to 6 = always scale), and consequences of cannabis use. a descriptive summary of reported pbsm was conducted, and then we examined correlations between the number of pbsm reported and number of hangover symptoms experienced. exploratory analyses were conducted examining relationships between pbsm and subscales of cannabis hangover symptoms (i.e., physical, cognitive, affective). results: the most commonly endorsed pbsm were related to marijuana possession-related concerns. on average, participants reported experiencing 9.65 (sd = 6.69) hangover symptoms. pbsm was not associated with overall hangover symptoms (r = -.104, p = ns), but was a negative correlation between mean pbsm score and the cognitive (r = -.100, p < .01) and affective (r = -.175, p < .001) cannabis hangover symptoms subscales. discussion/purpose: these preliminary results suggest use of pbsm may be associated with fewer residual effects of cannabis use; this information may be effective to encourage adoption of pbsm to reduce the negative consequences of cannabis use. as such, cannabis hangover symptoms may be a relevant short-term adverse consequence that effects decision-making and may motivate harm reduction strategies, such as engaging in pbsm. future directions include examining relationships between specific pbsm and cognitive/affective hangover symptoms. numerous reports of hangover symptoms on social media and news sites, displays the need to better examine cannabis hangover and its effects empirically. the impact of chronic and non-chronic cannabis use on overall quality of life rachel m. murley, bradley r. forbes, ashylnn steinbaugh, talamahe’a tupou, henry eve, rayna hirst (palo alto university) conference abstracts 175 objective: since cannabis legalization has increased in the united states, usage has also increased (meier, 2021). previous studies have focused on the cognitive effects of cannabis, but few have investigated life outcomes (borque & potvin, 2021). the world health organization’s quality of life (who-qol) measure is commonly used to assess qol for individuals who frequently use alcohol (srivastava & bhatia, 2013); however, there remains a gap in the literature measuring qol and overall life functioning (olf) among frequent cannabis users. therefore, this study aimed to measure olf of chronic cannabis users (ccu; 3.5+ days per week for at least one year) and non-chronic cannabis users (nccu). a functional composite variable operationalized olf outcomes across four domains (physical health, mental health, social relationships, and environment), modeled from the who-qol (kirouac et al., 2017). methods: participants included 333 cannabis users (m=31.1 years old, range 18-64; 52.3% male; 43.7% people of color) who completed questionnaires including demographics, cannabis usage, and impact of use on different areas of daily functioning. a between-groups one-way analysis of variance (anova) compared olf between ccu (n=194) and nccu (n=140). pearson’s bivariate correlation assessed the relationship between olf, age, and duration of current usage rate (i.e., days per week, grams per day). a threeway univariate anova examined the effects of the primary reason for cannabis usage (medicinal, recreational, or both) on olf. results: there was no significant difference in olf between ccu and nccu (f(1, 331 = [2.017], p = .175). olf positively correlated with older age (r(331) = .11, p = .045) and a longer duration of current usage (r(331) = .123, p = .024), though these two variables were also highly intercorrelated (r(333) = .41, p = .000). there were no significant group differences in olf based on the reason for current use or initial use (p’s >.05); however, medicinal users had slightly higher olf compared to recreational and both users. conclusion: results indicated no difference in olf among ccus and nccus. the findings highlight that ccus were able to obtain qol similar to nccus, suggesting that more frequent use might not negatively impact olf. these results contradict those found in a meta-analysis of studies examining the correlation between alcohol use and qol, which identified chronic alcohol use and longer duration of chronic use negatively impacts olf (levola et al., 2014). reasons for currently using and initiating cannabis use did not influence olf, suggesting that recreational users’ olf is not significantly more impacted by ccu than medicinal users. therefore, future studies may investigate other factors that may contribute to cannabis users' olf, such as personality traits, life stressors, or route of administration. further, being older and using cannabis at the same rate for a longer period of time had a positive effect on olf. this suggests that older people may be able to use cannabis more responsibly, with a less negative impact on their life. disentangling the association between personality traits and cannabis use and disorder in people of european ancestry samantha g. cassidy (emory university, kent state university) chelsie e. benca-bachman, kathleen p. martin. rameez a. syed, rohan h.c. palmer (emory university) introduction: lifetime cannabis use (cu) and cannabis use disorder (cud) are becoming increasingly prevalent and are associated with poor health and behavioral outcomes. individuals with low levels of conscientiousness and openness, and high levels of agreeableness are at increased risk for cu and cud. twin studies estimate the heritability of cu and cud to be 61% and 78% respectively, and genome-wide association studies (gwass) have also found some single-nucleotide polymorphisms (snps) to be associated with cu and cud. although personality traits and cannabis involvement are heritable, a gwas has identified only one overlapping snp to be associated with conscientiousness. the current study investigated shared polygenic effects between personality, cu, and cud. we hypothesized that agreeableness and conscientiousness, and their respective polygenic scores (pgss), would be negatively associated, but openness and its respective pgs would be positively associated with cu and cud. methods: data were from wave iv of the national longitudinal study of adolescent to adult health; variable n’s ranged from 4461 to 4514. the sample conference abstracts 176 was 47.05% male, and the mean age was 28.90 (sd=1.74). cu was operationalized by asking if participants had ever used cannabis (0=no, 1=yes). cud was dichotomized based on dsm-5 criteria (0=participant endorsed 0 or 1 symptom; 1=participant endorsed 2+ symptoms). personality was measured using the miniinternational personality item pool, and items corresponding to each personality factor were averaged to create a composite score. polygenic effects were evaluated using pgss that were created using summary statistics provided by gwass for personality, cu, and cud, which used the top ten-thousand snps due to the restriction of publicly accessible data. hypotheses were tested using path analysis in mplus to account for direct and indirect effects of personality pgss while controlling for age, sex, income, and the first ten genetic principal components. results: we found that higher scores on the agreeableness pgs were associated with lower odds of cu (β[95% ci]= -0.07[-0.12,-0.02], or=0.93) and cud (β[95% ci]= -0.06[-0.11,-0.01], or=0.94). similarly, higher scores on conscientiousness were associated with lower risk for cu (β[95% ci]= -0.08[-0.13,-0.03], or=0.89) and cud (β[95% ci]= -0.10[-0.15,-0.04], or=0.87). higher scores on openness were associated with greater odds of cu (β[95% ci]=0.17[0.13,0.21], or=1.33) and cud (β[95% ci]=0.10[0.05,0.15], or=1.18). higher scores on agreeableness were also associated with a greater likelihood of cu ([95% ci]=0.06[0.01,0.10], or=1.10). there was limited evidence of indirect pgs effects via personality, as well as direct effects on respective personality phenotypes. discussion: the current study provides evidence supporting the application of pgss to understand the liability for cu and cud. the limited predictive utility of the agreeableness pgs combined with the partial support of our hypotheses regarding personality traits, as evidenced by the direct effect of the pgs on cu and cud, but not on the agreeableness phenotype, underscores the need for future, more powerful, gwass of cannabis and personality traits using multivariate approaches. future studies should also explore if these results might be attributable to the use of different personality inventories to assess the phenotypes and to create the pgss. theoretical correlates of cannabis use and intentions among us and israeli adults cassidy r. loparco, yuxian cui, zongshuan duan (george washington university) hagai levine, yael bar-zeev (the hebrew university of jerusalem and hadassah medical center) lorien c. abroms, yan wang (george washington university) amal khayat (the hebrew university of jerusalem and hadassah medical center) carla j. berg (george washington university) background: several countries have legalized adult non-medical (i.e., “recreational”) cannabis use. in the us and israel, cannabis remains illegal at the national level; however, in the us, 21 states, 3 territories, and the district of columbia legalized non-medical cannabis at the state/jurisdictional level. cross-country research may elucidate differences in correlates of cannabis use, which may be impacted by social/legislative contexts. methods: in fall 2021, we conducted a crosssectional survey among us (n=1,128) and israeli (n=1,094) adult online panelists (ages 18-45, mage=32.19, 50.3% female). descriptive and bivariate analyses (chi-square for categorical variables; t-tests/anova for continuous variables) were used to describe the sample and examine differences in the outcomes and correlates of interest based on country. multivariable logistic and linear regression analyses were utilized to examine potential correlates of: (1) past-month cannabis use (yes/no), (2) next-year use intentions (1=not at all 7=extremely), and (3) likelihood to use in the home or near children if non-medical cannabis use was legal (1=not at all 4=very). results: in bivariate analyses, us (vs. israeli) participants were more likely lifetime (49.9% vs. 22.5%) and past-month users (22.0% vs. 11.2%, ps<.001) and perceived lower risk (addictiveness and harm to health) and greater social norms (acceptability and use within social networks; ps<.05). us (vs. israeli) lifetime users reported younger age at first use, and greater proportions using primarily recreationally (vs. primarily for medical purposes), obtaining from retailers (vs. conference abstracts 177 illegal sources), and using via smoking without tobacco, vaping liquid, dabbing, and edibles (vs. smoking with tobacco or vaping dried leaves/herbs) (ps<.05). us (vs. israeli) past-month users indicated more days of use (m=15.09, sd=12.29 vs. m=9.66, sd=9.67, p<.001). in multivariable analyses, correlates of past-month cannabis use included being male, being sexual minority, lower cannabis-related perceived risk, and more positive perceived social norms (ps<.05); country was not associated. correlates of greater use intentions and greater likelihood to use in the home or near children if legal included being israeli, male, lower cannabis-related perceived risk, more positive perceived social norms, and past-month cannabis use (ps<.05). conclusions: findings suggest differences in cannabis use and use intentions based on cannabis-related risk perceptions and social norms, primary reasons of use, mode of use, and access/source. moreover, findings indicate differences in these factors across countries. as cannabis legislation and attitudes evolve, regulatory and prevention efforts must be informed by global surveillance of its use. state requirements for cannabis retail personnel among states with legal adult nonmedical cannabis markets in the us cassidy r. loparco, alexandria pannell, carla j. berg (george washington university) introduction: as of april 2023, 20 us states have legalized adult non-medical (i.e., ‘recreational’) cannabis use, allowing the establishment of a rapidly expanding retail market. however, states’ requirements for personnel working in cannabis retail stores (i.e., ‘budtenders’) have not been examined. given that cannabis retail personnel are often used as sources of cannabis-related information among consumers and play a key role in product safety, it is important to assess the requirements of retail personnel, including permits, background checks, and/or types of training (if any). methods: two independent coders extracted and summarized information on the 20 states’ cannabis retail personnel requirements from vangst.com, a website providing state-specific information regarding cannabis-related careers. links to external sources (i.e., state licensing boards) were visited to ensure data accuracy and to obtain details regarding training among states that required it. results: the age requirement for retail personnel was ≥21 years old in seventeen states; the other three (connecticut, missouri, virginia) require retail personnel to be ≥18. two states (virginia, washington) had no application/licensing requirements, and missouri only required prospective employees to complete an online application assessing basic information. the other seventeen states (all but missouri, virginia, and washington) required background checks, with fingerprinting also required in eight states (arizona, colorado, illinois, maine, maryland, montana [every three years], nevada, new jersey [if personnel in an alternative treatment center]). of the seventeen states requiring background checks, eight (alaska, arizona, maine, maryland, montana, nevada, new jersey, oregon) specified that felony convictions would prevent employment, with the type of conviction and when the conviction occurred being state-specific. in some states, how background check results impacted employment was decided by the employer (california), could be overruled by the state cannabis board (michigan, new york), or could be petitioned to be exempt (rhode island). in colorado, felony convictions did not automatically disqualify applicants. four states (connecticut, illinois, massachusetts, new mexico) did not specify how the findings from background checks would impact employment. six states (alaska, california, michigan, new mexico, new york, oregon) had no additional requirements outside of background checks and/or fingerprinting. other states required completing an application form, payment of fees, and/or training. thirteen states (all except california, maryland, michigan, new mexico, new york, virginia, washington) required applicants to pay fees to receive a cannabis retailer permit, ranging from $25 (new jersey) to ≥$150 (arizona). some form of training was required in six states (alaska, illinois, montana, new jersey, new mexico, oregon). the nature of the trainings varied in terms of content, timing, frequency, and assessment of knowledge acquisition (i.e., testing). discussion: the requirements for cannabis retail personnel varied widely across these 20 states, with strict requirements in some states (montana) and almost no requirements in other states (missouri, virginia). it is critical to conference abstracts 178 evaluate the impact of such requirements, for example, the impact of application fees and employment being contingent on background checks on social inequities, as well as the quality and impact of personnel training on their interactions with consumers, safe cannabis handling practices, and other outcomes. a web intervention to prevent alcohol and cannabis-impaired driving among adolescents in driver education karen chan osilla (stanford school of medicine) elizabeth j. d’amico, justin hummer, anthony rodriguez (rand corporation) elizabeth ueland, katherine nameth (stanford school of medicine) alcohol and cannabis are the most commonly used substances among adolescents in the u.s. the consequences related to using both substances together are significantly higher relative to use of either substance alone. teens’ propensity to engage in risky driving behaviors and their relative inexperience with the timing and duration of cannabis’ effects puts them at heightened risk for experiencing harms related to driving under the influence. targeting novice teen drivers prior to licensure is thus an ideal time for prevention efforts focused on reducing alcohol and/or cannabis initiation, use, and impaired driving. in this presentation, we will describe our webchat pilot study that evaluates the efficacy of a single web-based intervention to prevent impaired driving in the context of driver education. teens aged 15.5-17 years in driver education are randomly assigned to driver education with and without the webchat intervention. the presentation has two goals. first, we will describe our intervention adaptation results where we conducted focus groups (n=11) and interviews (n=6) with adolescents 15.5-17 years to assess their feedback on the intervention. second, we will present preliminary baseline data (n=85) from our pilot study describing sample characteristics including rates of alcohol and cannabis use and risk behaviors (e.g., driving under the influence, riding with an impaired driver). we will describe our study design and share lessons learned to date to help inform future trials in this area. comparing youth in and out of recovery who resolved cannabis use problems alex lee, douglas c. smith (university of illinois at urbana-champaign) background and significance: many people consider themselves to have resolved a serious problem with substances, but do not identify as being “in recovery.” recovery identity is a new concept and some representative adult studies exist that have compared problem resolvers and individuals in recovery. however, little is known about youth who either resolve problems or enter recovery during high school. building off our prior work showing heterogeneity in recovery definitions among youth, this is the first study to examine differences in adolescents who have resolved problems with cannabis and identify as either being in recovery or not. methods: data were from the 2022 illinois youth survey (iys), a school-based survey designed collecting information on various health and social indicators, especially substance use and related prevention measures. the iys typically yields representative statewide data that includes respondents from 8th to 12th grades. we subset the sample to youth (n=1552, 1% of n=146,780) who answered yes to the question “did you used to have a problem with cannabis but no longer do?” we then compared the demographic characteristics, patterns of poly-substance use, behavioral health outcomes, and crafft scores of two groups: 1) youth who had resolved cannabis use problems and were in recovery (pir, n= 645 (42%), m[sd] age= 16.4[1.15], 53.0% female, 55%white) and youth who had resolved cannabis use problems but were not in recovery (pnr, n=907 (58%), m[sd] age=16.4 [1.16], 43.9% female, 64.4% white). results: youth in the pir group reported lower past-year cannabis (p<0.01), alcohol (p<0.01), and cigarette (p<0.001) use compared to those in pnr, but there was no difference in past-year ecigarette use (p=.67). pir youth also reported lower past 30-day cigarette use (p<0.001), but no differences existed for other substances in the past 30-day period. crafft scores were significantly higher among youth in the pir group (m=3.30, sd=2.04) compared to the pnr group (m=2.78, sd=1.93) (p<0.001). however, on average, youth in both groups met clinical conference abstracts 179 thresholds for probable substance use disorder (i.e., scores ≤ 2). in terms of behavioral health outcomes, pir reported a higher likelihood of having suicidal thoughts (p<0.001) and depressive symptoms (p<0.001) in the past year compared to pnr. conclusion: this novel study investigated differences between youth who resolved problems with cannabis and reported different recovery statuses. similar to one large representative adult study, only four in ten youth who resolved a serious problem with cannabis reported being in recovery (i.e., do you consider yourself to be in recovery?). both groups had some elevated substance use risks, but youth in recovery had more severe problems on some measures. additional research is needed to further understand the needs and trajectories of youth who resolve problems with cannabis during high school. public awareness campaign metrics for public health in legalized adult-use cannabis states alexander m. colby, graelyn humiston, hailey pensky, olivia laramie, marianne sarkis, julie k. johnson (commonwealth of massachusetts) background: twenty-two us states have enacted adult-use cannabis laws, allowing adults aged 21years or older to purchase, possess, and consume cannabis for nonmedical adult-use (“recreational”) purposes. public awareness campaigns (pacs) are key public health interventions that multiple legalized states implemented to prevent adverse effects of legalization. as outlined in the enabling legislation st. 2017, c. 55, an act to ensure safe access to marijuana, the massachusetts cannabis control commission (“commission”) and the department of public health (dph) jointly implemented the more about marijuana pac, consisting of two sub-campaigns: 1) responsible use awareness campaign for massachusetts adults ages 21 years old and older (“responsible use campaign”) and 2) a youth prevention campaign targeting parents (“parent campaign”). the effectiveness of pacs for cannabis harm mitigation is not well-known. methods: this quasi-experimental, crosssectional design study used a logistic regression analysis of pre-implementation and postimplementation surveys of massachusetts residents to examine whether there were changes in cannabis knowledge in four key pac message domains: 1) knowledge of age legal to use, 2) driving behaviors, 3) youth risks, and 4) cannabis storage, and whether there were differential effects based on the two sub-campaign surveys (n=2,500). results: we found that 51% of survey respondents reported seeing at least one pac message. survey participants reported seeing campaign messages on the internet (38.2%), tv (38%), social media (36%), highway billboards (35%), and public transit (22%). the post-campaign survey responses were associated with greater odds of reporting that individuals aged 21 and older were old enough to try cannabis. respondents who reported seeing either pac components or the two specific youth campaign components had greater associated odds of reporting that people are old enough to use cannabis at 21 compared to 18. post-campaign survey responses were associated with greater odds of reporting that cannabis-use is either more dangerous or just as dangerous as driving after alcohol use. respondents who saw the pac were more likely to report that cannabis has greater risk for youths than adults, and those who saw the parent campaign were even more likely to agree with this statement. those who saw the parent campaign were also more likely to report that they would store cannabis in a locked storage area compared to those who reported not seeing the campaign. conclusion: further research is needed to assess knowledge obtained and changed behaviors, however, based on a preliminary assessment of massachusetts’s pac, there is evidence that educational public health mechanisms can promote responsible adult and medical cannabis use. development of an adaptive ecological momentary intervention for simultaneous alcohol and marijuana use olivia l. bolts, mark a. prince (colorado state university) michael m. phillips (university of hawai'i at mānoa) kristina t. phillips (kaiser permanente hawai'i) simultaneous alcohol and marijuana (sam) use, defined as using both substances at the same time conference abstracts 180 with overlapping effects, is common among young adults. sam use can lead to more negative consequences than use of either substance alone. currently, there are few brief interventions specifically designed for sam use and even fewer designed for community populations (i.e., not specifically designed for college students). recent technological advancements, including smartphones, provide a unique opportunity to bring intervention content to a person in real time when they need it. further, intervention content can be tailored to a person’s specific use patterns and goals. adaptive ecological momentary interventions (a-emis) and just-in-time adaptive interventions (jitais) take advantage of technological advancements by delivering intervention components in real time. the benefits of these state-of-the-science interventions are vast; however, one challenge for researchers is to determine what content to deliver and with what frequency. this poster presents key aspects of a stage i treatment development project of an a-emi titled “smartphone app for effectively reducing risk (saferr).” grounded in self-regulation and social cognitive theories, saferr will include intervention content focused on protective behavioral strategies and craving reduction exercises that individuals can use in the moment to reduce sam use or single use of alcohol or marijuana and associated negative consequences. a critical component of the development and testing of saferr is varying the frequency of delivery of the intervention content from one time per day to multiple times per day. in addition to intervention content delivered in real-time, participants will receive psychoeducation, personalized feedback, and goal setting intervention components. to test which components of saferr are the most effective, the project will utilize the multiphase optimization strategy (most) framework and an innovative fractional factorial experimental design. this project will include two stages, a pilot stage and a small randomized clinical trial. in the pilot stage, participants will be randomly assigned to one condition such that each intervention component is pilot tested by at least one person. we will solicit feedback on the content and frequency of the messaging and use this feedback to refine the methodology for the randomized clinical trial. in the trial, diverse young adults who report sam use will be recruited from primary care clinics in hawai'i and randomly assigned to one of eight groups. this presentation describes the development of the research design and testing of the saferr aemi in young adults recruited from primary care clinics who engage in sam use and may not be seeking treatment. cannabis retailer communication about cannabis products, health benefits, and risks: a mystery shopper study of retailers in 5 us cities katelyn f. romm (university of oklahoma health sciences center) patricia a. cavazos-rehg (washington university school of medicine) river williams, campbell dopke, yuxian cui, cassidy r. loparco, yan wang, zongshuan duan, y. tony yang, carla j. berg (george washington university) significance. despite increases in legalization of cannabis for recreational use in the us (21 states, 3 territories) and rapid increases in us cannabis retail sales, little is known regarding retailer practices, especially related to product health claims and risks. documenting personnel communication with consumers may elucidate problematic implications (e.g., low perceived risk of use) or regulatory noncompliance (e.g., making prohibited health claims) and ultimately inform regulatory and enforcement efforts. the current study used a mystery shopper approach to examine regulatory compliance and personnel communication regarding product recommendations, health benefits, safety, and/or risks among cannabis retailers in 5 us cities with recreational cannabis sales. methods. in spring 2022, recreational cannabis retailers in 5 cities in different us states with recreational cannabis sales (denver, colorado; seattle, washington; portland, oregon; las vegas, nevada; los angeles, california) were identified from state regulatory agencies and screened for having a current operational brickand-mortar retail storefront. we randomly selected ~30 locations/city. in summer 2022, mystery shoppers (2 student research staff) participated in a 2-day training before completing assessments. mystery shoppers coded store type (recreational, recreational-medical), contextual conference abstracts 181 factors (bars/pubs/clubs, schools, parks/playgrounds, public transit within 2 block radius), age verification, and onsite consumption. using a soft script with store personnel, mystery shoppers coded product availability and suggestions (for someone new to cannabis, whether they could sample products for free/cheaply); health claims and warnings (regarding use for anxiety/insomnia, pain, pregnancy-related nausea, cautions for cannabis use [impacts on behavior or driving]); and other products including cbd and synthetic thc (availability of products at store, safety, reasons for use). descriptive and bivariate analyses characterized the retailers overall and across cities. results. in this sample of 140 retailers (61.4% recreational only, 38.6% recreational-medical), several were within 2 blocks of bars/pubs/clubs (30.0%), schools (14.3%), public transit (14.3%), and parks/playgrounds (7.9%), particularly in los angeles. additionally, 90.6% asked for age verification immediately upon entry and 2.9% later during the visit; 6.5% never asked (most frequently in portland). there were incidents of seemingly intoxicated patrons (8.6%) and outdoor on-premise use (5.0%) across cities, excluding los angeles. common product recommendations for new users included bud/flower (56.4%), edibles (38.6%), and pre-rolled joints (37.9%); 8.6% offered free/inexpensive ways to sample products. over 93% of store personnel verbally endorsed cannabis use for anxiety, insomnia, and pain, respectively, and only 26.4% warned against use during pregnancy (least common in denver). regarding use-related warnings, 23.6% indicated that most people are not greatly impacted by cannabis use, but 52.1% warned against driving after use (least common in las vegas). almost all (>90%) sold cbd products and endorsed their health benefits and safety, but few (<10%) sold or endorsed synthetic thc (all in los angeles). conclusions. findings highlight concerns regarding cannabis retailer regulatory compliance, particularly related to health claims. while some differences across cities reflected regulatory variation, other differences did not, potentially pointing to implementation and enforcement gaps – which are critical to address as cannabis markets expand. current results also underscore the need for surveillance methods that capture various dimensions of the retail environment. building an academic-community partnership to facilitate federally-funded cannabis research in a tribally-owned clinic elizabeth t. smith, naomi bender, ross bindler, mariah brigman (washington state university) katrina iiams-hauser (qwibl: a natural healing consultation & research center) sara mills, ashlin parsons (washington state university) sam lozeau (qwibl: a natural healing consultation & research center) abram j. lyons (university of pennsylvania) marjorie matheson, melissa owens (qwibl: a natural healing consultation & research center) crystal lederhos smith, michael mcdonell, marian wilson (washington state university) background: american indian/alaska native (ai/an) people are disproportionally affected by chronic pain. despite growing acceptance of cannabis for pain management, scant research exists to evaluate its palliative effects. a triballyowned clinic contacted washington state university and northwest indian college researchers to investigate the use of cannabis as medicine in their community. the goal of this poster is to describe methods used to create, fund, and implement a study developed in partnership with a northwest tribe. materials/methods: initial meetings included key stakeholders to plan a competitive research proposal for federal funding. the project used decolonization methodologies that prioritized the needs of the tribe. ai/an health science students and research personnel were recruited to ensure the project maintained an ai/an-centered approach. permissions were obtained to designate a single institutional review board and create a data sharing agreement. the tribe’s legal representation was included to assure that contracts maintained tribal sovereignty. weekly videoconference meetings facilitated teambuilding while specifying roles and study conference abstracts 182 procedures. results: funding was secured from the national institutes of health for a 4-year prospective longitudinal observational study. two in-person meetings joined western and eastern washington team members to foster relationshipbuilding and trust. implementation of recruitment and data collection began november 2022 with the goal of 350 participants. qualitative data collection includes interviews structured to center ai/an voices and experiences. conclusion: intentional collaboration between project stakeholders led to successful proposal development and launch of study protocols. inperson meetings allowed for questions and issues to be resolved in real-time. prevalence of other cannabinoids in product advertising among brick-and-mortar retailers olivia horton, cindy suerken, alfonso romero-sandoval, beth reboussin, kimberly wagoner (wake forest university school of medicine) in recent years, there has been an increase in the availability of cbd products the united states (us). this is a direct result of the passage of the agriculture improvement act of 2018, commonly known as the farm bill, which made hempderived products containing less than .3% thc content legal. hemp has over 100 cannabinoids in addition to cbd. while much attention has focused on cbd, little is known about the availability of other hemp-derived cannabinoids in the us market and how they are marketed to consumers. we sought to document the types of new hemp-derived cannabinoid products advertised in brick-and-mortar retailers in three states with disparate state cannabis policies (co, md, nc). two trained data collectors documented advertisements in 150 randomly selected retailers using wearable imaging technology between december 2021 and april 2022. advertisements were content analyzed for type of cannabinoid present (e.g., cbd, cbn, delta-8). we also documented the presence of claims prohibited by the united states food and drug administration (fda), including unapproved new drug claims. unapproved drug claims imply the product can diagnose, treat, cure, mitigate or prevent a disease or other condition, despite not having explicit approval from the fda. we documented 1948 advertisements about cannabinoids; 831 for cbd and 918 for other hemp-derived cannabinoids. advertisements for other cannabinoids were more frequently found in nc (352) and md (408) compared to co (158). the most frequently advertised other hemp-derived cannabinoids were cbn, cbg, cbc, delta-8, delta-10 and thc-v, which made up 74% of the advertisements for other hemp-derived cannabinoids. while advertisements for cbn, cbg, cbc and thc-v were documented at similar frequencies in the three states, delta-8 advertisements were less frequent in co (n=8) compared to nc (n=177) and md (n=145). no delta-10 ads were documented in co; 27 were documented in nc and 26 in md. unapproved drug claims were documented for all six most frequently advertised other hemp-derived cannabinoids and were found in all three states. unapproved drug claims were most frequently documented in advertisements for cbc (81.3% of ads), thc-v (71.4% of ads), cbn (60.0% of ads) and cbg (47.8% of ads), compared to delta-10 (11.3% of ads) and delta-8 (9.4% of ads). we documented frequent advertising for many different hemp-derived cannabinoids. we identified prevalent unapproved drug claims in the marketing of these hemp-derived cannabinoids. this is of public health concern because these poorly characterized products are growing in popularity and consumers may be influenced to delay treatment or switch from approved medicines for these products. continued documentation of advertisements for hempderived cannabinoids is warranted. ease of access to a medical cannabis license among adults in a permissive medical cannabis policy environment: associations with demographic factors and cannabis use disorder hannah s. appleseth (oklahoma state university, university of oklahoma health sciences center) sarah ehlke (old dominion university) michael a. smith, darla e. kendzor, amy m. cohn (university of oklahoma health sciences center) background: oklahoma is one of the few medical cannabis states that does not require a qualifying condition to obtain a medical cannabis license conference abstracts 183 (mcl) and has the most dispensaries per capita of any state in the u.s. consequently, cannabis may be perceived as easy to access. this may be particularly relevant to sub-groups with higher rates of cannabis use, like males, racial/ethnic minorities, younger individuals, and those with lower income and educational attainment. passage of medical cannabis laws and ease of access to medical cannabis is frequently associated with problematic cannabis use. we examined the associations of perceptions of ease of access to a mcl with sociodemographic factors and the likelihood of cannabis use disorder (cud). methods: the sample (n=1203) included adults (≥18 years) from oklahoma with an mcl issued by the oklahoma medical marijuana authority, who were recruited into a larger repeated crosssectional online survey. measures included sociodemographics (age, sex, race/ethnicity, income, education, employment, health insurance), cud diagnosis using the brief cannabis use disorder identification test (cudit-r), and perceived ease of access to obtaining a mcl (1=very difficult to 5=very easy). anova tests examined associations of sociodemographics with ease of access, using tukey post-hoc for multiple group comparisons. a logistic regression model assessed the association between ease of access and the likelihood of a cud, controlling for sociodemographics correlated with the outcome using backward step selection (sex, age, race/ethnicity, employment). results: the sample was primarily non-hispanic white (67.3%), female (53.0%), and in middle adulthood (m=36.96, sd=14.01). participants’ average ease of access score was 3.45 (sd=1.19), indicating that most perceived it was neither easy nor difficult to attain a mcl. in anova tests, perceived ease of access differed by race/ethnicity, age, education, employment, and sexual minority status (p’s<.05). specifically, hispanic respondents (vs nh white), individuals ages 1824 (vs ages 35-44, ages 45-54, and ages 65+), those with less than a high school diploma (vs some college or technical school education), and those who were employed (vs unemployed) reported greater difficulty obtaining an mcl. in the logistic regression, easier perceived access to an mcl was associated with lower likelihood of a cud (aor=0.87, 95% ci=0.78-0.97, p=.01). discussion: socially vulnerable groups reported greater difficulty obtaining a mcl, with the exception of unemployment being associated with easier mcl access. unemployed individuals may seek out information to receive a mcl because they may use medical cannabis rather than traditional medical care to offset expenses of emergency room and primary care visits. unexpectedly, easier mcl access was associated with lower odds of cud symptoms. those who easily obtain a mcl may be more likely to use it for medical reasons, and less likely to misuse it. the groups that reported difficulty in obtaining a mcl are also known to report the highest rates of cannabis use in the literature. perhaps medical cannabis policies are protective for those who are more susceptible to problematic use. longitudinal observations of mcl access and cannabis use patterns are needed to better understand the dynamics between policy and individual use. deriving an objective best practices rate of budtenders in new mexico: validation of a pseudo patron protocol haydee andujo, randall starling, matthew r. pearson, joey c. mok, lauren taylor (university of new mexico) with legalization and commercialization of cannabis in the state of new mexico for adults ages 21 and older, there is a pressing need to develop optimal training programs that help to ensure that budtenders comply with state laws/regulations and recommended best practices. effective budtender training programs can help to mitigate potential cannabis-related harms ranging from underage use, driving while intoxicated, addiction, among others. as a first step toward developing an effective training program, we must first identify the level of compliance with state laws/regulations and recommended best practices. we employed a pseudo-patron protocol focused on identifying the degree to which cannabis dispensaries and ‘budtenders’ working at cannabis dispensaries in the state of new mexico are complying with recommended and/or required best practices. although data analysis is ongoing (current n = 47), the overall best practices rate across all domains that have been coded to date is 54.5%, highlighting the need for improved responsible budtending training. for domain a (cannabis and the body), the best practices rate was 40.0%, which reflects a weighted average of very low best conference abstracts 184 practices rates on the subdomain of discussing chemovars (7.14%), low best practices rates on the subdomain of effects of cbd (28.5%), and a moderate-to-high rate on individual differences of the effects of cannabis (78.6%). for domain b (knowing the laws), the best practices rate was 75% overall, with a high best practices rate regarding the daily purchasing limits (86%), but a complete absence of discouraging out of state transport of cannabis products (0%). for domain c (verifying age and identity), we observed the highest best practices rate (96.7%) with id being requested 100% of the time from our underageappearing pseudo patron, 100% of the time from our intoxicated-appearing pseudo patron, and 90% of the time as part of other pseudo patron protocols. for domain d (recognizing problem cannabis users), the best practices rate was 25%, reflecting a low level of awareness of the symptoms of cannabis hyperemesis syndrome. for domain e (reducing cannabis-related harms), the best practices rate was 77.2%, reflecting high best practices rates regarding starting with a low dosage (82%) and waiting significant amount of time to observe effects (77.3%). taken together, these pilot data demonstrate that the pseudo patron protocol successfully detects variability in budtenders’ engagement in best practices, and can serve as a highly precise, sensitive outcome measure for responsible budtender training. directly observing (responsible) budtending practices in new mexico: a qualitative examination of budtenders in new mexico joey c. mok, haydee andujo, randall starling, matthew r. pearson (university of new mexico) in states with cannabis dispensary operating to legally sell cannabis products, budtenders could play an important role in mitigating cannabisrelated harms ranging from preventing underage use, decreasing driving while intoxicated, curbing problematic cannabis use, and preventing negative acute cannabis-related problems. the present study used a pseudo patron protocol such that trained pseudo patrons asked questions of budtenders either as a naïve user or a problem user. these interactions were transcribed and coded for the degree to which information provided is correct and/or consistent with best practices. under the naïve user protocol, the pseudo patron asked questions regarding the difference between sativa and indica, purchasing limits, the time course of intoxication from different edible products, and what dose one should take of edibles. we observed a wide range in the quality of information shared by budtenders with some providing very careful and comprehensive dosing information (consistent with ‘start low, go slow’ recommendations), and others providing very little guidance, or markedly false information. in the problem user protocol, the pseudo patron expressed experiencing the symptoms of cannabis hyperemesis syndrome (i.e., vomiting from cannabis use), and asked for advice from the budtender. on most occasions, budtenders recommended alternative products (e.g., edibles, ‘indica’, ‘wax’), but excellent advice of stopping cannabis use immediately was provided at one dispensary along with very accurate information regarding the etiology, course, and resolution of the condition. we explore each response to the questions of the pseudo patrons and rank these responses in terms of quality. in certain cases, we compare real responses to ‘ideal’ responses that are focused on minimizing negative cannabis-related harms while maintaining compliance for current laws/regulations. we discuss the implications of prevalent myths held by budtenders, and how interventions could target myth reduction. acknowledging the primary objective of budtenders (i.e., sell products), we believe improved training of budtenders can help to mitigate cannabis-related harms. alleviating cancer-related symptoms with cannabis: a systematic review elena kalina, jianli wu, angela starkweather, hwayoung cho (university of florida) introduction: research about cannabis use among cancer and hiv populations is limited. experimental research is even more scarce. the current systematic review sought to describe existing experimental research testing efficacy of cannabis to alleviate symptoms among individuals diagnosed with cancer and/or hiv. methods: the literature was systematically combed for peer-reviewed articles published between 2017-2022 about cannabis use among hiv and cancer populations. the search was conference abstracts 185 completed in october 2022. we entered terms such as “hiv”, “cancer”, “medical cannabis”, “pain”, and “depression” into medline, cinahl, embase, and psycinfo databases. we identified 1825 peer-reviewed articles and reviewed each in covidence, a software for managing systematic reviews. eligibility criteria included studies (1) involving individuals over 18 years old who have been diagnosed with cancer or hiv, (2) testing the efficacy of cannabis use, (3) including at least one disease-related symptom as an outcome measured, and (4) using the experimental study design. study protocols, reviews, and conference abstracts were excluded. duplicates were removed (n = 87). after abstract screening remained 142 papers for full-text review. nine studies remained; data was extracted and synthesized. results: the final nine studies pertain to cannabis efficacy among cancer patients; no studies with hiv patients met our criteria. four studies were quasi-experimental; five were randomized control trials. four studies tested administration of an oro-mucosal spray, four tested an oral capsule or tincture, and one tested a variety of administration routes (e.g., inhalation, oral). sample sizes ranged from 17-399. regarding primary outcomes, five studies assessed changes in pain levels, two studies assessed changes in weight or nutritional symptoms (e.g., anorexia), one study assessed safety of the treatment, and one study assessed symptoms of peripheral neuropathy. six studies yielded findings indicating efficacy of cannabis treatments: three resulted in pain improvement (p < .001), two resulted in increased weight ≥10% from baseline or caloric intake (p < .041), and one yielded significant results indicating safety of cannabis use among cancer patients (p < .042). two studies yielded non-significant results: primary endpoints included changes in peripheral neuropathy and pain. one study yielded non-significant results in an unexpected direction, such that greater pain improvement was reported in the placebo group (p=.274). treatment effects included: 3/17 patients reached the endpoint of gaining ≥10% body weight from baseline; survival after one year was 83% among treatment and 44% among the placebo group (p < .042); and treatment effect of a cannabinoid-medication on pain reduction for treatment vs. placebo was 5.39% (p < 0.038). conclusion: nine experimental studies testing cannabis efficacy in cancer populations were systematically reviewed. results indicate an overall treatment effect of cannabis on symptoms of pain and anorexia. cannabis was deemed safe to use in this group. the range of sample sizes is relatively small, suggesting that replication of these findings in larger samples may yield different results. furthermore, future cannabis treatment studies should employ a randomized control trial design. overall, results from the current systematic review suggest that cannabis is a potentially efficacious treatment for pain and anorexia symptoms in cancer populations. emergency department visits for cannabinoid hyperemesis syndrome in california from 2016 to 2021 catherine hess, shahnaj b. safi (california department of public health) background and methods: cannabinoid hyperemesis syndrome (chs) is a condition characterized by cyclical vomiting, nausea, and abdominal pain following heavy and prolonged cannabis use. increases in cases of chs have been reported in legal cannabis states following legalization, though the scope of the issue is not well characterized. this analysis examines cases of chs presenting to california emergency departments (ed) from 2016 to 2021 among individuals aged 10 and older. data are from the california department of healthcare access and information (hcai) ed visits and admissions datasets. no commonly agreed-upon case definition of chs has been described in the literature. for the purpose of this analysis we chose to maximize the inclusion of potential cases and so we defined chs as ed encounters with any cannabis-related icd-10-cm code (icd-10-cm f12 or t40.7) and persistent vomiting (icd-10cm r11). results: between 2016 and 2021 ed visits involving chs increased by 200 percent from 5,039 visits in 2016 to 15,161 visits in 2021. ed visits involving chs increased by 100 percent or greater across all adult age groups, with the largest increases among 26to 34-year-olds (260 percent) and 18to 20-year-olds (236 percent). among youth aged 10 to 17, chs related ed visits increased 140 percent from 418 in 2016 to 1,005 in 2021. there was a greater increase in chs ed conference abstracts 186 visits among females (245 percent) than males (166 percent) from 2016 to 2021. among females the greatest increases were among those aged 26 to 34 (314 percent) followed by those aged 18 to 20 (310 percent). among males the greatest increase was among those aged 26 to 34 (219 percent), followed by those aged 35 to 49 (174 percent). among youth 10 to 17, there was an increase of 181 percent among females and 97 percent among males, which may reflect increasing cannabis use among adolescent females. conclusions: ed visits for chs have increased substantially in california since cannabis was legalized in 2016. this may be due to an increasing prevalence of cannabis use and/or to changing patterns of cannabis use behavior among adults and youth. prevention messaging and education aimed at cannabis users and youth is needed to raise awareness of this potentially serious consequence of regular cannabis use. disclaimer: the findings and conclusions in this article are those of the author(s) and do not necessarily represent the views or opinions of the california department of public health or the california health and human services agency. cannabis use among the breast cancer patients in the united states: a systematic review samia amin, si woo chae, pallav pokhrel, kayzel r tabangcura, rachel taketa, crissy t kawamoto (university of hawaii cancer center) background: cannabis use interest continues to grow among patients with cancer and several studies support the efficacy of cannabis for various cancer and treatment-induced symptoms. yet, there is little data available on cannabis use among breast cancer patients. objectives: our aim was to identify and evaluate the scientific evidence of cannabis use among breast cancer patients in the united states. method: pubmed and psychinfo databases were scanned to include studies that focused on breast cancer patients who were using cannabis. independent reviewers screened and extracted data on study design characteristics, recruitment methods, and cannabis use. we used the kappa coefficient to assess inter-rater agreement between reviewers. a narrative synthesis was generated by using prisma 2015 guidelines. result: the database search retrieved 1,162 citations. after the removal of duplicates, 330 articles were included in abstract screening, and 45 articles were taken into consideration for fulltext review. we identified 9 relevant studies (5 longitudinal and 4 cross-sectional studies) which included 870 (34.5%, 870 of 2,515) breast cancer patients. the kappa coefficient was 0.86. included study participants' data collection ranged from 2014 to 2020. a total of 4 studies collected retrospective data from electronic health records and 4 studies used the online survey method. various forms of cannabis such as capsules, oral sprays, vaporizers, lotion, powder, and lozenges were used. the most common cause of the use of cannabis was for symptoms management (such as pain, anxiety, sleep, depression, appetite, numbness, nausea, vomiting, and diarrhea) of the breast cancer patient. the main reason for discontinued cannabis use was cost and societal stigma. the adverse effect of cannabis use reported was impaired mental functioning, dry mouth, or lack of energy. conclusion: although our study contributes to the literature on the use of cannabis among breast cancer patients, there were only a limited number of eligible studies, several of which included small sample sizes of breast cancer patients. exposure and outcome parameters varied, and the generalizability of their results was limited. policy and implication: this review may guide healthcare providers or policymakers in designing future tailored cannabis intervention programs in breast cancer management. clinicians must assess and manage cannabis-induced cognitive impairment at different stages of breast cancer chemotherapeutic treatment. effects of unmet medical treatment need and medical cannabis license on cannabis use behavior among adults living in a permissive medical cannabis state taylor niznik, darla e. kendzor (university of oklahoma health sciences center) sarah j. ehlke (old dominion university) michael a. smith, amy m. cohn (university of oklahoma health sciences center) background: medical cannabis was legalized in oklahoma in 2018. plausibly, individuals with a medical cannabis license (mcl) may use cannabis conference abstracts 187 as an alternative to traditional medical treatment given its availability and affordability. this could result in not seeking traditional medical care when needed and more problematic cannabis use behavior. this study examined differences between those with and without unmet treatment need on demographics, mental health, and cannabis use behavior (e.g., past 30-day use and cannabis use disorder), and the main and interactive effects of unmet treatment need and mcl status on cannabis use behavior. methods: a secondary analysis was conducted using online survey data collected from 3,588 adult oklahomans (70.4% non-hispanic white, 54.0% female, m age=41.8). participants reported on their income (dichotomized to <$30k vs ≥$30k), health insurance coverage (dichotomized to any/none), past 30-day cannabis use, depression (patient health questionnaire-2), anxiety (generalized anxiety disorder-2), cannabis use disorder (cud; brief cannabis use disorder identification test), and if they were issued an oklahoma mcl. unmet treatment need was assessed by asking: “in the past 12 months, was there ever a time when you needed to see a medical specialist about a health issue but did not get it?” (yes/no). bivariate analyses examined differences between those with and without unmet treatment need on demographics, cannabis use behavior, and depression and anxiety. logistic regression models examined the main and interactive effects of unmet treatment need and mcl on past 30-day cannabis use and likelihood of a cud, controlling for survey wave, demographics, anxiety, and depression. results: a third of the sample reported past 30day cannabis use (33.3%), and 23.6% had an mcl. twenty percent reported having no health insurance, and the majority had depression (58.6%) or anxiety (59.7%). bivariate tests showed that a significantly greater proportion of individuals with unmet treatment need (vs. met treatment need) were female (57.5% v. 52.6%), had income <$30,000 (43.6% v. 37.9%), had no health insurance (22.3% v. 18.6%), had an mcl (34.6% vs. 19.3%), reported past 30-day cannabis use (49.6% v. 27.6%), and endorsed depression (80.7% v. 50.0%), anxiety (83.4% v. 50.3%), and a cud (49.2% v. 32.9%; all ps<0.05). an interaction of mcl and unmet treatment need was significant on past 30-day cannabis use (p=.001), but not on cud (p=.260). in stratified analyses, the association between having an mcl and any past 30-day cannabis use was greater among those with met treatment need (aor=28.97, p<.001) than with unmet treatment need (aor=13.70, p<.001). there were significant main effects for mcl (aor=2.65) and unmet treatment need (aor=1.48) on likelihood of a cud; ps<.001. conclusion: separately, mcl and unmet treatment need predicted greater likelihood of a cud. mcl and unmet treatment need together predict decreased odds of current cannabis use, suggesting adults with an unmet treatment need may not find treatment needs met by cannabis. those with met treatment need may have the financial means to obtain an mcl and thus use cannabis. future studies should examine the impact of cannabis legalization on healthcare access and symptom management. unregulated and regulated cannabis market trends in massachusetts, 2019-2021 alexander m. colby, hailey pensky, marianne sarkis, julie k. johnson (commonwealth of massachusetts) aim: to examine patterns of cannabis sourcing and rationale in unregulated and regulated markets in massachusetts to understand the scope of the unregulated market. background: currently, 22:50 u.s. states have legalized adult-use cannabis, and 13:22 have adult-use retail cannabis stores, including massachusetts. an aim cited for cannabis legalization and retail implementation is to curb activity in unregulated markets and provide constituents access to safe, regulated products. still, the unregulated market for cannabis continues to operate and, in some states, appears to be larger than the regulated market. this phenomenon can present dangers to public health and safety as unregulated market products are often untested and may not be fit for consumption. monitoring the scope of the unregulated market presents a challenge as it is designed to be untraceable. methods: this quasi-experimental study used data from the international cannabis policy study (icps), waves 2019-2021 (n = 6,446), from a sample of massachusetts residents aged 16-65 (mage = 44.04 years; 69% woman, 29% man, 1% other). we used summary statistics to assess the scope of the unregulated market in massachusetts conference abstracts 188 through sourcing and rationale metrics, including: 1) overall, how much of the marijuana that you used in the past 12 months was purchased from legal/authorized sources?; 2) “overall, about what percentage (%) of the [mode] that you used in the past 12 months came from legal/authorized sources?”; 3) “in the past 12 months, have you gotten any type of marijuana from the following sources?”; 4) “what were the main reasons you bought from unauthorized sources instead of authorized sources?” results: results suggest purchasing behaviors have transitioned towards the legal market. respondents (n = 6,446) reported that 76% of their cannabis products were legally sourced in 2021, compared to 61% in 2019. increases in legal purchasing were pronounced among 21–25-yearolds, who reported purchasing 74% of their cannabis from legal sources in 2021 compared to 48% in 2019. we also observed differences in sources with reports of store purchases increasing by 59%, and reports of dealer purchases decreasing by 21%. we further probed differences in the percent of legal purchases by product, where flower shifted heavily to the legal market from 2019 (46.5%) to 2021 (66.3%). the purchase of vaporizers also shifted towards the legal market from 2019 (59.3%) to 2021 (77.8%), perhaps in part due to the evali crisis. finally, we investigated respondents’ reasons for sourcing from the unregulated market. we observed evidence that legal sources are becoming more accessible, with reports that stores were ‘too far away’ decreasing from 15% to 7%, and reports that stores were ‘less convenient’ decreasing from 22% to 16%. although the unregulated market remains a concern, results suggest consumer purchasing behaviors have shifted towards safer products available from regulated sources. medical cannabis program resilience in the era of adult-use cannabis legalization: a tale of three medical programs alexander m. colby (commonwealth of massachusetts) julia dilley (multnomah county/oregon public health division) julie k. johnson (commonwealth of massachusetts) aim: to assess medical program activity in three u.s. states after the enactment of adult-use legalization and implementation of retail stores to better understand medical program sustainability alongside adult-use legalization. background: as of april 2023, 22 u.s. states have legalized adult-use cannabis, with 13 of these states having both medical and adult-use cannabis retail establishments (“retailers”). while adult-use retailers provide safe access to the general population for cannabis use, medical programs often present safer, more affordable, and more diverse product options for patients’ unique medical needs. despite the importance of medical programs, growing evidence suggests that medical program activity decreases following adult-use retail implementation (i.e., adult-use market preeminence). this decreased activity suggests a decreased sustainability of these programs after adult-use implementation, which may be highly detrimental to patients who are more likely to be low-income, older, and in poorer health than the general population. to better serve medical patients, it is critical for medical programs to be designed for sustainability and operationalized alongside adult-use programs to ensure these programs do not become artifacts of adult-use cannabis legalization. methods: we conducted a quasi-experimental, cross-sectional study using cannabis regulatory data to compare outcomes in three states with both medical and adult-use cannabis programs and retailers (colorado, massachusetts, oregon). linear regression analyses were conducted to assess three outcome measures: 1) medical-use retail sales, 2) adult-use retail sales, and 3) number of registered medical patients in all fiscal quarters after adult-use retail sales were implemented in each state to september 2022. results: medical program sales and patient registrations only increased in massachusetts despite adult-use sales increasing in all three states after adult-use retail was implemented. over the time since implementation, medical sales were not available for oregon and decreased non-significantly in colorado, while patient registrations decreased significantly in both colorado and oregon. over the first three years of adult-use retail, patient registrations dropped by 22% in colorado and 55% in oregon but increased by 51% in massachusetts. conference abstracts 189 conclusions: study results indicate that medical cannabis programs undergo critical changes after the implementation of adult-use retail store policy provisions. data demonstrates that medical cannabis markets are not inherently dismantled by the co-operating of adult-use markets. rather, results suggest that specific aspects (i.e., provisions, priorities, functionality) of a medical program assist in its sustainability, a phenomenon that additional research may help isolate for future policy. key policy differences, such as program design and regulatory differences in the implementation of adult-use sales, may have differential impacts on medical programs. for continued patient access, it is critical that future research assesses the differences within and between states’ medicaluse and adult-use program design (i.e., policy and regulation) that permit medical program sustainability alongside adult-use legalization and implementation. provider review: evaluating individual criteria to support cannabis use disorder nique pichette (salve regina university) evaluating individual criteria to support cannabis use disorder diagnosis is an exploratory qualitative survey pilot study aimed to evaluate the current criteria for diagnosing cannabis use disorder (cud) by utilizing the dsm-v (2013) criteria and current research to establish an inclusive assessment of cannabis use. the cannabis assessment reliability and validity evaluation (carve) provides a single, uniform data source as a cohesive and functional tool that can assess for appropriate and inappropriate cannabis use. study participants were limited to healthcare providers licensed to diagnose cud. the study aimed to answer the following research questions: 1) could inappropriate and appropriate cannabis usage be measured and differentiated? 2) did the criteria covered in the survey provide a complete assessment of cannabis use and cannabis use disorder? results show a generalized agreement that inappropriate and appropriate cannabis usage can be measured and differentiated. healthcare providers also agreed that the carve survey provides a complete assessment of cannabis use that could be utilized to assist in diagnosing cannabis use disorder. these research study findings can be potentially used to establish future diagnostic criteria, policy development, and increase quality outcomes. keywords: cannabis use disorder, endocannabinoid system, diagnostic and statistical manual of mental disorders, marijuana use and abuse, cannabis education, cannabis addiction, medical marijuana, medical cannabis, recreational marijuana, recreational cannabis, ncsbn guidelines, cannabis nursing. longitudinal transitions between combustible, non-combustible, and poly-cannabis product use from adolescence to young adulthood and intersections with nicotine use dae-hee han, junhan cho (university of southern california) erin a. vogel (university of oklahoma) alyssa f. harlow (university of southern california) alayna p. tackett (ohio state university) sandrah p. eckel, rob mcconnell, jessica l. barrington-trimis, adam m. leventhal (university of southern california) understanding transitions between non-use, exclusive use, and poly-use of cannabis products and how it intersects with nicotine use in young people is important for informing etiology and prevention. this study examined transitions across combustible and non-combustible cannabis use and poly-use from adolescence to young adulthood and the role of nicotine use in transitions. applying markov multistate transition modeling to data collected from 3,298 adolescents (baseline mean[sd]=16.1[0.4] years) across nine semi-annual survey waves, we estimated adolescent short (two-wave) and longterm (nine-wave) transition probabilities across five cannabis states: never use of any product, prior use with no past 6-month (p6m) use of any product, p6m exclusive non-combustible, p6m exclusive combustible, and p6m poly product use (non-combustible+combustible). sizable direct transition probabilities from prior and exclusive non-combustible and combustible cannabis use to poly cannabis product use were observed in short (10.7%-38.9%) and long-term (43.4%-43.8%) analyses. p6m nicotine use were associated with conference abstracts 190 increased risk of transitioning from never and prior use to non-combustible and combustible cannabis use. cannabis use in any form, even temporary use in mid-adolescence, was associated with later poly cannabis product use. nicotine use may amplify probability of future cannabis use onset or recurrence. beyond frequency and quantity of cannabis consumption: context of using cannabis matison w. mccool, matthew r. pearson (university of new mexico) due to little knowledge regarding the contextual factors related to cannabis use, we aimed to provide descriptive statistics regarding contextual factors related to cannabis use and examine the predictive ability of contextual factors. we included college student participants (n = 5700; male = 2893, female = 3702, other gender identities = 48, missing = 57; see table 1 for descriptives) from three multi-site studies in our analyses. we examined the means and standard deviations of 34 contextual factors related to cannabis use (subjective intoxication factors, purchase locations, use locations, the forms of cannabis consumed, routes of administration, and social contexts of consumption). additionally, we tested the predictive ability of the contextual factors on cannabis use consequences (marijuana consequences questionnaire; macq), protective behavioral strategies (protective behavioral strategies for marijuana scale; pbsm), and severity of cannabis use disorder (cannabis use disorder testrevised; cuditr), via exploratory machine learning models (random forests and neural networks). college students endorsed a wide range of contextual use factors. on average, participants reported using a plant material via a joint they did not purchase, at home, with their friends. for a full list of the descriptive statistics of each contextual factor by study, see table 2. we split the data into training (75% of available data) and testing (25% of available data) datasets to conduct machine learning analyses where only contextual factors were entered as predictors. training datasets were used to fit the model, and testing datasets were used to test model predictions. we used the mean absolute error (mae), the root mean squared error (rmse), and the proportion of variance explained (r2) as indices of model fit based on testing dataset predictions. the neural network model for the macq (mae=0.71, rmse=0.937) and cuditr (mae=0.61, rmse=0.82) performed better than their relative random forest model (macq; mae=2.54, rmse=3.46; cuditr; mae=2.89, rmse=4.07). the random forests achieved higher r2 than the neural network models, possibly indicating overfitting by the random forests. for the pbsm, the neural network (mae=0.75, rmse=0.96, r2=0.15) and random forests (mae=0.71, rmse=0.93, r2=0.23) models performed relatively equally. we extracted the relative importance of the variables from the random forests models and used garson’s algorithm to extract relative importance from the neural networks. in all six models, money spent on cannabis in the past month was in the top three most important predictors. contextual factors of cannabis use warrant further exploration, especially considering the difficulty in assessing dosage when individuals are likely to consume in a group context. we propose measuring contextual factors along with use in the past 30 days and the consequences of use. precise doses of cannabis consumed are challenging to collect outside of a laboratory. measuring contextual factors alongside validated scales may provide additional variance explained beyond the scales. additionally, measuring contexts of use within theoretical frameworks could provide pertinent information on how the environment affects cannabis use in different contexts. cannabis use disorder and eating disorder symptoms among male and female college students keegan buch, ireland shute, stuart b. murray (university of southern california) reagan e. fitzke (university of colorado colorado springs) mark a. prince (colorado state university) eric r. pedersen (university of southern california) college students are at risk for heavy cannabis use and cannabis use disorder (cud), with rates of cud highest among the young adult population. heavy use in young adulthood can lead to subsequent physical and cognitive health conference abstracts 191 problems. also prevalent in young adulthood, and among college students in particular, are eating disorders, which typically emerge in early young adulthood and can have lasting detrimental impacts on physical and mental health. though some work has examined the co-occurrence of heavy alcohol use, alcohol use disorder symptoms, and eating disorder symptoms among college students, very little work has addressed the cooccurrence of cannabis use, cud symptoms, and eating disorders symptoms in this population, with even less attention paid to sex-specific differences between male and female students. in this study we examined the association between cannabis use frequency, cud symptoms, and symptoms of eating disorders (i.e., positive versus negative screens for an eating disorder using the scoff questionnaire) among a sample of 471 college students recruited for a study addressing heavy drinking. participants completed an online survey assessing past 30 day use of cannabis, cud symptoms on the cannabis use disorder identification test, and the scoff (score of 2+ out of 5 on the scoff indicated a positive screen for an eating disorder). participants reported using cannabis on a mean of 5.8 days in the past 30 days (6.9 days for males, 5.3 days for females). seventy-four participants (15.3%) screened positive for cud (21.4% of males, 12.9% of females), while 157 participants (32.4%) screened positive for an eating disorder (19.5% of males, 40.1% of females). using two linear regression models with outcomes of cannabis use days and cudit scores, we found that cannabis use days and cudit scores were significantly predicted by sex (males had greater use and cud symptoms) and scoff screening status (positive screen associated with greater use and cud symptoms). there was a significant interaction effect for sex and scoff screens, such that males with positive screens for an eating disorder reported the greatest level of cud symptoms, whereas for females, similar levels of cudit scores were observed regardless of eating disorder screens. these findings provide new insights into the associations between cannabis use and eating disorders among college students. prevention and intervention efforts in young adulthood are needed to address both cud and eating disorders during this vulnerable period. while continued efforts should focus on female students, there are growing concerns about eating disorders among male students, and these findings suggest more attention to male students is needed. cross-cutting disorder domains and method of cannabis administration in a community sample brenna carter, eleftherios hetelekides, kira sturgess, hollis karoly, bradley conner (colorado state university) introduction: we have extensive records of predisposing factors acting as a catalyst for substance use and similar evidence concerning cannabis use as a form of self-medication across multiple disorder domains. given interest in cannabis method of administration (maccallum & russo, 2018) and cannabis use comorbidity with diagnoses (arias et al.,2013), research into the different factors surrounding self-medicating cannabis use is required. since the speed and intensity of cannabis effects are dependent on dosage and method of administration, evaluation of any association between method of administration and specific disorder domains warrants further investigation. this study looks at the association between cannabis method of administration and cross-cutting diagnostic indicators with the hopes of evaluating if further research should be conducted concerning the influences of culture and diagnoses on the method of cannabis administration for specific factors of self-medication. methods: this will be a secondary-data analysis using a community sample of 410 adults using prolific data collection cannabis and alcohol couse survey. we will be conducting chi-square analyses to determine dependency between the variables of interest. anticipated results: we hypothesize that our cross-cutting dsm diagnostic scale will be significantly associated with method of cannabis administrated. discussion: should our hypotheses be supported, results will be interpreted to determine differential risk associated with specific methods of administration (e.g., higher potency products associated with more negative consequences of cannabis use) and mental health diagnoses. do beliefs about cannabis’ moderating impact on alcohol effects predict simultaneous alcohol and cannabis use and related consequences? conference abstracts 192 kyra n. farrelly, sophie g. coelho (york university) christian s. hendershot (university of north carolina at chapel hill) john a. cunningham (kings college london, centre for addiction and mental health, and university of toronto) roisin m. o’connor (concordia university) jeffrey d. wardell (york university, centre for addiction and mental health, and university of toronto) background: simultaneous alcohol and cannabis use is common during young adulthood and is associated with negative consequences. while some researchers have examined beliefs about effects from simultaneous use (e.g., waddell et al., 2022), the extent to which individuals expect that cannabis can alter specific alcohol effects has received limited attention. theoretically, young adults may be motived to engage in simultaneous if they expect that cannabis will reduce negative alcohol effects (e.g., negative-arousal effects such as aggression; negative-sedation effects like intoxication/impairment), and enhance positive alcohol effects (e.g., positive arousal effects such as sociability; positive-sedation effects like relaxation). the present study examined if young adults’ beliefs about these moderating effects of cannabis predict simultaneous use and related consequences over and above alcohol expectancies alone. method: data came from a larger longitudinal study of young adults (n=150 19–25-year-olds; 57.9% female) who reported simultaneous use of cannabis and alcohol (i.e., using both in the same two-hour period). alcohol expectancies (aes) were measured using the anticipated effects of alcohol scale (aeas; morean et al., 2012) which assesses alcohol expectancies along valence and arousal dimensions (i.e., positive or negative arousal and sedation). participants also completed an adapted version of the aeas assessing whether they believe that using cannabis makes each alcohol effect more or less intense (cannabis moderation expectancies; cmes). responses were scored along the same four dimensions as the aeas. participants then completed a 21-day burst of daily surveys assessing previous day alcohol use, simultaneous use (i.e., using both alcohol and cannabis in the same two-hour period), and positive and negative substance-related consequences. four outcome variables were derived from the daily data: number of alcoholonly days, number of simultaneous use days, and number of positive and negative consequences across a) simultaneous use days and b) alcoholonly days. for each outcome, a separate negative binomial regression was run with each cme scale as a predictor (controlling for the parallel ae scale, age, sex, and other relevant covariates). results: unexpectedly, number of simultaneous use days was predicted only by positive-sedation aes (b=0.28, se=0.11, p=0.008), and not by any of the cme scales. further no aes or cmes predicted number of alcohol-only days. on simultaneous use days, greater negative-sedation cmes (b=0.40, se=0.15, p=0.009) and positivearousal aes (b=0.33, se=0.16, p=0.041) predicted greater negative consequences. conversely, on alcohol-only days, negative-arousal aes (b=0.57, se=0.22, p=0.010) and negative-sedation aes (b=0.54, se=0.25, p=0.031) predicted greater consequences. finally, positive-arousal aes predicted greater positive consequences on alcohol-only days (b=0.43, se=0.19, p=0.027), but neither cmes nor aes predicted positive consequences on simultaneous use days. conclusions: beliefs about cannabis’ moderating impact on alcohol effects appear to be less relevant than alcohol expectancies themselves for predicting simultaneous use frequency. however, specific cmes did predict substance use consequences on simultaneous use days. these findings may reflect a self-fulfilling prophecy whereby beliefs that cannabis increases alcohol’s negative intoxication/impairment effects lead to more negative consequences when using cannabis with alcohol. the findings may have implications for expectancy-based interventions among young adults who engage in simultaneous use. motives, patterns of use, and mental health symptoms among young adult who co-use nicotine and cannabis rebecca k. denson, robin j. mermelstein (university of illinois at chicago) background: co-use of nicotine and cannabis products is increasing among young adults, and may pose greater risks to mental and physical health than use of either substance alone. little is known about how rates of co-use relate to co-use conference abstracts 193 motives, psychopathology, and types of products used (e.g., vaporizers, combustibles). the present study evaluated self-reported cannabis and nicotine use, motives, and mental health symptoms in a sample of young adults. methods: participants aged 18-29 were recruited for a longitudinal study of nicotine and cannabis co-use. data were collected in illinois following legalization of recreational cannabis use. participants completed an online screening survey and a phone interview to assess eligibility; inclusion criteria included cigarette and/or ecigarette use on at least 15 days in the past month, combustible and/or vaporized cannabis use on at least 8 days in the past month, and cannabis use on at least 2 days in the past week. eligible participants completed a baseline questionnaire that assessed cannabis and nicotine use rates, co-use motives, frequency of different product use (e.g., vaporizer, combustible), and symptoms of depression, anxiety, and attentiondeficit/hyperactivity disorder (adhd). results: to date, 52 participants have completed baseline measures (28.8% women, 53.8% men, 13.5% non-binary/nonconforming, 3.8% transgender; 67.3% white, 17.3% hispanic/latino or spanish, 9.6% asian, 9.6% middle eastern or north african, 5.8% black or african american, 1.9% native hawaiian/pacific islander). the pastmonth average smoking rate was 11.83 days/month (sd = 13.19), and past-month nicotine vaping averaged 19.54 days/month (sd = 12.97). participants reported using cannabis on an average of 26.94 days per month (sd = 6.45). couse motives related to improved buzz/high, increased pleasure/satisfaction, improved cognitive performance, and coping were rated highest. the most common patterns of administration for co-use were using a tobacco/nicotine product while using cannabis (63% of participants) and vaping nicotine before/after using cannabis (52% and 50% of participants, respectively). the overall sample displayed high depression symptoms (ces-d-10 m = 10.42, sd = 6.18) and mild anxiety symptoms (gad-7 m = 7.48, sd = 5.61). participants endorsed an average of 3.02 symptoms on an adhd screening measure (asrs). depression and anxiety symptoms were each positively correlated with cannabis coping motives and nicotine negative affect (na) expectancies, but not with co-use coping motives. adhd symptoms were not associated with cannabis, nicotine, or couse motives. cannabis coping motives were positively associated with nicotine na expectancies and co-use coping motives; however, nicotine na expectancies and co-use coping motives were not related. conclusions: these findings characterize the motives, types of products, and mental health symptoms of young adults who co-use nicotine and cannabis. co-use was most commonly reported as simultaneous use of nicotine and cannabis or vaping nicotine before/after cannabis use. depression and anxiety symptoms were associated with using cannabis and nicotine individually to cope with low mood but were not associated with co-use coping motives, suggesting that motives for single product use vs. co-use may differ. adverse childhood experiences and poly-use of alcohol, tobacco, and cannabis: an exploration of 2020 hawai‘i behavioral risk factor surveillance system (brfss) data mika d. thompson, laura johnston, john massey, michael m. phillips (university of hawai‘i at mānoa) introduction: approximately 60% of u.s. adults have endured at least one adverse childhood experience (ace). aces are defined as potentially traumatic negative experiences that occur before the age of 18 and can take the form of abuse, neglect, and household dysfunction. approximately 16% of u.s. adults have experienced four or more aces. previous research suggests that specific demographic groups are more likely to experience at least one ace, including native hawaiians and whites, those with lower educational attainment and lower annual household income. aces are also associated with a number of health conditions and high-risk behaviors. others have found a positive correlation between aces and nicotine, cannabis and alcohol use; yet, few have examined the relationship between aces and co/poly-use of these three substances. our research objective was to explore the association of aces with co and poly-use of alcohol, cannabis, and/or tobacco/nicotine in hawai‘i. methods: utilizing data from the 2020 hawai‘i brfss (n=7,754) we examined the prevalence of self-reported current alcohol, tobacco/nicotine, conference abstracts 194 and cannabis use with nine aces. using four regression models, we quantified the association between aces and use of each individual substance (quasi-poisson) and between aces and single-, co-, and poly-substance use (multinomial logistic). all analyses were adjusted for complex sampling design. results: self-reported past 30-day alcohol, cannabis, and current tobacco/nicotine use was 46.8%, 9.8%, and 17.1%, respectively. single use for either alcohol, cannabis, or tobacco/nicotine was 40.5%, 12.4% for some combination of co-use and 2.6% for poly-use of all three. all aces were significantly associated (p<0.05) with current use of cannabis and tobacco/nicotine, with the strongest association with the cannabis outcome. however, only the following ace items were associated with any current alcohol use: (1) living with someone who was mentally ill, (2) parents separated or divorced, and (3) parents/adults in home who swore or insulted the child. similarly, all aces were associated with higher odds of co and poly-use relative to no current use, with the highest odds for poly-use, followed by co-use. only the three ace items associated with current alcohol use were associated with single use. discussion: the occurrence of aces tends to predict a greater prevalence of co-/poly-use of all three substances. this evidence draws attention to the need for further screening in light of others who have found poly-use related to greater negative consequences. aces are associated with increased odds of poly-use, which necessitates the integration of aces screening with substance use prevention efforts. understanding aces in hawai‘i also contributes to new knowledge in the existing field of research on aces and substance use by potentially providing insight into the role of community, family structure, and cultural values in the prevention and treatment of aces and substance use. effects of simultaneous alcohol and marijuana use frequency on depression, anxiety, and stress in male and female college students eleftherios hetelekides, tabitha mcmichael, hollis karoly (colorado state university) simultaneous use of alcohol and cannabis is common among college students. there is evidence that simultaneous alcohol and marijuana/cannabis use (sam) is associated with greater consumption rates and more severe consequences than alcohol or cannabis alone, as well as concurrent use (cam; use such that effects of each substance do not overlap). sam may be uniquely associated with mental health outcomes, especially in college students who engage in sam use at high rates. more research is needed to assess impacts of sam on distinct mental health symptoms and how this may differ across sexes. the present study (ntotal = 377) aimed to examine whether individuals who engage in sam use more than once per month (nsam+ = 126) differ on scores of the depression, anxiety and stress scale (dass) subscales compared to individuals that engage in sam use less than once per month (nsam= 251). the overall sample consisted of 249 (66.0%) afab individuals, with 68 (18.0%) identifying as hispanic or latino/a/e/x, 324 (85.9%) identifying as white, 4 (1.1%) as american indian or alaska native, 8 (2.1%) as asian, 4 (1.1%) as black or african american, 3 (0.8%) as native hawaiian or other pacific islander, and 34 (9.0%) chose not to respond. a multigroup path analysis was conducted using mplus to simultaneously regress the dass symptom domains (depression, anxiety, and stress subscales) onto a dichotomously coded sam group variable, with sex assigned at birth as the grouping variable, with age and past 30-day cannabis and alcohol frequency as covariates in the model. results indicated that the effects of monthly or more sam on each dass subscale did not differ significantly across sexes (p’s < .05), but different patterns of effects were observed for each sex. specifically, sam use significantly predicted depression (p = .002), anxiety (p < .001), and stress (p < .001) in males, but only depression (p = .013) in females. these preliminary results indicate that greater frequency of sam use is significantly associated with anxiety and stress symptoms for males but not for females. programs aimed at reducing mental health outcomes should assess for patterns of substance use like sam, because different substance use patterns appear to relate to differences in mental health outcomes, possibly in a differential manner across sex. future research should directly assess whether sex differences exist in the effects of sam on mental health outcomes, as well as the directionality of these relationships, i.e., whether sam use is resulting in mental health symptoms or whether conference abstracts 195 individuals are engaging in sam to cope with mental health problems/self-medicate. impulsivity, mood, and unplanned alcohol and cannabis use in young adults: an ecological momentary assessment study nicolle fox (york university) christian s. hendershot (university of north carolina–chapel hill) jeffrey d. wardell (york university; institute for mental health policy research, centre for addiction and mental health, toronto, canada; department of psychiatry, university of toronto) background: unplanned use of cannabis and alcohol is a risk factor for heavier use and greater harms than planned use, but the factors contributing to unplanned use among co-users of cannabis and alcohol require further study. although positive and negative mood have an impact on substance use, findings are mixed for the relationship between mood and unplanned use specifically. it is possible that the link between heightened positive or negative mood states and unplanned substance use may be stronger for those with greater impulsivity, but the role of impulsivity in these associations has not been examined. this study examined the moderating role of impulsivity in daily associations between mood and unplanned alcohol and cannabis use among young adult co-users. methods: data came from young adults (n=155; 59.4% female, mean age = 22.09) who participated in a larger ecological momentary assessment (ema) study of alcohol and cannabis co-use. participants completed surveys each morning for 21 days assessing the previous day’s alcohol (standard drinks) and cannabis (grams) use, and the maximum amount of each substance they intended to use over the next 24h. unplanned use of cannabis and alcohol was defined in two ways: 1) reporting use when no previous intention to use was indicated, and b) reporting using more than the maximum intended amount. twice daily, randomly timed surveys captured momentary mood states and impulsivity traits were assessed at baseline using the uppsp impulsive behavior scales. results: compliance with the daily morning surveys was 89%. fifty percent of the 600 alcohol use days were unplanned, and 27% of the 1008 cannabis use days were unplanned. multilevel models showed significant daily-level relationships of increased positive mood and decreased negative mood with greater likelihood of unplanned vs. planned drinking and decreased negative mood with consuming fewer standard drinks than intended. decreased boredom was associated with increased likelihood of unplanned cannabis use at the day level. several impulsivity traits moderated relationships between specific mood variables and unplanned alcohol use, such that mood changes were more predictive of unplanned use among those low vs. high in impulsivity. impulsivity did not moderate associations between mood and unplanned cannabis use. conclusion: we found that daily mood changes were linked with unplanned use of alcohol and cannabis among young adult co-users, although this relationship appeared stronger for alcohol than for cannabis. results suggest that unplanned use may be more likely on days when young adults experience more pleasant and fewer unpleasant moods, perhaps reflecting spontaneous decisions to use in social or celebratory contexts, although future work is needed to better understand the role of context. further, high impulsivity appeared to reduce the impact that daily deviations in mood have on unplanned alcohol use among co-users, suggesting that unplanned use is as likely as planned use across a range of mood states for impulsive individuals. findings can inform harm reduction interventions by identifying risk factors for unplanned alcohol and cannabis use in a population at risk for harms from co-use. food restriction on simultaneous alcohol and marijuana use days: exploring motivations and consequences among college students ireland m. shute, reagan e. fitzke (university of southern california) mark a. prince (colorado state university) stuart b. murray, eric r. pedersen (university of southern california) simultaneous alcohol and marijuana use (sam) and food restriction on days when students intend to drink are associated with an increased risk of substance use-related consequences. however, conference abstracts 196 the negative outcomes associated with food restriction on substance use days as they relate to substance use have been studied mostly in alcohol-only use contexts. moreover, little is known about the combination of sam use and food restriction behaviors. therefore, the current study investigated substance use-day food restriction frequency, food restriction motivations specific to substances, and substance use consequences in college students who use alcohol and marijuana simultaneously (n = 901). hierarchical regression analyses tested the relations between alcohol and marijuana use patterns and food restriction on substance use-related consequences. results indicated that, for individuals who used alcohol and marijuana simultaneously in the past month, sam use frequency significantly predicted greater alcohol and marijuana use consequences. alcohol and marijuana use quantity on sam use days also predicted greater alcohol and marijuana use consequences, respectively. finally, the interaction between food restriction and marijuana use quantity on sam days significantly predicted greater marijuana use consequences. when asked why participants restricted food on substance use days, several core themes emerged. prominent restriction motivations included "calorie compensation," "expedited intoxication," "sickness prevention," "lack of appetite," "forgetting to eat," and "previously diagnosed eating disorder." these results provide the basis for further exploration of food restriction and sam use, as well as targeted interventions among atrisk populations. cannabis use and alcohol outcomes among sober living house residents in california meenakshi s. subbaraman, elizabeth mahoney, amy a. mericle, douglas polcin (public health institute) background. some studies suggest that cannabis may be used as a safer substitute for other drugs, e.g., alcohol. historically, sober living houses (slhs) have been abstinence-based environments designed for individuals in recovery to live with others in recovery. however, the evolving social, legal, and medical landscapes around cannabis have left slh operators and managers in a difficult position regarding policies related to its use among residents. data are urgently needed regarding cannabis’ potential impacts in this population. thus, this study examines how cannabis use is related to alcohol use and related outcomes among slh residents. data. baseline, 6-month, and 12-month data were collected from 557 slh residents living in 48 houses in los angeles, ca from 2018-2021. methods. longitudinal multilevel regressions tested associations between any past six-month cannabis use and alcohol outcomes: past-month any drinking, past-month number of drinking days, past six-month number of drinking days, any past six-month alcohol problems, and current dsm-5 alcohol use disorder (aud). final regressions adjusted for resident age, sex, race and ethnicity, past-month substance use treatment, past six-month 12-step attendance, percent of social network using drugs/alcohol heavily, and psychiatric symptoms. logistic regression was used for dichotomous outcomes and negative binomial regression was used for count outcomes. all regressions adjusted for clustering at the slh level. results. at baseline, 107 (19.2%) of residents reported having used cannabis use in the past six months. at 12 months, 80 (17.5%) of residents reported having used cannabis use in the past six months. any past six-month cannabis use was related to significantly (ps<0.001) higher odds of any past-month alcohol use (or=4.84, 95% ci: 3.11, 7.53); more drinking days in the past month (irr=2.77, 95% ci: 2.03, 3.66); more drinking days in the past six months (irr=1.81, 95% ci: 1.44, 2.27); and higher odds of any alcohol problems (or=3.05, 95% ci: 1.98, 4.72). past sixmonth cannabis use was not significantly (ps<0.05) related to current dsm-5 aud. conclusions. a considerable number of individuals residing in california sober living houses report having used cannabis in the past six months. past six-month cannabis use was related to worse alcohol outcomes, suggesting that cannabis does not work as a substitute for alcohol in this population. future research should examine whether cannabis use is related to other outcomes as well as how frequency and quantity of cannabis use impact alcohol use outcomes among slh residents. cannabis and other recreational drug use among psychoactive prescription medication users conference abstracts 197 kelly w. sun, neel muzumdar, kelsey l. piersol, amanda colangelo, jennifer f. buckman (rutgers university – new brunswick) use of recreational cannabis is common in the united states, with more than 31 million pastmonth adult users (samhsa, 2019). in addition, 58 million us adults report past-month tobacco use and nearly 140 million report past-month alcohol use. much research has examined cannabis co-use with alcohol and nicotine; however, there has been less attention on cannabis co-use with prescription medications. cannabinoids have been shown to inhibit and be metabolized by the cytochrome p450 (cyp) enzyme pathway (antoniou et al, 2020; doohan et al., 2021), which can affect the plasma concentration of various medications. concurrently, mental health diagnoses (e.g., anxiety and depression) and prescription rates for psychoactive medications (e.g., antidepressants, benzodiazepines, stimulants, narcotics) continue to increase. currently, there is limited research on the cannabis and other recreational drug use habits of people who are prescribed psychoactive medications. this poster will assess the prevalence of self-reported cannabis, alcohol, and nicotine in individuals who are and are not prescribed medication. this is a secondary analysis of survey data from 277 college students (64% female) who participated in a 2-year longitudinal study on the effects of college health behaviors on cardiovascular function. thirtyseven (13%) participants reported using psychoactive prescription medication. among the prescription users, 54% also reported using cannabis in the past 30 days. this rate of cannabis use was not significantly different compared to the prescription non-users. in addition, 30% of prescription users reported nicotine use and 80% reported alcohol use in the past 30 days. these rates were also not significantly different between the prescription groups. these findings suggest that prescription medication use does not substantively interrupt cannabis and other recreational drug use habits. this has clinical implications for how physicians should communicate with patients when prescribing psychoactive medication. adverse drug-drug interactions should be taken into account not only between different prescription medications but also between prescription medications and recreational drugs. for cannabis in particular, physicians should consider how its effects on cyp enzymes may necessitate changes to prescription dose regimens. anxiety symptoms, delaying gratification, substance use coping motives, and problematic substance use: an examination among co-users of alcohol and marijuana ruth hailemeskel, adrian j. bravo (william & mary) background: multiple theories/models (e.g., stress-dampening model; tension-reduction model; self-medication hypothesis) posit that individuals engage in substance use because they expect that using that substance provides immediate coping benefits by alleviating their negative affect. in support of these theories, studies among college students have found substance use coping motives to mediate the associations between negative affect and both alcohol (bravo & pearson, 2017) and marijuana (farris et al., 2016) outcomes, including among cousers of alcohol and marijuana (bravo et al., 2019). however, limited research has investigated what factors link poor mental health to higher coping motives and in turn more negative substance use consequences. objective: the present study aimed to expand prior research by exploring the associations between generalized anxiety disorder symptoms, delaying gratification, alcohol/marijuana use coping motives, and negative alcohol/marijuanarelated consequences among u.s. college students who consumed both alcohol and marijuana in the past month. specifically, we hypothesized that higher anxiety symptoms would relate to more negative alcohol/marijuana-related consequences via lower delaying gratification and higher coping motives. method: college students were recruited from psychology department participant pools at ten universities across ten u.s. states to participate in an hour-long online survey examining substance use and mental health outcomes. for the present study, we limited our analytic sample to students who consumed both alcohol and marijuana in the previous month and completed a measure of generalized anxiety disorder symptoms (n = 616; 72.6% female). a path analysis model was conducted testing the serial conference abstracts 198 unique associations between anxiety symptoms → delaying gratification → alcohol/marijuana coping motives → negative alcohol/marijuana-related consequences. multi-group analysis was performed to determine if the proposed model was invariant across gender and co-use status (co-use vs simultaneous use). results: within our comprehensive model, we found two significant double-mediation effects for both alcohol (indirect β = .01, 99% cis = 0.000, 0.02) and marijuana (indirect β = .01, 99% cis = 0.001, 0.03) negative consequences. specifically, we found that higher anxiety symptoms was related to lower levels of delaying gratification, which in turn was associated with higher alcohol/marijuana use coping motives, which in turn was associated with more negative alcohol/marijuana-related consequences. this model was invariant across co-use status and gender groups suggesting replicability and generality. conclusions: our findings suggest that delaying gratification is important to understanding the relationship between negative affect (i.e., higher anxiety symptoms) and problematic alcohol and marijuana use. interventions aimed at reducing problematic substance use among individuals endorsing high anxiety symptoms may benefit from targeting delaying gratification which may in turn reduce motivations to use alcohol/marijuana to cope. our preliminary findings encourage further exploration of these associations in longitudinal and experimental studies and lends support to the therapeutic targeting of delaying gratification and alcohol/marijuana coping motives to mitigate substance use harms stemming from mental health struggles among college students. desire to quit smoking and lifetime cessation attempts among cigarette-only smokers and cigarette-cannabis co-users: examining differences across health disparity groups madelyne wilson, michael a. smith, brittany zaring-hinkle (university of oklahoma health sciences center) sarah j. ehlke (old dominion university) darla kendzor, amy cohn (university of oklahoma health sciences center) background: the co-use of cannabis and cigarettes is common, particularly among vulnerable populations, like racial and ethnic minorities, those with lower income, and sexual and gender minorities (sgm). while co-use is associated with worse smoking cessation outcomes and greater nicotine dependence in the general population, few studies have examined differences in smoking cessation behaviors across vulnerable sub-groups. this study examined differences in desire to quit smoking and lifetime cessation attempts among cigarette-only smokers and cigarette-cannabis co-users across race/ethnicity, income, and sgm identification. methods: this study focused on n=720 adults aged ≥18-years from oklahoma who reported past 30-day cigarette smoking. participants provided information on demographics [sex; age; race/ethnicity, non-hispanic (nh) white, nh black, hispanic, nh american indian, nh other (asian, native hawaiian, more than one race)]; income [<$20k vs. ≥$20k]; and sgm vs. heterosexual identity), past 30-day cannabis use, and past 30-day alcohol use. participants provided information on number of lifetime tobacco quit attempts and ranked desire to quit smoking cigarettes (1=don’t want to stop to 7=really want to stop in the next month), where higher scores indicated greater desire. participants were categorized as past 30-day cigarette-only users or cigarette-cannabis cousers. bivariate tests assessed demographic differences between cigarette-only and co-users. analysis of covariance (ancova) tests examined the main and interactive effects of co-use status (cigarette-only vs. cigarette-cannabis co-use) and race/ethnicity, income, and sgm identification (in separate models) on desire to quit smoking and number of lifetime tobacco cessation attempts (as the outcomes), controlling for relevant covariates. outliers for number of tobacco cessation attempts were capped at the 95% percentile. results: thirty-five percent of the sample were cigarette-cannabis co-users. a higher proportion of co-users (versus cigarette-only users) were racial/ethnic minorities (nh african american, hispanic, nh american indian), had an income <$20k (33.3% vs. ≥$20k: 24.9%), were male (55.7% vs. female: 43.4%), and reported past 30-day alcohol use (66.7% vs. no alcohol use: 55.1%). there were no differences by sgm status. there was a significant co-use x race/ethnicity conference abstracts 199 interaction on desire to quit (p<.05). simple effects revealed that nh other co-users reported significantly lower desire to quit (madjusted=3.21) than nh other cigarette-only users (madjusted=4.96), p<.05. furthermore, there were racial/ethnic differences on desire to quit among cigarette-only users, where hispanic cigarette-only users (madjusted=2.25) reported lower desire to quit compared to nh black (madjusted=3.69) cigarette-only users, and nh other cigarette-only users reported the greatest desire to quit (madjusted=4.96) compared to all other racial/ethnic groups of cigarette-only users (nh white, nh black, nh american indian, and hispanic) (ps<.05). no other significant main or interactive effects were found. conclusion: differences in desire to quit smoking among nh other co-users and cigarette-only users could be explained by higher prevalence of mental health and substance use disorders (sud) and cultural differences among nh other populations. whereas prior research has shown higher sud among nh hawaiian and pacific islanders, asian americans report greater desire to quit smoking. future research should further examine desire to quit cannabis use among nh other co-users and cigarette-only users. differences in substance use patterns and correlates among polysubstance use groups abigail e. mcdonald, will corbin (arizona state university) introduction: polysubstance use continues to be a concern in young adults and on college campuses. previous research suggests strong links between alcohol use, cannabis use, and prescription drug misuse. the prevalence of prescription drug misuse in young adults has been steadily increasing since the early 2000s. concurrently, there has been a rise in the co-use of alcohol and cannabis among college students in recent years. the strong association between prescription drug misuse and the use of other substances complicates the identification of specific risk factors and consequences. given the prevalence of polysubstance use and the importance of identifying unique risk factors and consequences of prescription drug misuse, further research on substance use patterns and correlates among college students is warranted. method: this study evaluated group differences in alcohol use, cannabis use, alcohol and cannabis couse, alcohol consequences, impulsivity, demographics, and internalizing symptoms among college students who: a) endorsed only past-month alcohol use b) endorsed past-month alcohol and past-year cannabis use c) endorsed past-month alcohol, past-year cannabis use, and past-year co-use and d) endorsed past-month alcohol use, past-year cannabis use, past-year couse, and past-year prescription drug misuse. the data were obtained from an online survey study about substance use and psychopathology in college students at a southwestern university. the sample included 843 undergraduate students who were enrolled in an introductory psychology course and who endorsed past-month alcohol use. results: among the participants, 14.8% fell into the alcohol-only group (n=125), reporting pastmonth alcohol use without past-year cannabis use or prescription drug misuse. the alcohol and cannabis group comprised 8.3% of the sample (n=70), reporting past-month alcohol use and past-year cannabis use without past-year co-use or prescription drug misuse. 59.7% of the sample reported past-month alcohol use, past-year cannabis use, and co-use use without prescription drug misuse (n = 503). lastly, 17.2% reported past-month alcohol use, past-year cannabis use, co-use, and past-year prescription drug misuse (n=145). significant group differences were found in substance use patterns, alcohol consequences, internalizing symptoms, and impulsivity, with the highest rates observed in the prescription drug misuse group. planned contrasts indicated that the prescription drug misuse group exhibited significantly greater alcohol consequences, internalizing symptoms, and impulsivity compared to the co-use group. conclusions: findings support the prevalence of polysubstance use on college campuses and highlight the potential heightened risks of consequences and mental health problems. prevention efforts should prioritize targeting protective strategies that are effective in addressing multiple forms of substance use. copyright: © 2023 authors et al. these are open access abstracts distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and https://creativecommons.org/licenses/by/4.0/ conference abstracts 200 source are credited, the original sources is not modified, and the source is not used for commercial purposes. research article 85 ved abstract objective: expectancies play a critical role in cannabis use behavior and are influenced by sociodemographic and intrapersonal factors. this study examined daily endorsement of positive and negative cannabis use expectancies using 28 days of ecological momentary assessments (emas) in relation to sociodemographics, mental health symptoms, and cannabis use disorder (cud) among young adult cannabis-tobacco co-users. method: ninety-seven young adult (ages 18-24) cannabis and tobacco co-users reported on anxiety symptoms, depressive symptoms, and possible cud at baseline. during the 28 days of emas, participants reported on 16 positive (n = 7) and negative (n = 9) cannabis use expectancies they anticipated would occur in the next 24 hours. descriptive statistics examined the proportion of ema days each expectancy was endorsed. multivariable logistic regressions examined associations of expectancies with anxiety symptoms, depressive symptoms, and possible cud, controlling for sociodemographics. results: the most frequently endorsed expectancies were positive (e.g., feeling good, getting along with others), while the least frequently endorsed were negative (e.g., drinking too much, having an argument). in regression models, participants endorsing more days of expecting to feel anxious displayed higher odds of anxiety and depressive symptoms; those endorsing more days of expecting to be in a bad mood displayed higher odds of depressive symptoms; those endorsing more days of expecting to feel tired or unmotivated displayed higher odds of possible cud. conclusions: expectancies of cannabis benefits and consequences are heterogeneous, endorsed in different frequencies across days, and they may have important implications for mental health symptoms and cannabis use severity among young adults who co-use. key words: = cannabis; expectancies; young adults; cannabis use disorder; anxiety; depression; ecological momentary assessment katelyn f. romm1,2, robin mermelstein3, ryan vandrey4, donald hedeker5, & amy m. cohn1,2 1tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center 2department of pediatrics, college of medicine, university of oklahoma health sciences center 3department of psychology, institute for health research and policy, university of illinois chicago 4johns hopkins university school of medicine 5department of public health sciences, the university of chicago cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000277 volume 8, issue 2 daily assessment of positive and negative cannabis use expectancies in young adult cannabis and tobacco cousers: differences by sociodemographics, mental health symptoms, and possible cannabis use disorder cannabis, a publication of the research society on marijuana 86 nearly a quarter of young adults (22.4%) report past month cannabis use (substance abuse and mental health services administration, 2022). cannabis use is associated with alcohol, tobacco, and other drug use (cohn et al., 2015; hasin et al., 2016), as well as mental health problems (gobbi et al., 2019). cannabis-tobacco co-use is also increasingly popular in this age group (cohn & chen, 2022; rubenstein et al., 2024). because young adulthood is a developmental period when lifelong behaviors are cemented, understanding how young adults’ behaviors and attitudes promote or sustain substance use, and vice versa, is critically important. expectancies, which are the effects one anticipates to experience from substance use, are important correlates and predictors of cannabis use (buckner et al., 2013; livingston et al., 2024). common positive cannabis use expectancies include relaxation and tension reduction (hyman & sinha, 2009), mood enhancement, social facilitation (buckner et al., 2013; buckner & schmidt, 2008), and the alteration of sensory experiences (cloutier et al., 2022). common negative cannabis use expectancies include loss of motivation, cognitive impairment, mental health problems, and occupational or social consequences (foster et al., 2016; king et al., 2020; livingston et al., 2024). negative expectancies are associated with less frequent use and use consequences (arterberry et al., 2013; foster et al., 2016), and positive expectancies are associated with more frequent and problematic use, initiation, and worse mental health (amiet et al., 2020; bolts et al., 2023; buckner et al., 2013; curry et al., 2018; foster et al., 2016; hayaki et al., 2010). however, some research shows that negative cannabis use expectancies are higher among those with a cannabis use disorder (cud) and positively correlated with cud symptoms and cannabis use consequences (foster et al., 2016; hides et al., 2009; schuster et al., 2019; waddell et al., 2021). intrapersonal factors beyond cannabis use, like mental health, likely have a proximal impact on cannabis use expectancies, particularly positive outcome expectancies (king et al., 2020). according to motivational models of substance use, individuals with anxiety or depression may perceive cannabis as providing temporary relief from negative affect or emotional distress (cooper et al., 2016). mood enhancement and anxiety reduction are key drivers of cannabis use among young individuals and may influence, or be influenced by, mental health (cooper et al., 2016; lucatch et al., 2018). individuals with a cud may also hold positive expectancies that cannabis will improve sleep, negative mood, and impaired motivation associated with withdrawal and/or the acute phase of ‘coming down’ (budney et al., 2003; cousijn & van duijvenvoorde, 2018; hasin et al., 2008; preuss et al., 2010). beliefs about the anticipated effects of cannabis may be shaped by experiences using both cannabis and tobacco. co-users may have strong positive cannabis use expectancies, such as enhanced high or euphoria (kong et al., 2018; reboussin et al., 2021; schauer et al., 2017), increased positive mood and alertness due to the stimulating effects of tobacco on cannabis use (berg et al., 2018; harrell et al., 2022), and facilitation of social interactions (d’amico et al., 2020). co-use is associated with greater cannabis dependence and mental health problems (cohn et al., 2016; ramo et al., 2012; tucker et al., 2019), intrapersonal factors that are correlated with cannabis use expectancies. factors associated with cannabis use expectancies have not been examined among young adults who co-use. research has traditionally examined cannabis use expectancies via retrospective reports that provide a “one time” snapshot of behavior. because cannabis use varies across contexts and time (hughes et al., 2014; shrier et al., 2012), expectancies may vary when assessed at the daily level. existing day-level studies have found reductions in negative affect hours after cannabis use, and other work shows increases in positive affect after cannabis use (sznitman et al., 2022), specifically among those with cud (ross et al., 2018). positive and negative reinforcing experiences could influence expectancies about cannabis use. we hypothesized that anxiety and depressive symptoms and cud would be associated with more frequent endorsement of positive expectancies, like mood enhancement and social facilitation, and less frequent endorsement of negative expectancies. corresponding author: amy m. cohn, phd, tset health promotion research center, stephenson cancer center, department of pediatrics, college of medicine, university of oklahoma health sciences center, 655 research pkwy #400, oklahoma city, oklahoma, 73104. phone: (405) 271-1903. email: amy-cohn@ouhsc.edu cannabis and harm perceptions 87 methods participants and procedures participants were 97 young adult cannabis and tobacco co-users recruited into a 28-day ema study via print and social media advertisements from 2 northeastern u.s. cities (2017 to 2019). emas were collected via interactive voice response (ivr) technology (corkrey & parkinson, 2002). eligibility criteria were: aged 18-24, using cannabis >2 times per week in the past month, and “someday” or “everyday” tobacco use (including ecigarettes). exclusion criteria were: severe psychiatric disturbance; potential for lethal alcohol consumption >1x in the past 3 months (as evidenced by self-reported bac ≥0.20); dependence on substances other than alcohol, cannabis, caffeine, or nicotine; and pregnant, planning to become pregnant, or breastfeeding. after completing a screener (n = 1,425) and then a baseline survey (n = 137), 97 participants completed a brief ema training and were enrolled in 28 days of emas, during which they received 3 calls/day to their phone at random times (morning, midday, and evening of their typical sleep/wake cycle), resulting in 84 possible surveys/person. participants received $25 for the baseline survey, and could receive a maximum of $184 for completing emas. more details about the methodology can be found here (niznik et al., 2023; wilhelm et al., 2020). ema compliance averaged ~55%, and no baseline factors were associated with compliance (niznik et al., 2023). this study was approved by the irb. measures sociodemographic information, anxiety symptoms, depressive symptoms, and cannabis use behaviors were assessed at baseline. sociodemographic information included age, sex assigned at birth, race and ethnicity employment, relationship status, income, and education. the generalized anxiety disorder-7 (gad-7) (spitzer et al., 2006) assessed past 2-week anxiety symptoms (0=not at all to 3=nearly every day). summed scores (α=.88) of >8 indicated current anxiety symptoms (kroenke et al., 2007). the 10item centers for epidemiologic studies depression scale-revised (cesd-r) assessed past week depressive symptoms (0=less than 1 day to 4 = 5-7 days). summed scores (α = .71) of >10 indicated current depressive symptoms (björgvinsson et al., 2013). the 8-item cannabis use disorder identification test-revised (cuditr) assessed possible cud (scores of >12 indicating possible cud; α = .62; adamson et al., 2010). participants also reported on the number of days they used cannabis in the past 30 and indicated ever use of a range of cannabis modes of use (i.e., joint, bowl, bong, one-hitter or pipe, blunt, spliff, edibles, vaporizer, concentrates). during each morning survey, participants reported positive (n = 7) and negative (n = 9) cannabis expectancies (yes/no), with the item stem: “do you think you will experience the following from using cannabis in the next 24 hours?” items were created specifically for this study (see table 1). scores were computed to capture the proportion of ema days each expectancy was endorsed (0 to 100% of days). a variable was also created to indicate whether participants endorsed each expectancy >1 of the 28 days. to further characterize the sample, we computed scores reflecting the proportion of days participants used both cannabis and tobacco within a single day (0 to 100% of days). data analysis descriptive statistics characterized the sample. bivariate analyses examined associations between cannabis expectancies (i.e., proportion of days endorsed, endorsing >1 days of the 28 days) with anxiety symptoms, depressive symptoms, and possible cud. three multivariable logistic regressions examined associations between expectancies with each outcome (anxiety, depressive symptoms, possible cud). we operationalized expectancies as the proportion of days endorsed to prevent reducing power in multivariable models, and so that ema compliance was not conflated with expectancy ratings. all expectancies and sociodemographic covariates were allowed to covary. descriptive and bivariate analyses were conducted with ibm spss statistics (version 28) and logistic regressions with mplus 8.8. results the sample was majority 21-24 years old and single, and roughly half were nh white and cannabis, a publication of the research society on marijuana 88 employed (table 1). over a third (37.1%) reported anxiety symptoms, 46.4% depressive symptoms, and 61.9% possible cud. positive cannabis expectancies were most frequently endorsed, specifically feeling good or positive (m = 55.0; % of days), getting along better with people (m = 50.8), and feeling more creative (m = 49.4). negative expectancies were least frequently endorsed, specifically getting in an accident (m = 2.2; % of days), having an argument (m = 2.2), and drinking too much (m = 3.9). not shown in the tables, participants reported using cannabis 24.67 (sd = 7.98) of the past 30 days, with the most frequently endorsed modes of ever use being blunts (95.9%), then joints (93.8%), bowls (87.6%) or edibles (87.6%), bong (85.6%), pipe (77.3%), concentrates (74.2%), spliffs (63.9%), and vaporizers (56.7%). in bivariate analyses (table 1), participants with (vs. without) anxiety symptoms, depressive symptoms, and cud more frequently endorsed expectancies of feeling tired or unmotivated and feeling anxious. participants with anxiety and depressive symptoms more frequently endorsed expectancies related to concentration problems. participants with depressive symptoms more frequently endorsed expectancies of being in a bad mood or getting in an argument. participants with depressive symptoms and cud more frequently endorsed expectancies related to getting in trouble at school or work. multicollinearity tests for most expectancies showed that tolerance and vif values were >.25 (range = .27-.67) and <4 (range = 1.50-3.66), respectively, indicating that multicollinearity was not present (kim, 2019). however, tolerance and vif values for expectancies of “getting along better with people,” “feeling motivated,” and “doing better on a task” were slightly below and above collinearity thresholds (range = .17-.24 and 4.28-5.76, respectively). to ensure that this did not influence findings, we conducted models with and without these variables, and findings were consistent across both models. multivariable logistic regressions (table 2) indicated that more frequent endorsement of expecting to feel anxious from cannabis use was associated with higher odds of anxiety (aor = 1.05, 95% ci = 1.01, 1.10) and depressive symptoms (aor = 1.07, 95% ci = 1.01, 1.14); more frequent endorsement of expecting to be in a bad mood was associated with higher odds of depressive symptoms (aor = 1.18, 95% ci=1.02, 1.38); more frequent endorsement of expecting to feel tired or unmotivated was associated with higher odds of possible cud (aor = 1.03, 95% ci = 1.01, 1.08). additionally, more frequent endorsement of expecting to avoid fights was associated with lower odds of possible cud (aor = 0.96, 95% ci = 0.92, 0.99); however, this finding should be interpreted with caution, as these variables were unrelated at the bivariate level. males (vs. females) displayed higher odds of cud (aor = 3.84, 95% ci = 1.06, 13.91), and those married or in a relationship (vs. single) displayed lower odds of depressive symptoms (aor = 0.17, 95% ci = 0.03, 0.94). sensitivity analyses examined associations of the outcomes with day-level expectancies controlling for sociodemographics. intraclass correlation coefficients ranged from .06-.63 for expectancies. multilevel regression models indicated that anxiety (b = 0.08, se = 0.07, p = .021) and depressive symptoms (b = 0.18, se = 0.06 , p = .003) were associated positively with expecting to feel anxious, depressive symptoms were associated positively with expecting to be in a bad mood (b = 0.10, se = 0.04, , p = .005), and cud was associated negatively with expecting to be in a fight (b =-0.16, se = 0.09, p = .045) and positively with expecting to feel tired (b = 0.22, se = 0.09, p = .011). we also examined associations of day-level expectancies with day-level cannabistobacco co-use (vs. single cannabis use). on average, co-use occurred across 31.93% of ema days. multilevel regression models indicated that cannabis expectancies did not differ on days of couse vs. days of cannabis-only use. discussion consistent with other work (cloutier et al., 2019; gray et al., 2024; livingston et al., 2024), our study shows that cannabis use expectancies varied by individual-level factors and were not homogenous. positive expectancies were endorsed more often than negative expectancies. frequently endorsed positive expectancies were “feeling good or positive,” “getting along better with people,” and “feeling more creative”. there were no differences in frequency of endorsing positive expectancies across those with anxiety/depressive symptoms or possible cud (vs without). this highlights young people’s favorable attitudes about cannabis more generally (pew cannabis and harm perceptions 89 research center, 2019) and especially among cannabis-tobacco co-users. the frequent endorsement of expectancies related to stress reduction and mood enhancement also suggests that young people use cannabis to cope with stress, underscoring the need for messaging highlighting cannabis use risks that might outweigh these benefits, like cud or driving while intoxicated. participants infrequently endorsed negative expectancies. this is concerning because 37.1% to 46.9% of the sample reported anxiety and depressive symptoms, and most endorsed possible cud. in regression models, those who endorsed “feeling anxious” from cannabis use more often were also more likely to report anxiety and depressive symptoms; those who endorsed “being in a bad mood” from cannabis use more often were more likely to endorse depressive symptoms. one speculation is that young adults with anxiety/depression may be more likely to feel anxious or depressed on a given day, independent of cannabis use. it may also be that young adults with anxiety/depression anticipate feeling negative emotions after using cannabis, particularly during the “come down” period. an alternative hypothesis is that young adults with anxiety/depression are more likely to use cannabis to alleviate negative mood in the short-term “moment” (matheson et al., 2020), but then use again once the mood-enhancing effects fade. this cycle could contribute to the development or worsening of mental health and substance use problems over time (lucatch et al., 2018; sideli et al., 2020; swift et al., 2012). this might also explain, in part, why participants who endorsed the expectancy of “feeling tired or unmotivated” more often were also more likely to report possible cud. that is, while cannabis use may acutely increase arousal and alertness (matheson et al., 2020), prolonged or chronic use may decrease motivation (petrucci et al., 2020) and lead to dependence. amplifying these potential negative effects of cannabis use via health messaging could help mitigate problematic use. this study had several limitations. causal associations among the study variables cannot be determined. we did not assess cannabis use expectancies, mental health, or cud symptoms multiple times per day, as this would have increased survey time and burden. we were unable to assess within-day variability in mental health characteristics as a function of variability in expectancies. other unmeasured factors, like pro-cannabis messaging, tobacco use expectancies, peer use, and norms promoting cannabis use experiences could impact expectancies and should be examined in future work. individual modes of cannabis use (combusted, vaped, edible, etc.) were not examined in relation to each expectancy, though this is an important direction for future studies, as young adults perceive different levels of risk across cannabis products (nguyen et al., 2022). the cannabis legalization landscape has continued to change since data were collected, likely increasing positive attitudes and use among young adults (manthey et al., 2023; patrick et al., 2023). conclusions mental health and cud risk are associated with how young adult cannabis and tobacco cousers perceive cannabis use harms and benefits on a day-to-day basis. promoting accurate information about the shortand long-term effects of cannabis use may be crucial to preventing problematic use and co-occurring mental health conditions in young adults. assessing expectancies can also inform treatment planning by targeting beliefs associated with problematic use. cannabis, a publication of the research society on marijuana 90 table 1. descriptive statistics and bivariate associations among key study variables, n = 97 total anxiety symptoms depressive symptoms possible cud variable total (n = 97, 100%) yes (n = 36, 37.1%) no (n = 61, 62.9%) p yes (n = 45, 46.4%) no (n = 52, 53.6%) p yes (n = 60, 61.9%) no (n = 37, 38.1%) p sociodemographics age, n (%) a .894 .138 .993 18-20 years old 34 (36.2) 12 (35.3) 22 (36.7) 19 (44.2) 15 (29.4) 21 (36.2) 13 (36.1) 21-24 years old 60 (63.8) 22 (64.7) 38 (63.3) 24 (55.8) 36 (70.6) 37 (63.8) 23 (63.9) sex, n (%) b .366 .139 .087 female 41 (43.2) 13 (37.1) 28 (46.7) 15 (34.9) 26 (50.0) 21 (36.2) 20 (54.1) male 54 (56.8) 22 (62.9) 32 (53.3) 28 (65.1) 26 (50.0) 37 (63.8) 17 (45.9) race, n (%) .198 .100 .659 non-hispanic black 20 (20.6) 10 (27.8) 10 (16.4) 7 (15.6) 13 (25.0) 14 (23.3) 6 (16.2) non-hispanic white 49 (50.5) 19 (52.8) 30 (49.2) 28 (62.2) 21 (40.4) 30 (50.0) 19 (51.4) another race or ethnicity 28 (28.9) 7 (19.4) 21 (34.4) 10 (22.2) 18 (34.6) 16 (26.7) 12 (32.4) employment, n (%) .221 .037 .225 employed 50 (51.5) 21 (58.3) 29 (47.5) 22 (48.9)a 28 (53.8)a 35 (53.8) 15 (46.9) unemployed 18 (18.6) 8 (22.2) 10 (16.4) 13 (28.9)a 5 (9.6)b 14 (21.5) 4 (12.5) student 29 (29.9) 7 (19.4) 22 (36.1) 10 (22.2)a 19 (36.5)a 16 (24.6) 13 (40.6) relationship status, n (%) .064 <.001 .376 single 65 (68.4) 28 (80.0) 37 (61.7) 38 (88.4)a 27 (51.9)b 45 (71.4) 20 (62.5) married or in a serious relationship 30 (31.6) 7 (20.0) 23 (38.3) 5 (11.6)a 25 (48.1)b 18 (28.6) 12 (37.5) income .642 .662 .736 <$19,999 43 (44.8) 18 (50.0) 25 (41.7) 22 (48.9) 21 (41.2) 30 (46.2) 13 (41.9) $20,000-$39,999 21 (21.9) 8 (22.2) 13 (21.7) 10 (22.2) 11 (21.6) 15 (23.1) 6 (19.4) >$40,000 32 (33.3) 10 (27.8) 22 (36.7) 13 (28.9) 19 (37.3) 20 (30.8) 12 (38.7) education .749 .197 .280 less than high school 5 (5.2) 2 (5.6) 3 (4.9) 3 (6.7) 2 (3.8) 2 (3.1) 3 (9.4) high school or ged 23 (23.7) 10 (27.8) 13 (21.3) 14 (31.1) 9 (17.3) 14 (21.5) 9 (28.1) some college or higher 69 (71.1) 24 (66.7) 45 (73.8) 28 (62.2) 41 (78.8) 49 (75.4) 20 (62.5) cannabis use expectancies – proportion of days endorsed, m (sd) 1. feeling good or positive 55.00 (26.56) 53.98 (30.16) 55.61 (24.40) .773 54.85 (29.69) 55.12 (23.90) .961 54.14 (25.60) 56.81 (28.83) .648 2. getting along better with people 50.76 (29.41) 54.90 (28.78) 48.28 (29.74) .228 56.32 (29.94) 46.06 (28.39) .089 50.14 (29.77) 52.08 (29.08) .764 3. feeling more creative 49.39 (30.22) 51.57 (28.94) 48.08 (31.13) .586 54.04 (29.30) 45.46 (30.71) .167 48.72 (29.29) 50.80 (32.54) .755 4. laughing more than usual 43.21 (32.21) 43.54 (34.66) 43.01 (30.95) .938 46.98 (33.96) 40.02 (30.62) .294 42.01 (32.21) 45.74 (32.59) .598 5. avoiding fights 37.96 (30.02) 40.10 (30.69) 36.67 (29.79) .591 41.68 (30.71) 34.81 (29.34) .266 35.04 (29.12) 44.09 (21.42) .168 6. doing better on a task or studying better 36.01 (31.26) 36.13 (31.17) 35.94 (31.57) .977 36.61 (32.36) 35.49 (30.60) .862 33.66 (29.62) 40.92 (34.42) .290 7. feeling motivated to get things done 36.48 (31.19) 35.49 (30.04) 37.07 (32.10) .811 38.13 (32.01) 35.08 (30.73) .635 35.13 (29.67) 39.30 (34.52) .543 8. feeling tired or unmotivated 21.10 (25.28) 28.38 (23.78) 16.74 (23.78) .028 32.06 (28.14) 11.83 (18.22) <.001 25.25 (27.34) 12.41 (17.72) .007 9. having concentration problems 15.36 (21.08) 21.82 (25.26) 11.48 (17.22) .034 21.58 (23.89) 10.10 (16.89) .009 17.91 (22.04) 10.01 (18.12) .086 10. feeling anxious 13.63 (18.04) 22.54 (21.43) 8.28 (13.19) <.001 22.06 (21.62) 6.50 (9.94) <.001 16.18 (18.80) 8.27 (15.24) .031 11. smoking too many cigarettes or using too much tobacco 8.31 (17.43) 8.97 (17.74) 7.91 (17.37) .774 12.24 (21.72) 4.98 (11.97) .052 9.07 (18.37) 6.71 (15.42) .538 12. getting in trouble at school or work 4.71 (12.34) 7.88 (18.63) 2.80 (5.41) .119 7.82 (17.21) 2.07 (4.28) .036 6.30 (14.53) 1.36 (3.81) .012 cannabis and harm perceptions 91 13. being in a bad mood 5.12 (9.10) 5.51 (7.86) 4.89 (9.83) .752 8.31 (11.52) 2.43 (5.14) .003 5.32 (9.78) 4.72 (7.64) .767 14. drinking too much 3.88 (10.57) 4.82 (13.63) 3.31 (8.30) .501 6.14 (14.49) 1.96 (4.80) .073 4.29 (12.22) 3.02 (5.88) .585 15. having an argument 2.24 (4.85) 3.13 (6.17) 1.70 (3.81) .165 3.33 (6.20) 1.31 (3.08) .041 2.71 (5.63) 1.25 (2.33) .076 16. getting in an accident 2.24 (4.72) 2.20 (2.92) 2.26 (5.55) .949 3.15 (5.80) 1.47 (3.43) .095 2.59 (5.34) 1.51 (2.99) .298 cannabis use expectancies –endorsed >1 of the 28 days, n (%) 1. feeling good or positive 93 (96.9) 34 (94.4) 59 (98.3) .289 42 (95.5) 51 (98.1) .462 62 (95.4) 31 (100.0) .244 2. getting along better with people 90 (93.8) 35 (97.2) 55 (91.7) .276 43 (97.7) 47 (90.4) .139 61 (93.8) 29 (93.5) .955 3. feeling more creative 90 (93.8) 34 (94.4) 56 (93.3) .828 43 (97.7) 47 (90.4) .139 61 (93.8) 29 (93.5) .955 4. laughing more than usual 86 (89.6) 31 (86.1) 55 (91.7) .388 40 (90.9) 46 (88.5) .696 56 (86.2) 30 (96.8) .111 5. avoiding fights 82 (85.4) 33 (91.7) 49 (81.7) .179 40 (90.9) 42 (80.8) .161 55 (84.6) 27 (87.1) .747 6. doing better on a task or studying better 79 (82.3) 30 (83.3) 49 (81.7) .836 36 (81.8) 43 (82.7) .911 53 (81.5) 26 (83.9) .780 7. feeling motivated to get things done 76 (79.2) 28 (77.8) 48 (80.0) .795 35 (79.5) 41 (78.8) .933 52 (80.0) 24 (77.4) .771 8. feeling tired or unmotivated 65 (67.7) 31 (86.1) 34 (56.7) .003 39 (88.6) 26 (50.0) <.001 46 (70.8) 19 (61.3) .353 9. having concentration problems 59 (61.5) 26 (72.2) 33 (55.0) .093 33 (75.0) 26 (50.0) .012 43 (66.2) 16 (51.6) .171 10. feeling anxious 56 (58.3) 27 (75.0) 29 (48.3) .010 31 (70.5) 25 (48.1) .027 42 (64.6) 14 (45.2) .071 11. smoking too many cigarettes or using too much tobacco 38 (39.6) 16 (44.4) 22 (36.7) .451 22 (50.0) 16 (30.8) .055 28 (43.1) 10 (32.3) .311 12. getting in trouble at school or work 33 (34.4) 15 (41.7) 18 (30.0) .244 18 (40.9) 15 (28.8) .215 27 (41.5) 6 (19.4) .032 13. being in a bad mood 40 (41.7) 19 (52.8) 21 (35.0) .087 26 (59.1) 14 (26.9) .001 28 (43.1) 12 (38.7) .685 14. drinking too much 23 (24.0) 9 (25.0) 14 (23.3) .853 13 (29.5) 10 (19.2) .238 14 (21.5) 9 (29.0) .421 15. having an argument 28 (29.2) 15 (41.67) 13 (21.7) .037 18 (40.9) 10 (19.2) .020 20 (30.8) 8 (25.8) .617 16. getting in an accident 29 (30.2) 15 (41.7) 14 (23.3) .058 18 (40.9) 11 (21.2) .036 21 (32.3) 8 (25.8) .517 note. bolded values denote statistical significance at p<.05. a 3 participants with missing data on age. b 2 participants with missing data on sex. cannabis, a publication of the research society on marijuana 92 table 2. multivariable logistic regression analyses predicting anxiety symptoms, depressive symptoms, and possible cud, n = 97 anxiety symptoms depressive symptoms possible cud variable aor 95% ci aor 95% ci aor 95% ci sociodemographics age 18-20 years old ref ref ref ref ref ref 21-24 years old 0.76 0.19, 3.03 0.49 0.09, 2.68 0.68 0.18, 2.52 sex female ref ref ref ref ref ref male 1.19 0.38, 3.74 1.07 0.26, 4.30 3.84 1.06, 13.91 race non-hispanic black 3.61 0.80, 16.38 0.11 0.01, 1.09 2.78 0.51, 15.09 non-hispanic white ref ref ref ref ref ref another race or ethnicity 0.41 0.10, 1.64 0.66 0.14, 3.09 1.20 0.31, 4.67 employment employed 0.79 0.16, 3.88 0.06 0.01, 1.00 1.10 0.20, 6.08 unemployed ref ref ref ref ref ref student 0.28 0.05, 1.72 0.13 0.01, 1.35 0.26 0.04, 1.59 relationship status single ref ref ref ref ref ref married or in a serious relationship 0.35 0.09, 1.34 0.17 0.03, 0.94 0.53 0.15, 1.93 cannabis use expectancies 1. feeling good or positive 0.98 0.94, 1.02 0.94 0.87, 1.01 1,00 0.96, 1.05 2. getting along better with people 1.06 0.99, 1.12 1.10 0.99, 1.20 1.02 0.98, 1.07 3. feeling more creative 1.01 0.98, 1.05 0.99 0.94, 1.05 1.00 0.96, 1.04 4. laughing more than usual 0.99 0.96, 1.01 1.00 0.97, 1.03 0.99 0.96, 1.02 5. avoiding fights 1.00 0.97, 1.04 1.00 0.96, 1.04 0.96 0.92, 0.99 6. doing better on a task or studying better 1.01 0.97, 1.05 0.97 0.93, 1.02 1.00 0.96, 1.04 7. feeling motivated to get things done 0.95 0.91, 1.00 1.02 0.95, 1.10 1.02 0.98, 1.07 8. feeling tired or unmotivated 0.97 0.93, 1.01 1.05 0.98, 1.12 1.03 1.01, 1.08 9. having concentration problems 1.02 0.98, 1.07 1.00 0.94, 1.06 1.00 0.95, 1.06 10. feeling anxious 1.05 1.01, 1.10 1.07 1.01, 1.14 0.99 0.95, 1.04 11. smoking too many cigarettes or using too much tobacco 0.98 0.94, 1.02 0.99 0.94, 1.03 1.01 0.97, 1.05 12. getting in trouble at school or work 1.05 0.94, 1.17 1.03 0.90, 1.16 1.09 0.94, 1.27 13. being in a bad mood 1.01 0.93, 1.09 1.18 1.02, 1.38 0.94 0.86, 1.02 14. drinking too much 1.03 0.95, 1.11 0.95 0.86, 1.06 0.97 0.89, 1.06 15. having an argument 0.91 0.75, 1.09 0.87 0.68, 1.11 1.06 0.85, 1.31 16. getting in an accident 1.05 0.91, 1.21 1.25 0.96, 1.63 1.11 0.93, 1.31 note. bolded values denote statistical significance at p < .05. cannabis and harm perceptions 93 references adamson, s. j., kay-lambkin, f. j., baker, a. l., lewin, t. j., thornton, l., kelly, b. j., & sellman, j. d. 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(2012). cannabis and progression to other substance use in young adults: findings from a 13-year prospective population-based study. journal of epidemiology and community health, 66(7), e26-e26. doi.org/10.1136/jech.2010.129056 sznitman, s. r., van rijswijk, l., & cousijn, j. (2022). cannabis use as a predictor and outcome of positive and negative affect in college students: an ecological momentary assessment study. addictive behaviors, 128, 107221. https://doi.org/10.1016/j.addbeh.2021.107221 tucker, j. s., rodriguez, a., dunbar, m. s., pedersen, e. r., davis, j. p., shih, r. a., & d’amico, e. j. (2019). cannabis and tobacco use and co-use: trajectories and correlates from early adolescence to emerging adulthood. drug and alcohol dependence, 204, 107499. https://doi.org/10.1016/j.drugalcdep.2019.06.0 04 waddell, j. t., corbin, w. r., meier, m. h., morean, m. e., & metrik, j. (2021). the anticipated effects of cannabis scale (aecs): initial development and validation of an affect-and valence-based expectancy measure. psychological assessment, 33(2), 180. https://doi.org/10.1037/pas0000881 wilhelm, j., abudayyeh, h., perreras, l., taylor, r., peters, e. n., vandrey, r., hedeker, d., mermelstein, r., & cohn, a. (2020). measuring the temporal association between cannabis and tobacco use among co-using young adults using ecological momentary assessment. addictive behaviors, 104, 106250. https://doi.org/10.1016/j.addbeh.2019.106250 funding and acknowledgements: this paper was supported in part by p30ca225520 awarded to the stephenson cancer center and r21da041548-01 awarded to amc. no conflicts of interest to declare. we thank the efforts of haneen abudayyeh, lexie perreras, and lauren viray for project management, survey development, and data collection. we thank bonnie king and jess wilhelm for data cleaning and data management. data availability statement: data were shared with the senior author via a data sharing agreement from the institution at which the data were collected. the senior author does not have permission to share data with others. cannabis and harm perceptions 97 copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: romm, k. f., mermelstein, r., vandrey, r., hedeker, d., & cohn, a. m. (2025). daily assessment of positive and negative cannabis use expectancies in young adult cannabis and tobacco co-users: differences by sociodemographics, mental health symptoms, and possible cannabis use disorder. cannabis, 8(2), 85 97. https://doi.org10.26828/cannabis/2025/000277 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ research article 121 ved abstract objective: almost half of u.s. states have passed recreational cannabis laws as of may 2024. while considerable evidence to date indicates cannabis may be a substitute for prescription opioids in the treatment of pain, it remains unclear if patients are treating pain with cannabis alone or concomitantly with other medications. method: using data from a national sample of commercially insured adults, we examine the effect of recreational cannabis legalization (through two sequential policies) on prescribing of opioids, nsaids, and other pain medications by implementing synthetic control estimations and constructing case-study level counterfactuals for the years 2007-2020. results: overall, we find recreational cannabis legalization is associated with a decrease in opioid fills among commercially insured adults in the u.s., and we find evidence of a compositional change in prescriptions of pain medications more broadly. specifically, we find marginally significant increases in prescribing of non-opioid pain medications after recreational cannabis becomes legal in some states. once recreational cannabis dispensaries open, we find statistically significant decreases in the rate of opioid prescriptions (13% reduction from baseline, p < .05) and marginally significant decreases in the average daily supply of opioids (6.3% decrease, p < .10) and number of opioid prescriptions per patient (3.5% decrease, p < .10). conclusions: these results suggest that substitution of cannabis for traditional pain medications increases as the availability of recreational cannabis increases. there appears to be a small shift once recreational cannabis becomes legal, but we see stronger results once users can purchase cannabis at recreational dispensaries. the decrease in opioids and marginal increase in non-opioid pain medication may reflect patients substituting opioids with cannabis and non-opioid pain medications, either separately or concomitantly. reductions in opioid prescription fills stemming from recreational cannabis legalization may prevent exposure to opioids in patients with pain and lead to decreases in the number of new opioid users, rates of opioid use disorder, and related harms. key words: = cannabis; cannabis legalization; opioids, pain medication; private insurance as of may 2024, more than one in three u.s. residents lived in a state that has passed a recreational cannabis law, and the majority of states have passed medical cannabis laws (procon.org, 2024; steuart, 2023). prior research suggests that legal access to recreational cannabis increases adult use of cannabis by 13 to 38% (abouk, 2021; cerdá et al., 2020; hollingsworth et al., 2020; maclean et al., 2021). additionally, 61.9 million people, or about 22% of americans aged 12 and older, reported using cannabis at least once in 2022 (substance abuse and mental health shelby r. steuart1, felipe lozano-rojas2, victoria bethel2, hailemichael bekele shone3, amanda j. abraham2 1crown family school of social work, policy, and practice, the university of chicago 2department of public administration and policy, university of georgia 3irsay institute and o’neill school of public and environmental affairs, indiana university bloomington cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000268 volume 8, issue 1 recreational cannabis laws and fills of pain prescriptions in the privately insured corresponding author: shelby steuart, phd, university of chicago, 969 e. 60th street, chicago, illinois, 60637. phone: (773) 702-5289. email: ssteuart@uchicago.edu rcls and pain prescriptions 122 services administration, 2023). new research also shows that, in 2022, for the first time in the history of the us, there were more daily or near daily users of cannabis than alcohol (caulkins, 2024). in the years following 2017 when the national academies of sciences, engineering, and medicine reported “conclusive evidence” supporting the treatment of chronic pain with cannabis, evidence indicating substitution of pain medications for cannabis has grown (national academies of sciences, engineering, and medicine, 2017). in addition to clinical research, studies using insurance claims data have consistently found that prescribing of opioids decreased following legalization of cannabis, suggesting that patients substitute cannabis for some traditional pain medications (bradford et al., 2018; bradford & bradford, 2016, 2017; mcmichael et al., 2020; raman et al., 2023). while much of the work in this area has focused on medical cannabis legalization, there is reason to believe that recreational cannabis legalization (rcl) will continue this trend because adults over age 21 have easier access to cannabis following rcl implementation (lucas & walsh, 2017). in contrast to recreational cannabis users, medical cannabis users must maintain an active state license to purchase, possess, and consume cannabis (steuart, 2023). this requires medical cannabis users to have medical evaluations, pay fees, and update paperwork on an annual basis (steuart, 2023), which may prove to be too heavy an administrative burden for some adults with pain conditions. therefore, in addition to opening the door to adult consumption of cannabis, rcls may increase access among individuals intending to use cannabis for medical purposes. while evidence of the substitutability of cannabis for opioids has grown, little is known about the relative substitutability by opioid formulation or strength. clinical literature indicates cannabis can be an effective treatment for chronic pain, which can alternatively be treated with relatively high doses of extended release opioid formulations (hill et al., 2017; kraft et al., 2008; russo, 2019; wallace et al., 2007). there is also recent evidence that patients use cannabis concomitantly with lower strength opioids to lower their daily opioid consumption (steuart & bradford, 2024). further, cannabis has been shown to improve the efficacy of opioids and reduce the opioid dose in the treatment of chronic, non-cancer pain (lynch & clark, 2003). many studies analyzing the effect of cannabis legalization on prescriptions (or fills) of pain medications are limited to opioid utilization and focus primarily on the effects of medical cannabis legalization (bradford et al., 2018; bradford & bradford, 2016, 2017; lozano-rojas et al., 2022; mcmichael et al., 2020; raman et al., 2023; shi et al., 2019; wen & hockenberry, 2018; wen et al., 2021). using data from a national sample of commercially insured adults from 2007-2020, we examine the effect of recreational cannabis legalization and dispensary openings on prescribing of opioids, nsaids, and other pain medications by implementing synthetic control estimations and constructing case-study level counterfactuals. our study builds upon the existing literature in several ways. first, to the best of our knowledge, we are the first include non-opioid pain medications, such as nsaids. including non-opioid pain medications allows us to gather more evidence on how patients use other pain medications once recreational cannabis is legalized. second, whereas most work in this area has focused on the publicly insured, our study is focused on americans who are privately insured. most americans are privately insured, therefore our findings are highly generalizable and can inform policymakers regarding the impacts of rcls on opioid and non-opioid pain medication utilization. finally, we build on the quasiexperimental work in this area (mcmichael et al., 2020; wen et al., 2021) and contribute new innovations in the econometric literature by addressing the issue of heterogeneous policy adoption timing using a modified synthetic control methodology (scm) that flexibly accommodates each state’s rcl policy adoption timing. methods data on all patients who fill prescriptions for opioids, nsaids, and other non-opioid pain medications between january 1, 2007 and december 31, 2020 were extracted from optum’s de-identified clinformatics® data mart database (clinformatics®). clinformatics® is derived from a database of administrative health claims for members of large commercial and medicare advantage health plans. these administrative claims are submitted for payment by providers cannabis, a publication of the research society on marijuana 123 and pharmacies and are verified, adjudicated, adjusted, and de-identified. the database is icd10 compliant. only covered lives with both medical and prescription drug coverage are included. the database includes approximately 15 to 20 million annual covered lives, with over 62 million unique covered lives over a 12-year period. we limited our analyses to individuals aged 18-64 and excluded claims for medicare advantage patients to avoid introducing selection bias, since most medicare advantage beneficiaries are aged 65 and older and because medicare advantage is not equally representative across the states in this dataset. we also excluded patients who did not have at least six months of continuous enrollment during the study period and patients with a cancer diagnosis at any point during the study period. prescription opioid fills were identified using the national drug code (ndc) and the ndcactive ingredient crosswalk of all prescription opioids from the centers for disease control and prevention’s national center for injury prevention and control (cdc, 2021). all opioid pill strengths were converted to morphine milligram equivalent doses (mmes) to compare at standardized strengths.1 length of a prescription was measured in the number of days supplied. non-pain formulations of opioids, such as buprenorphine formulated for the treatment of opioid use disorder, were omitted from our analysis.2 additionally, we omitted all methadone formulations as our data do not allow us to distinguish between formulations for pain versus opioid use disorder. prescription fills of nsaids and other nonopioid pain medications were identified using american hospital formulary service pharmacologic-therapeutic classification system (ahfs) codes.3 in addition to opioids, nsaids and other non-opioid pain medications, we extracted prescription claims for five additional drug classes as part of a series of placebo tests. the medications included in the placebo tests are primarily prescribed for mental health and sleep disorders (antidepressants, anticonvulsants, barbiturates, benzodiazepines, and z-drugs) and are analyzed only in states without rcls (see more detailed description below). we constructed three measures of prescription fills for each class of medications. first, to measure the extensive margin, we calculated the rate of patients with prescriptions filled per 10,000 enrollees in each state-quarter. second, to measure the intensive margin, we calculated the average number of days supplied per prescription. third, also to measure the intensive margin, we calculated the average number of prescriptions per patient in each state-quarter. our independent variables measured whether a state had legal protection to use recreational cannabis (rcl legal) or had recreational dispensaries open (rcl dispensary) in each year of the study period. rcl legal indicates the date when recreational adult-use cannabis was legal to possess in a state. rcl dispensary indicates the date the first recreational cannabis dispensary opened in a state. we considered legalization as a two-step process: statutory legalization of cannabis followed by a legal mechanism for users to purchase recreational cannabis through dispensaries. while statutory legalization may be enough legal permission for some individuals to become cannabis users, especially given that rcls are typically passed after several years of medical cannabis legalization, legalization without a recreational dispensary still requires individuals to acquire cannabis on a black or gray market. therefore, we expect to see some initial substitution of cannabis for pain medications following legalization with larger effects once recreational dispensaries open. in order to ensure an appropriate preand posttreatment window, our analyses included only states that passed recreational cannabis laws between 2011-2017. specifically, our analyses included seven state case studies where we evaluate the effect of legalization of recreational cannabis (rcl legal) and four state case studies where we evaluate the effect of the opening of recreational cannabis dispensaries (rcl dispensary). figure 1 presents maps with specific states according to the rcl status as of the end of 2022, and figure 2 presents the timeline of rcl policies and our study period. states with an adequate post-period for our study are shown in navy blue. 1see cdc information regarding conversions by different opioids: www.cdc.gov/drugoverdose/modules 2we excluded prescriptions for buprenorphine, except the patch (butrans), buccal film (belbuca) and the injection (buprenex), which are schedule iii buprenorphine formulations for pain. we also exclude suboxone, which is used for treatment of opioid use disorder (moud). rcls and pain prescriptions 124 figure 1. geographic policy variation note. in this article we follow states whose policy variation started in 2011 or after, and before 2017. this allows us to guarantee that we will always have 16 quarters for the preand post-treatment. for rcl legal, seven states comply with this requirement: ak, ca, co, dc, ma, or and wa. for rcl dispensary, four states comply with this requirement: ak, co, or and wa. figure 2. rcl dispensary timeline cannabis, a publication of the research society on marijuana 125 analytic strategy our analytic strategy uses a series of synthetic control case-studies at the state-medication level, following abadie, diamond, and hainmueller (2007, 2010; french et al., 2022). a separate synthetic control is constructed for each treated state and policy considered (rcl legal or rcl dispensary). we follow seven states for rcl legal (ak, ca, co, dc, ma, or, wa) and four treated states for rcl dispensary (ak, co, or and wa). the synthetic ‘state-medication’ series is constructed first using all available information from the time-series structure (lags) up to the policy intervention, and second, donors are constructed from the state-medication series of states that by the end of 2020 had not implemented rcls. hollingsworth and wing (2020) suggest that, in addition to considering the prescriptions of interest, prescription fills of classes of drugs that are unlikely to be impacted by the pseudo version of the policy can contribute to the donor pool (meaning they are used for comparison in untreated states only; hollingsworth & wing, 2020). following this logic, we include prescription fills of additional medications (benzodiazepines, zdrugs, barbiturates, antidepressants, and anticonvulsants) in the donor states to widen the donor unit pool and improve power. accordingly, in each case study, for the donor states we consider the pain medication series of interest, but we also consider the other medication fill rates as additional placebos. if the rcl policy did not affect pain prescriptions in an untreated state (a state without an rcl policy), it also should not affect the other medication series in an untreated state (hollingsworth & wing, 2020). in total, for each untreated state we follow prescription fills for eight therapeutic classes (opioids, nsaids, other pain medications, benzodiazepines, z-drugs, barbiturates, antidepressants, and anticonvulsants), aggregated at the state-quarter level. we follow three pain-related therapeutic classes in treated states (opioids, nsaids, and other pain medications). our methodology is further detailed below. we are interested in analyzing the effect of state recreational cannabis policies (rcl legal or rcl dispensary) in treated states, on three measures of pain prescription fills (one extensive, two intensive) of three classes of pain medications (opioids, nsaids, and other pain medications). accordingly, the series of pain medications, 𝑌𝑖𝑡 , in state 𝑖 and quarter 𝑡, can be defined as follows: 𝑌𝑖𝑡 = 𝑌𝑖𝑡 𝑁 + 𝛼𝑖𝑡 . 𝐷𝑡 ; 𝑊ℎ𝑒𝑟𝑒 𝐷𝑡 = { 1 𝑖𝑓 𝑖 = 1 𝑎𝑛𝑑 𝑡 ≥ 0 0 𝑜𝑡ℎ𝑒𝑟𝑤𝑖𝑠𝑒 (1) where, in the context of potential outcomes notation, 𝑌𝑖𝑡 𝑁 is the value of the prescription fills in the absence of treatment and the treatment effect is 𝛼𝑖𝑡 in state-medication and quarter observations with recreational cannabis policies (when 𝐷𝑖𝑡 = 1). 𝑌𝑖𝑡 𝑁 is always observed for the non-treated states but is observed for treated states only in periods prior to the implementation of recreational cannabis policies. we estimate 𝑌𝑖𝑡 𝑁 for the treated states, in post-treatment observations (separately for legal possession or open dispensaries), by estimating separate state-level case studies.4 in each case study, the treated state is denoted by i = 1, as the remainder of the treated units are not considered jointly, such that in synthetic control estimation there is only a treated state-medication series. the counterfactual outcome of interest is denoted by 𝑌𝑖𝑡 �̂� and we estimate this term using the adh synthetic control method with the pool of donor units (i ≥ 2). the synthetic control estimation procedure generates a set of weights (𝑤2 ∗, … , 𝑤𝐽 ∗), which are used to aggregate the contribution of all donor units to generate the “synthetic” control hat (𝑌𝑖𝑡 �̂�). this synthetic series (𝑌𝑖𝑡 �̂�) is constructed such that it approximates, as closely as possible, the treated unit when 𝑌𝑖𝑡 = 𝑌𝑖𝑡 𝑁, in the pre-policy period (t < 0), by minimizing the root mean square 3ahfs codes of 280804 capture nonsteroidal anti-inflammatory agents (nsaids) including cox-2 inhibitors, ibuprofen and naproxen. ahfs codes of 280892 capture other pain medications including miscellaneous analgesics and antipyretics such as formulations of acetaminophen, salicylamides, sodium thiosalicylate and ziconotide. 4i.e., 36 case studies for rcl legal (3 drug classes x 3 outcomes x 4 states) and 63 case studies for rcl dispensary openings (3 drug classes x 3 outcomes x 7 states with rcl dispensary). rcls and pain prescriptions 126 prediction error (rmspe).5 we want to consider donor series where the synthetic control can be estimated accurately. hence, we trim 5% of placebo donor units with the highest rmspe (root mean square prediction error) in the pretreatment period for each case study, resulting in the set used for analysis: approximately, 326 donor units to examine the effects of rcl legal and 304 donor units to examine the effect of rcl dispensary, in each state-level case study. the estimated synthetic control hat, (𝑌𝑖𝑡 �̂�), is then projected into the post-policy period and used as the counterfactual outcome against which the treated state’s observed outcome is compared. the difference between the two is interpreted as the treatment effect of the policy in period t, represented as: 𝛼1�̂� = 𝑌1𝑡 − 𝑌1𝑡 �̂� , where 𝑌1𝑡 �̂� = ∑ 𝑤𝑖 ∗𝐽 𝑖=2 ⋅ 𝑌𝑖𝑡 (2) the synthetic control method often provides very close matches in the pre-policy period to the state it is approximating. the closely overlapping synthetic and actual lines in the graphs in figure 3 illustrate this, for rcl dispensary. figure 3. synthetic control time series of opioid prescription rates by state time series of opioid prescription rates by state (active rcl dispensary) 5the rmspe is the average euclidean distance between the treated series and the synthetic control in pre-policy period and measures how well the synthetic series replicates the treated series prior to the intervention. cannabis, a publication of the research society on marijuana 127 in order to recover dd-equivalent point estimates to summarize the treatment effects captured in the post-treatment period, we follow hollingsworth and wing (hollingsworth & wing, 2020) and average the differences between the actual series and the synthetic series, for each period during the post-treatment time frame, up to four s post-policy. this aggregation can be represented as: 𝛼1̅̅ ̅ = 1 17 ⋅ ∑ (𝑌1𝑡 − 𝑌1𝑡 �̂�)𝑇=16 𝑡=0 (3) the baseline synthetic control model does not include a parametric form to conduct statistical inference. thus, we rely on placebo inference by comparing how large or small the rcl effect on a given treated state is in comparison to the donor series from untreated states (abadie, 2021; buchmueller et al., 2011; hagemann, 2019). our placebo test estimates the likelihood of attaining similarly large treatment effects if treatment were assigned to non-treated donor units. specifically, we derive the p-value of the synthetic control treatment effects from the percentage of placebo treatment effects as large as the true treatment effects. the key assumption, similar to difference-in-difference assumptions, is that the true treatment effect only occurs for the actually treated states, at the timing of the treatment, with otherwise no systematic changes in outcomes in the placebo-treated units at the exact timing of the assigned placebo-treatment. the treatment effect can be considered statistically significant if the treatment effects fall outside the bulk (99%, 95%, or 90%) of the placebo treatment effects. so far, the methodology we have described allows us to estimate the treatment effect for a particular case-study exercise of a statemedication, but we are measuring the treatment effect across several treated states. to obtain the point estimate of the average treatment effect on the treated (att), we average across all treated case studies. for instance, we average across four states when following the effect of rcl dispensaries. we follow the procedure proposed by cavallo et al. (2013), which draws samples of untreated series to approximate a placebo average treatment effect, one series for each treated unit. we draw 5,000 combinations of the more than 300 donor series on the four treated units (rcl dispensary) or seven treated units (rcl legal). currently, some concern exists about the plausibility of overfitting following synthetic control estimation. this stems from the inclusion of the time-series structure of each outcome series in the construction of the counterfactual, even if only up to the policy intervention (abadie, 2021; chernozhukov et al., 2022). to address this concern, we implement the methodology suggested by chernozhukov et al. (2020), where a k-fold cross-fitting procedure is estimated for each case-study. in their procedure, the pre-period is split into k subgroups,6 and in each cross-fitting attempt, the weights from equation 2 are estimated without one of the pre-period subgroups. with the weights estimated in a fraction of the pre-period, the k subgroup is forecasted along with the post-period treatment effects. the forecast in the k subgroup is used to assess the bias. the process is repeated and an average bias from over-fitting is obtained. the result is a treatment effect net of the overfitting bias. furthermore, their procedure is also based on the demonstration that inference can be conducted by the implementation of a t-test on the case-study coefficient. for the results we present we also implement this approximation to inference, but for the general exercise we consider the placebo inference as it does not require assumptions or the imposition of this structure. we present the results of this exercise in the appendix and discuss how this exercise compares to our main results in the last part of the results section. results results of synthetic control estimates overall show statistically significant decreases in the rate of opioid prescriptions and marginally significant decreases in the rate of the average daily supply of opioids and number of opioid prescriptions per patient (see tables 1-4). 6their recommendation is k = 3, and for larger pre-periods they recommend k = 4. we report k = 3, where the attenuation over the treatment effects is bigger, and the estimated statistical significance renders a more conservative outcome. rcls and pain prescriptions 128 we estimate effects separately by state case studies and provide nationally aggregated estimates. first, we estimate the effect of recreational cannabis legalization (rcl legal) to evaluate whether legal protection or legal access to cannabis is the mechanism causing fills of medications to decrease. we calculate the average treatment effects of recreational cannabis legalization by subtracting average outcome values of placebos from average outcome values across the 16-quarter post-treatment period. figure 3 displays these effects on extensive and intensive opioid prescribing in select states. we find statistically significant decreases in the number of patients per 10,000 enrollees who are filling opioid prescriptions in colorado (56.68 fewer patients per 10,000; p < 0.05), d.c. (68.13 fewer patients per 10,000; p < 0.01), and oregon (110.40 fewer patients per 10,000; p < 0.10) following recreational cannabis legalization. we additionally find reductions in the average daily supply of opioids per prescription in some states, with estimated prescribing changes in california (2.78 reduction in the average daily supply of mmes; p < 0.10), d.c. (2.67 reduction in the daily supply of mmes; p < 0.01), and oregon (2.31 reduction in daily supply of mmes; p < 0.10), demonstrating statistically significant reductions in average daily opioid supply in terms of milligram morphine equivalents. finally, legalization results in a lower average number of opioid prescriptions per patient in colorado (0.05 reduction in the number of opioid prescriptions per patient; p < 0.10), d.c. (0.12 reduction in the number of opioid prescriptions per patient; p < 0.05), oregon (0.7 reduction in the number of opioid prescriptions per patient; p < 0.10), and washington (0.06 reduction in the number of opioid prescriptions per patient; p < 0.10). interestingly, we find statistically significant decreases in opioid prescribing in d.c. for all measured extensive and intensive outcomes after recreational cannabis legalization. aggregate analyses for rcl legal can be found in figure 4. in the aggregate analyses, we only find a decrease in the average daily supply of opioids (1.70 decrease in average daily supply, p < 0.10). we do not find any national, statistically significant effects on nsaid or other non-opioid pain medication prescribing following legalization of recreational cannabis. figure 4. synthetic control time series of opioid prescription rates by state time series of opioid prescription rates by state (active rcl dispensary) panel a prescription rate per 10,000 enrollees opioids nsaids other pain panel b average daily supply per prescription opioids nsaids other pain cannabis, a publication of the research society on marijuana 129 panel c average prescription per patient opioids nsaids other pain the lollipop graphs in figure 5 provide a visual interpretation of the state-level point estimates and indicate decreases in opioid prescribing across most states and outcomes for recreational dispensary openings (rcl dispensary). figure 5. causal synthetic controls rcl legalization effect on opioid outcomes panel a prescription rate per 10,000 enrollees opioids nsaids other pain panel b average daily supply per prescription opioids nsaids other pain panel c average prescriptions per patient opioids nsaids other pain rcls and pain prescriptions 130 the overall trends displayed in the lollipop graphs can be understood in detail using the state-level point estimates in table 3. following recreational dispensary openings, all states except for washington show statistically significant decreases in the rate of patients with prescriptions of opioids. rcl dispensary models for alaska show a 166.1 decrease (p < 0.05) from a baseline of 427.5. colorado shows a 78.98 decrease (p < 0.10) in the rate of patients per 10,000 enrollees with opioid prescriptions, from a baseline of 571.8. in colorado, the average opioid fills per patient also decrease by 0.052 (p < 0.10) from a baseline of 2.1. oregon rcl dispensary models show a 116.88 decrease (p < 0.10) from a baseline of 460.06 in the number of opioid prescriptions per 10,000 patients and a 2.8 decrease (p < 0.05) in the number of days supplied by the average opioid prescription, from a baseline of 26.8 days. we see no statistically significant effects on opioid prescriptions from recreational cannabis dispensaries opening in washington state. one important evaluation of the fit provided by a synthetic control is the matching of the synthetic and actual state in the pre-policy period. the synthetic control method often provides very close matches in the pre-policy period to the state it is approximating. this is evidenced by the synthetic control case studies in figure 5. all the case study states match on most quarters in the pre-policy period, with colorado and washington matching almost perfectly. these case studies, except for washington state, also indicate a deviation between the synthetic and actual in the post-policy period, although the placebo tests (figure 6) should be used to infer and calculate causal effects. figure 6. causal synthetic controls rcl legalization effect on opioid outcomes cannabis, a publication of the research society on marijuana 131 we aggregate all states to detect the overall effect of recreational cannabis dispensary openings on fills of opioids and non-opioid prescription pain medications at the national level. we find a statistically significant 70.21 reduction (p < 0.05) in the number of patients with opioid prescriptions per 10,000 enrollees, about a 13% change from the baseline (531.85; table 4). similarly, we see a decrease of 0.07 (p < 0.05) opioid fills per patient following recreational dispensary openings. changes in the average daily supply of opioids are not statistically significant. we do not see statistically significant effects in the prescriptions of nsaids or other non-opioid pain medications, on extensive or intensive margins. however, it is worth noting the baseline average number of prescriptions of nsaids is less than half of opioids. other nonopioid pain medications are rarely prescribed, so it is possible that any change in prescribing as a result of recreational dispensaries is too small to detect. these results can also be seen in the causal synthetic control event study graphs (figure 7). figure 7. causal synthetic control event studies of rcl dispensary effects on all outcomes rcl legalization effect on pain prescriptions panel a prescription rate per 10,000 enrollees opioids nsaids other pain panel b average daily supply per prescription opioids nsaids other pain panel c average prescription per patient opioids nsaids other pain rcls and pain prescriptions 132 discussion we analyze the effects of rcl implementation on opioid and non-opioid pain medication prescribing at the aggregate, national-level and at the state-level by leveraging a synthetic control method estimation. our state-level case studies allow us to investigate the differential effects resulting from heterogeneous rcl implementation. overall, we find reductions in opioid prescribing and estimate ambiguous relationships between rcl implementation and non-opioid prescription pain medication outcomes among the commercially insured. we find marginally significant increases in nsaid prescribing in some states, following recreational cannabis legalization (before dispensaries open). this finding is consistent with the idea that some people may use cannabis and non-opioid pain medications concomittantly for pain following recreational legalization (and perhaps decrease opioid usage to a level subperceptual for our methodology), but the larger effects of recreational cannabis legalization are likely to occur once there is a mechanism for cannabis users to legally purchase cannabis through dispensaries. prior work shows that, while some subset of the population uses cannabis when it becomes recreationally legal, many wait until dispensaries open. still, many more wait until dispensaries have been open for several years (montgomery et al., 2022). results from our state-level case studies indicate that, aside from estimating an increase in the average daily supply of opioids prescribed in alaska, we find decreases in the rate of patients with opioid prescriptions and average opioid prescription fills per patient in all case study states when using the opening of recreational dispensaries as the treatment. in colorado, oregon, and washington state, we also find decreases in the average daily supply of opioids following recreational dispensary openings. in alaska, we estimate the largest magnitude decreases in rates of patients with opioid fills and average opioid fills per patient despite finding a statistically significant increase in the daily supply of opioids. this finding may suggest that a smaller number of patients are receiving a higher frequency of daily doses following recreational dispensary openings. these findings may also suggest that alaska provides a unique case study. following recreational dispensary openings, we only observe a statistically significant increase in the number of nsaid prescriptions per patient in alaska. however, we do not observe a similar relationship between changes in nsaid and other non-opioid pain medication prescribing in other case-study states. in oregon, we find a statistically significant decrease in the rate of nsaid prescriptions per patient as well as opioid prescribing reductions following recreational dispensary openings, which potentially supports the pain relieving qualities of cannabis. however, these findings are not replicated in other case study states. in colorado, oregon, and washington state, we largely find non-significant increases and decreases in non-opioid prescription outcomes, which indicates an unclear relationship between rcl implementation and non-opioid pain medication prescribing at the state level. because we do not observe over-the-counter nonopioid prescription consumption, our inconclusive findings must be considered cautiously. we also acknowledge that the market for cannabis and pharmaceuticals can be influenced by unique factors in each state. overall, we find recreational cannabis dispensary openings are associated with a significant decrease in opioid fills among commercially insured adults in the us. at the national level, we find decreases in opioid prescribing on both intensive and extensive margins among the commercially insured following recreational dispensary openings. our estimates for non-opioid pain medication prescribing are not statistically significant when using rcl dispensary openings as our treatment. nsaids are largely available over-the-counter and less frequently prescribed than opioids, so our analyses using these medications as outcomes are relatively under-powered. our findings may therefore support the analgesic properties of cannabis because patients are prescribed fewer opioids without a statistically significant increase in non-opioid pain medication when cannabis is available. alternatively, our results could suggest changes in physician prescribing behavior following rcl implementation. prescription drug monitoring programs (pdmps) allow prescribers to monitor patients who are prescribed medical cannabis in some states and there is some evidence this impacts their prescribing practices cannabis, a publication of the research society on marijuana 133 (steuart, 2024), but it is possible that providers may not be informed about their patients’ recreational cannabis use. with imperfect information between patients and prescribers in the context of recreational cannabis use, we cannot attribute estimated reductions in average fills per patient or rate of patients with opioid fills solely to provider caution. whether driven by patients or healthcare providers, reductions in opioid fills stemming from rcl implementation may prevent exposure to opioids in patients with pain and lead to decreases in the number of new opioid users, rates of opioid use disorder, and related harms. to our knowledge, previous studies examining the impacts of cannabis legislation and prescription pain medication utilization among the commercially insured have largely focused on medical cannabis legislation (lozano-rojas et al., 2022; mcginty et al., 2023; mcmichael et al., 2020; wen et al., 2021). we expand on this literature by examining recreational cannabis legislation. furthermore, we include a novel examination of non-opioid pain medications. while previous works include non-opioid prescription pain medications, they do not look specifically at nonopioid pain medication prescribing (bradford et al., 2018; bradford & bradford, 2016, 2017; raman & bradford, 2022). our study separates non-opioid medications from the aggregate of prescription analgesics, and our results indicate that reductions in pain-related prescriptions following cannabis legislation are driven largely by opioid fill reductions. limitations this study has several limitations. first, we do not observe patient use of cannabis or patient referrals for cannabis; therefore, the reductions we observe are not directly measuring substitutions. as the cannabis literature has evolved, the dates researchers use to measure cannabis policy implementation have changed. instead of making a definitive assessment about the best moment to consider recreational cannabis “in effect,” we use two measures of recreational cannabis legalization and follow this up with robustness exercises evaluating the effects of alternative date definitions and specifications. second, our individual state case studies are underpowered, so we may be classifying effects as not statistically significant, when in fact they are. thus, our results should be interpreted as a conservative estimate. our goal is to be transparent about these unstable results by disclosing which results are affected and including both real and synthetic time series. further, the unstable case studies do not change the overall results. it is important to consider that during this timeframe, efforts were being made locally and nationally aimed at decreasing excessive opioid prescribing. therefore, other contextual factors may have also impacted rates of opioid prescribing. the methodology we use compares states with legal recreational cannabis to states without legal recreational cannabis which controls for any trends that are occurring for both the treated and untreated states (such as national efforts or state policies occurring across states in both groups simultaneously). however, it is possible that states legalizing recreational cannabis were using additional or alternative policies to decrease opioid prescribing. still, we do not observe patient or prescriber behavior directly, and thus we cannot with certainty distinguish mechanisms. we hope future research can address these topics more directly. conclusion our study adds to the growing evidence of the substitutability of cannabis for opioids and nonopioid pain medications and highlights state variation in two recreational cannabis policy settings. importantly, this study provides evidence of potential concomitant use of cannabis and non-opioid pain medications as an alternative to opioids when individuals have easier access to legal cannabis through recreational dispensaries. reductions in opioid prescription fills stemming from recreational cannabis legalization may prevent exposure to opioids in patients with pain and lead to decreases in the number of new opioid users, rates of opioid use disorder, and related harms. we recommend that future studies explore the relative substitutability of cannabis for opioids or use of cannabis concomitantly with nonopioid pain medications. we also recommend future studies explore observing patient or prescriber behavior directly, to more certainly distinguish mechanisms of cannabis substitution. rcls and pain prescriptions 134 table 1. state-level point estimates, rcl legal effect on all outcomes opioid outcomes alaska california colorado district of columbia massachusetts oregon washington rate of patients with fills (10,000 enrollees) att 6.0614 -30.519 -56.683** -68.130*** -20.470 -110.40* -12.812 p-value 0.5508 0.2640 0.0767 0.0230 0.4125 0.0759 0.3630 basepre 410.14 345.09 615.61 281.53 267.26 471.31 478.00 avg. daily supply att 0.7834 -2.7783** 0.1594 -2.6687*** 0.4932 -2.3061** -0.5967 p-value 0.6234 0.0962 0.5296 0.0065 0.6838 0.0660 0.2716 basepre 33.947 28.818 28.111 16.456 21.973 27.074 26.587 avg. fills per patient att -0.1471 -0.0234 -0.0524* -0.1201** 0.0115 -0.1691* -0.0577* p-value 0.1881 0.3702 0.0514 0.0495 0.6055 0.0660 0.0740 basepre 2.1345 1.7987 2.1090 1.5332 1.7212 2.0184 2.0485 table 2. aggregated results, rcl legal effect on all outcomes opioids nsaids non-opioid pain rate of patients with fills (10,000 enrollees) att -39.15 -11.23 -1.370 p-value 0.1224 0.1530 0.2844 basepre 416.53 317.13 11.39 avg. daily supply att -1.700* 0.560 1.120 p-value 0.0824 0.8556 0.8978 basepre 27.70 32.66 21.86 avg. fills per patient att -0.040 0.030 0.02 p-value 0.1916 0.9562 0.7580 basepre 1.88 1.37 1.60 cannabis, a publication of the research society on marijuana 135 table 3. state-level point estimates, rcl dispensary effect on all outcomes opioid outcomes alaska colorado oregon washing ton rate of patients with fills (10,000 enrollees) att -166.10** -78.980* -116.88* -12.22 p-value 0.02778 0.07012 0.07927 0.3628 basepre 427.50 571.77 460.06 478.00 avg. daily supply att 3.3816 -0.7419 -2.7990** -0.5994 p-value 0.7792 0.2690 0.0466 0.2827 basepre 31.530 28.489 26.777 26.587 avg. fills per patient att -0.2034 -0.0524* -0.08049 -0.04969 p-value 0.1075 0.0533 0.2098 0.1650 basepre 2.1322 2.1090 1.9532 1.996 table 4. aggregated results, rcl dispensary effect on all outcomes opioid outcomes alaska colorado oregon washington rate of patients with fills (10,000 enrollees) att -166.10** -78.980* -116.88* -12.22 p-value 0.02778 0.07012 0.07927 0.3628 basepre 427.50 571.77 460.06 478.00 avg. daily supply att 3.3816 -0.7419 -2.7990** -0.5994 p-value 0.7792 0.2690 0.0466 0.2827 basepre 31.530 28.489 26.777 26.587 avg. fills per patient att -0.2034 -0.0524* -0.08049 -0.04969 p-value 0.1075 0.0533 0.2098 0.1650 basepre 2.1322 2.1090 1.9532 1.996 rcls and pain prescriptions 136 references abadie, a. 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(2021). the impact of medical and recreational marijuana laws on opioid prescribing in employer-sponsored health insurance. health economics, 30(5), 989–1000. https://doi.org/10.1002/hec.4237 funding and acknowledgements: the content of this study is solely the responsibility of the authors and does not necessarily represent the official views of national institute on drug abuse (nida) or nih. nida had no role in the study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. this study was supported by award r01da047365 from nida. no financial disclosures were reported by the authors of this paper. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: steuart, s. r., lozano-rojas, f., bethel, v., bekele shone, h., & abraham, a. j. (2025). recreational cannabis laws and fills of pain prescriptions in the privately insured. cannabis, 8(1), 121-138. https://doi.org/10.26828/cannabis/2024/000268 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 134 ved abstract although canada legalized cannabis beverages in 2019, most available research on acute cannabis intoxication derives from dried flower and edible products. the distinct bioavailability and pharmacokinetic properties of phytocannabinoids ingested from beverages, however, contribute to significantly different acute and long-term effects that need to be better understood to ensure consumer safety. objective: this review investigates existing cannabis beverage literature, with a particular focus on acute intoxication effects. method: pubmed, psycinfo and web of science databases were systematically searched. a structured search generated 29 eligible studies, comprising studies of consumption patterns and beliefs, advertisements and marketing, acute effects in human models, and drink composition. results: human studies report aversive acute subjective and physiological effects induced by cannabis beverages in healthy, infrequent users. beverages also showed inaccurate cannabinoid labeling, posing potential risks to consumers. this review highlights the paucity and inconsistency of available research, further exacerbated by the sheer diversity of formulations investigated, while beginning to address some questions surrounding the safety and risks associated with cannabis beverages. conclusions: given the extensive differences in effects across cannabis-infused beverages, and the growing ‘drinkables’ market, it is essential that more studies directly examine both acute and long-term impacts of cannabis beverage consumption. key words: = cannabis beverages; cannabis; acute intoxication; cannabinoids; systematic review canada legalized recreational cannabis in october 2018 to improve safety regulations and reduce associated health risks (health canada, 2022a). by october 2019, the canadian government expanded the provision of qualitycontrolled cannabis products to include both edible and concentrate products such as topicals, extracts, and beverages (department of justice, 2021; rubin-kahana et al., 2022). recent amendments to the cannabis act now allow adults to possess up to 17.1l of cannabis-infused beverages for recreational purposes while maintaining controls to prevent overconsumption (health canada 2022a). other regulations implemented for the sale of cannabis edibles include child-resistant packaging, prominent anna marie froude1,2,3*, nikki pangborn1,2,3*, phillip britzmckibbin4,5, james mackillop1,2,5, & iris balodis1,2,5 1peter boris centre for addictions research, st. joseph’s healthcare hamilton and mcmaster university 2department of psychiatry and behavioural neurosciences, mcmaster university 3neuroscience graduate program, mcmaster university 4department of chemistry and chemical biology, mcmaster university 5michael g. degroote centre for medicinal cannabis research * these two authors contributed equally to this work. cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000271 volume 7, special issue 3 potential risks from cannabisinfused beverages: a critical review corresponding author: iris m. balodis, phd, mcmaster university, 100 west 5th street, hamilton, ontario, l8s 4l8. phone: (905) 522-1155 ext. 39703.email: balodisi@mcmaster.ca cannabis, a publication of the research society on marijuana 135 health warning labels, serving size, and nutritional information (ventresca & elliott, 2022). improved manufacturing standards are critical to ensure consistent phytocannabinoid content labeling and consistent dosing for consumers (miller et al., 2022). the onset and duration of δ9tetrahydrocannabinol (thc), the primary psychotropic phytocannabinoid constituent with affinity to bind to cannabinoid receptor 1 (kendall & yudowski, 2017), effects differ across cannabis products. for instance, thc bioavailability and pharmacokinetics are highly dependent on the route of administration and vehicle composition, with edible products often metabolising more slowly than inhaled smoked or vaporised cannabis (thayer et al., 2019; vandrey et al., 2017). thus, despite single drinkable cannabis beverages maintaining a 10 mg thc limit (health canada, 2022a), the neurocognitive effects resulting from their consumption will differ from dried flower or non-beverage edibles (thayer et al., 2019; vandrey et al., 2017). individuals consuming cannabis edibles, including beverages, can experience delayed intoxication relative to smoking/vaping due to slower delivery and bioactivation, increasing overdose risk (russel et al., 2018). effects on cognition, memory, and driving performance are modulated by variable amounts of cannabidiol (cbd) and thc:cbd ratios (arkell et al., 2020), and memory deficits may be further exacerbated by psychotropic constituents in cannabis-infused energy drinks, such as caffeine (panlilio et al., 2012). however, despite the growing popularity of cannabis beverages in canada, most acute cannabis effects research derives from dry cannabis flower inhalation or non-beverage edibles (russel et al., 2018). considering the novelty of cannabis beverages as a consumable product, a broader examination of research pertaining to their consumer reach, acute effects, and composition is necessary to address potential risks for consumers and guide future research avenues. thus, the current review provides a critical review of empirical findings on cannabis-infused beverages across the aforementioned domains. methods search strategy table 1. search phrases employed for psycinfo, pubmed and wos article search database boolean search phrase number of results psycinfo (via ovid) (de "cannabis infused drink" or de "cannabinoid infused drink" or de "cannabis drink" or de "cannabinoid drink" or de "cbd drink" or de "tetrahydrocannabinol infused drink" or de "thc infused drink" or de "weed drink" or de "weed infused drink" or de "marijuana drink" or de "marijauna infused drink" or de "cannabis infused beverage" or de "cannabinoid infused beverage" or de "cannabis beverage" or de "cannabinoid beverage" or de "cbd beverage" or de "tetrahydrocannabinol infused beverage" or de "thc infused beverage" or de "weed beverage" or de "weed infused beverage" or de "marijuana beverage" or de "marijauna infused beverage") 884 pubmed ("cannabis infused drink" or "cannabinoid infused drink" or "cannabis drink" or "cannabinoid drink" or "cbd drink" or "tetrahydrocannabinol infused drink" or "thc infused drink" or "weed drink" or "weed infused drink" or "marijuana drink" or "marijauna infused drink" or "cannabis infused beverage" or "cannabinoid infused beverage" or "cannabis beverage" or "cannabinoid beverage" or "cbd beverage" or "tetrahydrocannabinol infused beverage" or "thc infused beverage" or "weed beverage" or "weed infused beverage" or "marijuana beverage" or "marijauna infused beverage") 5523 potential risks from cannabis-infused beverages 136 web of science (core collection) ts=((cannabis* or cannabinoid* or cbd or infused or tetrahydrocannabinol or tetrahydrocannabinol or marihuana* or marijuana* or thc or weed) near/3 (beverage* or drink*)) ti=((cannabis* or cannabinoid* or cbd or infused or tetrahydrocannabinol or tetrahydrocannabinol or marihuana* or marijuana* or thc or weed) near/3 (beverage* or drink*)) ab=((cannabis* or cannabinoid* or cbd or infused or tetrahydrocannabinol or tetrahydrocannabinol or marihuana* or marijuana* or thc or weed) near/3 (beverage* or drink*)) 925 table 2. search phrases employed for psycinfo, medline and wos article search database boolean search phrase number of results psycinfo (via ovid) ((cannabis/ or exp cannabinoids/) and exp beverages/) use medall (exp cannabis/ and exp "beverages (nonalcoholic)"/) use psyh ((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) and (beverage* or drink or drinks or thandai or lassi)).ti. ((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) adj5 (beverage* or drink or drinks or thandai or lassi)).ab,kf,kw,id. ((bhang-infus* or cannabis-infus*) and (beverage* or drink or drinks or thandai or lassi)).tw,kf,kw,id. or/1-5 42 medline (via ovid) ((cannabis/ or exp cannabinoids/) and exp beverages/) use medall (exp cannabis/ and exp "beverages (nonalcoholic)"/) use psyh ((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) and (beverage* or drink or drinks or thandai or lassi)).ti. ((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) adj5 (beverage* or drink or drinks or thandai or lassi)).ab,kf,kw,id. ((bhang-infus* or cannabis-infus*) and (beverage* or drink or drinks or thandai or lassi)).tw,kf,kw,id. or/1-5 309 web of science (core collection) ti=(((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) and (beverage* or drink or drinks or thandai or lassi))) ak=(((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) and (beverage* or drink or drinks or thandai or lassi))) ts=(((bhang? or cannabi* or ganja? or hashish? or hemp? or marihuana? or marijuana? or txid1302822 or txid3482 or txid3483 or cbd or thc) near/2 (beverage* or drink or drinks or thandai or lassi))) all=(((bhang-infus* or cannabis-infus*) and (beverage* or drink or drinks or thandai or lassi))) #4 or #3 or #2 or #1 319 cannabis, a publication of the research society on marijuana 137 a systematic literature search was conducted in september 2022 using psycinfo, pubmed, and web of science, resulting in 7,332 articles (table 1). an additional search of the beverage ‘bhang’ was conducted in may 2023 using the same databases (table 2), producing 670 results. title and abstract screening identified articles meeting inclusion criteria; full-text review determined their eligibility. our inclusion criteria comprised englishwritten, peer-reviewed primary research articles examining cannabis, hemp, or bhang beverages. acute effect articles in animal models were included, so long as the cannabis beverages were consumed by choice and not injected. there was no limit on age, sex, or the presence of comorbid disorders. meta-analyses and review articles were excluded; however, their reference lists were screened to identify other relevant articles. results this review broadly explores the current state of available cannabis beverage literature. our search identified 8,002 articles, with 29 meeting inclusion criteria (figures 1 and 2). results describe studies examining consumption patterns and beliefs (n = 11), marketing tactics (n = 1), acute effects in humans (n = 6), and compositional aspects of cannabis and hemp beverages (n = 11). figure 1. inclusion flowchart from initial search potential risks from cannabis-infused beverages 138 figure 2. inclusion flowchart from secondary search consumption patterns and beliefs studies exploring consumption patterns are summarized in table 3. although cannabis drinks were consistently chosen less often than smokeable or edible cannabis products (donovan et al., 2022; dowd et al., 2023; dunbar et al., 2022; fedorova et al., 2021; goodman et al., 2020; kerr et al., 2019; schauer et al., 2020; sikorski et al., 2021; sullivan et al., 2022), use rates varied significantly. consumption of cannabis beverages was particularly low among youth, observed in less than 0.1% of participants over four years (sullivan et al., 2022). adult past-month cannabis users reported greater beverage use in a canadian study, where 27.3% reported lifetime consumption and 14.3% reported past-year consumption (sikorski et al., 2021). among pastyear consumers (sikorski et al., 2021), 51.8% reported monthly use, averaging 2.8 drinks monthly, and 19.1% consumed beverages weekly, with drinks primarily being sourced from family or friends (25.7%). still, only 13.8% and 10% could accurately estimate the amount of thc and cbd present in their products, respectively. in us populations, 4.3% of adult past-month users reported consuming beverages (schauer et al., 2020). legal beverage purchasing grew from 71.4% in 2020 to 81.6% in 2021 (wadsworth et al., 2023), and purchasing was 1.5-2.5x higher in legal compared to illegal markets (goodman et al., 2020). legal sourcing did vary by sex, however, as males had significantly greater odds of sourcing “some” drinks illegally (wadsworth et al., 2023). clinical populations in the us reported low consumption of cannabis beverages; 1.1% of cancer patients endorsing past-year cannabis use consumed beverages and 0.8% of lifetime users consumed beverages (donovan et al., 2022). among epilepsy patients, cannabis beverages were consumed less than all other modalities (7.7%), but were the most prevalent method consumed by patients 51-60 years old (kerr et al. 2019). among cbd-only consumers (dunbar et al., 2022), 10.2% reported past-year beverage use, 8.6% reported lifetime use, and 9.8% reported past-month use, 14.7% of which exclusively used cannabis, a publication of the research society on marijuana 139 cbd beverages and 8.4% combined other cannabis products. alternatively, 2.6% consumed alcoholic cbd beverages in their lifetime, and 3.1% reported past-year consumption. preferences for major cannabinoids were reportedly inconsistent across studies. cannabis consumers from one study reported a preference for cbd-dominant (endorsed by n = 18 participants) over thc-dominant beverages (endorsed by n = 6 participants; fedorova et al., 2021). the opposite has been observed in other research; among n = 38 cannabis beverage consumers, 34% were more likely to use thcdominant products, while 18% preferred cbddominant products (dowd et al., 2023). users noted “enjoyment” and “wanting something to do” as primary motivations for consumption on the comprehensive marijuana motives questionnaire (cmmq; lee et al., 2009) short form, and reported that beverages took an average of 19 minutes for acute effects to onset – significantly quicker than edibles. interest in replacing alcohol with a cannabis beverage dropped to 15.8% from 26.6% in 2017 (charlebois et al., 2020), and substitution motivations were attributed to therapeutic reasons (31.8%), curiosity (25.8%), and psychoactive effects (17.9%) potential risks from cannabis-infused beverages 140 table 3. summary of findings on cannabis beverage consumption patterns and beliefs author(s) year purpose subjects protocol summary of results charlebois et al. 2020 measure perceptions surrounding edible use in canada. general canadian population n = 1051 participants received the survey, and 94% responded age range ≥18 years old an online survey was administered to randomly selected individuals in 2019 to measure aspects of cannabis use, including: perception of legalisation, legal consumption patterns, social stigma, and perceptions of cannabis edibles. 15.8% of respondents would replace an alcoholic drink with a cannabis-infused drink (dropping from 26.6% in 2017). 14.8% of respondents would be willing to substitute a conventional alcoholic drink with cannabis. reasons for substituting alcohol with cannabis beverages included therapeutic reasons (31.8%), curiosity (25.8%), and psychoactive effects (17.9%). donovan et al. 2022a measure cannabis use patterns in a population of young adults with cancer. cancer patients -age range = 18–39 years old n = 144 males; n = 328 females; n = 4 unspecified gender an online questionnaire was administered to patients to measure aspects of cannabis use, including: motives, consumption methods, effectiveness, side effects, source of products, and medical licence status. among weekly cannabis users, 49% reported eating or drinking cannabis. of past-year cannabis consumers (n = 352), four indicated they were using cannabis beverages purchased from a legal storefront. of the patients endorsing cannabis use prior to the last year (n = 127), one reported consuming cannabis beverages. dowd et al. 2023 examine various factors related to oral cannabis use. cannabis users in the us mean age=32 years old n = 174 males; n = 185 females administered online survey program to participants measuring aspects of cannabis use, including: prevalence, motives, formulation, thc/cbd dose, perceived subjective effects, co-use (alcohol), and advice received about reducing use symptoms. n = 38 (10%) of users consumed cannabis beverages, making it the second least prevalence mode reported. beverages, baked goods, gummies, hard and chocolate candy users reported significantly greater "enjoyment" motives compared to oils/tinctures. beverages, baked goods, and chocolate candy users reported significantly greater "wanting something to do" motives compared to oils/tinctures. beverage users displayed a trend toward the highest scores for using "to replace the use of another drug/medicine", though this was not significant. cannabis, a publication of the research society on marijuana 141 34% (n =13) of cannabis beverage consumers used thc-dominant products, 24% (n = 9) used a 1:1 ratio of thc:cbd, 18% (n = 7) used cbd-dominant products, and 24% (n = 9) were unsure about the cannabinoid composition. using only data from 35 cannabis beverage consumers, participants reported that beverages took approximately 19 minutes (sd = 15) for their effects to onset, which was a significantly lower onset duration compared to baked-good and gummy candy consumers. dunbar et al. 2022 explore patterns and correlates of cannabidiol product and marijuana co-use in a sample of young us adults. young adults in the us mean age(sd) = 22.6(0.8) years old n = 2534 males and females examined cross-sectional survey data collected from wave 12 of the choice-strata cohort study. the survey assessed for lifetime, past-year, and past-month frequency, as well as the type of cbd products used, frequency and amount of cannabis consumed, and indicators of problematic cannabis use. differences in cbd use between participants reporting past-month use of cbd but not marijuana products (“cbd-only”) and those who co-use both cbd and marijuana products. alcohol containing cannabis beverages 2.6% reported lifetime use of cbd beverages 3.1% reported past-year use of cbd beverages 3.1% reported past-month cbd beverages 1.5% reported past-month use of cbdonly beverages 3.6% reported past-month cbd and marijuana use no significant differences in rates of use between past-month cbd-only and pastmonth cbd and marijuana groups for those who consumed alcoholic cannabis beverages. alcohol-free cannabis beverages 8.6% reported lifetime use of cbd beverages 10.2% reported past-year use of cbd beverages 9.8% reported past-month cbd beverages 14.7% reported past-month use of cbdonly beverages potential risks from cannabis-infused beverages 142 8.4% reported past-month cbd and marijuana use no significant differences in rates of use between past-month cbd-only and pastmonth cbd and marijuana groups for those who consumed alcohol-free cannabis beverages. fedorova et al. 2021 measure cannabis use patterns and cannabinoid preferences. recent cannabis users (past 90 days) mean age(sd) = 25.3(2.5) years old n = 147 males; n = 92 females data from year 5 of a longitudinal quantitative survey was analysed which measured aspects of cannabis use, including: cbd versus thc-dominant use frequency, mode of administration, general use frequency, and motives. cannabis users were classified as either cbd dominant users or thc dominant users. these groups were further divided into four subgroups: (1) (cbd dominant): cbd-only (2) (cbd dominant): mostly cbd (3) (cbd dominant): half cbd/half thc (4) (thc dominant): some cbd the following rates of cannabis beverage consumption were recorded in each subgroup: cbd-only: n = 11 (19.3%) mostly cbd: n = 0 (0%) half cbd/half thc: n = 7 (26.9%) some cbd: n = 6 (8.7%) therefore, the cbd-only users had the largest number of people using cannabis beverages (n = 11), but the half cbd/thc subgroup had the greatest proportion of beverage consumers (26.9%). drinks and edibles were tied for highest overall prevalence in the half cbd/thc subgroup, compared to all other modes of use. goodman et al. 2020 examine associations between the legal status of non-medical cannabis and patterns of consumption in canada and legal and illegal regions of the us. male and female participants from canada and the us age range = 16-65 years old n = 27,042 canada (n = 9976) illegal us states (n = 9686) data was collected using selfcompleted web-based surveys assessing aspects of cannabis use, including: measurement windows (lifetime, most recent and current use), frequency and prevalence of cannabis use, type of cannabis products used, and age of first using cannabis. prevalence of use of cannabis beverages % (n) canada: 8.1% (224), illegal us states: 8.7% (201) legal us states: 17.0% (430) regular (daily and weekly) use of cannabis beverages among past 12-month cannabis users canada: 38.4% illegal us states: 58.9% legal us states: 30.0% cannabis, a publication of the research society on marijuana 143 legal us states (n = 7362) frequency of use and prevalence of regular cannabis beverage use among past 12-month users % (n) <once a month: canada: 33.7% (71) illegal us states: 17.3% (33) legal us states: 41.6% (171) monthly: canada: 28.0% (59) illegal us states: 24.2% (46) legal us states: 28.4% (117) weekly: canada: 29.1% (61) illegal us states: 41.7% (79) legal us states: 18.9% (78) daily: canada: 9.3% (20) illegal us states: 16.8% (32) legal us states: 11.1% (46) kerr et al. 2019 measure cannabis use patterns among individuals who received treatment for epilepsy. patients receiving treatment for epilepsy mean age(sd) = 38(12.4) years old n = 19 males; n = 20 females patients were administered a survey measuring aspects of cannabis use, including: consumption method, source of purchase, use frequency, and cannabinoid content. cannabis beverages were the least used mode of cannabis, with 7.7% of patients reporting use. cannabis beverages were a preferred mode of cannabis consumption for patients between 51–60 years old. schauer et al. 2020 identify cannabis use patterns and prevalence of multimodal consumption. recent cannabis users (past 30 days) n = 6174 males and females age range≥18 years old administered the 2016 brfss survey via telephone to measure prevalence of different consumption methods, multimodal use, and demographic correlates. 4.3% of the sample reported cannabis beverage consumption, compared to 90.7% of participants reporting smoking cannabis. 0.2% of cannabis beverage users reported it as their only mode of consumption. sikorski et al. 2021 measure cannabis use patterns and rates. recent cannabis users (past 30 days) mean age (sd) = 23.9(4.3) years old n = 110 males; n = 75 females administered the online cpct survey to measure aspects of cannabis use, including: mode of consumption, purchase source, price, average consumption rate, and cannabinoid content. 27.3% had used beverages at least once in their lifetime. 14.3% had used beverages within the past year, 51.8% of which used monthly and 19.1% used weekly. potential risks from cannabis-infused beverages 144 participants reported using an average of 2.8 beverages (range: 0.3–21.8) per month. 13.8% provided a valid response about how much thc might be present in their cannabis beverages. 3.2% of users reported an invalid response (i.e., an unrealistic possible amount). 10% provided a valid response of how much cbd is present in their cannabis beverages. overall, individuals who used beverages, concentrates, tinctures, and edibles were more likely to report a valid range of thc and cbd in their products than individuals who used other modes of consumption. source of purchasing a cannabis beverage: social category: shared around a group of friends = 7.8% from a family member or friend = 25.7% from someone else i know = 16.2% dealer category: in person = 2.3% mail delivery = n/a retail category: medical marijuana from a store (e.g. dispensary) = 20.5% medical marijuana mailed from a licensed producer = 4.7% non-medical marijuana from a store = n/a ordered it online (not from a licensed producer) = 6.6% grown/made category: on my own = 19.9% for me = 20.4% cannabis, a publication of the research society on marijuana 145 therefore, the most likely source of cannabis beverages amongst past-month users was from a family member or friend. sullivan et al. 2022 identify the associations between previously identified common risk factors of early substance use experimentation and initiation from the abcd study. male and female participants (n = 11,876 at baseline) mean age = 9.5 years old at baseline data from the 11,876 participants enrolled in the abcd study at baseline (y0), with all available yearly follow-ups (y1, y2, y3) biological measures and behavioural modules of substance use were collected. proportion of participants reporting lifetime (y0) or past-year (y1–3) cannabis beverage use both male and female participants from baseline and follow-up periods (y0-y3): <0.1% males at follow-up periods y0, y2, and y3: <0.1% males at y1: 0.1% females at follow-up periods y1 and y3: <0.1% females at follow-up periods y0 and y2: 0% wadsworth et al. 2023 examine cannabis use patterns amongst individuals who have purchased products legally. recent cannabis users (past 12 months) age range = 16–65 years old 2020: n = 1830 males; n = 2822 females 2021: n = 2485 males; n = 3317 females an online survey was administered between 2019–2021 to measure aspects of cannabis use, including: mode of consumption, use frequency, and legal product sourcing. only data from 2020–2021 will be reported as beverages were not yet legal in 2019. in 2020, 71.4% (of n = 1316) of participants who legally purchased all cannabis products in the past 12 months used beverages. in 2021, 81.6% (of n = 1316 individuals) of participants who legally purchased all cannabis products in the past 12 months used beverages. consumers of beverages, dried flower, solid concentrates, vape oils, edibles, and hash/kief had higher odds of sourcing all products legally in 2021 vs. 2020. sex was associated with proportion of legal cannabis sourcing, where males had greater odds of sourcing "some" cannabis drinks legally. ethnicity/race was associated with amount of legal sourcing for all cannabis products except for beverages and vape oils. education was associated with legal sourcing for all cannabis products except beverages. note. abbreviations: abcd = adolescent brain cognitive development; brfss = behavioural risk factor surveillance system; cbd = cannabidiol; cpct = cannabis purchase and consumption tool; thc = tetrahydrocannabinol. adata reported within the table was received through correspondence with the first author. potential risks from cannabis-infused beverages 146 advertisement and marketing marketing tactics and safety measures at coloradoan dispensaries showed that 90% of stores followed appropriate security guidelines (e.g., signs indicating age requirements, customer identity verification, exterior security cameras), with similar beverage prices across dispensaries (~$6-8/serving) and cannabis beverages displayed on 16.3% of dispensary advertisements (berg et al., 2017). acute effects in human models studies exploring cannabis beverage effects in human participants are summarized in table 4. two of six studies were conducted in emergency care settings, whereas the remaining four studies directly acutely administered beverages and broadly examined subjective, neurocognitive, and physiological outcomes of cannabis ingestion. different reaction severities to accidental cannabis drink exposure were observed across n = 9 (2%) calls made to the emergency care room (cao et al., 2016); one case described potentially toxic exposure causing vomiting, and two cases indicated adverse reactions inducing tachycardia, confusion, and mydriasis. in patients seeking emergency psychiatric care after consuming bhang (a cannabis-infused beverage), patients were more likely to be chronic bhang users and score significantly greater psychiatric ratings than controls, with greater “mania-like” symptoms (chaudry et al., 1991). administration of a thc beverage increased pulse rate and anxiety in healthy subjects who were either occasional users or non-users (karniol et al., 1974; zuardi et al., 1982). thc ingestion altered time perception, but this effect was attenuated by combined thc+cbd doses (karniol et al., 1974). thc+cbd at low, medium, and high-cbd dose combinations shifted subjective effects to be more pleasant, while medium and high-cbd dose combinations blunted the heart rate increase induced by lowcbd dose combinations and thc-alone. cbdonly lowered pulse rate and induced more pleasant subjective experiences than thc, whereas thc+cbd had no significant effect on subjective feelings (zuardi et al., 1982). water-soluble cbd beverages increased plasma levels, bioavailability, half-life, and absorption rate of cbd compared to fat-soluble beverages (hobbs et al., 2020). while the cbd elimination rate did not differ between beverages, cbd was more vastly distributed across tissue in participants consuming the fat-soluble drink. following hemp tea consumption, enzyme multiplied immunoassay technique did not detect any cannabis metabolites, whereas gas chromatography–mass spectrometry produced a positive thc screen in 7/20 participants’ urine (steinagle et al., 1999). cannabis, a publication of the research society on marijuana 147 table 4. summary of findings on acute effects of cannabis and hemp beverages in human models author(s) year purpose subjects protocol summary of results caoa et al. 2016 characterise edible marijuana exposures reported to poison centres within the us. individuals reporting toxic cannabis exposure. median age = 18 n = 430 males and females collected information from calls to the npds over two years which reported edible and drinkable cannabis exposure. 2% (n = 9) of calls were made regarding cannabis beverages, mostly in individuals ≥ 19 years old. three toxic exposure reports following cannabis drink consumption were provided by the primary author: 1. 30 year old male: minor adverse reaction with tachycardia, confusion, mydriasis, and symptom coded "other". 2. 35 year old male: minor adverse reaction with symptom coded "other". 3. 27 year old male: potentially toxic exposure with vomiting chaudry et al. 1991 systematically characterise symptoms of bhang-induced psychosis among individuals seeking psychiatric care in pakistan. psychiatric patients in emergency care following consumption of bhang. mean age(sd) = 25(6.71) n = 15 males control bhang users presenting no psychiatric symptoms. mean age(sd) = 19(1.70) n = 10 males psychiatric symptoms were assessed using the bprs in an emergency care setting. clinical estimation of bhang use frequency for patients and controls, respectively: first time users: n = 1 (7%); n = 1 (10%) occasional users: n = 6 (40%); n = 9 (90%) chronic users: n = 8 (53%); n = 0 (0%) significantly more psychiatric patients were considered chronic bhang users compared to control participants. total bprs scores for patients were significantly higher than ratings for the control group. psychiatric symptoms were categorised into "factors" to describe symptom groupings that most significantly impacted differences in bprs scores between patients and controls: factor 1 ("mania-like behaviour": excitement, grandiosity, hostility, and uncooperativeness) potential risks from cannabis-infused beverages 148 accounted for 37.3% of total variance between groups. factor 2 ("paranoid psychosis": suspiciousness, mannerisms & posturing, hallucinatory behaviour, and tension) accounted for 20.3% of variance between groups. factor 3 ("cognitive dysfunction": unusual thought content, conceptual disorganisation, disorientation, blunted affect) accounted for 13.7% of variance between groups. hobbs et al. 2020 compare the antiinflammatory properties between a water-soluble and fat-soluble cbd beverage. healthy participants age range=22–51 years old n = 4 males; n = 6 females 30mg fat-soluble or water-soluble cbd beverages were administered. blood samples measured cbd, pbmcs, and cytokines (i.e., il-10, tnf) and were collected at baseline and 15, 30, 45, 60, 90, 120, 240, and 360 mins after beverage consumption. blood pressure was collected prior to each blood sample. more plasma cbd was detected in the watersoluble group between 45–120 min; peak cbd levels were significantly larger and were reached significantly faster than the lipid-soluble group. bioavailability of cbd was 4.5 times greater, the half-life of cbd was significantly longer, and the absorption rate was significantly greater in the water-soluble compared to the lipid-soluble group, though the elimination rate did not differ. the volume of distribution of cbd throughout the body was significantly greater in the lipidsoluble compared to the water-soluble group. neither group displayed changes in sbp or dbp throughout the study. neither group displayed changes in levels of il10 or tnf between 0 and 90 minutes. across both groups, tnf levels were lower compared to baseline at 90 minutes in lpsstimulated cells, but were not associated with cbd. karniol et al. 1974 determine if high percentages of cbd induce less 'high' or psychotic-like healthy participants age range=21–34 years old n = 40 males participants either received a beverage containing 30 mg of thc, 15 mg, 30 mg or 60 mg of cbd, a combination of 30 mg of thc + subjective effects onset between 30–50 min post-ingestion, peaked between 30–60 min following onset, and subsided 2 to 3 hours afterwards. cannabis, a publication of the research society on marijuana 149 effects than would be expected based on the concentration of thc. either 15 mg, 30 mg or 60 mg of cbd, or a placebo beverage. pulse rate was measured before and after beverage consumption. "time production task": participants counted to a minute, either receiving no accuracy feedback (estimation t1) or receiving feedback (estimation t2). this was repeated 45, 90, and 180 minutes following beverage ingestion, alternating without feedback (estimation t3, t5, t7) and with feedback (estimations t4, t6, t8). at 55, 95, 155, and 185 min after beverage ingestion, participants were interviewed about subjective experiences which were graded by researchers from 0 to 4. placebo and cbd-only beverages did not significantly alter psychological effects, time production accuracy, or pulse rate. thc-only beverages produced significant psychological effects such as anxiety and nearpanic occurring in waves, with 4 of 5 subjects scoring grade 4 effects. thc-only significantly altered time perception at t3, t5, and t7 (without feedback) compared to the placebo beverage, with participants estimating time elapsing too quickly (averaging below 40 seconds), as well as at t4, t6, and t8 (with feedback), but with comparatively less significant underproduction. thc-only increased pulse rate by 35% compared to baseline, peaking between 50–70 minutes following ingestion. thc+cbd (15 mg, 30 mg, 60 mg) significantly reduced psychological effects compared to thconly, and subjective feelings shifted from anxiety and panic to more pleasurable experiences. thc+cbd (15 mg, 30 mg, 60 mg) significantly blunted time perception effects produced by thc, such that inaccuracies made on trials with feedback were not significantly different than the placebo group. thc+cbd (15 mg) increased the average pulse rate by 53%; whereas thc+cbd (30 mg, 60 mg) significantly blunted this increase, reducing to an increase of 6.2% in the thc+cbd (60 mg) group. steinagle et al. 1999 determine the presence of cannabis metabolites in urine following the consumption of a hemp beverage. healthy participants (no cannabis use in past 60 days) age range = 27–62 years old n = 7 males; n = 15 females participants either received one 12-ounce cup of hemp tea, two 12ounce cups of hemp tea, or one 12ounce cup of placebo tea (orange pekoe tea). delta-9-thc was present in both hemp tea and hemp seed samples. n = 7 (of 20) participants consuming hemp beverages had positive gc/ms results for 9,11 thc-cooh: four were initially positive after four hours (one of which tested positive again at potential risks from cannabis-infused beverages 150 hemp tea and hemp seed samples were analysed for the presence of thc using gc/ms. urine samples were collected at baseline and again 4, 8, and 24 hours following ingestion. emit test was used to detect cannabis urinary metabolites, and gc-ms assays were used to identify presence of 9,11 carboxythc. 8 and 24 hours, and two of which tested positive again at 8 hours only), two were initially positive after eight hours, and one was initially positive after 24 hours. majority of positive tests (n = 5) came from the low hemp-dose group. no metabolites were detected using the emit test. zuardi et al. 1982 examine the impact of cbd on thc-induced anxiety in healthy individuals. healthy participants mean age = 27 years old n = 6 males; n = 2 females five experimental sessions occurred (separated by at least 1 week) where participants were administered an oral mixture of: thc (0.5mg/kg), cbd (l mg/kg), a combination of thc+cbd (0.5 mg/kg+1 mg/kg), or placebo. pulse rate was collected before and 70 and 130 min following beverage ingestion. at 30, 60, 120, and 180 min after drug ingestion, researchers interviewed participants about their subjective experiences, rated their anxiety on a scale of 0-3, and rated the predicted effects of c. sativa on a scale of 0-4. participants self-rated anxiety on the stai, subjective symptoms using the asrs-sf and the sbs, and drug-effects using the arcima, before and 65 and 125 min after drug ingestion. placebo and cbd drinks significantly decreased pulse rate after 1 and 2 hours, while thc and thc+cbd significantly increased pulse rate after 1 hour only. self-reported anxiety significantly increased in only the thc and thc+cbd groups. self-reported subjective effects were only measured in thc and thc+cbd groups, and significantly increased over time, with cbd altering feelings of being "quick witted" and "clear minded", and thc altering feelings of being "feeble", "incompetent", "muzzy", "discontented", "troubled" and "withdrawn". thc-only and cbd-only produced opposite effects for subjective feelings of "alert-drowsy", "strong-feeble", "incompetent-proficient", "mentally-slow-quick-witted", and "muzzy-clearminded". cbd-only and thc-only produced significantly different feelings of "muzzy-clear minded" compared to placebo, but cbd+thc beverage did not produce significantly different effects compared to placebo. note. abbreviations: arci-ma = addiction research center inventory for marihuana effects; asrs-sf = analogue self-rating scale for subjective feelings; bprs = brief psychiatric rating scale; cbd = cannabidiol; dbp = diastolic blood pressure; emit = enzyme multiplied immunoassay technique; gc-ms = gas chromatography– mass spectrometry; il-10 = interleukin-10; lps = lipopolysaccharide; npds = national poison data system; pbmcs = peripheral blood mononuclear cells; sbp = systolic blood pressure; sbs = scale of bodily symptoms; stai = spielberger's state-trait anxiety inventory; thc = tetrahydrocannabinol; tnf = tumour necrosis factor adata reported within the table was received through correspondence with the first author. cannabis, a publication of the research society on marijuana 151 drink composition the compositional makeup of cannabis beverages was examined across 11 studies, which are summarized in table 5. three primary themes emerged across study aims: 1) examining the accuracy of beverage labeling; 2) examining cannabinoid makeup or potential beverage contamination; 3) examining how different preparation techniques impact cannabinoid levels. inaccurate and inconsistent cannabis beverage labeling was identified across three studies. thc was over-labeled in 61.5% of cannabis beverages, compared to 15.4% under and 23.1% accurately labeled (vandrey et al., 2015), while cbd was over-labeled in 78.57% of cannabis beverages, compared to 14.29% under and 7.14% accurately labeled (miller et al., 2022). across 41 cannabis products, only six provided labels indicating the presence of cannabis and excluded other important requirements (e.g., ingredient lists, product name, expiration date; lindsay et al., 2021); although it was not specified if this included beverage labels, beverage samples contained 0.01 mg of thc and 0.03 mg of cbd on average. several cannabinoids were quantified across cannabis and hemp drinks, including cbd, cannabinolic acid (cbda), cannabinol (cbn), and thc (christodoulou et al., 2023; ciolino et al., 2018; drager et al., 2022; hazekamp et al., 2007; lindsay et al., 2021; miller et al., 2022; pacifici et al., 2017; song et al., 2023; vandrey et al., 2015), and in some cases, trace levels of heavy metals and aflatoxins were also measured (catenza et al., 2022; greaves et al., 2021). an immunoaffinity column cleanup and enrichment step prior to liquid chromatography (lc), as required for determination of trace levels of aflatoxin and ochratoxin a in cannabis products, was validated and revealed no initial cannabis beverage contamination with toxins above method detection limits (greaves et al., 2021). moreover, cbd and thc drinks fell below maximum allowable consumable limits of 14 different heavy metals as observed through inductively coupled plasma (icp)-ms, although tea samples still contained greater concentration ranges of heavy metals relative to other beverages (catenza et al., 2022). quantifiable thc content was observed in 31% of nonalcoholic hemp beverages (drager et al., 2022). on the high end, thc content of 0.529 mg/l yielded a thc intake of 0.093 mg/day, resulting in an acute reference dose (arfd; a measure of substance amount ingested with no appreciable health risk, expressed in milligrams per body weight in kilograms) exhaustion of 133%. in contrast, 88% of hemp teas had quantifiable thc, and its mean intake of 0.157 mg/day showed a much higher arfd exhaustion of 224%. lc with diode array detection (lc-dad) identified a respective average cbd content of 0.0058% (w/w), 0.0040% (w/w), and 0.033% (w/w) in hemp-based grapefruit sparkling coconut water, lemon sparkling black tea, and cbd coffee (song et al., 2023). other findings (ciolino et al., 2018) yielded lc-dad assay results of 0.042 mg/g of cbd in coffee beverage products (n = 3), 0.28 mg/g of cbd in flavoured liquid products (n = 3), and 0.30 mg/g of cbd and 0.012 mg/g of thc in aqueous supplement products (n = 2). two studies tested differences in cannabinoid content using lc in conjunction with tandem ms (ms/ms) based on altered tea preparations. although changing water volume and increasing cannabis dosage did not significantly alter the thc or thca concentration relative to a standard tea preparation, lowering the cannabis dose significantly reduced the concentration of both phytocannabinoids (hazekamp et al., 2007). thc also significantly increased across boiling time length (10, 20, and 30 min), whereas thca was minimally affected by boiling time. conversely, a different study reported that increasing boiling times induced a trending decrease in the total cannabinoid concentration compared to a standard tea preparation (pacifici et al., 2017); however, poor and inconsistent recovery rates of phytocannabinoids were observed, and thc:cbd ratios significantly decreased, due to lower extraction efficiencies of thc/thca than cbd and cbda. potential risks from cannabis-infused beverages 152 table 5. summary of findings on compositional analyses of cannabis beverages author(s) year purpose composition target & analysis summary of results catenza et al. 2022 determine the presence of metals in different cannabis products for safety analysis. 14 heavy metals were targeted for analysis: v, cr, co, ni, cu, zn, as, se, mo, cd, hg, tl, pb, u. icp-ms analysed various cannabinoid products, including beverages and teas. this method was validated prior to sample analyses. n = 12 cannabis beverage samples were used for heavy metal analysis. cbd content ranged from 2.5mg 20mg, and thc content ranged from 0mg 2.5mg. n = 4 cannabis tea samples were used for heavy metal analysis, and all samples contained 10mg of cbd and 5mg of thc. summary of the range of heavy metal concentrations (µg/kg) in all beverage and tea products, respectively: v: 0.31 – 5.68; 75.51 – 106.30 cr: 1.93 – 6.35; 143.52 – 326.76 co: 0.05 – 1.45; 39.15 – 246.04 ni: 0.63 – 4.96; 380.55 – 3,305.35 cu: 2.80 – 61.20; 3,375.07 – 8,661.02 zn: 28.19 – 261.62; 8,359.80 – 8,515.14 as: 0.79 – 2.41; 12.20 – 55.48 se: 0.15 – 0.38; 25.65 – 122.83 mo: 0.11 – 3.31; 16.23 – 200.20 cd: 0.11; 6.91 – 40.65 hg: 0.08; 1.73 – 5.47 tl: <loq; 0.89 – 35.08 pb: 0.17 – 1.76; 56.31 – 3189.23 u: 0.09; 2.58 – 7.03 tea and chocolate products had greater heavy metals concentrations compared to powders and beverages. heavy metal concentrations in all products were below the danger threshold for consumption. christodoul ou et al. 2023a determine a suitable technique for cannabinoid extraction in different liquid and solid forms of cannabis-based products. cannabinoids of interest: cbc, cbd, cbg, cbn, oh-thc, thc, thc-cooh. cannabinoid concentration data was obtained via hplc-ms analysis. soxhlet extraction: hemp tea (ug/g) cbd: 111 ± 4.40 cbg: 44.5 ± 5.18 spe extraction: cannabis energy drink (ng/g) cbd: 0.170 ± 0.020 uae extraction: cannabis tea (μg/g) cbc: 75.1 ± 9.02 cbd: 4381 ± 76.5 cbg: 750 ± 9.97 cbn: 57.0 ± 2.00 thc: 180 ± 4.56 cannabis, a publication of the research society on marijuana 153 soxhlet and uae extraction were used for the extraction of cannabinoids from solid cannabis edibles, including hemp tea. spe and uae were used for the extraction of cannabinoids from cannabis beer and cannabis energy drinks. decoction and infusion processes were used for cannabis-based roasted coffee and hemp tea cannabinoid extraction, respectively. cbg: 0.312 ± 0.010 oh-thc: 1.28 ± 0.030 cannabis beer (ng/g) cbd: 0.380 ± 0.010 cbg: 0.474 ± 0.030 infusion: hemp tea (μg/g) cbc: 0.100 ± 0.010 cbd: 19.6 ± 0.410 cbg: 2.43 ± 0.110 cbn: 0.080 ± 0.010 thc: 0.080 ± 0.001 cannabis energy drink (ng/g) cbd: 0.150 ± 0.013 cbg: 0.240 ± 0.010 cannabis beer (ng/g) cbd: 0.830 ± 0.014 cbg: 0.271 ± 0.020 decoction: roasted coffee (μg/g) cbd: 0.042 ± 0.001 cbg: not quantified ciolino et al. 2018 determine the presence of cannabinoids in commercial consumer products using hplc-dad. cannabinoids of interest: cbc, cbd, cbda, cbdv, cbg, cbga, cbn, thc, thca, and thcv. target compound retention, uv absorbance spectra/response was determined via hplc-dad analysis. for aqueous substances such as coffee, 100% ethanol extractant was used. cbd and thc were the only cannabinoids present in drinkable cannabis products. coffee beverage products (n = 3) cbd assay (mg/g), spike (mg/g), and % spike recovery were: 0.042, 0.036, and 96, respectively. no thc reported. flavoured liquid products (n = 3) cbd assay (mg/g), spike (mg/g), and % spike recovery were: 0.28, 0.29, and 94, respectively. no thc reported. aqueous supplement products (n = 2) cbd assay (mg/g), spike (mg/g), and % spike recovery were: 0.30, 0.30, and 100, respectively. thc assay (mg/g), spike (mg/g), and % spike recovery were: 0.012, 0.011 and 101, respectively. dräger et al. 2022b identify thc content in a variety of hemp food products. thc content was determined using gc in combination with with methods of mass spectrometry and lc-ms. thc intake, arfd, and loael was calculated using average daily consumption scenarios. nonalcoholic hemp-containing beverages (n = 61) thc content in 11% of the samples was below the loq, with 57% of samples falling below the lod. 31% of the samples showed a quantifiable thc content; mean thc intake (0.0002 mg/day) exhausted the arfd with 0.3% to a low extent, while the exhaustion of the arfd by the mean thc intake (0.005 mg/day) was 7% potential risks from cannabis-infused beverages 154 thc content (mg/kg product) was converted to daily thc intake (mg/day) using the mean daily consumption (g of product/day). thc intake for the sample with the highest thc content (0.529 mg/l) was 0.093 mg/day, which resulted in an arfd exhaustion of 133%. hemp-containing teas (n = 89) 88% of samples demonstrated quantifiable thc content; mean thc intake (0.157 mg/day) demonstrated a high arfd exhaustion of 224%, with a low loael exhaustion of 6%. the median thc intake (0.049 mg/day) was below the arfd and demonstrated an arfd exhaustion of 70%. greaves et al. 2021 to validate a method used to analyse the presence of aflatoxins and ota in several cannabis products. three cannabis-infused beverages were used for analysis of both toxins. an immunoaffinity column cleanup lc method was used to analyse the product. beverages were spiked with four different aflatoxins, and ota, at low, medium, and high levels. initial analysis of all cannabis products showed no contamination of any aflatoxins or ota. the total within-day recovery rate (%) of aflatoxins was reported for cannabis beverages at each spiking level (low, medium, high) respectively: 93.2%, 92.6%, 95.7%. the total within-day recovery rate (%) of ota was reported for cannabis beverages at each spiking level respectively: 83.1%, 84.3%, 81.7%. the within-day repeatability analysis yielded the following rsd (%) values for aflatoxins at each spiking level, respectively: 7.8%, 7.4%, 3.6%; and for ota: 5.4%, 4.1%, 6.4%. the total between-day recovery rate (%) of aflatoxins was reported for cannabis beverages at each spiking level (low, medium, high) respectively: 88.9%, 92.1%, 93.1% the total between-day recovery rate (%) of ota was reported for cannabis beverages at each spiking level respectively: 75.5%, 78.3%, 80.7% the between-day repeatability analysis yielded the following rsd (%) values for aflatoxins at each spiking level, respectively: 8.5%, 11.3%, 12.8%; and for ota: 9.4%, 14.5%, 11.6% hazekamp et al. 2007 analyze how different methods of cannabis tea preparation impacts their cannabinoid composition. cannabinoids of interest: thc and thca. lc was applied to quantitatively analyze the presence of both phytocannabinoids. cannabis residue on the sieve was analyzed using lc to determine the there was no loss of total thc (thc+thca) during tea preparation. relative to the standard cannabis tea preparation: altering the water volume did not significantly change thc or thca concentrations. cannabis, a publication of the research society on marijuana 155 concentration of cannabinoids before and after preparation. tea preparation was altered in three ways: 1. water volume: preparing 250 mg of cannabis in 250 ml of water, or 1 g of cannabis in 1 l of water. 2. cannabis: preparing tea using either 0.5, 1, or 1.5 g of cannabis. 3. boiling time: boiling tea for either 10, 20, or 30 min. all tea samples were compared to a standard preparation of cannabis tea, which was created by boiling 1.0 g of cannabis in 1.0 l of water for 15 minutes. tea samples were also stored for 1, 3, 5, or 12 days, then removed for a subsequent analysis to test possible reductions in cannabinoid concentrations. lowering the dose of cannabis to 0.5g significantly decreased the presence of thc and thca to approximately half. increasing the dose of cannabis to 1.5 g did not significantly alter the presence of thc or thca. increasing the boiling time significantly increased the concentration of thc, but had no significant effect on thca levels. however, thc concentration still remained lower than thca concentration in every preparation. after one day of storage, thc levels significantly decreased to 60% of its original concentration, and thca levels significantly decreased to 71%. after 12 days of storage, thc decreased to 6% of its original concentration and thca decreased to 8%. recovery of precipitates were equal to the relative amount of cannabinoids lost from the solution – thus, the qualitative composition remained stable while overall potency declined. cyclodextrin and coffee creamer successfully stabilized teas during storage, such that the levels of thc and thca were relatively unchanged after 5 days of storage. lindsay et al. 2021 to determine the presence of thc and cbd in different cannabis products. cannabinoids of interest: cbd, cbn, thc. 45 cannabis samples were collected over four years, only two of which were cannabis beverages. gc-ms was used to analyse cannabinoid concentrations in each sample. safety standards for packaging were also examined. the lowest levels of thc were detected in beverages compared to any other product, while baked goods had the highest concentration of thc. amongst the two beverages samples analysed: mean and median levels of thc per beverage product were 0.01mg. mean and median levels of cbd per beverage product were 0.03mg. most products (n = 39) did not adhere to packaging guidelines (i.e., excluded ingredients, name, storage condition, expiration date, etc.). 85% of samples also did not indicate the amount of thc miller et al. 2022 determine the purity and labelling accuracy of nonprescription commercial cbd cannabinoids of interest: cbd, cbn, and thc. samples were analysed using lc to determine the concentration of cbd, cbn, and thc. observed concentrations were observed cbd content of the aqueous hemp products analysed (n = 21), only 14 provided specific cbd label claims, with a mean cbd concentration vs label claim of 59.93%. of the aqueous hemp products that provided a label claim, only one was labelled accurately. potential risks from cannabis-infused beverages 156 and hemp products. then compared to product labels to assess for product labelling accuracy. two of aqueous hemp products were found to be underlabelled, while 11 were identified as being over-labelled. observed cbn content cbn was detected in two aqueous hemp products, both of which contain a cbn concentration of 0.0015% (w/v). observed thc content thc was detected in five aqueous hemp products, with a maximum observed thc concentration of 0.0005% (w/v) and a minimum observed thc concentration of 0.0002% (w/v). pacifici et al. 2017 analyzing cannabinoid composition of specific strains to examine their potential therapeutic effects. cannabinoids of interest: cbc, cbd, cbda, cbg, cbn, thc, thca. a standard cannabis tea was prepared by boiling 500 mg of medical cannabis in 500 ml of water for 15 min. the effect of boiling time on the presence of cannabinoids was tested, altering its boiling by increments of 5 minutes, from 0 to 35 min total stability was tested of tea samples, storing either at room temperature or in the fridge for intervals of 1, 3, 7, and 14 days. lc-ms/ms analysed tea samples the respective extraction efficiencies (mean recovery) for thc, thca, cbd, cbda, cbn, cbg, cbc cannabinoids were 18.5%, 13.8%, 28.1%, 58.2%, 19.6%, 16.6%, 11.5%. respective extraction efficiencies of thc and thc-aa, and cbd and cbda, significantly reduced the total thc:cbd ratio from 0.71 to 0.25. altering boiling time significantly altered the cannabinoid concentration, and the standard preparation yielded the greatest concentration. there was a trending decrease in cannabinoid concentration from 20–35 minutes boiling time. cbda was the only cannabinoid to maintain a stable concentration across 14 days of refrigeration. thc, cbn, cbg, and cbc reduced to less than 65% of their original concentrations by day 3 of refrigeration. thca reduced to less than 70% its original concentration by day 7 of refrigeration. cbd reduced to less than 40% its original concentration by day 7 of refrigeration. in non-refrigerated samples, mold began growing by day 5 of storage. mold began growing in samples after 5 days of nonrefrigerated storage. song et al. 2023 analysing the presence of 16 different cannabinoids across several cannabinoids of interest: cbla cbca cbc thca, d8-thc, thc, cbn, thcva, cbd, thcv, cbd, cbg, cbga, cbda, cbdv, cbdva. only cbd was present in hemp-infused beverages, and was present in the following concentration levels (%, w/w): sparkling coconut water = 0.0058 lemon sparkling black tea = 0.0040 cbd coffee = 0.033 cannabis, a publication of the research society on marijuana 157 hemp-infused products. solutions were prepared for lc-dad analysis to examine the concentration of different cannabinoids. vandrey et al. 2015 to determine label accuracy of different cannabis products throughout dispensaries in the us. dispensaries which sold a minimum of one edible product were randomly chosen across three us cities (san francisco, los angeles, seattle). purchasers bought a variety of products that were analysed using hplc. label accuracy of thc and cbd was determined within a 10% range: anything >10% than labelled was determined to be “under labeled”, anything <10% less than labelled was determined to be “over labelled”. a total of 75 products (from 47 different brands) were included in the analysis. 13 of the 75 products analysed were cannabis beverages. only 3 (23.1%) cannabis beverages had accurately labelled amounts of thc in the product (the product’s true amount was within 10% of its label). 2 (15.4%) beverages were under labelled (>10% more thc than indicated on the label), and 8 (61.5%) were over labelled (<10% thc than indicated on the label). comparatively, 9.1% of baked goods were accurately labelled, and 20% of candy/chocolate products were accurately labelled. note. abbreviations: arfd = acute reference dose; cbc = cannabichromene; cbca = cannabichromenic acid; cbd = cannabidiol; cbda = cannabidiolic acid; cbdv = cannabidivarin; cbdva = cannabidivarinic acid; cbg = cannabigerol; cbga = cannabigerolic acid; cbla = cannabicyclolic acid; cbn = cannabinol; d8-thc = δ8tetrahydrocannabinol; gc = gas chromatography; gc-ms = gas chromatography–mass spectrometry; hplc = high performance liquid chromatography; hplc-dad = high performance liquid chromatography–diode-array detection; hplc-ms = high performance liquid chromatography–mass spectrometry; icp-ms = inductively coupled plasma–mass spectrometry; lc = liquid chromatography; lc-dad = liquid chromatography–diode array detection; lc-ms = liquid chromatography–mass spectrometry; lc-ms/ms = liquid chromatography–tandem mass spectrometry; loael = lowest observed adverse effect level; lod = limit of detection; loq = limit of quantification; oh-thc = 11-hydroxy-δ9-tetrahydrocannabinol; ota = ochratoxin a; rsd = relative standard deviation; spe = solid-phase extraction; thc = tetrahydrocannabinol; thca = tetrahydrocannabinolic acid; thc-cooh = 11-nor-9-carboxy-tetrahydrocannabinol; thcv = tetrahydrocannabivarin; thcva = tetrahydrocannabivarinic acid; uae = ultrasound-assisted extraction ain the interest of brevity, cannabinoids of interest that were not detected through extraction processes are not reported in the table. bthe loael dosage corresponds to 36 µg/kg of body weight in a 70 kg person. potential risks from cannabis-infused beverages 158 discussion consumption patterns and beliefs consumption rates and attitudes across studies provide limited insight into beverage intake prevalence and perceptions. all but one of these studies (sikorski et al., 2020) were conducted in the us; however, numbers are relatively consistent with the 2022 canadian cannabis survey, where 19% of past-year cannabis users consumed beverages and 8% of past-month users drank cannabis (health canada, 2022b). clinical populations residing in the us also mirror low canadian consumption rates; 1.1% of cancer patients and 7.7% of epilepsy patients consumed cannabis beverages (donovan et al., 2022; kerr et al., 2019), while 8% of canadians reported using cannabis beverages for medical purposes in the past year (health canada, 2022b). legalizing beverages showed a trend toward increasing consumption, with legal purchasing growing 10.2% between 2020–2021 (wadsworth et al., 2023), and consumers being 1.5-2.5x more likely to purchase drinks in legal than illegal markets (goodman et al., 2020). although cannabis beverages before legalization could have been made by consumers at home, availability in stores likely increased their accessibility and thus the ease of consumption. differences in the legal status of cannabis beverages may partially explain varied reports of cannabis beverage prevalence identified in this review, considering some studies were conducted where cannabis was illegal (dowd et al., 2023; goodman et al., 2020; schuaer et al., 2020; sikorski et al., 2021). heterogeneity could also be influenced by mean age; many studies were conducted in young adults (dunbar et al., 2022; fedorova et al., 2021; sikorski et al., 2021; sullivan et al., 2022) consistent with the mean age of cannabis use initiation (health canada, 2022b). these cohort effects make it difficult to draw clear consumption patterns across studies, and more research is necessary across wider population demographics to obtain more potential cohort effects. studies on beverage preferences and attitudes suggest low reports of alcohol replacement, since 15.8% reported desire to replace alcohol with a cannabis drink (charlebois et al., 2020). both medical and recreational motives for cannabis beverage consumption are reported (dowd et al., 2023; fedorova et al., 2021); while some consumers may be cbd-only users and others prefer thc-dominant products, it is possible that the appeal of these beverages may be in unique cannabinoid effects, which cannot be substituted with alcohol. advertisement and marketing the marijuana retail surveillance tool (mrst) in colorado dispensaries suggest that most dispensaries investigated follow appropriate security guidelines (berg et al., 2017), including cannabis beverages offered across all dispensaries, with relatively consistent prices. comprehensive marketing and promotion regulations should be widely applied across markets as novel products continue to emerge, including standardised cannabis surveillance tools, such as the mrst, to identify public health risks and monitor responsible marketing practices. acute effects in human models human studies elucidated aversive cannabis beverage effects in emergency care settings and following acute administration, including increased pulse rate, anxiety, symptoms of mania, and inaccurate time perception (cao et al., 2016; chaudry et al., 1991; karniol et al., 1974; zuardi et al., 1982). however, these effects were often mitigated when thc was combined with cbd doses or when participants were administered cbd alone. only one of these four studies reported including chronic or frequent cannabis users. notably, infrequent cannabis users are more susceptible to psychoactive and physiological effects induced by thc and the blunting effects of cannabinoid interactions (colizzi et al., 2018; solowij et al., 2019). thus, the frequency of cannabis use should be considered an important variable when understanding reported acute effects in these studies. aversive outcomes of consumption and thc+cbd interactions may be heightened due to participants’ infrequent consumption rates, and may therefore not be generalizable to all consumers’ experiences with cannabis beverages. furthermore, new cannabis users should take caution with the cannabinoid dosage and makeup when consuming to limit any potential health-related and psychological harm. cannabis, a publication of the research society on marijuana 159 one study reported greater bioavailability of water-soluble cbd beverages relative to fatsoluble drinks (hobbs et al., 2020). this may have occurred due to the prior fasting of participants, which alters phytocannabinoid bioavailability and pharmacokinetics enhanced by the fat content of meals (birnbaum et al., 2019). future investigations should therefore require control of participants’ fed status – ideally following a standardised meal. potential adverse drug interactions when consuming cannabis-infused beverages with variable thc and cbd content also require greater attention given cbd inhibition of cyp2c9-mediated oral thc clearance (bansal et al., 2023). hobbs and colleagues (2020) also reported no changes in interleukin-10 or tumour necrosis factor levels following the consumption of waterand fatsoluble cbd drinks, contrasting previous findings indicating suppressive effects of cbd administration on inflammation in human and rat models (el-remessy et al., 2006; han et al., 2009). thus, broader investigations are required to determine whether cbd beverages can reduce inflammation and be used as a viable medical treatment. administration of hemp beverages produced a positive thc screen in some participants (steinagle et al., 1999). in this case, cannabis plants with low residual thc content < 0.3% on a dry weight basis are classified as hemp from a regulatory framework in north america and europe. although this could only be detected using a precise analytic method, these findings highlight trace cannabinoid amounts still present in hemp products, which is important to highlight to consumers who may not be knowledgeable of their presence. drink composition two studies observed that changes to tea preparation techniques altered cannabinoid composition (hazekamp et al., 2007; pacifici et al., 2017), albeit with conflicting results. despite both studies using the same cannabis:water ratios in their standard preparations, trending decreases and significant increases in cannabinoid levels at increasing boiling times were observed. regardless of these inconsistencies, potential differences in phytocannabinoid concentrations can vary depending on preparation techniques; thus, it is essential for consumers to be knowledgeable of these effects to minimize risks for overconsumption. inconsistent labeling accuracy observed across current research (lindsay et al., 2021; miller et al., 2022; vandrey et al., 2015) may partially occur due to the illicit or criminalized nature of cannabis in certain regions. specifically, these studies were conducted in the us and jamaica, where cannabis has not yet been nationally legalized, and thus, packaging and label requirements either vary between states or are nonexistent (kruger et al., 2022; lindsay et al., 2021). labeling inaccuracy still occurs for other cannabis products within regulatory frameworks, and another systematic review has identified five studies reporting between 17 and 86% packaging accuracy. thus, while the canadian government has implemented strict packaging requirements (health canada, 2022c), consumers should still take caution when consuming cannabis products. inaccurate reports of cannabis content can pose serious risks for overconsumption, and it is therefore essential to inform consumers of these risks. considering cannabis has been legalized in canada since 2018, more research should examine label and packaging accuracy, including minor cannabinoids, terpenes, caffeine, and other psychoactive constituents, to directly observe the influence of cannabis legalization and regulations. regulated cannabis products require validated analytical methods to determine cannabinoid potency and ensure product efficacy, safety, and consistency. surveillance testing for adulterated cannabis products is warranted, as accidental exposure can lead to injury or death, such as emerging synthetic cannabinoid receptor agonists (krotulski et al., 2021). minor cannabinoids, such as cbn, cannabichromene (cbc) and cannabigerol (cbg; walsh et al., 2021), were not consistently reported in most studies involving drinkable cannabis products. importantly, two acidic variants of thc and cbd, thca and cbda, are widely overlooked constituents of cannabis that have unique physiological properties and therapeutic applications (kim et al., 2023), but these were only targeted in four of 11 studies (ciolino et al., 2018; hazekamp et al., 2007; pacifici et al., 2017; song et al., 2023). thus, the inclusion of thca and cbda information (rather than total thc potential risks from cannabis-infused beverages 160 and cbd) in cannabis beverages is important to accurately assess product formulation. terpene profiles are widely used to classify cannabis strains, as they impact aroma attributes and generate synergistic effects with phytocannabinoids (kaur et al., 2023); however, their analysis in cannabis-infused beverages is sparse. reversed-phase lc with uv absorbance or dad detection is frequently used for phytocannabinoid potency testing with improved selectivity and lower detection limits achieved by lc-ms/ms; however, different extraction and/or sample cleanup methods may be applied to various cannabis products, which might yield variable recovery rates. for instance, christodoulou et al. (2023) demonstrated that solid-phase extraction increased recovery for accurate determination of cannabis-infused beverages (e.g., cannabis coffee, beer, energy drinks, and hemp tea) prior to lc-ms analysis compared to ultrasound-assisted extraction. therefore, optimising pre-analytical protocols to process distinct cannabis products is critical for reliable determination of phytocannabinoid content without bias. limitations and future directions this review highlights a dearth of available research on cannabis beverages, particularly acute intoxication. a lack of standard dosing produces limitations across studies. from a policy perspective, maximum legal dosages are vague; although the canadian government enforces a legal limit of 10 mg/thc per beverage and a possession limit of 17.1 l of cannabis beverages (health canada, 2022a), it is not stated how much liquid must be present per 10 mg of thc. thus, there is no government-determined standard size for cannabis beverages, which range from 30 ml ‘shots’ to over 500 ml. considering the amount of liquid may affect the speed at which someone consumes their beverage, this may affect the onset and duration of intoxication. this issue is not specific to cannabis drinks, as standard cannabis doses across modes do not yet exist (volkow & weiss, 2020). although a standard of 5 mg per product has been proposed (freeman & lorenzetti, 2020), this may not produce consistent intoxication effects (cloutier et al., 2022; hughes et al., 2014; russel et al., 2018; thayer et al., 2019). therefore, effects observed in human and animal models may not be indicative of real-world effects. importantly, thc bioavailability and pharmacokinetics are highly dependent on the specific formulation of the cannabis beverage and whether it is consumed with meals and/or use of other drugs co-metabolized by cytochrome p450 enzymes. future work should seek to replicate findings using consistent dosages, including considerations of phytocannabinoid profiles, mode of consumption, and individual consumer characteristics. most methods to date have been developed for the analysis of cannabis dried flowers and concentrates/resins rather than edibles or beverages that have different matrix interferences. recently, the association of official agricultural chemists have issued standard method performance requirements in 2022 for the quantification of five phytocannabinoids in beverages within a recommended analytical range (0.002-10% w/w), recovery (< 70-130%) and reproducibility (cv < 12%), namely cbd, cbda, thc, thca and cbn (audino et al., 2017); moreover, nine additional minor phytocannabinoids were named in a desirable list for quantification, including cbg, cannabigerolic acid (cbga), cbc, cannabichromenic acid (cbca), cannabidivarin (cbdv), cannabidivarinic acid (cbdva), δ8-thc, tetrahydrocannabivarin (thcv), and tetrahydrocannabivarinic acid (thcva). with the exception of song et al. (2023), few studies have performed comprehensive potency testing of up to sixteen phytocannabinoids in cannabis beverages using lc-ms/ms that also allows for chromatographic resolution of isomeric phytocannabinoids, such as δ8-/δ9-thc. while the global cannabis beverage market is expanding to include drugs, such as caffeine, herbal extracts, taurine, and alcohol, few systematic studies exist for these blends. the us national alcohol survey reports that most cannabis users simultaneously consume alcohol (subbaraman & kerr, 2015), increasing the likelihood of consuming greater quantities of alcohol, drinking more frequently, reporting more alcohol-related consequences than alcohol-only users, and increasing odds of drunk driving, social consequences, and personal harms. a systematic review (gunn et al., 2022) reported heightened behavioural and cognitive effects and increased plasma thc following low dose alcohol consumption among individuals concurrently cannabis, a publication of the research society on marijuana 161 consuming alcohol and cannabis. higher alcohol doses can also blunt subjective thc effects, which may encourage overconsumption, thereby highlighting the need for explorations of blended drinks. given the historical and cultural significance that the cannabis beverage bhang holds, particularly in eastern countries such as india (karki & rangaswamy, 2023), our review conducted a secondary search to uncover more on this drink. however, despite its widespread use, no additional studies assessing acute bhang effects were revealed. while one study highlighted the potential psychotic effects of bhang (chaudry et al., 1991), more research should apply similar systematic and controlled explorations of bhang consumption. conclusion while the canadian government made amendments to the cannabis act in december 2022 to facilitate better access to cannabis beverages for research (health canada, 2022c), there are minimal investigations of acute intoxication effects. current evidence also makes it difficult to draw conclusive statements, due to limited systematic comparisons of subjective, physiological, and cognitive effects across cannabis products. conducting more comprehensive research using cannabis drinks, implementing different cultural applications, and targeting broader subject groups can help fill these gaps. although cannabis beverages may offer a less harmful mode of delivery than smoking/vaping, it is also more convenient and socially acceptable. thus, strategies are needed to mitigate the potential harms from misuse or overconsumption of novel cannabis-infused beverages. references arkell, t. r., vinckenbosch, f., kevin, r. c., theunissen, e. l., mcgregor, i. s., & ramaekers, j. g. 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(1982). action of cannabidiol on the anxiety and other effects produced by delta 9-thc in normal subjects. psychopharmacology, 76(3), 245–250. https://doi.org/10.1007/bf00432554 funding and acknowledgements: this work was supported by the michael g. degroote centre for medicinal cannabis research and the peter boris centre for addictions research. jm is supported by the peter boris chair in addictions research and a canada research chair in translational addiction research (crc-202000170). pb-m acknowledges support from the natural sciences and engineering research council of canada, canada foundation for innovation, and genome canada. the authors have no conflicts of interest to report. ib has received funding from the international centre for responsible gaming and the gambling research exchange ontario as well as consulting fees from bausch. jm is a principal and senior scientist in beam diagnostics inc and has served as a consultant to clairvoyant therapeutics inc. no funding from these entities was used to support the current work, and all views expressed are solely those of the authors. we thank kaitryn campbell, mlis (st. joseph's healthcare hamilton, on) for formulation and refinement of boolean search phrases and karin dearness, mlis (st. joseph's healthcare hamilton, on) for peer review of the ovid search strategy. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ potential risks from cannabis-infused beverages 166 citation: froude, a. m., pangborn, n., britzmckibbin, p., mackillop, j., & balodis, i. (2024). potential risks from cannabis-infused beverages: a critical review. cannabis, 7(3), 134–166. https://doi.org/10.26828/cannabis/2024/000271 issue date: december 12, 2024 research article 56 ved abstract objective: cannabis demand, as measured by the marijuana purchase task (mpt), holds associations with concurrent cannabis consumption and associated risks (e.g., cannabis use disorder [cud]). as few studies have examined prospective associations between cannabis demand and future cannabis use, the current study examined this association in young adults who use cannabis. in addition, the present study explored the novel construct of projected future cannabis demand and its associations with future cannabis use. method: participants first completed a current time1 (t1) mpt, projected future time2 (t2) mpt (i.e., “three months from now”), and measures of past-month cannabis use frequency and cud symptoms during an initial session. they returned three months later (t2) to complete a current t2 mpt and measures of cannabis use and cud symptoms. results: measures across the three mpts (observed t1, projected future t2, and observed t2) indicate relatively stability of demand across time and accuracy in projecting future demand. prospective associations between t1 demand measures and cannabis use were observed, with both observed t1 and projected future t2 demand measures associated with t2 cannabis use frequency. conclusions: results of the current study highlight the potential of current and projected future cannabis demand measures to better understand the trajectory of cannabis use in this high-risk population. key words: = cannabis; demand; behavioral economics; marijuana purchase task; young adult cannabis is the most commonly used illicit drug in the united states, with 22.0% of americans reporting cannabis use in the past year (samsha, 2023), and is highest among young adults aged 18 to 25 (38.2%). the high prevalence of cannabis use among young adults is associated with a myriad of negative cannabis-related outcomes (figueiredo et al., 2020; grant et al., 2012; patel & amlung, 2019). cannabis use disorder (cud) in the past year is highest among young adults (16.5%; samsha, 2023), representing a significant clinical and public health concern. cannabis misuse has been linked to the willingness to spend a considerable amount of time, effort, or money to obtain and use cannabis, suggesting a high reinforcing value (bickel et al., 1998). thus, behavioral economic theory views rebecca kurnellas1,2, cassandra a. sutton1,2, daiil jun1,2, hailey taylor 1,2, aaron p. smith3, ricarda foxx4, ali m. yurasek5, & richard yi1,2 1cofrin logan center for addiction research and treatment 2department of psychology, university of kansas 3division of biomedical informatics, university of kentucky 4department of health education and behavior, university of florida 5department of psychology, gettysburg college cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000324 volume 8, issue 3 current and projected cannabis demand predict future consumption in young adults who use cannabis corresponding author: richard yi, phd, university of kansas, 1000 sunnyside ave. lawrence, kansas, 66045. phone: (785)864-6476. email: ryi1@ku.edu cannabis, a publication of the research society on marijuana 57 heavy cannabis use as an overvaluation of cannabis relative to non-cannabis reinforcers (bickel et al., 2014). we can utilize behavioral economic methods, typically involving measurement of amount of output (i.e., cost) in order to gain access to a drug, to measure its relative reinforcing value (rachlin, 1997). the marijuana purchase task (mpt; aston et al., 2015; collins et al., 2014) is a hypothetical commodity purchase task that examines relative reinforcing value, or demand, by asking participants to imagine a typical day when they would use marijuana, and report how much marijuana they would purchase for consumption at a variety of prices. cannabis demand and use the mpt is a widely-used, valid assessment of the relative reinforcing value of cannabis (for review, see aston & meshesha, 2020), and measures from the mpt are correlated with real world measures of cannabis consumption (aston et al., 2015; 2016a; gonzález-roz et al., 2023; strickland et al., 2017). specifically, high demand for cannabis is an independent risk factor for problematic use, and individuals with any cannabis dependence symptoms show significantly higher demand intensity and more inelastic demand (i.e., relative insensitivity to price increases) compared to those with less problematic use. the mpt has demonstrated that higher demand for cannabis among young adults is correlated with higher cannabis consumption, poor executive functioning, and driving while impaired by cannabis (coelho et al., 2023; patel & amlung, 2019). taken together, the existing literature suggests that cannabis demand as measured by the mpt can offer insight into concurrent cannabis use. findings from existing literature also suggest that demand metrics may predict future substance use. for example, current alcohol demand is associated with drinking quantity and heavy drinking days in the future, even after accounting for risky alcohol use (strickland et al., 2019). in addition, alcohol demand measures among young men predict drink quantity, heavy drinking, and alcohol-related consequences 4 years later, even after accounting for the same measures at baseline (gaume et al., 2022). aston and merrill (2023) demonstrated that alcohol demand intensity predicted drinking quantity at the next drinking event. thus, alcohol demand may exhibit predictive validity for subsequent consumption beyond that of other concurrent alcohol use measures. some recent evidence suggests similar associations with cannabis use. aston et al. (2023) examined the prospective relationship between cannabis demand and future cannabis use frequency at 6-months in a sample of military veterans. they found that higher baseline demand intensity, pmax, and breakpoint were associated with more frequent future cannabis use, indicating that cannabis demand measures may provide insight into future cannabis use. the current study existing research establishes the relationship between cannabis demand and concurrent cannabis use frequency (aston et al., 2016a; strickland et al., 2017). furthermore, alcohol demand is associated with future alcohol use (aston & merrill, 2023; gaume et al., 2022; strickland et al., 2019). however, the predictive relationship between current cannabis demand and future cannabis use in a sample of young adults is unknown. thus, one aim of the current study is to extend the findings on alcohol (aston & merrill, 2023; gaume et al., 2022; strickland et al., 2019) to cannabis and extend findings on demand and concurrent (aston et al., 2016a; strickland et al., 2017) and future (aston et al., 2023) cannabis use frequency. we expect that young adults’ current cannabis demand will predict future cannabis use frequency. in addition to standard demand measures, research indicates that projected future demand might also provide good insight into future consumption. for example, aston and merrill (2023) found associations between alcohol demand intensity projected for the next expected drinking event (i.e., later that same day) and subsequent alcohol consumption. additionally, recent evidence shows that college students project significant increases in demand for 3 months in the future, and these projections are associated with future drinking (kurnellas et al., 2025). thus, a second aim of this project is to examine the novel construct of projected future cannabis demand. a modified mpt that asks participants to make purchasing decisions for a current and projected cannabis demand predict future use 58 future timepoint will allow for exploration of how young adults project their future cannabis demand and whether their projections are accurate. considering this construct will also allow for evaluation of the relationship between projected future cannabis demand and future cannabis use, we expect that projected demand will predict future cannabis use frequency. to address these aims, we collected measures of concurrent cannabis demand, consumption, and projected future demand in an initial session, with measures of concurrent cannabis demand and consumption collected again 3 months later. methods participants one hundred and sixteen (n = 116) young adults were recruited using flyers posted in the community, on a university campus, and on local websites (e.g., craigslist) in a state where cannabis use is legal only for medical use (i.e., recreational use is not legal). participants were eligible to participate if they were between 18 and 29 years of age and reported using cannabis at least once in the past month. see figure 1 for a full breakdown of participant exclusions. one (1) participant was ineligible to participate at recruitment due to not having used cannabis in the past month. twenty (20) participants met at least one criteria for nonsystematic purchase task data (i.e., trend, bounce, reversals from zero; stein et al., 2015) on at least one purchase task, leaving 95 participants with systematic purchase task data. eighteen (18) participants who completed session 1 did not return to complete session 2. a final sample of 77 participants were included in all analyses (see table 1 for demographic variables of the final sample), noting that 55 participants is the minimum sample size to obtain adequate statistical power (0.80 using g*power, with α = .05, two-tailed) for the predicted medium effect size in a regression analysis with five predictor variables (faul et al., 2007). overall study design, effect size estimates, and sample size considerations were informed by kurnellas et al. (2025). all procedures were approved by the university institutional review board . figure 1. participant exclusions cannabis, a publication of the research society on marijuana 59 table 1. participant demographics final sample: n = 77 variable % (n) age in years m = 20.58 (sd = 2.4) gender woman 48% (n = 37) man 52% (n = 40) college student yes 95% (n = 73) freshman 18% (n = 14) sophomore 22% (n = 17) junior 19.5% (n = 15) senior 23% (n = 18) graduate school 9% (n = 7) no 5% (n = 4) race/ethnicity asian 14% (n = 11) black or african american 8% (n = 6) indian 1% (n = 1) white 69% (n = 53) other 4% (n = 3) multiracial 4% (n = 3) hispanic yes 26% (n = 20) no 73% (n = 56) yearly income less than $10,000 77% (n = 59) $10,000 to $29,999 19% (n = 15) $30,000 to $49,999 1% (n = 1) employment status full-time student / no job 43% (n = 33) employed full-time 5% (n = 4) employed part-time 16% (n = 12) full-time student / part-time job 29% (n = 22) self-employed or employment seeking 6% (n = 5) housing situation alone 9% (n = 7) with roommates/partner/parents 91% (n = 70) cannabis route of administration (roa) smoke only 53% (n = 41) vape only 4% (n = 3) eat only 3% (n = 2) concentrate only 3% (n = 2) multiple roas 37% (n = 29) measures marijuana purchase task (mpt; aston et al., 2015). the computerized mpt asked participants to read a vignette, placing several constraints on their consumption (e.g., cannot use marijuana kept from before, cannot stockpile) and report how much marijuana they would purchase for consumption. cannabis hits were quantified as 0.09g of participants’ typical cannabis grade and potency (i.e., 10 hits = 1 joint or 0.9 g or 1/32nd of an ounce), consistent with previous literature (aston et al., 2015). participants entered the number of hits they would smoke if one hit would cost them the current and projected cannabis demand predict future use 60 following prices : $0 (free), $.25 increments to $2, $.50 increment to $7, and $1 increments to $10 (22 total prices). during the first session (t1), participants completed a standard mpt for a typical day during the past month (observed t1 demand) and a projected future mpt for a typical day three months in the future (projected t2 demand). the projected t2 demand mpt asked participants to report purchasing decisions for 3 months in the future (see both vignettes in appendix a). participants returned three months later to complete a second standard mpt (observed t2 demand). timeline follow-back (tlfb). we used the tlfb methodology to assess cannabis consumption frequency during the past month (robinson et al., 2014). participants were given paper handouts with tlfb calendars, marked with relevant holidays and events to best assist participants with accurately reporting how many days they consumed cannabis in the past 30 days. dsm-v cannabis use disorder (cud) symptoms. participants indicated if they have experienced any of the 11 symptoms of cud (yes/no) in the past 12 months, including withdrawal and craving, based on criteria in the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5; american psychiatric association, 2013). procedure. this study was conducted across two in-person sessions, occurring three months apart. participants received a total of $30 in the form of a prepaid debit card if they participated in both sessions (~ 75 min each). immediately after the first session they received $10, and after attending the second session, the card was reloaded with an additional $20. if the first questionnaire in session 1 indicated ineligibility, the participant received a prorated compensation of $5 and was discontinued. consent and baseline – time 1 (t1). in the first session, participants first provided written informed consent. following a demographic survey and a cud questionnaire, participants completed a short interview to complete the tlfb. subsequently, participants completed a standard mpt and projected future mpt on a personal computer in a private room. the experimenter read instructions prior to administering each assessment and was available to answer questions. time 2 (t2). the second session occurred ~3 months after the first session (mean days between sessions = 95 [sd = 8.29], median = 93) in the same setting. the procedure was similar to t1, except that participants did not complete the demographic survey nor the projected future mpt. we note that cud symptoms were collected at this session, but as the assessment asks about past-year use (substantially overlapping with the t1 assessment), this second assessment is not included in any regression analyses. data analysis data were scored and analyzed using ibm spss statistics (version 29) and r programming language (r core team, 2023). cannabis use. means and standard deviations were calculated for cud symptoms and pastmonth cannabis use frequency from the tlfb at t1 and t2. bivariate pearson correlations were performed on cud symptoms, past-month cannabis use frequency, and demand indices at each timepoint. all tests conducted were planned a-priori and theoretically informed, and thus no correction for potential inflation of type 1 error was conducted. demand. responses on each mpt were screened for violations of trend, bounce, and reversals from zero and removed if at least one criterion was failed (stein et al., 2015; see figure 1). we conducted outlier analyses by identifying values ± 3.29 sds at each price on the raw mpt data and replaced outliers with the greatest nonoutlier value (tabachnick et al., 2013),using the “beezdemand” r package (kaplan et al., 2018). the following individual-level observed demand indices were calculated: intensity (consumption when the commodity is available at no cost), pmax (the unit price at which maximum expenditure occurs), omax (the expenditure associated with pmax) , and breakpoint (the lowest unit price at which consumption is zero). elasticity of demand (indexing responsiveness of consumption to price increases, or price sensitivity) was empirically derived using the exponentiated demand equation (equation 1; koffarnus et al., 2015) at the group-level: q=q0 * 10k(e α q 0 c -1) , (1) cannabis, a publication of the research society on marijuana 61 where q represents quantity consumed at a given price, q0 represents derived intensity (i.e., consumption as price approaches zero), k represents a constant across individuals that denotes the range of the dependent variable (hits), α represents the rate of change of elasticity, and c represents cost. raising part of the equation to the power of 10 allows the untransformed consumption values including zero values to be fit. we used a consistent k value of 2.158429 (i.e., the mean of the three default k values) when modelfitting all purchase task data (see figure 2 for group-level demand curves). each demand measure was positively skewed and underwent log-10 transformations to achieve normality. tests of normality, linearity, homoscedasticity, and absence of multicollinearity were performed to ensure that assumptions of linear regressions were met (flatt & jacobs, 2019; mishra et al., 2019). figure 2. group-level demand curves from observed t1, projected t2, and observed t2 data note. n = 77. note logged price axis. current demand and future use to examine if current cannabis demand predicts future cannabis use, we performed a series of linear regressions on observed t1 demand indices and future cannabis use. for each observed t1 demand predictor (i.e., intensity, omax, pmax, breakpoint, and elasticity), separate linear regressions were performed to determine if current demand predicts future cannabis use frequency, as measured by the tlfb at t2. t1 cud symptoms and t1 cannabis use frequency were added to the regression models one at a time to examine the partial effects of observed t1 demand indices. projected demand to examine projected change in demand (i.e., how participants think their demand will change in 3 months), projected change was calculated by subtracting observed t1 demand from projected t2 demand (see table 2). bivariate pearson correlations were conducted on projected t2 and observed t1 demand. paired-samples t-tests were performed on projected t2 and observed t1 demand to examine if participants project changes in demand. to examine observed change in demand (i.e., how participants’ demand actually changed in 3 months), observed change was calculated by subtracting observed t1 demand from observed t2 demand (see table 2). bivariate pearson correlations were conducted on observed t1 and observed t2 demand to examine the relative stability of demand. paired-samples t-tests were performed on observed t1 and observed t2 current and projected cannabis demand predict future use 62 demand to examine if demand changes across timepoints. to determine accuracy in projections, we performed delta calculations by subtracting observed t2 from projected t2 demand (see table 3). bivariate pearson correlations were performed on the projected change and observed change, representing relative accuracy of projections. paired-samples t-tests were performed on projected t2 and observed t2 demand to examine accuracy. projected demand and future use to examine if projected future demand predicts future cannabis use, we performed a series of regressions on projected t2 demand indices and future cannabis use. for each projected t2 demand predictor (i.e., intensity, omax, pmax, breakpoint, and elasticity), separate linear regression models were estimated to determine if projected demand predicts the outcome of t2 cannabis use frequency. t1 cud symptoms and t1 cannabis use frequency were added to the regression models one at a time to examine the partial effects of projected t2 demand indices. additional study measures and procedures not relevant to this study are reported elsewhere (foxx et al., 2023). results data quality to test the assumption of normality, predicted probability (p-p) plots of the residuals were examined and all plots demonstrated a normal distribution for each variable included in analyses. scatterplots of residuals demonstrated patterns of homoscedasticity. the variance inflation factors (vif) all fell below 5.00, indicating an absence of multicollinearity (kutner et al., 2004). thus, the data met all assumptions of linear regressions. the exponentiated model (koffarnus et al., 2015) provided an excellent fit across purchase tasks (observed t1 r2 mean = .900 [range .730 to .993], projected t2 r2 mean = .883 [range .614 to .990], observed t2 r2 mean = .912 [range .740 to .996]). table 2 provides descriptive statistics of all demand, projected change, observed change, and accuracy measures. table 3 provides results on bivariate correlations between demand and cannabis use measures. each projected t2 measure was correlated with its respective observed t1 and observed t2 measure; the novel projected demand task demonstrated adequate construct validity given its close associations with valid and reliable standard measures at two timepoints (aston et al., 2015; bush et al., 2023). additionally, the exponentiated demand model yielded an r2 mean of .883 for the projected task, demonstrating goodness of fit for these novel measures (koffarnus et al., 2015). table 2. descriptive statistics of non-transformed observed t1, projected t2, and observed t2 demand indices; descriptive statistics and t-test results of log-transformed projected change, observed change, and accuracy of projections demand index observed t1 projected t2 observed t2 m (sd) m (sd) m (sd) intensity 11.25 (7.63) 12.64 (9.78) 14.14 (12.77) omax 6.81 (4.73) 8.89 (6.90) 9.23 (11.00) pmax 2.20 (2.28) 2.05 (2.14) 2.01 (1.85) bp1 3.05 (2.78) 3.19 (2.81) 3.19 (2.76) elasticity () .029 (.024) .025 (.024) .030 (.040) † projected change † observed change † accuracy ∆ (projt2-obst1) ∆ (obst2-obst1) ∆ (projt2-obst2) intensity +.025 (.124) +.052 (.238) -.027 (.241) omax +.075 (.176)** +.048 (.297) +.027 (.296) pmax -.012 (.175) -.005 (.229) -.007 (.229) bp1 +.015 (.121) +.018 (.237) -.003 (.229) elasticity () -.001 (.005)* +.001 (.013) -.002 (.013) note. † indices were log-transformed. *p < .05, ** p < .01. n = 77. cannabis, a publication of the research society on marijuana 63 table 3. bivariate pearson correlations of demand and cannabis use measures at each timepoint variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1. obs. t1 intensity .357** -.236* -.099 -.511** .908** .356** -.265* -.139 -.451** .659** .256* -.302 -.122 -.237* .321** .182 .334** .193 2. obs. t1 omax .574** .640** -.860** .319** .808** .490** .560** -.753** .315** .517** .230** .307** -.470** .035 .285* .052 .292* 3. obs. t1 pmax .888** -.441** -.224 .435** .722** .770** -.374** -.138 .202 .499** .439** -.247* -.078 .125 -.190 .169 4. obs. t1 bp1 -.557** -.059 .545** .733** .887** -.488** .036 .352** .554** .565** -.373** -.045 .203 -.073 .205 5. obs. t1 elasticity -.483** -.741** -.333** -.489** .868** -.424** -.511** -.266* -.369** .557** -.128 -.308** -.187 -.303** 6. proj. t2 intensity .488** -.240* -.032 -.538** .677** .327** -.231* -.037 -.264* .247* .195 .318** .187 7. proj. t2 omax .514** .648** -.858** .394** .567** .248* .374** -.507** -.051 .240* .010 .216 8. proj. t2 pmax .847** -.392** -.177 .209 .481** .411** -.237* .273* .014 .336* .002 9. proj. t2 bp1 -.567** .004 .373** .570** .601** -.370** -.145 .122 -.148 .116 10. proj. t2 elasticity -.425** -.537** -.289* -.390** .576** .004 -.221* -.072 -.222* 11. obs. t2 intensity .621** -.076 .172 -.491** .207 .340** .409** .256** 12. obs. t2 omax .471** .641** -.731** -.033 .410** .188 .293** 13. obs. t2 pmax .871** -.435** -.193 .148 -.107 .057 14. obs. t2 bp1 -.564** -.085 .205 -.003 .133 15. obs. t2 elasticity .091 -.165 -.112 -.101 16. t1 tlfb .417** .696** .396** 17. t1 cud .499** .793** 18. t2 tlfb .426** 19. t2 cud note. highlighted cells represent associations between obs t1 and corresponding proj t2 and obs t2 demand measures. boxed cells represent associations between proj t2 and corresponding obs t2 demand measures demand indices were log-transformed. *p < .05 **p < .01. n = 77. current demand and future cannabis use our first aim was to examine if current cannabis demand is associated with future cannabis use frequency. table 4 provides findings related to linear regression models of observed t1 demand predicting t2 cannabis use frequency (i.e., tlfb). findings from the five unadjusted models demonstrated that observed t1 intensity was a statistically significant positive predictor of cannabis use frequency at t2 (p = .003). when t1 cud symptoms were added as a covariate to the five adjusted models, observed t1 demand intensity was still a statistically significant positive predictor of cannabis use frequency at t2 (p = .012), and observed t1 pmax was a statistically significant negative predictor of cannabis use frequency at t2 (p = .010). when cannabis use frequency at t1 was added as a covariate to the five independent adjusted models, observed t1 demand intensity and pmax were no longer statistically significant predictors of future cannabis use frequency. table 4. linear regressions of observed t1 demand predicting future cannabis use frequency at t2 observed t1 demand std. β unstandardized b p r2 outcome: timeline follow-back at t2 unadjusted models intensity .334 12.948 .003** .112 omax .052 2.068 .656 .003 pmax -.190 -8.075 .097 .036 bp1 -.073 -2.896 .530 .005 elasticity () -.187 -189.918 .103 .035 adjusted for timeline follow-back at t1 intensity .123 4.767 .162 .489 omax .027 1.091 .746 .485 pmax -.137 -5.815 .100 .503 bp1 -.042 -1.659 .620 .486 elasticity () -.100 -101.293 .235 .494 current and projected cannabis demand predict future use 64 adjusted for cannabis use disorder symptoms at t1 intensity .252 9.751 .012* .310 omax -.099 -3.960 .348 .258 pmax -.257 -10.902 .010* .314 bp1 -.181 -7.230 .076 .280 elasticity () -.037 -37.189 .730 .250 note. demand indices were log-transformed. all predictor variables were entered into separate models. *p < .05, **p < .01. n = 77 existing research suggests that demand measures may fall into two factors holding distinct associations with aspects of substance use, with a latent two factor structure underlying demand indices (aston et al., 2017; bidwell et al., 2012; mackillop et al., 2009). the latent factors are said to characterize persistence (i.e., price insensitivity; elasticity, pmax, omax, breakpoint) and amplitude (i.e., volumetric consumption; omax [at times] and intensity). given our contrasting results, we conducted exploratory analyses on the associations between the latent factors of current demand and future cannabis use. based on factor analyses by aston et al. 2017, persistence was calculated as the mean of the standardized observed t1 omax, pmax, breakpoint, and elasticity scores. prior to this calculation, elasticity values were reversed (i.e., 1/) so that greater values reflect greater persistence (bidwell et al., 2012). amplitude was calculated as the mean of the standardized observed t1 intensity scores (aston et al., 2017). results of linear regressions indicate that amplitude was a statistically significant positive predictor of t2 cannabis use frequency, even after accounting for baseline cud symptoms (standardized β = .282, r2 = .328, p = 004). however, persistence was not a statistically significant predictor of t2 cannabis use frequency (standardized β = -.196, r2 = .285, p = .056). projected demand our second aim was to explore the novel construct of projected future cannabis demand. we examined if young adults project changes in their future demand for cannabis relative to current demand. significant, positive bivariate correlations between observed t1 and projected t2 demand (see light gray cells in table 2) suggest relative stability of projected future demand compared to observed t1 demand (r ranged from +.722 to +.908; all p < .001). results of pairedsamples t-tests on projected t2 and observed t1 demand measures indicate there were no significant differences in intensity, t(76) = 1.791, p = .077; pmax, t(76) = -.602, p = .549; or breakpoint, t(76) = 1.045, p = .299. however, projected t2 omax was significantly higher compared to observed t1 omax, t(76) = 3.747, p < .001, and projected t2 elasticity was significantly lower compared to observed t1 elasticity, t(76) = 2.450, p = .017. we examined if demand in young adults changes across timepoints. significant, positive bivariate correlations between observed t1 and observed t2 demand (see dark gray cells in table 2) suggest relative stability in demand across timepoints (r ranged from +.499 to +.659; all p < .001). results of paired-samples t-tests on observed t1 and observed t2 demand indices indicate that young adults did not display significant changes in intensity, t(76) = 1.925, p = .058; omax, t(76) = 1.413, p = .162; pmax, t(76) = .206, p = .837; breakpoint, t(76) = .648, p = .519; or elasticity, t(76) = .374, p = .709. we examined if young adults are accurate in their projections of future cannabis demand. bivariate correlations between projected t2 and observed t2 demand (see boxed cells in table 2) revealed that projected t2 demand indices were statistically significantly, positively correlated with each of their respective observed t2 demand indices (r ranged from +.481 to +.677; all p < .001). bivariate correlations between projected change and observed change in demand reveal that projected change in intensity (r = +.230, p = .044), omax (r = +.300, p = .008), pmax (r = +.382, p < .001), breakpoint (r = +.323, p = .004), and elasticity (r = +.240, p = .035) are statistically significantly, positively correlated with each of their respective observed change variables, suggesting relative accuracy in projections. results of paired-samples cannabis, a publication of the research society on marijuana 65 t-tests on projected t2 and observed t2 demand indices indicate no statistically significant difference for intensity, t(76) = -.979, p = .331; omax, t(76) = .087, p = .422; pmax, t(76) = -.254, p = .800; breakpoint, t(76) = -.116, p = .908; or elasticity, t(76) = -1.346, p = .182. projected demand and future cannabis use we examined if projected future cannabis demand predicts future cannabis use frequency. table 5 provides findings from linear regressions of projected t2 demand predicting t2 cannabis use frequency. findings from the five unadjusted models demonstrated that projected t2 intensity was a statistically significant positive predictor of cannabis use frequency at t2 (p = .005), and projected t2 pmax was a statistically significant negative predictor of cannabis use frequency at t2 (p = .003). when cud symptoms at t1 were added to the five independent adjusted models, projected t2 intensity was still a statistically significant positive predictor of observed t2 cannabis use frequency (p = .023), and projected t2 pmax (p < .001) and projected t2 breakpoint (p = .035) were statistically significant negative predictors of observed t2 cannabis use frequency. however, when cannabis use frequency at t1 was added to the five independent adjusted models, none of the projected t2 measures were significant predictors of future cannabis use frequency. given our contrasting results on projected future demand and observed future use, we assessed the associations between projected future demand latent factors and future use. projected future persistence was calculated as the mean of the standardized projected t2 omax, pmax, breakpoint, and elasticity (reversed) scores. projected future amplitude was calculated as the mean of the standardized projected t2 intensity scores, as in aston et al. (2017). results of linear regressions indicate that projected future amplitude was a statistically significant positive predictor of cannabis use frequency at t2 after accounting for baseline cud symptoms (standardized β = .244, r2 = .308, p = .015). in addition, projected future persistence was a statistically significant negative predictor of cannabis use frequency after accounting for baseline cud symptoms (standardized β = -.213, r2 = .293, p = .034). table 5. linear regressions of projected t2 demand predicting future cannabis use frequency at t2 projected t2 demand std. β unstandardized b p r2 outcome: timeline follow-back at t2 unadjusted model intensity .318 10.921 .005** .101 omax .010 .345 .088 .000 pmax -.336 -14.690 .003** .113 bp1 -.148 -5.816 .198 .022 elasticity () -.072 -74.664 .533 .005 adjusted for timeline follow-back at time 1 intensity .156 5.345 .068 .507 omax .045 1.541 .587 .487 pmax -.157 -6.871 .068 .507 bp1 -.048 -1.888 .569 .487 elasticity () -.075 -77.260 .371 .490 current and projected cannabis demand predict future use 66 adjusted for cannabis use disorder symptoms at time 1 intensity .230 7.883 .023* .300 omax -.116 -3.942 .262 .262 pmax -.343 -15.009 <.001** .366 bp1 -.212 -8.318 .035* .293 elasticity () .040 41.562 .698 .251 note. demand indices were log-transformed. all predictor variables were entered into separate models. *p < .05, **p < .01. n = 77 discussion current demand and future cannabis use based on existing research showing associations between cannabis demand and concurrent (aston et al., 2016a; strickland et al., 2017) and future (aston et al., 2023) consumption, our first aim was to examine the associations between current cannabis demand and future cannabis use in young adults who use cannabis. our results indicated that observed t1 intensity was a positive predictor of t2 cannabis use frequency (i.e., tlfb past-month use days), even after accounting for t1 cud. this indicates that higher reported consumption of free (i.e., $0.00) cannabis in the present is associated with more frequent cannabis use in the future. previous literature demonstrates that alcohol demand intensity, one of the most key demand measures, predicts future alcohol use frequency beyond what can be accounted for by baseline use severity (i.e., audit; strickland et al., 2019). alcohol demand intensity also predicts subsequent drinking quantity in the short-term (i.e., same day, aston & merrill, 2023) and in the long-term (i.e., 4 years, gaume et al., 2022). cannabis demand intensity is also associated with more frequent cannabis use 6 months later, with intensity being the only cannabis demand measure to demonstrate prospective validity (aston et al., 2023). however, our more unexpected finding is that pmax was a negative predictor of future cannabis use frequency. this suggests that reporting lower prices at which the most amount of money on cannabis is spent is associated with more frequent cannabis use in the future, which is inconsistent with previous evidence of pmax being related to greater future cannabis use (aston et al., 2023). we explored these findings further by examining associations of current amplitude (ad libitum consumption) and persistence (consumption despite price increases) factors with future cannabis use. findings indicated that amplitude (specifically intensity of demand) was a significant positive predictor of future cannabis use, but persistence was not a significant predictor of future cannabis use. given that pmax was the only persistence measure that was a predictor on its own, the result is consistent with previous knowledge that pmax may be a poor predictor of substance use outcomes (zvorsky et al., 2019). intensity appears to be the most informative current cannabis demand measure for predicting future use. given the clinical and public health concern of cannabis use in young adults (figueiredo et al., 2020; grant et al., 2012; nsduh, 2022; patel & amlung, 2019), these results provide valuable information on their consumption behaviors. specifically, if future frequency of cannabis use days (this study’s outcome variable) is the primary outcome of clinical concern, then present consumption at no or low cost is likely the best mpt predictor. in contrast, degree of sensitivity to price increases does not appear to be an effective predictor. we note that while current intensity/amplitude predicted future cannabis use even accounting for current cud symptom count, it did not remain a significant predictor for future cannabis use after controlling for current cannabis use. this suggests that current cannabis use is at least an equally effective predictor of future cannabis use as current intensity, and that studies that examine cannabis use longitudinally should consider the value-added of tasks like the mpt beyond a measure as straightforward as current use. projected future demand cannabis, a publication of the research society on marijuana 67 our second aim was to explore the novel construct of projected future cannabis demand. our results revealed that young adults projected higher future expenditure on cannabis (i.e., higher omax) and a relatively inelastic demand. these results demonstrate that young adults expect diminished sensitivity to cannabis price increases in the future relative to their current selves, which is partially consistent with the previous evidence of young adults projecting future increases in alcohol demand across all measures (kurnellas et al., 2025). the previous study on projected future alcohol demand only included young adults who specifically engage in heavy drinking, which might explain their expected future increases across all demand measures, compared to our current participants with any presence of past-month cannabis use only projecting future increases in some measures. we also observed that young adults were relatively accurate in their projections of all five future demand measures. specifically, projected future and observed t2 demand for all metrics did not significantly differ, and all projected change and observed change variables were significantly correlated, further indicating relative accuracy of future projections. kurnellas et al. (2025) previously found that young adults with heavy alcohol use were also relatively accurate in their projections of future demand measures, other than overestimating their future omax. cannabis use is shown to be relatively stable over time (i.e., 6 months; aston et al., 2023), which is consistent with our study (tlfb t1 m = 15.03, sd = 9.9; tlfb t2 m = 14.9, sd = 10.1), while alcohol use might exhibit greater variability (goldman et al., 2011). ultimately, our results indicate that young adults have a generally sound estimation of their cannabis demand for 3 months into the future. based on existing evidence that projected future alcohol demand is associated with subsequent consumption (aston & merrill, 2023; kurnellas et al., 2025), we also examined the associations between projected future cannabis demand and future cannabis use. our results revealed that projected future intensity positively predicted future cannabis use, where projecting higher consumption of free (i.e., $0.00) cannabis in the future is associated with more frequent cannabis use in the future. this finding is consistent with previous literature on the association between projected future alcohol demand intensity and future consumption (kurnellas et al., 2025) but even further supports the utility of cannabis demand intensity (aston et al., 2023) given its unique associations (i.e., beyond what can be explained by cannabis use severity) not shown with alcohol. however, our more unexpected finding is that projected future pmax and breakpoint were negative predictors of future cannabis use frequency, where projecting lower prices at which 1) maximum expenditure on cannabis and 2) suppression of consumption occur is associated with more frequent cannabis use in the future. we note that, like the analyses of present demand predicting future use, significant findings were preserved when accounting for current cud symptoms, but not after accounting for current cannabis use. we further explored these findings by examining projected future amplitude and persistence factors’ associations with future cannabis use. projected future amplitude was a significant positive predictor of future cannabis use frequency, where expecting greater future consumption unrestricted by price is associated with more frequent cannabis use in the future. this finding is consistent with factor analysis showing that higher amplitude (only intensity for cannabis) was associated with more frequent use (aston et al., 2017). additionally, projected future persistence was a significant negative predictor of future cannabis use frequency, where expecting decreased consumption in the face of price increases in the future is associated with more frequent cannabis use in the future. previous factor analysis revealed that higher persistence is associated with lower expectancies of negative cannabis outcomes (aston et al., 2017), which may be attributable to expected tolerance to acute effects of cannabis long-term (volkow et al., 2014), but may also be attributable to expectations of lower cannabis risk. this existing work broadly supports other evidence showing associations between higher persistence and lower perceptions of cigarette-related risks (o’connor et al., 2016). this is particularly problematic, as the perception of lower cannabis risk is shown to reflect a higher likelihood of risk behavior (e.g., driving after consuming cannabis; aston et al., 2016b). therefore, it is possible that an expectation of high price sensitivity (i.e., cannabis use that is responsive to increasing costs, including negative current and projected cannabis demand predict future use 68 consequences) might be indicative of a misinformed belief that current cannabis use is unlikely to result in future escalation of use or development of problematic use; this belief may then result in increased vulnerability to subsequent escalation of use. overall, results on the predictive validity of the projected future demand measures suggest that projected future intensity and price sensitivity (i.e., omax, pmax, breakpoint, elasticity) may serve distinct purposes in understanding the trajectory of cannabis use in young adults. limitations and future directions despite potentially valuable contributions to the knowledge on this high-risk population, we note some limitations and future directions. specifically, the generalizability of the findings is limited to our sample’s demographics (i.e., primarily white young adults who attend college), including the legal status of cannabis (legal only for medicinal purposes). in addition, our mpt constrained participants to one cannabis product (joint) and route of administration (smoking), and future research might consider using an adaptive mpt (bush et al., 2023) to increase the individuallevel relevance of the task. we note that four participants (all female) reported that their only current route of administration was oral/concentrates. as this would not rule out familiarity with cannabis hits, and their data were consistent with sample observations while meeting systematicity thresholds, their data were retained in our analyses. we also did not collect a number of measures (e.g., reasons for use, disposable income, consumption quantity) that might contribute to expectations of future use, and thus projected future demand. additionally, research should measure projected future demand across longer time periods, as substance use is shown to vary in accordance with time of year, academic requirements, and holidays in emerging adults (goldman et al., 2011). finally, it is important to note that for both current demand and future projected demand, none of the demand indices predicted future cannabis use after accounting for current cannabis use. while this does not completely undermine the potential utility of the (current and projected future) demand measures of the current study, it does highlight that baseline measures of substance use should be included in longitudinal analyses of use/consequences in order to assess the valueadded of novel assessments or constructs. conclusion the present study is the first to examine the predictive utility of cannabis demand in young adults, as well as introduce the novel construct of projected future cannabis demand. the measure of current cannabis amplitude (i.e., intensity), and measures of projected future cannabis amplitude and persistence, predict cannabis use frequency in the future, even accounting for current cud symptoms. given this evidence that some projected future demand measures are not wholly redundant with measures of current demand, we believe further research on projected future demand may contribute to both theoretical and practical insights into factors that contribute to the escalation of cannabis use and negative userelated consequences. while in need of further replication, the present results suggest that cannabis-using young adults exhibiting projections of high future amplitude or low persistence may benefit from targeted interventions that seek to lower the reinforcing value of cannabis or highlight the decrease in price sensitivity that often accompanies continuation/escalation of cannabis use. references american psychiatric association. 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(2019). sensitivity of hypothetical purchase task indices when studying substance use: a systematic literature review. preventive medicine: an international journal devoted to practice and theory, 128. https://doi.org/10.1016/j.ypmed.2019.105789 funding and acknowledgements: this work was supported by funding from the university of florida and the cofrin logan center at the university of kansas. the authors have no conflicts of interest to disclose. we are grateful to disha patel for support in the preparation of this manuscript. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: kurnellas, r., sutton, c. a., jun d., taylor, h., smith, a. p., foxx, r., yurasek, a. m., & yi, r. (2025). current and projected cannabis demand predict future consumption in young adults who use cannabis. cannabis, 8(3), 56–71. https://doi.org/10.26828/cannabis/2025/000324 https://creativecommons.org/licenses/by/4.0/ research article 112 ved abstract objective: cannabis use among adults over age 50 is increasing, but data on specific products, co-use, and cannabis-related problems in this age group are lacking. the current study assessed differences in cannabis use patterns and alcohol and nicotine co-use by select demographic factors and medical cannabis status, as well as associations with problem cannabis use, among adults over 50. method: adults over age 50 who used cannabis use in the past 30 days were recruited from a healthcare system and invited to complete an online survey. results: participants (n = 367) were 43% female, with an average age of 65.9 (sd = 8.6), and predominantly white (67.9%), native hawaiian or pacific islander (nhpi; 12.3%), or asian (9.3%). mean frequency of cannabis use within the past 30 days was 18.7 days (sd = 11.5), and 27% reported use of nonmedical cannabis-only. co-use of cannabis with other substances was common, especially alcohol. although group comparisons showed several differences by age, sex, and medical cannabis status, greater differences were found by race/ethnicity. white participants were more likely than others to have a state medical cannabis card, source their cannabis solely from medical dispensaries, and report alcohol co-use. nhpi participants were most likely to smoke cannabis and use tobacco. smoking, as compared to consuming edibles and “other” methods, and greater cannabis frequency, were associated with problem cannabis use. conclusions: findings illustrate patterns of cannabis and other substance use, with important demographic differences. future research among older adults should include development of targeted interventions to address cannabis use problems and polysubstance use. key words: = cannabis; older adults; native hawaiian and pacific islanders; asian; race; problem cannabis use; cannabis use disorder kristina t. phillips1,2, kathryn l. pedula3, kara tsuzaki1, catherine erickson1, jonathan lai1, vanessa simiola1, samantha wong4, pallav pokhrel5, & derek d. satre6,7 1center for integrated health care research, kaiser permanente hawaii 2department of health systems science, kaiser permanente bernard j. tyson school of medicine 3hawai‘i permanente medical group, kaiser permanente hawaii 4john a. burns school of medicine, university of hawai‘i 5population sciences program, university of hawai‘i cancer center 6department of psychiatry and behavioral sciences, university of california, san francisco 7division of research, kaiser permanente northern california cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000303 volume 8, issue 2 cannabis use patterns and couse of alcohol and nicotine in adults over 50 by demographic factors and medical cannabis use corresponding author: kristina t. phillips, phd, center for integrated health care research, kaiser permanente hawaii, 2828 paʻa st., suite 2055. honolulu, hawai‘i, 96819. phone: (808) 432-5777 x1946. email: kristina.t.phillips@kp.org cannabis, a publication of the research society on marijuana 113 as cannabis becomes legalized for medical and non-medical (recreational) purposes, prevalence among adults over age 50 has increased. recent estimates suggest that up to 15% of adults over 50 report past-year cannabis use, and approximately 6-11% have used it in the past month, with higher rates in those aged 50-64 compared to those over the age of 65 (fernandez et al., 2023; han & palamar, 2018, 2020; kepner et al., 2023; patrick et al., 2022; salas-wright et al., 2017). public opinion surrounding cannabis has become more permissive in the u.s. over time, coinciding with changes in state cannabis policies and cultural norms surrounding use (carliner et al., 2017). perceptions of risk related to cannabis are also changing among older adults. a recent study with a national sample of adults age 65 and older showed that perceived risk associated with regular cannabis use decreased from 53% to 43% from 2015 to 2019 (han et al., 2021). the changing landscape of cannabis acceptance has been accompanied by a transformation in consumption methods. a growing body of evidence finds that cannabis, and particular ways of consuming it, are linked to potential health risks (fischer et al., 2022). smoking cannabis remains the most common method of ingestion across all age groups and can lead to respiratory issues, such as chronic bronchitis and lung irritation (fischer et al., 2022; leal & moscrop-blake, 2024; russell et al., 2018). vaping cannabis oil, flower, or high-potency products in aerosol form, which allows for greater discretion, has grown in popularity and is often viewed as a safer alternative to smoking (aston et al., 2019). although health outcomes related to vaping remain unclear, vaping cannabis has been linked to e-cigarette or vaping product useassociated lung injury (evali), often caused by additives like vitamin e acetate (cherian et al., 2020). use of high-potency thc and dabbing, or inhaling concentrated cannabis extracts, can increase the risk of cannabis use disorder (cud) and psychiatric effects, such as psychosis (arterberry et al., 2019; hoch et al., 2025). lastly, cannabis edibles (e.g., cookies, candies), while thought to be the most benign of the consumption methods, can result in unintentional overconsumption due to their slower effects, especially in those with less tolerance to cannabis (hoch et al., 2025; russell et al., 2018). little is known about cannabis product use, patterns, co-use, and cud among older adults. past work suggests that middle-aged and older u.s. adults are more likely than younger adults to consume cannabis using one method vs. multiple methods, mostly consume cannabis via smoking, and are less likely to consume cannabis concentrates or vape (livne et al., 2024). a study of adults in washington state found that smoking and oral consumption were the most common methods of cannabis ingestion among participants over age 50 (subbaraman & kerr, 2021). onethird to half of participants over age 50 reported usually or always using cannabis with alcohol. another study found that older adults who reported past year alcohol use were more likely to endorse cannabis use in the past year, with increasing odds of cannabis use as level of alcoholrelated harm increased (fernandez et al., 2024). a study examining electronic health records of adults over age 50 found that patients who had cannabis noted in their medical record had a greater risk of alcohol or tobacco use disorder compared to matched controls (phillips et al., 2024). further evidence on patterns of cannabis use and co-use in older adults would be useful to understand potential cannabis-related health risks in the aging population. given the physiological and cognitive changes associated with aging, adults over age 50 may be at higher risk of cannabis-related adverse health effects. older adults are more prone to a wide range of health conditions, including cardiovascular events and diseases (e.g., hypertension, myocardial infarction), respiratory illnesses (e.g., chronic obstructive pulmonary disorder [copd]), and injuries/falls (centers for disease control and prevention, 2020; kochanek et al., 2023). a growing body of evidence has linked cannabis use with declines in respiratory function, chronic bronchitis, gastrointestinal problems (e.g., cannabinoid hyperemesis syndrome), motor vehicle crashes, and risk for certain mental health disorders (e.g., schizophrenia; gracie & hancox, 2021; national academies of sciences and medicine [nasem], 2017; phillips et al., 2022; tan et al., 2019; wolfe et al., 2023). however, there is a significant gap in research assessing cannabis-related health outcomes in older adults (wolfe et al. 2023). couse of cannabis with alcohol and nicotine further complicate the examination of cannabis-related cannabis use patterns in adults over 50 114 health effects due to overlapping and interacting influences on health outcomes. the prevalence of alcohol use and binge drinking among older adults is a growing concern (white et al., 2023). low-risk drinking has been shown to be associated with higher mortality in older adults who have underlying health conditions or socioeconomic risk factors (ortolá et al., 2024). as the frequency and amount of alcohol increases, additional risks for cancer and cardiovascular disease also rise (ortolá et al., 2024). although smoking cigarettes has declined in all age groups, including older adults, smoking can exacerbate age-related health challenges and increase the likelihood of severe health outcomes, including mortality, cancer, dementia, and cardiovascular disease (gellert et al., 2012; hunt et al., 2023). with younger populations, there is evidence that the combined effects of cannabis and tobacco smoking or vaping contribute to a higher risk profile, particularly with a lengthier smoking history (meier & hatsukami, 2016; smith et al., 2020; winhusen et al., 2019), but few studies have examined health impacts of cannabis and nicotine or alcohol co-use (or poly-substance use of all three) in older adults. it is not clear whether using multiple substances significantly elevates health risks for older adults above and beyond singlesubstance use, particularly in those with preexisting health conditions. while cannabis has demonstrated adverse health effects, it may also provide therapeutic benefits. according to the national academies of sciences & medicine (nasem, 2017), there is conclusive or substantial evidence that cannabis or cannabinoids are effective in treating chronic pain, chemotherapy-induced nausea and vomiting, and patient-reported spasticity associated with multiple sclerosis. there is moderate evidence that cannabis can improve sleep associated with specific health conditions (e.g., sleep apnea). however, evidence for other conditions remains limited or insufficient. surveys with older adults using cannabis medically (brown et al., 2020; manning & bouchard, 2021; reinarman et al., 2011) and medically/non-medically (lum et al., 2019) suggest that many use cannabis to treat chronic pain, anxiety, depression, insomnia, nausea, and arthritis, with respondents reporting improved outcomes. despite the limited evidence of therapeutic benefit, a wide range of medical and behavioral health diagnoses qualify the general public for state-approved medical cannabis programs (boehnke et al., 2019). furthermore, most studies assessing medical benefits have not addressed safety and efficacy in older adults (nasem, 2017; wang et al., 2023). this is an important limitation as specific cannabis products, administration methods, and doses may affect older adults differently (levy et al., 2020). this paper aims to address some of these knowledge gaps by examining cannabis use for medical and non-medical purposes among a diverse sample of adults over 50, including cannabis use patterns (frequency, forms used, methods of ingestion, medical vs. non-medical use, and access to/use of medical dispensaries) and couse of cannabis with nicotine and alcohol. additionally, we compare differences in cannabis use patterns by medical vs. non-medical cannabis status, age (50-64 vs. 65 and older), sex assigned at birth, and race/ethnicity, and assess factors associated with cannabis use problems. all data were collected in one state (hawaiʻi) with a diverse population and legal medical cannabis use since 2000 (no current state-approved nonmedical use). as data were primarily exploratory and the literature on cannabis use in older adults remains limited, there were no a priori hypotheses. methods participants and procedures participants were recruited from kaiser permanente hawaii, a large, not-for-profit integrated healthcare provider with services across hawaiʻi and a socioeconomically diverse membership. electronic health records were used to identify adults over 50. recruitment emails were sent to a total of 18,000 older adults, inviting those who used cannabis in the past 30 days to participate in the survey. in addition to the initial email, one reminder email was sent to nonresponders. participant eligibility included age over 50, use of any type of cannabis (including medical/non-medical; cannabidiol [cbd] or tetrahydrocannabinol [thc]) in the past month, and state of hawaiʻi residency. redcap was used to administer a brief online screener to identify eligibility. this was followed by informed consent and the “cannabisover50” survey for eligible and cannabis, a publication of the research society on marijuana 115 interested participants. of the 18,000 individuals who were sent recruitment materials, 650 clicked on the eligibility survey; 422 completed the eligibility items and were eligible to participate. the remaining 228 were either not eligible (n = 202) or did not answer any or all of the eligibility items (n = 26). of those who screened as eligible, 367 completed the survey. the survey took approximately 30 minutes and participants were compensated with a $10 gift card to a local grocery store. although participation was not anonymous (we collected contact information to send compensation), participant survey responses were not linked to names and medical record numbers to promote confidentiality. the kaiser permanente southern california-hawaii institutional review board (irb) approved all procedures. measures sociodemographic characteristics. participants were asked to report their sex assigned at birth, gender identification, age, work status, race/ethnicity, and island of residence. as is common with hawaiian samples (kaneshiro et al., 2011), participants who reported any native hawaiian ancestry were classified as native hawaiian to reflect the unique culture and indigenous status. daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu; cuttler & spradlin, 2017). a modified and abbreviated version of the dfaq-cu was used to assess frequency of cannabis use (days used in the past 30 days), primary method of ingestion (smoke, vape, eat edibles, and “other methods” such as skin application and dabbing), and primary form of cannabis used (flower, edibles, concentrates, skin products, vapes, other). responses for the primary form of cannabis were revised based on the cannabinoid type used (thc, cbd, or thc-cbd blend). cannabis use disorders identification testrevised (cudit-r; adamson et al., 2010). the psychometrically-validated cudit-r includes eight items that examine hazardous or problem cannabis use. each item is scored from 0 – 4, and total scores range from 0 – 32. as suggested for screening community-based participants, we provide descriptive data related to a cut-off score of ≥9 to indicate problem cannabis use (coelho et al., 2024). medical and non-medical cannabis use. participants were asked to self-report if their cannabis use was medical-only, non-medical-only, or both. if they reported any medical use, they were asked if they had a current state of hawaiʻi medical cannabis card. all participants were asked where they sourced their cannabis from, and a separate variable assessed solely sourcing cannabis from a medical dispensary. alcohol and nicotine use. participants were asked if they had consumed any alcohol in the past three months. those who reported any alcohol use were asked about the frequency of their alcohol use in the past 30 days. participants were also asked whether they currently used nicotine products (including cigarettes and ecigarettes). co-use was defined as past month use of cannabis and alcohol -orpast month use of cannabis and nicotine. poly-substance use was defined as use of all three substances in the past month. simultaneous use (i.e., use that occurs at approximately the same time) was not assessed. data analyses sample characteristics were examined using descriptive statistics. comparisons of cannabis use characteristics between groups (age, sex at birth, race, and any medical cannabis use) were evaluated using t-tests, one-way anova, chisquare, and fisher’s exact tests as appropriate. we treated the cudit-r both continuously and categorically (cutoff score of ≥9 vs <9) for descriptive purposes and group comparisons. in a model examining factors associated with problem cannabis use, continuous cudit-r score was used as the outcome. demographic characteristics, cannabis use and co-use patterns, and purpose of cannabis use (medical/nonmedical), as well as pairwise interaction terms, were all considered in the multiple linear regression model. only those variables reaching significance at p < .05 were retained in the final model. we report parameter estimates (and ses) for the independent relationship between each regressor with total cudit-r score. all analyses used sas 9.4 (sas institute). as respondents were not required to answer every question, missing data varied for each comparison. thus, reported p-values are based on complete case analyses. sensitivity analyses with missing cannabis use patterns in adults over 50 116 values included as a separate category yielded similar results. results sample characteristics as shown in table 1, over half of the participants (55.6%) endorsed male sex assigned at birth. participants endorsed identifying as a man (54.8%), woman (42.5%), or transgender, non-conforming, or another gender (2.7%). average age was 65.9 (sd = 8.6) years, ranging from 50 – 99 years old. participants lived on five of the six major hawaiian islands, with the majority living on oʻahu (49.2%) and the big island of hawaiʻi (30.8%), representing a mix of urban, suburban, and rural communities. over half of participants (54.8%) reported being retired or not working, while 27% were working full-time. most participants self-identified as white (67.9%), followed by native hawaiian and pacific islander (nhpi; 12.3%), asian (9.3%), multiracial (6.8%), and unknown (3.8%). cannabis use patterns and co-use with other substances the largest proportion of participants (47.8%; n = 151) endorsed using cannabis both medically and non-medically, while 25% (n = 79) reported medical use only, and 27.2% (n = 86) endorsed only non-medical use. of those reporting any medical use (n = 230), 114 (50%) reported having a state-approved medical cannabis card. of the full sample of 367 participants, over one-fourth (n = 93) reported solely obtaining their cannabis through a medical dispensary. although participants reported consuming a range of cannabis products, the majority (59.9%) reported that thc-based (i.e., thc or thc/cbd) flower was the primary form they used. other thc products used included edibles (16.7%), vapes (6.3%), concentrates (2.9%), and skin products (2%). a small subset endorsed cbd-only products (6.3%). most participants (56.7%) reported smoking, followed by oral consumption (22%), vaping (11.9%), skin application (6.1%), or dabbing (1.2%). mean days of cannabis use in the past 30 days was 18.7 (sd = 11.5). over 30% of participants scored above the cut-off score for problem cannabis use on the cudit-r. of the full sample, 71.7% reported drinking alcohol in the past three months. almost 10% of the sample endorsed current nicotine use. in looking at combinations of co-use, 29.9% of participants reported sole use of cannabis and no other substances in the past month, 3.7% reported using cannabis and nicotine, 5.6% reported cannabis, nicotine, and alcohol use, and 60.9% endorsed cannabis and alcohol use. differences in cannabis and co-use patterns by participant demographics and medical/nonmedical use we compared participants by age (50-64 vs. 65+), sex assigned at birth (female vs male), race/ethnicity, and medical (i.e., “any selfreported medical use”) vs. non-medical use on the following variables: frequency of cannabis use (days out of the past 30), primary form of cannabis used, primary method of cannabis ingestion, problem use (cudit-r-total score and cudit-r score ≥9), having a state medical cannabis card, sourcing cannabis from a medical dispensary, frequency of alcohol use (days out of past 30), current nicotine use, and co-use of multiple substances. group comparisons can be found in table 2. age. few differences emerged by age. adults over age 65 reported a greater number of days of alcohol use in the past month (m = 7.8, sd = 10) compared to adults ages 50-64 (m = 5.9, sd = 8.1; p = .04). other variables did not differ significantly. sex assigned at birth. male participants were more likely to smoke cannabis, and females were more likely to use other ingestion methods (apply oils/creams, dab rig, other); vaping and edible use were similar (p = .01). males had higher problem cannabis use scores (cudit-r 7.9 vs 6.7, p = .01) and were more likely to score above the cut-off score of 9 on the cudit-r (37.3% vs 21.3%, p = .001). race/ethnicity. when stratified by race/ethnicity, the number of days of cannabis use differed significantly, with white and multiracial participants using more frequently than asian and nhpi participants (p = .004). nhpis were more likely than other racial/ethnic groups to report use of thc flower (77.5%) as their primary form of cannabis and smoking as their primary method of ingestion (82.5%). asian participants cannabis, a publication of the research society on marijuana 117 were more likely than other groups to use cbdonly products. non-white participants were less likely than white participants to have a state medical cannabis card (p = .03) or to obtain their cannabis solely through a medical dispensary (p = .02). co-use of cannabis with alcohol and/or nicotine also differed by race/ethnicity, with greater numbers of nhpi participants endorsing nicotine use (19%) compared to other groups (p = .02), and white and multiracial participants reporting more frequent alcohol use compared to asians and nhpis (p < .001). when examining different combinations of co-use, several trends were noted despite cell size limitations. multiracial participants were most likely to use cannabis solely, white participants were most likely to co-use cannabis and alcohol, and nhpis were most likely to engage in poly-substance use (cannabis, alcohol, and nicotine use). medical vs. non-medical use. participants who endorsed any medical cannabis use reported more frequent use (20.9 vs. 13.7 days, p < .001) and were more likely to use a medical dispensary as their only source of cannabis compared to those using non-medically (33.5% vs. 10%, p < .001). participants using cannabis non-medically were more likely to smoke cannabis compared to those using medically (68.2% vs 54.8%, p = .02). factors associated with cannabis-related problems. we first assessed whether age, cannabis use frequency (days in past 30), alcohol use frequency (days in past 30), nicotine use, race/ethnicity, medical/non-medical cannabis use, form of cannabis used, and method of cannabis ingestion were significantly associated with problem cannabis use (as assessed by total cudit-r score) in simple regression models. any variable that was significantly associated with problem use at p < .05 (i.e., sex, cannabis use frequency, form of cannabis used, and method of cannabis ingestion) was evaluated in the multiple linear regression model (table 3). method of ingestion (i.e., smoking cannabis as compared to consuming edibles and using “other methods”; β = -2.55, p < .001 and β = -2.62, p = .02 respectively) and greater cannabis use frequency (β = 0.41, p < .01) were significantly associated with greater cudit-r scores. discussion findings from the current study provide insight into cannabis use patterns and factors associated with problem use in a diverse sample of adults ages 50 and over who reported at least monthly cannabis use. participants endorsed use of a wide-range of cannabis products, most of which were thc-based, and various methods of ingestion. a substantial number of participants co-used cannabis with alcohol and/or nicotine, which may have health implications. results illustrated notable trends across age, sex at birth, medical/non-medical cannabis use, and race/ethnicity. findings contribute to the growing body of work related to cannabis use in older age groups, whose use of cannabis has increased as the status of cannabis changes across the u.s. (han & palamar, 2018, 2020). consistent with other studies focused on adults over age 50, females were less likely to smoke cannabis as their primary method of ingestion and used less frequently than males (haug et al., 2017; subbaraman & kerr, 2021). although men still tend to have higher rates of cannabis use, recent work suggests that this gap may be narrowing (chapman et al., 2017). trends noted in older adults may differ from younger adults due to cohort differences related to traditional gender norms and greater acceptance of cannabis use in the baby boomer generation (han et al., 2017). participants who self-reported medical cannabis use consumed cannabis more frequently than non-medical users, which could be associated with needing to maintain therapeutic benefits. non-medical users were more likely to endorse cannabis smoking compared to medical users; however, half of medical users reported primarily smoking. ingestion of harmful toxins via smoking vs. other consumption methods for medical cannabis users has received little attention and may be particularly pertinent for older adults with multiple health comorbidities. lastly, similar to other studies with older adults, few participants endorsed use of concentrates (livne et al., 2024; yang et al., 2021). as a state, hawaiʻi has low rates of dabbing (less than 4% dab their cannabis), which could reflect the absence of a legal non-medical cannabis market (state of hawaii, 2024). racial/ethnic differences in specific cannabis use patterns were more prominent. white and multiracial participants reported the highest frequency of use, while asians and nhpis used cannabis use patterns in adults over 50 118 less often. substantially greater numbers of nhpis (83%) reported smoking their cannabis compared to other groups, which is of particular concern given the impact on lung functioning in this age group (tan et al., 2019). though evidence is still inconclusive due to limited studies and other methodological limitations, a recent systematic review examining four methods of cannabis ingestion (smoking, dabbing, vaping, and oral ingestion) found that smoking had the most significant respiratory and cardiovascular health effects (muheriwa-matemba et al., 2024). due to greater risk of these health issues in older adults and among nhpis, cannabis smoking in nhpis should be monitored and further studied (gordon et al., 2019). we found significant racial/ethnic disparities related to having a state medical cannabis card and sourcing cannabis from medical dispensaries. among medical users, white participants were the most likely to have a medical card. they were also the most likely to source their cannabis solely from dispensaries. nhpis were the least likely racial/ethnic group to source their cannabis solely from medical dispensaries. this suggests a potential barrier to accessing legal, regulated, and safer cannabis for medical purposes. the literature is mixed when it comes to analyzing medical dispensary location by race/ethnicity and income, with some research demonstrating that medical dispensaries concentrate in neighborhoods with a greater number of racial/ethnic minority and lower-income groups (cohn et al., 2023; shi et al., 2016) and others finding the opposite (cunningham et al., 2022; yang et al., 2021). in hawaiʻi, we suspect other factors such as a low cap on the number of medical dispensaries allowed to operate, cost, growing one’s own cannabis, and lack of trust across multiple establishments (e.g., healthcare, government) may influence purchase habits related to medical cannabis. these factors may have been particularly influential for participants on some of the smaller and less populated hawaiian islands, some of whom have no access to medical cannabis dispensaries (state of hawaii, 2025). asian participants were more likely than other racial/ethnic groups to report use of cbdonly as their primary form of cannabis and were more likely to vape cannabis compared to other racial/ethnic groups. research on cannabis use and patterns in asian and nhpi populations is limited, but several epidemiological studies with adult populations have shown that asian groups typically have the lowest rates of cannabis use, frequency, and cud (jeffers et al., 2021; wu et al., 2016). though no studies have examined vaping or cbd-only use as safer alternatives to smoking or thc-consumption in older adult asian populations, a qualitative study found that vaping e-cigarettes was perceived by asian americans as less harmful than cigarettes (maglalang et al., 2019). it is possible that such perceptions could be driving greater use of cbd and cannabis vaping among asian populations. problem cannabis use, as assessed by scores on the cudit-r, was slightly lower in our sample compared to the few others that have assessed problem use in older adults (haug et al., 2017). despite this, 31% of participants scored above the cutoff for problem cannabis use on the cudit-r. scores may have been impacted by sample differences (e.g., greater number of asian participants) and method of recruitment from a healthcare system. unsurprisingly, cannabis use frequency was associated with problem use, as demonstrated in studies with younger samples (buu et al., 2017; cooke et al., 2023; khan et al., 2013). smoking cannabis, as compared to other methods of ingestion, was associated with problem cannabis use. as a method of consumption, smoking cannabis is most likely to contribute to respiratory and other adverse health effects. interventions for older adults might emphasize potential health risks and the increased risk of cud associated with smoking, as well as promote alternative methods of consumption. though vaping cannabis and the consumption of edibles are not necessarily safe, these methods may have less risk, especially if purchased through legal dispensaries that test their products. although one-third of participants solely used cannabis, over 70% of the sample used alcohol in the past 90 days. older adults used alcohol more frequently than middle-aged adults. recent work suggests that singular alcohol use and co-use with cannabis in adults over 50 is increasing (kepner et al., 2023). reasons for these trends are speculative, but cannabis policy and the use of alcohol to enhance the effects of cannabis potentially contribute to increased rates (keyes, 2023). as a generation, baby boomer groups are cannabis, a publication of the research society on marijuana 119 historically more likely to use substances than prior cohorts (han et al., 2017), and this may have influenced the co-use patterns observed in our sample. almost 10% of participants co-used cannabis and nicotine products. nhpis were more likely than other groups to use cannabis, nicotine, and alcohol, which may contribute to higher health disparities overall. these findings have important implications for public health and clinical practice, due to medical and psychiatric consequences of polypharmacy (crummy et al., 2020). the high rates of cannabis co-use with other substances underscore the need for comprehensive screening and integrated treatment approaches that address polysubstance use. tailoring interventions and educational efforts to account for age, sex, race/ethnicity, and medical/non-medical use patterns may also improve their reach and effectiveness. depending on the individual’s goals related to cannabis, harm reduction strategies may be applicable regardless of medical or non-medical use. for example, older adults should be aware of protective strategies to avoid medication interactions and overconsumption, particularly when they have underlying health conditions. those who are interested in cessation might consider evidencebased interventions, such as motivational interviewing or cognitive behavioral therapy (calomarde-gómez et al., 2021; dellazizzo et al., 2023). individuals with interest in medical cannabis might consider applying for a stateissued medical cannabis card to ensure use of safer products. however, to change purchase habits, it will be important to address any mistrust of government and medical systems operating dispensaries, as well as other structural barriers (valencia et al., 2017). while this study contributes to the limited knowledge base on cannabis use in adults over age 50, it also has limitations. the sample was 68% white, which is greater than census figures for hawaiʻi (u.s. census bureau, 2021). while we are unsure if underrepresented groups were hesitant to participate, white health system members and those using cannabis legally via the state medical cannabis program may have been more comfortable endorsing cannabis use via a survey delivered through their healthcare provider. future similar studies might consider oversampling participants from underrepresented groups to ensure a more diverse sample. despite low numbers, 12% of our sample included nhpi participants, who are often excluded from samples due to low numbers or are merged with asian groups (montgomery et al., 2022; saraiya et al., 2024), despite evidence that they demonstrate marked health disparities (gordon et al., 2019). our questions regarding nicotine products were limited to cigarettes and e-cigarettes. although cigarettes are the primary method of tobacco consumption among older adults (cornelius et al., 2023), alternative modes such as cigars or chewing tobacco were not assessed, potentially leading to under-identification of nicotine users. participants were recruited from one state (hawaiʻi) that does not have legal non-medical cannabis. all participants in the study had health insurance, and although kaiser permanente represents a range of employerand publiclysupported insurance plans (e.g., medicaid), findings may not be generalizable to uninsured groups or those living in states with legal nonmedical (recreational) cannabis. however, hawaiʻi has a long history of cannabis use and a large representation of asian and nphi groups and retirees, whose use of cannabis is understudied. conclusions as cannabis is used increasingly for medical and non-medical purposes, it is critical to better understand patterns of use and their effect on aging populations. findings highlight the importance of considering demographic factors when developing and implementing cannabisrelated policies, programs, and interventions to meet the unique needs of this growing population of users. future studies should further examine the implications of polysubstance use among older adults, smoking cannabis alone and with nicotine, and the impact of select patterns on risk for cud. ultimately, a more comprehensive understanding will be essential to guide intervention efforts among adults over 50 who choose to use cannabis. table 1. sociodemographic characteristics, cannabis, and other substance use among adults ages 50+ who reported recent cannabis use cannabis use patterns in adults over 50 120 variable n (%) n (%) m sd age (years) 65.9 8.6 age group 50-64 153 (41.7) 65+ 214 (58.3) sex assigned at birth female 158 (43.1) male 204 (55.6) missing or other 5 (1.3) gender identification woman 156 (42.5) man 201 (54.8) trans man 1 (0.3) trans woman 1 (0.3) genderqueer/non-conforming/another 8 (2.1) employment status full-time 99 (27.0) part-time 43 (11.7) retired or not working 201 (54.8) other 24 (6.5) race/ethnicity white 249 (67.9) nhpi 45 (12.3) asian 34 (9.3) multiracial 25 (6.8) unknown/other 14 (3.8) island of residence oʻahu 179 (49.2) hawaiʻi (big island) 112 (30.8) maui 69 (19.0) kauaʻi 3 (0.8) molokaʻi 1 (0.3) form of cannabis used* flower 208 (59.9) edibles 58 (16.7) skin products 7 (2.0) concentrates 10 (2.9) cbd-only (any form) 22 (6.3) vape products 22 (6.3) other 20 (5.8) cannabis ingestion method smokea joint blunt hand pipe/small pipe bong 196 (56.7) 68 (34.7%) 2 (1%) 100 (51.0%) 26 (13.3%) vape 41 (11.9) oral consumption 76 (22.0) skin application 21 (6.1) dab rig 4 (1.2) other 8 (2.3) purpose of cannabis use medical-only 79 (25.0) non-medical-only 86 (27.2) cannabis, a publication of the research society on marijuana 121 both medical and non-medical 151 (47.8) co-use of cannabis with other substances cannabis only 106 (29.9) cannabis with alcohol 216 (60.9) cannabis with cigarettes/e-cigarettes 13 (3.7) cannabis with alcohol and cigarettes/e-cigarettes 20 (5.6) state medical cannabis cardb 114 (50.0) medical dispensary use only 93 (27.6) days cannabis use (0-30) 18.7 11.5 any alcohol use (past 90 days) days alcohol use (0-30) 251 (71.4) 7 9.3 current nicotine use 33 (9.3) total cudit-r score 7.4 4.5 cudit-r score ≥9 106 (30.6) note. *unless indicated, all cannabis forms include thc or a thc/cbd blend; cudit-r = cannabis use disorders identification test, revised; asmoking included specific methods that are indicated in the third column; column 2 reflects the total number and percentage who reported smoking, while column 3 indicates the number who used each specific smoking method and the percentage out of total smoking; bof the full sample, only participants who reported any medical use (n = 230) were asked if they have a state of hawaiʻi medical cannabis card. of those who responded to this question, 114 (50%) reported having a medical card. cannabis use patterns in adults over 50 122 table 2. differences in cannabis and co-use patterns by participant demographics and medical/non-medical use variable age group sex at birth racer non-medical/medical use 50-64 (n = 153) 65+ (n = 214) p value male (n = 204) female (n = 158) p value white (n = 249) asian (n = 34) nhpi1 (n = 45) 2+2 p value nonmedical use only (n = 86) any medical use (n = 230) p value days cannabis use (0-30): m (sd) 17.7 (12.0) 19.5 (11.1) .1627 19.2 (11.3) 18.0 (11.7) .3602 20.1 (11.1) 14.7 (11.9) 14.3 (11.9) 20.7 (11.6) .0035 13.7 (11.2) 20.9 (10.8) <.0001 form of cannabis used*: n (%) cbd-only products 10 (6.9) 12 (5.9) .8627 9 (4.7) 13 (8.7) .0709 10 (4.2) 7 (20.6) <5 <5 .0032 <5 17 (7.4) .0595 flower 84 (58.3) 124 (61.1) 124 (64.3) 81 (54.0) 139 (58.4) 17 (50.0) 31 (77.5) 15 (65.2) 62 (72.1) 132 (57.4) concentrates 5 (3.5) 5 (2.5) 7 (3.6) <5 9 (3.8) <5 <5 <5 <5 8 (3.5) edibles 27 (18.8) 31 (15.3) 32 (16.6) 25 (16.7) 44 (18.5) 5 (14.7) <5 <5 16 (18.6) 38 (16.5) vape products 9 (6.3) 13 (6.4) 12 (6.2) 10 (6.7) 19 (8.0) <5 <5 <5 <5 16 (7.0) skin products, other, don't know 9 (6.4) 18 (8.9) 9 (4.7) 18 (12.0) 17 (7.1) <5 <5 <5 <5 19 (8.3) cannabis ingestion method: n (%) smoke 85 (59.0) 111 (55.0) .8758 118 (61.5) 76 (50.7) .0129 128 (54.0) 12 (35.3) 33 (82.5) 15 (65.2) .0002 58 (68.2) 126 (54.8) .0206 vape 17 (11.8) 24 (11.9) 22 (11.5) 19 (12.7) 30(12.7) 8 (23.5) <5 <5 6 (7.1) 28 (12.2) edibles 29 (20.1) 47 (23.3) 42 (21.9) 32 (21.3) 60 (25.3) 8 (23.5) <5 <5 19 (22.4) 48 (20.9) apply oils/creams, dab rig, other 13 (9.0) 20 (9.9) 10 (5.2) 23 (15.3) 19 (8.0) 6 (17.7) 5 (12.5) <5 <5 28 (12.2) source of cannabis: n (%) only from medical dispensary 36 (26.1) 57 (28.6) .6057 53 (28.6) 39 (26.4) .6413 76 (33.0) 8 (24.2) 5 (12.8) 3 (13.0) .0181 8 (10.0) 76 (33.5) <.0001 obtain other ways 102 (73.9) 142 (71.4) 132 (71.4) 109 (73.6) 154 (67.0) 25 (76.8) 34 (87.2) 20 (87.0) 72 (90.0) 151 (66.5) state medical carda: n (%) 54 (55.7) 60 (45.8) .1406 63 (53.4) 50 (45.9) .2577 89 (56.0) 7 (30.4) 8 (40.0) 6 (31.6) .0272 n/a 114 (50.0) n/a total cudit-r score: m (sd) 7.8 (4.5) 7.1 (4.5) .1790 7.9 (4.6) 6.7 (4.3) .0107 7.4 (4.5) 6.9 (5.3) 7.5 (4.0) 8.0 (4.8) .8250 7.0 (4.1) 7.7 (4.7) .1918 cudit-r score ≥9: n (%) 52 (36.1) 54 (26.6) .0581 72 (37.3) 32 (21.3) .0014 68 (28.6) 10 (29.4) 15 (37.5) 8 (34.8) .6706 20 (23.3) 77 (33.5) .0795 days alcohol used (0-30): m (sd) 5.9 (8.1) 7.8 (10.0) .0465 7.7 (9.5) 6.0 (8.9) .0798 8.3 (9.9) 3.1 (6.1) 3.3 (5.5) 6.4 (10.3) .0005 8.1 (9.2) 6.4 (9.0) .1232 nicotine use: n (%) 18 (12.3) 15 (7.2) .1000 20 (10.1) 13 (8.5) .6096 16 (6.6) <5 8 (19.0) <5 .0239 11 (12.8) 17 (7.4) .1328 co-use of cannabis with other substances: n (%) cannabis-only 48 (32.9) 58 (27.8) .0721 53 (26.8) 52 (34.0) .0910 63 (25.9) 13 (38.2) 13 (31.0) 12 (50.0) .0073 17 (19.8) 76 (33.0) .0890 cannabis+alcohol 80 (54.8) 136 (65.1) 125 (63.1) 88 (57.5) 164 (67.5) 17 (50.0) 21 (50.0) 8 (33.3) 58 (67.4) 137 (59.6) cannabis+nicotine 5 (3.4) 8(3.8) 5 (2.5) 8 (5.2) 8 (3.3) <5 <5 <5 <5 7 (3.0) cannabis+alcohol+nicotine 13 (8.9) 7 (3.4) 15 (7.6) 5 (3.3) 8 (3.3) <5 5 (11.9) <5 7 (8.1) 10 (4.3) note. *unless indicated, all cannabis forms include thc or a thc/cbd blend; r14 individuals who reported black, american indian or alaskan native, other, or who skipped item were excluded from race statistics; 1native hawaiian / pacific islander; 2more than one race; aonly participants who reported any medical use (n = 230) were asked if they have a state of hawaiʻi medical cannabis card; cells with counts less than 5 are denoted as such, but the actual value is used in the statistical calculations; cudit-r = cannabis use disorders identification test, revised. cannabis, a publication of the research society on marijuana 123 table 3. factors associated with cudit-r total score cudit-r total variable estimate (se) p value sex at birth maler female -0.63(0.45) .1608 days cannabis use (0-30) 0.14 (0.02) <.0001 cannabis ingestion method smoker vape -1.56 (0.89) .0801 edibles -2.55 (0.89) .0047 apply oils/creams, dab rig, other -2.62 (1.10) .0179 form of cannabis used* ediblesr skin products, other, don't know -1.29 (1.16) .2672 cbd only products -1.89 (1.17) .1069 flower, thc or thc/cbd blend -0.40 (0.97) .6813 concentrates, thc 0.60 (1.60) .7053 vape products, thc or thc/cbd blend -0.94 (1.38) .4961 note. rreference group; 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(2021). cannabis: an emerging treatment for common symptoms in older adults. journal of the american geriatrics society, 69(1), 91-97. https://doi.org/10.1111/jgs.16833 cannabis use patterns in adults over 50 128 funding and acknowledgements: this research was supported by internal funding from the center for integrated health care research at kaiser permanente hawaii. the authors have no conflicts of interest to report. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: phillips, k. t., pedula, k. l., tsuzaki, k., erickson, c., lai, j., simiola, v., wong, j., pokhrel, p., & satre, d. d. (2025). cannabis use patterns and co-use of alcohol and nicotine in adults over 50 by demographic factors and medical cannabis use. cannabis, 8(2), 112 128. https://doi.org10.26828/cannabis/2025/000303 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 176 abstracts from the 2025 research society on marijuana and society for research on nicotine and tobacco post conference workshop march 15, 2025 special section editor: jamie e. parnes, ph.d. all abstracts were peer-reviewed by (in alphabetical order): bradley t. conner (colorado state university), jamie e. parnes (brown university; bradley hospital), kristina t. phillips (kaiser permanente hawaii, center for integrated health care research; kaiser permanente bernard j. tyson school of medicine, department of health systems science), jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. paper presentations concurrent use and simultaneous use of nicotine and marijuana: a cross-national examination among college students in six countries adrian j. bravo (william & mary) cross-cultural addictions study team background: marijuana and tobacco/nicotine use (including electronic nicotine delivery systems) is highly prevalent on college campuses and recent research suggests that many college students engage in either co-use (i.e., use of both substances within a similar time period [month, year, lifetime]) and/or simultaneous use (i.e., use of both substances during the same use time so that the effects overlap) of these substances. clinically, co-use and simultaneous use of marijuana and tobacco/nicotine has been found to be associated with greater substance use problems, poorer mental health, and poorer physical health. however, the vast majority of studies have been conducted among north american samples (i.e., the u.s. and canada) and less is known about rates of co-use and simultaneous use of these drugs among other countries/regions. the goal of the present multi-country study was to examine prevalence rates of marijuana use, tobacco/nicotine use, co-use, and simultaneous use of these drugs among a large sample of college students from six countries (canada, u.s., argentina, spain, south africa, and england). further, we examined differences in self-reported physical health symptoms (i.e., general health; immune function, colds, coughs) based on endorsement of past 30-day co-use (or not) and simultaneous use (or not) of these cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000327 volume 8, issue 2 conference abstracts 177 drugs. methods: a total of 4,801 (u.s., [n = 2,171; 59.6% female], canada [n = 392; 74.7% female], south africa [n = 495; 79.4% female], spain [n = 837; 72.3% female], argentina [n = 700; 70.3% female], england [n = 206; 80.6% female]) college students completed a longitudinal study examining the effects of covid-19 on mental health and substance use patterns. to test study aims, data from the baseline survey were analyzed to examine crossnational comparisons of distinct patterns of substance use: 1) lifetime marijuana and nicotine [separated across cigarette and e-cigarette] use, 2) past 30 day use of marijuana and nicotine [separated across tobacco and e-cigarettes] use, 3) past 30 day co-use [combined marijuana and cigarette and/or e-cigarette use], and 4) among co-users past 30 day simultaneous use. further, anovas were conducted to compare co-use (versus not) and simultaneous use (versus co-use only) groups on self-reported past 3-month physical health symptoms. results: there were many cross-country differences found in lifetime marijuana use (lowest in canada), cigarette use (lowest in north america), and ecigarette use (highest in europe) prevalence rates. among individuals who endorsed lifetime use, prevalence rates of past 30-day use of these drugs were largely similar across countries. past 30-day co-use of these drugs was prevalent in each country (nearly 50% in each country) with some minor country differences. among past 30day co-users, simultaneous use was widely prevalent (over 50% in each country) with minor country differences. anova results indicated differences among simultaneous versus co-use individuals on self-reported coughing symptoms (greater frequency of coughing symptoms among simultaneous users). conclusions: college students from around the world endorse high rates of co-use and simultaneous use of marijuana and tobacco/nicotine. on college campuses, co-use and simultaneous use of these drugs should be a target of clinical prevention/intervention efforts and the mechanisms underpinning the unique harms of these use patterns need to be clarified. tobacco and cannabis co-use among adolescent and young adults with and without a cancer history melissa basile (northwell health) michael a. diefenbach (northwell health) brittney greene (state university of new york at buffalo) eun jeong oh (northwell health) elizabeth j. siembida (northwell health) nehal p. vadhan (northwell health, hofstra university) kara p. wiseman (university of virginia school of medicine) background: approximately 38% of adolescent and young adult (aya; diagnosed ages 15-39) cancer survivors are tobacco users. no research has explored the co-use of tobacco and cannabis among aya survivors, despite evidence suggesting that co-use conference abstracts 178 in other populations reduces tobacco cessation rates. we described the prevalence of tobacco and cannabis single product and co-use among aya survivors and their peers, and tested associations between tobacco + cannabis co-use, major depression, and nicotine dependence. methods: we analyzed responses from the 2015-2019 national survey on drug use and health surveys (n = 733 aya survivors; n = 26,530 peers; ages 1634). we determined the prevalence of tobacco (cigarettes, cigars, or smokeless tobacco) and cannabis use and co-use in the past 30 days and compared single product use and co-use between ayas with and without cancer using second-order rao-scott chisquare tests and weighted multivariable logistic regression. we then tested the association between tobacco + cannabis co-use and nicotine dependence (nicotine dependence syndrome scale) in aya cancer survivor tobacco users (n = 228), exploring if past-year major depression moderates this relationship using weighted multivariable logistic regression. results: the prevalence of past month single product use was similar between survivors and their peers for tobacco (30% vs. 29% for survivors vs. peers, respectively) and cannabis (18% vs. 19% for survivors vs. peers, respectively). among tobacco users, aya survivors were significantly less likely than their peers to report tobacco + cannabis couse in univariable models (29% vs. 39%; or = 0.64, 95% ci = 0.44, 0.94). in multivariable logistic regression there was no association between cancer history and tobacco + cannabis co-use (aor = 0.83, 95% ci = 0.54, 1.28). compared to those 16-20 years old, older ayas (26-34 years) were less likely to report past 30-day tobacco + cannabis co-use (aor = 0.65, 95% ci: 0.52, 0.82). overall, 33% of aya tobacco users with cancer were nicotine dependent and 25% had a major depressive episode in the past year. nicotine dependence (36% vs. 32%) and major depression (30% vs. 23%) were similar between tobacco-only and tobacco + cannabis co-users. tobacco + cannabis co-use was not associated with nicotine dependence (aor = 1.29, 95% ci = 0.56, 2.98) and there was no evidence of effect modification of major depression with this association. conclusions: despite having lower rates of tobacco + cannabis co-use among ayas with a history of cancer compared to those without, the rate of tobacco + cannabis co-use is high among aya survivors who use tobacco. unlike previous research in non-aya and non-survivor populations, tobacco + cannabis co-use was not associated with nicotine dependence, suggesting levels of nicotine dependence are similar for tobacco only and tobacco + cannabis co-users. increased rates of tobacco + cannabis co-use among the youngest subgroup of ayas suggests that targeted interventions may be needed in this population. tobacco use represents a significant problem among survivors already at high risk for poor outcomes, and these results highlight the importance of considering co-use of cannabis when developing interventions. conference abstracts 179 incidental or purposeful nicotine exposure and its effects on cotinine as a result of cannabis blunt use among young black men in america laura d'anna (charles drew university) jefferson wood (charles drew university) kyle chang (cal state long beach) jaelen owens (cal state long beach) bradley conner (colorado state university) black men experience more smoking related illnesses compared to other groups, and they are disproportionately burdened with tobacco-related deaths. cannabis use occurs at higher frequency among black individuals in the united states and this is especially true for individuals who identify as black males. there are growing concerns that cannabis and tobacco co-use may contribute to the tobacco-related disparities observed among black men. in the present study, we aimed to assess the field-measured cotinine levels associated with blunt use and explore how these changed according to blunt construction characteristics. to understand the unique impact of blunt use on nicotine exposure, we only engaged participants who did not smoke cigarettes or use e-cigarettes. we were also interested in establishing how closely self-reported tobacco exposures matched cotinine levels assessed with saliva samples among young black men. in addition, we examined several variables that may predict blunt use, such as cannabis and blunt cravings, and positive and negative affect, and how they may affect cotinine levels. there were 46 participants who completed the assessment, reported no tobacco use apart from co-use with cannabis during the 7-day recall period, and provided two saliva samples. higher cotinine concentrations were significantly associated with total number of blunts reported during the previous 7 days, t1: r(44) = .31, p = .04; t2: r(44)=.29, p = .047, and whether blunt smoking occurred on the most recent day, r(44) = 0.32, p = 0.03. additionally, the estimated quantity of marijuana smoked between collection of the first and second saliva samples (approximately 10 hours) was significantly correlated with cotinine measured in the second sample, r(43) = .426, p = .004. cotinine was significantly associated with several scores for the cannabis and blunt craving questionnaires, including the mcq total score, t1: r(44) = .359, p = .014; t2: r(44) = .324, p = .028, mcq compulsivity subscale, t1: r(44) = .395, p = .014; t2: r(44) =.407, p = .005, mcq expectancy subscale, t1: r(44) = .319, p = .031; t2: r(44) = .291, p = .050, bcq total score, t1: r(44) = .476, p = .001; t2: r(44) = .459, p = .001), bcq emotionality subscale, t1: r(44) =.390, p = .007; t2: r(44) = .396, p = .006, bcq expectancy subscale, t1: r(44) = .409, p = .005; t2: r(44)=.404, p = .005, bcq compulsivity subscale, t1: r(44)= . 440, p = .002; t2: r(44) = .378, p = .010. as expected, cotinine was also significantly associated with the cudit, t1: r(44) = .319, p = .031; t2: r(44) = .291, p = .050. the cudit was conference abstracts 180 also significantly associated with calculated cannabis used between baseline and follow-up, r(43)=.306, p = .046. of interest, many of the participants reported that they did not consider themselves tobacco users, even though their cotinine levels were similar to those of people who use nicotine regularly. thus, it is likely that incidental or purposeful exposure to nicotine through the use of blunts does present a risk for misuse of nicotine and developing nicotine use disorder. future research should examine interventions to reduce blunt use or alter blunt construction to offset the negative effects of this incidental or purposeful nicotine exposure. high potency cannabis and nicotine co-use among high school students in colorado mohammad i. habib (colorado state university) bradley t. conner (colorado state university) introduction: as cannabis markets have evolved, high potency cannabis products are more readily available and frequently co-used with tobacco. higher potency forms of cannabis are associated with more negative outcomes and may especially affect adolescents. moreover, many consumers believe that cannabis products and nicotine vaporizers pose little threat to health. in this study, we examine rates of high potency cannabis and tobacco co-use and attitudes towards vaping nicotine among highschool aged youth in colorado. methods: data in this study was obtained from the healthy kids colorado survey. high school aged youth (n = 6941) completed a survey asking about frequency and method of administration for both cannabis and tobacco products. attitudes towards nicotine vaporizers were assessed by asking about the perceived harm of the vaporizers and the secondhand vapor. data were collected from students at randomly selected public high schools in the state of colorado. data were analyzed using r version 4.2. results: the average age of the sample was 16.0 (sd: 1.19). in the sample, 47% identified as female, 69% as heterosexual, and 70% as white. approximately 20% of the sample only used nicotine products, 41% only used cannabis products and 39% used both. among participants who consumed cannabis, those who co-used nicotine were more likely to use high potency cannabis (67%) as opposed to those who only consumed cannabis (43%; χ2 = 437.0, p < 0.01). students who only used cannabis products (40%) were more likely to believe daily nicotine vapor use posed a great risk to health as compared to students who only used nicotine products (28%) and co-users (31%; χ2 = 353.1, p < 0.01). students who only used cannabis products (21%) were more likely to believe secondhand nicotine vapor use posed a great risk to health as compared to students who only used nicotine products (13%) and co-users (15%; χ2 = 686.2, p < 0.01). conclusions: cannabis use is popular among high school students in colorado and high potency cannabis appears to be more popular among students who co-use nicotine and cannabis products as compared to students who only consume cannabis. conference abstracts 181 students who only consumed cannabis appear to have more negative attitudes towards nicotine products. more research is needed to determine what types of interventions may affect attitudes towards nicotine and high potency cannabis use. vaping nicotine and cannabis on the same occasion is linked to increased vaping consumption among young adults: a smartphone-based daily diary study nhung nguyen (university of california, san francisco) salomeh keyhani (san francisco veterans affairs health care system) gregory m. marcus (university of california, san francisco) vuong v. do (university of california, san francisco) deanna m. halliday (university of california, san francisco) ellen d. herbst (university of california, san francisco) pamela m. ling (university of california, san francisco) significance: vaping both nicotine and cannabis in the past 30 days (covaping) is common among young adults. it is unclear which co-vaping patterns may increase substance use and dependence. we examined daylevel associations between vaping patterns with vaping quantity. method: daily assessments of vaping behaviors were collected via smartphone for 30 consecutive days among 111 young adults (aged 18-29, vaping nicotine/cannabis at least 20 days during the past month) in california, us, in 2023-2024. participants reported daily use of nicotine/tobacco (e.g., e-cigarettes, cigarettes) and cannabis products (e.g., vaporized/combustible cannabis). vaping intensities were the number of times a participant vaped nicotine/cannabis in an entire day. vaping patterns on a given day were categorized into non-vaping, singlesubstance vaping, same-day differentoccasion co-vaping, and same-occasion co-vaping. generalized linear mixedeffect models examined day-level associations between these patterns and vaping intensity outcomes, controlling for covariates. results: of the participants, 84.7% reported covaping and 15.3% reported singlesubstance vaping in the past 30 days. of the 2,522 daily assessments, 42.7% were nicotine-only vaping, 9.7% cannabis-only vaping, 16.5% same-day different-occasion co-vaping, and 16.9% same-occasion co-vaping. participants reported a greater intensity of vaping nicotine and cannabis on days with same-occasion co-vaping compared to days with other vaping patterns. vaping intensities on days with sameday different-occasion co-vaping were greater than on days with singlesubstance vaping or non-vaping. conclusions: closer temporal proximity of co-vaping was associated with greater intensities of vaping nicotine and cannabis. same-occasion co-vaping is linked to the greatest increase in vaping intensity. conference abstracts 182 interventions addressing this high-risk pattern are warranted. translating epidemiological data to the design of a community-based just-in-time adaptive intervention for young adults co-using ecigarettes and cannabis kristina t. phillips (kaiser permanente hawaii) pallav pokhrel (university of hawaii) michael m. phillips (university of hawaii at mānoa) yan yan wu (university of hawaii at mānoa) kara tsuzaki (kaiser permanente hawaii) crissy t. kawamoto (university of hawaii) mika d. thompson (university of hawaii at mānoa) scott k. okamoto (university of hawaii) significance: there has been renewed interest in translating epidemiological research findings into substance use prevention interventions, with emphases on disparities and community-level factors. limited work suggests high rates of exclusive ecigarette or cannabis use in vulnerable populations, such as indigenous and sexual and gender minority (sgm) groups, with minimal exploration of couse. this active study utilizes two sources of epidemiologic data to identify the most vulnerable subgroups for cannabis use, e-cigarette use, and co-use, and examines unique risk factors that drive greater co-use to guide the development of a just-in-time adaptive intervention (jitai) for young adults. methods: data from hawaiian young adults (n = 2353) who completed the annual cdc survey, behavioral risk factor surveillance system (brfss) from 2020-2022, and the 2017-2024 young adult health behavior survey (yahb; n = 2565), an nih-funded dataset based on a hawaii cohort, were examined to establish past-month co-use prevalence. demographic differences in e-cigarette, cannabis, and co-use were analyzed, along with effects of advertising and social influences. results: brfss data suggests an overall prevalence of 7.7% for past-month co-use in hawaii young adults ages 18-29. 18.8% reported cannabis use (cannabis-only: 11.1%) and 21.3% used e-cigarettes (ecigarettes-only: 13.6%) in the past month. data from the yahb baseline survey found higher rates of pastmonth co-use (11.2%), cannabis use (25.9%; 14.7% cannabis-only), and ecigarette use (23.1%; 11.9% ecigarettes-only). brfss young adults ages 18-24 had double the prevalence of co-use (9.8%) compared to those ages 25-29 (4.7%), while those 25-29 had higher rates of cannabis-only use (13.2%) than younger participants (9.7%). co-use among yahb young adults did not differ significantly by age group, though older participants reported greater cannabis-only use. brfss males, but not yahb, had higher rates of co-use (8.8%) compared to females (6.4%). brfss co-use and cannabis-only rates were significantly higher in sgm participants (19.6%, 18.3% respectively) compared to cisgender heterosexual participants (5.9%, 10%). brfss data showed that white (10.2%) and native hawaiian conference abstracts 183 and pacific islander (nhpi; 8.8%) participants had the highest rates of co-use, which yahb data supported (nhpi=13%, white=12.1%). further, nhpis and whites had the highest rates of cannabis-only use, and indigenous (nhpi and american indian/alaska native) and filipino participants had the highest rates of ecigarette-only use. brfss participants with the lowest household income were more likely to co-use, while co-use varied by income level in yahb. yahb young adults with a family member or partner who used e-cigarettes had significantly higher odds of co-use (ors = 2.53-2.71), cannabis-only use (ors = 1.42-1.44), and e-cigarette-only use (ors = 2.81-3.93). greater exposure to point-of-sale cigarette/e-cigarette marketing increased odds of co-use, cannabis-only use, and e-cigarette-only use (ors = 1.08-1.15). conclusions: couse is common among young adults in hawaii, but differences emerge among sub-groups, with nhpi, white, and sgm participants being at the greatest risk for co-use. social and marketing factors that appear to impact singlesubstanceand co-use warrant further exploration. next steps involve identifying profiles of use for vulnerable groups and linking local point-of-sale tobacco retail location data with co-use rates to examine its impact. findings from comprehensive data analyses will allow us to calibrate the new jitai. harm perceptions, problems, and intentions to quit among adults engaging in poly-cannabis and polytobacco couse bethany shorey fennell (university of kentucky) cherell cottrell-daniels (health choice network) significance: evidence suggests tobacco and cannabis co-use (co-use) is associated poorer health outcomes and more difficulty quitting either substance. yet little is known about how different types of co-use (single use vs. poly use) may influence problematic cannabis use and intentions to quit tobacco and cannabis. methods: we describe multiple cannabis and tobacco use among us adults who co-use. participants who used tobacco were recruited nationally online between july and october 2024 (n = 4013). of these, 2058 (51.3%) reported using cannabis in the last month and were categorized as co-using. one-way anova and chi-square tests examined perceptions of relative risk (range -2 = cannabis much less harmful than tobacco, 2 = cannabis much more harmful), problematic cannabis use (cudit, range 0-32), and intentions to quit tobacco and cannabis among groups of co-users who engaged in single or multiple use of tobacco and cannabis products. results: on average, participants were 47.55 (sd = 16.39) years old, cis-gender men (50.1%) or women (49.0%), and were primarily non-hispanic white (58.6%) or black (22.0%). among adults who coused, 22.1% used one tobacco and one cannabis product (single use co-use, su), 10.8% (222) used multiple tobacco products and one cannabis product (tobacco poly use, tpu), 26.8% (551) used one tobacco product and multiple cannabis products (cannabis poly use, cpu), and 40.3% (827) used multiple conference abstracts 184 tobacco and cannabis products (dual poly use, dpu). cpu participants perceived cannabis as less harmful than tobacco (m = -.95) compared to those who dpu (-.87), tpu (-.67), or su (-.82), p < .001, χ2 = .005. dpu participants had cudit scores associated with possible cannabis use disorder (m = 13.14), while all other groups had scores associated with hazardous cannabis use (cpu m = 10.69, tpu m = 10.24, su m = 8.52, p =< .001, χ2 = .064). there were no differences between the groups in intentions to quit, χ2(9)= 8.87, p = .45. overall, 37.5% intended to quit all tobacco use within 6 months, 36.1% intended to quit sometime beyond 6 months, and 26.4% were not planning to quit. there were, however, significant differences in intentions to quit cannabis, χ2(9) = 44.80, p < .001. cpu participants were most likely to not plan on quitting cannabis at all (75.0%) followed by dpu (63.5%), su (63.5%), and tpu (53.0%). cpu cousers were also least likely to intend to quit in the next 6 months (14.7%), dpu and su were intermediate (21.6% dpu, 22.1% su), and tpu participants were most likely to intend to quit cannabis within 6 months (28.6%). discussion: dpu participants made up the largest proportion of co-users and compared to other groups, they perceived cannabis use to be less harmful than tobacco use while simultaneously reporting more problems associated with cannabis use disorder. intentions to quit tobacco were similarly high across all groups and intentions to quit cannabis differed. cpu co-users were least likely to intend to quit, and dpu and su cousers were also unlikely to quit, despite greater problems among dpu. future work should focus on understanding the relationship between harm perceptions, cannabis problems, and other factors, such as stress or chronic health conditions on intentions to quit cannabis and tobacco among different groups of co-users. does cannabis use moderate the impact of tobacco cue exposure on craving and use of cigarettes and ecigarettes? evidence from a naturalistic observational study alexander w. sokolovsky (brown university) suzanne colby (brown university) rachel n. cassidy (brown university) ashlynn m. ruleman (brown university) kristina m. jackson (rutgers university) introduction. although cue reactivity (cr) to tobacco in controlled settings is a well-established phenomenon, research on cr in natural environments and on real-world moderators of cue-elicited craving remains limited. laboratory studies typically focus on participant factors and cue characteristics as potential moderators of cr effects. however, theories of addiction would likely posit that other factors in naturalistic settings, especially associative learning factors, may be more proximal moderators of cue effects on both craving and use. among such factors is the use of other substances and especially as it pertains to tobacco conference abstracts 185 cannabis use. almost half of young adults who currently use tobacco report past-month co-use of cannabis, with couse occurring both proximally in time and via co-administration (e.g., blunts and spliffs). despite the likelihood for cross-conditioned craving, research has yet to extensively investigate the impact of cannabis use on cr to tobacco cues. methods. young adult dual users (n = 43; age 21-34) completed a baseline survey, two laboratory sessions, and 28 days of ecological momentary assessment (ema) comprising random, cue, and tobacco use surveys. we fit linear mixed effects models regressing craving for cigarettes and e-cigarettes from the random surveys onto past-hour cue exposure, past-hour cannabis use, and their interaction. we then fit a series of generalized linear mixed models regressing survey type (smoking versus vaping/none; vaping versus smoking/none) from the tobacco use and random surveys on the same predictors, controlling for sex, age, race, and ethnicity. results. past-hour cigarette and e-cigarette cues elicited significantly increased craving for the cued product but not for the non-cued product. past-hour cannabis use did not impact tobacco craving, nor did it moderate the impact of tobacco cue exposure on craving, regardless of the cue or tobacco product. past hour cigarette and e-cigarette cue exposure were also associated with greater odds of using the cued product. further, past-hour e-cigarette cue exposure was associated with reduced odds of using cigarettes. consistent with the findings on cue-elicited craving, cannabis did not impact tobacco use or moderate the effect of cue exposure on use. conclusion. tobacco cues elicited strong effects on craving and use of the cued products in the natural environment; however, these effects were not significantly moderated by cannabis use in our sample. crossconditioned effects between tobacco products that have been observed in laboratory settings were not replicated naturalistically nor were they moderated by cannabis use. additionally, cannabis did not have a direct effect on either craving or use of tobacco naturalistically. although cannabis and tobacco co-use is a highly prevalent phenomenon, the neural and behavioral processes underlying their co-use may be unique to their combination, similar to the crossproduct effects observed for the two different tobacco products. in other words, there may be unique learned couse cues that elicit craving and co-use of tobacco and cannabis that do not generalize or impact other patterns of substance use. future research should seek to examine such co-use specific antecedent processes. the impact of cannabis use on smoking cessation in people with hiv: evidence from a recent nicotine patch preloading trial garrett s. stang (brown university) danish azam (brown university) megan e. piper (university of wisconsin) christopher w. kahler (brown university) patricia a. cioe (brown university) conference abstracts 186 significance: tobacco use prevalence among people with hiv (pwh) is 2-3 times higher compared to the general us population, yet smoking cessation rates among pwh remain poor. cannabis use, prevalent in pwh at twice the rate of use as the general population, may hinder tobacco cessation outcomes since many pwh report cannabis use to manage hivrelated symptoms. a recent 16-week randomized control trial examined the feasibility, acceptability, and preliminary efficacy of preloading with nicotine replacement therapy (nrt) in pwh who smoke to improve cessation outcomes. this secondary analysis explores how the use of cannabis may influence tobacco cessation outcomes observed in the trial. methods: participants who smoked at least 5 cigarettes per day and were motivated to quit were randomized to nicotine patch preloading for 3 weeks before the target quit date (tqd) or no preloading. starting on the tqd, all participants initiated combination nrt (patch/lozenge or patch/gum) for 8 weeks. a trained clinic nurse provided five behavioral counseling sessions based on standard guidelines. at 12 weeks post-tqd, co-verified (< 5 ppm cutoff) 7-day point-prevalence abstinence was assessed. daily cannabis, cigarette, and nrt use was assessed at each follow-up period using a 7-day timeline follow-back (tlfb). reductions in cannabis use were calculated as the difference in use days from baseline and as the percentage change from baseline across follow-up periods. an exploratory regression analysis examined the relationship between nrt use days and cannabis use days. results: a total of 49 participants were randomized (mean age = 52.2 years; 63.5% white; 37% female). participants smoked a mean of 14.8 (sd = 9.0) cigarettes per day with moderate dependence (mean 4.9 [sd = 2.3]). at baseline, 47% (n = 23) of participants reported current cannabis use, of whom 12 (52.1%) used daily. by week 16, eight participants (15.4%) achieved co-verified abstinence (4 in the preloading condition, 4 in the control condition). at week 16, half of those who were abstinent reported cannabis use at baseline, with three out of four individuals experiencing some form of reduced cannabis use throughout the trial. participants reduced cannabis use by an average of 1.2 days per week from baseline across follow-up periods, corresponding to a 17.3% reduction in use. the greatest reductions were observed at week 16, with an average reduction of 2.7 days per week (a 38.1% reduction). by week 16, two participants achieved complete cannabis abstinence. reductions in cannabis use often coincided with decreased cigarette use; however, some participants quit smoking while continuing cannabis use, indicating independent cessation behaviors. moreover, at week 4, each additional day of nrt use was associated with a reduction of 0.1 days of cannabis use; however, this relationship was not statistically significant (p = 0.299). notably, cannabis use patterns did not differ between the preloading and control arms. conclusions: participants who reduced or stopped cannabis use may have found it easier to quit smoking conference abstracts 187 cigarettes, though this was not universal. some participants successfully quit smoking cigarettes while continuing daily or frequent cannabis use. these findings suggest that cannabis and tobacco cessation are independent behaviors among pwh. issue date: july 15, 2025 research article 8 ved abstract objective: rates of chronic pain are higher among rural versus urban individuals and rural individuals experience higher levels of socioeconomic disadvantage, poor or no health insurance coverage, and unmet treatment need. medical cannabis is legal in oklahoma. with 40% of oklahoma’s population living in rural areas, and nearly 17% uninsured, the medical legalization of cannabis may present as an accessible and relatively low-cost alternative treatment, particularly for those with chronic pain. this study investigated differences in cannabis use by rural (vs. urban) status and unmet (vs. met) treatment need among adults with and without chronic pain living in oklahoma. method: to be eligible, participants had to be 18 years or older, reside in oklahoma, and be able to read and write english-language surveys. results: the sample (n = 3622) was primarily made up of non-hispanic white (70.4%) females (53.8%) in their early middle age (m = 41.80, sd = 16.88), employed full-time or part-time (53.8%), with some college/technical school (37.2%) or a bachelor’s degree (28.5%). nearly one-fifth of the sample (18.2%) endorsed chronic pain, and individuals with chronic pain were eight times more likely to report past 30-day cannabis use. no difference was detected when only rurality (vs. urban residence) was examined. among adults with chronic pain, those who were rural dwelling and who reported unmet treatment need were almost two times more likely to report past 30-day cannabis use, compared to urban dwelling chronic pain adults with unmet treatment need. conclusions: in oklahoma, adults in rural areas with unmet treatment need and chronic pain may benefit from increasing access to chronic pain treatment, as well as education on cannabis use and harm reduction strategies to inform healthcare decision-making. key words: = chronic pain; cannabis; rurality; treatment need chronic pain is one of the leading causes of disability and primary care visits among u.s. adults (van oostrom et al., 2014). approximately 20% of u.s. adults experience chronic pain, defined as pain that lasts more than 3 months, which can fluctuate in severity and interference (dydyk & conermann, 2023; katz et al., 2015). chronic pain is associated with psychological, physical, and economic consequences, all of which can be exacerbated by inadequate pain treatment (fine, 2011). early pain management can mitigate these consequences and help people maintain or return to practical levels of daily functioning (fine, 2011). unfortunately, chronic pain remains poorly treated due to a variety of barriers (e.g., physical distance from healthcare hannah appleseth1, desiree r. azizoddin2,3, & amy m. cohn2,4 1department of psychology, oklahoma state university 2tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center 3department of family and preventive medicine, college of medicine, university of oklahoma health sciences center 4department of pediatrics, college of medicine, university of oklahoma health sciences center cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000233 volume 8, issue 1 the intersection of rurality, unmet treatment need, and cannabis use for adults with chronic pain corresponding author: hannah appleseth, m.a., oklahoma state university, 118 psychology building, stillwater, oklahoma 74048. email: hannah.appleseth@okstate.edu. cannabis, a publication of the research society on marijuana 9 facilities, lack of treatment providers, limited or no insurance coverage) (darnall et al., 2016), leaving many adults to seek out their own pain management solutions. individuals with chronic pain are more likely to experience social and economic vulnerabilities, such as poverty, rurality, and comorbid psychological or physical conditions (albrecht et al., 2021; day & thorn, 2010; keralis, 2021; rios & zautra, 2011; tunks et al., 2008; van oostrom et al., 2014), all of which can augment pain management challenges. cannabis-based treatment options have increased in popularity for chronic pain management (romero-sandoval et al., 2018). as of 2023, medicinal cannabis is legal in 38 united states jurisdictions, and chronic pain (nonmalignant) is the most commonly cited reason for medical cannabis use in the u.s. (hameed et al., 2023). estimates vary, but among a recent u.s. national sample of adults with chronic pain, 23.2% reported using cannabis within the past 30 days to manage their pain (bicket et al., 2023). cross-sectional findings suggest that more than 35% of individuals using cannabis to treat pain report they have substituted cannabis for opioids, viewing it as an attractive harm reduction strategy (corroon et al., 2017; lim et al., 2023). with the widespread availability of cannabis and lower cost relative to traditional medical treatment, adults with chronic pain may be less likely to seek out efficacious non-pharmacological treatments for pain. for example, bicket and colleagues (2023) found that the increased use of medical cannabis for chronic pain was associated with a decrease in use of effective nonpharmacological treatments including physical therapy and cognitive behavioral therapy. increased use of cannabis as a replacement for other pharmacologic and non-pharmacologic treatment may be problematic because the evidence demonstrating the efficaciousness of cannabis for treating chronic pain is limited and mixed, with methodological issues such as short follow-up periods (<6 months), small sample sizes, industry funding (which can constitute significant bias), and inconsistent measurement practices (wang et al., 2021). moreover, the pharmacokinetics and pharmacodynamics of cannabinoids for chronic pain are unclear, leaving important prescribing questions, such as dosage and drug-drug interactions, unanswered (sharon & brill, 2019). use of cannabis for chronic pain has also been associated with short-term adverse events including dizziness, nausea, dry mouth, and confusion, although there is a low evidence of cannabis use causing significant harm compared to controls (nugent et al., 2017). the long-term consequences of medical cannabis use are yet to be clearly established (zeraatkar et al., 2022). despite the known acute risks of cannabis use and the possibility of undetermined long-term risks, medical cannabis remains a desired and often accessible pain management option for many (babalonis et al. 2021). this is particularly true for vulnerable populations, like individuals living in rural locations, with lower income, or with limited or no health insurance. in rural areas, 28.1% of adults report chronic pain compared to 16.4% in large urban areas (wang et al., 2021, p. 20). even after adjusting for age, chronic pain is still more prevalent in rural areas in comparison to large urban areas (25.4% vs. 16.8%) (rikard et al., 2023). rural dwelling individuals with chronic pain are more likely to be uninsured, younger, report higher levels of disability, and have historically faced challenges in accessing specialty treatment for pain (goode et al., 2013; spleen et al., 2014). the challenges of accessing healthcare in rural areas may lead to delays or avoidance of needed care (spleen et al., 2014). this is supported by the finding that people with chronic pain in rural areas are more likely to use prescription opioids and less likely to use nonpharmacologic treatments or self-management strategies (eaton et al., 2018). increased cannabis use could amplify chronic disease and mental health disparities—which are elevated in rural areas (coughlin et al., 2019; morales et al., 2020). for example, recreational cannabis use has been associated with increased risk of cardiovascular disease and a decline in executive functioning abilities (crean et al., 2011; goyal et al., 2017). as such, cannabis use for chronic pain management may place vulnerable populations in a position to experience worse outcomes in a variety of domains. it may be the case that the barriers preventing people from accessing evidence-based treatments for chronic pain management (e.g., financial constraints, physical distance, transportation barriers, lack of providers) are the same ones that might motivate people, particularly vulnerable groups, to seek medical relief via cannabis use. thus, the current study investigated associations rurality, unmet treatment need, and cannabis use for chronic pain 10 of rurality, unmet treatment need, and cannabis use among adults with and without chronic pain living in oklahoma, a legal medical cannabis state with a large rural and uninsured population (kff, 2022). oklahoma legalized medical cannabis in 2018, and 10% of adults in the state now possess a patient medical cannabis license (mcl; omma, 2022). specifically, objectives of the current study were to: 1) compare adults with and without chronic pain on demographics (including rurality) and on factors related to cannabis use (e.g., licit and illicit substance use), medical comorbidities, and unmet treatment need; 2) assess the unique and combined associations of chronic pain and rurality on past 30-day cannabis use behavior; and 3) assess the unique and combined associations of rurality and unmet treatment need on past 30-day cannabis use behavior, separately across those with and without chronic pain. findings will provide insight into possible group differences in cannabis use among adults with chronic pain. we hypothesized that rural-dwelling individuals with chronic pain would have a higher likelihood of past 30-day cannabis use when compared to those in urban areas with chronic pain. we also hypothesized that among those with chronic pain, those living in rural (vs. urban) areas and with unmet (vs. met) treatment need would be most likely to report past 30-day cannabis use. methods participants and procedures data were collected from english-speaking adults ages 18+ living in oklahoma (verified by self-reported residential zip code) who completed one wave of a three-wave cross-sectional online survey. three survey waves were fielded 6months apart (september 2020-september 2021). respondents were recruited from a professionally maintained panel vendor, lucid, based on the demographics (state of residence, age, gender, race/ethnicity) of panel member profiles. surveys took 10-12 minutes to complete. sampling quotas for age, gender, and race/ethnicity were used to increase the likelihood that respondent demographics would be similar to the oklahoma population (based on oklahoma census data). surveys remained active and accessible until the sampling quotas for each wave were filled. participants were compensated based on incentives provided by the panel to which they belonged (e.g., cash, gift cards, points to redeem reward prizes, or gift cards, equating to roughly $1). more detail on the study methodology and data quality are published here (cohn, alexander, et al., 2023; kendzor et al., 2022). procedures were approved by the university of oklahoma health sciences center irb. demographic characteristics of the three-wave sample were within a 3-5% standard deviation of the oklahoma census data. participants who completed more than one wave (n = 145) of the three-wave study were identified and data from their most recent survey were retained. the final analytic sample for this analysis consisted of 3,622 adults in waves 2 and 3 who were asked about unmet medical treatment need (survey item not included in wave 1). measures sociodemographic variables participants were asked to report age, race/ethnicity (categorized as non-hispanic [nh] white, nh black/african american, hispanic, and nh other), income (≤$19,999, $20,000– $39,999, $40,000–$59,999, $60,000–$79,999, $80,000–$99,999, ≥$100,000), employment (categorized as full‐ or part‐time, unemployed and looking for work, unemployed and not looking for work, student, other), education (<12 years, high school diploma/ged, some college/technical school, associate’s degree, bachelor’s degree, or graduate school), and current health insurance (medicare, medicaid, private insurance, military insurance, no insurance). health insurance was dichotomized for analyses as no insurance vs. any insurance (medicare, medicaid, private insurance, military insurance). participants reported whether they had a medical cannabis license (mcl) issued by the oklahoma medical marijuana authority (omma) (yes/no). cannabis and other substance use participants reported the number of days in the past 30 days they had used cannabis, alcohol, cigarettes, prescription painkillers (opiates, such as hydrocodone, buprenorphine, codeine, fentanyl) and other illicit drugs (cocaine, crack, cannabis, a publication of the research society on marijuana 11 meth, heroin). those who reported use on >1 day were coded as having used that substance in the past 30 days. rural/urban the rural-urban commuting area (ruca) 30 codes associated with participants’ selfreported zip code of residence were used to classify the participants as either rural or urban residents. ruca codes 1-3 indicated urban residence and codes 4-10 indicated rural residence (usda ers rural-urban commuting area codes, n.d.). chronic pain and other medical conditions participants were asked to review a list of 14 medical conditions or symptoms and indicate the ones they had received a medical diagnosis for or self-diagnosed. participants who responded “yes” to having been medically or selfdiagnosed with “chronic pain” were categorized as such for the analysis. the list of medical conditions was summed and then categorized (none, 1-2 conditions, 3-4 conditions, 5 or more conditions). unmet treatment need using an item adapted from the national survey of drug use and health (samhsa, 2019; walker et al., 2015) participants were asked: “in the past 12 months, was there a ever time when you needed to see a medical specialist about a health issue but did not get it?” those who responded “yes” were categorized as having an “unmet treatment need” (coded as 1), and those who responded “no” were categorized as having “met treatment need” (coded as 0). data analysis frequencies were calculated for sociodemographic characteristics, unmet treatment need, substance use, and healthrelated behaviors in the full analytic sample. the demographic, substance use, and healthrelated correlates of those with and without chronic pain were assessed using crosstabulations. next, models assessed the main and interactive effects of chronic pain (yes/no) and rurality (rural vs. urban) on odds of reporting past 30-day cannabis use (yes/no). the sample was then stratified by whether they had chronic pain to investigate the main and interactive effects of rurality (rural vs. urban) and unmet treatment need (yes/no) on odds of reporting past 30-day cannabis use with binary adjusted logistic regression models. all models adjusted for age, race/ethnicity, and health insurance status, which were identified via a backward step selection to reduce the number of parameters in the models. we chose to exclude the number of medical conditions from the model because our categorization of chronic pain (vs. no chronic pain) was derived from the list of medical conditions, thus the two variables were highly collinear (r = .67, p < .001). results participant characteristics table 1 shows sociodemographic characteristics of the full analytic sample (n = 3622) and compares those with (18.2%, n = 659) and without chronic pain (81.8%, n = 659). in the full sample, slightly over half were female (53.8%), early middle-aged (m = 41.80, sd = 16.88), employed full-time or part-time (53.8%), received either some college/technical school (37.2%) or a bachelor’s degree (28.5%), and the majority identified as non-hispanic white (70.4%). just over one-third (37.3%) resided in a rural area, 20% did not have health insurance, close to a quarter (27.8%) reported unmet treatment need and reported having a medical cannabis license (23.5%). just over half of participants (55.4%) endorsed not having any medical conditions. in terms of substance use, 33.5% reported past 30-day cannabis use, 34.5% reported past 30-day cigarette use, 48.5% reported past 30-day alcohol use, 18.1% reported past 30-day prescription pain medication use (opioids, such as hydrocodone, buprenorphine, codeine, fentanyl), and 22.5% reported past 30-day illicit drug use (cocaine, crack, meth, heroin). rurality, unmet treatment need, and cannabis use for chronic pain 12 table 1. sample descriptives overall (n = 3,622) no chronic pain (n = 2,963) 81.8% chronic pain (n = 659) 18.2% p (n) % (n) % (n) % sex male (1673) 46.2 (1402) 47.3 (271) 41.1 .004 female (1949) 53.8 (1561) 52.7 (388) 58.9 race/ethnicity non-hispanic (nh) white (2546) 70.4 (2086) 70.5 (460) 69.8 .07 nh black (285) 7.9 (238) 8.0 (47) 7.1 nh other (440) 12.2 (342) 11.6 (98) 14.9 hispanic (346) 9.6 (292) 9.9 (54) 8.2 age 18-24 (682) 18.8 (604) 20.4 (78) 11.8 <.001 25-34 (758) 20.9 (604) 20.4 (154) 23.4 35-44 (728) 20.1 (586) 19.8 (142) 21.5 45-54 (522) 14.4 (399) 13.5 (123) 18.7 55-64 (479) 13.2 (376) 12.7 (103) 15.6 65+ (453) 12.5 (394) 13.3 (59) 9.0 education less than 12 years (274) 7.6 (218) 7.4 (56) 8.5 <.001 highschool diploma/ged (964) 26.6 (801) 27.1 (163) 24.7 some college/technical school (1348) 37.2 (1035) 35.0 (313) 47.5 bachelor’s degree or higher (1033) 28.5 (906) 30.6 (127) 19.3 household income < $20,000 (897) 26.2 (703) 25.3 (194) 30.2 <.001 $20,000 – $39,999 (819) 23.9 (634) 22.8 (185) 28.8 $40,000 – $59,999 (589) 17.2 (477) 17.1 (112) 17.4 $60,000 – $79,999 (419) 12.2 (350) 12.6 (69) 10.7 $80,000 – $99,999 (274) 8.0 (239) 8.6 (35) 5.4 $100,000 or more (428) 12.5 (380) 13.7 (48) 7.5 employment employed (fullor parttime) (1947) 53.8 (1646) 55.6 (301) 45.7 <.001 unemployed, not seeking (1068) 29.5 (804) 27.1 (264) 40.1 unemployed, looking (357) 9.9 (294) 9.9 (63) 17.6 student (149) 4.1 (130) 4.4 (19) 2.9 other (101) 2.8 (89) 3.0 (12) 1.8 no. of medical conditions none reported (2005) 55.4 (2005) 67.7 (0) 0.0 <.001 1-2 (460) 12.7 (412) 13.9 (48) 7.3 3-4 (516) 14.2 (367) 12.4 (149) 22.6 5 or more (641) 17.7 (179) 6.0 (462) 70.1 health insurance yes (2903) 80.2 (2353) 79.5 (550) 83.5 .02 no (715) 19.8 (606) 20.5 (109) 16.5 rural/urban rural (1350) 37.3 (1092) 36.2 (258) 39.2 0.27 urban (2272) 62.7 (1871) 63.1 (401) 60.8 unmet treatment need yes (1006) 27.8 (715) 24.2 (291) 44.2 <.001 no (2611) 72.2 (2243) 75.8 (368) 55.8 medical cannabis license yes (852) 23.5 (499) 16.9 (353) 53.6 <.001 no (2766) 76.5 (2460) 83.1 (306) 46.4 cannabis, a publication of the research society on marijuana 13 past 30-day cannabis use yes (1157) 33.5 (703) 25.0 (454) 72.1 <.001 no (2289) 66.4 (2113) 75.0 (176) 27.9 past 30-day cigarette use yes (1235) 34.5 (894) 30.5 (341) 52.1 <.001 no (2349) 65.5 (2035) 69.5 (314) 47.9 past 30-day alcohol use yes (1737) 48.5 (1377) 47.1 (360) 54.8 <.001 no (1846) 51.5 (1549) 52.9 (297) 45.2 past 30-day rx painkillers yes (656) 18.1 (431) 14.5 (225) 34.1 <.001 no (2966) 81.9 (2532) 85.5 (434) 65.9 past 30-day illicit drug use yes (809) 22.5 (554) 18.9 (255) 38.7 <.001 no (2784) 77.5 (2380) 81.1 (404) 61.3 wave 2 (1826) 50.4 (1512) 51.0 (314) 47.6 .12 3 (1796) 49.6 (1451) 49.0 (345) 52.4 note. health insurance was dichotomized for analyses as no insurance vs any insurance (medicare, medicaid, private insurance, military insurance). prescription painkillers included opioids, such as hydrocodone, buprenorphine, codeine, fentanyl, and illicit drugs included cocaine, crack, meth, heroin. differences between participants with and without chronic pain compared to participants without chronic pain, a higher proportion of participants with chronic pain were female (58.9% vs. 52.7%), unemployed (40.1% vs. 27.1%), and reported having some college or technical school education (47.5% vs. 35.0%). a larger proportion of adults with chronic pain also reported unmet treatment need (44.2% vs. 24.2%), endorsed 5 or more medical conditions (70.1% vs. 6.0%), and had a medical cannabis license (53.6% vs. 16.9%). similarly, concerning substance use, a higher proportion of those with chronic pain reported past 30-day cannabis use (72.1% vs. 27.9%), past 30-day prescription pain medication use (34.1% vs. 14.5%), past 30-day alcohol use (54.8% vs. 47.1%), past 30-day cigarette use (52.1% vs. 30.5%), and past 30-day illicit drug use (38.7% vs. 18.9%). the proportion of participants with chronic pain (vs. those without chronic pain) did not significantly differ across study waves (47.6% vs. 52.4%). associations of rurality and chronic pain with past 30-day cannabis use table 2 shows results of the adjusted binary logistic regression of the main and interactive effects of rurality and chronic pain on the odds of past 30-day cannabis use. results showed a main effect of chronic pain, but no significant interaction of chronic pain with rurality emerged. specifically, having chronic pain (vs. no chronic pain) was associated with increased odds of reporting past 30-day cannabis use (aor = 8.90, 95% ci = [6.83-11.61]), after adjusting for covariates, yet there was no main effect of rurality on increased odds of reporting past 30-day cannabis use (aor = 0.91, 95% ci = [0.76-1.09]). table 2. adjusted logistic regression model of of the main and interactive effects of chronic pain and rurality with past 30-day cannabis use any past 30-day cannabis use (vs no past 30-day use) aor (95% ci) p chronic pain no ref yes 8.90 (6.83, 11.61) <.001 rural vs. urban urban ref rural 0.91 (0.76, 1.09) .31 chronic pain x rurality 1.11 (0.73, 1.68) .62 note. models control for age, race/ethnicity, and health insurance status (none vs any). ref=reference group. rurality, unmet treatment need, and cannabis use for chronic pain 14 associations of rurality and unmet treatment need with past 30-day cannabis use, stratified by chronic pain status table 3 presents results of adjusted binary logistic regression models of the main and interactive effects of rurality and unmet treatment need among those with and without chronic pain. among those with chronic pain, a significant interaction of rurality and unmet treatment need emerged on past 30-day cannabis use (aor = 2.39, 95% ci = [1.11, 5.14]). in explicating the interaction, among those with chronic pain, the odds of reporting past 30-day cannabis were nearly two times greater for rural residents who experienced unmet treatment need compared to urban residents with unmet treatment need (aor = 1.97, 95% ci = [1.053.69]); while there was no association between rurality and increased odds of past 30-day cannabis among those who did not report unmet treatment need (aor = 0.74, 95% ci = [0.461.19]). see figure 1 for proportions of respondents with chronic pain who reported past 30-day cannabis use, stratified by rural and unmet treatment need status. no main effects of either rurality (aor = 0.74, 95% ci = [0.46, 1.19]) or unmet treatment need (aor = 1.21, 95% ci = [1.53-2.48]) emerged. among those without chronic pain, no significant interaction emerged, but a main effect of unmet treatment need did. specifically, those with unmet treatment need (vs. met treatment need) had higher odds of reporting past 30-day cannabis use (aor = 1.95, 95% ci = [1.53-2.48]). there was no main effect of rurality on increased odds of past 30-day cannabis use (aor = .93, 95% ci = [0.74-1.16]). table 3. adjusted logistic regression model of the main and interactive effects of rurality and unmet treatment need with past 30-day cannabis use, stratified by chronic pain status (yes/no) any past 30-day cannabis use (vs. no past 30-day use) aor (95% ci) p participants with chronic pain (n=630) rural vs. urban urban ref rural 0.74 (0.46, 1.19) .22 unmet treatment need no ref yes 1.21 (0.75, 1.94) .44 rural x unmet treatment need 2.39 (1.11, 5.14) .03 participants without chronic pain (n = 2809) rural vs. urban urban ref rural 0.93 (0.74, 1.16) .51 unmet treatment need no ref yes 1.95 (1.53, 2.48) <.001 rural x unmet treatment need 0.95 (0.63, 1.43) .79 note. models control for age, race/ethnicity, and health insurance status (none vs any). ref = reference group. cannabis, a publication of the research society on marijuana 15 post-hoc analyses given the overlap between chronic pain and possession of a mcl (e.g., 53.4% of those with chronic pain reported having an mcl), we reanalyzed the model that included individuals with chronic pain and included mcl as a covariate. results showed that the interaction between unmet treatment need and rurality inclusion among those with chronic pain was no longer significant once possession of an mcl was included as a covariate in the model. the odds of past 30-day cannabis use was 11 times greater among those with chronic pain with an mcl (aor = 11.08, 95% ci = [7.01, 17.50], p <.001). the interactive effect of rurality and chronic pain on the odds of past 30-day cannabis use was not significant (aor = 1.71, 95% ci = 0.72, 4.07, p = 0.22). there were no significant main effects of rurality (aor = 0.90, 95% ci = 0.52, 1.55, p = 0.71), nor unmet treatment need (aor = 1.61, 95% ci = [0.94, 2.77], p = 0.08). figure 1. association of rurality and unmet treatment need with proportion of past 30-day cannabis use among those with chronic pain discussion in this sample of adults in oklahoma, about 20% reported chronic pain, which is consistent with previously published u.s. population-based studies (dydyk & conermann, 2023; yong et al., 2022). overall, those with chronic pain reported worse overall physical health and more substance use than those without chronic pain. consistent with other published work (martel et al., 2018), adults with chronic pain in our sample were more likely to be female, have lower income and education, and to be unemployed; all of which are factors that could exacerbate chronic pain symptoms and/or treatment utilization (huffman et al., 2019). people with chronic pain frequently experience co-occurring medical conditions and often have difficulty accessing treatment (foley et al., 2021), as shown by our findings that 70.2% of participants with chronic pain reported having at least 5 medical conditions or more and 44.2% reported having unmet treatment need in the past year. unmet treatment need may exacerbate pain intensity and interference, both of which are associated with high-frequency cannabis use (boehnke et al., 2020; john & wu, 2020). in our sample, 70% of those with chronic pain reported past 30-day cannabis use, which is much higher than recent national estimates showing that in medically legal cannabis states, 25% of those with chronic pain reported ever using cannabis (leung et al., 2022). further, 54% of those with chronic pain (compared to 17% of those without chronic pain) reported having an mcl issued by the 83% 63% 75% 70% 17% 37% 25% 30% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% unmet met unmet met rural urban past 30-day cannabis use no past 30-day cannabis use rurality, unmet treatment need, and cannabis use for chronic pain 16 oklahoma medical marijuana authority. this may be a by-product of oklahoma’s permissive policy environment, easy access to an mcl, and the wide availability of cannabis dispensaries in oklahoma (cohn, sedani, et al., 2023). notably, in oklahoma, approximately 10% of all adults have an mcl (marijuana policy project, 2023). we also evaluated associations among rurality, chronic pain, and unmet treatment need on past 30-day cannabis use, while controlling for age, race, and health insurance. previous studies have typically found that cannabis use tends to be higher among those with chronic pain versus those without, but findings have been mixed regarding rurality (day & thorn, 2010; eaton et al., 2018). we identified that individuals with chronic pain were eight times more likely to report past 30-day cannabis use, but no difference was found between those who were rural dwelling versus those urban dwelling on propensity to engage in past 30-day cannabis use. when we evaluated the relationship further between rurality and unmet treatment need on past 30-day cannabis, separately across adults with and without chronic pain, we found that adults with chronic pain who were rural dwelling and who reported unmet treatment need were almost two times more likely to report past 30-day cannabis use compared to urban dwelling adults with chronic pain and unmet treatment need. in contrast, those individuals without chronic pain who had unmet treatment need were also two times more likely to report cannabis use; however, in this case, rural or urban dwelling status did not seem to play a role in their cannabis use. these findings highlight the importance of individuals’ unmet treatment need when considering their propensity to engage in cannabis use. this may be especially true for adults with chronic pain who are living in rural areas. historically, rural individuals with chronic pain have been less likely to have access to specialty pain management care and more likely to use prescription opioids for pain management (eaton et al., 2018). as more states legalize cannabis for medical (and/or recreational) use, it may be that rural residents are using cannabis to self-medicate their pain symptoms. while our study did not investigate the specific medical conditions for which participants were using cannabis, kendzor et al. (2022) found that chronic pain ranked among the primary reasons for medical cannabis use within wave 1 of this sample. once possession of a mcl was included in the analytic model, the interaction of rurality and unmet treatment need, among adults with chronic pain, was no longer significant. this suggests that legalized use, via possession of a legal medical license, may serve as a more direct proxy of the associations between rurality and unmet treatment and cannabis use than each factor separately. three times as many adults with chronic pain (vs. no chronic pain) reported having an mcl (54% vs. 16%), even though adults with chronic pain were overall more likely to have unmet treatment need. the legalization of medical cannabis may influence use among chronic pain patients as an alternative therapy option. more research is needed to understand what factors motivate chronic pain patients to seek out alternative therapies such as cannabis. future research should investigate whether patients are using cannabis to replace evidence-based, pharmacological and non-pharmacological chronic pain treatments. examining if and why substitution is occurring will provide greater insight into how the legalization of medical cannabis could be impacting those with chronic pain and their healthcare decisions. for example, in oklahoma, license application fees are significantly lower for adults enrolled in medicaid or medicare ($20) compared to those without such coverage ($100), which may encourage individuals facing barriers to accessing traditional medical care to pursue medical cannabis as a potential treatment option (omma, 2024). this study extends previous work by clarifying the conditional effects of chronic pain, rural residence, and unmet treatment need on risk for cannabis use (eaton et al., 2018; park & wu, 2017). the use of medical cannabis for chronic pain treatment often fails to align with actual medical guidelines or be administered by medical healthcare professionals, resulting in unintended overdose or poisoning, higher risk consumption modalities (e.g., smoking, vaping), higher rates of co-use with prescription opioids (34% in this sample), and greater negative adverse events (e.g., car accidents, falls) (azizoddin et al., 2023; busse et al., 2021). additionally, in oklahoma, a recent assessment found that 55% of patients with an mcl still obtain at least some of their cannabis from illicit sources (mudd et al., 2023), which can cannabis, a publication of the research society on marijuana 17 place them at a higher risk for using contaminated supply (e.g., contains pesticides or microorganisms), using more than intended due to mislabeling, or legal issues (boehnke et al., 2020; maccallum et al., 2023). future research should examine access to cannabis (both licit and illicit) and sources of cannabis purchasing specifically among rural dwelling adults living with chronic pain. this study had several limitations. first, while we assessed unmet treatment need, we did not measure factors impacting unmet treatment need, including distance to treatment provider(s), perceptions of trust/distrust of the medical care system, and knowledge about how to find a chronic pain treatment provider (among others). additionally, our measure of unmet treatment need was selected as it aligns with the nsduh and provides greater generalizability; however, it does not allow us to discern whether the unmet treatment need stemmed from chronic pain issues specifically or other medical conditions. similarly, while the measurement of past 30-day cannabis use aligns with national surveys, it lacks granularity, such as frequency and modality of use. future work can extend these findings by examining unmet treatment need specifically related to chronic pain symptoms and while using a more detailed assessment of cannabis use to evaluate patient outcomes. another limitation is that our data are cross-sectional, restricting the ability to conclude whether unmet treatment need and rurality lead to cannabis use, or whether cannabis use leads to greater pain and unmet treatment need. future work should examine the longitudinal linkages between cannabis use and treatment need among rural/urban adults with chronic pain to further illuminate the impact of cannabis use on pain outcomes and the potential interaction with treatment availability. lastly, data collection occurred in oklahoma, a legal medical cannabis state, with high rates of both uninsured and rural residents. findings may not generalize to states without legal medical cannabis, or states with a higher proportion of urban dwelling and insured residents. conclusion in this large sample of adults from oklahoma, rural dwelling individuals with unmet treatment need and chronic pain appear to be uniquely at risk of cannabis use and could benefit from targeted community efforts for chronic pain treatment, as well as education on cannabis use and harm reduction strategies to inform healthcare decision-making. the consequences resulting from the lack of treatment providers and increased use of cannabis for self-management of chronic pain suggest that some of the most vulnerable populations may offset traditional medical treatment for an unsupported but widely available alternative—cannabis. references albrecht, d., kim, m., akeju, o., torradocarvajal, a., edwards, r., zhang, y., bergan, c., protsenko, e., kucyi, a., & wasan, a. 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(2022). long-term and serious harms of medical cannabis and cannabinoids for chronic pain: a systematic review of nonrandomised studies. bmj open, 12(8), e054282. https://doi.org/10.1136/bmjopen2021-054282 funding and acknowledgements: this work was supported by oklahoma tobacco settlement endowment trust (tset) contract #r22-03 and the national cancer institute grant awarded to the stephenson cancer center (p30ca225520). we thank michael a. smith for his assistance in data procurement and project management and sarah j. ehlke for data management. authors report no conflicts of interest. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: appleseth, h., azizoddin, d. r., & cohn, a. m. (2025). the intersection of rurality, unmet treatment need, and cannabis use for adults with chronic pain. cannabis, 8(1), 8-20. https://doi.org/10.26828/cannabis/2024/000233 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 103 ved abstract objective: people with (versus without) disabilities may be more likely to use cannabis medicinally, especially if they lack social support to cope with symptoms. however, associations of social support and disability with cannabis use remain largely unexplored. method: adults with clinically significant anxiety and/or depressive symptoms participating in a clinical trial completed a baseline survey assessing pastmonth medical and recreational cannabis use, self-perceived disability (yes/no), perceived social support, and sociodemographics. regression models examined the association between disability and social support, and the main and interactive effects of disability and social support on past-month medical and recreational cannabis use, adjusting for race and ethnicity, gender, age, and income. results: the sample (n = 822) was 25.3% american indian, 25.1% black, 25.1% white, and 24.6% latinx (64.6% female; mage = 38.3 [sd = 12.8]). half (51.1%) self-reported a health condition that limited activities (i.e., disability); 24.9% reported past-month medical cannabis use, and 25.4% reported past-month recreational cannabis use. participants with a self-reported disability reported lower average social support than those without (p = .031). a significant (p = .045) disability x social support interaction indicated that social support was associated with lower odds of medical cannabis use among those without (p = .038), but not with (p = .525), disability. disability and social support were not significantly associated with recreational cannabis use (p-values > .05). conclusions: individuals with disabilities had elevated odds of using medical cannabis, regardless of social support. social support is imperative for well-being, and cannabis use may alleviate some symptoms; however, more accessible, comprehensive healthcare may be needed to support individuals with disabilities. key words: = disability; social support; cannabis; anxiety; depression as of 2024, medical cannabis use is legal in 37 united states (us) states, 24 of which have also legalized recreational use (breen & johnston, 2024). rising availability and use prevalence of cannabis for medical and recreational purposes may have both positive and negative effects on erin a. vogel1,2, katelyn f. romm1,2, dj mcmaughan3, michael j. zvolensky4,5,6, lorra garey6,7, & michael s. businelle1,8 1tset health promotion research center, university of oklahoma health campus 2department of pediatrics, university of oklahoma health campus 3school of community health science, counseling and counseling psychology, oklahoma state university 4seattle children’s hospital, seattle children’s research institute 5department of behavioral science, the university of texas md anderson cancer center 6health institute, university of houston 7department of psychology, university of houston 8department of family and preventive medicine, university of oklahoma health campus cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000305 volume 8, issue 3 associations of disability and social support with cannabis use among adults with anxiety and depressive symptoms corresponding author: erin vogel, phd, university of oklahoma health campus, tset health promotion research center, 655 research parkway, suite 400. oklahoma city, ok, 73112. phone: (405) 271-8001 x 50493. email: erin-vogel@ou.edu cannabis, a publication of the research society on marijuana 104 public health. legalization has coincided with increased potency of cannabis products and increased prevalence of cannabis use disorder (chiu et al., 2021). however, cannabis may have health benefits for certain health conditions and symptoms, including multiple sclerosis, treatment-resistant epilepsy, chemotherapyinduced nausea, and chronic pain (fischer et al., 2022; stetten et al., 2020). importantly, cannabis use can also exacerbate health conditions, including mood and anxiety disorders (muheriwamatemba et al., 2024; sorkhou et al., 2024; stetten et al., 2020). cannabis use prevalence is disproportionately high among individuals with (versus without) elevated anxiety and depressive symptoms (rup et al., 2021). people with disabilities (i.e., limitations resulting from the interaction between an individual’s impairments and the barriers in their physical and social environments) may be more likely to use cannabis than their peers without disabilities (gimm et al., 2023; goulet-stock et al., 2017; hasin et al., 2019; yang et al., 2023). understanding drivers of associations between disability and cannabis use among those with anxiety and depressive symptoms is crucial to informing interventions to meet the specific healthcare needs of this population (e.g., accessible mental and physical health support, psychoeducation on the effects of cannabis on mental health symptoms). adults with (versus without) disabilities are more likely to report a lack of social support (centers for disease control and prevention, 2023). social support may include both emotional support (e.g., affirmation and processing of emotions) and instrumental support (e.g., assistance with completing tasks or paying for medical care; o’brien, 1993; scott & havercamp, 2014). social support may promote positive health outcomes among individuals with disabilities, as receiving social support is associated with higher life satisfaction, better quality of life, lower pain severity, and better mental and behavioral health (haegele et al., 2024; saravanan et al., 2021; scott & havercamp, 2014; wei et al., 2023; wu et al., 2024). however, associations of social support with cannabis use among individuals with disabilities remain largely unexplored. in the absence of social support, individuals with disabilities may use cannabis to cope with the inaccessibility of social and physical environments. indeed, low social support is associated with greater odds of cannabis use and cannabis use disorder symptoms (gliksberg et al., 2022; gulliver & fowler, 2022; li & rhubart, 2024; studer et al., 2017). this issue is concerning because coping motives for cannabis use are associated with anxiety symptoms, depressive symptoms, and cannabis use disorder symptoms (scarfe et al., 2022). if found to be associated with disability and cannabis use, social support is an actionable intervention target to reduce hazardous cannabis use patterns among individuals with elevated anxiety and depressive symptoms. differences in cannabis use by disability status may be driven by medical, rather than recreational, cannabis use (goulet-stock et al., 2017; lin et al., 2016). people with (versus without) disabilities have greater healthcare needs on average (kennedy et al., 2017) and may use medical cannabis to try to ameliorate symptoms, especially if their healthcare needs are not otherwise met (goulet-stock et al., 2017; vogel et al., 2024). the distinction between medical and recreational cannabis use may be particularly blurred among individuals with depressive and anxiety symptoms. for example, using cannabis to elevate one’s mood and relieve stress could be considered medical (i.e., to alleviate depressive and anxiety symptoms), recreational (i.e., to feel happy and relaxed), or both. indeed, research suggests that depressive and anxiety symptoms are more severe among individuals reporting medical than recreational cannabis use (turna et al., 2020), despite the highly prevalent perception that cannabis use relieves their mental health symptoms (turna et al., 2019). combining medical and recreational cannabis use may mask differences in medical cannabis use prevalence by disability status. understanding associations among social support and self-perceived types of cannabis use among individuals with disabilities may help refine researchers’ understanding of the needs that cannabis fills for individuals with disabilities who have anxiety and depressive symptoms (e.g., relief from loneliness, relief from symptoms). therefore, it is important to measure medical cannabis use and recreational cannabis use separately. the present study, a secondary analysis of a large study (garey et al., 2022), examined associations of disability status and perceived social support with current medical cannabis use disability, social support, and cannabis use 105 and current recreational cannabis use in a sample of us adults with clinically significant anxiety and/or depressive symptoms. consistent with nationally representative data (centers for disease control and prevention, 2023), we hypothesized that individuals with (versus without) disabilities would have, on average, lower perceived social support. we predicted that individuals with disabilities and individuals with lower social support would have greater odds of medical cannabis use. lastly, we explored the disability x social support interaction on medical cannabis use, explored associations of disability and perceived social support with recreational cannabis use, and conducted sensitivity analyses examining associations of disability and social support with cannabis use days among participants reporting current use. methods participants and procedures data were derived from the baseline survey of the easing anxiety sensitivity for everyone (ease) study, a two-arm randomized controlled trial of a novel smartphone app for adults experiencing clinically significant anxiety and/or depressive symptoms (garey et al., 2022). purposive, quota-based sampling was used to recruit approximately equal distributions of participants from four racial and ethnic groups: american indian, black/african american, hispanic/latinx, and non-hispanic (nh) white. eligibility criteria were clinically significant anxiety and/or depressive symptoms, defined as scoring 8+ on the overall anxiety severity and impairment scale (campbell-sills et al., 2009) and/or the overall depression severity and impairment scale (bentley et al., 2014); aged 18+ years; self-identification as black, hispanic, american indian, or nh white; english literacy; and willingness to complete all study assessments. participants were recruited from community organizations and online advertisements for a 6-month intervention during which participants engaged with their assigned smartphone app (ease or a mindfulness/relaxation-based comparator; garey et al., 2022). participants also completed a baseline survey, two brief daily surveys during the 6-month intervention, and follow-up surveys and interviews at 3and 6-months post-randomization. further details have been published previously (garey et al., 2022). baseline data were used in the present analysis. study procedures were approved by the university of oklahoma health campus institutional review board (# study00002802) and adhered to ethical guidelines. all participants provided informed consent. measures outcomes. current medical cannabis use and current recreational cannabis use were measured with two items: “in the past 30 days, on how many days did you use marijuana/cannabis for medical reasons (e.g., to treat or decrease symptoms of a health condition) / for non-medical reasons (e.g., for pleasure or satisfaction, to have fun)?” (0-30; dichotomized for primary analyses as no [0 days] versus any [1-30 days] use). primary predictors. disability was measured with: “are you limited in any way in activities because of physical, mental, or emotional problems?” (yes/no; centers for disease control and prevention, 2017). perceived social support was measured with the perceived social support questionnaire (kliem et al., 2015), a 6-item measure of perceived availability of social support (score range: 6-24;  = .86). sample items include, “there is someone very close to me whose help i can always count on” and “if i’m very depressed, i know who i can turn to” (1 = definitely false, 4 = definitely true). secondary predictor. disability severity from anxiety and depressive symptoms was captured with 4 items measuring past-month impairment from anxiety and depression symptoms in: 1) work performance, 2) household maintenance, 3) social interactions, and 4) relationships (1 = strongly disagree, 5 = strongly agree; score range: 0-5;  = .77). sociodemographic covariates. sociodemographic characteristics measured included race and ethnicity (american indian, black, hispanic/latinx, nh white), sex assigned at birth (male, female), age, marital status (married or cohabitating versus single, divorced, widowed, or separated), household income (0 = less than $9,999; 8 = $80,000 or greater; measured in increments of $9,999 and dichotomized at “less than $50,000” versus “$50,000 or more” because approximately half reported income below cannabis, a publication of the research society on marijuana 106 $50,000), and urban/rural residence, determined by zip code and classified using the rural-urban commuting area (ruca) codes (u.s. department of agriculture economic research service, 2023). statistical analysis bivariate analyses (i.e., chi-square tests, oneway anovas, independent-samples t-tests, pearson’s correlations) examined associations of sociodemographic characteristics with outcome variables. sociodemographic characteristics associated with one or more outcome variables were included as covariates in all models. missing data were minimal. a subset of participants (n = 29) selected “refuse to answer” on the income item. they were retained in the models using a missing indicator approach (i.e., assigning a numeric code to the “refuse to answer” response category). primary analyses consisted of adjusted, multivariable linear and logistic regression models examining: 1) the association of disability with perceived social support (linear), and 2) main and interactive effects of disability and perceived social support on past-month medical cannabis use (logistic) and past-month recreational cannabis use (logistic). spss process macro model 1 was used to probe significant interactions. secondary analyses were parallel to the primary analyses, but substituted disability severity from anxiety and depressive symptoms (mean-centered) for the binary disability item. among those who use cannabis, frequency of use may differ by disability status and social support. as such, two sensitivity analyses were conducted among participants reporting any pastmonth: 1) medical, and 2) recreational, cannabis use. adjusted, multivariable negative binomial regression models examined main and interactive effects of disability status (yes/no) and perceived social support on past-month cannabis use days (130 days). results participant characteristics the sample (n = 822) was 25.3% american indian, 25.1% black, 25.1% nh white, and 24.6% latinx (64.6% female; mage = 38.3 [sd = 12.8]). most (85.9%) lived in urban areas; 37.7% were married or cohabitating; 53.5% had an annual household income of less than $50,000. half (51.1%) had a self-reported disability. perceived social support averaged 16.7 (sd = 4.6) on a scale of 6 (low) to 24 (high). approximately one-fourth of the sample reported past-month medical (24.9%) and recreational (25.4%) cannabis use. in the full sample, most participants (67.5%) reported no cannabis use, 7.5% used recreationally but not medically, 7.1% used medically but not recreationally, and 17.9% used both medically and recreationally ( = 0.61, p < .001). bivariate associations in bivariate analyses (table 1), sociodemographic correlates of disability included american indian race (p = .017), older age (p < .001), and household income less than $50,000 (p = .002). higher social support was associated with white race (p = .002), younger age (p = .006), being married/cohabitating (p < .001), and household income less than $50,000 (p < .001). past-month medical cannabis use was associated with american indian race (p < .001), male sex (p = .036), and household income less than $50,000 (p = .001). past-month recreational cannabis use had the same correlates as medical cannabis use (pvalues < .031), plus younger age (p < .001). disability, social support, and cannabis use 107 table 1. participant characteristics and bivariate associations of sociodemographic characteristics with disability and alcohol and cannabis use (n = 822). full sample disability perceived social support past-month medical cannabis use past-month recreational cannabis use yes (n = 420) no (n = 402) p test stat p yes (n = 205) no (n = 617) p yes (n = 209) no (n = 613) p race and ethnicity .017 4.81 .002 <.001 .005 black 25.1% (206) 23.1% (97)a 27.1% (109)a 17.6% (36)a 27.6% (170)b 19.1% (40)a 27.1% (166)b american indian 25.3% (208) 30.0% (126)a 20.4% (82)b 36.1% (74)a 21.7% (134)b 33.5% (70)a 22.5% (138)b latinx 24.6% (202) 22.9% (96)a 26.4% (106)a 20.0% (41)a 26.1% (161)a 25.8% (54)a 24.1% (148)a non-hispanic white 25.1% (206) 24.0% (101)a 26.1% (105)a 26.3% (54)a 24.6% (152)a 21.5% (45)a 26.3% (161)a sex assigned at birth (%/n female) 64.6% (531) 67.6% (284) 61.4% (247) .064 1.17 .243 58.5% (120) 66.6% (411) .036 55.5% (116) 67.7% (415) .001 age 38.3 (12.8) 39.8 (13.2) 36.8 (12.1) <.001 -.10 .006 37.8 (11.4) 38.5 (13.2) .485 35.0 (11.2) 39.5 (13.1) <.001 married or cohabitating (%/n unmarried) 37.7% (310) 35.7% (150) 39.8% (160) .227 -3.85 <.001 39.5% (81) 37.1% (229) .540 34.9% (73) 38.7% (237) .336 residence (%/n urban) 85.9% (706) 83.8% (352) 88.1% (354) .080 1.72 .086 82.4% (169) 87.0% (537) .102 84.7% (177) 86.3% (529) .564 household income .002 13.70 <.001 .001 .030 < $50,000 53.5% (440) 59.3% (249)a 47.5% (191)b 64.4% (132)a 49.9% (308)b 59.8% (125)a 51.4% (315)b $50,000 + 42.9% (353) 37.1% (156)a 49.0% (197)b 33.7% (69)a 46.0% (284)b 35.4% (74)a 45.5% (279)b unreported 3.5% (29) 3.6% (15)a 3.5% (14)a 2.0% (4)a 4.1% (25)a 4.8% (10)a 3.1% (19)a disability (%/n yes) 51.1% (420) disability severity from anxiety and depressive symptoms (m/sd) 3.9 (0.7) 4.1 (0.6) 3.7 (0.8) <.001 -.20 <.001 4.0 (0.7) 3.8 (0.7) <.001 4.0 (0.6) 3.8 (0.7) .002 perceived social support (m/sd) 16.7 (4.6) 16.2 (4.7) 17.2 (4.5) .002 past-month medical cannabis use (%/n yes) 24.9% (205) 28.8% (121) 20.9% (84) .009 1.67 .095 medical cannabis use days (030, m/sd) 4.7 (9.9) 5.3 (10.5) 3.9 (9.2) .042 -.08 .021 past-month recreational cannabis use (%/n yes) 25.4% (209) 25.2% (106) 25.6% (103) .899 1.88 .060 71.7% (147) 10.0% (62) <.001 recreational cannabis use days (0-30, m/sd) 3.3 (8.0) 3.4 (8.2) 3.1 (7.8) .659 -.11 .001 note. each subscript letter denotes a subset of the column categories that do not significantly differ at the p < .05 level. bolded p-values indicate a significant omnibus test at the p < .05 level. cannabis, a publication of the research society on marijuana 108 multivariable associations among disability status, social support, and cannabis use participants with a self-reported disability had lower average social support than those without (b = -.69, se = .32, p = .031; table 2). black (b = -1.06, se = .45, p = .017) and american indian (b = -1.21, se = .45, p = .007; versus nh white) race, older age (b = -.03, se = .01, p = .027), and household income less than $50,000 (b = 1.52, se = .33, p < .001) were also associated with lower social support . table 2. association of disability with perceived social support (n = 822) b (se) p race and ethnicity (ref: non-hispanic white) black -1.06 (.45) .017 american indian -1.21 (.45) .007 latinx -.49 (.45) .282 gender (ref: female) -.58 (.33) .081 age -.03 (.01) .027 household income (ref: < $50k) $50,000 or more 1.52 (.33) <.001 unreported .86 (.87) .324 disability (ref: no) -.69 (.32) .031 note. bolded p-values indicate a significant association (p < .05). having a disability (aor = 1.45, 95% ci [1.04, 2.03], p = .030; table 3) and having lower perceived social support (aor = .94, 95% ci [.89, 1.00], p = .038) were associated with greater odds of medical cannabis use. a statistically significant disability x perceived social support interaction (aor = 1.08, 95% ci [1.00, 1.16], p = .045) was observed (figure 1). simple slopes indicated that among those with a disability, social support was not associated with medical cannabis use (b = .015, se = .02, p = .525). however, among those without a disability, higher social support was associated with lower odds of medical cannabis use (b = -.06, se = .03, p = .038). black (versus nh white; aor = .55, 95% ci [.34, .90], p = .016) and male (versus female; aor = 1.58, 95% ci [1.13, 2.22], p = .008) participants were statistically significantly more likely to use medical cannabis; higher-income participants were statistically significantly less likely (aor = .57, 95% ci [.40, .81], p = .002). disability and perceived social support were not statistically significantly associated with recreational cannabis use. american indian (versus nh white; aor = 1.77, 95% ci [1.12, 2.79], p = .015) and male (versus female; aor = 1.85, 95% ci [1.32, 2.59], p < .001) participants were statistically significantly more likely to report recreational cannabis use; older (aor = .97, 95% ci [.95, .98], p < .001) and higherincome (aor = .66, 95% ci [.47, .93], p = .019) participants were less likely. figure 1. disability status x social support interaction on medical cannabis use note. “low” and “high” social support were -1 and +1 standard deviations from the mean, respectively. social support was mean-centered such that m = 0, sd = 4.62. odds ratios were converted to predicted probabilities. simple slopes were tested using the process macro for spss, model 1 (hayes, 2013). the interaction was plotted in accordance with dawson (2014). disability, social support, and cannabis use 109 table 3. associations of disability and perceived social support with medical and recreational cannabis use (n = 822) medical cannabis use recreational cannabis use aor (95% ci) p aor (95% ci) p race and ethnicity (ref: non-hispanic white) black .55 (.34, .90) .016 .81 (.49, 1.33) .403 american indian 1.39 (.90, 2.15) .139 1.77 (1.12, 2.79) .015 latinx .64 (.40, 1.03) .067 1.09 (.68, 1.75) .719 gender (ref: female) 1.58 (1.13, 2.22) .008 1.85 (1.32, 2.59) <.001 age .99 (.98, 1.00) .101 .97 (.95, .98) <.001 household income (ref: < $50k) $50,000 or more .57 (.40, .81) .002 .66 (.47, .93) .019 unreported .35 (.12, 1.03) .057 1.15 (.51, 2.64) .734 disability (ref: no) 1.45 (1.04, 2.03) .030 .98 (.70, 1.37) .903 perceived social support .94 (.89, 1.00) .038 .95 (.90, 1.00) .073 disability x perceived social support 1.08 (1.00, 1.16) .045 1.03 (.96, 1.10) .473 note. bolded p-values indicate a significant association (p < .05). in secondary analyses, greater disability severity from anxiety and depressive symptoms was statistically significantly associated with lower social support (b = -1.21, se = .22, p < .001). disability severity was also associated with greater odds of medical cannabis use (aor=1.42, 95% ci [1.10, 1.83], p = .007) and recreational cannabis use (aor = 1.40, 95% ci [1.09, 1.82], p = .010). however, there were no main effects of social support on medical or recreational cannabis use (p-values > .186), nor disability severity by social support interactions (p-values > .738). sensitivity analyses among participants reporting any past-month medical cannabis use, there were no statistically significant main effects of disability (irr = 1.04, 95% ci [0.77, 1.41], p = .789) nor social support (irr = 0.99, 95% ci [0.94, 1.03], p = .558) in relation to days of use. there was no statistically significant disability x social support interaction (irr= 1.00, 95% ci [0.94, 1.07], p = .949) in relation to days of use. similarly, among participants reporting any past-month recreational cannabis use, disability was not associated with days of use (irr = 0.90, 95% ci [0.66, 1.22], p = .481) nor social support (irr = 0.98, 95% ci [0.94, 1.03], p = .507) the disability x social support interaction was not statistically significant (irr = 0.98, 95% ci [0.91, 1.04], p = .486) in relation to days of recreational cannabis use. discussion in a sample of us adults with clinically significant anxiety and/or depressive symptoms, odds of medical cannabis use differed by disability status and perceived social support. among participants with disabilities, odds of medical cannabis use did not differ based on perceived social support. however, among participants without disabilities, higher perceived social support was associated with lower odds of medical cannabis use. recreational cannabis use was not associated with disability or social support. the lack of a statistically significant association between social support and medical cannabis use among people with disabilities suggests that social support and medical cannabis use may meet different needs. people with disabilities may use medical cannabis to try to alleviate symptoms when other medical care has been ineffective or inaccessible (garcia-romeu et al., 2022; vogel et al., 2024), while using social support for general well-being. disability was not associated with recreational cannabis use, consistent with prior literature suggesting that disability was only overrepresented among people who use cannabis medicinally, not among people who use recreationally (goulet-stock et al., 2017). reasons for cannabis use (medical versus recreational) were self-reported, and do not necessarily reflect differences in actual use behavior (e.g., products, dosing, desired effects; bostwick, 2012). people with (versus without) disabilities may be more likely to attribute their cannabis use to a desire for symptom relief. disability severity from anxiety and depressive cannabis, a publication of the research society on marijuana 110 symptoms was significantly associated with both medical and recreational cannabis use. the line between medical and recreational cannabis use may be blurrier for individuals who are using cannabis to alleviate mental health symptoms. for example, using cannabis to elevate one’s mood could be aimed at alleviating depression (i.e., medical use) or simply feeling good (i.e., recreational use). all participants in this study had clinically significant anxiety and/or depressive symptoms, which may be ameliorated by social support (roohafza et al., 2014). for participants who did not perceive their mental or physical health conditions as reaching the threshold of disability, social support may be greatly beneficial in relieving their mental health symptoms. although social support likely benefits individuals with disabilities (haegele et al., 2024; saravanan et al., 2021; scott & havercamp, 2014; wei et al., 2023; wu et al., 2024), results suggest that social support may not mitigate the need to use cannabis to treat medical symptoms. other structural-level interventions may be needed, particularly improving healthcare access for individuals with disabilities, who may face multiple barriers to receiving care (e.g., lack of transportation, inaccessible healthcare facilities, limited availability of specialists; meade et al., 2015). in secondary analyses, disability severity from depressive and anxiety symptoms was significantly associated with lower perceived social support. individuals with severe symptoms may struggle with socializing due to factors such as low energy, low motivation, poor selfperceptions, or strained relationships (hajek et al., 2025). social isolation can lead to lower social support and further worsen anxiety and depressive symptoms (magomedova & fatima, 2025). lower perceived social support observed among adults with (versus without) disabilities is consistent with hypotheses and with nationally representative data (centers for disease control and prevention, 2023). on average, individuals with disabilities may experience greater loneliness than their peers (emerson et al., 2021), due to inaccessibility of spaces and social situations that may have provided opportunities for social support (bell & clegg, 2012; rokach et al., 2006). in addition to disability and social support, cannabis use may be influenced by factors such as minority stress (i.e., prejudice, discrimination, internalized stigma and other negative sociopsychological experiences based on one’s stigmatized identity; meyer, 2003) and high density of cannabis retail outlets in marginalized communities (buckner et al., 2023; cohn et al., 2023; firth et al., 2022). in this study, black and american indian participants were more likely than nh white participants to report medical or recreational cannabis use. people of color are also affected by health inequities stemming from minority stressors such as discrimination in healthcare settings and socioeconomic disparities (bailey et al., 2017). as cannabis legalization becomes increasingly widespread, ongoing attention should be paid to inequities in healthcare access and cannabis use. limitations this study recruited a nationwide, racially and ethnically diverse sample of adults with anxiety and depressive symptoms, both with and without disabilities. however, results should be interpreted considering several limitations. first, past-month medical and recreational cannabis use were dichotomized for primary analyses, due to the relatively low prevalence of cannabis use in the sample, and we did not collect data on cannabis dependence symptoms. future research should examine associations of disability and social support with cannabis dependence symptoms in a larger sample of adults who use cannabis. second, participants were not asked which health condition(s), if any, limited their activities. disability is not monolithic, and some disabilities may be more strongly associated with cannabis use than others. for example, while most adolescents with disabilities display greater risk for cannabis use than their peers without disabilities, one study suggested that those with self-care limitations may not display such risk (schulz et al., 2024). among us adults, population prevalence of cannabis use increased more rapidly among those with (versus without) disabilities related to hearing, walking, multiple impairments, and kidney disease (yang et al., 2023). although all participants had clinically significant mental health symptoms, some may have reported having a disability due to physical health symptoms, or both mental and physical health symptoms. only half reported having a disability, social support, and cannabis use 111 disability, suggesting that despite their clinically significant anxiety and/or depressive symptoms, not all participants experienced limitations in their activities. the single-item measure of disability was intentionally broad, to capture the range of limitations an individual may experience when interacting with their environments; however, future research should include survey items on the type(s) of disabilities participants experience. third, cannabis use among adults with clinically significant anxiety and/or depressive symptoms may differ from peers without these symptoms. results should not be generalized to all us adults. fourth, this study was cross-sectional, and causality could not be inferred. longitudinal research is needed to examine temporal ordering of associations among disability, social support, and cannabis use. conclusions cannabis use may have both health benefits (e.g., pain relief, reduced seizure activity) and health harms (e.g., cannabis use disorder, worsened anxiety and depressive symptoms) (chiu et al., 2021; fischer et al., 2022; muheriwamatemba et al., 2024; sorkhou et al., 2024; stetten et al., 2020). results suggest that among adults with clinically significant anxiety and/or depressive symptoms, individuals with disabilities have elevated odds of using medical cannabis, regardless of how much social support they perceive having. social support has been shown to increase well-being (haegele et al., 2024; saravanan et al., 2021; wei et al., 2023; wu et al., 2024) and cannabis use may provide some symptom relief (fischer et al., 2022; stetten et al., 2020). however, as cannabis legalization expands, improving the accessibility of comprehensive healthcare services may be needed to support individuals with disabilities. . references bailey, z. d., krieger, n., agénor, m., graves, j., linos, n., & bassett, m. t. 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(2023). trends in past-month cannabis use among us adults across a range of disabilities and health conditions, 20152019. preventative medicine, 177, 107768. https://doi.org/10.1016/j.ypmed.2023.107768 funding and acknowledgements: this research was supported by the national institute on mental health (r01mh126586, mpis: mb and mz), the oklahoma tobacco settlement endowment trust (grant r22-02), the national institute on drug abuse (k01da055073, pi: vogel), the national cancer institute (grant p30ca225520), and the work used the stephenson cancer center’s mhealth shared resource. michael businelle is an inventor of the insight mhealth platform that was used to develop the smartphone application that was used in this study. he receives royalties when investigators outside of the university of oklahoma health campus use the platform. however, he was a pi on this study, and thus did not receive royalties in this case. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which https://creativecommons.org/licenses/by/4.0/ disability, social support, and cannabis use 115 permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: vogel, e. a., romm, k. f., mcmaughan, d. j., zvolensky, m. j., garey, l., & businelle, m. s. (2025). associations of disability and social support with cannabis use among adults with anxiety and depressive symptoms. cannabis, 8(3), 103–115. https://doi.org/10.26828/cannabis/2025/000305 research article 133 ved abstract objective: cannabis and alcohol are among the substances most frequently used by adolescents. adolescents also frequently co-use these substances, with use of alcohol predicting subsequent initiation of cannabis use, and vice-versa. minimal research has explored adolescents’ attitudes towards cannabis use qualitatively, and how these attitudes may directly/indirectly relate to attitudes towards alcohol use and vice versa. method: forty u.s. adolescents (mage = 16.68, sd = 0.86) who had recently completed a study reporting their in-vivo exposure to substance use content in media completed follow-up interviews focused on substance depictions in media and attitudes towards substance use. interviews were individual, semistructured, and approximately one hour long. a priori codes were derived from the interview agenda. interviews were transcribed and qualitatively coded by a team of three graduate students. percent agreement across coders was 80%, suggesting substantial agreement. results: several themes emerged from analysis. most adolescents reported that their approval/disapproval of cannabis use was contingent on several factors including legality, age, degree of use/problematic use, and purpose (i.e., medicinal/recreational). participants more commonly endorsed cannabis use as more acceptable than alcohol. common reasons for this comparative approval included perceived social and health impacts (e.g., alcohol poisoning, liver disease), perceived addictive potential, and different effects of intoxication. conclusions: results of the present study provide rich context to recent trends in adolescent cannabis and alcohol use and perceptions, as well as co-use and abstention. understanding teens’ attitudes towards substance use may be beneficial in developing appropriate substance prevention and intervention strategies (e.g., effectively communicating health risks of cannabis use). key words: = adolescent; cannabis; alcohol; qualitative research; attitudes adolescent alcohol and cannabis use cannabis and alcohol are two of the most used substances by adolescents in the united states. data from the 2023 monitoring the future survey showed that when asked about substance use in the past month, 24.3% of 12th graders and 13.7% of 10th graders reported drinking alcohol, while 18.4% and 10.3% of 12th and 10th graders respectively reported using cannabis in any form alex clement1, erin corcoran1, kristina m. jackson2*, & joy gabrielli1 1department of clinical and health psychology & center for addiction research and education, university of florida 2center for alcohol and addiction studies, brown university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000332 “if you need to light up … you gotta do what you gotta do”: a qualitative study of adolescent attitudes towards cannabis use and comparison with alcohol attitudes corresponding author: alex clement, ms, university of florida, 1225 center drive, gainesville, florida 326100165. email: alexclement@phhp.ufl.edu cannabis, a publication of the research society on marijuana 134 (miech et al., 2024). while rates of adolescent use have decreased from 10 years prior for both substances (as has the rate of adolescent co-use of these substances; keyes et al., 2022), current prevalence rates highlight adolescent substance use as a continuing public health concern. countering aggregate trends, adolescents’ use of vaporized cannabis and use of cannabis for medicinal purposes has increased since first reported seven years ago, showing shifts in how teens are using cannabis, in the context of decreasing use overall (miech et al., 2018; 2024), which could indicate subtle shifts in adolescents’ attitudes towards cannabis. there are numerous immediate and long-term risks of both alcohol and cannabis use, with earlier and heavier use in both cases predicting less favorable outcomes (patton et al., 2007; scholes-balog et al., 2016; yuen et al., 2020). further, co-use of alcohol and cannabis is associated with increased long-term risk as well as increased risk related to acute intoxication. considering these risks, gaining a deep understanding of factors contributing to adolescent use of cannabis and alcohol and identifying appropriate prevention and intervention efforts are worthy public health endeavors. the present study aims to contribute towards these endeavors through qualitative analysis of semi-structured interviews focused on adolescents’ cannabis approval and cannabisrelated attitudes in direct relation to attitudes towards alcohol. theoretical framework – substance use attitudes despite the rich quantitative data on trends of substance use adolescence, few qualitative studies address teens’ perceptions of and attitudes about cannabis as it compares to other substances. ajzen’s theory of planned behavior (tpb; 1991) posits that attitudes (including expected consequences and evaluative attitudes; ajzen & fishbein, 2000; ajzen, 2001), are valuable predictors of future behaviors and behavioral intentions. per ajzen (2020), “attitude toward [a] behavior is assumed to be a function of readily accessible beliefs regarding the behavior's likely consequences, termed behavioral beliefs.” in the case of substance use, adolescents could develop a behavioral belief that cannabis use is useful for coping with stress, which would contribute towards making the adolescent’s aggregate attitude towards cannabis use more positive. conversely, an adolescent could develop a behavioral belief that cannabis use is likely to bring about adverse health consequences or social harm, contributing to a more negative aggregate attitude towards this behavior. positive attitudes are theorized as a causal factor in behavioral intentions. this theory is supported by a significant body of work across countries indicating that adolescents’ attitudes regarding substance use can reflect current substance use behaviors and serve as a valuable predictor of future substance use initiation and progression (bashirian et al., 2012; cooke et al., 2016; kam et al., 2009; malmberg et al., 2012; marcoux & shope, 1997; morell-gomis et al., 2019). further, perceived peer attitudes have been shown to impact adolescent substance use behaviors (mason et al., 2014; trucco, 2020). attitudes and behavioral beliefs are also common mechanistic targets of substance use prevention and intervention efforts in adolescents and beyond (bashirian et al., 2013; derzon & lipsey, 2001; donaldson et al., 2021; huang et al., 2017). joint exploration of cannabis and alcohol use is supported by the frequent co-use of these substances among adolescents (keyes et al., 2022; patrick et al., 2018; yurasek et al., 2017) as well as their common co-occurrence in media (corcoran et al., 2024). further, initiation of cannabis use is shown to predict later use of alcohol, and problematic use of cannabis predicts problematic use of alcohol (hasin et al., 2016; keyes et al., 2019). the inverse relationships are also shown to be true (linakis et al., 2022). while these associations are well supported, it should be noted that there is still significant debate as to whether these relationships are best explained by directional associations, e.g., a “gateway” model, as opposed to a model of common vulnerability to substance use (van leeuwen et al., 2011; vanyukov et al., 2012). although both substances are commonly used, adolescent co-use of these substances has shown a slow decline over the past 15 years, while sole use of cannabis has increased (keyes et al., 2022), which could indicate subtle shifts in adolescents’ attitudes towards each substance. substance use prevention efforts targeting adolescents also frequently target substance use generally, as opposed to developing content specific to individual substances adolescent cannabis and alcohol attitudes 135 (tremblay et al, 2020). it is possible that programming structured in this generalist manner could be ineffective if adolescents hold opposing attitudes towards different substances targeted in prevention efforts, especially if these opposing attitudes are functionally related to each other. for example, an adolescent could hold a belief that use of alcohol is quite dangerous and decide to use cannabis instead, as a perceived safer alternative behavior. therefore, understanding how adolescents conceptualize different substances and their relation to each other could inform future public health and prevention programming. current gaps in research on adolescent cannabis attitudes understanding how adolescents’ attitudes towards alcohol and cannabis relate to each other may provide additional, unique information that may not be ascertained through studying each substance in a vacuum. adolescents’ views on this topic are likely quite nuanced and may not be fully captured through solely quantitative data collection methods, indicating that qualitative inquiry into these attitudes could provide valuable context to recent trends. qualitative data could also provide greater understanding of adolescents’ attitudes and behavioral beliefs nested within the social context and lived experiences of the individual. several studies have utilized interviews with teens and other qualitative methods to investigate factors contributing to adolescent substance use (e.g., alhyas et al., 2015; janssen et al., 2014; karashiali et al., 2022; moradi et al., 2019). however, much prior work is limited by small sample size, has been conducted in non-u.s. samples, or has not interviewed adolescents directly. further, past work has often leaned on focus groups rather than individual interviews which may shade how adolescents talk about risk behaviors (see colonna et al., 2023). additionally, while past qualitative work with adolescents has queried adolescents about multiple substances (e.g., friese, 2017; price wolf et al., 2019), to our knowledge, no past work has queried adolescents directly about how their attitudes towards cannabis and alcohol may be interrelated, beyond their differential contribution to dating violence perpetration (rothman et al., 2016). the current study the present study aims to expand upon this existing body of qualitative work by conducting individual interviews with adolescent participants who had recently completed an ecological momentary assessment study of in-vivo exposure to substance use content in digital media (r01-aa027968; pi: jackson, see jackson et al., 2025 for full parent study methodology). importantly, the parent study was not interventional in nature; rather aiming to understand the frequency, characteristics, and interpretation of these exposures. however, through completion of the parent study, participants may have had their awareness and salience of attitudes towards these two substances raised through recalling and appraising media imagery of each product. analysis of these interviews offers insight into adolescent attitudes on cannabis and alcohol and the interrelation of these attitudes among adolescents both with and without engagement in substance use. findings are valuable both for understanding recent trends in adolescent substance use and for informing public health campaigns and other prevention and intervention efforts targeting adolescent substance use behaviors. additionally, novel themes that emerge could serve to inform future quantitative or mixed-methods investigation. methods participants participants included a subset of 302 adolescents (n = 40) enrolled in a parent study on exposure to alcohol content in the media who agreed to participate in an additional interview focused on cannabis/vaping in the media upon completion of the primary study. interview participants were 80% female, with a mean age of 16.68 years (sd = 0.86 years). fifteen percent of participants identified as male and two participants (5%) identified as non-binary. about half of the participants identified as white (45.5%), followed by 27.5% black/african american, and 27.5% asian. twenty five percent identified as hispanic. most participants received free or reduced-price lunch (75%). forty percent reported past use of cannabis and 62.5% reported past use cannabis, a publication of the research society on marijuana 136 of alcohol (not including as part of a religious ceremony). lifetime prevalence rates in the present sample for both cannabis and alcohol use closely align with national rates for 12th graders (miech et al., 2024). full participant demographics can be seen in table 1. recruitment and study procedures participants were recruited to the parent study through paid advertisements distributed nationally on facebook and instagram. eligibility criteria included smartphone ownership, being between 15 and 18 years old, and endorsing that either they or a close peer used alcohol (to ensure adequate recruitment of youth across a range of risk behaviors; niaaa, 2011; tubman et al., 2021). upon confirming eligibility, study staff obtained informed consent via zoom (zoom communications, inc., san jose, ca) call from 18year-old participants and from parents of 15to 17year-old participants and secured assent from 15 to 17-year-old participants. enrolled participants participated in a study orientation session via zoom and completed an approximately 40-minutelong baseline survey including questions on demographic characteristics (e.g., age, grade, state of residence, race, ethnicity, sex, gender, and receipt of lunch subsidy), substance use, and technology use, among other measures. participants were compensated $30 for completion of the orientation and baseline measures. see jackson et al., 2025 for full procedures of the parent study. all parent study participants were contacted via email with information (e.g., procedures and compensation) about the qualitative interview follow-up study. interested participants completed another brief eligibility survey on qualtrics (qualtrics, llc, provo, ut). parents of eligible and interested participants aged 15-17 received an email with study information and a digital informed consent form. upon confirming completion of the parental informed consent form, participants under 18 completed a digital assent form. participants aged 18 directly received the study information and digital informed consent form. a semi-structured interview agenda included topics broadly related to alcohol, cannabis, and vaping, as well as exposure and reaction to substance use content in the media. the semistructured format of the interviews allowed for flexibility in modifying or adapting the interview agenda and codes based on participant reports and novel information. interviews were conducted by trained clinical psychology doctoral students (ec, ac, mr) and an undergraduate research assistant (nw), with most interviews lasting approximately 60 minutes. once scheduled, participants were provided with a link to a secure zoom videoconference. while in the waiting room, participant names were changed to their subject id for deidentification. interviewers provided a brief introduction where participants were informed of how their information will be kept private, affirmed that they were in a private location where they felt comfortable sharing openly, and agreed to the session recording. sessions were then recorded and saved to a secure institutional cloud storage system along with an automatically generated session transcript before being transferred to secure folders within a university shared drive. the session transcript was reviewed alongside interview audio and edited to create a verbatim transcript. each transcript was subsequently reviewed for accuracy by another undergraduate or graduate research assistant. participants were compensated an additional $30 for completion of the interview. all methods were approved by the brown university and university of florida institutional review boards. analytic plan data were analyzed utilizing a hybrid deductive, template-style to inductive analytical approach (crabtree & miller, 1992; 1999; king, 2014; proudfoot, 2023). an initial hierarchical codebook was developed comprised of a priori codes derived from the agenda of the semistructured interview (brooks et al., 2015). after transcripts were finalized, they were subsequently qualitatively coded in lumivero nvivo 14 (2023; nvivo, version 14, www.lumivero.com) participant quotes and responses were coded across 49 a priori codes derived from the semi-structured interview agenda encompassing six broad thematic content areas: (1) feedback on the parent study, (2) cannabis knowledge and attitudes, (3) media portrayals of cannabis and other substances, (4) cannabis advertising, (5) impacts of cannabis use, and (6) other feedback. of note, results from the present study are derived largely from the http://www.lumivero.com/ adolescent cannabis and alcohol attitudes 137 cannabis knowledge and attitudes content areas. each transcript was double coded by two graduate research assistants (ac, ec, mr). all coders initially coded two full interviews, with initial agreement ranging from 76-83%. coders then met to resolve discrepancies, identify and review exemplars of coding categories, and clarify code definitions. each coder subsequently coded 26 to 28 transcripts. percent agreement across all coders and transcripts averaged at 80%, indicating substantial agreement between coders (mchugh, 2012). content identified as belonging to each code was compiled across participants and reviewed by at least two coders to identify emergent themes and exemplar quotes. video recordings of interviews were destroyed upon completion of coding and analyses. past work on theme saturation in qualitative research has indicated that a sample of 20-30 interviews provides sufficient power for meaning saturation, such that additional interviews beyond this are likely to result in redundant information and few unique/novel issues (dworkin, 2012; marshall et al., 2013). as such, the sample size for the present study was sufficient for this purpose. neither the transcripts nor demographic data were manipulated in any way, nor were any participants’ transcripts excluded from qualitative analysis. participant quotes below are accompanied by participant number, as well as the participant’s race, self-identified gender identity (female [f], male [m], non-binary [nb]), grade at time of interview, past and/or current cannabis and alcohol use (cannabis +/cannabis , alcohol +/alcohol ), and the legal status of cannabis in their state at the time of their interview (legal, illegal, mixed-status). mixed legality status was generally characterized by medicinal use being legal, while recreational use was illegal. while meaningful group comparison is not feasible due to sample size of the present study, this information may be beneficial in providing additional context to individual participant quotes. table 1. sample descriptives n (%) participants 40 100 age (m/sd) 16.68 0.86 15 2 5.0 16 17 42.5 17 13 32.5 18 8 20.0 grade -- 9 1 2.5 10 2 5.0 11 16 40.0 12 21 52.5 gender identity -- male 6 15.0 female 32 80.0 non-binary 2 5.0 race/ethnicity -- white or caucasian 18 45.0 hispanic/latino 10 25.0 black or aa 11 27.5 american indian or alaskan native 1 2.5 asian 11 27.5 other 2 5.0 native hawaiian or other pacific islander 0 0 ever cannabis use -- yes 16 40 no 24 60 ever alcohol use -- yes 25 62.5 cannabis, a publication of the research society on marijuana 138 no 15 37.5 state cannabis legal status -- legal 23 57.5 mixed 9 22.5 not legal 8 20.0 receipt of free/reduced lunch -- free lunch 29 72.5 reduced-price lunch 1 2.5 neither 10 25.0 results representative quotes for two major thematic areas are discussed below: (1) adolescent attitudes towards cannabis and (2) how adolescents' attitudes towards alcohol and cannabis compare to each other. emergent subthemes related to each theme are further discussed in the corresponding sections below. cannabis attitudes when asked about cannabis attitudes independent of alcohol attitudes, three broad thematic clusters emerged: (1) youth who primarily or unconditionally disapproved of cannabis use, (2) youth who primarily/unconditionally approved of or accepted cannabis use, and most commonly, (3) youth who conditioned their approval of cannabis use upon certain factors like age, legality, medicinal versus recreational use, and degree of use (e.g., if use was interfering with daily life). generally, conditional approval of cannabis was common, while both unconditional approval and disapproval were infrequently described by participants. additionally, outside of attitudes towards cannabis broadly, adolescent participants shared feedback on how their perceptions of and attitudes towards cannabis varied by route of administration (e.g., ingestible, combustible, vaporized). general approval or acceptance. some participants expressed primarily approval or acceptance of cannabis use that was not conditioned on any factors related to its use. one participant, for example, noted their acceptance of peers’ cannabis use behaviors, and further expressed that they perceived engaging in risky and prohibited/taboo behavior as normative and even enticing or desirable for young people. “i mean, personally for me…if you're comfortable with doing that, that's fine. like, i personally don't partake in smoking. but, like, i— the friends i do have that smoke weed it's, like, okay, like, ‘you do you.’ …at the end of the day, people like doing what's, like, prohibited, if you know what i mean. like, people are attracted to doing what they know they can't do.” sid 166 (black, f, 12th grade, legal, cannabis , alcohol ) for other participants, their approval of cannabis appeared to be related to a behavioral belief that it was not harmful or dangerous. “i don’t really think weed’s that bad. i could ... i could probably see myself ... if i didn’t have this [medical disorder precluding use of cannabis], using weed more frequently.” sid 186 (white, f, 11th grade, mixed legality, cannabis +, alcohol +) this perception of minimal risk may also be a function of teens’ risk appraisal of cannabis in relation to other substances. “i don't actually have too many opinions about people my age using cannabis because i'm not sure it's as bad as nicotine. [vaping] nicotine could have side effects 20 years in the future and no one would know because it hasn't been around for that long. cannabis, however, if you use it … well then i guess you're better off that way even though it is still smoking.” sid 293 (white, f, 12th grade, legal, cannabis +, alcohol +) conversely, a different participant stated their approval despite acknowledging possible negative effects. they noted cannabis use could provide a means of coping with difficult contemporary events and news. “it definitely affects your brain, but i also think everything affects your brain, and the world is really scary right now. so, if you need to light up every once in a while, or if you need to light up consistently to get through it, like, you gotta do what you gotta do.” sid 111 (white, f, 12th grade, legal, cannabis +, alcohol +) conditional approval. the most commonly held perspective among the participants interviewed was that their approval or acceptance adolescent cannabis and alcohol attitudes 139 of cannabis use was not unconditional, but rather depended on who was using cannabis, how, and where. for example, a number of participants noted that they approved of cannabis if it was used for medicinal management of mental or physical health concerns. “i think that it could be used really, really good for really good ways. i've seen, like, people on chemo using it for, like, nausea, and stuff like that, or other people using it for other medical reasons.” sid 153 (white, f, 12th grade, legal, cannabis , alcohol ) some expanded that their approval of medicinal cannabis use was contingent on the medical need for cannabis being “legitimate,” as opposed to individuals leveraging a feigned or actual medical condition to obtain a prescription for cannabis that is not truly medically necessary. “i think that [medical use is] fine, but, like, there's obviously not any way to really control this, but i think that it needs to be legit … i know there's also people thatwhere here it's not legal, where people are using that as an excuse to get it. like, there's a, there is a medicinal marijuana shop, doctor’s office type thing that is close to my house … and anytime i go around there, there's always a huge line, like people literally out the door into the parking lot, and you look and it's all young people, like, probably in their twenties.” sid 108 (white, f, 12th grade, mixed legality, cannabis , alcohol ) participants commonly noted that their approval of others using cannabis was conditional upon the frequency/degree of use and the level of impairment to daily activities resulting from that use. as such participants expressed that cannabis use was less acceptable for those who use cannabis excessively, were dependent on cannabis, or were otherwise impaired in some way by their cannabis use (e.g., grades, school, social relationships). for example, “me, personally, i don't really have a problem with it as long as it's not like affecting your, like, day-to-day life. like, ... i have a few friends who like started using it as, like, fun. and then it turned into now it’s affecting how they are in school and their grades and everything.” sid 104 (mixed-race, f, 12th grade, legal, cannabis +, alcohol ) beyond dependence or degree of impairment to daily life caused by cannabis use, frequency of use was described as an important factor in approval of substance use generally, such that “sporadic” use of either was acceptable, while “over-indulging" was not. “responsible use is a big thing, too. like, i don't approve of over drinking or over-indulging in smoking and all, but if it's used sporadically, then i approve more of it.” sid 268 (asian, f, 12th grade, mixed legality, cannabis , alcohol +) participants generally varied in how they characterized problematic use (e.g., frequency, impairment, reasons for use). for example, it was noted that, even in the context of perceived low risk for addiction to cannabis, use of cannabis as a coping mechanism may result in negative outcomes. “i think, like, what mainly matters for me is how often people use it and why, because i know it's not, like, as addictive as other substances they could be using, but, like, if they're using it often when they're alone to, like, get through hard times, then i think it could be pretty bad for them.” sid 247 (white, f, 11th grade, legal, cannabis +, alcohol ) it was somewhat rare that participants conditioned their approval of cannabis use upon whether or not it was legal for the individual to use it based on their age and geographic location. “i think the only thing is, like, ifif you're legally allowed to do it, then i don't really care if you do it or not.” sid 164 (asian, m, 12th grade, legal, cannabis , alcohol +) another participant who conditioned their approval based on legality further clarified that they found it acceptable to travel to a different jurisdiction to use cannabis legally, even if it is not currently legal where an individual is currently living. “if it's legal for you to use it, go ahead. if it's illegal, that's not a ‘that you're using it’ problem that’s a, ‘you're using it illegally’ problem … i know, my friend’s sister, before it was legalized in new jersey, because that was only a few years ago, would just travel to canada with her friends because it was legal there … so, like, that's perfectly fine, even if it's illegal in your area, you're not doing it in your area.” sid 154 (white, f, 11th grade, legal, cannabis , alcohol +) unconditional disapproval. comparatively fewer participants reported unconditional disapproval of cannabis use. participants mentioned several reasons for their disapproval including impact on health, the smell of smoke, cannabis, a publication of the research society on marijuana 140 impact on decision-making, and belief that it can impair one’s ability to engage in important activities (e.g., academics, studying). for example, one asian participant described the importance of academic success in their family’s cultural value system, and how engaging in substance use was not congruent with these values. “i don't think it is a wise decision, especially if they're underage, or if they're in school. i think just growing up in the asian household, i think the most important thing to do is study. study hard to get good grades. so, i would say vaping, doing drugs, does get in the way of your studies for sure.” sid 260 (asian, f, 12th grade, mixed legality, cannabis , alcohol ) interestingly, another participant reported social impacts secondary to their disapproval of cannabis use. they noted that they initially try to discourage friends from using cannabis, and if they persist or progress in their cannabis use, they will attempt to socially distance from that friend. “no, i don't support it. and most of the times when, like, i become friends with someone, and i notice that they engaged themselves with that, i first encourage them to, like, step away from that and i realized if they don't want to, they want to make that, like, a part of their daily lives, then slowly i, like, gradually take myself away from that person.” sid 251 (black, f, 11th grade, legal, cannabis , alcohol ) variable attitudes by route of administration. participants also broadly shared that their perceptions of risk and approval of cannabis also varied as a function of the route of cannabis administration. participants remarked on route of administration in the context of societal bias, dependent use, and ease of use. while there was no unified belief as one route as most acceptable or unacceptable, several participants did acknowledge combustible forms of cannabis as harmful due to effects of smoke inhalation. “i've seen people, like … if they have an edible they will usually ingest those instead, because they're like, ‘oh, i don't want to burn my lungs, or anything,’ so, like, the way they would take cannabis is to ingest it instead in edibles.” – sid 143 (asian, f, 12th grade, mixed legality, cannabis , alcohol ) another participant specifically spoke to potential socialization effects related to smoking when noting a perception of edible forms of cannabis as less acceptable. “i would say [peers] would like edibles better than smoking, just because i feel like—like it's always for trade, like in the media, or, like, our parents, that like smoking is bad for you, like, don't smoke. but, like, an edible [is] just like eating a gummy bear. so, they don't really think of it as wrong.” – sid 136 (asian, 12th grade, legal, cannabis +, alcohol +) another participant shared the belief of smoke inhalation as a harmful element of combustible cannabis use, while also expanding on perceived ease of use across these routes of administration. “i don't know that there's any, like, science behind this, but i do think, like, i view smoking weed like a lot more harmful than, like, taking an edible, but i think it's just, like, that smoking aspect that i think makes it more harmful. and i think most people my age like opt to take edibles instead of like smoking it or any other way of ingesting it. just because it's, like, easier.” – sid 121 (black, f, 11th grade, legal, cannabis , alcohol +) others, while not remarking specifically on risk, also noted similar differences in ease of use and concealment between combustible cannabis versus ingested or vaporized as being factors contributing to choices in route of administration among adolescents who use cannabis. “i think for kids my age, vaping is just easier. it’s more like accessible. and it's easier to hide, i guess, so they probably look at them, a little bit differently in that perspective.” – sid 153 (white, 12th grade, legal, cannabis , alcohol ) also of note, participants shared that adolescents may hold stereotyped perception of individuals who use cannabis that vary based on their preferred route of administration of cannabis. one participant specifically noted an association between combustible cannabis and being a “stoner.” “i think a lot of people view smoking marijuana as, like, the ‘stonery’ kind of classic, ‘yeah, they smoke weed. they're like that,’ kind of thing. i think people mainly think of smoking weed and the stereotypes that go with it.” – sid 111 (white, f, 12th grade, legal, cannabis +, alcohol +) another participant remarked that use of ingestible cannabis was less stigmatized than combustible cannabis, partially as a function of risk perception. adolescent cannabis and alcohol attitudes 141 “yeah, i feel like there's, like, less stigma around like taking edibles than actually smoking it … i feel like taking edibles—i see that people view it as more safe, in a way.” – sid 281 (black, f, 10th grade, legal, cannabis +, alcohol +) similarly, another participant remarked on the association between route of administration and perceptions of dependence on cannabis, noting that vaporized cannabis was perceived as more associated with dependent use. “i think that the general association with the people who would vape that sort of thing is that they are more dependent on it, they are more addicted to it. you know the people who smoke or the people who do it you know more casually. you know they still do it all the time, but that's something that they do. you know, when they're at a party, after school, when they're at their house.” – sid 179 (mixed-race, m, 12th grade, legal, cannabis , alcohol ) comparing adolescent attitudes on cannabis use versus alcohol use participants were later asked if they had differing attitudes about alcohol compared to cannabis. four thematic clusters of participants emerged: (1) attitudes related to both substances are similar and primarily negative, (2) attitudes related to both substances are similar and primarily positive, (3) attitudes of both substances are different, with the participant expressing more positive views of alcohol use, and most commonly, (4) attitudes of both substances are different, with the participant expressing more positive views of cannabis use. mostly equivalent. most adolescents in the study expressed a view that they approved of use of one substance more than the other. however, some participants expressed that their views on alcohol and cannabis are approximately equivalent. for some, these views were neutral to positive towards both substances. one participant specifically reported that they shifted towards approving more of substance use as they had aged. “i think cannabis and alcohol are probably about the same level of approval … i think i became more okay with that sort of stuff as i got older, but it also just depends on the environment a person grows up in.” sid 117 (white, f, 11th grade, illegal, cannabis , alcohol +): for other participants, degree of use and impairment from use were again important, such that use of both cannabis and alcohol is equally acceptable so long as it is not excessive or interrupting daily activities. “i care about, like, how present people are when i'm spending time with them, but like … about their own use of cannabis and alcohol … it's not really my place—but if they are close to me, and they are using [cannabis] or, like, drinking, really, really, often. then, like, i will worry about like, why they’re doing it so frequently.”sid 234 (asian, f, 12th grade, legal, cannabis , alcohol ) one participant was keenly aware of differing degrees of social acceptability of both substances, but expressed that they personally held similar views, so long as use is not harming the individual using the substance or others around them. “[my views are] similar, but yet not so much because alcohol is, like, just a social thing, and to my understanding, cannabis is like—it's not so socially acceptable, you won't go to a restaurant and get cannabis with your dinner. ... whereas you will go to a restaurant, get a glass of wine with your dinner. it's ... they're different. alcohol is more socially acceptable. but they are kind of similar in the way that if it's harmless and you're not hurting anyone, you're not hurting yourself, go ahead.” sid 154 (white, f, 11th grade, legal, cannabis , alcohol +) adolescent participants rarely expressed an equivalent disapproval of both substances. one participant noted that use of either by teens was unacceptable, but that they would be more accepting of use in adults. “neither of them are particularly, like, awesome if you're a teenager, but i mean, if you're an adult. and you know, again, i—i feel like it's just a matter of age and maturity.” sid 177 (white, m, 11th grade, mixed legality, cannabis , alcohol +). more positive views towards alcohol. some participants expressed generally more negative valence and less approval towards cannabis use as compared to drinking alcohol. for some this was driven by perceptions of normality or acceptability of use. ubiquitous presence of alcohol in american society seems to be a contributing factor of these views. after expressing their comparative approval of alcohol, one participant noted specifically that in their culture, cannabis use was communicated as being bad, while drinking was cannabis, a publication of the research society on marijuana 142 modeled as being acceptable through parental use. “i think it's like … like it comes back to like my own experiences that, like … my culture, i guess, it's just weed, cannabis, that's all viewed as, like, ‘don't do it. it's really bad.’ smoking is bad. whereas, like, drinking is okay. because, like, parents drink, right?” sid 164 (asian, m, 12th grade, legal, cannabis , alcohol +) another participant noted that they approved of alcohol use in certain settings (e.g., religious ceremonies), but did not approve of cannabis use in any setting. consequently, they expressed that alcohol use was comparatively more acceptable. “you know there are occasions in which i think that alcohol is acceptable, and there are not occasions where i think that cannabis is acceptable. so, i suppose that's the difference. you know. ii think that it's fine, for you know, a catholic person to drink wine when they're … if they think that it's the blood of jesus, or something along those lines.” sid 179 (mixedrace, m, 12th grade, legal, cannabis , alcohol ) for another adolescent, their views were mixed. similar to previous participants, they expressed that alcohol use was more acceptable due to likelihood of encountering its use at celebrations. however, they also noted that they perceived cannabis use as being less detrimental to health, despite being socialized to believe that cannabis use was bad. “i would say that drinking is a little bit better … you're not going to go to a wedding and everyone's going to be, like, smoking weed, you know. so even if it's not, you know, medically, and everything like that, like if maybe weed is less, you know, detrimental to your body than drinking. but just in regards to what's more, like, advertised as being not as bad, i would say, drinking alcohol.” sid 108 (white, f, 12th grade, mixed legality, cannabis , alcohol ) more positive views towards cannabis. participants much more commonly expressed that they approved of cannabis use more so than use of alcohol. some of the reasons included perceived social and health impacts (e.g., risk of alcoholism, alcohol poisoning, vomiting, liver damage, death), perceived addictive potential, and the perceived level of bodily control with each substance. for example, one participant described witnessing others experience detrimental alcohol-related outcomes, which impacted their comparative approval of cannabis use. “and i think [cannabis is] way, way, way, way better for you than alcohol is. i think alcohol can maybe…i've seen it destroy people, so i know i would prefer people to look to—to [do] weed than to—to [drink] alcohol.” sid 111 (white, f, 12th grade, legal, cannabis +, alcohol +) another participant described cannabis as “healthier,” in part because it is a plant and from a natural source. in contrast they described alcohol as poisonous to the body as it is consumed. “i probably approve of cannabis more, just because it's healthier for you, and alcohol is literally poisoning you as you drink it. and just cannabis is from like a natural plant source.” sid 153 (white, f, 12th grade, legal, cannabis , alcohol ) participants occasionally compared their personal observations of individuals under the influence of both alcohol and cannabis, with one participant describing those under the influence of the former as “unsettling.” “i feel like i'm somewhat more approving of [cannabis] because, like, the people, like people that i've been around who have, like, been under the influence of cannabis, like they, like their behavior wasn't like necessarily alarming, but people that i've been around who are like drunk obviously like the behavior was kind of unsettling.” sid 241 (black, f, 12th grade, legal, cannabis +, alcohol +) another participant made their decision based on the perceived addictive potential of each substance. notably, they also indicated that peers commonly hold the belief that alcohol is addictive. “i approve of cannabis more than alcohol … because alcohol isit affects your liver fast and it's very … it's addictive. because most of the people just like my age who are drinking, they're drinking, and then they like … they're drinking every day. they’re not, like, just taking one sip and going about their day. they're drinking it every day. that's why [there’s] not a lot of people drinking alcohol because they know how addictive it is.” sid 305 (black, f, 12th grade, illegal, cannabis +, alcohol +) discussion the present study utilized a qualitative approach to capture a rich and descriptive account adolescent cannabis and alcohol attitudes 143 of adolescents’ attitudes towards cannabis use as well as how these attitudes directly relate to their attitudes related to alcohol. this study is one of few to directly prompt adolescents about their attitudes towards cannabis use (e.g., karashiali et al., 2022) and to our knowledge, is the first to qualitatively describe how youth conceptualize attitudes towards alcohol and cannabis in relation to each other. youth reported a range of attitudes towards cannabis and alcohol use that can serve to explain recent trends related to adolescent substance use, inform clinical care, and serve as the basis for future quantitative and qualitative inquiry into adolescent substance use beliefs and attitudes. interpreting these behavioral beliefs and attitudes within the framework of the theory of planned behavior (tpb) provides insight into adolescents’ subsequent behavioral intentions and behaviors, as well as possible mechanisms for prevention and intervention. adolescents’ nuanced approval of cannabis results from the present study seem to indicate that adolescents are nuanced in their degree of approval of cannabis use and provided a range of reasons for both their approval and disapproval. for those who approved of cannabis use, they described a lack of care or, alternatively, a desire to not police the behavior of their peers. interestingly, participants captured within this theme included both cannabis-naïve participants and participants who had endorsed past cannabis use. most youth did not hold black-and-white opinions in their approval of cannabis use, rather conditioned their approval upon who is using cannabis, how they are using it, or why they are using it. for example, participants reported approving of use by those who were older and could use cannabis legally in their jurisdiction, while others noted that medicinal use and recreational use that does not cause significant impairment in activities of daily life is acceptable. some of these factors are well documented in the literature, while others are more novel. past work has consistently demonstrated that adolescents disapprove of regular use of cannabis at somewhat high rates, and that early adolescents are especially disapproving of heavy use (miech et al., 2024). notably, the present study expands upon prior qualitative insight into adolescents’ approval of medicinal cannabis use. over time, medicinal use of medicinal cannabis by adolescents has increased (miech et al., 2024). teens in the present study reported mixed views of use in this manner, in that genuinely “needed” use of medicinal cannabis was acceptable, while use of cannabis to cope, or alternatively, feigning medical need to obtain cannabis, was less acceptable. budney (2021) captures this dilemma and notes that there is some lack of clarity in past work (e.g., wardell et al., 2021) in the definition and operationalization of medicinal cannabis use. this conceptual ambiguity must also be considered in concert with the known differences in efficacy of medicinal cannabis in managing various mental and physical health symptoms (hill, 2015; wilkinson et al., 2016). as such, further work that qualitatively and quantitatively captures adolescent attitudes towards each of the interpretations of “medicinal” use listed above is likely needed. furthermore, past work has demonstrated that legality of cannabis does not necessarily increase risk of adolescent cannabis initiation, and that other related mechanisms (e.g., increased access) have more causal influence on adolescent cannabis use (coley et al., 2019; harper et al., 2012). relatedly, several participants in the present study noted that their approval of cannabis was at least in part related to its legality. although not explicitly stated by these participants, conditioning approval based on legality would necessarily imply that underaged use by similarly aged peers would not be acceptable. however, it is unclear if participants expressing this belief are fully aware of age restrictions within jurisdictions that have legalized recreational and/or medicinal use. this finding might suggest that adolescent cannabis attitudes can be shaded by legality, such that adolescents may be more likely to endorse cannabis use as acceptable while within states that have legalized its use. this is a finding demonstrated in past qualitative work based in california (which had legalized medicinal use at the time of the study) in which participants seem to have evaluative attitudes shaped at least in part by the legal status of cannabis (friese, 2017). for example, one participant in this study remarked “if it was all that bad of a drug, they wouldn’t be trying to legalize it. it’s not like they’re trying to legalize crack or anything like that” (friese, 2017). as such, cannabis attitudes cannabis, a publication of the research society on marijuana 144 could serve as an additional factor mediating the relationship between legalization of cannabis and rates of adolescent cannabis use. further, it is imperative that prevention messaging highlight the limited empirically-supported therapeutic benefits of medicinal use of cannabis (see bilbao & spanagel, 2022; pratt et al., 2019). contrasting attitudes towards cannabis and alcohol despite more adolescent participants in the study reporting having used alcohol in the past (62.5%) than cannabis (40%), this pattern of use was not necessarily reflected in self-reported attitudes related to cannabis and alcohol use. in fact, participants were much more likely to express having more positive attitudes towards cannabis use than alcohol use. participants who viewed cannabis more positively perceived alcohol as a more addictive substance with greater potential for both short-term consequences (e.g., alcohol poisoning, impaired bodily control) and long-term consequences (e.g., liver damage and early death), which parallels prior qualitative work with a sample largely consisting of adolescents with current or prior cannabis use (friese, 2017). those endorsing alcohol as more acceptable indicated the opposite, that cannabis was more addictive and detrimental to health, while also noting that their view was shaped by how alcohol use is culturally normalized and viewed as more socially acceptable. levy and colleagues (2018) demonstrated that the proportion of youth endorsing that cannabis use is a “low-risk” behavior has more than doubled in the last two decades. this trend is also seen in data from monitoring the future, which shows that perceived risk of harm from experimental, occasional, and regular cannabis use has seen significant decrease over time among 8th, 10th, and 12th graders (miech et al., 2024). similar stark changes in perceived risk of both experimental and heavy use of alcohol were not seen in 10th and 12th graders, who now perceive binge drinking at least once weekly as more harmful than regular use of cannabis (miech et al., 2024). adolescents holding these contrasting behavioral beliefs simultaneously are likely to hold more positive attitudes towards cannabis than alcohol, and thus are more likely to have intentions to use cannabis. broadly, the results of the present study seem to indicate that adolescent attitudes towards cannabis and alcohol could be interrelated. further, findings from the present study may be of particular interest to substance use prevention and intervention scientists and clinicians. a number of substance use interventions for young people delivered in both traditional and digital settings target alcohol and cannabis simultaneously (e.g., coughlin et al., 2021; newton et al., 2010), or alternatively, target substance use generally (e.g., hecht et al., 2003; schwinn et al., 2018, 2019). while this polysubstance approach may be beneficial for some youth, others may benefit from separate and tailored intervention for each substance to ensure the appropriate potential mechanisms of change are being addressed adequately. preventive interventions could additionally be tailored to youth based on where they fall on the spectrum of approval and disapproval of cannabis, as well as the reasons for and types of use they find to be acceptable. public health programming development may also benefit from a youth participatory action framework, in which youth are engaged as active stakeholders in creating intervention content. for example, a campaign targeting substance use injunctive norms in youth and adolescents may be more effective if modeled in such a way that youth are receiving messaging created by similarly aged peers. while past interventions have utilized youth-created messaging (e.g., the truth campaign; farrelly et al., 2009; zucker et al., 2000), having youth additionally contribute to presenting the information (e.g., featuring youth in videos or ads) could contribute to additional program efficacy. participants’ qualitative feedback from the present study indicates that a greater depth of understanding could be gained through directly querying teens about attitudes towards one substance as they relate to attitudes towards a separate substance. insight in this regard could help explain transitions in primary or sole-use patterns (e.g., substitution) versus complementary use or total abstention (subbaraman, 2016; weinberger et al., 2021). asking open-ended questions (e.g., “what do you know about the risks of substance use/using cannabis or alcohol?”) in clinical settings (e.g., primary care) may also be beneficial in identifying adolescents who may benefit from brief counseling adolescent cannabis and alcohol attitudes 145 on risk of other non-preferred substances. importantly, within tpb, objective truth regarding the risks of behavior are not meaningful in predicting behavioral intentions, as individuals are believed to act in concordance with subjective held beliefs (ajzen, 2020). sole-substance prevention programming could feasibly foster behavioral beliefs that a non-discussed substance is safer in comparison, as the individual has not had their belief confronted that use of the alternative substance is safe, or safer in comparison. in this regard, providing corrective feedback to youth regarding risks of both cannabis use and alcohol use simultaneously could foster subjective behavioral beliefs regarding the risk of both substances. as such, general substance use prevention programming may have particular utility in communicating health risks, as opposed to targeting specific, and possibly varying, mechanisms of substance refusal and abstinence. findings of the present study are also meaningful in the context of the broader substance use prevention literature and the parent study’s focus on the impact of adolescents’ exposure to alcohol content in the media. adolescents’ attitudes towards substances are socially constructed both within built world and online social networks (fujimoto & valente, 2012; strowger et al., 2023). as such, understanding what attitudes adolescents have internalized through social influence (e.g., frey & friemel, 2023) and may be transmitting to others in different digital and physical social contexts (e.g., direct digital communication, social media posting, in-person conversation) is essential. future longitudinal and mixed-methods approaches could be beneficial in investigating the spread of specific substance-related attitudes within adolescent social networks. this approach would be especially beneficial in understanding development of attitudes or norms within smaller (e.g., close friend groups) and larger (e.g., schools) social networks that contrast or vary from national level trends. further, this granular understanding could serve the effective application of targeted, social network-informed prevention and intervention strategies. study strengths and limitations this study has some notable strengths. first, the sample size was relatively large for individual interview-based qualitative research with adolescents, allowing for thematic saturation. second, the sample was relatively racially and ethnically diverse and also included a significant proportion of substance-naïve teens and teens who have used cannabis and alcohol (closely aligned with national rates). additionally, the present study utilized individual interviews, rather than focus groups. this can reduce pressure to agree with peers within the group and allows participants to share openly and honestly without fear of negative peer evaluation. it also reduces privacy concerns that can arise in group settings. some limitations should also be noted. first are those inherent to qualitative inquiry: its comparatively small sample size limits its representativeness and does not allow for objective statements of prevalence rates, relatedness, or causality. sample size was not sufficient among study subgroups (e.g., males, smokers, etc.) to reach subgroup saturation, precluding cross-group comparison. as some participants in the present study noted that their attitudes and approval of substance use was related to cultural identity and upbringing, future studies are needed to understand unique and nuanced viewpoints that could be held by different groups. the study also had an overrepresentation of female participants and did not have a significant number of 9th and 10th grade participants. as such, generalizability of the results to males and students in earlier grades is limited. finally, to ensure adequate representation of youth in the parent study across a range of risk with regards to exposure to alcohol content, our sampling approach included having endorsed having used alcohol at least once, or having at least one close friend who drinks. this strategy was aligned identified as necessary by the research team to counter known difficulties of recruiting and consenting youth with higher engagement in risk behaviors into research, especially research targeting risk behaviors they are engaging with (e.g., kekkonen et al., 2015; tigges, 2003). while rates of substance use engagement in full parent study and this subsample approximate those found in large, nationally representative samples (e.g., monitoring the future), results of the present study must still be considered in the context of these limitations. cannabis, a publication of the research society on marijuana 146 conclusions the present study is a valuable step in developing a rich understanding of adolescent attitudes towards and approval of cannabis use. findings suggest that these beliefs are quite nuanced, such that approval/disapproval is generally conditioned on several factors, with most youth expressing that they approve of cannabis use in at least limited circumstances (e.g., for medicinal use, if used moderately, etc.). further, the present study seems to indicate that degree of approval of one substance may be related to approval or disapproval of other substances. for example, youth who perceive alcohol as being highly risky, harmful to health, or addictive may in turn be more likely to express a belief that cannabis use is not risky or harmful. this 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(2000). florida's “truth” campaign: a counter-marketing, antitobacco media campaign. journal of public health management and practice, 6(3), 1-6. https://doi.org/10.1097/00124784-20000603000003 adolescent cannabis and alcohol attitudes 151 funding and acknowledgements: this study was supported by niaaa grant r01-aa027968 (pi: jackson). author ac was supported by the uf substance abuse training center in public health from the national institute of drug abuse (nida) of the national institutes of health under award number t32da035167. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors have no relevant financial or nonfinancial interests to disclose. author note: *affiliation at time of data collection and analysis; author kj has since moved to the rutgers addiction research center, rutgers university, piscataway, nj. ethics approval: the methodology and materials of this study were approved by the brown university and university of florida institutional review boards. consent to participate: informed consent was obtained from all individual participants and legal guardians included in the study. participants under the age of 18 additionally provided written assent. author contribution statement: alex clement: conceptualization, data curation, formal analysis, investigation, writing – original draft, writing – review & editing. erin corcoran: conceptualization, data curation, formal analysis, methodology, investigation, writing – original draft, writing – review & editing. joy gabrielli: supervision, writing – review & editing. kristina m. jackson: supervision, writing – review & editing, funding acquisition. data availability statement: aggregated and non-identifiable data will be made available upon reasonable request to the corresponding author. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: clement, a., corcoran, e., jackson, k. m., & joy, g. (2025). “if you need to light up … you gotta do what you gotta do”: a qualitative study of adolescent attitudes towards cannabis use and comparison with alcohol attitudes. cannabis, 8(3), 133–151. https://doi.org/10.26828/cannabis/2025/000332 https://creativecommons.org/licenses/by/4.0/ research article 72 ved abstract objective: california legalized adult cannabis use in 2016 with the passing of proposition 64: the adult use marijuana act (prop 64). this qualitative study aimed to explore the impact of legalization on various stakeholders and institutions within california, especially as it relates to public policy, health, and safety. method: twenty-two semi-structured interviews were conducted from january to march 2022 with stakeholders that included subject matter experts (sme) from the following categories: clinicians (primary care, pain management, addiction medicine, cannabis clinicians), researchers, advocates, dispensary owners/personnel, legal professionals, and cannabis consumers. nine interview guides were constructed to assess participants' perceptions of prop 64 and its impact on their given sector/industry as it relates to the use, production, distribution, and access to medicinal and adult cannabis use. thematic analysis was conducted to identify salient themes from the interviews. results: the three primary themes and subthemes included: (1) successes of prop 64 (quality control, justice reform, stigma reduction), (2) shortcomings of prop 64 (high cost, licensing, bureaucracy, social inequity), and (3) recommendations for improvement of prop 64 (need for research, policy change, the transformation of business model). conclusions: the implementation of cannabis legalization in california had a broad impact on many key stakeholders. while demonstrating some success, sme described key areas for improvement of prop 64. a multidisciplinary approach with support from government, state, and local municipalities is necessary to facilitate proper regulation, provide timely support, and reduce social injustice, harm, and unforeseen consequences of use. updating federal regulations (e.g., schedule i status) might be an important step to allow for improving regulation and operations (e.g. banking) within the cannabis industry, further research and education, and greater cross-state consistency regarding law enforcement/regulation of cannabis. public health implications: the information gathered will help inform public policy, as well as help health professionals design new health education campaigns for the general public. key words: = cannabis legalization; california; proposition 64; stigma reduction; justice reform; subject matter experts cannabis is a plant-based product that existed 5000 years ago and has been widely used in the united states since 1850 (holland, 2010; the university of sydney, 2024). through the “marihuana tax act of 1937,” and “the controlled substance act of 1970 (csa),” cannabis was daniel ageze1, renee dell’acqua1, thomas d. marcotte2, sara baird1, jesus garcia1, jill rybar1, & linda hill1 1herbert wertheim school of public health and human longevity science, uc san diego 2department of psychiatry, center for medicinal cannabis research, uc san diego cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000291 volume 8, issue 1 the impact of adult cannabis use legalization in california: a qualitative review of subject matter expert opinions on proposition 64 corresponding author: daniel ageze, md, mph, university of california san diego, 9500 gilman drive, la jolla, california 92093‑0994. email: dageze@health.ucsd.edu cannabis, a publication of the research society on marijuana 73 federally restricted with severe legal penalties for possession and use (holland, 2010, ortiz & preuss, 2025). in 1996, with the enactment of the compassionate use act (proposition 215), and in 2016, through the adult use of marijuana act (proposition 64), cannabis was approved for medicinal and recreational use in california, respectively (compassionate use act, 2024; proposition 64: the adult use of marijuana act, 2016). implemented in 2018, proposition 64 (prop 64) allowed retail sales of adult cannabis use to adults aged 21+ (proposition 64: the adult use of marijuana act, 2016; roth et al., 2022). today, cannabis is the most widely used substance after alcohol and tobacco in the united states, and more states are moving towards cannabis legalization (woodruff et al., 2021). despite a federal dea schedule 1 status (indicating that cannabis has no medical benefit and a high risk of addiction), as of april 2023, 24 states have legalized both recreational and medicinal cannabis, 38 states allow medical cannabis use, and only 13 states remain without any form of legalization (american nonsmokers’ rights foundation, 2022; roth et al., 2022; u.s. drug enforcement administration, 2018). this is due to a shift in societal perception and acceptance of cannabis use, as well as the emerging medicinal benefits of fda-approved cannabinoid medications such as dronabinol, nabilone, and epidiolex (gali et al., 2021; mcginty et al., 2017; lutge et al., 2013; smith et al., 2015; kafil et al., 2018; mücke et al., 2018; national center for complementary and integrative health, 2019). contrary to the emerging medicinal benefits and future promises of selected cannabinoids, most professional societies, such as the american medical association (ama), american board of family medicine (abfm), and american society of addiction medicine (asam) are opposed to the legalization of recreational cannabis use until “additional scientific research has been completed to fully document the public health, medical and economic consequences of its use” (american society of addiction medicine 2020; bailey, 2021 american academy of family physicians, 2019). states that have legalized adult cannabis use also point out that “given that recreational cannabis has only recently been legalized, there is relatively little robust evidence of its impact, and the evidence that exists is inconclusive” (hammond et al., 2020; sobesky & gorgens, 2016). this is also true when it comes to california – several studies have been done related to public policy, health, and safety (bailey, 2021; santaellatenorio et al., 2020; wang et al., 2022; wang, et al., 2022; wang et al., 2017, 2021; zvonarev et al., 2019). numerous concerns related to the legalization of adult cannabis use have been raised. using the social-ecological model (sem), a systems-level approach that is helpful to understand interactions at several levels, at the individual level, experts are concerned with decreased perception of harm of cannabis use, increased cannabis use, risk of co-use of other substances, psychosis, dependence/cannabis use disorder, worsened rates of cyclic vomiting syndrome, and anxiety (borodovsky et al., 2016; centers for disease control and prevention, 2022; hall & lynskey, 2020;). at the interpersonal level, concerns include increased cannabis access to youth, changes in patient-provider relationships, as well as changes in the way individuals receive guidance (rubin-kahana et al., 2022; sobesky & gorgens, 2016). at the organizational level, concerns related to the justice system, work environment, regulation of cannabis retailers (i.e., dispensaries), health care, and educational systems are areas of interest/concern (kan et al., 2020; zhu et al., 2021). at the societal level, concerns include potential societal harm inflicted by driving under the influence (dui), the risk for harm from second-hand smoking, inadequate public education, inappropriate advertisement and public safety from informal sales channels, and crime (kruger et al., 2024; steinberg et al., 2020). at the policy level, concerns include the risk of increasing tobacco/nicotine use, the proliferation of new products, cannabis monitoring, and federal and state regulations pertinent to changing those policies (e.g., controlled substance act, compassionate use act of 1996, medicinal and adult use cannabis regulation and safety act).(department of cannabis control california, 2025; kruger et al., 2024; steinberg et al., 2020). with these concerns in mind, this preliminary study of the impact 64 project aimed to better describe key concerns of cannabis stakeholders following the implementation of proposition 64, especially as it relates to public health, safety, and policy. these findings were then used to inform subject matter expert opinions on prop 64 74 the full impact 64 study, which aimed to investigate the impact of cannabis legalization in california. methods participants and recruitment key stakeholders representing a variety of sectors in california were identified and invited to participate through purposive sampling strategies. the study team sought to identify clinical, research, and legal subject matter experts, cannabis advocates, public health advocates, owners of cannabis retailers (i.e., dispensaries), and one self identified cannabis user. the initial group of stakeholders were known to the study team through prior collaboration networking, and professional societies. snowball sampling (referrals from enrolled participants) was used to recruit additional participants, including three out of state smes who are “multi-state operators.” potential participants were contacted through email to be considered for participation. participant background, profession, expertise, and region of employment were all considered to ensure a diverse sample of sme. participants who completed the interview were provided a $100 gift card for their time. study design an exploratory qualitative study design grounded in thematic analysis (ta) was used to explore the perspective of stakeholders with varying backgrounds and interests in cannabis (castleberry & nolen, 2018). prior to developing the semi-structured interview guide, a literature review was conducted by looking at previous measures and scales used to assess cannabis consumption, motivation, attitudes, perception of harm, and dependency to define key areas of interest across all stakeholders and sme categories, as well as develop specific learning objectives for each of the categories of sme, as shown in figure 1. these included questions assessing the participant’s background and expertise, the demographic makeup of the populations they serve, and their perceptions of cannabis legalization (the successes/benefits and shortcomings/drawbacks of prop 64) on their field of expertise and the population they serve. clinicians were also asked to describe their knowledge of prop 64, their experience with cannabis, the reasons their patient’s used cannabis, the effects cannabis had on their patients, their experience integrating medicinal cannabis into their practice, as well as any reasons they have not integrated medicinal cannabis into their practice. each sme was also asked about any changes they would make to prop 64 in future revisions. interview guides are included in the appendix. figure 1. impact 64: stakeholders, subject matter experts (sme) & interview guide cannabis, a publication of the research society on marijuana 75 data collection participants consented to the recording of interviews (60 minutes) through zoom (zoom video communications, inc, 2023) between january and march 2022. for all but five of the sme interviews, 5 or more impact 64 team members were present at each interview. transcriptions from zoom recordings were directly imported into dedoose software (dedoose, 2021) for analysis. de-identified interview transcripts were stored on a password-protected server. data analysis thematic analysis (ta) using both deductive and inductive approaches was conducted using dedoose software (dedose, 2021). ta is a widely used method in qualitative research that is used to “identify, analyze, and report patterns (themes) within data.” (castleberry & nolen, 2018). ta takes the open-ended responses from surveys and transcribed interviews to explore the context at a level of depth that quantitative analysis lacks. it also allows for flexibility and interpretation of data that can build a complex, holistic picture of the topic at hand. prior to the interviews, a predefined codebook was developed based on the literature review and the interview guide. this included the themes of the perceived successes and shortcomings of proposition 64, as well as recommendations to revise prop 64 as shown in figure 1. during data cleaning and analysis, using an inductive approach new subthemes were included as part of the data analysis which are presented in the results section. two raters (da, rd) independently assessed the data with a third person (jg) available to resolve any difference in categorization. interrater reliability analysis was conducted by comparing coding manually between raters. results study sample out of fifty potential sme that were identified and contacted, twenty-two semi-structured zoom interviews were completed. reasons for not participating included non-response to the initial invitation and lack of availability. sme consisted of eight clinicians (two primary care, one pain management, two addiction specialists, three cannabis clinicians), three clinical cannabis researchers, two cannabis advocates, five dispensary owners/personnel, three legal professionals (lawyer/policy maker, judge, law enforcement), and one self-identified cannabis consumer (figure 1). sme demographics were not specifically collected, but all were over 30 years old, had an almost equal distribution of gender, with racial/ethnicity distribution of white nonhispanic (17 out of 23), one black/african american, one latinx, and one of middle eastern origin. their educational level included bachelor, masters, ph.d., md/do, and naturopathic doctor (nd). eleven were from san diego, three from los angeles, one each from humboldt county, santa clara, central california, and ohio, and two from denver, colorado. figure 2. impact 64: sme interview themes and subthemes subject matter expert opinions on prop 64 76 emerging themes during qualitative thematic analysis, themes were grouped into 3 major areas based on themes that had the highest count of similar content based on the pre-defined topics as shown in figure 2: (1) successes of prop 64, (2) shortcomings of prop 64, and (3) recommendations for improvement of prop 64. successes of prop 64 “successes of prop 64” refers to descriptions of the benefits of legalization of adult cannabis use through prop 64. three main subthemes were identified: stigma reduction, quality control, and justice reform. following the narratives below, specific quotations are found in table 1. stigma reduction. the sme noted that after prop 64 implementation, there was a shift toward acceptance of cannabis, which contributed to stigma reduction. it also legitimized the use of medicinal cannabis among former non-users. initially, fears surrounding legalization centered on perceptions that cannabis use would increase significantly and that it would cause harm to public health and safety. sme noted these fears did not come to fruition. clinicians were now able to focus on the benefits and harms of cannabis use instead of arguing about the ethics of legalization. patients also did not feel like they were consuming unregulated drugs.. quality control. sme communicated that prop 64 instituted requirements that improved cannabis product quality and testing. every cannabis product was being tracked from “seed to sale.” products were tested for strict dosage, ingredient composition, and pesticide/preservative content, and packaged and labelled correctly. there was an emphasis on quality, which increased trust in the products available. clinical sme with more knowledge about cannabis described an increase in comfort level after prop 64, noting the ability to recommend specific products, titrate the dose, and avoid adverse effects, particularly in older adults, and the risk of intoxication or possible development of a cannabis use disorder. justice reform. according to sme, legalization extensively helped individuals who were incarcerated for cannabis-related offenses. they were released the “next day, and ankle bracelets were immediately taken off.” this also was evident for individuals whose cannabis-related offenses were dismissed while waiting for trial. law enforcement sme also reported that they no longer pursued cannabis-related encounters just because they smelled cannabis. it helped reduce unnecessary interactions and possible altercations with the public, especially given recent increases in mistrust by the public. other successes of prop 64 that are considered minor themes are shown in table 1 without a detailed discussion. table 1. success of prop 64 themes and subthemes with smes statements themes subthemes smes statement successes of prop 64 stigma reduction “the attitudes were not as negative. because with the legalization came a shift in attitudes with judges and juries.” – legal professional “walking into a store that didn't make people feel like they were about to do drugs.” – cannabis clinician “the main lesson of prop 64 is that people told us this sky was going to fall and nobody is going to go to work, and nobody is going to be motivated. and that did not happen. and any of those sorts of ancillary harms have not happened.” – addiction specialist/pcp “there's just more people who are willing to talk about it now.” – policy quality control “the real beauty of this recent legalization was the product testing and consistency.”cannabis clinician “the quality control of cannabis is at a higher level than any other supplement you could buy on a shelf in a store.” – cannabis clinician “you can measure and give exact milligram dosing; it makes it look more like a medicine “– cannabis clinician cannabis, a publication of the research society on marijuana 77 justice reform “decriminalization, to some extent, has removed another source of oppression from members of my community.” – addiction specialist/pcp “she had one of those ankle bracelets on and they took that off the next day and people got out of jail” – cannabis advocate “the felons were around, as i recall, 15,013 thousand a year, even in the last years of prop 215 when things were loosening up, and now i think they're probably under 2000 or 1000.” – cannabis researcher other successes of prop 64 safety measures “senior groups they want to be able to dose in very controlled ways, and the regulations have been good for that.” – cannabis clinician “there's added security because of it. that was an unexpected bonus.” – policy innovation – proliferation of products “a lot more products developed in the last few years, which is nice.” – cannabis clinician increased access to information “now we're knowing something about people consumption habits.” – legal professional “you know the ability to read a label and educate them about the potency of what to shop for has been a game changer.” – cannabis advocate shortcomings of prop 64 sme also described the drawbacks and unintentional, negative consequences of prop 64. these fell under four subthemes: the high cost of products, challenges with licensing and staying in business, excessive bureaucracy, and social inequity and injustice. following the narratives below, specific quotations are found in table 2. high cost of products. sme noted that prop 64 introduced high tax rates, forcing dispensaries to increase the sale price of cannabis products. individuals are thus paying more than they used to, waiting for promotions, or perhaps turning back to the unregulated market for less expensive products. this is impacting the end user, as described by the sme. challenges with licensing and staying in business. sme noted many barriers to entering and staying in the regulated cannabis industry, including cost and regulatory challenges. financially, sme noted high tax rates including state, excise, local, distribution, and manufacturing taxes. dispensary locations can be charged high rent, “two, three, four times” the market value. it takes 2-3 years to obtain a license, given the many bureaucratic steps required, frequently deemed excessive by the sme. a dispensary owner must have a location/store secured before even applying for a license, requiring them to pay rent while waiting for licensure approval and before generating income. every product is tracked from “seed to sale,” which sme noted to be hard to maintain. with most dispensaries desiring to be vertically integrated, produce and sell cannabis, this has been challenging and expensive, per sme. excessive bureaucracy. according to dispensary sme, cannabis is the “most regulated legal crop; the testing requirements are more stringent than the food we eat,” one dispensary owner mentioned. a mixed cannabis-food product failed testing due to pesticides that are allowed in food. in addition, environmental impact reviews are time-consuming and expensive. moreover, additional regulation by local jurisdictions leads to varying rules and fees, and the inability to have products and services in certain areas. for instance, only 36 licenses were planned to be issued at the start of prop 64, and only 20 had been approved as of 2021, per dispensary owners. social inequity and injustice. sme described the significant impact legalization had on the ‘mom and pop’ retailer shops, farmers, and communities with historic medicinal cannabis sales. policymakers reported that equity was not considered at the beginning of the planning phase of the legalization of prop 64. sme felt that the high cost of entering and sustaining legal business created inequities in who can be in the industry, giving an unfair advantage to those who established and well-financed groups such as tobacco and alcohol companies. individuals who are cannabis users in multitenant homes were subject matter expert opinions on prop 64 78 also facing restrictions that were discriminatory and unjust, per sme. table 2. shortcomings of prop 64 themes and subthemes with smes statements themes subthemes smes statement shortcomings of prop 64 high costs of products “the immediate impact of prop 64 was on average cannabis price went up 40%.” – clinician “everyone immediately started paying a 15% state excise tax, local excise tax (additional 8%) , and cultivation manufacturing and distribution taxes.” – dispensary owner challenges with licensing & staying in business “you can't be within 100 feet of a church, 1000 feet from school, or residential. this is actually the hardest part of the business.” dispensary owner. “…not to mention the 280a taxation amount from the irs. you can’t write off rent, labor, arm guards. it’s ridiculous.” dispensary owner “people are paying 2,3, or 4 times the average rents…my arm guard bill was over $300 grand a year.” – dispensary owner “it costs me about $70,000 just for city staff time.” – dispensary owner excessive bureaucracy “they want to know what batch, what clone that came from, they trace it all the way back and that’s a lot.” – dispensary owner “i think over 75%, maybe even over 80% of all licensed cannabis facilities in ca do not have final licenses.” – cannabis advocate. “now i have to pay all this money in rent and the process can take literally two or three years.” – dispensary owner social inequity & injustice “we [legislators] did not consider social equity at all.” – dispensary owner “not a fan of banning things in your own home. that is bringing the ‘drug war’ 2.0 straight into people’s houses.” – cannabis advocate “the pain department won’t even refer people to me that they know can’t afford it.” – clinician other shortcomings of prop 64 unforeseen consequences “some people are now taking the legal cbd and creating these highpowered new products that are much more impairing” – legal professional “they tend to think that high thc content is going to sell the best and pack their shelves with it” – addiction specialist safety ramification “there's no real cap on the potency of the drug.” – cannabis researcher “everybody’s perception is that oh it's ok to do this no matter what now. and that's where we've seen the big, uptake in duis” – law enforcement “everybody’s perception is that oh it's ok to do this no matter what now. and that's where we've seen the big, uptake in duis” – law enforcement issues with law creation “there was stronger representation of corporate and wealthy people and less representation of public health people” – dispensary owner “in most cities, they all copy each other when it comes to these ordinances, … the problems just keep getting duplicated.”-dispensary owner lack of medical guidance “they're practicing medicine without a license, absolutely.” – addiction specialist “i'm not going to send him out with this prescription that says go pick up whatever variety of blood pressure medication you'd like to take and use as much of it as you think you need to feel alright, like i would never do that.” – cannabis clinician cannabis, a publication of the research society on marijuana 79 impact on medicinal cannabis users “patients now go through the public health office and spend an additional 50 to $100 per year in la. it's really like 10 to 15% off a 30% tax” – cannabis clinician “some products evaporated – i called the marketplace my achilles heel.” cannabis clinician “older people can't even get into some of these containers” – cannabis clinician proliferation of unregulated market “now black-market dealers are going to deliver to you.” -dispensary owner “did they expect the black market to just disappear it takes 2 years and at least $300,000. “– dispensary owner differing state vs federal laws “we're a border town and so 50 miles out from any international border is really federal jurisdiction.” – cannabis researcher “we need the federal government to allow banking.” – dispensary owner in addition to the four major themes outlined above, sme interviews also revealed three minor themes regarding shortcomings of prop 64. on the consumer side, there was an unforeseen increase in potent (high thc) products, as well as derivatives. sme also noted an increase in cannabis being marketed toward youth, with attractive and disguisable products— for example, a vaping device disguised to look like a calculator, or edibles packaged to look like candy. sme also reported safety-related changes after implementation of prop 64. there was general frustration about the differing state and federal laws, noting its impact on transportation and banking. sme noted that dispensaries, working as a cash-only business, saw an increase in robberies, which may be avoided if there were alternate banking options available. a law enforcement sme reported an increase in duis and noted lack of guidance about driving and cannabis use. finally, sme noted an unanticipated trend away from programs that support medicinal cannabis users. for example, elimination of the compassion programs, which provide free or reduced cost cannabis to severely ill medical card holders. budtenders were increasingly being seen as 'medical experts.' during prop 64 planning and implementation, sme reported inadequate representation of public health and medical experts, whose involvement may have mitigated these unintended changes. the unregulated market partly proliferated due to excessive regulation, taxation, and business challenges, in addition to changes in amount and area of enforcement. finally, the increase in potency and decrease in product selection was also noted to disproportionally have a negative impact on medicinal users. recommendations for improvement of prop 64 “recommendations for improvement of prop 64” summarizes sme perceptions on how prop 64 could be revised. under this theme, four subthemes were identified: policy change, need for research, adjustment in power, and transform business model. the details are presented in table 3. policy changes. there were several recommendations for direct changes to prop 64. a policy maker emphasized that regulation efforts for cannabis should not be reduced or stopped. smes suggested lowering taxes and fees, setting potency limits, revising licensing procedures, and addressing bureaucratic hurdles. potential changes to licensing and policy could involve shortening the wait time for licensing, simplifying the requirement to own rental property before obtaining a license, and lowering the associated fees. social equity support packages and inclusion of stakeholders with diverse backgrounds could facilitate more equitable involvement in the cannabis industry. this could be in providing guidance and/or financial support in the initial phases of starting the business or a transition from a “mom and pop” shop to a large cannabis business that can compete with the big companies. clinical experts advocated for potency limits on cannabis products, particularly to safeguard vulnerable populations (e.g., youth, older adults). for medicinal cannabis patients, smes suggested reducing cost by reducing or subject matter expert opinions on prop 64 80 eliminating taxes, reinstating compassion programs, and providing insurance coverage. furthermore, it was recommended that pharmacies be established for medicinal cannabis dispensation to ensure appropriate care delivery, and that medicinal users should be encouraged to get guidance from clinicians. need for research. various smes identified areas for further research in the realm of cannabis. legal professional smes (lawyer, judge, law enforcement) underscored the need to investigate the medicinal qualities of hemp derivatives like cannabidiol (cbd), cannabinol (cbn), and cannabichromene (cbc). clinicians smes advocated for studies examining unintentional poisonings from edibles among children, while law enforcement emphasizes the necessity of establishing personal limits for driving under the influence of cannabis. the addiction specialist sme highlighted the absence of fda-approved medications for treating cannabis use disorder. furthermore, a cannabis researcher emphasized the dearth of research on the effects of cannabis on acute injuries, despite anecdotal reports from elite athletes regarding its potential benefits compared to opioids. adjustment in power. various stakeholders have highlighted the necessity for adjustments in power dynamics regarding cannabis legalization policies and implementation. smes described the lack of diversity of stakeholders in the decision makers and promoted the need for change. a cannabis clinician expressed concerns about the lack of representation for cannabis physicians in public health and the dcc, potentially leading to biases against cannabis. dispensary owners emphasized the importance of proactively shutting down on unregulated cannabis activities. furthermore, clinicians stressed the need for change from the top while also promoting initiatives from below, including comprehensive education on the endocannabinoid system in medical schools, to foster a more informed and balanced approach to cannabis-related discussions and policies. transform business model. smes proposed transformations in the business model surrounding cannabis distribution and manufacturing. cannabis clinicians advocated for the segregation of medical cannabis and adult cannabis use dispensaries to ensure distinct and specialized services. a dispensary owner highlighted the importance of convenient accessibility to dispensaries, suggesting integration into shopping areas that people routinely frequent. additionally, the idea of an incubator program was suggested by another dispensary owner, aiming to facilitate collaboration between property owners and equity applicants, thereby reducing costs and fostering mutual support within the cannabis industry. this was elaborated by how a more seasoned cannabis owner may serve as a guide or sponsor to support an equity applicant with knowledge, space, or financial means to diversify the industry. table 3. recommendation of improvement of prop 64 themes and subthemes with smes statements themes subthemes smes statement recommendations for improvement of prop 64 policy change “legalization of cannabis does not mean no more regulations of cannabis” policy "need lowered taxes, revise licensing and bureaucratic challenges, and need federal rescheduling and safe banking act" dispensary owner increased social equity by providing equity support packages, involving representative stakeholders, and reducing cannabis use restriction. "we need to limit how high the potency of products can go, we need to look have precautions set for vulnerable populations" clinician/advocate "for medicinal cannabis patients, reduce or eliminate tax. they also need insurance coverage… medical advices should not be given by nonclinicians and restore compassion program. ideal, i would like a pharmacy for medicinal cannabis dispensation" cannabis clinician need for research “hemp derivatives cbd, cbn, cbc, all of the minor derivatives and whether they have any kind of medicinal qualities.” legal professional cannabis, a publication of the research society on marijuana 81 “see if there have been unintentional poisonings from the edible in kids.” clinician “biggest one, we have to find a personal limit for driving.” law enforcement “i don’t have a medicine, an fda approved medicine to give someone if they do indeed have a cannabis use disorder.” – addiction specialist “there’s absolutely no research on the effects of cannabis on acute injury. even though elite athletes are reporting that it speeds up their recovery and they would rather use opioids – they want some science behind it.” -cannabis researcher adjustment in power “ok, at the public health level and the dcc, there is only one of twenty representatives, roughly speaking, and one physician. he's an addiction physician, which presumably would mean that he's against cannabis.” – cannabis clinician “shutting down the illicit is really important.” -dispensary owner “so, it really needs to start at the top and in med schools and starting to train people on the endocannabinoid system they need to start looking at this from a different lens.” -clinician transform business model “in my ideal world, medical cannabis would not be dispensed with recreational cannabis at all. they would be totally separate entities. i would like to have my own compounding pharmacist.” –cannabis clinician “i think if it's near their regular shopping access, they're not making a special drive into some industrial park somewhere.” -dispensary owner “incubator program where a property owner could share the manufacturing space with an equity applicant and so they don't have to pay for the most expensive part, is a brilliant way to help each other in this space.” -dispensary owner discussion the legalization of cannabis, a complex compound with multiple active ingredients, is a huge undertaking requiring a careful approach. otherwise, individuals and societies can face negative, and possibly unintended, consequences, and it may take years of effort and financial spending to undo the damage done, as seen in the tobacco and alcohol industry. vermont and colorado are good examples of states that have either carefully planned the legalization of adult cannabis use or revised a proposition (chen & searles, 2017). in california, adult cannabis use was legalized in 2016 with the passage of proposition 64: the adult use of marijuana act, and like in vermont, california deliberately took 2 years before implementation in 2018 to build an adult cannabis use infrastructure. as part of the impact 64 project, semi-structured qualitative interviews were conducted with 22 stakeholders and subject matter experts (sme) in the cannabis industry and identified significant perceived successes and shortcomings of prop 64, as well as specific recommendations for improvement. success of prop 64 stigma reduction. stigma is a complex phenomenon with several domains (e.g. perceived, internalized, anticipated, enacted) that has profound social consequences impacting personal identity and has well-known deleterious health consequences in addition to widening health disparities (pescosolido & martin, 2015). american’s history of cannabis is complex with initial use of cannabis, to its criminalization of use since 1937, and progressive changes over the last century (marijuana law, 2024). pre-legalization, proposition 215 was the first law to allow the use of cannabis for medicinal purposes in ca (marijuana law, 2024). one of successes of prop 64 identified during these interviews is stigma reduction at the societal level and legitimizing the use of cannabis for both medicinal and recreational purposes at the individual level. societal stigma has reduced as shown in various studies although structural and interpersonal subject matter expert opinions on prop 64 82 stigma is still prominent. for instance, in the realm of the patient-provider relationship, nondisclosure was associated with anticipated stigma (dahlke et al., 2024; king et al., 2024). factors that allow for normalization of cannabis in addition to responsible use include availability/access, cannabis trying rates, regular use, social accommodations for use, cultural acceptance, nonproblematic rhetoric/action by government (reid, 2020). quality control. similarly, prop 215 had little effect to improve the quality of cannabis prior to legalization (michael g. degroote centre for medicinal cannabis research, 2017). with prop 64, quality control including the “seed to sale” model has increased trust in product dosage and composition at the organizational/community sem level. california also instituted stringent testing and procedures on labels and packaging, although sme mentioned that labelling may be inconsistent. there is an increased perceived comfort among users and providers with cannabis use, with respect to avoiding contaminants, limiting adverse effects, and maximizing intended effects. on the other hand, studies report concerns for testing facilities lacking federal standards, having failed yeast/mold testing rates, and having inflated potencies (departmnet of cannabis control, 2022). as such, it is important to implement policy-level changes to make up for the nuances. justice reform. pre-legalization there were high rates of case filings and arrest in many states such as oregon, washington, and qualitative data for california (farley & orchowsky, 2019). per smes, legalization has freed many individuals of undue and historical oppression, based upon use of a substance that is perhaps not as harmful as most unregulated substances and also, regulated medical prescription substances such as opioids and benzodiazepines. it is important to note, sme’s are highlighting the most obvious changes and may miss other aspects of continued oppression such as in those seeking housing or employment that may have formally had a criminal justice violation on a criminal offender record information (cori), or an adolescent caught with possession (fair housing and criminal history faq, 2022). minor themes. there were some categories where sme identified partial successes of prop 64 regulations. limiting sales to adult-only outlets seemed successful; however, while cannabis sales are restricted to adults, advertising is not, and many products on the market are designed to appeal to minors, such as by disguising cannabis products (pechmann et al., 2024). a sme clinician who is a cannabis advocate mentioned that the kids have access to cannabis through older siblings or friends. access to youth has mixed findings; however, overall trends show an increase in access to cannabis, particularly among those from disadvantaged backgrounds and those experiencing “chronic sadness” (california youth cannabis use dashboard, 2022; marijuana and california youth, 2025; howard, 2023; paschall et al., 2021). special attention to address each sem levels for such a subgroup will be important. shortcoming of prop 64 the key identified themes of shortcomings of prop 64 included high cost of cannabis products, regulatory and bureaucratic challenges to enter and stay in business, and social inequity. these categories were not mutually exclusive. prior to legalization, during, and post legalization, state and local governments continue to be “cautious” on the control and use of cannabis. in that, smes noted that the unregulated cannabis market continued to thrive. studies show mixed trend when it comes to pricing and that it changes from region to region (padon et al., 2022). stores also try to create promotional events to increase sales by lowering prices. forum searches for the unregulated market price shows markedly low prices as low as 1/4 to 1/2 of retail price (department of cannabis control california, 2025; childers, 2024). the dcc also outlines the steps necessary to get a license, and has a fee waiver for minorities and disadvantages groups although that may not have been the case at the early stages of prop 64 as described by smes (application and license fees, 2025). policies that minimize unnecessary regulation without compromising the safety and allow for procedures that allow integration of the unregulated market into the legal market will be paramount. minor themes – dui and medical cannabis users. sme noted the need for better methods of detecting impairment and impaired driving, as well as more dui-related public education. currently, there are no consensus to the level of cannabis to define impairment or a way to enforce cannabis, a publication of the research society on marijuana 83 it (fitzgerald et al., 2023; wong et al., 2014). california has given each municipality the power to determine its rules in terms of sales, location/buffer zones, and advertising (department of cannabis control california, 2025). even though that can be helpful in some instances, it can lead to public confusion and variations in availability, which could increase dui as consumers travel to other locations to access legal dispensaries, or the unregulated market in regard to medicinal cannabis users, an unintended consequences included the elimination of the compassion program. prior to legalization, cannabis growers and distributors donated cannabis to nonprofit collectives and later dispensaries to provide free cannabis to lowincome medicinal patients (howard, 2023; kreidler, 2019. with legalization, every donation was to be taxed as high as 40%, eliminating such program, making it more difficult for a low-income medicinal patient to afford cannabis. moreover, it takes multiple steps to get a medical marijuana identification card, and the tax benefits are too low (medical marijuana identification card: how to apply, 2025). the lower availability and variety of low-thc products also affects this population (cash et al., 2020). policies that bring back such initiatives and create balance will be helpful. recommendations for improvement of prop 64 there were many recommendations for improving prop 64 regulations and implementation. california might consider applying the lessons learned from colorado, which used the public health framework (phf) to create infrastructure to understand the knowledge gaps related to cannabis legalization and develop policies to protect the public (ghosh et al., 2016). the first recommendation is to assess and monitor health issues through populationbased surveys, and hospital/ed/recreational incident tracking. the second is to develop policy through education and community partnerships. this is highlighted in the sme recommendations of having a multi-disciplinary approach to creating/revising proposition 64, including social equity in the process, and having community engagement with stakeholders in each sector. lastly, it is key to provide assurance by having regulations and enforcement that are reasonable – improve labelling and safe packaging, continuing “seed to sale” tracking with an efficient system for dispensaries, and standardizing quality control regulations. it would also be beneficial to have a primary contact person at each county/city to facilitate communication with stakeholders, as desired by the sme. policy changes – challenges to licensing and pharmacy model. recommendations to change specific policies were lowering taxes and revising licensing procedures in the cannabis industry. it is important to note implementation might be difficult given the decentralized local government structure of each province (fitzgerald et al., 2023; wong et al., 2014). amendments at the higher sem levels such as the justice reform may be easier as recently done in 2023 (orange county public defender, 2025). moreover, implementing a pharmacy model for medicinal patients might be more promising as such models exists in various states, and because california has made steps to allow cannabis use for terminally ill hospitalized patients as of 2021 (pharmacists’ cannabis coalition of california, 2024).. need for research. currently, researchers have to follow stringent rules and steps to conduct research and only with specific fda approved cannabinoids and products (u.s. food and drug administration, 2023). the cdc has created strategic plan to foster research and policies while the ajph and the canadian government outlines research gaps that are helpful to address (american public health association, 2024; canadian centre on substance use and addiction, 2023; michael g. degroote centre for medicinal cannabis research, 2017). per sme, with proliferation of potent product types and derivatives, research of their safety profile, dosing requirements, and treatment alternatives for cannabis use disorder, as well as driving limits with cannabis use were especially emphasized. this study had several strengths. the inclusion of 23 sme with a variety of expertise and backgrounds participated in the semistructured interviews, which contributed to wellrounded theme results, which adds qualitative complement to the current literature base. each interview had several interviewers present during the interview which helped insure a consistent representation of the themes. the content of each interview was coded with two independent raters subject matter expert opinions on prop 64 84 and a third person to resolve any disputes and inter-rater reliability. in terms of limitations, each sme subgroup consisted of only 2-3 individuals, and thus a possible constriction of viewpoints. this could be especially true when using a snowball sampling method after initially using a purposive sampling method. despite including multiple stakeholder groups (cannabis dispensaries, cannabis clinicians, cannabis advocates, addiction doctors, pain management, law enforcement, judges, researchers), we did not sample pediatricians, school educators, religious/spiritual leaders and might have benefited from a higher number of primary care or addiction medicine physicians, and cannabis consumers. three smes were from out of state although they were considered “multistate operators.” these sme interviews informed a subsequent survey of 5,000 californians regarding cannabis use attitudes and behaviours (results to be reported elsewhere). conclusion the stakeholder and sme interviews done as part of impact 64 shows that the implementation of cannabis legalization has a broad effect on various sectors (individuals, professionals, institutions) as seen through the sem model. a multidisciplinary approach is strongly suggested to improve regulation, provide timely support for each stakeholder, reduce social injustice, harm, and anticipate initially unforeseen consequences of use and legislative/regulatory changes. input from government, state, and local municipalities, with key professional and lay stakeholders, is necessary. reconsideration of the federal regulations (e.g., schedule i status) as proposed by the fda would be an important step to allow for proper research, education, and consistency in law enforcement/regulation of cannabis use. references american academy of family physicians. 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(2019). the public health concerns of marijuana legalization: an overview of current trends. cureus. https://doi.org/10.7759/cureus.5806 funding and acknowledgements: this research was supported in part by a grant from the california department of cannabis control. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ethical protocol: the study protocol was reviewed and exempted by the university of california san diego institutional review board (irb). the authors declare that they have obtained ethics approval from an appropriately constituted ethics committee/institutional review board where the research entailed animal or human participation. the authors declare that the work reported herein did not require ethics approval because it did not involve animal or human participation. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: ageze, d., dell’acqua, r., marcotte, t. d., baird, s., garcia, j., rybar, j., & hill., l. (2025). the impact of adult cannabis use legalization in california: a qualitative review of subject matter expert opinions on proposition 64. cannabis, 8(3), 72–88. https://doi.org/10.26828/cannabis/2025/000291 https://creativecommons.org/licenses/by/4.0/ research article 116 ved abstract objective: the link between attention-deficit/hyperactivity disorder (adhd) and cannabis-related problems is well documented, though research has primarily focused on cannabis use disorder (cud) or cannabis consequences in aggregate. this study examined how inattentive (in) versus hyperactive/impulsive (hi) adhd symptoms relate to cud symptoms as well as distinct domains of cannabis consequences (social-interpersonal consequences, impaired control, negative self-perception, selfcare, risk behaviors, academic/occupational consequences, physical dependence, and blackout use) in young adults. total amount of cannabis flower used over the past 90 days was explored as a potential mediator of these associations. method: young adults (n = 160; 41% male; ages 19-25, m = 22, sd = 2.06) with a history of regular cannabis use completed self-report measures of adhd symptoms and cannabis consequences. participants also completed a 90-day timeline follow back assessing grams of cannabis flower consumed each day, along with a structured clinical interview for cud. results: in symptoms were directly associated with cannabis-related occupational/academic consequences, self-care consequences, and blackouts/memory impairment, independent of quantity of cannabis consumption. hi symptoms showed positive indirect associations with physical dependence, impaired control, and cud through greater amount of cannabis used. conversely, in symptoms had negative indirect associations with these outcomes, mediated by amount of cannabis used. conclusions: findings reveal distinct pathways through which in and hi adhd symptoms relate to cannabis problems in young adults. findings highlight the need to consider adhd symptom domains separately when assessing specific cannabis-related risks, which may have implications for tailoring interventions. key words: = cannabis; marijuana; adhd; young adults; problems cannabis is one of the most widely used psychoactive substances in north america, with young adults representing the largest proportion of individuals who use cannabis compared to other age groups (health canada, 2024; vidourek et al., 2022). the age ranges that encompass young adulthood vary from study to study, but often include individuals between the ages of 18 to 24 (health canada, 2024) or sometimes 18 to 29 (arnett et al., 2014). according to a recent claire minister1, christian s. hendershot2,3, matthew t. keough1, & jeffrey d. wardell1,4, 5 1department of psychology, york university 2department of population and public health sciences, university of southern california 3institute for addiction science, university of southern california 4institute for mental health policy research, centre for addiction and mental health 5department of psychiatry, university of toronto cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000312 understanding the relationships between adhd symptoms and cannabisrelated consequences among young adults corresponding author: jeffrey wardell, phd, department of psychology, york university, 2700 behavioural sciences building, 4700 keele st., toronto, ontario, m3j 1p3, canada. e-mail address: jwardell@yorku.ca cannabis, a publication of the research society on marijuana 117 population-based survey in canada, where cannabis is fully legal for adult use, 23% of young adults who use cannabis reported having consumed cannabis daily or near daily (health canada, 2024). frequent cannabis use during young adulthood is associated with a range of adverse health effects, including social impairments, physical dependence, difficulties in self-care, and an increased risk of motor vehicle collisions (pearson et al., 2017; rotermann, 2021). additionally, as brain maturation continues into the mid-20s, young adults may be particularly susceptible to adverse neurocognitive effects of cannabis use (blest-hopley et al., 2020). consequently, this age group has been identified as one of the most at-risk groups for experiencing cannabis-related adverse health outcomes (campeny et al., 2020; fischer et al., 2022). of notable concern is the high rate of cannabis use and cannabis use disorder (cud) among young adults with attention-deficit / hyperactivity disorder (adhd), who have 1.46 to 2.88 times higher odds of developing cud compared to their peers without adhd (agnew-blais et al., 2016; estévez et al., 2016; fuller-thomson et al., 2022). adhd, a neurodevelopmental condition that first presents in childhood and may continue through the lifespan, has an estimated global prevalence of 6.12% to 13.03% among young adults ages 18-24 (song et al., 2021). adhd is characterized by impairments in social, academic, and psychological functioning. the condition encompasses three clinical subtypes: inattention (in; e.g., difficulty maintaining focus, disorganization), hyperactivity/impulsivity (hi; e.g., excessive motor activity or inner restlessness; engaging in hasty and potentially harmful behaviours), and combined presentation (american psychiatric association, 2013). prospective research has demonstrated that a childhood diagnosis of adhd predicts more prevalent cannabis use in adulthood (charach et al., 2011; lee et al., 2011; sibley et al., 2014). additionally, individuals with adhd tend to initiate cannabis use at an earlier age relative to their peers without adhd (brandt et al., 2018; charach et al., 2011; dunne et al., 2014; lee et al., 2011; molina et al., 2013; pingault et al., 2012). further, a higher number of adhd symptoms in both childhood and adulthood correlates with more severe cannabis-related problems, and risk of cud is higher among young adults with persisting adhd symptoms compared to those whose childhood symptoms have remitted (agnew-blais et al., 2016; bidwell et al., 2014). collectively, these findings suggest that adhd symptoms may contribute to both the onset and maintenance of cannabis use and cud. research indicates that individuals with adhd frequently use cannabis to cope with the psychological and physical distress associated with the disorder (asselin et al., 2022; mitchell et al., 2016; stueber & cuttler, 2022). according to self-medication theory, the reduction of symptomrelated distress serves as a powerful negative reinforcer, leading to increased substance use behaviours and associated problems over time (khantzian, 1985, 1997). with regard to the use of cannabis to manage adhd symptoms, recent findings indicate that regular cannabis use is perceived as beneficial for managing hyperactivity symptoms but not inattention and memory symptoms (stueber & cuttler, 2022). given the association between self-medication motives and a higher risk of negative cannabisrelated consequences (beck et al., 2009; hyman & sinha, 2008; vedelago et al., 2022), individuals with hi adhd symptoms – who may be more inclined to use cannabis for symptom relief – could be at greater risk of developing cud compared to those with in symptoms. however, results of existing studies are mixed, with some finding that hi symptoms are more predictive of cannabis use frequency than in symptoms, other studies finding the opposite, and still other studies finding no differences or that associations depend on moderating factors (bidwell et al., 2014; brandt et al., 2018; capusan et al., 2019; kolla et al., 2016; looby et al, 2023; petker et al., 2020; upadhyaya & carpenter, 2008). among the studies examining separate hi and in symptoms in relation to cannabis outcomes, only a few have focused specifically on young adults (e.g., bidwell et al., 2014; looby et al, 2023; upadhyaya & carpenter, 2008). when examining self-reported adhd symptoms among university students, bidwell et al. (2014) found that current in symptoms (but not hi symptoms) were independently associated with increased cannabis craving, frequency of use, and cannabis-related problems. in also moderated the relationship between frequency of use and adverse cannabis outcomes, with higher in associated with increased risk of dependence and cannabisadhd and cannabis-related consequences 118 related problems. similarly, upadhyaya and carpenter (2008) found that only in symptoms (and not hi symptoms) were associated with more frequent cannabis use in the past month; however, both in and hi symptoms were associated with more frequent cannabis use in the past year. in contrast, looby et al. (2023) found that only hi symptoms (and not in symptoms) were positively associated with cannabis-related consequences after controlling for cannabis use and other covariates. given these mixed findings, more research in the young adult population is needed to explore the unique relationships between in and hi adhd symptoms and cannabis use consequences. cannabis-related problems extend beyond dependence risk; they also encompass broader impacts, such as reduced psychosocial functioning (meier, 2021), poorer academic performance (arria et al., 2015; volkow et al., 2014), job loss (airagnes et al., 2019), and negative impacts on self-care, such as unhealthy eating habits (gibson et al., 2023) and sleep disturbances (edwards & filbey, 2021). additionally, cannabis use is linked to worsened self-perception and negative impacts on mood (sorkhou et al., 2024) and increased engagement in risky behaviours like dangerous driving (rogeberg & elvik, 2016). however, studies investigating the relationship between adult adhd subtypes and cannabis use problems have generally focused on cud (brandt et al., 2018, capusan et al., 2019, kolla et al., 2016, loflin et al., 2014, petker et al., 2020). only two studies, to our knowledge, have examined the association of separate in and hi adhd symptoms with other cannabis use consequences beyond cud (bidwell et al., 2014; looby et al., 2023); however, these studies used an aggregate measure that combined different domains of cannabis-related consequences, rather than examining domain-specific effects. while it is conceivable that in or hi symptoms may be distinctly associated with different types of cannabis consequences, the evidence is currently unclear. for instance, individuals with higher in adhd symptoms may be more prone to outcomes such as poor academic performance (jaekel et al., 2013), while those with hi symptoms may be at greater risk for engaging in risky behaviour when using cannabis (shoham et al., 2021). research is needed to examine whether individuals with in and hi symptoms have differential vulnerabilities to certain types of cannabis-related problems. the current study the purpose of the current study was to examine differential associations of in versus hi adhd symptoms with cud as well as distinct types of cannabis use problems (i.e., socialinterpersonal consequences, impaired control, negative self-perception, self-care, risky behaviors, academic/occupational consequences, physical dependence, and blackout/memory consequences). we also aimed to examine the mediating role of amount of cannabis used in these relationships to assess the extent to which cannabis consequences are driven by greater cannabis consumption versus other factors, such as riskier cannabis use. we expected that different types of adhd symptoms would uniquely heighten the risks of experiencing certain cannabis consequences. however, given mixed findings in the literature on associations between adhd symptoms and cannabis outcomes, and given that no previous studies have examined the relationships of separate in and hi adhd symptoms with specific domains of negative cannabis consequences (as opposed to composite indices of overall consequences), the analysis was exploratory in nature. further, we included age and sex as covariates in our analyses given that the established show robust correlations with cannabis use and adhd in the literature. for instance, research has demonstrated that rates of cannabis use and dependence are higher among males than females (hawke et al., 2018, leatherdale & burkhalter, 2012; pearson et al., 2013), and males also have higher prevalence of adult adhd symptoms (faheem et al., 2022). additionally, cannabis use disorder varies with age, even among young adults (leadbeater et al., 2019), and age-related changes in adhd prevalence have also been noted (vos & hartman, 2022). given the potential for age and sex to confound the association between adhd symptoms and cannabis outcomes, we included these variables in all models. methods participants cannabis, a publication of the research society on marijuana 119 the data were collected as part of a larger study on cannabis use and cognitive functioning in young adulthood. data from the larger study have been previously published (coelho, hendershot, aston, et al., 2024; coelho, hendershot, quilty, et al., 2024; daros et al., 2022); however, the current analysis is the first from this dataset to examine measures of adhd symptoms and domains of cannabis consequences. participants were a community sample of 160 young adults (59% female) in toronto, canada, recruited via online ads and fliers posted in the community. eligibility criteria included: 1) ages 19 – 25, 2) at least one period of regular cannabis use in their lifetime (i.e., ≥ twice per month for 6 months), 2) absence of current or prior treatment for alcohol or any substance use other than cannabis, 3) absence of regular (monthly) use of illicit substances other than cannabis, 4) no history of psychosis, mania, neurological disorder (e.g., epilepsy), or neurodevelopmental disorder (e.g., autism spectrum disorder), 5) not using cannabis exclusively for medical reasons, 6) fluency in english. 95% (n = 152) of participants reported consuming cannabis in the past 90 days, and participants consumed an average of 33.41 grams of cannabis flower during that time period (sd = 52.28). 53.8% (n = 86) of participants met criteria for cannabis use disorder over the past year according to a structured interview (see measures below). see table 1 for participant characteristics. table 1. participant demographics demographics n % race/ethnicity (check all that apply)a white/caucasian 83 51.9 african descent/african american 28 17.5 asian 26 16.3 east indian 16 10.0 middle eastern 6 3.8 caribbean 4 2.5 pacific islander 4 2.5 native north american 1 0.6 other 4 2.5 student status nonstudent 54 33.8 part-time student 16 10.0 full-time student 90 56.3 gender (check all that apply)a man 65 40.6 woman 92 57.5 transgender 2 1.3 non-binary 2 1.3 other 1 0.6 annual household incomeb 0 $9,999 22 13.8 $10,000 = $19,999 25 15.6 $20,000 $49,999 37 23.1 $50,000 $59,999 35 21.9 ³$100,000 33 20.7 current cudc 86 53.8 note. n = 160. aparticipants were counted in all categories they endorsed. b8 participants were missing data on income. ccud = cannabis use disorder; symptoms assessed using structured clinical interview for dsm-5 (scid-5) cannabis use disorder module. adhd and cannabis-related consequences 120 procedure interested individuals completed an online eligibility screening survey, and eligible participants were scheduled for an in-person clinical and cognitive assessment. given the aims of the larger study, participants were asked to abstain from alcohol and cannabis for 48 hours prior to the assessment and were rescheduled if they reported using either substance within 48 hours of the session or showed visible signs of intoxication. a breathalyzer test confirmed absence of recent alcohol use, and a urine drug screen confirmed absence of recent use of illicit drugs. participants completed a computerized questionnaire during the assessment, which included measures of adhd symptoms and cannabis consequences. interview-based assessments of recent cannabis use and symptoms of cannabis use disorder also were administered. measures world health organization adult adhd selfreport scale. the adhd self-report scale (asrs; kessler et al., 2005) is an 18-item measure that assesses the frequency of adhd symptoms over the past 6 months, with items rated on a scale from 0 = never to 4 = very often. the asrs is shown to be valid and reliable for use as a screening instrument for adhd in adults (adler et al., 2006; kessler et al., 2007; silverstein et al., 2018). the asrs comprises two subscales: inattention (9 items, e.g., “how often do you have difficulty keeping your attention when you are doing boring or repetitive work”, cronbach’s α = .781), and hyperactive/impulsivity (9 items, e.g., “how often do you feel overly active and compelled to do things, like you were driven by a motor?”, cronbach’s α = .80). responses to items were summed to derive separate in and hi scores, with higher scores indicating greater symptom severity. additionally, the scale includes a 6-item screening subtest (cronbach’s α = .65), where summed scores of 14 indicate a positive adhd screen (adler et al., 2006; kessler et al., 2007; silverstein et al., 2018). timeline follow back. the timeline follow back (tlfb; sobell & sobell, 1992) interview was administered to collect information on cannabis use over the previous 90 days. specifically, participants were asked to retrospectively selfreport on the quantity of cannabis flower (in grams) used each day over the prior 90 days. to facilitate accurate reporting, a cannabis substitute (oregano) was used to provide examples of cannabis joints containing varying quantities of cannabis flower (norberg et al., 2012). use of other forms of cannabis (e.g., concentrates, oils, edibles) were also assessed for each day, but consumption quantities were not assessed for nonflower cannabis products and thus they were not incorporated into the index of cannabis consumption quantity. the tlfb has demonstrated reliability and validity as a retrospective measure of cannabis use against other self-report and biological measures (hjorthøj et al., 2012; robinson et al., 2012). marijuana consequences questionnaire. the 50-item marijuana consequences questionnaire (macq; simons et al., 2012) was used to measure eight domains of cannabis consequences: socialinterpersonal consequences (6 items, α2= .80), impaired control (6 items, α = .90), negative selfperception (5 items, α = .90), self-care (9 items, a = .91), risk behaviors (8 items, α = .88), academic/occupational consequences (5 items, a = .93), physical dependence (4 items, α = .93), and blackout use (7 items, α = .82). participants were asked to indicate whether they had experienced each negative consequence in the past six months either during or after using cannabis (0 = no; 1 = yes). summed scores were calculated for each domain. the macq has demonstrated test-retest reliability as well as convergent and discriminant validity in a college student population (simons et al., 2012) and has been cross-culturally validated (bravo et al., 2017). structured clinical interview for dsm-5 (scid-5). the cannabis use disorder (cud) module of the scid-5 (first, 2015) was used to assess current and lifetime symptoms of cud. interviews were conducted by trained master’s level research assistants who received regular supervision from the principal investigator (a licensed psychologist). for analyses, a continuous variable representing current (past year) cud symptom count was calculated. 1reliability estimates (alpha coefficients) for all reported measures were calculated based on data from the current sample. 2because items are binary (yes/no), the tetrachoric correlation matrix was used to calculate coefficient alpha. cannabis, a publication of the research society on marijuana 121 data analysis descriptive analyses were conducted, and variables were screened for extreme outliers (i.e., those that were > 3.29 sd above the mean and were disconnected from the rest of the datapoints; tabachnick & fidell, 2013); outliers were winsorized by recoding them to one unit greater than the next highest non-outlying value. to explore the relationships between adhd symptoms, cannabis consumption, and cannabisrelated outcomes, two path models were specified in mplus v. 7.4 (muthén & muthén, 2017) using the maximum likelihood estimator: one model included cud symptom count from the scid (as an index of cud severity) as the outcome, while the other model included the 8 domains of cannabis consequences from the macq as simultaneous outcomes. the outcomes were specified as count variables in mplus using a negative binomial distribution, which provided a better fit to the data compared to the poisson distribution (cud model: δbic = -25.10; consequences model: δbic = -143.54). in each model, in and hi adhd symptom scales were specified as the independent variables, and cannabis consumption (measured as total grams of cannabis flower consumed over the past 90 days) as the mediator. in both models, each outcome variable and the mediator variable were regressed onto the covariates age and sex. as the cannabis consumption variable (total grams consumed over the past month) had a large variance, this variable was rescaled for the analysis by dividing by a constant of 10. for all estimates of direct and indirect associations in the path models, 95% bias-corrected bootstrapped confidence intervals were obtained (with 10,000 bootstrapped samples), with confidence intervals that did not contain zero providing support for the statistical significance of the estimate. results descriptive results the mean scores for each adhd subscale were comparable to one another (in: m = 15.47, sd = 5.59; hi: m = 14.41, sd = 6.17) with a large observed range (in range = 0.00-32.00; hi range = 0.00-33.00). based on part a of the asrs, 17.5% of participants met the ≥14 clinical cut-off for a positive adhd screen; see supplementary figure s1 for a histogram of asrs screener scores. across the eight cannabis consequences domains from the macq, the mean scores ranged from m = 5.88 (risk behaviours) to m = 22.13 (self-care). see supplementary table s1 for detailed means, standard deviations, and bivariate correlations of all variables included in the path models. path model with cannabis use disorder symtoms see figure 1 for a schematic depiction of the results of the path analysis along with supplementary table s2 for the full set of path coefficients. regarding direct paths, no significant direct relationship was observed between either in or hi symptoms and cud (95% cis contained zero, see table s2). hi symptoms were positively and directly associated with cannabis consumption, but no direct association was observed between in symptoms and cannabis consumption (see table s2). there was a significant direct association between total grams of cannabis flower consumed in the past 90 days and number of cud symptoms (table s2). with respect to indirect associations, greater amount of cannabis consumed mediated the positive indirect relationship between hi symptoms and cud symptoms (b = .01, 95% ci = .003, .02), and lower amount of cannabis consumed mediated the negative indirect relationship between in symptoms and cud symptoms (b = -.01, 95% ci = -.03, -.001)3 3to investigate whether this negative association could be a result of a suppression effect owing to the correlation between in and hi symptoms, the model was rerun without hi symptoms included. results revealed that the negative indirect association between in symptoms and cud symptoms was no longer significant (b = -.003, 95% ci = -.021, .006), suggesting the presence of a suppression effect. adhd and cannabis-related consequences 122 figure 1. path model of adhd symptoms, quantity of cannabis consumed, and cannabis use disorder symptoms note. significant paths are highlighted in bold, while non-significant paths are depicted as grey dotted lines. the quantity of cannabis use variable (total grams of cannabis used in the past 90 days) was divided by a constant of 10 for analyses to facilitate model convergence. covariates (age, sex) and non-significant coefficients have been omitted from the figure for clarity – see supplementary s2 for additional results of path analysis. path model for domains of negative consequences see figure 2 for a schematic depiction of the path analysis results, and tables 2 and supplementary table s3 for full results of the path analysis. in terms of direct paths, in adhd symptoms were directly associated with greater endorsement of cannabis use consequences in three out of eight domains: self-care, academic and occupational consequences, and blackout use (95% cis did not contain zero; see table s3). there were no significant direct associations between hi symptoms and any of the cannabis consequences domains. additionally, total amount of cannabis flower consumed was directly associated with two of the cannabis consequences: increased impaired control and physical dependence (95% cis did not contain zero; see table s3). figure 2. path model of adhd symptoms, quantity of cannabis consumed, and domains of cannabis consequences note. significant paths are highlighted in bold, while non-significant paths are depicted as grey dotted lines. the quantity of cannabis use variable (total grams of cannabis used in the past 90 days) was divided by a constant of 10 for analyses to facilitate model convergence. covariates (age, sex) and non-significant coefficients have been omitted from the figure for clarity – see tables 2 and supplementary table s3 for full results of path analysis. cannabis, a publication of the research society on marijuana 123 with respect to indirect associations, a greater amount of cannabis consumed mediated the relationship between hi symptoms and two of the cannabis consequence domains: impaired control and physical dependence (95% cis did not contain zero; see table 2). in contrast, a lower amount of cannabis consumed mediated the negative indirect associations between in symptoms and both impaired control and physical dependence (95% cis did not contain zero; see table 2)4 table 2. indirect associations from adhd symptoms to domains of cannabis consequences via quantity of cannabis consumed variables b confidence intervals rate ratio lower 2.5% upper 2.5% social-interpersonal consequences adhd hyperactivity .01 .000 .01 1.01 adhd inattention -.01 -.02 .000 0.99 impaired control adhd hyperactivity .01 .002 .02 1.01 adhd inattention -.01 -.02 -.001 0.99 self-perception adhd hyperactivity .001 -.004 .01 1.00 adhd inattention -.001 -.01 .004 1.00 self-care adhd hyperactivity .004 .000 .01 1.00 adhd inattention -.004 -.01 .000 1.00 risk behaviors adhd hyperactivity .01 -.002 .02 1.01 adhd inattention -.01 -.02 .002 0.99 academic/occupational consequences adhd hyperactivity .01 -.001 .02 1.01 adhd inattention -.01 -.02 .001 0.99 physical dependence adhd hyperactivity .01 .003 .02 1.01 adhd inattention -.01 -.02 -.001 0.99 blackout use adhd hyperactivity .002 -.002 .01 1.00 adhd inattention -.002 -.01 .002 1.00 note. b = unstandardized regression coefficient (bolded if significant). the mediating variable (total grams of cannabis used in the past 90 days) was divided by a constant of 10 for analyses to facilitate model convergence. supplementary analysis with number of cannabis days as the mediator because total grams of cannabis consumed excluded non-flower cannabis products, the models were re-run using number of cannabis use days (including any form of cannabis) as the mediator instead of total grams. results differed in that hi symptoms were not associated with cannabis use frequency (b = .01, 95% ci = -.005, .015), unlike with total cannabis grams, nor were in symptoms associated with cannabis frequency (b = -.01, 95% ci = -.016, .006). in turn, none of the indirect associations from adhd symptoms to 4to investigate whether these negative associations could be a result of a suppression effect, the model was rerun without hi symptoms included. results revealed that the negative indirect associations of in symptoms with impaired control and physical dependence were no longer significant (95% cis contained zero), suggesting the presence of a suppression effect. adhd and cannabis-related consequences 124 consequences or cud were significant (all 95% confidence intervals contained 0). discussion the present study aimed to investigate the distinct relationships of in and hi adhd symptoms with specific types of cannabis-related consequences in young adults, as well as explore whether these associations were mediated by quantity of cannabis consumption. overall, our results confirm that adhd symptoms are associated with cannabis consequences in this population (bidwell et al., 2014; fuller-thomson et al., 2022; looby et al., 2023; goldstein et al., 2021), and also contribute to the mixed literature examining whether in and hi adhd symptoms have differential relationships with cannabis use patterns and use-related problems (bidwell et al., 2014; brandt et al., 2018; capusan et al., 2019; de alwis et al., 2014; elkins et al., 2007, 2018; kolla et al., 2016; looby et al., 2023, upadhyaya & carpenter, 2008). our study also extends prior research by demonstrating that in and hi adhd symptoms are each uniquely linked with specific types of cannabis consequences and by clarifying the mediating role of amount of cannabis consumed in these relationships. finally, our findings reveal contrasting indirect relationships between in and hi adhd symptoms and cud via cannabis consumption. the results of this study have implications for understanding the specificity of in and hi adhd symptoms in conferring risk for unique cannabis-related problems and indicate the potential need for tailored interventions. this study builds on previous research that observed differing associations between hi and in symptoms with general cannabis-related problems among young adults (bidwell et al., 2014; looby et al., 2023), offering new evidence that these distinct adhd symptom profiles are associated, both directly and indirectly, with different types of cannabis consequences. for instance, our findings showed that individuals with a greater number of in adhd symptoms (but not hi symptoms) were more likely to experience negative cannabis consequences in areas requiring sustained attention, such as academic and occupational settings. in adhd is characterized by difficulties with tasks that demand mental effort, distractibility, and forgetfulness. given that cannabis is known to impair cognitive performance (bourque & potvin, 2021), its use may worsen these challenges in individuals with in adhd symptoms, further impeding their ability to maintain concentration and process information effectively, potentially resulting in negative academic and occupational consequences. analyses also revealed that individuals with elevated in adhd symptoms were more prone to negative impacts of cannabis on self-care. the challenges associated with in adhd such as attention deficits, disorganization and lack of motivation can make it inherently difficult to maintain self-care routines (e.g., sleep, diet, physical activity). cannabis use, which has been shown to diminish motivation (petrucci et al., 2020) and is associated with impairments in selfcare even in the general population (simons et al., 2012), may potentially compound these difficulties for individuals with attentional struggles. moreover, results indicated that higher levels of in adhd symptoms were associated with a greater likelihood of experiencing blackout use (e.g., feeling dazed after cannabis consumption, forgetting periods of time during use). cannabis has documented impairing effects on attention and memory (dellazizzo et al., 2022), and the combined effects of cannabis-induced cognitive slowing and the attentional and memory deficits characteristic of in adhd may increase the risk of memory impairments, such as blackouts. notably, the relationships between in adhd symptoms and cannabis-related problems in academics/occupation, self-care, and blackouts were found to be independent of quantity of consumption (i.e., total grams of cannabis flower in the past 90 days), indicating that in symptoms may heighten risk for these cannabis consequences irrespective of the amount of cannabis used. furthermore, there was no direct association between in adhd symptoms and quantity of cannabis consumed; only hi adhd symptoms were associated with heavier cannabis use. interestingly, when controlling for the shared variance between in and hi adhd symptoms, in symptoms were found to have a negative, indirect association with physical dependence, impaired control, and cud through quantity of cannabis consumed (but no association through frequency of cannabis use). notably, these findings differ cannabis, a publication of the research society on marijuana 125 from those of bidwell and colleagues (2014), who reported that in symptoms had a stronger positive association with cannabis use frequency and cannabis-related problems when controlling for hi symptoms. this discrepancy may be due to differences in measurement instruments or populations (i.e., university students versus community sample including nonstudents). considering the current findings alongside prior research suggesting that cannabis use was perceived as either ineffective or even exacerbating for inattentive symptoms (stueber & cuttler, 2022), it is conceivable that individuals with elevated in adhd symptoms avoid heavier cannabis use due to its associated cognitive impairments, which may worsen in adhd symptoms. alternatively, individuals with higher in adhd symptoms may simply be less motivated to consume cannabis heavily if it does not alleviate their inattentive symptoms. it is also possible that the symptoms of in adhd may directly impact consumption amount by disrupting follow-through — for example, through distraction or forgetfulness when intending to use, leading to lower or no use. however, that the negative indirect paths involving in symptoms were only significant when including hi symptoms in the mediation models suggests the presence of a suppression effect, which occurs when the magnitude of the association among variables is strengthened by controlling for a correlated variable (mackinnon et al., 2000). these types of suppression effects can be difficult to interpret – they can merely reflect a statistical artefact, or they can have a substantive interpretation (see mackinnon et al., 2000). for example, perhaps the negative indirect associations between in and certain cannabis consequences are obscured by in’s positive association with hi symptoms, which are also positively associated with cannabis consumption and consequences; only when holding hi symptoms constant might the negative associations for in symptoms come into relief, such that an increase in in symptoms will predict lower impaired control and physical dependence consequences at a given level of hi symptoms. because of the complexities of such suppression effects, future research on the mechanisms explaining the differential associations of in and hi adhd with cannabis use and problems is needed. unlike in adhd, elevated hi adhd symptoms were directly associated with increased quantity of cannabis use, which was in turn linked with cannabis consequences that typically only emerge with heavy consumption, such as physical dependence, impaired control, and cud. due to the unique association of hi symptoms with greater amount of cannabis use, hi symptoms indirectly influenced these negative outcomes via their relationship with higher quantity of consumption. research shows that individuals with symptoms of hi adhd are more likely to perceive cannabis as beneficial for improving hyperactivity (stueber & cuttler, 2022), and perhaps larger amounts of cannabis may be needed to alleviate symptoms such as arousal and restlessness. consistent with self-medication theory (khantzian, 1985, 1997), to the extent that individuals high on hi symptoms consume larger amounts of cannabis in attempts to alleviate their symptoms, they may in turn be at increased risk of developing cannabis dependence and cud, a pathway that was supported in our data. additionally, impulsivity, which is a hallmark of hi adhd, may further contribute to difficulties in regulating cannabis use, leading to heavier consumption and associated consequences such as impaired control over use (kearns et al., 2022; vanderveen et al., 2016). our study has several limitations that warrant consideration. first, the cross-sectional design limits casual inference, as observed associations may be influenced by other factors, such as a generalized risk for externalizing traits (johnson et al., 2020; molinero & hinckley, 2023; pingault et al., 2012). while the study explored potential mediational pathways, longitudinal studies are needed to establish the temporal ordering of variables to provide stronger evidence for mediation. second, the modest sample size and recruitment based at a single location limit generalizability of the findings, lead to low statistical power, and introduce potential sampling bias. moreover, the sample size does not provide enough power to meaningfully examine interaction effects; future research with larger samples should consider examining interactions between hi and in symptoms to determine if those high on both symptom types (e.g., combined adhd subtype) are especially likely to experience certain consequences. the relatively small sample size also limited our ability to stratify results by adhd and cannabis-related consequences 126 potentially relevant factors such as race or other demographic factors; this may be explored in future larger studies. third, the study focuses on self-report adhd symptomology without formal clinical diagnosis, and given that only a subsample of the participants scored positive on the adhd screener, the current results cannot be generalized to a clinical sample of young adults with severe adhd. including clinical diagnoses in future studies would facilitate a more nuanced understanding of how adhd, both diagnosed and subclinical, relates to cannabis use outcomes. additionally, such studies should account for the potential effects of adhd medications, which could alter cannabis use patterns or consequences. further, our study focused exclusively on quantities of cannabis flower used and did not examine quantities of non-flower cannabis products, as retrospective interviews pose challenges in quantifying non-flower cannabis consumption. future studies could employ methods such as ecological momentary assessment to capture more detailed data on all forms of cannabis used (coelho et al., 2025). finally, observed effect sizes of our significant associations were small (see table 2). an increase of one unit on the hi hyperactivity scale was associated with an estimated 1% increase in the number of impaired control and physical dependence consequences, mediated through quantity of cannabis consumed, which translates to approximately a 6% increase in the number of consequences for every one standard deviation increase in hi symptoms. while these effects may be meaningful from a conceptual standpoint, their small size may limit their clinical implications. despite these limitations, this study elucidates the nuanced relationships between in and hi symptoms of adhd and specific cannabisuse problems among young adults, along with the mediating role of cannabis consumption amounts. given increasingly liberal cannabis policies and the high prevalence of use among young adults with adhd, the findings of this study underscore the importance of considering adhd symptom dimensions separately when assessing cannabisrelated risks in this population. future research should examine the utility of tailoring interventions to better address the unique cannabis-related risks of young adults with different adhd symptom profiles and may inform personalized prevention strategies that educate young adults on the potential impacts of using cannabis in the context of hi and in symptoms. references adler, l. a., spencer, t., faraone, s. v., kessler, r. c., howes, m. j., biederman, j., & secnik, k. 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(2022). the decreasing prevalence of adhd across the adult lifespan confirmed. journal of global health, 12, 03024. https://doi.org/10.7189/jogh.12.03024 funding and acknowledgements: data collection for this study was funded by the caskey/francis family award in clinical research awarded from the centre for addiction and mental health foundation (pis: jeffrey d. wardell and christian s. hendershot). the authors declare that they have no conflicts of interest. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: minister, c., hendershot, c. s., keough, m. t., & wardell, j. d. (2025). understanding the relationships between adhd symptoms and cannabis-related consequences https://creativecommons.org/licenses/by/4.0/ adhd and cannabis-related consequences 132 among young adults. cannabis, 8(3), 116–132. https://doi.org/10.26828/cannabis/2025/000312 research article 26 ved abstract objective: this study examined cannabis use and motives (i.e., medical, non-medical [‘recreational’]) for first use and current use among young adult cancer survivors (ages 18-39). method: we analyzed 2024 baseline survey data from 155 young adult cancer survivors (mage = 32.89 [sd = 4.89], 87.7% female, 81.9% white, m = 1.34 [sd = 1.04] years post-treatment) regarding cannabis use, use motives (i.e., medical, nonmedical), use characteristics (e.g., frequency/mode), and quality of life (promis). analyses characterized participants by lifetime use, past-month use, and first use for medical or non-medical purposes; multivariable binary logistic regression assessed correlates of past-month cannabis use among all participants and among those reporting lifetime use, respectively. results: of those reporting lifetime use (n = 68, 43.9%), 48 (70.6%) first used for non-medical purposes and 18 (26.5%) for medical. among those reporting past-month use (n = 41, 26.5%), 4 (9.8%) used for only medical purposes, 12 (29.3%) primarily medical but some non-medical, 6 (14.6%) equally medical/non-medical, 6 (14.6%) primarily non-medical but some medical, and 4 (9.8%) only non-medical. common reasons for first and current medical use included pain, insomnia, anxiety, and nausea. past-month use among all participants was associated with less advanced cancer stage, treatment involving chemotherapy, and greater anxiety symptoms. among those reporting lifetime use, past-month use was also associated with first using for non-medical purposes. conclusions: a large proportion of young adult survivors first used cannabis for non-medical purposes but also reported medical use. it is crucial to understand use motives and trajectories over time to identify those who may benefit from medical use or face use-related harms. key words: = cancer survivorship; young adult cancer survivors; cannabis use; cannabis use motives; quality of life; young adults darcey m. mccready1, laura c. schubel1,2, hannah arem2,3, cassidy r. loparco1, afrah howlader4, sheena shajan1, palash bhanot1, & carla j. berg1,5 1department of prevention and community health, milken institute school of public health, george washington university 2healthcare delivery research, medstar health research institute 3department of oncology, georgetown university 4department of health policy and management, milken institute school of public health, george washington university 5gw cancer center, george washington university cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000321 volume 8, issue 3 cannabis use for medical or non-medical purposes in a sample of young adult cancer survivors in the united states corresponding author: carla j. berg, phd, mba, professor, department of prevention & community health, milken institute school of public health, george washington university, science & engineering hall, 800 22nd st nw, #7000c, washington, dc 20052. phone: (202) 994-0168. email: carlaberg@gwu.edu. cannabis, a publication of the research society on marijuana 27 cannabis has become increasingly accessible as more states legalize medical and non-medical (i.e., ‘recreational’) cannabis. this has coincided with increases in cannabis use, particularly among young adults (substance abuse and mental health services administration [samhsa], 2024). notably, young adult cancer survivors may have particularly high cannabis use rates (lee et al., 2023). this is an important population, given the >80,000 cancer diagnoses among us young adults (ages 18-39) annually (american cancer society [acs], 2023) and their high survival rates (e.g., 5-year survival is >80%) and increasing life expectancy (acs, 2023). motives for cannabis use are diverse. nonmedical purposes may include enjoyment, social enhancement, or relaxation, and medical use may be aimed at addressing certain symptoms such as pain or nausea. for many individuals, particularly young adults, first time cannabis use is largely experimental or for non-medical purposes (lee et al., 2007). however, cannabis use motives are not mutually exclusive. a canadian study found that, among individuals using cannabis, 80.6% reported using for non-medical reasons, and 38.6% also used for some therapeutic benefit (turna et al., 2020). one us-based study of young adults reporting past-month cannabis use found that 37.1% used only for non-medical purposes, 23.5% primarily non-medical, 21.5% equally for both medical and non-medical, and 17.8% for only or primarily medical (sridharan et al., 2024). furthermore, motives for use may change over time; for example, an individual’s use could transform from non-medical to medical use after noticing the effects of cannabis on certain physical or mental health symptoms or conditions. conversely, medical use may change to nonmedical use if the symptoms being treated with cannabis are resolved (or cannabis did not prove to be an effective treatment option) or other effects are perceived as enjoyable. furthermore, use motives may coincide with one another and/or become challenging to differentiate (turna et al., 2020). among the most widely-acknowledged medical uses of cannabis relate to cancer and its treatment (e.g., chemotherapy-related nausea and/or vomiting, pain; abrams, 2022). the national academies of sciences, engineering, and medicine reported that there is conclusive evidence for cannabis or cannabinoid-based treatments to ameliorate chemotherapy-related nausea, as well as evidence for reducing chronic pain (abrams, 2022). while the medical community has been slowly (but increasingly) accepting the use of cannabis-based therapies for these symptom (abrams, 2022; acs, 2024), a significant proportion of young adult cancer survivors report using cannabis and often indicate sleep disturbances, pain, and mood disorders as primary use motives (halpern et al., 2024). understanding cannabis use motives can provide insight into use patterns and the potential risks and benefits of cannabis use (gex et al., 2024; halpern et al., 2024). while cannabis may have potential for treating certain medical conditions or symptoms (abrams, 2022), its use among young adults may be associated with negative consequences (e.g., occupational, academic, and financial challenges, etc.) when used improperly (jordan & andersen, 2017; pearson et al., 2017; rioux et al., 2018; terrymcelrath et al., 2022). moreover, one possible risk is problematic use or addiction, especially if use is frequent or involves highly potent products (e.g., cannabis concentrates; terry-mcelrath et al., 2022), both of which are particularly likely in young adults (cerdá et al., 2020). with increases in cannabis use among young adults (samhsa, 2024), in access to medical and non-medical cannabis nationally, and in interest in utilizing cannabis to offset cancer side effects among the medical community (sexton et al., 2021), understanding correlates and patterns of cannabis use among young adult cancer survivors may allow researchers and medical professionals to identify those who may develop detrimental use trajectories or related outcomes. thus, this study analyzed data from a sample of young adult cancer survivors and examined: 1) cannabis use characteristics and reasons (i.e., medical, nonmedical) for first use and current use; and 2) factors (including reasons for first use) associated with past-month use. methods study design current analyses focus on baseline survey data (february-september 2024) among 155 young adult cancer survivors (ages 18-39) who participated in the achieving wellness after cannabis use among young adult cancer survivors 28 reaching the end of treatment (aware) study, a randomized clinical trial (rct) testing a behavioral intervention focused on quality of life (mccready et al., 2024). this study was approved by the george washington university institutional review board. participants and recruitment in february–september 2024, participants were recruited via ads through a third-party vendor, buildclinical. participant inclusion criteria were: 1) 18–39 years old, 2) within 3 years of completing cancer treatment or on maintenance chemotherapy, 3) us resident, and 4) englishspeaking. exclusion criteria were: 1) cancer recurrence since initial treatment completion; 2) diagnosis of central nervous system cancer (to ensure requisite mental/emotional functioning for program engagement); 3) prior diagnosis of alcohol/drug dependency, psychosis, bipolar disorder, or major depressive disorder; and 4) in hospice. those who clicked on ads (e.g., “remote cancer survivor research study”) were sent to a webpage describing study procedures, risks, benefits, and compensation. interested and potentially eligible participants authorized buildclinical to provide their contact information (name, state residency, email, phone number) to the study team. the study team then contacted potential participants via email, text, and/or phone to obtain consent, confirm eligibility, and administer the baseline survey (via redcap). data collection data collection for the parent trial involved ~15-minute web-based surveys administered (via redcap) at baseline, end-of-treatment (8 weeks post-baseline), and follow-up (16 weeks postbaseline), with $50 amazon e-gift codes for completing each survey. current analyses used the following measures collected at baseline: cannabis use, reasons for first and current use, use characteristics. participants were asked if they ever used cannabis in their lifetime; if they indicated ‘yes’, they were asked how many days in the past 30 days they used cannabis (1-30). those reporting lifetime use were also asked, “do you have a medicinal marijuana card? (yes/no)”; “did you first use marijuana for medical or recreational purposes?” (yes/no). those indicating medical purposes were then asked, “for what medical condition did you first use marijuana?” [openended]. participants reporting past-month use were asked, “would you consider your current use of marijuana to be for medical or recreational purposes? only medical; primarily medical but occasionally recreational; equally for medical and recreational; primarily recreational but occasionally medical; only recreational” (sridharan et al., 2024). those indicating any medical use were asked, “for what medical condition(s) do you currently use marijuana?” [open-ended]. those reporting past-month use were also asked, “how do you use marijuana most of the time? smoked in a joint, bowl, or water pipe; vaporized with a vaporizer; ingested with or without food (e.g., cannabis oil, drink, edible); other (specify)” and “where do you usually buy/get marijuana? don't buy it; get it from friends for free; medical dispensary; recreational dispensary; purchase from dealer/acquaintance; other (specify)” (berg et al., 2024). quality of life. we administered the 43-item patient reported outcome measurement information system (promis) global health scale v2 (hays et al., 2009). we computed mean scores for each of the following 7 subscales: ability to participate in social roles/activities (6 items; α = .95), physical functioning (6 items; α = .90), fatigue (6 items; α = .94), sleep disturbance (6 items; α = .91), pain interference (6 items; α = .96), anxiety (6 items; α = .93), and depression (6 items; α = .93). pain intensity is a single item. sociodemographic and cancer-related factors. participants reported sociodemographic characteristics (e.g., age, sex, sexual orientation, ethnicity, race, education level, employment status, relationship status, parental status), state of residence, and cancer diagnosis/treatment factors (e.g., site and stage at diagnosis, treatments, date of diagnosis and treatment completion). data analysis survey data were analyzed using ibm spss statisics version 27 with an alpha of .05. descriptive analyses were used to characterize participants. bivariate analyses were used to characterize participants’ sociodemographics, cannabis, a publication of the research society on marijuana 29 cancer-related factors, and quality of life measures in relation to lifetime cannabis use, past-month use, and first use for medical vs. nonmedical use, using t-tests and anovas for continuous variables and chi-square tests for categorical variables. we conducted 2 multivariable binary logistic regression models assessing factors associated with: 1) past-month use among all participants; and 2) past-month use among participants reporting lifetime use (to assess first use for medical vs. non-medical purposes as an independent variable of pastmonth use). each model included the quality of life measures; first use for medical vs. nonmedical purposes was also included in the model among participants reporting lifetime use. covariates included in the models were guided by the existing literature and bivariate analyses. few associations were found between sociodemographics, cancer-related factors, and past-month use. thus, to adjust for potential confounding variables, we conservatively chose to include the following variables: 1) age, to address potential cohort effects; 2) sex assigned at birth, given the well-documented differences in prevalence among males and females (samhsa, 2024); 3) cancer stage, due to different treatment experiences based on stage; 4) whether chemotherapy was used in treatment, as chemotherapy-related symptoms (e.g., nausea) are common and frequently cited reasons for medical cannabis use (abrams, 2022); and 5) time since treatment completion, to account for potentially greater intensity of physical symptoms or emotional distress related to time since completion (berkman et al., 2023; wong et al., 2017). results participant characteristics shown in table 1, the survey sample (n = 155) was an average age of 32.89 (sd = 4.89), 87.7% (n = 136) female, 8.4% (n = 13) hispanic, 81.9% (n = 127) white, 7.1% (n = 11) black, 12.2% (n = 19) asian, 42.6% (n = 41.9) with >bachelor’s degree, 81.3% (n = 126) employed fullor part-time, 63.2% (n = 98) with income ≥$4,200 per month, 63.9% (n = 99) married/cohabitating, and 66.5% (n = 103) had children. nearly half (48.4%, n = 75) were diagnosed with breast cancer, and 13.7% (n = 21) were diagnosed with stage 1 cancer, 52.3% (n = 80) stage 2, 22.2% (n = 34) stage 3, and 11.8% (n = 19) stage 4. on average, participants were 2.26 (sd = 1.22) years post-diagnosis and 1.34 (sd = 1.04) years post-treatment. cannabis use characteristics shown in tables 1 and 2, 43.9% (n = 68) participants reported lifetime cannabis use, and 26.5% (n = 41) reported past-month use. among participants reporting past-month use (table 3), average number of days used was 10.00 (sd = 10.54), 26.8% (n = 11/41) had a medical cannabis card, and primary modes of use were ingesting via edibles (75.6%, n = 31/41), vaporizing (22.0%, n = 9/41), and smoking (14.6%, n = 6/41). the largest proportion obtained cannabis from non-medical dispensaries (46.3%, n = 19/41), followed by medical dispensaries (22.0%, n = 9/41), friends (12.2%, n = 5/41), or dealers (4.8%, n = 2/41). cannabis use among young adult cancer survivors 30 table 1. participant characteristics in relation to lifetime cannabis use and purpose of first use in young adult cancer survivors lifetime cannabis use among participants reporting lifetime use, purpose of first use a all n = 155 (100%) no n = 87 (56.1%) yes n = 68 (43.9%) medical n = 18 (26.5%) non-medical n = 48 (70.6%) variables m (sd) or n (%) m (sd) or n (%) m (sd) or n (%) p-value m (sd) or n (%) m (sd) or n (%) p-value legal factors (n, %) * medical use legal 109 (76.8) 55 (70.5) 54 (84.4) .072 14 (82.4) 38 (84.4) .999 non-medical use legal 83 (58.5) 40 (51.3) 43 (67.2) .062 13 (76.5) 29 (64.4) .544 sociodemographic factors age (m, sd) 32.89 (4.89) 32.77 (4.45) 33.04 (5.43) .730 33.67 (6.08) 32.75 (5.32) .776 female (n, %) 136 (87.7) 74 (85.1) 62 (91.2) .326 18 (100.0) 42 (87.5) .254 hispanic/latino (n, %) 13 (8.4) 9 (10.3) 4 (5.9) .391 2 (11.1) 2 (4.2) .530 race (n, %) b white 127 (81.9) 70 (80.5) 57 (83.8) .676 16 (88.9) 40 (83.3) .361 black 11 (7.1) 9 (10.3) 2 (2.9) .114 1 (5.6) 1 (2.1) .735 asian 19 (12.2) 9 (10.3) 10 (14.7) .465 1 (5.6) 8 (16.7) .189 other 5 (3.2) 3 (3.4) 2 (2.9) .999 2 (0.0) 2 (4.2) .651 education >bachelor’s degree (n, %) 65 (41.9) 34 (39.1) 31 (45.6) .424 9 (50.0) 22 (45.8) .202 employed full/part-time (n, %) c 126 (81.3) 71 (81.6) 55 (80.9) .985 10 (55.6) 43 (89.6) .068 household income ≥$4,200/mo (n, %) d 98 (63.2) 49 (56.3) 49 (72.1) .103 10 (55.6) 38 (79.2) .074 married/cohabitating (n, %) 99 (63.9) 55 (63.2) 44 (64.7) .468 10 (55.5) 33 (68.7) .742 parent (n, %) 103 (66.5) 58 (66.7) 45 (66.2) .999 12 (66.7) 31 (64.6) .583 medical history cancer type (n, %) .166 .785 breast 75 (48.4) 41 (47.1) 34 (50.0) 10 (55.6) 22 (45.8) lymphoma 34 (21.9) 22 (25.3) 12 (17.6) 2 (11.1) 10 (20.8) leukemia 17 (11.0) 12 (13.8) 5 (7.4) 1 (5.6) 4 (8.3) other e 29 (18.7) 12 (13.8) 17 (25.0) 5 (27.8) 12 (25.0) cancer stage (m, sd) f 2.32 (0.86) 2.36 (0.839) 2.27 (0.89) .534 2.33 (0.84) 2.30 (0.89) .118 years since diagnosis (m, sd) 2.26 (1.22) 2.26 (1.24) 2.25 (1.20) .957 2.56 (1.20) 2.17 (1.20) .344 treatments (n, %) chemotherapy 138 (89.0) 74 (85.1) 64 (94.1) .118 18 (100.0) 44 (91.7) .413 radiation 69 (44.5) 39 (44.8) 30 (44.1) .999 10 (55.6) 18 (37.5) .114 surgery 101 (65.2) 54 (62.1) 47 (69.1) .399 13 (72.2) 32 (66.7) .574 years since treatment completed (m, sd) 1.34 (1.04) 1.40 (1.01) 1.25 (1.08) .367 1.44 (0.98) 1.23 (1.12) .198 quality of life – promis (m, sd) social roles/activities 51.09 (8.39) 51.52 (8.44) 50.53 (8.35) .469 47.07 (8.25) 52.04 (8.17) .066 physical function 48.13 (7.57) 48.35 (7.53) 47.85 (7.66) .687 44.33 (6.47) 49.38 (7.77)) .036 fatigue 54.35 (8.94) 53.85 (9.41) 54.99 (8.33) .433 57.81 (7.36) 53.85 (8.65) .218 sleep disturbance 51.17 (9.20) 50.47 (9.61) 52.07 (8.64) .286 54.26 (8.04( 51.20 (8.96) .440 pain interference 50.64 (8.78) 50.04 (8.73) 51.40 (8.84) .339 55.96 (8.23) 49.47 (8.59) .018 anxiety 58.00 (8.89) 56.27 (9.32) 60.21 (7.83) .006 62.13 (7.88) 59.39 (7.90) .415 depression 51.86 (9.08) 50.63 (9.91) 53.44 (7.69) .056 55.64 (8.12) 52.57 (7.50) .348 note. * 13 participants missing state identifiers. a prefer not to answer n = 2. b totals >156 due to “check all that apply”. other: american indian/alaskan native n = 1; middle eastern/north african n = 3; unspecified n = 1. c other: student n = 12; homemaker n = 9; out of work >1 year n = 4; out of work <1 year n = 2; unable to work/disabled n = 2; unspecified n = 1. d prefer not to answer n = 10. e other: colorectal n = 6; cervical n = 5; sarcoma n = 5; other n = 13 (n = 1 for mouth, lung, melanoma, multiple myeloma, testicular, thyroid, etc.). f cancer stage – 1: n = 21 (13.7), 2: n = 80 (52.3%), 3: n = 34 (22.2%), 4: n = 19 (11.8%). cannabis, a publication of the research society on marijuana 31 table 2. participant characteristics in relation to past-month cannabis use and purpose if first use in young adult cancer survivors past-month cannabis use among participants reporting pastmonth use, purpose of first use a all n = 155 (100%) no n = 114 (73.5%) yes n = 41 (26.5%) medical n = 13 (31.7%) non-medical n = 26 (63.4%) variables m (sd) or n (%) m (sd) or n (%) m (sd) or n (%) p-value m (sd) or n (%) m (sd) or n (%) p-value legal factors (n, %) * medical use legal 109 (76.8) 76 (72.4) 33 (89.2) .042 10 (83.3) 21 (91.3) .594 non-medical use legal 83 (58.5) 57 (54.3) 26 (70.3) .120 9 (75.0) 16 (69.6) .999 sociodemographic factors age (m, sd) 32.89 (4.89) 32.71 (4.64) 33.39 (5.54) .447 33.54 (5.78) 33.23 (5.74) .949 female (n, %) 136 (87.7) 99 (86.8) 37 (90.2) .782 13 (100.0) 22 (84.6) .278 hispanic/latino (n, %) 13 (8.4) 11 (9.6) 2 (4.9) .516 1 (7.7) 1 (3.8) .825 race (n, %) b white 127 (81.9) 92 (80.7) 35 (85.4) .506 11 (84.6) 23 (88.5) .332 black 11 (7.1) 10 (8.8) 1 (2.4) .290 1 (7.7) 0 (0.0) .332 asian 19 (12.2) 14 (12.3) 5 (12.2) .999 1 (7.7) 3 (11.5) .232 other 5 (3.2) 4 (3.5) 1 (2.4) .999 0 (0.0) 1 (3.8) .744 education >bachelor’s degree (n, %) 65 (41.9) 46 (40.4) 19 (46.3) .191 7 (53.8) 12 (46.2) .186 employed full/part time (n, %) c 126 (81.3) 95 (83.3) 31 (75.6) .568 7 (53.8) 22 (84.6) .442 household income ≥$4,200/mo (n, %) d 98 (63.2) 71 (62.3) 27 (65.9) .418 7 (53.8) 19 (73.1) .088 married/cohabitating (n, %) 99 (63.9) 72 (63.1) 27 (65.8) .866 7 (54.9) 19 (73.1) .910 parent (n, %) 103 (66.5) 77 (67.5) 26 (63.4) .631 10 (76.9) 14 (53.8) .202 medical history cancer type (n, %) .506 .897 breast 75 (48.4) 54 (47.4) 21 (51.2) 7 (52.8) 12 (46.2) lymphoma 34 (21.9) 27 (23.7) 7 (17.1) 2 (15.4) 5 (19.2) leukemia 17 (11.0) 14 (12.3) 3 (7.3) 1 (7.7) 2 (7.7) other e 29 (18.7) 19 (16.7) 10 (24.4) 3 (23.1) 7 (26.9) cancer stage (m, sd) f 2.32 (0.86) 2.36 (0.82) 2.21 (0.95) .324 2.38 (0.96) 2.21 (0.93) .160 years since diagnosis (m, sd) 2.26 (1.22) 2.23 (1.21) 2.35 (1.27) .588 2.69 (1.37) 2.21 (1.23) .374 treatments (n, %) chemotherapy 138 (89.0) 98 (86.0) 40 (97.6) .042 13 (100.0) 25 (96.2) .744 radiation 69 (44.5) 49 (43.0) 20 (48.8) .522 7 (53.8) 11 (42.3) .263 surgery 101 (65.2) 73 (64.0) 28 (68.3) .624 9 (69.2) 17 (65.4) .596 years since treatment completed (m, sd) 1.34 (1.04) 1.33 (1.02) 1.34 (1.11) .966 1.62 (1.04) 1.31 (1.12) .155 quality of life – promis (m, sd) g social roles/activities 51.09 (8.39) 51.36 (8.34) 50.34 (8.58) .507 46.39 (8.94) 52.59 (7.96) .065 physical function 48.13 (7.57) 48.25 (7.75) 47.80 (7.12) .742 45.09 (7.05) 49.52 (6.96) .114 fatigue 54.35 (8.94) 53.99 (9.51) 55.33 (7.12) .413 58.92 (7.16) 53.41 (6.77) .067 sleep disturbance 51.17 (9.20) 50.62 (9.48) 52.69 (8.30) .219 53.84 (9.02) 52.08 (8.36) .828 pain interference 50.64 (8.78) 50.46 (8.87) 51.12 (8.61) .681 55.65 (9.33) 48.43 (7.47) .027 anxiety 58.00 (8.89) 56.70 (9.42) 61.61 (5.93) .002 63.55 (5.99) 60.57 (5.96) .336 depression 51.86 (9.08) 50.94 (9.45) 54.43 (7.50) .034 56.62 (7.55) 53.32 (7.48) .443 notes: * 13 participants missing state identifiers. a prefer not to answer n = 2. b totals >156 due to “check all that apply”. other: american indian/alaskan native n = 1; middle eastern/north african n = 3; unspecified n = 1. c other: student n = 12; homemaker n = 9; out of work >1 year n = 4; out of work <1 year n = 2; unable to work/disabled n = 2; unspecified n = 1. d prefer not to answer n = 10. e other: colorectal n = 6; cervical n = 5; sarcoma n = 5; other n = 13 (n = 1 for mouth, lung, melanoma, multiple myeloma, testicular, thyroid, etc.). f cancer stage – 1: n = 21 (13.7), 2: n = 80 (52.3%), 3: n = 34 (22.2%), 4: n = 19 (11.8%). cannabis use among young adult cancer survivors 32 first and current use for medical vs. nonmedical purposes of those reporting lifetime use, 70.6% (n = 48/68) reported first using for non-medical purposes and 26.5% (n = 18/68) for medical; reasons for first medical use included anxiety (n = 7), pain (n = 5), chemotherapy in general (n = 4), insomnia (n = 3), nausea (n = 2), and cancer in general (n = 2). shown in table 3, among those reporting pastmonth use, 9.8% (n = 4/41) reported using for only medical purposes, 29.3% (n = 12/41) primarily medical but some non-medical (‘recreational’), 14.6% (n = 6/41) equally medical and non-medical, 14.6% (n = 6/41) primarily non-medical but some medical, and 9.8% (n = 4/41) only non-medical. common reasons for current medical use among the 8 people who responded to that question included pain (n = 3), insomnia (n = 3), survivorship in general (n = 3), anxiety (n = 2), fatigue (n = 1), and nausea (n = 1). among those reporting lifetime use, the majority reported first use for non-medical purposes but no past-month use (25.0%, n = 17/68), current use for only non-medical purposes (13.2%, n = 9/68), primarily medical but some nonmedical (10.3%, n = 7/68), equally medical and non-medical (7.4%, n = 5/68), primarily nonmedical but some medical (5.9%, n = 4/68), or only medical (4.4%, n = 3/68). others reported first using for medical purposes and current use primarily for medical but some non-medical purposes (11.8%, n = 8/68), only medical (4.4%, n = 3/68), equally medical and non-medical (4.4%, n = 3/68), no past-month use (2.9%, n = 2/68), or currently using for primarily non-medical but some medical (1.5%, n = 1/68; note: n = 5 did not respond to 1 of the 2 assessments.) table 3. cannabis-related factors by reason for first use among participants reporting past-month use reason for first use past-month use n = 41 (100.0%) medical n = 13 (31.7%) non-medical n = 26 a (63.4%) variables m (sd) or n (%) m (sd) or n (%) m (sd) or n (%) p days used, past 30 days (m, sd) 10.00 (10.54) 14.92 (11.57) 8.00 (9.66) .108 has medical cannabis card (n, %) 11 (26.8) 6 (46.2) 4 (15.4) .093 current use purposes (n, %) b .020 only medical 4 (9.8) 1 (7.7) 2 (7.7) primarily medical, some non-medical 12 (29.3) 8 (61.5) 4 (15.4) equally medical and non-medical 6 (14.6) 3 (23.1) 3 (11.5) primarily non-medical, some medical 6 (14.6) 1 (7.7) 4 (15.4) only non-medical 4 (9.8) 0 (0) 4 (15.4) current primary use mode (n, %) c smoked 6 (14.6) 2 (15.4) 3 (11.5) .332 vaporized 9 (22.0) 3 (23.1) 6 (23.1) .744 edibles 31 (75.6) 11 (84.6) 19 (73.1) .503 current primary source (n, %) d .531 medical dispensary 9 (22.0) 4 (40.0) 4 (16.0) non-medical dispensary 19 (46.3) 5 (50.0) 14 (56.0) don’t buy; get it from friends 5 (12.2) 0 (0) 4 (16.0) dealer 2 (4.8) 0 (0) 2 (8.0) note. a prefer not to answer n = 2. b prefer not to answer n = 9. c other n = 1. d prefer not to answer n = 4; other n = 1. bivariate analyses assessing correlates of medical vs. non-medical use table 1 shows bivariate analyses assessing factors associated with first use for medical vs. non-medical purposes among those reporting lifetime use. those reporting lifetime use who first used medically (vs. non-medically) reported lower physical function (m = 44.33, sd = 6.47 vs. m = 49.38, sd = 7.77, p = .036) and greater pain interference (m = 55.96, sd = 8.23 vs. m = 49.47, sd = 8.59, p = .018), as well as marginally lower likelihood of employment (55.6%, n = 10 vs. 89.6%, n = 43, p = .068), higher likelihood of having ≥$4,200 monthly household income (55.6%, n = 10 vs. 79.2%, n = 38, p = .074), and lower ability to participate in social roles/activities (m = 47.07, sd = 8.25 vs. m = 52.04, sd = 8.17, p = .066). table 2 also shows bivariate analyses assessing factors associated with first use for cannabis, a publication of the research society on marijuana 33 medical vs. non-medical purposes among those reporting past-month use. those who first used for medical purposes (vs. non-medical) reported greater pain interference (m = 55.65, sd = 9.33 vs. m = 48.43, sd = 7.47, p = .027), as well as marginally lower income (53.8%, n = 7 vs. 73.1%, n = 19, p = .088) and ability to participate in social roles/activities (m = 46.39, sd = 8.94 vs. m = 52.59, sd = 7.96, p = .065) and greater fatigue (m = 58.92, sd = 7.16 vs. m = 53.41, sd = 6.77, p = .067). factors associated with cannabis use bivariate analyses (table 1) indicated that those reporting lifetime use (vs. not) reported greater anxiety symptoms (m = 60.21, sd = 7.83 vs. m = 56.27, sd = 9.32, p = .006), as well as marginally greater depressive symptoms (m = 53.44, sd = 7.69 vs. m = 50.63, sd = 9.91, p = .056). shown in table 2, factors associated with past-month use included more likely receiving chemotherapy treatment (n = 40, 97.6% vs. n = 98, 86.0%, p = .042) and reporting more anxiety (m = 61.61, sd = 5.93 vs. m = 56.70, sd = 9.42, p = .002) and depressive symptoms (m = 54.43, sd = 7.50 vs. m = 50.94, sd = 9.45, p = .034). in the multivariable binary logistic regression model assessing factors associated with pastmonth use among all participants (table 4), pastmonth use was associated with less advanced cancer stage (compared to stage 1, stage 2: aor = 0.12, 95%ci = 0.03, 0.44; stage 3: aor = 0.16, 95%ci = 0.04, 0.67; stage 4: aor = 0.17, 95%ci = 0.03, 0.92), treatment involving chemotherapy (aor = 15.37, 95%ci = 1.49, 58.09), and greater anxiety symptoms (aor = 1.11, 95%ci = 1.02, 1.21). in the regression model assessing factors associated with past-month use among those reporting lifetime use (table 4), past-month use was associated with being male (vs. female; aor = 12.50, 95%ci = 2.08, 28.43), cancer stage 1 vs. 2 (aor = 0.11, 95%ci = 0.02, 0.85), greater anxiety symptoms (aor = 1.18, 95%ci = 1.03, 1.34), and using first for non-medical purposes (aor = 4.76, 95%ci = 1.15, 20.00). table 4. multivariable binary logistic regression identifying factors associated with past-month cannabis use among all participants and among participants reporting lifetime cannabis use (assessing reasons for first use as a correlate) past-month cannabis use among all participants past-month cannabis use among participants reporting lifetime use variables aor 95% ci p-value aor 95% ci p-value sociodemographic factors age 1.04 0.95, 1.13 .445 1.04 0.94, 1.16 .441 male (ref: female) 1.41 0.34, 5.88 .631 12.50 2.08, 28.43 .006 medical history cancer stage (ref: 1) 2 0.12 0.03, 0.44 .001 0.11 0.02, 0.85 .034 3 0.16 0.04, 0.67 .012 0.20 0.03, 1.62 .132 4 0.17 0.03, 0.92 .039 0.30 0.02, 4.15 .366 chemotherapy (ref: no) 15.37 1.49, 58.09 .022 1.24 0.19, 7.93 .823 years since treatment completed 0.90 0.59, 1.36 .603 0.76 0.42, 1.38 .363 quality of life – promis social roles/activities 1.02 0.94, 1.11 .693 0.97 0.86, 1.11 .683 physical function 0.99 0.91, 1.08 .891 1.01 0.89, 1.14 .895 fatigue 0.96 0.89, 1.05 .389 0.96 0.85, 1.09 .531 sleep disturbance 1.02 0.96, 1.07 .580 1.06 0.98, 1.14 .158 pain interference 0.73 0.24, 2.24 .583 0.41 0.09, 1.94 .261 anxiety 1.11 1.02, 1.21 .017 1.18 1.03, 1.34 .017 depression 1.02 0.95, 1.09 .651 0.94 0.84, 1.05 .244 used first for non-medical purposes (ref: medical) --4.76 1.15, 20.00 .031 nagelkerke r-square .263 .389 note. including state laws for medical or non-medical cannabis use did not significantly contribute to the models and reduced power; thus, models not including those legal factors were presented. cannabis use among young adult cancer survivors 34 discussion in this sample of young adult cancer survivors, over 40% had ever used cannabis, with over 70% reporting first using for non-medical purposes and over one-fourth first using for medical reasons. two prior studies documented similar findings, with 50-80% of those who currently used cannabis indicating that they had used prior to cancer treatment (donovan et al., 2023; podda et al., 2020). furthermore, over one-fourth reported past-month use, with only ~10% using only for medical purposes or non-medical purposes, respectively. the remainder used for a mix of medical and non-medical purposes (i.e., ~30% primarily medical, ~15% primarily non-medical, ~15% equally medical and non-medical). another key finding in the current study was that, among participants reporting lifetime use, past-month use was associated with first using for nonmedical purposes. this is particularly important given that one study found that nearly half of those who first used cannabis before diagnosis increased their use during treatment (podda et al., 2020). notably, the vast majority of existing research on cannabis use among young adults with a history of cancer has focused on medical cannabis use and use during treatment; much less research (donovan et al., 2023; podda et al., 2020) has assessed cannabis use outside of the cancer treatment period or for reasons other than medical purposes among young adults with a prior cancer diagnosis. this is particularly relevant for young adult cancer survivors who may have higher rates of cannabis use than older groups and feel more hesitant to discuss their cannabis use with oncology treatment teams (baral et al., 2024). commonly-endorsed reasons for medical use in this sample included pain, insomnia, anxiety, and nausea, and some participants reported more general cancer-, chemotherapy-, or survivorshiprelated reasons. aligning with these medical use motives, past-month use was associated with greater anxiety symptoms and receiving treatment involving chemotherapy. these findings are consistent with findings from several studies regarding common medical use motives (donovan et al., 2021; donovan et al., 2023; halpern et al., 2024); some prior research suggests that young adult cancer survivors indicate that cannabis is effective for addressing these symptoms (donovan et al., 2023; halpern et al., 2024). unfortunately, like most prior studies, this study did not distinguish and assess young adult cancer survivors’ reasons for non-medical use. a previous study found differences in use motives outside of cancer treatment (e.g., social and enhancement motives) vs. during treatment (e.g., pain, sleep; podda et al., 2020) which may be mirrored in the current sample, many of whom used for dual purposes. current results also highlight important use characteristics among this population. for example, studies in the us have shown that smoking cannabis is a common mode of consumption among young adults in the general population (berg et al., 2024; samhsa, 2024) and young adult cancer survivors (donovan et al., 2023; vinette et al., 2022). however, this study and others have shown that ingesting via edibles or oils are distinctly relevant modes among young adult cancer survivors (donovan et al., 2023; vinette et al., 2022). this may reflect young adult cancer survivors awareness of the carcinogenic effects of combusted cannabis use along with attempts to minimize cannabis-related risks (national academies of sciences & medicine, 2024). current findings have implications for research and practice. first, the sparse research to-date that has explored both medical and nonmedical cannabis use has indicated the importance of assessing both use motives across the spectrum (preto post-treatment; donovan et al., 2023; podda et al., 2020). future research must leverage various designs (e.g., qualitative, longitudinal) in order to better understand different motives for use and how use patterns may evolve over time. in particular, longitudinal research using comprehensive and precise assessments is needed to characterize patterns and trajectories of cannabis use – as well as other substance use and health outcomes more generally – before, during, and after treatment in order to elucidate the associations among cannabis use, mental and physical health, and changes in specific symptoms (e.g., pain, sleep). finally, future research should also focus on identifying individuals who may experience medical benefits from medical use, as well as potential detrimental effects of use. limitations cannabis, a publication of the research society on marijuana 35 while the sample was drawn from across the us, it was limited in diversity and size, hindering power for some analyses and the ability to assess subgroup differences. further, self-selection bias may have impacted findings. assessments were also limited and did not capture all potentially relevant factors influencing use or use characteristics, or motives (e.g., non-medical motives). thus, more comprehensive research using various designs (e.g., qualitative, longitudinal) is warranted with a larger, more diverse sample, particularly involving greater representation of under-researched populations (e.g., men, sexual minorities, racial/ethnic minorities) conclusions a large proportion of young adult survivors first used cannabis for non-medical purposes but also reported medical use. it is crucial to understand use motives and trajectories over time to identify those who may benefit from medical use or face use-related harms. qualitative studies are needed to provide in-depth insights on use motives, characteristics, and related mechanisms, and longitudinal studies are needed to elucidate changes in cannabis use motives, trajectories, and related effects over time. references abrams, d. i. 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(2017). patterns of unmet needs in adolescent and young adult (aya) cancer survivors: in their own words. journal of cancer survivorship, 11(6), 751764. https://doi.org/10.1007/s11764-017-06134 funding and acknowledgements: this work was supported by the us national cancer institute (r21ca261884, mpis: berg, arem). the authors declare no conflicts of interest. the authors declare no conflicts of interest. we would like to thank the participants of this study. author’s contributions: darcey m. mccready: conceptualization, data collection, data curation, investigation, methodology, project administration, writing – original draft, writing – review & editing. laura schubel: conceptualization, methodology, writing – review & editing. hannah arem: conceptualization, data collection, funding acquisition, investigation, methodology, project administration, supervision, writing – review & editing. cassidy r. loparco: conceptualization, methodology, writing – review & editing. afrah howlader: conceptualization, methodology, writing – review & editing. sheena shajan: conceptualization, methodology, writing – review & editing. palash bhanot: conceptualization, methodology, writing – review & editing. carla berg: conceptualization, data collection, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, writing – original draft, writing – review & editing. ethical approval: this study was approved by the george washington university institutional review board (irb# ncr224269). informed consent was obtained from all study participants. data availability statement: limited data from this study are available on request from the corresponding author. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: mccready, d. m., schubel, l. c., arem, h., loparco, c. r., howlader, a., shajan, s., bhanot, p., & berg, c., j. (2025). cannabis use for medical or non-medical purposes in a sample of young adult cancer survivors in the united states. cannabis, 8(3), 26–37. https://doi.org/10.26828/cannabis/2025/000321 https://creativecommons.org/licenses/by/4.0/ research article 50 ved abstract objective: to assess the longer-term impacts of recreational cannabis markets on cannabis use among adolescents and adults across five u.s. states. method: drawing on state-level data from the national survey on drug use and health, this study uses a novel method of causal inference called the synthetic control method with staggered treatment adoption to estimate the pooled effect of recreational markets on prevalence and initiation of use in colorado, washington, oregon, alaska, and nevada. three separate models were used for those 12-17, 18-25, and 26 and older. pre-treatment state-level characteristics and trends in cannabis use were used to generate synthetic control weights. confidence intervals were constructed using a leave-one-out jackknifing method. results: synthetic controls and treated states were similar in terms of sociodemographic characteristics, prevalence of other drug use, and trends in cannabis use prior to the implementation of recreational markets. the study results revealed moderate increases in prevalence and initiation of use among adolescents aged 12-17 (11% and 13%, respectively), and large increases in prevalence and initiation of use among young adults aged 18-25 (17% and 33%, respectively) and older adults aged 26 and older (33% and 82%, respectively) 2-4 years after dispensaries became operational. conclusions: the findings of this study suggest recreational cannabis markets have increased prevalence and initiation of cannabis use among adolescents and adults. these increases may lead to adverse health outcomes depending on factors such as frequency of use and characteristics of users. key words: = cannabis; prevalence of use; initiation of use; recreational legalization; dispensary over the past few decades, the cannabis policy landscape has changed rapidly, shifting away from prohibition. while cannabis remains illegal at the federal level, states have legalized cannabis for medical and recreational use. as of january 2024, 23 states have legalized recreational commercial cannabis markets, wherein private firms produce, distribute, and sell cannabis to adults 21 and older at retail locations and cannabis is taxed and regulated similarly to alcohol (national conference of state legislatures; marijuana policy project). in contrast, some jurisdictions have legalized recreational use without commercial production and retail sale, allowing consumers to cultivate small amounts of cannabis for personal use (including states that later legalized recreational markets) (marijuana policy project). in states that legalized recreational markets, it can take years for these markets to be established and for consumers to have access to cannabis products at retail locations, known as dispensaries (e.g., over two years until dispensaries opened in colorado and over one year in michigan). in the interim, there may only be legal access through personal, small-scale cultivation. understanding the impacts of recreational markets on cannabis use is of public interest, as cannabis use, particularly heavy (daily or near daily use) and problem use (meeting the criteria for cannabis use disorder samantha marinello1 1division of health policy and administration, school of public health, university of illinois chicago cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2024/000224 volume 8, issue 1 the impact of recreational cannabis markets on cannabis use among adolescents and adults: a synthetic control analysis corresponding author: samantha marinello, ph.d., university of illinois chicago, 1603 w. taylor street, m/c 923. chicago, illinois 60612-4394. phone: (847) 224-0746. email: smarin23@uic.edu. cannabis, a publication of the research society on marijuana 51 [cud] [patel 2021]), is associated with adverse social and health outcomes (fergusson & boden, 2008; hall et al., 2020; hudson, 2020; silins et al., 2014; the national academies of sciences, engineering, and medicine, 2017), although more research is needed to determine whether these associations are causal. adolescents are especially at risk for harms associated with cannabis; a substantial body of evidence finds early initiation and frequent use negatively affects brain development in the areas responsible for memory and learning and is associated with cud, other illicit drug use, mental disorders, school dropout, low life satisfaction, and unemployment (hall et al., 2020; fergusson & boden, 2008; silins et al., 2014; the national academies of sciences, engineering, and medicine, 2017). adults who use cannabis may also be at risk for developing mental disorders, especially with heavy use and use of high-potency cannabis products (i.e., high levels of tetrahydrocannabinol [thc]) (hudson, 2020; petrilli et al, 2022). additionally, preliminary research indicates cannabis use may be associated with cardiovascular diseases such as heart attack and stroke, including among younger, healthier adults (goyal et al., 2017; jeffers et al., 2024). currently, cannabis is the most commonly used federally illegal drug in the u.s. in 2021, 52.5 million (18.7%) americans 12 and older reported using cannabis at least once in the past year (substance abuse and mental health services administration, 2022). of those who used cannabis in the past year, 2.6 million (5%) used cannabis for the first time and 16.3 million (31%) met the criteria for cud (substance abuse and mental health services administration, 2022). evidence from studies published since 2000 that used nationally representative data suggests prevalence of use and cud have increased among adults and decreased or remained the same among adolescents (hasin et al., 2019). legalizing recreational markets could lead to increases in initiation and/or frequency of cannabis use through multiple channels. five potential mechanisms are (1) increasing availability, (2) reducing costs associated with use, (3) normalizing use, (4) decreasing risk perceptions, and (5) increasing popularity of products that may be more harmful. while policy alternatives, such as legalizing comprehensive access to medical cannabis or legalizing recreational use without legal sales, can impact cannabis use through these channels, characteristics of commercial markets may amplify these effects. first, the proliferation of retailers makes cannabis much more accessible by effectively lowering search costs, or time and effort needed to obtain a product. in some states with developed retail markets, dispensaries are ubiquitous. for example, in colorado there were more medical and recreational dispensary licenses than starbucks and mcdonalds combined in 2018 (sabet, 2021). a second mechanism is costs—there is strong evidence that cannabis users are sensitive to prices (davis et al., 2016; pacula & lundberg, 2014). cannabis prices are expected to decrease in legal markets because suppliers do not need to be compensated for the legal risks of production and can take advantage of efficiencies from economies of scale and innovation in methods of production (hunt & pacula, 2017). indeed, preliminary evidence suggests that prices in recreational markets have declined since their inception (hunt & pacula, 2017; smart et al., 2017). a third potential mechanism is normalization of use. marketing and advertising from cannabis companies, as well as the presence of retailers at commonplace locations, may normalize use by reducing stigma and raising the social desirability of use (sabet, 2021; sznitman & taubman, 2015). indeed, studies have shown that exposure to cannabis advertising is associated with use and initiation of use among adolescents (d'amico et al., 2015; d'amico et al., 2018; dai, 2017; whitehill et al., 2020). a fourth potential mechanism is risk perceptions. allowing cannabis to be sold for recreational use in a store could signal to the public that cannabis use is safe (khatapoush & hallfors, 2004). risk perceptions are an important mechanism because evidence suggests they are causally related to use (bachman et al., 1998; merrill, 2015). lastly, the implementation of recreational markets may lead to greater consumption of cannabis products that are typically high in thc, such as vape pens and cannabis concentrates (borodovsky et al., 2017; daniulaityte et al., 2017; smart et al., 2017); this finding is important, as use of high-potency products is associated with the development of cud (loflin & earleywine, 2014; petrilli et al., 2022), more severe cud (freeman & winstock, impacts of recreational cannabis markets on use 52 2015), and psychosis (di forte et al., 2009, 2015; petrilli et al., 2022). numerous studies have evaluated the impacts of recreational cannabis legalization and commercialization on cannabis use. some studies use the date of policy enactment as the treatment start date (e.g., anderson et al., 2019; cerda et al. 2017; cerda et al., 2020; coley et al., 2021) while others use the date that recreational dispensaries became operational. evidence on adolescent use is mixed: studies have found no change (brooksrussel et al., 2019; cerda et al. 2017; coley et al., 2021; dilley et al., 2019; harpin et al., 2018), a decline (anderson et al. 2019; dilley et al., 2019), and increase (bailey et al., 2020; cerda et al. 2017; hollingsworth et al., 2022; paschall & grube, 2020; paschall et al., 2021; rusby et al., 2018) in prevalence of use among different adolescent age groups in the first few years after recreational legalization and/or sales. additionally, one study has found an increase in cud (cerda et al., 2020) and another found an increase in initiation of use among adolescents (hollingsworth et al., 2022). studies of younger adults (aged 18-25) and undergraduate students, however, have more consistently found an increase in prevalence of use (hollingsworth et al., 2022; kerr et al., 2017; kerr et al., 2018; miller et al., 2017) following legalization and sales with the exception of one study (cerda et al., 2020); among this age group, an increase in initiation has also been found (hollingsworth et al., 2022). two studies have also examined the effects on use in older adults (26 and older) and report an increase in prevalence of use (cerda et al., 2020, hollingsworth et al., 2022), frequency of use (cerda et al., 2020), initiation of use (hollingsworth et al., 2022), and cud (cerda et al., 2020). the purpose of this study is to estimate the effect of recreational markets on prevalence and initiation of cannabis use among adolescents, younger adults, and older adults across five states with established recreational cannabis markets for 2-4 years. this paper builds upon the evidencebase in several ways. first, it uses a novel method for causal inference, called the synthetic control method (scm) with staggered treatment adoption—an extension of the scm that estimates an average effect across treated sites that implemented a policy in different time periods (ben-michael et al., 2022). unlike studies that examined pre-post changes in use without a comparison group (bailey et al., 2020; brooksrussel et al., 2019; dilley et al., 2019; harpin et al., 2018; paschall et al., 2021; rusby et al., 2018), this empirical strategy can control for secular trends in cannabis use as well as competing interventions that impact use. a potential advantage of this method over study designs that used one or more comparison groups (anderson et al., 2019; cerda et al., 2017; cerda et al., 2020; coley et al., 2021; hollingsworth et al., 2022; kerr et al., 2017; kerr et al., 2018; miller et al., 2017; paschall & grube, 2020) is that it may generate more ideal controls that are similar to the treated sites in terms of characteristics (e.g., socioeconomic status, race/ethnicity) and trends in cannabis use prior to the implementation of recreational markets. additionally, the scm with staggered treatment adoption may serve as an alternative to two-way fixed effects difference-indifferences (did) regression models, which have been employed in studies of cannabis use that exploit variation in timing of cannabis policies (cerda et al., 2017; cerda et al., 2020; hollingsworth et al., 2022). recent studies have found that these models can be problematic and difficult to interpret (goodman-bacon, 2021; sun & abraham, 2021). in contrast to most published literature, this paper also focuses on longer-term impacts of commercial markets, when cannabis was more accessible to the general population. compared to legalizing recreational use alone, the establishment of recreational markets may be more likely to impact use; additionally, it is important to examine the longer-term effects, as it will likely take time for the cannabis industry to develop and for norms and behaviors to shift. methods the synthetic control method with staggered treatment adoption this paper uses a generalization of the scm developed by ben-michael, rothstein, and feller that allows for staggered adoption of policies across multiple treated sites (ben-michael et al., 2022). the scm, formalized by abadie et al. (2010), is an increasingly popular method for estimating the effects of large-scale interventions implemented in a single treated site on aggregate cannabis, a publication of the research society on marijuana 53 outcomes. the idea behind the scm is to construct a counterfactual (i.e., what would have happened in the treated site in the absence of the intervention), called a synthetic control, that is similar to the treated site using a weighted average of control site outcomes. optimal weights, which are non-negative and sum to one, are chosen by minimizing differences in pretreatment predictors and outcomes between the treated site and the synthetic control. control sites with positive weights are selected from a group of potential control sites called a “donor pool”. it is more plausible that the synthetic control is a good counterfactual when there is balance on predictors and the treated site and synthetic control follow similar pre-treatment trends. in the scm, the impact of the intervention is the difference in the outcome between a treated site and its synthetic control in the post-treatment period. a limitation of the scm is that it was designed to evaluate an intervention in a single treated site. extensions that allow for multiple treated sites and staggered treatment timing have not been formalized with the exception of a recent paper by ben-michael et al. (2022). the authors propose a partially pooled scm that generates weights to simultaneously minimize “unit-specific imbalance” (i.e., pre-treatment differences between each treated site and its synthetic control) and “imbalance for the average of the treated units” (ben-michael et al., 2022). this method moves between two extremes: (1) a “separate scm”, which generates weights by minimizing pre-treatment imbalance for each treated site and (2) a “pooled scm”, which minimizes imbalance for the average of the treated sites (ben-michael et al., 2022). the authors show that both sources of imbalance can lead to bias in the estimate of the average treatment effect (ben-michael et al., 2022). a hyperparameter ν, which ranges from 0 to 1, provides the relative weight for each measure of balance; higher values of ν correspond to greater weight given to the pooled fit over the fit for individual treated sites (ben-michael et al., 2022). in the application developed by the authors, ν is set to be “the ratio of the pooled fit to the average of the unit-level fit” (ben-michael et al., 2022). in the staggered adoption scm method, the donor pool consists of never-treated sites and time is indexed on event time, or time since treatment exposure. the primary estimands of interest are the average treatment effect on the treated (att) in each post-treatment period. the atts are calculated as simply the average of site-level treatment effects (i.e., difference between each site and its synthetic control). as one method of inference, ben-michael et al. (2022) construct confidence intervals for estimates using a leaveone-out jackknifing approach. data and sample data on the outcome variables, prevalence of use and initiation of use, were obtained from the national survey of drug use and health (nsduh) small area estimate (sae) files, which provide publicly available state-level estimates that are representative of the population 12 and older. prevalence of cannabis use was measured as the proportion of the population that used cannabis in the last year. initiation of cannabis use was measured as average annual rate of cannabis initiation. each year, state-level estimates from the nsduh are published by pooling two years of data for different age groups (12 and older, 18 and older, 12-17, 18-25, and 26 and older for cannabis use outcomes). the age groups used in this analysis were 12-17, 18-25, and 26 and older. a limitation of grouping 18–25-year-olds together is that it includes young adults with and without legal access to cannabis, as states do not allow legal sale to those under 21 years of age. the study period included pooled estimates for the following years: 2002-2003, 2004-2005, 2006-2007, 20082009, 2010-2011, 2012-2013, 2014-2015, 20162017, and 2018-2019. the treated states consisted of five states that implemented recreational cannabis markets prior to 2018: colorado, washington, oregon, alaska, and nevada. one model that included all treated states was used for each age group. the model was limited to two post-treatment periods because alaska and nevada had only two post-treatment periods. for each state, the treatment period began the first pair of years when recreational sales began. the date of first legal sales was determined using the protocol described in appendix a. table 1 shows the first month and year of legal sales in each state as well as the years included in the first and second post-treatment periods. during the first post-treatment period, most states received impacts of recreational cannabis markets on use 54 partial treatment exposure while the second posttreatment period represents the longer-term effects of commercialization (2-4 years after legal sales). table 1. recreational sales start date and posttreatment periods the donor pool consisted of states that did not legalize recreational cannabis during the study period. additionally, states were excluded if they offered limited or no access to medical cannabis during the entire study period (i.e., alabama, georgia, idaho, indiana, iowa, kansas, kentucky, louisiana, mississippi, missouri, nebraska, north carolina, south carolina, south dakota, tennessee, texas, utah, virginia, west virginia, wisconsin, and wyoming). therefore, the donor pool consisted of states that provided comprehensive medical access for at least part of the study period. these states are likely more similar to treatment states in terms of attitudes and beliefs around cannabis use and policies. in fact, some states in the donor pool legalized recreational use/markets right after the study period. states with limited or no medical cannabis access were identified using the national conference of state legislators. the primary predictor used to generate synthetic control weights is the lagged outcome, i.e., values of the outcome variable in all pretreatment time periods (i.e., 2002-2003, 20042005, 2006-2007, 2008-2009, 2010-2011, and 2012-2013 for all treated states; and the addition of 2014-2015 for alaska and nevada). several auxiliary predictors were also included. the purpose of these predictors was to generate a synthetic control that was similar to the treated states in terms of characteristics that are correlated with cannabis use: other drug use, education, and race/ethnicity (gunn et al., 2022; jeffers et al., 2021; lemyre et al., 2019; substance abuse and mental health services administration, 2022). balance on these predictors is important because the treated states and synthetic controls are more likely to react similarly to “global” factors that impact use during the study period (e.g., changes in economic conditions or attitudes towards cannabis use in the u.s.). three of these predictors were from the nsduh: proportion of the population (based on age group: 12-17, 18-25, and 26 and older) that (1) used illicit drugs other than cannabis in the past month, (2) binge drank alcohol in the past month, and (3) used a tobacco product in the past month. for these variables, the average from 2002-2003 to 2012-2013 was used (i.e., averaged over the entire baseline period prior to first legal recreational sales in the u.s.). education and race/ethnicity variables were also collected from the american community survey (2009-2013; 5year estimate prior to legal sales in the u.s.). the education variables included percentage of the population with (1) less than a high school degree, (2) a high school degree, (3) associate’s degree or some college, and (4) bachelor’s degree or more; race/ethnicity variables included percentage of the population that was black, white, asian, and hispanic (any race). analyses were conducted in r version 4.1.0 using the multisynth package 0.3.1. results tables 1b-6b, appendix b describe average prevalence of use and average rate of cannabis initiation in the pre-treatment and posttreatment periods for the treated states and the synthetic controls (i.e., weighted average of the comparison states) for those 12-17, 18-25, and 26 and older, respectively. table 2 shows the staggered adoption scm results for prevalence of use and rate of cannabis initiation, respectively, by age group. the tables include: (1) estimated baseline prevalence of use or rate of cannabis initiation (used to calculate percent change in use), (2) the att in the first and second posttreatment periods, i.e., the percentage-point change in prevalence of use or rate of cannabis initiation with 95% confidence intervals (derived from statistical model), and (3) percentage change state month and year of first recreational sales first posttreatment period second posttreatment period colorado january 2014 2014-2015 2016-2017 washington july 2014 2014-2015 2016-2017 oregon october 2015 2014-2015 2016-2017 alaska october 2016 2016-2017 2018-2019 nevada july 2017 2016-2017 2018-2019 cannabis, a publication of the research society on marijuana 55 from baseline (att [percentage-point change in use] divided by baseline use estimate). the att is the average of the state-level treatment effects; each state-level treatment effect is the difference in outcome between the treated state and its synthetic control in the post-treatment period. baseline values were calculated as the average prevalence of use or initiation of use in the treated states in 2012-2013, the time period prior to first recreational sales in the u.s. table 2. baseline prevalence and initiation rate, average treatment effect on the treated, and percentage change from baseline for prevalence and initiation of cannabis use by age group prevalence of use age group baseline prevalence (%) period 1 period 2 att: % point change (95% ci) % change from baseline att: % point change (95% ci) % change from baseline 12 to 17 16.80% 1.55* (0.72, 2.38) 9.20% 1.87* (0.14, 3.59) 11.10% 18 to 25 36.50% 1.73 (-1.19, 4.65) 4.70% 6.31* (1.75, 10.87) 17.30% 26 and older 14.90% 2.36 (-0.11, 4.82) 15% 5.00* (2.15,7.85) 32.80% rate of initiation of use age group baseline rate (%) period 1 period 2 att: % point change (95% ci) % change from baseline att: % point change (95% ci) % change from baseline 12 to 17 6.70% 0.71* (0.01, 1.42) 10.60% 0.88 (-0.03, 1.80) 13.10% 18 to 25 8.60% 1.15 (-0.11, 2.40) 13.20% 2.84* (0.47, 5.22) 33.00% 26 and older 0.40% 0.13 (-0.09, 0.36) 32.50% 0.33* (0.06, 0.60) 82.50% note. baseline values were calculated as the average prevalence of use or initiation of use in the treated states in 2012-2013, the time period prior to first recreational sales in the u.s. in the first post-treatment period, most states received partial treatment and in the second post-treatment period states had active recreational cannabis markets for 2-4 years. *p<0.05 att—average treatment effect on the treated; ci—confidence interval figures 1 and 2 are graphical representations of the results. each graph shows the difference in outcome between the treated states and their synthetic controls as well as the average of the treated states (i.e., att) during the study period. period 1 on the x-axis represents the first posttreatment period when legal sales began; period 2 is the second post-treatment period where all states received full treatment. the vertical line separates the pre-treatment period from the posttreatment period. across all age groups, prevalence of use and rate of cannabis initiation increased in the first period (partial treatment) and the second period (full treatment for 2-4 years), with the second period always showing a larger increase than the first treatment period. in the first post-treatment period, the increase in prevalence and initiation of use were only statistically significant for youth aged 12-17 at the 5% level; the estimated percentage-point changes were 1.6% (9.2% increase from baseline) and 0.7% (10.6% increase from baseline) for prevalence and initiation of use, respectively. in the second post-treatment period, the increase in prevalence of use was significant for all age groups: there was a 1.9% (11.1% increase from baseline), 6.3% (17.3% increase from baseline), and 5.0% (32.8% increase from baseline) percentage-point increase for those aged 12-17, 18-25, and 26 and older, respectively; estimates for initiationof use were significant for those 18-25 and 26 and older: there was a 2.8% impacts of recreational cannabis markets on use 56 figure 1. prevalence of cannabis use by age group: difference between treated states and synthetic controls before and after recreational markets became operational and the average treatment effect on the treated note. figures show the percentage-point differences in prevalence of use between the treated states and their respective synthetic control before and after dispensaries became operational. additionally, the thick black line represents the average of the treated states, or att. the dashed vertical line separates the pre-treatment period (i.e., before recreational sales) from the post-treatment period (i.e., after recreational sales). in the post-treatment period, the percentage-point difference in prevalence of use represents the impact of recreational commercialization on prevalence of use. cannabis, a publication of the research society on marijuana 57 figure 2. rate of initiation of cannabis use by age group: difference between treated states and synthetic controls before and after recreational markets became operational and the average treatment effect on the treated note. figures show the percentage-point differences in initiation of cannabis use between the treated states and their respective synthetic control before and after dispensaries became operational. additionally, the thick black line represents the average of the treated states, or att. the dashed vertical line separates the pre-treatment period (i.e., before recreational sales) from the post-treatment period (i.e., after recreational sales). in the post-treatment period, the percentage-point difference in initiation of use represents the impact of recreational commercialization on initiation of use. impacts of recreational cannabis markets on use 58 (33% increase from baseline) and 0.3% (82.5% increase from baseline) percentage-point increase for those 18-25 and 26 and older respectively. in terms of model fit, the figures show small differences in outcomes between the treated states and their synthetic controls in the pretreatment period (i.e., they followed similar pretreatment trends in use). there is also balance on auxiliary pre-treatment predictors for all models (see tables 1c and 2c, appendix c). together, these results suggest the synthetic controls are valid counterfactuals for the treated states. tables 1d-6d, appendix d show weights for donor pool states used to construct the synthetic controls. discussion in the present study, recreational cannabis markets were associated with moderate to large increases in initiation and prevalence of use among adolescents (12-17), young adults (18-25), and older adults (26 and older). in every case, the estimated increases were larger in the second post-treatment period, when states had operational recreational dispensaries for 2-4 years, compared to the first treatment period, which represented a partial treatment (i.e., did not have commercial markets the entire period for some states). the effect in the second period may have been larger because all states had markets for the entire pair of post-treatment years. another possibility is that it may take time for recreational markets to impact cannabis use through potential mechanisms such as lower costs, greater accessibility, normalization of use, reductions in risk perceptions, and increased popularity of products that may be more harmful. this theory is consistent with a study that found a larger impact of recreational sales on cannabis use compared to recreational use alone (hollingsworth et al., 2022). commercialization may be more likely to impact use through these channels; in the open, it may be easier for companies to innovate methods of production to reduce costs, develop new products that may be more appealing and addictive, and engage in marketing and advertising. some studies have found cannabis marketing increases in intensity over time (marinello, 2024) and contains content that may be appealing to youth (cao et al., 2020; marinello et al., 2024; shi & pacula, 2021). additionally, newer cannabis products sold at dispensaries may have qualities that could lead to earlier initiation of use, greater frequency of use, and dependency. for example, compared to smoking cannabis bud, vaping cannabis concentrate—which is substantially higher in thc—is perceived as healthier, better tasting, and more efficient (aston et al., 2019; budney et al., 2015). the moderate increase in initiation and prevalence of use among adolescence is of public health importance because adolescents experience the greatest harms from cannabis use (fergusson & boden, 2008; hall et al., 2020; silins et al., 2014; the national academies of sciences, engineering, and medicine, 2017). these results for adolescents are not consistent with studies that found no impact or decrease in adolescent use following recreational legalization or the implementation of recreational markets (anderson et al., 2019; brooks-russel et al., 2019; cerda et al., 2020; coley et al., 2021; dilley et al., 2019; harpin et al., 2018) but are similar to some papers that find a positive impact (bailey et al., 2020; cerda et al., 2017; hollingsworth et al., 2022; paschall & grube 2020; rusby et al., 2018). one potential explanation for why this study found a positive effect, whereas others did not, is that the scm was able to generate a more ideal control group. generally, cannabis use among adolescents decreased or remained about the same in the treated states, which is consistent with secular trends in the u.s. (hasin et al., 2019); however, the synthetic controls saw a greater reduction in use in the post-treatment periods, resulting in a relative increase in the treated states. these findings are similar to those of an evaluation of legal sales in oregon: adolescent use decreased in counties with and without recreational dispensaries, however, the reduction was steeper in those without dispensaries (paschall & grube 2020). the estimates for percentage change in prevalence of use and initiation of use among adolescents in the second post-treatment period were nearly identical to the estimated impacts after legal sales from hollingsworth et al. (2022) (10% vs. 11% in this study for past-year prevalence of use; 15% vs. 13% in this study for initiation of use), which used the same dataset (nsduh sae) but did regression models. the fact that adolescent use increased suggests some cannabis may have been diverted from the legal cannabis, a publication of the research society on marijuana 59 market to underage youth. it is also possible that recreational markets impacted youth cannabis use through other channels, for example, by increasing youth exposure to cannabis marketing, normalizing use, and reducing risk perceptions. results for young adults aged 18-25 revealed large increases in prevalence and initiation of use in the second post-treatment period, which represents the longer-term impacts. the finding for prevalence of use is consistent with two studies conducted on undergraduate students in oregon (23% increase in past-month use) and washington (did estimates: 8.6-9.6 percentage-point increases in past-month use) that found increases after recreational legalization (kerr, et al., 2018; miller et al., 2017). while the study of washington did not find an additional impact after legal sales, the study period only goes through 2015, or 1.5 years after dispensaries opened. a limitation of those studies is that they may not be generalizable to all young adults of that age. additionally, estimates from this study are similar to those in hollingsworth et al. (2022) (15% vs. 17% in this study for past-year prevalence of use; 24% vs. 33% in this study for past-year initiation of use). these results stand in contrast to those from cerda et al. (2020), which used individual-level data from the nsduh and found no significant changes in prevalence of use among this age group after recreational use became legal. one explanation for the discrepancy is that cerda et al. (2020) had a shorter analytic period and began their treatment start date at policy enactment (i.e., legal recreational use without sales) instead of when dispensaries became operational. in terms of older adults aged 26 and older, there were even larger increases in use in the second post-treatment period. these findings are consistent with cerda et al. (2020), which also found a 20% increase in past-month prevalence of use in this age group, and hollingsworth et al. (2022), which found substantial increases in both past-year prevalence and initiation of use (25% vs. 33% in this study for prevalence of use; 31% vs. 82% in this study for initiation of use). overall, the impacts of recreational markets on use may have been larger for adults compared to adolescents because adults 21 and older have legal access to cannabis and are more likely able to afford products sold at dispensaries, which are more expensive than cannabis purchased from the illicit market (fataar et al., 2021; goodman et al., 2022). increases in prevalence and initiation of cannabis use among adolescents and adults may have adverse health and social impacts depending on a number of factors such as frequency of use, timing and setting of use, potency of products, and user characteristics. while there is a substantial amount of evidence that early and heavy cannabis use is harmful for adolescents (hall et al., 2020; fergusson & boden, 2008; the national academies of sciences, engineering, and medicine, 2017; silins et al., 2014), emerging evidence indicates that use among adults may be associated with the development or worsening of mental disorders and cardiovascular diseases (goyal et al., 2017; hudson, 2020; jeffers et al., 2024; petrilli et al., 2022). states may mitigate the impact of commercialization on use and associated health harms through policies and programs; for example, mass media campaigns to educate the public on health harms of cannabis use, restrictions on cannabis company advertising that would prohibit youth-oriented content and require health warnings, restrictions on potency levels of cannabis products, and tax increases to ensure prices remain high over time. strengths and limitations strengths of this study include the use of data that is representative at the state level and the use of the scm with staggered treatment adoption, a novel method for causal inference that may serve as an alternative to did models with differential treatment timing. this method generated counterfactuals that had similar trends in cannabis use prior to the implementation of recreational markets and were similar in terms of racial/ethnic composition, educational attainment, and use of other drugs. compared to most of the literature, this study focuses on longer-term effects of commercial recreational markets, which is important because these markets provide greater access to cannabis and may be more likely to impact use over time. this study has several limitations. first, this study does not examine the impact of recreational markets on frequency of use or cud because of restrictions to the public use dataset. these dimensions of cannabis use are important for predicting potential health harms. if prevalence of use increased because of increases in casual use, impacts of recreational cannabis markets on use 60 then cannabis markets are less likely to have negative effects on health. second, this study did not assess whether there were heterogeneous effects by demographic characteristics. third, findings may not be generalizable to other regions of the u.s., as all treated states were located in the west. fourth, there may have been timevarying factors that influenced cannabis use that differed by treatment status. fifth, treatment exposure was binary when it likely varied in terms of characteristics and intensity across treated states; for example, the number of dispensaries per capita and prices likely varied depending on state and local policies. lastly, a potential limitation is that cannabis use was selfreported and survey respondents may have been more likely to report cannabis use once it was legal. conclusions overall, this study finds moderate to large increases in prevalence and initiation of cannabis use among adolescents and adults 2-4 years after dispensaries became operational in five u.s. states. findings suggest that characteristics of recreational commercial cannabis markets may drive up demand for cannabis and that there may be adverse health and social consequences of legalizing a for-profit cannabis industry. the results for adolescents are especially important, as this population experiences greater health harms from use; a possible explanation for why these results differ from many previous studies is that the scm with staggered treatment adoption was able to create more ideal counterfactuals that controlled for secular trends in adolescent use. it is important that future work investigates the impacts of markets in other states as more data becomes available and on other aspects of use, such as frequency of use, cud, methods of consumption, and potency of products. additionally, more evidence is needed to understand the health effects of cannabis use, especially among adults. references abadie, a., diamond, a., & hainmueller, j. 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(2020). exposure to cannabis marketing in social and traditional media and past-year use among adolescents in states with legal retail cannabis. journal of adolescent health, 66(2), 247-254. http://doi.org/10.1016/j.jadohealth.2019.08.02 4 funding and acknowledgements: this work received no specific funding from any funding agency in the public, commercial, or not-for-profit sectors. the author has no conflicts of interest. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: marinello, s. (2025). the impact of recreational cannabis markets on cannabis use among adolescents and adults: a synthetic control analysis. cannabis, 8(1), 50-64. https://doi.org/10.26828/cannabis/2024/000224 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 153 ved abstract objective: estimating delta-9 tetrahydrocannabinol (mgthc) using hits involves converting hits to grams via a grams-per-hit ratio (gphr). previous studies assumed a single hit size (shs), ignoring individual hit size variations. this study investigates a multiple qualitative hit size (mqhs) approach based on selfreported hit sizes (small, medium, large) to improve mgthc estimates. method: adults (n = 1,824) who used cannabis in the past week completed an online survey on cannabis consumption, reporting quantities in hits and grams, and estimating their hit sizes. we calculated mgthc using both shs (0.06g/hit for flower, 0.012g/hit for concentrate) and mqhs. for the mqhs approach, we calculated median gphrs for each hit size group and assigned those medians to individuals within that group. results: for flower, median gphr increased with hit size (small: 0.042, medium: 0.062, large: 0.093). the mqhs estimate for mgthc from flower was higher than shs for large hits (95% ci:[12.4, 50.0]) but showed no difference for medium or small hits (95% ci: [-3.2, 8.1]; 95%ci: [-27.6, 3.4]). for concentrate, median gphr was similar for small and medium hits but lower than large hits (small: 0.024, medium: 0.025, large: 0.035). mqhs estimates for mgthc were higher than shs for all hit sizes (95% ci: [46.3, 86.3]; 95% ci: [24.8, 45.5]; 95% ci: [11.5, 36.5] for large, medium, small hits, respectively). conclusions: the mqhs estimates captures hit size variability for flower. the floor effect with median gphrs for concentrates suggests further investigation is needed for mqhs estimates with concentrates. the mqhs approach illustrates a method to develop new standard gphrs for each qualitative hit size group, after further investigation. key words: = thc exposure; cannabis quantification methods; cannabis, estimation; thc dosing cannabis use is gaining popularity in the united states, and the diversity of cannabis products continues to grow with changing cannabis laws (davenport, 2021; hall & lynskey, 2020; spindle et al., 2019). δ9tetrahydrocannabinol (thc) is a major psychoactive cannabinoid in most cannabis products that can cause intoxication and behavioral impairment related to the amount consumed (compton et al., 2019; rajapaksha et al., 2020). similarly, potential therapeutic benefits of cannabis products may be related to dosing effects. understanding how much thc individuals consume is important to both limit adverse effects and maximize potentials benefits of cannabis use. yet, with the vast variety of mohammad i. habib1, alan j. budney1, cara a. struble1, deborah s. hasin2,3,4, ofir livne3,4, efrat aharonovich2,3, caroline wisell4, sara n. fragione1, jacob t. borodovsky1 1center for technology and behavioral health, geisel school of medicine, dartmouth college 2department of psychiatry, columbia university irving medical center 3new york state psychiatric institute 4department of epidemiology, columbia university mailman school of public health cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000285 volume 8, issue 2 estimating cannabis consumption in milligrams of thc from self-reported hit size corresponding author: mohammad habib, b.a., colorado state university, 410 w pitkin st. fort collins, co, 80523. phone: (970) 491-6197. email: mohammad.i.habib@colostate.edu cannabis, a publication of the research society on marijuana 154 products on the market, it is difficult to standardize the measurement of thc consumption across multiple product types (i.e., edibles, flower, concentrates, etc.). accurately estimating thc consumption in real-world settings is difficult due to multiple factors. many cannabis products do not have adequate labels that indicate milligrams of thc (mgthc) per product/serving. for instance, the most commonly used products, cannabis flower and concentrate, might not be labeled, and those that are may only list the potency (%thc) and product weight rather than the total amount of mgthc in the product (davenport, 2021). translating potency and weight to mgthg consumed requires additional information about 1) the quantity of product that was consumed (i.e., how many grams were loaded in the pipe/joint or how many hits/puffs were taken) and 2) the method of administration to account for any thc that is lost while consuming the product (i.e., side smoke, pyrolysis, etc.). prior work quantifying mgthc our group has been working towards a solution to quantify thc consumption across multiple routes of administration and product types. an initial study on smoked and vaped products indicated that consumers showed preferences for how they estimated the amount of cannabis consumed; 55% vs. 45% selected to report in number of grams and hits, respectively (borodovsky et al., 2023). allowing a choice of how to report amounts consumed reduces cognitive burden and likely increases accuracy. to estimate mgthc for those reporting in number of grams (formula 1), we multiplied the number of grams of product by the potency of product and then adjusted for lost thc during the consumption process, using the method of administration efficiency constant (maec; budney et al., 2022). 𝐹𝑜𝑟𝑚𝑢𝑙𝑎 1 𝑚𝑔𝑇𝐻𝐶 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑔𝑟𝑎𝑚𝑠 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 ∗ 𝑃𝑜𝑡𝑒𝑛𝑐𝑦 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 (%𝑇𝐻𝐶) ∗ 𝑀𝐴𝐸𝐶 for those reporting in hits, we converted the number of hits into the number of grams using a grams-per-hit ratio (gphr) derived from prior lab studies (formula 2). after converting hits to grams, we calculated mgthc by multiplying the derived grams value by the potency of product and applied the maec adjustment. in this hits-tograms model, the accuracy or validity of the gphr substantially impacts the precision of the mgthc estimate. 𝐹𝑜𝑟𝑚𝑢𝑙𝑎 2 𝑚𝑔𝑇𝐻𝐶 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 ℎ𝑖𝑡𝑠 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 ∗ 𝐺𝑃𝐻𝑅 ∗ 𝑃𝑜𝑡𝑒𝑛𝑐𝑦 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 (%𝑇𝐻𝐶) ∗ 𝑀𝐴𝐸𝐶 grams-per-hit ratios (gphr) no consensus for an appropriate gphr is available. in our initial study and in two other published studies, a single gphr drawn from human lab studies was used for all participants (borodovsky et al., 2022; budney et al., 2022; lynch et al., 2021; mcclure et al., 2012; varlet et al., 2016). this single gphr assumes all participants have the same single hit size (shs). an shs gphr could potentially provide a reasonable estimate among all cannabis consumers, as it represents an average value across a multitude of cannabis consumers. however, prior studies clearly demonstrate that consumers inhale hits that vary substantially in size and across product types (heishman et al., 1989; matthias et al., 1996; mcclure et al., 2012). thus, an shs gphr could substantially overestimate or underestimate mgthc consumption for many consumers. to better estimate individual use, we developed two methods to capture individual hit size (borodovsky et al., 2023). the first approach required two survey items asking participants to report their consumption in both the number of hits and grams, regardless of the preferred unit. individual gphrs were calculated by dividing the grams of product consumed per day by the hits of product per day. the second approach used one survey item asking participants how many hits it would take them to finish a half gram of flower or concentrate using their preferred method of administration. their individual gphr was multiple qualitative hit size 155 calculated by dividing a half gram by the estimated number of hits. a within-subject comparison of these two approaches found that regardless of product type or gphr approach, 45% of participants had an individual gphr that was 50% larger or smaller than the shs gphr used in the initial study. while both individual approaches addressed the variability in hit size, both also required individuals to think about their consumption in number of grams, which can be potentially challenging, given that many cannabis consumers struggle to accurately estimate small quantities of cannabis in grams (prince et al., 2018). such contemplation increases cognitive burden and likely decreases the accuracy of mgthc among those who prefer to report their use in number of hits. the current study to further reduce burden without sacrificing accuracy, we sought to develop a gphr approach that accounted for multiple qualitative hit sizes (mqhs) and allowed those who prefer the hits unit to estimate their use by only thinking about hits. this mqhs approach requires asking one qualitative hit size survey question: “when you smoke or vape, do you take a small, medium, or large hit?” the present study illustrates a method to generate and establish standard mqhs gphrs for those who report taking small, medium, or large hits, and then compares mgthc estimates derived using the mqhs gphr approach with estimates calculated using the shs gphrs. if standard mqhs gphrs can be established and validated, future studies that require mgthc estimates would only need to include this single mqhs item to obtain a gphr for those who prefer to report in hits. methods sample recruitment and sample size this study is part of a larger study detailed elsewhere (borodovsky et al., 2023). adults 18+ were recruited using facebook and instagram advertising with cannabis related key-word targeting (borodovsky et al., 2018). those who clicked on the advertisement were redirected to the survey consent page hosted on qualtrics (qualtrics, provo, ut). participants were recruited between june 1 july 9, 2022. the dartmouth committee for protection of human subjects approved all study procedures. no compensation was provided for participation. a total of n = 3,658 clicked on the advertisement link, of whom 39 were ineligible (i.e., 4 were less than 18 years old, 35 were potentially bots). among those who consented and were eligible, 812 were excluded due to inconsistent responding. of the remaining n = 2,807, 447 were excluded for not using flower or concentrate products in the past week, and 536 were excluded for not providing all necessary items to calculate milligrams of thc. the final analytic sample size was n = 1,824. survey items and design the survey consisted of 59 items, designed based on prior literature (borodovsky et al., 2018; cuttler & spradlin, 2017; sikorski et al., 2021) and included data quality checks, such as recaptcha, bot-only items, and attention checks. additionally, the survey queried sociodemographics, past 30 and past 7-day frequency, and methods of administration (smoking flower, vaping flower, vaping concentrate, dabbing concentrate, edibles, liquids/tinctures, and capsules). all participants reported their past-week flower and concentrate consumption both in the number of hits and grams of product. to control for ordering effects, participants were randomized with equal probabilities to either report number of hits first (n = 912) or report number of grams first (n = 912). consumption quantity. participants were initially asked if they used the same amount of product on each day they used for flower and concentrates, separately. those who used the same amount were asked to estimate their typical number of hits and grams of flower and/or concentrate used per time-of-day quadrant (morning 6am – 12pm, afternoon 12pm – 4pm, evening 4pm – 8pm, night 8pm – 6am). those who did not use the same amount were asked for the number of hits/grams of flower and concentrate per time-of-day quadrant for their most recent day of use. response options for number of hits of both flower and concentrate were 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11-15, 16-20, 21-25, 26-30, over 30 hits. for calculation of mgthc, midpoints were used for ranges (i.e., if participant selected 16-20 hits, we cannabis, a publication of the research society on marijuana 156 used 18 hits in the formula). response options for number of grams of flower and concentrate were: 1/16, 1/8, 1/4, 1/2, 3/4, 1, 1 1/4, 1 1/2, 1 3/4, 2, over 2g. more details can be found elsewhere (borodovsky et al., 2022). potency. participants reported their product potency (%thc) using a sliding scale. the survey assessed the potency of flower, prefilled thc cartridges, and other concentrates (e.g., oils, wax, shatter, etc.). flower potency ranged from 0% to 30% thc. both prefilled thc cartridge and other concentrate potency options ranged from 40% to 100% thc. qualitative hit size. participants were asked to report their estimated hit size for their flower and concentrate use. response options were “small hit,”, “medium hit,” and “large hit,” and included the following statement in the instructions: “a large hit would be the amount of air you inhale to hold your breath for as long as possible.” gphr approaches single hit size (shs). gphrs were derived from the average number of grams consumed per hit as described in lab-based research studies. the final assumptions of the averages being one hit of flower results in consumption of 0.06g of the product (gphr for flower = 0.06g), and one hit of concentrate results in 0.012g of concentrate product being consumed (gphr for concentrate = 0.012g (budney et al., 2022; lynch et al., 2021; mcclure et al., 2012; varlet et al., 2016). multiple qualitative hit sizes (mqhs). gphrs that correspond to small, medium, or large hit sizes were determined as follows: each participant’s individual gphr was first calculated by dividing the number of grams consumed per day by the number of hits taken per day. median gphrs were then calculated separately for participants that reported small, medium, or large hit sizes, respectively. each participant who reported a small hit size was assigned the small hit size median gphr, those reporting medium hit size were assigned the medium hit size gphr, and so forth. this procedure was followed for both flower and concentrate products. calculating milligrams of thc to calculate milligrams of thc (mgthc), we used formula 2 described above. two mgthc estimates were obtained for each participant: one using the shs gphr (formula 3) and one using the mqhs gphr (formula 4), with the only difference being the gphr constant. 𝐹𝑜𝑟𝑚𝑢𝑙𝑎 3. 𝑚𝑔𝑇𝐻𝐶 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 ℎ𝑖𝑡𝑠 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 ∗ 𝑆𝐻𝑆 𝐺𝑃𝐻𝑅 ∗ 𝑃𝑜𝑡𝑒𝑛𝑐𝑦 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 (%𝑇𝐻𝐶) ∗ 𝑀𝐴𝐸𝐶 𝐹𝑜𝑟𝑚𝑢𝑙𝑎 4. 𝑚𝑔𝑇𝐻𝐶 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 ℎ𝑖𝑡𝑠 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 ∗ 𝑀𝑄𝐻𝑆 𝐺𝑃𝐻𝑅 ∗ 𝑃𝑜𝑡𝑒𝑛𝑐𝑦 𝑜𝑓 𝑝𝑟𝑜𝑑𝑢𝑐𝑡 (%𝑇𝐻𝐶) ∗ 𝑀𝐴𝐸𝐶 data analysis quantile regressions compared the median individual gphrs across the three mqhs groups for both flower and concentrate products. quantile regressions then compared the mgthc estimates derived from the shs and mqhs approaches for overall consumption from flower products and for each mqhs group, and the same was performed for concentrate products. all regressions included cluster-robust standard errors and were controlled for the order of items. analyses were conducted using stata version 16.1. all distributions are described using medians, as the distributions were skewed. results sample demographics the sample had a mean age of 39.1 (sd = 16.2) years and was 80.0% non-hispanic white. the sample was 48.2% female, 50.6% were employed full time, and 55.1% completed an associate’s degree or higher education. full sample demographics have been previously published (borodovsky et al., 2023). cannabis use characteristics the average age of cannabis use onset was 16.5 (sd = 4.7) years. the sample was composed of primarily frequent and heavy consumers with multiple qualitative hit size 157 participants using on average 26.3 (sd = 7.1) days in the past month and 6.3 (sd = 1.6) days in the past week. smoking flower was the most common method of administration (90.8%), followed by vaping concentrate (42.2%), vaping flower (20.7%), and dabbing concentrate (18.3%). the most common method used to smoke flower was joints (37.2%), and the most common method for using concentrate was prefilled cannabis cartridge (66.9%). additionally, 50.7% reported using either edibles, capsules, liquids, or another method. nearly 71.2% reported using 2 or more methods of administration. the median number of hits of flower per day was 14 (q1: 7, q3: 29), and the median number of hits of concentrate per day was 7 (q1: 4, q3: 14). the median number of grams of flower per day was 1 (q1: 0.4, q3: 2.3), and the median number of grams of concentrate per day was 0.2 (q1: 0.1, q3: 0.4). individual gphrs among mqhs groups descriptive statistics can be seen in table 1. the median flower gphr for those who reported taking small (n = 304), medium (n = 2,252), and large (n = 827) hits was 0.042g/hit, 0.062g/hit and 0.093g/hit respectively. of note, the shs gphr (0.06) was very similar to the median gphr among the medium hit size group. as shown in figure 1a, participants reporting a large hit size for flower had a greater first quantile, median, and third quantile gphr than those reporting a medium (q1: 0.013, 95%ci: [0.006, 0.021]; q2: 0.028, [95%ci: 0.016, 0.041]; q3: 0.041, 95%ci: [0.027, 0.056]) or a small hit size (q1: 0.021, 95%ci: [0.013, 0.029]; q2: 0.042, [95%ci: 0.028, 0.057]; q3: 0.068, 95%ci: [0.051, 0.086]). those reporting a medium hit size had a greater first quantile, median, and third quantile gphr for flower than those reporting a small hit (q1: 0.008, 95%ci: [0.003, 0.013]; q2: 0.014, 95%ci: [0.005, 0.023]; q3: 0.027, 95%ci: [0.012, 0.041]). figures 1a & 1b. individual flower grams-per-hit ratios (gphrs) for each participant grouped by selfreported hit size; individual concentrate grams-per-hit ratios (gphrs) for each participant grouped by self-reported hit size. cannabis, a publication of the research society on marijuana 158 note. a: the median gphrs for each hit size group is the gphr assigned to each hit size group for the multiple qualitative hit size (mqhs) gphr approach. the single hit size (shs) gphr approach contains only one gphr (0.06) and is represented to allow comparisons between the gphrs in the mqhs and shs approaches. * denotes significant difference. b: individual concentrate grams-per-hit ratios (gphrs) for each participant grouped by self-reported hit size. the median gphrs for each hit size group is the gphr assigned to each hit size group for the multiple qualitative hit size (mqhs) gphr approach. the single hit size (shs) gphr approach contains only one gphr (0.06) and is represented to allow comparisons between the gphrs in the mqhs and shs approaches. * denotes significant differences. table 1. descriptive statistics for individual grams-per-hit ratios and milligrams of thc estimates mean sd min q1 median q3 max skewness kurtosis individual flower gphr 0.10 0.14 0.00 0.03 0.07 0.13 3.50 12.62 272.27 individual concentrate gphr 0.05 0.07 0.00 0.02 0.03 0.06 0.90 5.93 53.31 single hit size (shs) estimates mgthc per day 117.97 147.97 1.80 32.34 68.04 144.18 1775.52 3.48 22.60 mgthc from flower 97.25 119.85 1.80 27.00 54.00 115.74 972.00 2.88 13.41 mgthc from concentrate 58.00 80.12 2.12 15.30 32.94 67.20 803.52 4.14 27.48 multiple qualitative hit size (mqhs) estimates mgthc per day 169.88 248.65 1.26 39.55 91.51 198.47 3081.00 4.58 35.44 mgthc from flower 113.51 153.67 1.26 29.14 61.60 138.31 1276.50 3.42 18.02 mgthc from concentrate 137.02 200.61 4.20 32.80 75.79 150.00 2082.00 4.17 26.96 note. thc = delta-9 tetrahydrocannabinol for concentrates, the median gphrs for those selecting small (n = 471), medium (n = 849), and large (n = 349) hits were 0.024g/hit, 0.025g/hit, and 0.035g/hit, respectively. the gphr for each mqhs group was larger than the shs gphr (0.012). as seen in figure 1b, those reporting a large hit size had a greater median gphr than those reporting a medium hit size (q2: 0.008, 95%ci: [0.002, 0.014[), but the gphr did not differ significantly at the first or third quantile (q1: 0.002, 95%ci: [-0.001, 0.006]; q3:0.009, 95%ci: [-0.001, 0.019]). those reporting a large hit size had a greater first quantile, median, and third quantile gphr than those reporting a small hit size (q1: 0.005, 95%ci: [0.001, 0.010]; q2: 0.010, 95%ci: [0.003, 0.016]; q3: 0.016, 95%ci: [0.001, 0.031]). the gphr for those reporting a medium or a small hit size did not differ significantly at any quantile (q1: 0.003, 95%ci: [-0.0003, 0.006]; q2: 0.002, 95%ci: [0.007, 0.003]; q3: 0.006, 95%ci: [-0.008, 0.020]). mqhs vs. shs approach for calculating mgthc the overall median mgthc per day estimate for all participants was greater with the mqhs gphr approach than with the shs approach (92.6mg vs 68.0mg respectively; q2: 22.5, 95%ci: [14.8, 30.2]). the mgthc per day estimate for all participants was also greater at the first and third quantile with the mqhs gphr approach than the shs approach (q1:7.6, 95%ci: [3.9, 11.3]; q3: 56.2 95%ci: [49.3, 73.0]). flower. comparisons of mgthc estimates from flower products resulted in greater overall estimates from the mqhs approach than the shs approach at the median and third quantile, but not the first quantile (medians: 60.4mg vs 54mg; q1: 1.6 95%ci: [-1.1, 4.3]; q2: 6.5 95%ci: [0.9, 12.1]; q3: 16.5, 95%ci: [3.8, 29.2]). separate comparisons by mqhs groups showed that among those reporting a large hit size, the mqhs approach produced greater estimates of mgthc than the shs approach: 99.9mg vs 72.0mg; q1: 15.4 95%ci: [5.9, 24.9]; q2: 31.2, 95%ci: [12.4, 50.0]; q3: 56.2 95%ci: [23.9, 88.5] (figure 2a). no differences between the mqhs and shs approaches in mgthc were observed among the multiple qualitative hit size 159 medium hit size group (56.3mg vs 54mg; q1: 1.2, 95%ci: [-1.6, 4.1]; q2: 2.4, 95%ci: [-3.2, 8.1]; q3: 5.3, 95%ci: [-8.4, 18.9]) or at the median and third quantile for the small hit size group (25.5mg vs 36.6mg; q2: -12.1, 95%ci: [-27.6, 3.4]; q3:-30.2, 95%ci: [-74.2, 13.8]), but there were significant differences at the first quantile for the small hit size group (q1: -5.4, 95%ci: [-9.4, -1.3]). concentrates. comparisons of mgthc estimates from concentrate products resulted in greater overall estimates from the mqhs than the shs approach (73.9mg vs 32.9mg; q1: 17.2, 95%ci: [13.9, 20.6]; q2: 39.9, 95%ci: [31.8, 48.0]; q3: 79.5, 95%ci: [65.3, 93.7]). for each of the three mqhs groups, the mqhs approach produced larger estimates of mgthc than the shs approach (figure 2b; 104.1mg vs 39.1mg; q1: 11.4, 95%ci: [6.2, 16.5]; q2: 66.3, 95%ci: [46.3, 86.3]; q3: 45.7, 95%ci: [19.0, 72.3]; 70mg vs 33.8mg; q1: 16.0, 95%ci: [11.1, 20.9]; q2: 35.1, 95%ci: [24.8, 45.5]; q3: 67.9, 95%ci: [50.6, 85.2]; 49.8mg vs 25.2mg; q1: 32.4, 95%ci: [21.1, 43.9]; q2: 24.0, 95%ci: [11.5, 36.5]; q3: 125.7, 95%ci: [77.8, 173.6] for the large, medium, and small hit size groups, respectively). figures 2a and 2b. estimates of milligrams of thc (mgthc) consumed from flower and concentrates; grouped by grams-per-hit ratio approach and qualitative hit size note. a: estimates of mgthc consumed from only flower products using both the single hit size approach (shs) and the multiple qualitative hit size approach (mqhs) among each self-reported hit size group (small, medium, large). * denotes significant differences between the shs and mhs approaches. b: estimates of mgthc consumed from only concentrate products using both the single hit size approach (shs) and the multiple qualitative hit size approach (mqhs) among each self-reported hit size group (small, medium, large). * denotes significant differences between the shs and mhs approaches. cannabis, a publication of the research society on marijuana 160 discussion these findings contribute to the ongoing development of survey methods for increasing the accuracy of estimating mgthc consumption. the present study illustrates a novel, low-burden method of personalizing grams-per-hit ratios (gphrs) to account for varying hit sizes (i.e., small, medium, large) when calculating mgthc among cannabis consumers who report their consumption in hits/puffs/tokes. this novel mqhs gphr approach accounts for some of the variability in hit size among cannabis consumers, which in turn improves the accuracy of the mgthc estimate compared to using a single gphr for all consumers. the method used in this study to derive mqhs gphrs provides a roadmap for developing standard constants for the mqhs approach that will allow researchers to ask only one question (i.e., “do you take a small, medium, or large sized hit?”) to determine an individual’s gphr when calculating mgthc. improving mgthc estimation methods is crucial for precise prevention messaging, assessing cannabis policy impact, and evaluating clinical trial outcomes on cannabis efficacy and adverse reactions. results showed that gphrs, derived by dividing self-reported grams consumed per day by hits per day, differed among groups who reported taking low, medium, or large sized hits. this supports observations from laboratory studies that documented individual differences in hit size when cannabis is smoked or vaped. (heishman et al., 1989; matthias et al., 1996; mcclure et al., 2012) for flower products, the gphrs for the three hit size groups clearly differed from each other, suggesting strong potential for developing standardized mqhs gphrs for calculating mgthc from self-reported number of hits of flower products. the mqhs and shs approaches produced similar mgthc estimates for those who reported medium-sized hits, as the gphr for the medium hit size group in the mqhs approach (0.062) was similar to the shs gphr (0.06). this observation supports the mqhs approach, given that the medium hit size likely approximates our sample’s average and the shs gphr value represents the average hit size across laboratory studies. for those who reported taking large-sized hits, the mqhs approach produced a greater mgthc estimate than the shs approach, likely reflecting more valid individual estimates, as hit size impacts the amount of thc consumed. (azorlosa et al., 1995) we did not observe a significant difference among those reporting small hits (i.e., less mgthc with the mqhs approach), although values were in the expected direction. limited low-end response options for reporting grams per day and difficulty estimating small quantities of flower may have contributed to this null finding. presumably, many consumers choose to report their quantity of use in hits rather than grams because they struggle to accurately report small numbers of grams. moreover, the findings generally tend to be more extreme at the third quantile as compared to the median and findings at the first quantile tend to be less extreme, making it more difficult to detect differences. we believe this is a result of differences being amplified or diminished with more or less use (i.e., there is less of a difference between one and two hits as compared to 10 and 20 hits). the findings for estimating mgthc for concentrates indicate more exploration is needed. the median gphr derived for all three mqhs groups was larger than the shs gphr comparison value, which was determined using estimates from prior laboratory studies. the large hit size group’s gphr was greater than the small and the medium hit size groups at the median, which did not differ from each other. however, the large hit size group’s gphr did not differ at the first or third quantile from the medium hit size group. all three mqhs groups produced greater estimates of mgthc than the shs approach. generally, consumers struggle to report small numbers of grams of concentrate accurately (prince et al., 2018). the response options in our survey for the number of grams consumed per day likely did not include a low enough quantity category, as the lowest was 1/16g, causing a potential floor effect and overestimating mgthc. this likely artificially increased estimates for lowend obfuscated potential differences in gphrs and associated mgthc estimates between those who reported small and medium hit sizes. several additional methodological limitations should be noted. the study sampling methodology was not designed to be representative of all cannabis consumers. thus, the majority of the analytic sample were non-hispanic white multiple qualitative hit size 161 individuals who reported frequent and heavy cannabis use. all respondents self-selected to participate via an advertisement on facebook or instagram. self-report and recall biases may also influence the findings. conclusions and future studies this study demonstrated a novel approach (mqhs gphr) to account for varying hit sizes when using detailed cannabis use survey items to estimate mgthc from smoked or vaped cannabis products. the mqhs approach performed well for estimating consumption from flower products, but more work is needed to test its value for concentrate products. we believe these data represent an important first step in demonstrating how new standard gphrs can be developed for an mqhs approach, such that future studies only need to ask about qualitative hit size to assign an individual a gphr. specifically, subsequent studies need to include more expansive response options on the lower end of consumption to avoid gphr floor effects. moreover, the gphrs derived in this study for the three mqhs groups for flower products should not be used as new standard gphr estimates until these findings are replicated in studies with larger and more representative samples. additionally, future laboratory studies should evaluate how accurately consumers can estimate the number of hits to finish a half-gram of cannabis product using their preferred method. this would likely involve the participant estimating the number of hits to finish a half gram prior to consuming any cannabis and the researcher observing a participant consume a half gram and counting the number of hits they consume. such future studies would help validate the methods needed to derive the multiple qualitative hit size gphrs. future studies that incorporate objective measures of consumption (e.g., topography, urinalysis) could aide in validating the mqhs. further, studies can assess for other cannabinoid use and explore moderators (e.g., biological sex differences) that may influence mgthc exposure and dosing effects. lastly, future studies can assess the clarity of the items used in this study. we hope that this limited demonstration stimulates others to investigate similar approaches to capturing variability in hit size to develop standard gphrs for this type of multiple qualitative hit size approach. efforts to improve cannabis estimation models are sorely needed, and accounting for individual variation in hit size will improve estimates of mgthc and facilitate more accurate studies of the effects of cannabis consumption. references azorlosa, j. l., greenwald, m. k., & stitzer, m. l. 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(2016). drug vaping applied to cannabis: is "cannavaping" a therapeutic alternative to marijuana? scientific reports, 6, 25599. https://doi.org/10.1038/srep25599 funding and acknowledgements: this work was supported by the national institute on drug abuse (nida) r01-da050032, t32-da037202, p30da037202. the funding sources were not involved in the study design; collection, analysis, and interpretation of data; writing of the report; or in the decision to submit the article for publication. drs. alan budney and jacob borodovsky report funding from nida as a potential conflict of interest. dr. budney is a member of the scientific review board of canopy growth and a consultant for jazz pharmaceuticals. all other authors of this manuscript have no conflicts of interest to report.. we would like to thank all the participants in this study. multiple qualitative hit size 163 copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: habib, m. i., budney, a. j., struble, c. a., hasin, d. s., livne, o., aharonovich, e., wisell, c., fragione, s. n., & borodovsky, j. t. (2025). estimating cannabis consumption in milligrams of thc from selfreported hit size. cannabis, 8(2), 153 163. https://doi.org10.26828/cannabis/2025/00028 5 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ research article 51 ved abstract objective: cannabis retail dispensaries have proliferated in the united states in recent years, making it an important time for conducting research. research is needed to learn more about consumer purchasing behaviors, including the impact of product marketing both inside and outside of retail spaces, and studies are needed to explore how both consumers and retail staff interpret the health benefits and potential risks associated with cannabis products within these environments. current research on cannabis dispensaries often involves surveys or interviews with customers and dispensary staff outside of dispensary environments, but much can be learned through observational and experimental methods within dispensaries themselves. however, researchers have traditionally relied on surveillance methods, where researchers visit dispensaries to gain a deeper understanding of real-world encounters in these environments. although these methods provide helpful insights into purchasing and selling behavior, as well as regulatory compliance, these studies are conducted in an uncontrolled environment, as products, messaging, and interactions are specific to the dispensaries in which the research is conducted. method: we therefore created a mock cannabis dispensary to offer participants a retail experience that can be controlled and manipulated (e.g., adjustable cannabis product prices, placement of health and risk information in the dispensary, scripted interactions with dispensary staff) to help balance ecological and internal validity and answer questions about purchasing and selling behavior beyond what current methods allow. results: we describe the process of developing and stocking the first known mock cannabis dispensary for research purposes, the cannabis annex (“the cannex”), including interior design, product selection, feedback solicitation from 20 cannabis industry workers, and plans for future research studies within the environment. conclusions: by describing our process, we hope to aid researchers in developing their own similar mock dispensaries to continue learning about the health benefits, risks from use, and policy implications of cannabis in an increasingly legal recreational atmosphere. key words: = cannabis retailers; budtenders; dispensary; marijuana eric r. pedersen1,2, mark a. prince1,2, ireland m. shute1, megan e. brown1, bethany gray3, keegan d. buch1, and john monterosso2,4 1department of psychiatry and behavioral sciences, keck school of medicine, university of southern california 2institute for addiction science, university of southern california 3department of psychology, colorado state university 4department of psychology, university of southern california cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000297 volume 8, issue 2 developing a mock retail cannabis shop for research: a description of the cannex corresponding author: eric pedersen, phd, keck school of medicine, university of southern california, 2250 alcazar st. suite 2200. los angeles, california, 90033. email: eric.pedersen@med.usc.edu cannabis, a publication of the research society on marijuana 52 cannabis has been available for legal purchase in the united states since 1996, when california began selling cannabis for medicinal purposes in licensed dispensaries (department of cannabis control, n.d.). since january 2014, when colorado opened the first licensed recreational cannabis dispensary, cannabis retail dispensaries have proliferated in the united states. as of early 2024, there were over 15,000 cannabis dispensaries in the united states (chapekis & shah, 2024), with customer access to recreational, medicinal, or both types of cannabis varying by state. a recent pew research center analysis reports that over half (54%) of americans live in a state that has legalized cannabis for recreational sale and possession, and approximately four out of five americans live in a county that has at least one cannabis dispensary wherein the substance can be purchased for recreational and/or medicinal purposes (chapekis & shah, 2024). the cannabis industry has vastly expanded in recent years, with projections that cannabis sales will reach nearly $40 billion in the united states by the end of 2024 (statista, 2024). moreover, the cannabis industry currently supports more than 440,000 jobs (barcott & whitney, 2024). the rise of the legal cannabis market underscores the importance of research on individuals’ purchasing behaviors and exposure to product marketing within cannabis retail environments. inside cannabis dispensaries, consumers are exposed to a wide variety of products in packages that contain unique labels describing the required risk statements, recommended serving sizes, purported health benefits, and ingredients (cf. leafly.com). most brick-and-mortar retailers offer a wide variety of cannabis products, including flower (e.g., packaged flower, prerolled joints), concentrates, vape cartridges, extracts, edibles (e.g., gummies and beverages), and topicals (e.g., lotions and balms). customers may also purchase cannabis use accessories, such as pipes, rolling papers, and vape cartridge batteries, as well as novelty items like coffee grounds and bath bombs containing cannabinoids. researchers have begun to examine how cannabis consumers view and interpret cannabis product packaging, including consumer inferences about the products’ purported health benefits and potential risk factors based on labeling (goodman et al., 2019; winstock et al., 2021), as well as how certain products may appeal to children through packaging that is intentionally similar to popular snacks and candies (ompad et al., 2022; tan et al., 2022). in addition, despite a lack of rigorous randomized control trials, the health benefits of cannabis are becoming more heavily researched (national academies of sciences & medicine, 2017; pratt et al., 2019; walsh et al., 2017). consumers are learning about research-backed health effects of cannabis from multiple sources (e.g., health providers, traditional media, internet-based platforms), which have been associated with more favorable perceptions about cannabis use and increased perceptions about use safety (ishida et al., 2020; khademi et al., 2023; lau et al., 2021). as such, consumers may be more likely to seek out cannabis retail dispensaries for a wide range of purposes, including intentions to use recreationally and/or for medicinal or wellness reasons. in these retail environments, individuals are likely to encounter additional, more direct health and risk marketing (e.g., promotional material on display, product packaging). dispensary employees have also been shown to be an influential source of product messaging, including promotion of health benefits (cameron et al., 2023; peiper et al., 2017; popova et al., 2017). thus, it is important to examine how packaging, retail environments, and interactions with retail employees (i.e., “budtenders” or “cannabis consultants,” herein referred to as budtenders only) affect purchasing behaviors. both survey and qualitative (e.g., focus groups, interviews) research can offer important insights into cannabis product sales (carlini et al., 2022; donnan et al., 2022; donnan et al., 2023; haug et al., 2016; kepple & freisthler, 2018; merlin et al., 2021). further, examining customer and budtender behaviors within actual cannabis retail environments can enhance ecological validity and offer a deeper understanding of realworld encounters. researchers have generally adopted observational surveillance methods when studying cannabis selling and buying behavior. for example, these methods have been used to locate both licensed and unlicensed cannabis dispensaries to help explore the availability of cannabis retailers in specific cities and how such availability may be associated with use in a legalized environment (pedersen et al., 2020; thomas & freisthler, 2016; unger et al., 2020). the cannex research lab 53 researchers have also visited cannabis dispensaries to learn more about compliance with local regulations (e.g., age verification procedures, signage posted about risks), to observe how products are marketed within the dispensaries (e.g., price promotions, membership deals), and to document potency and prices of current products (berg et al., 2017; berg et al., 2023). similarly, discussions with budtenders have been conducted with surveillance methods, such as “mystery shopper” methods in which researchers have learned about specific health claims offered by retail staff (romm et al., 2024; vastis et al., 2020). though much is learned from surveillance methods, these methods are subject to uncontrolled environmental conditions, and there is a lack of standardization across studies conducted in the real world. currently, if researchers want to learn about customers’ purchasing behaviors, they must either ask participants about their behaviors directly (e.g., asking about potential purchases based on hypothetical price points) or observe customers in real-world dispensaries with prices controlled by the dispensary. having a research environment in which aspects of the retail experience could be controlled and manipulated (e.g., adjustable cannabis product prices) would balance ecological and internal validity to help answer questions beyond what current methods allow. moreover, observing and studying the selling behavior of cannabis retail staff within an experimentally manipulated dispensary would offer valuable insights into how products are marketed to consumers. the present study we describe our process for developing a mock cannabis dispensary, which we named “the cannabis annex (the cannex),” including interior design, product selection, feedback solicitation from cannabis industry workers, and building a plan for research studies to be conducted within the space. we describe the development of this first known mock cannabis dispensary for research purposes in two phases. the first phase describes the design of the dispensary, including the rationale for the location and the strategy for stocking the dispensary, followed by the results from these procedures. the second phase includes the procedures and findings from a series of interviews with cannabis industry workers to finalize the dispensary and prepare it for future observational and experimental studies. our hope is that our process descriptions will aid future researchers in developing similar mock dispensaries on their own campuses. phase 1 methods location of the cannex we built the cannex on the health sciences campus of the university of southern california (usc), located just northeast of downtown los angeles, california. this geographic location is uniquely suitable for the cannex. california has more cannabis dispensaries than any other state (chapekis & shah, 2024). it was the first state to open licensed medicinal cannabis dispensaries and among the first states to open licensed recreational cannabis dispensaries in 2018. los angeles county alone, which spans over 4,000 square miles, has more dispensaries than any single state (besides california itself). this dispensary is located within the biobehavioral simulated research environment unit (“the biosim”) on campus. the biosim, funded by the usc institute for addiction science, is a series of multipurpose research participation suites, including rooms with one-way mirrors for observation and ventilation to clear smoke for inhalational drug administration studies, reception and waiting areas, offices and conference rooms, and private patient counseling and exam space. a central feature of the biosim is an open space designed to simulate at least three environments: a bar, a convenience store, and a cannabis dispensary. it is approximately 240 square feet, with shelving, high ceilings with topdown lighting, a mounted flat screen television, high top tables, bar stools, and a reversible, movable bar/cabinet that can serve as either a bar for patrons to sit at or as a countertop with glass case shelving for products. it has a large closet for storage of any materials not necessary for one of the specific settings (e.g., bar stools can be stored when using the biosim as a convenience store). the bar setting functions similarly to other simulated bar laboratories on college campuses, where participants can consume alcohol (or perhaps placebo) in a bar environment that closely cannabis, a publication of the research society on marijuana 54 matches a setting where they would consume alcohol in real life (corbin et al., 2015; corbin et al., 2020; marlatt & rohsenow, 1981; rung et al., 2024). similar to other mock convenience stores (grummon et al., 2019; hall et al., 2021; shadel et al., 2016), the convenience store setting can function as a point-of-sale observational space for risky products, such as cigarettes, nicotine vapes, and sugar-sweetened beverages, as well as the promotional material and advertisements one may see when checking out. unique to the biosim is the cannabis dispensary environment (i.e., the cannex), which seeks to replicate a typical licensed recreational cannabis dispensary, albeit without any real cannabis products containing psychoactive components that are still illegal at the federal level and not allowed on campus. design of the cannex we visited multiple cannabis dispensaries in the area, including small, single-site retail stores and larger chain dispensaries. we aimed to create an inviting atmosphere that blended lush greenery with a minimalist modern aesthetic. lifelike artificial plants were displayed throughout the space with stained glass window coverings, making the traditional windows more pleasing. this helped to soften the atmospheric lighting in the cannex, which also features dimmable top-down lights to create a more comfortable, adaptable environment. we purchased additional shelving for products that were placed around the perimeter of the room. product packaging was also displayed on the existing counter space and in the glass door cabinets featured in the center of the room. in an effort to not overwhelm future participants with too many products placed together in a small space, we also integrated décor into the shelving units and counter spaces (i.e., small display cases, cards). additionally, we bought frames and cannabis imagery posters, a small refrigerator for beverages and concentrates, and an artificial neon sign that reads “the cannex” (see figures 1, 2, and 3.) using the large, flat screen television in the biosim space, we displayed two rotating images with the cannex logo and a menu with adaptable pricing for several of the products found in the store. we also provided a qr code at the front counter that allows customers to scroll through the menu (which can be manipulated by the researchers) on their mobile devices. like many california cannabis dispensaries, the space was designed in a “grocery store” fashion, giving customers the ability to explore and handle the product packaging without all products locked behind counters. this also gives the customers more freedom to self-guide their product selection during their shopping experience. figure 1. front right view of the cannex note. we have attempted to blur and/or obscure product brand names in these photos. certain branded materials have also been removed with photo-editing software. the cannex research lab 55 figure 2. front left view of the cannex note. we have attempted to blur and/or obscure product brand names in these photos. certain branded materials have also been removed with photo-editing software. figure 3. front center view of the cannex note. we have attempted to blur and/or obscure product brand names in these photos. certain branded materials have also been removed with photo-editing software. cannabis, a publication of the research society on marijuana 56 stocking the cannex of the initial 30 dispensaries we contacted, six (20%) responded and donated approximately 260 products across 19 different brands. in addition to offering product packaging, they invited us to visit their dispensary and provided us with advice on how to set up and stock the cannex. packaging nearly always contained information just like one would see in the dispensary, such as the mix of cannabinoids, potency, and required california warning labels (department of cannabis control, n.d.-b). however, some of the packaging received was blank except for the brand logo, making it easy to manipulate labels for future research studies. the initial dispensary contacts encouraged us to reach out to the brands directly and gave us the names of popular brands, distributors, and parent companies, though we did not receive any direct contact information or specific names of people to contact. we used the online search engine, weedmaps (cf. www.weedmaps.com), as the primary source to learn more about the popular brands being sold in local dispensaries. we contacted brands and distributors primarily by email, but we also reached out on the social networking website, linkedin. we continued to reach out to local dispensaries in the area using email and linkedin, providing our email and phone numbers for follow-ups. in total, we contacted 54 brands known to be popular in los angeles dispensaries and recommended by the staff members (i.e., budtenders and store managers) from the local dispensaries. they were large, well-known brands but also more local, lesser-known brands that customers would often see in los angeles retail dispensaries. of the 54 brands that we contacted, 18 (33.3%) of them responded. thirteen independent brands provided us with packaging, and the other five operated under parent distribution companies that provided an additional 14 brands. all together, we received packaging from 32 brands. including products from dispensaries (one brand of which overlapped with products sent to us by an independent company), the total number of different brands represented in the cannex is currently 51 (as of august 2024). we ensured that the cannex would be well stocked with the variety of products that individuals would encounter in a local dispensary. among the 51 brands, we received a total of 444 different cannabis products: 147 different edibles (including 9 different beverages and 3 syrups), 174 different kinds of flower (including prerolls and packaging/jars for bud), 81 disposable or “allin-one” vapes (either empty or filled with simulated cannabis oil), 20 different concentrates, 16 different kinds of tinctures, and six different topicals. within these different products, we often had multiples of the same products, which put our total number of products at 956 as of august 2024. this included 411 edibles (including beverages and syrups), 317 flower products (including prerolls and packaging/jars for bud), 176 vapes and concentrates, and 52 tinctures and topicals. all products in the cannex are donations. we aimed to stock the cannex with products of varying potencies and cannabinoid combinations. we targeted inclusion of high and low thc products, thc-only products, and products with a mix of thc and other featured cannabinoids (such as products with thc and cbd). we sought products that also contained cannabinoids growing in popularity, such as thca (tetrahydrocannabinolic acid), thcv (tetrahydrocannabivarin), cbg (cannabigerol), and cbn (cannabinol). products often have “buzz words” on the packaging, and we aimed to also collect products that contained such phrasing within broader categories of pain (e.g., “recover,” “alleviating”), sleep (e.g., “sedating”), social (e.g., “talkative”), calm (e.g., “relaxing,” “tranquil”), intimacy (e.g., “passion,” “arousal boost”), focus (“alert,” “peak productivity”), happiness (“euphoric,” “bliss”), and others (e.g., “creative,” “energy,” “introspective”). this allowed us to create a versatile inventory that is available to other researchers desiring to use the cannex. we also created a website with prices for the products that individuals visiting the cannex could access using a qr code on provided ipads or personal phones. individual products did not contain price tags, as we expect these prices to change according to the needs of specific studies. initial pricing was set using average pre-tax prices listed across stores on the weedmaps site as of august 2024. if we could not find a price point for a particular product, we priced that product based on similar available products. phase 1 results the cannex research lab 57 of the initial 30 dispensaries we contacted, six (20%) responded and donated approximately 260 products across 19 different brands. in addition to offering product packaging, they invited us to visit their dispensary and provided us with advice on how to set up and stock the cannex. packaging nearly always contained information just like one would see in the dispensary, such as the mix of cannabinoids, potency, and required california warning labels (department of cannabis control, n.d.-b). however, some of the packaging received was blank except for the brand logo, making it easy to manipulate labels for future research studies. the initial dispensary contacts encouraged us to reach out to the brands directly and gave us the names of popular brands, distributors, and parent companies, though we did not receive any direct contact information or specific names of people to contact. we used the online search engine, weedmaps (www.weedmaps.com), as the primary source to learn more about the popular brands being sold in local dispensaries. we contacted brands and distributors primarily by email, but we also reached out on the social networking website, linkedin. we continued to reach out to local dispensaries in the area using email and linkedin, providing our email and phone numbers for follow-ups. in total, we contacted 54 brands known to be popular in los angeles dispensaries and recommended by the staff members (i.e., budtenders and store managers) from the local dispensaries. they were large, well-known brands but also more local, lesser-known brands that customers would often see in los angeles retail dispensaries. of the 54 brands that we contacted, 18 (33.3%) of them responded. thirteen independent brands provided us with packaging, and the other 5 operated under parent distribution companies that provided an additional 14 brands. all together, we received packaging from 32 brands. including products from dispensaries (one brand of which overlapped with products sent to us by an independent company), the total number of different brands represented in the cannex is currently 51 (as of august 2024). we ensured that the cannex would be well stocked with the variety of products that individuals would encounter in a local dispensary. among the 51 brands, we received a total of 444 different cannabis products: 147 different edibles (including 9 different beverages and 3 syrups), 174 different kinds of flower (including prerolls and packaging/jars for bud), 81 disposable or “allin-one” vapes (either empty or filled with simulated cannabis oil), 20 different concentrates, 16 different kinds of tinctures, and 6 different topicals. within these different products, we often had multiples of the same products, which put our total number of products at 956 as of august 2024. this included 411 edibles (including beverages and syrups), 317 flower products (including prerolls and packaging/jars for bud), 176 vapes and concentrates, and 52 tinctures and topicals. all products in the cannex are donations. we aimed to stock the cannex with products of varying potencies and cannabinoid combinations. we targeted inclusion of high and low thc products, thc-only products, and products with a mix of thc and other featured cannabinoids (such as products with thc and cbd). we sought products that also contained cannabinoids growing in popularity, such as thca (tetrahydrocannabinolic acid), thcv (tetrahydrocannabivarin), cbg (cannabigerol), and cbn (cannabinol). products often have “buzz words” on the packaging, and we aimed to also collect products that contained such phrasing within broader categories of pain (e.g., “recover,” “alleviating”), sleep (e.g., “sedating”), social (e.g., “talkative”), calm (e.g., “relaxing,” “tranquil”), intimacy (e.g., “passion,” “arousal boost”), focus (“alert,” “peak productivity”), happiness (“euphoric,” “bliss”), and others (e.g., “creative,” “energy,” introspective”). this allowed us to create a versatile inventory that is available to other researchers desiring to use the cannex. we also created a website with prices for the products that individuals visiting the cannex could access using a qr code on provided ipads or personal phones. individual products did not contain price tags, as we expect these prices to change according to the needs of specific studies. initial pricing was set using average pre-tax prices listed across stores on the weedmaps site as of august 2024. if we could not find a price point for a particular product, we priced that product based on similar available products. phase 2 methods cannabis, a publication of the research society on marijuana 58 we invited employees from local cannabis dispensaries to visit the cannex and offer feedback via an audio-recorded interview and a brief online survey. for the feedback sessions, we displayed only a selection of products we received (primarily the products we had received first and that were the most popular) and often only put out one of the specific products, even if we had multiple of them. products without labels were not displayed. we first contacted the staff who had initially provided us with packaging. we then cold-called and -emailed other local dispensaries. in two instances, contacts from the dispensaries we connected with referred us to other employees from additional local dispensaries. these processes led to 20 completed interviews, with 20 employees from 14 local dispensaries and one parent cannabis company visiting the cannex and participating in interviews. there were two occasions in which two employees from one dispensary came during a single visit (i.e., two worked in the same store, while the other two worked in separate stores under the same parent company), while the remaining 16 employees participated in individual interviews. regarding their current position, seven participants were current budtenders, six were store managers, one was a regional manager, three were inventory managers, two were dispensary store owners, and one was a field marketing representative for their brand. each interview was facilitated within the cannex by one or two members of the research staff. all participants completed consent materials approved by the local institutional review board. online surveys were completed on provided ipads or participants’ personal devices in a private room following the interview. for their participation, which lasted approximately 90 minutes for the interview and survey, participants were provided with a $100 gift card redeemable at a number of different retailers (e.g., amazon, target, walmart, starbucks). interview questions as participants entered the cannex, we asked for their initial impressions (e.g., tell us what you think), as well as more directive questions to garner their feedback (e.g., does this feel like a real dispensary, what do you think of the design/décor). we asked participants what they thought about the layout of the cannex (e.g., layout of shelves by product type). as participants walked around the cannex and offered their impressions, we asked how familiar they were with the products we had in the space, as well as whether we were missing any products (or specific popular brands) that customers would typically find in their own and other dispensaries. we also asked them how they become familiar with the products that they sell in their own dispensary. these conversations were focused on these main questions, but the discussions were semi-structured to allow the participant ample time to discuss certain aspects of the cannex that caught their attention. we also sought feedback on how to improve the cannex, including layout, products, and any other constructive feedback about marketing and product placement they could offer. survey questions after the interview, each participant filled out a brief survey with demographic information, work and training history, items about training to be a retail staff member, and items about how they get familiar with the products they sell in their own dispensaries. phase 2 results description of the sample table 1 details the demographics and work histories of the 20 cannabis staff participants. participants were approximately 30 years old on average and split in terms of gender identification. about one-third were hispanic/latinx, one-third were white, and the other third were american indian/alaskan native, asian, african american/black, or identified with multiple races/ethnicities. participants had worked in the cannabis industry for a mean of 6.4 years (range 1 year to 18 years), and several had held multiple positions over that time period (e.g., budtender, store manager, marketing jobs). just five participants had roles as budtenders only. participants had much experience working specifically as budtenders (mean of 4.4 years, ranging from 1 to 18 years) across a number of different dispensaries (mean of 6 different dispensaries, ranging from 1 to 30 the cannex research lab 59 different ones). half (50%) had worked in cannabis dispensaries when only medicinal cannabis was available for sale in the u.s. (i.e., prior to 2014, but recreational stores did not open until 2018), with all but one participant working only in california during their careers in the cannabis industry (one worked in a colorado dispensary before moving to california). table 1. sample demographics and work history (n = 20) mean (sd)/frequency range age 30.50 (6.61) years old 23 to 46 years old sex 11 male, 9 female - gender 10 man, 10 woman - race/ethnicity 7 hispanic/latinx 7 white 1 american indian/alaskan native 1 asian 1 african american/black 3 other or multiple race/ethnicities1 - years worked in the cannabis industry 6.40 (4.72) years 1 to 18 years roles had in the cannabis industry 16 budtenders 11 store managers 8 marketing (including graphic design) 3 store owners 3 growers 3 store investors 2 inventory associate/buyer - years worked as a budtender 4.40 (4.53) 1 to 18 years number of different dispensaries worked at 6.16 (7.39) 1 to 30 dispensaries note. 1of the three other or multiple race/ethnicity participants, one identified as asian and white, one identified as hispanic/latinx and american indian/alaskan native, and one did not specify. feedback about the cannex the main function of the cannabis retail staff interviews was to gather general feedback on the cannex and how we could improve it for future research. thus, as participants entered the space, we asked them for their general impressions. all participants said that it felt like a real dispensary, with a “mom and pop” or “boutique” feel shared by many dispensaries in los angeles. for example, one participant said, “honestly this is just what most modern dispensaries look like nowadays. you got your green, your plants [referring to decorative plants]. and then you got that background [referring to the welcome sign on the screen] ... if i walked in and i didn't intend to buy marijuana, it wouldn't take long to figure out that i'm probably in a marijuana facility. but a very high end one.” cannabis, a publication of the research society on marijuana 60 another said, “it has a sophisticated vibe to it. meaning the wood paneling, this granite marbleish feel is very earth tone. there's not neon lights and house music playing. it's a very upscale and minimalist. but rustic in the sense – the foliage behind the tv. it all ties into the earth tones and the wood and the grains and everything. it has a very natural feel to it. nothing's overly glossy, shiny. everything has this subtle matte vibe.” participants reported liking the décor (e.g., hanging plants, wall art) and the layout by product type (e.g., edibles section, flower section with prerolls). one participant described two types of dispensaries in the los angeles area (i.e., boutique style and “packed stores…almost like a walmart or costco”) and noted that the cannex had successfully implemented a boutique style by not packing the shelves full of products. this participant specifically noted that this style tended to be associated with higher quality products and more knowledgeable staff (e.g., “and i think for the style that you guys chose, you could definitely expect walking in more expensive prices and maybe more knowledgeable employees”). participants liked the flow of the dispensary and the ability of the customers to shop without much contact from the budtender(s) unless desired. they noted that the small beverage refrigerator was well-placed, as were the items that tend to be less popular but one would want to push at the point of sale. several participants expressed approval at the number of products on display, favoring how it would not feel excessive or overwhelming for customers (e.g., “it's simple. it's nothing overwhelming ... people don't like it when it's too crazy”). all participants generally reflected that the cannex contained most of the main brands one would expect to see in a los angeles dispensary (e.g., “you guys have majority brands. like good brands, too”), as well as all expected product types, with the exception of some emerging specialty products. when we were missing a brand that the participant thought we should have in stock, we were able to contact the brand’s customer services to request packaging. notably, several participants mentioned that the cannex did not have any actual flower/buds in the shop. they described that customers who buy flower do tend to at least like to see, if not also smell, the flower product before purchase (e.g., “it does help move that product when you can see the bud. so maybe they're walking by and [the customer is] like, oh, ‘that's so purple.’ … and i always say the nose knows. so if it smells good, you're probably gonna at least think it tastes good or enjoy it a little bit. sometimes people smell something and they're like, ‘ugh’”). participants also gave advice on restructuring the stock, which mostly related to placing several products at eye level and relocating higher-end products on a slightly higher shelf. several also suggested that we increase our inventory of tinctures, topicals, and beverages, although they described that these products are generally the lowest in stock at dispensaries because of lower customer interest. a few participants also discussed how the space felt small and too quiet (i.e., no music playing in the space during interviews). many participants also recommended organizing flower by quantity (i.e., distinguishing between eighths and the larger quantities like half ounces and ounces in product displays; e.g., “for flower … a lot of people still don't even really know what an eighth is or how much they want … i would maybe keep the eighths together, the half and then the ounces at least that's what we do. we have all of our top shelf eighths and then we have cheaper eighths like [product name removeds]in a category. and then we have all our larger quantities in one area”). training and familiarity with products future studies using the cannex would necessitate having staff in the space to facilitate interactions with “customers” (i.e., research participants) and to act as budtenders to “sell” products. thus, we asked participants in the survey to describe any formal budtender training they might have received, as well as how budtenders gain familiarity with the products sold in their dispensaries. surprisingly, the majority of participants (n = 13; 65%) reported no formal training beyond what was taught in-house by their employer on the job. of the seven who received training, three (15%) took an online course for a budtender certification, and four (20%) took an in-person budtender training. regarding familiarity with products, participants tended to report on the surveys that they tried the majority of the products sold in their dispensaries. participants estimated on the survey that they try a mean of 62.8% (sd = 35.95) of the products they the cannex research lab 61 sell, with over half (55%) reporting they try 80% or more of the products that they sell. three (15%) reported trying every product. on the survey, participants were asked about their strategies for responding to customers who ask about products they have not personally tried. eight participants (40%) reported that they tell the customer they have never tried the product before, eight (40%) direct the customer to another employee who has tried the product, 12 (60%) offer anecdotes about the product that they have heard from other people, and seven (35%) refer to the packaging to help guide their description of the product. only one participant reported pretending that they have tried the product before. during interviews, participants seemed to be forthcoming about how they became familiar with their products. most discussed personally trying the products so that they felt confident making certain recommendations (e.g., “‘i need to try this … so i can be able to tell people what you feel”). they would also gather information from talking with other budtenders who had tried the products. in addition, participants discussed talking with brand ambassadors and representatives that would come to their stores and offer free samples to the staff at the stores, as well as incentives (e.g., discounts on future product inventory purchases) for featuring their newer or less popular products. participants reported looking at other dispensaries’ websites and on dispensary and product search engines like weedmaps and leafly. they said they would look at the label on the product to help inform them about the effects, but also noted how the labels (e.g., cannabinoid concentration) often sell the products themselves, as they offer much information (e.g., “so it sometimes is good to go off the packaging, but i feel like packaging usually does sell itself”). some of what they learned about products came from the customers themselves, who often share their personal experience of using products with budtenders. lastly, participants discussed the importance of knowing their customer base and what products certain kinds of customers are more likely to seek out. they mentioned how customers are often more interested in trying other products from a brand they already like. for example, participants mentioned it would be important to stock the cannex with an entire catalogue from a brand’s specific product, such as multiple flavors of edibles from the same brand (e.g., “the people that are coming in to buy edibles want a variety of that brand … like [brand name removed]. you have to have almost the entire lineup in order for it to make sense to the customer”). they discussed how most customers will enter the dispensary with pre-formed ideas about how they want to feel from using the product (e.g., “i ask people what are they looking to feel”). if their store of choice does not sell a certain product the customer is accustomed to, participants described how they may offer the customer an alternate product they think will give them a similar feeling to what they are describing. discussion it has become increasingly important to examine cannabis purchasing behavior, including what attracts consumers to certain products and what health and risk messages they glean from product packaging. beyond the messaging that the products alone convey to consumers, it is important to examine how storefront employees interpret product messaging and how they would convey such messaging to consumers. to expand beyond surveillance and observations methods currently used in cannabis dispensary research, we designed the first known mock cannabis dispensary laboratory as a place where researchers can conduct observational and experimental studies on cannabis purchasing and selling behaviors in a controlled and fully customizable environment. through direct collaboration with local cannabis dispensary owners, staff, distributors, and brands, we were able to fully stock our mock cannabis dispensary, the cannex, with products that allowed us to model a modern cannabis dispensary representative of those found in the los angeles area. cannabis retail staff participants offered constructive and generally positive feedback during interviews inside the cannex, which will help us make modifications to the environment in preparation for future research studies. we encourage researchers at our institution and at others to collaborate with our research team and use the cannex for their own unique research ideas. before we discuss some of the novel implications, there are important limitations to note regarding the use of a simulated environment. first, participants in the cannabis, a publication of the research society on marijuana 62 cannex know the environment is a research setting, and that awareness could impact their behavior in myriad ways. the health campus setting could, for example, prime participants to attend more to health features of products than they ordinarily would. perhaps more importantly, participants in a research mock dispensary such as the cannex are aware their behavior is being observed. while we took steps to establish a nonjudgmental rapport with participants, selfpresentation motivations likely remain. research questions pertaining to behaviors that participants might feel would be judged unscrupulous (e.g., false claims directed at upselling) or that are illegal (e.g., selling to minors) are likely addressed better by other methods. we are also limited by the specific brands that are featured in the cannex and recognize that continual updates of the products on the shelves will be necessary to match novel and popular products sold in real dispensaries. specific to the interviews conducted, our findings are limited by the geographical constraints of the cannabis industry workers in the los angeles area. though their perspectives were extremely helpful in finalizing the cannex, which was designed to model a dispensary full of products one would see in a similar los angeles dispensary, nearly all had only worked in california dispensaries, which limits the generalizability of the cannex outside the local area. however, despite the limitations, the ability to tightly control the environment in a simulated dispensary has important advantages for addressing many questions. first, the cannex can answer research questions related to purchasing decisions among individuals. mainly, what about certain products draws an individual’s attention to them and what environmental factors within a dispensary more generally influence individuals to buy certain products over others. many environmental factors in the cannex can be controlled, such as the general floor plan layout (e.g., display cases along the wall or centered in the room, posters and décor can be changed), lighting (e.g., lights dimmed or bright, spotlights on certain items, windows open or closed), and sound (e.g., music on or off, different styles of music, varying volume). video cameras can be installed to capture behavior in the cannex, and audio recording devices – either personal microphones or in-ceiling microphones – can be used to monitor and code discussions between customers and staff. regarding inventory, in addition to choosing specific products and brands to display on shelves, the location of products and prices can be changed dependent on studies’ needs. products themselves can be manipulated, with size and placement of labels able to be changed. warning labels and purported health effects on packaging can be altered to test how customers interpret a product’s effects based on labeling alone. the concentration and potency of specific cannabinoids, perhaps also paired with purported health effects, can be modified. product packaging can be manufactured to represent new and emerging products, including fabricated products with concentrations of cannabinoids not likely to be seen in regulated stores (e.g., if given the chance, would individuals purchase extremely high potency thc products that are not normally available in legal dispensaries). experimental and administration studies could also be conducted within the cannex and broader biosim space. for example, researchers can test purchasing behavior when deals/promotions are presented to customers, such as buy-one-get-one deals or loyalty programs, where customers are offered discounted products after spending a certain amount in the store. on-counter displays, posters, or presentations with educational material about cannabis products can be created and tested in the cannex to learn more about how individuals interpret information about risks and effects of products, and how the presence or absence of these educational materials influence the purchase of specific products. eye-tracking studies can be conducted in the tightly controlled environment to gather detailed data on what parts of product packaging customers are attending to most (e.g., do customers read warning labels, are they attracted to certain imagery or text on packaging). moreover, participants may eventually be able to “purchase” actual products in the cannex and use them within the larger biosim (which includes private spaces with ventilation), completing objective and subjective measures or taking part in experimental studies. in addition to learning about the purchasing behavior of customers, the cannex can be used to study budtender messaging within the dispensary environment, as storefront staff the cannex research lab 63 represent an important population that often provides both naïve and knowledgeable customers with details about products and their purported health benefits (cameron et al., 2023; peiper et al., 2017; popova et al., 2017). budtenders can be invited to the cannex to participate in interviews about how they sell certain products to customers, or scripts could be created for mock budtenders in the cannex to provide participants with recommendations or educational information when shopping in the store. the cannex could also be used to examine regulatory compliance (e.g., display of warnings) and help to inform policy about emerging high potency thc products, which are available in different formulations and methods of administration and have been implicated in rising rates of cannabis use disorder (cud), particularly among young adults (budney et al., 2019). in conclusion, the cannex represents the first known mock cannabis dispensary laboratory in the country that allows for observation of participants in a fully customizable dispensary environment to fit the needs of researchers. we encourage partnerships with other researchers interested in cannabis dispensary research and with those who work in the cannabis industry as the field continues to learn about the health benefits and risks of use, as well as the policy implications of cannabis in an increasing legal recreational atmosphere. references barcott, b., & whitney, b. 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(2020). are canadian cannabis dispensaries counselling pregnant women appropriately? journal of obstetrics and gynaecology canada, 42(5), 693. https://doi.org/https://doi.org/10.1016/j.jogc.20 20.02.104 walsh, z., gonzalez, r., crosby, k., s. thiessen, m., carroll, c., & bonn-miller, m. o. (2017). medical cannabis and mental health: a guided systematic review. clinical psychology review, 51, 15-29. https://doi.org/https://doi.org/10.1016/j.cpr.201 6.10.002 winstock, a. r., lynskey, m. t., maier, l. j., ferris, j. a., & davies, e. l. (2021). perceptions of cannabis health information labels among people who use cannabis in the u.s. and canada. international journal of drug policy, 91, 102789. https://doi.org/https://doi.org/10.1016/j.drugpo .2020.102789 funding and acknowledgements: this research was funded by a university of southern california institute for addiction science biobehavioral research facility pilot project award (pis pedersen, prince, monterosso). conflict of interest statement: cannabis associate editor adrian bravo served as the action editor for this article. the authors have no other conflicts to declare. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 66 source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: pedersen, e.r., prince, m. a., shute, i. s., brown, m. e., gray, b., buch, k. d., & monterosso, j. (2025). developing a mock retail cannabis shop for research: a description of the cannex. cannabis, 8(2), 51 66. https://doi.org/10.26828/cannabis/2025/000297 issue date: july 15, 2025 research article 1 ved abstract objective: since legalization in 2018, older canadians’ use of cannabis has increased steadily, yet little is known about their perceptions of cannabis. we aimed to determine cannabis usage, and characterize perceptions of safety, effectiveness and stigma in community dwelling older canadians. method: canadians aged 50 years and older were invited to participate in an electronic survey of their experience with cannabis and perceptions of cannabis safety, effectiveness, and stigma. data were categorized as participants reporting current use, non-use, prior use, and considering use. perceptions were assessed with a 5-point likert scale and open text box questions. logistic regression models were used to assess how age, sex, cannabis usage, and education influenced perceptions. results: one thousand six hundred fifteen participants completed the survey. current cannabis use was reported by 44% of respondents, followed by non-use (33.2%), prior use (16.5%) and considering use (6.1%). almost half (49.2%) perceived the risks of using cannabis to be low or very low. the greatest concerns regarding cannabis use were effects on cognition/mental health (40.8%), physical health (19.1%), and available product information (18.0%). participants somewhat or strongly agreed that there is not enough information on cannabis safety (60.4%) and effectiveness (63.8%), and 34.7% perceived there to be a negative stigma amongst family and friends. cannabis perceptions were influenced by age, sex, cannabis usage, and education. conclusions: generational and sex-based differences exist in cannabis usage and perceptions amongst older canadians. these differences require consideration by health practitioners and public health workers to meet the educational needs of older adults. key words: = cannabis; aged; older adults; perceptions; social stigma cannabis use has increased in older adults worldwide for both medicinal and recreational purposes (han & palamar, 2020; solomon et al., 2021). in canada, where cannabis use was legalized in 2018, the rate of new cannabis use is increasing fastest amongst older adults, jennifer bolt1,2, jacob movold3, melanie fenton4, megan behm3,4, jill williamson4, jennifer m. jakobi3,4,5 1faculty of pharmaceutical sciences, the university of british columbia 2department of pharmacy services, interior health authority community health & services centre 3school of health & exercise sciences, university of british columbia okanagan 4aging in place research cluster, university of british columbia okanagan 5institute for healthy living and chronic disease prevention, university of british columbia okanagan cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000306 volume 8, issue 2 cannabis use and perceptions of cannabis safety, effectiveness, and stigma amongst older canadians: a cross-sectional survey corresponding author: jennifer bolt, bscpharm, pharmd, mha, kelowna community health & services centre, 505 doyle ave. kelowna, british columbia, canada, v1y 6v8. phone: (250) 469-7070 ext. 13459. email: jennifer.bolt@interiorhealth.ca cannabis, a publication of the research society on marijuana 2 surpassing all other age cohorts (statistics canada, 2019). a recent survey found that 30% of canadians aged 50 years or older use cannabis, of whom 40% used cannabis for the first time since legalization (smith et al., 2020). despite this, little is reported on older canadians’ perceptions of cannabis since legalization. much of the data on cannabis use and perceptions are from the general adult population, with information on older adults combined into a single age cohort (statistics canada, 2019; keethakumar et al., 2021; levy et al., 2021; kleidon et al., 2023). prior research has shown that age, gender, and education can impact cannabis usage and perceptions of cannabis risk (cuttler et al., 2016; levy et al., 2021; wadsworth et al., 2025). however, this has not been independently explored across the diverse group of older adults. there is substantial heterogeneity in cannabis perceptions, and in older adults this may be exacerbated through the different lived experiences of the baby boomers (~57-75 years) and the silent generation (~76-95 years). a united states study found baby boomers to be unique in their cannabis use, as factors such as gender, ethnicity, and education were less predictive of cannabis use than in other generations (carlson et al., 2022). however, cannabis use was only compared in baby boomers to a single cohort of adults in other generations and lacked data on cannabis perceptions and a specific comparison to other older cohorts. additionally, it may not be applicable to the canadian context, where legalization is federally governed and applied nationwide. increased understanding of how cannabis usage and perceptions differ amongst older adults will better equip public health agencies and medical practitioners to support older adults who use cannabis or are seeking information on its use. to address this, our objective was to gather selfreported evidence about the use and perceptions of cannabis among community dwelling canadians aged 50 years and older. we hypothesized that significant differences in cannabis usage and perceptions of safety, effectiveness, and stigma would exist between different cohorts of age, sex, and education. methods an anonymous survey of older canadians was conducted online using the qualtrics xm platform. recruitment included advertisement through social media, and on websites and email listservs of the aging in place research cluster, the institute for healthy living and chronic disease prevention, national association of federal retirees and further spread through a snowball effect, whereby participants shared the survey invitation with social contacts (parker et al., 2019). the emails provided links to the aging in place website where potential participants could read about the study and link to the questionnaire. the survey was open from february 5, 2022 to september 6, 2022 and available in both french and english. canadians aged 50 years and older were invited to participate, regardless of cannabis use history. all participants provided informed consent, which was electronically documented. the survey had 45 multiple-choice and openended questions, intended to be completed in 15 minutes. it was drafted by researchers with extensive experience working with older adults and was informed by literature and clinical experience (cuttler et al., 2016; smith et al., 2020; spackman et al., 2017; yang et al., 2021). it was pilot-tested by several community-dwelling older adults who were representative of the population of interest, with feedback integrated prior to release of the survey. data were collected from all participants on demographics, cannabis use, and cannabis perceptions. postal codes were used to delineate the geographic distribution of respondents. participants self-reported their cannabis use history and were separated into four categories for analysis: non-use was defined as never having used cannabis; current use was defined as participants who self-identified as currently using cannabis at any frequency (daily to less than once per month); prior use was defined as having used cannabis at least once but no longer using it; those considering use had never used cannabis but were considering use. participants were asked to rank their agreement with the following statements on a 5point likert scale (1 = strongly disagree, 2 = somewhat disagree, 3 = neither agree nor disagree, 4 = somewhat agree, 5 = strongly agree): “there is not enough data on effectiveness of cannabis in seniors”; “there is a negative stigma within my perceptions and use of cannabis by older canadians 3 family and friend group towards cannabis”; “there is not enough data on safety of cannabis use in seniors”; “cannabis is safe to use with most medicines.” a higher score was interpreted as a higher level of agreement with the statement. participants were asked how they perceived the risk of using cannabis products (1 = very low, 2 = low, 3 = neutral, 4 = high, 5 = very high) and what they perceived as the greatest risk associated with cannabis use, with answers provided in an open text box. they were asked if their perceptions of cannabis had changed since legalization in canada, with options of yes, no and unsure. additionally, their perceptions of cannabis for medicinal purposes were captured and are described elsewhere (bolt et al., 2024). the database was cleaned, and incomplete survey data were removed. this included removing any respondents who answered less than 50% of the questions and discarding responses to open ended questions that did not answer the question posed. responses in french were translated to english by translation software. responses to open-ended questions were categorized via inductive content analysis (erlingsson & brysiewicz, 2017). a codebook was created by reviewing a subset of the responses. the codebook was used by two investigators (jm, mb) to code the dataset, and cross-checked by two additional investigators (jmj, jb). codes were collapsed into categories, agreed upon by four investigators (jm, mb, jmj, jb) for statistical analysis. the response variables had minimal missing data (< 2%), and, to have a complete dataset were estimated with a markovian chain monte carlo multiple imputation (mi) algorithm. all missing data were considered to be missing-at-random. the same regressors that were used in the final presented models were used to generate the mi dataset. the mi iterations were initiated at 10 and adjusted to ensure model convergence. subsequent regression estimates from the mi dataset and complete case analysis were virtually identical. likert scale dependent variables (perceptions of cannabis stigma, effectiveness and safety) were modelled with an ordinal logistic regression and presented as an odds ratio (or; 95% confidence interval). multinomial outcome variables (cannabis use, change in cannabis perceptions and perceived greatest risk with cannabis) were modelled with a multinomial logistic regression and presented as a relative risk ratio (rrr; 95% confidence interval). independent predictors and reference categories used in the regression models were: age (reference 50-60 years), sex (reference female), cannabis use history (reference current cannabis use), and education (reference graduate/professional education). interaction between covariates were tested prior to final model specification. the proportional odds assumption for the ordinal and multinomial logistic regressions was assessed with the brant’s test. statistical significance is defined with p < .05. categorical data is presented as a number and percent. statistical analysis was performed with stata 14 i/c. results a total of 1,700 responses were received, of which 85 were deemed incomplete and excluded from analysis, leaving 1,615 respondents that were included in this analysis (table 1). most respondents identified as males (49.7%) or females (48.6%), caucasian (92.1%), and having post-secondary (38.8%) or graduate/professional degrees (40.5%). forty-four percent of respondents reported current use of cannabis, 16.0% reported prior use, 33.1% had never used cannabis, and 6.1% were considering cannabis use. current or previous cannabis use was for recreational purposes (47.3%), medicinal purposes (32.7%), or both recreational and medicinal purposes (18.8%). since cannabis legalization in canada, 28.1% of respondents reported that their perceptions of cannabis had changed, 11.3% were unsure, and the perceptions of 60.7% were unchanged. almost half of respondents (49.3%) reported that they perceive the risks of using cannabis to be low or very low, while 18.4% perceived the risks of cannabis to be high or very high. the greatest perceived risks associated with cannabis were “cognitive or mental health concerns” (i.e., cognitive impairment, brain fog, impact on mood; 40.8%), “physical health concerns” (i.e., lung disease, impaired balance, or interactions with medications; 19.1%), “information or product concerns” (i.e., lack of available information on cannabis, uncertainty around cannabis quality and accessibility; 18.0%), multiple concerns (12.2%), and financial concerns (i.e., cost, affordability; 0.9%), while 8.8 % of respondents reported no concerns. over half of respondents cannabis, a publication of the research society on marijuana 4 reported that they somewhat or strongly agree that there is not enough information on the safety (60.4%) and effectiveness (63.8%) of cannabis in older adults (figure 1). approximately one-third reported that they somewhat or strongly agree that cannabis is safe to use with most medicines (34.5%) and somewhat or strongly perceive there to be a negative stigma within family and friends towards cannabis use (34.7%). table 1. participant demographics total (n = 1,615)a male (n = 803) female (n = 784) age (%) 50-60 years 224 (13.9) 87 (10.8) 132 (16.8) 61-70 years 676 (41.9) 315 (39.2) 351 (44.8) 71-80 years 588 (36.4) 329 (41.0) 247 (31.5) 81+years 127 (7.9) 72 (9.0) 54 (6.9) ethnicity (%) caucasian 1488 (92.1) 735 (91.5) 744 (95.0) indigenous 35 (2.2) 22 (2.7) 12 (1.5) otherb 41 (2.5) 27 (3.4) 14 (1.8) prefer not to say 51 (3.2) 19 (2.4) 14 (1.8) urban/rural distribution (%) urban 1316 (81.5) 643 (80.1) 650 (82.9) rural 263 (16.3) 145 (18.1) 114 (14.5) not reported 36 (2.2) 15 (1.9) 20 (2.6) education (%) elementary 5 (0.3) 4 (0.5) 1 (0.1) secondary 288 (17.8) 135 (16.8) 150 (19.1) post-secondary degree 627 (38.8) 300 (37.4) 325 (41.5) graduate degree and/or professional 654 (40.5) 351 (43.7) 289 (36.9) no formal schooling 2 (0.1) 0 2 (0.3) prefer not to say 39 (2.4) 13 (1.6) 17 (2.2) cannabis use history (%) considering use 98 (6.1) 50 (6.2) 46 (5.9) current user 709 (43.9) 368 (45.8) 334 (42.6) prior user 259 (16.0) 125 (15.6) 129 (16.5) non-user 535 (33.1) 254 (31.6) 268 (34.2) unknown/not reported 14 (0.9) 6 (0.7) 7 (0.9) note. a28 respondents reported a non-binary gender or did not provide a gender. these individuals are not separately reported in this table. bother ethnicities: asian (9), afro-canadian (2), south asian (7), hispanic (1), other (22) . perceptions and use of cannabis by older canadians 5 figure 1. perceptions of cannabis stigma, available information, and safety with most medicines note. perceptions of stigma (n = 1,603), effectiveness (n = 1,607), safety (n = 1,594), and safety with other medications (n = 1,077) rated on a likert scale of strongly agree to strongly disagree and reported as a percentage across total respondents age age significantly influenced cannabis use history (table 2), perceptions of cannabis effectiveness, safety, and stigma (table 3), as well as if perceptions of cannabis had changed since legalization (table 4). compared to those aged 5060, there was a lower probability of current or prior cannabis use amongst participants aged 6170 (current use rrr 0.41, 95% ci 0.24-0.69; prior use rrr 0.43, 95% ci 0.23-0.81), 71-80 (current use rrr 0.23, 95% ci 0.13-0.39; prior use rrr 0.26, 95% ci 0.13-0.50) and greater than 80 years (current use rrr 0.17, 95% ci 0.08-0.36; prior use rrr 0.10, 95% ci 0.03-0.34). there was an increased probability of being uncertain if their perceptions of cannabis had changed since legalization for respondents aged 71 – 80 (rrr 2.45, 95% ci 1.25-4.80) and 81 and above (rrr 3.11, 95% ci 1.36-7.12) compared to those aged 50-60 years. compared to those aged 50-60, participants aged 61-70 years (or 0.72, 95% ci 0.55-0.94) and 71-80 years (or 0.72, 95% ci 0.54-0.96) had lower odds of reporting agreement that there is a negative stigma within their family and friend group towards cannabis. there were higher odds of reporting agreement that there is not enough information on the effectiveness of cannabis in older adults in all older age cohorts when compared to those aged 50-60 (61-70: or 1.46, 95% ci 1.11-1.92; 71-80: or 1.67, 95% ci 1.252.22; >80: or 1.67, 95% ci 1.11-2.51). additionally, those aged 71-80 years (or 1.52, 95% ci 1.14-2.02) and 81 years and above (or 1.75, 95% ci 1.16-2.64) had higher odds of reporting agreement that there is not enough information on cannabis safety in older adults sex sex influenced cannabis use history (table 2), perceptions of cannabis effectiveness and safety (table 3), and if perceptions had changed since legalization (table 4). males, compared to females, had lower probability of prior cannabis use, as compared to a non-use of cannabis (rrr 0.20, 95% ci 0.07-0.63), and had a higher probability that their perceptions of cannabis had cannabis, a publication of the research society on marijuana 6 not changed (rrr 1.44, 95% ci 1.15-1.82) since legalization. males, compared to females, had lower odds of reporting agreement that there is not enough information on the effectiveness (or 0.73, 95% ci 0.61-0.87) or safety of cannabis in older adults (or 0.77, 95% ci 0.64-0.92; table 3) and higher odds of reporting agreement that cannabis is safe to use with most medicines (or 1.29, 95% ci 1.03-1.62). males, compared to females, had lower odds of citing information or product concerns as the greatest risk of cannabis use compared to citing no perceived risk (rrr 0.30, 95% ci 0.10-0.94) (table 5). age and sex an interaction between the variables of age and sex was present. this resulted in the relationship of each covariate with the outcome of interest being dependent on the value of the other interacting variable. this interaction between age and sex influenced cannabis use history (table 2) and what was perceived as the greatest risk associated with cannabis use (table 5). compared to females of the same age group, males aged 61-70 (rrr 6.56, 95% ci 1.95-22.06), aged 71-80 (rrr 7.08, 95% ci 2.07-24.21), and aged 81 and above (rrr 11.05, 95% ci 2.07-59.06) had a higher probability of prior cannabis use compared to non-use. compared to females of the same age, males aged 61-70 years (rrr 4.23, 95% ci 1.09-16.42) had higher probability of citing physical health effects as their greatest concern with cannabis use while males aged 71-80 years (rrr 7.54, 95% ci 1.36-41.69) had higher probability of stating cognitive and mental health concerns. males aged 71-80 (rrr 3.99, 95% ci 1.04-5.21) and over 80 (rrr 7.41, 95% ci 1.18-46.59) also had higher probability of citing information and productrelated concerns to be the greatest risk associated with cannabis. cannabis use history cannabis use history influenced the perceptions of cannabis stigma and safety and if perceptions had changed since cannabis legalization (tables 3 and 4). participants who reported prior use (rrr 4.86, 95% ci 2.76-8.58), non-use (rrr 5.92, 95% ci 3.74-9.37), and considering use (rrr 4.88, 95% ci 2.6-9.14) had an increased probability of being unsure if their perceptions had changed since legalization compared to participants who reported current cannabis use. prior use (rrr 2.66, 95% ci 1.863.79) and non-use (rrr 2.45, 95% ci 1.85-3.24) was also associated with higher probability of not having experienced a change in perceptions. participants who reported non-use, compared to current use, had higher odds of reporting agreement that there is a negative stigma within their family and friend group towards cannabis (or 1.95, 95% ci 1.58-2.39), that there is not enough information on cannabis safety (or 1.87, 95% ci 1.52-2.31) and lower odds of reporting agreement that cannabis is safe with most medicines (or 0.29, 95% ci 0.22-0.39). non-use, relative to current use (rrr 1.92, 95% ci 1.203.07), was also associated with higher odds of citing cognitive and mental health related concerns as the greatest risks associated with cannabis. compared to those who reported current cannabis use, those considering use had higher odds of reporting agreement that there is not enough information on the safety of cannabis (or 1.66, 95% ci 1.14-2.41) and lower odds of reporting agreement that cannabis is safe to use with most medicines (or 0.33, 95% ci 0.22-0.49). education education influenced cannabis use history (table 2), perceptions of cannabis safety with medicines (table 3), and how perceptions have changed since legalization (table 4). when compared to those with a graduate or professional degree, participants with post-secondary education (rrr 1.57, 95% ci 1.22-2.04) or elementary/secondary school education (rrr 1.44, 95% ci 1.04-1.99) had a higher probability of reporting current cannabis use versus non-use. those with an elementary or secondary degree had a higher probability of being uncertain if their perceptions had changed since legalization (rrr 1.77, 95% ci 1.08-2.90) and higher odds of reporting agreement that cannabis is safe to use with most medicines (or 1.62, 95% ci 1.18-2.24). discussion this study describes cannabis use and perceptions of safety, effectiveness, and stigma perceptions and use of cannabis by older canadians 7 among older canadians reported by age, sex, and education. cannabis use by older adults was common; however, many perceived there to be a lack of information on cannabis safety and effectiveness, as well as negative stigma amongst family and friends. almost half of the respondents perceived the risk of cannabis use to be low or very low, with cognitive or mental health concerns being the greatest perceived risks. age, sex, education and cannabis use were all found to significantly influence perceptions. respondents to this survey had a higher prevalence of current cannabis use (43.9%) and lower prevalence of lifetime non-use (33.1%) than previously reported (smith et al., 2020; statistics canada, 2019). a survey by statistics canada (2019) found 10.3% of those aged 45-65 years and 6.6% of those aged 65 years reported current cannabis use, while 55.5% and 70.9%, respectively, had never used cannabis. this difference may be influenced by the timeframe of our study (2022) relative to legalization, as evidence suggests increased cannabis use by older canadians in recent years (imtiaz et al., 2023; wadsworth et al., 2025; bc cannabis secretariat and bc stats, 2022). it may also be impacted by responder bias, with greater participation from those who currently use cannabis and individuals more interested in the topic. the probability of current or prior cannabis use decreased as the age of the cohort increased, with the probability of prior use also higher in older cohorts of males relative to females in the same age category. an age-related trend in cannabis use has been demonstrated in previous studies that have assessed older versus younger populations; however, this study uniquely demonstrates this association across multiple age cohorts of older adults. the age-sex interaction identified with prior cannabis use supports previous findings that sex is less influential on cannabis usage in baby boomers, while highlighting the importance of the age-sex interaction in older cohorts such as the silent generation (carlson et al., 2022) perceived risks of cannabis most participants perceived the risk associated with cannabis to be low to neutral, while participants in older cohorts were more likely to perceive an insufficiency of information regarding cannabis’ effectiveness and safety. literature suggests that there has been a reduction in the perceived risk of cannabis amongst older adults in more recent years (han et al., 2021). in canada, this has been influenced by legalization, which has increased social acceptability and decreased the risk perception amongst older adults (health canada, 2023). however, older cohorts in this study, including those within the silent generation, were more likely to be uncertain if their perceptions of cannabis had changed since legalization. perceptions can be influenced by knowledge and experience, and research suggests older canadians utilize online sources as a primary avenue for accessing information about cannabis (butler et al., 2023; shrestha et al., 2024). digital literacy does differ across older generations, with greater accessibility amongst baby boomers compared to the silent generation (lissitsa et al., 2022). hence, the uncertainty regarding perceptional change and greater concern regarding information insufficiency amongst older cohorts may be a result of information accessibility, suggesting a need to target educational delivery to the needs and modalities of different generations. sex also influenced perceptions of sufficient information on cannabis effectiveness and safety. sexand genderbased differences in cannabis perceptions have been identified in younger populations, with females and women perceiving greater risk with cannabis than their male and men counterparts (matheson & le foll, 2023). while a decrease in cannabis risk perception amongst both older males and females has been demonstrated over the past several decades (levy et al., 2021), our study found differences continue to exist not only in the perception of cannabis information sufficiency, but also of greatest risks associated with cannabis. cognitive/mental health and physical health concerns were identified as the two greatest perceived risks of cannabis, both of which were more commonly cited by older cohorts of males compared to females in the same age category. mobility impairment and memory loss have been identified as two of the most prominent health concerns in older canadian males, which may have influenced the degree to which males in this study reported physical or cognitive/mental health effects as a primary concern with cannabis cannabis, a publication of the research society on marijuana 8 (tannenbaum, 2012). conversely, information and product-related concerns were more commonly described by females, aligning with their perceptions of insufficient available information about cannabis. studies suggest many older adults have unmet cannabis-related educational needs (butler et al., 2023; shrestha et al., 2024). the needs may be influenced by genderbased differences that exist in healthand medication-information seeking behavior, including degree of interest, sources consulted, and information sought (tong et al., 2014). females are also more likely than males to use cannabis for medicinal purposes (cuttler et al., 2016; keethakumar et al., 2021; wadsworth et al., 2025), which may have influenced their desire for additional information on safety and effectiveness. further work is required to understand the sex and gender-specific information needs of older adults, including what specific information is desired and how/from whom older adults would prefer to receive such information. however, this study indicates that sex-specific approaches may be necessary to address the greater desire for information on cannabis effectiveness, safety, quality, and accessibility amongst older females. cannabis stigma older age cohorts and non-use of cannabis were independently associated with increased perception of cannabis stigma amongst family and friends. previous studies found that older adults perceive a negative stigma towards cannabis from healthcare professionals and social contacts (dahlke et al., 2024; shrestha et al., 2024; baumbusch & yip, 2022;). data suggest that the previous prohibition and views of cannabis as a gateway drug experienced by the silent generation continue to contribute to stigmatization (baumbusch & yip, 2022; dalke et al., 2024). conversely, baby boomers perceive legalization to have legitimized cannabis use, increasing social acceptability (dahlke et al., 2024). the dissimilarities in perceptions of cannabis stigma between age cohorts in this study necessitates consideration when interfacing with older adults and their family members, particularly in the medical context. these data offer health practitioners and public health workers valuable information to effectively tailor education and recommendations to the diverse population of older adults, and caregivers. limitations the participant group in this study was mainly caucasian, cis-gender, highly educated, and residing in urban settings, and as such, lacks diversity. aspects of race, culture, and faith may have influenced cannabis use and perceptions and require further study. this study did not separately examine current and previous cannabis use in terms of thc and cbd composition, dose, or route of administration, which could have an impact on cannabis perceptions. furthermore, this survey did not collect data to allow for the separate analysis of older adults who used cannabis in their youth and resumed cannabis use later in life, nor did it ask prior users why they stopped consuming cannabis products. these factors may provide further context around differences between current and prior use. additionally, we did not investigate if cannabis use or perceptions differed across regions of canada, which could have provided greater context to the findings. our recruitment strategy involved the voluntary completion of an electronic survey, which may have selected for those with greater technological skills and more interest in or experience with cannabis. finally, the small sample size and greater heterogeneity within some categories resulted in large confidence intervals, which should be interpreted cautiously. conclusion older adults generally view the risks of cannabis to be low. however, concerns exist amongst this population about the impacts of cannabis on cognition, mental health and physical health, and most perceive there to be a lack of available information on cannabis effectiveness and safety. generational and sex-based differences exist in cannabis usage, perceptions, and desire for information amongst older adults, with more caution and concern amongst females and older generations. this information warrant consideration from health professionals and public health agencies. perceptions and use of cannabis by older canadians 9 table 2. multilevel model results for cannabis use for age, sex and education rrr standard error p value 95% confidence interval age current use 50-60 61-70 0.41 0.11 .00 0.24-0.69 71-80 0.23 0.06 .00 0.13-0.39 >80 0.17 0.06 .00 0.08-0.36 prior use 50-60 61-70 0.43 0.14 .01 0.23-0.81 71-80 0.26 0.09 .00 0.13-0.50 >80 0.10 0.06 .00 0.03-0.34 considering use 50-60 61-70 1.12 0.75 .87 0.30-4.14 71-80 1.70 1.11 .42 0.47-6.12 >80 1.11 0.90 .90 0.22-5.47 sex current use female male 0.87 0.31 .69 0.43-1.74 prior use female male 0.20 0.12 .01 0.07-0.63 considering use female male 2.34 1.81 .27 0.51-10.63 age and sex current use females of same age category male 50-60 1.62 0.65 .23 0.74-3.55 male 61-70 1.88 0.76 .12 0.85-4.17 male 71-80 0.91 0.51 .87 0.31-2.71 prior use female of same age category male 50-60 6.56 4.06 .00 1.95-22.06 male 61-70 7.08 4.44 .00 2.07-24.21 male 71-80 11.05 9.45 .01 2.07-59.06 considering use females of same age category male 50-60 0.61 0.53 .57 0.11-3.29 male 61-70 0.35 0.29 .21 0.07-1.82 male 71-80 0.62 0.63 .64 0.08-4.60 education current use graduate or professional postsecondary 1.57 0.21 .00 1.22-2.04 elementary or secondary education 1.44 0.24 .03 1.04-1.99 prior use graduate or professional postsecondary 1.27 0.22 .16 0.91-1.77 cannabis, a publication of the research society on marijuana 10 elementary or secondary education 1.17 0.25 0.46 0.77-1.78 considering use graduate or professional postsecondary 1.31 0.32 0.26 0.82-2.10 elementary or secondary education 0.77 0.26 0.45 0.40-1.50 table 3. multilevel model results exploring perceptions of cannabis stigma, effectiveness and safety for age, sex, cannabis use, and education odds ratio std. err. p value 95% confidence interval age negative stigma amongst family and friends 50-60 61-70 0.72 0.10 .02 0.55-0.94 71-80 0.72 0.10 .02 0.54-0.96 >80 0.76 0.15 .18 0.51-1.13 not enough data on effectiveness 50-60 61-70 1.46 0.21 .00 1.11-1.92 71-80 1.67 0.24 .00 1.25-2.22 >80 1.67 0.35 .01 1.11-2.51 not enough data on safety 50-60 61-70 1.23 0.17 .14 0.94-1.62 71-80 1.52 0.22 .00 1.14-2.02 >80 1.75 0.37 .00 1.16-2.64 safe with most medicines 50-60 61-70 0.83 0.14 .27 0.60-1.15 71-80 0.83 0.15 .29 0.59-1.17 >80 1.14 0.32 .64 0.66-1.98 sex negative stigma amongst family and friends female male 1.01 0.09 .87 0.85-1.21 not enough data on effectiveness female male 0.73 0.067 .00 0.61-0.87 not enough data on safety female male 0.77 0.071 .00 0.64-0.92 safe with most medicines female male 1.29 0.15 .03 1.03-1.62 cannabis use negative stigma amongst family and friends current use prior use 1.15 0.15 .26 0.90-1.48 non-use 1.95 0.21 .00 1.58-2.39 considering use 1.35 0.26 .12 0.93-1.98 not enough data on effectiveness current use prior use 0.90 0.12 .43 0.70-1.16 non-use 1.17 0.12 .13 0.95-1.44 considering use 1.45 0.29 .06 0.99-2.14 perceptions and use of cannabis by older canadians 11 not enough data on safety current use prior use 1.12 0.15 .39 0.87-1.44 non-use 1.87 0.20 .00 1.52-2.31 considering use 1.66 0.32 .00 1.14-2.41 safe with most medicines current use prior use 0.29 0.04 .00 0.220.39 non-use 0.05 0.08 .05 0.0031.02 considering use 0.33 0.07 .00 0.220.49 education negative stigma amongst family and friends graduate or professional degree postsecondary degree 1.10 0.11 .32 0.91-1.34 elementary or secondary 1.00 0.13 .97 0.78-1.28 not enough data on effectiveness graduate or professional degree postsecondary degree 0.94 0.095 .55 0.77-1.15 elementary or secondary 0.89 0.11 .36 0.69-1.14 not enough data on safety graduate or professional degree postsecondary degree 0.92 0.09 .40 0.75-1.12 elementary or secondary 0.87 0.11 .26 0.68-1.11 safe with most medicines graduate or professional degree postsecondary degree 1.24 0.16 .09 0.97-1.60 elementary or secondary 1.62 0.27 .00 1.18-2.24 table 4. multilevel model results exploring changes in cannabis perceptions since legalization for age, sex, cannabis use, and education rrr std error p value 95% confidence interval age no change 50-60 61-70 1.20 0.21 .28 0.86-1.68 71-80 1.31 0.23 .14 0.92-1.86 >80 1.06 0.29 .84 0.62-1.80 uncertain 50-60 61-70 1.84 0.62 .07 0.95-3.6 71-80 2.45 0.84 .01 1.25-4.80 >80 3.11 1.31 .01 1.36-7.12 sex no change female male 1.44 0.17 .00 1.15-1.82 cannabis, a publication of the research society on marijuana 12 uncertain female male 0.80 0.15 .24 0.56-1.16 cannabis use no change current use prior use 2.66 0.48 .00 1.86-3.79 non-use 2.45 0.35 .00 1.85-3.24 considering use 0.73 0.18 .20 0.45-1.19 uncertain current use prior use 4.86 1.41 .00 2.76-8.58 non-use 5.92 1.39 .00 3.74-9.37 considering use 4.88 1.56 .00 2.60-9.14 education no change graduate or professional degree postsecondary degree 1.10 0.14 .44 0.86-1.42 elementary or secondary 1.33 0.23 .09 0.96-1.86 uncertain graduate or professional degree postsecondary degree 1.33 0.27 .17 0.89-1.99 elementary or secondary 1.77 0.45 .02 1.08-2.90 table 5. multilevel model results exploring perceived greatest risk with cannabis for age, sex, cannabis use and education rrr standard error p value 95% conf. interval age physical health concerns 50-60 61-70 0.96 0.46 .93 0.37-2.44 71-80 0.50 0.25 .16 0.19-1.32 >80 0.31 0.21 .09 0.08-1.19 financial concerns 50-60 61-70 0.78 1.02 .85 0.06-9.97 71-80 1.79 2.16 .63 0.178.99 >80 0.00 0.00 .99 cognitive and mental health concerns 50-60 61-70 1.04 0.47 .93 0.43-2.50 71-80 0.65 0.30 .35 0.27-1.60 >80 0.38 0.22 .10 0.12-1.21 information and product concerns 50-60 61-70 0.56 0.26 .21 0.22-1.40 71-80 0.55 0.26 .21 0.22-1.39 >80 0.41 0.25 .15 0.12-1.37 more than one concern 50-60 61-70 0.79 0.43 .66 0.27-2.29 71-80 0.58 0.33 .33 0.19-1.74 >80 0.42 0.32 .25 0.10-1.84 perceptions and use of cannabis by older canadians 13 sex physical health concerns female male 0.48 0.28 .21 0.15-1.51 financial concerns female male 0.00 0.00 .98 cognitive and mental health concerns female male 0.50 0.27 .20 0.17-1.43 information and product concerns female male 0.30 0.17 .04 0.10-0.94 more than one concern female male 0.40 0.28 .19 0.10-1.58 age and sex physical health concerns females of same age category males 50-60 2.06 1.39 .28 0.55-7.75 male 61-70 4.23 2.93 .04 1.09-16.42 male 71-80 4.97 5.05 .12 0.68-36.38 financial concerns females of same age category male 50-60 219393.20 1.36 x 108 .98 male 61-70 450411.10 2.80 x 108 .98 male 71-80 4.73 x 1011 4.46 x 1011 .98 cognitive and mental health concerns females of same age category male 50-60 1.77 1.11 .36 0.52-6.06 male 61-70 3.03 1.92 .08 0.88-10.49 male 71-80 7.54 6.58 .02 1.36-41.69 information and product concerns females of same age category male 50-60 1.84 1.27 .38 0.48-7.13 male 61-70 3.99 2.72 .04 1.04-15.21 male 71-80 7.41 6.95 .03 1.18-46.59 more than one concern females of same age category male 50-60 2.10 1.70 .36 0.43-10.24 male 61-70 2.65 2.18 .24 0.53-13.33 male 71-80 2.05 2.57 .57 0.18-23.97 cannabis use physical health concerns current use prior use 0.87 0.26 .63 0.48-1.57 non-use 0.78 0.21 .36 0.46-1.32 considering use 0.94 0.44 .90 0.38-2.34 financial concerns current use prior use 0.48 0.40 .38 0.09-2.43 non-use 0.14 0.15 .07 0.02-1.15 considering use 0.67 0.76 .72 0.07-6.24 cognitive and mental health concerns current use prior use 1.35 0.38 .29 0.78-2.34 non-use 1.92 0.46 .01 1.20-3.07 considering use 1.43 0.60 .40 0.62-3.26 cannabis, a publication of the research society on marijuana 14 information and product concerns current use prior use 0.59 0.19 .11 0.32-1.12 non-use 0.80 0.21 .40 0.48-1.35 considering use 1.01 0.46 .99 0.41-2.46 more than one concern current use 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(2021). cannabis: an emerging treatment for common symptoms in older adults. journal of the american geriatric society, 69(1), 91-97. https://doi.org/10.1111/jgs.16833 funding and acknowledgements: work performed by jmj, jm, mb, mf, jw was funded by the eminence award from vice president research and innovation at university of british columbia okanagan for research clusters of excellence. the authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ethical considerations: all procedures performed in this study were in accordance with the ethical standards of the institutional research committees (interior health authority and the university of british columbia’s behavioral research ethics boards [h21-03287]) and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. consent to participate: informed consent was obtained from all participants and documented electronically. consent for publication: not applicable. data availability statement: data is available from the corresponding author upon reasonable request. author statement: jennifer bolt: conceptualization, methodology, investigation, writing – review & editing, visualization. jacob movold: conceptualization, methodology, investigation, formal analysis, writing – original draft. melanie fenton: conceptualization, methodology, investigation, writing – review & editing, project administration. megan behm: formal analysis, writing – review & editing. jill williamson: writing – review & editing, project administration. jennifer m. jakobi: conceptualization, methodology, investigation, writing – review & editing, visualization, supervision. acknowledgements: we would like to acknowledge the contributions richard saczkowski, who performed the statistical analysis for this manuscript. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: bolt, j., movold, j., fenton, m., behm, m., williamson, j., & jakobi, j. m. (2025). cannabis use and perceptions of cannabis safety, effectiveness, and stigma amongst older canadians: a cross-sectional survey. cannabis, 8(2), 1-17. https://creativecommons.org/licenses/by/4.0/ perceptions and use of cannabis by older canadians 17 https://doi.org/10.26828/cannabis/2025/000306 issue date: july 15, 2025 research article 38 ved abstract objective: cannabis use has been increasing among the hispanic/latinx population in the united states (us). little research has expressly focused on culturally relevant factors related to cannabis use processes and problems among this group. the present investigation sought to help bridge this gap and test the main and interactive effects of perceived ethnic discrimination and negative emotional reactivity to minority stress in terms of cannabis use processes, including perceived barriers for cannabis reduction, cannabis use problems, and cannabis use motives, among hispanic/latinx adults in the us. method: participants were recruited through qualtrics panels and included 521 adults who engaged in current (past month) cannabis use (mage = 36.52 years, sd = 10.26; 55.1% male). results: in adjusted models, for perceived barriers for cannabis reduction and cessation as well as cannabis use problems, both perceived ethnic discrimination and negative emotional reactivity to minority stress were independently associated with higher odds of endorsement. for cannabis use motives, negative emotional reactivity to minority stress was positively associated with enhancement, social, coping, and expansion motives, whereas perceived ethnic discrimination was a contributor to conformity motives; effects ranged from small to medium. no interactive effects emerged as statistically significant. conclusions: the current findings suggest that among the u.s. hispanic/latinx population, screening and intervening upon perceived ethnic discrimination and negative emotional reactivity to minority stress may help mitigate challenges with the continued use of cannabis. key words: = hispanic/latinx; tobacco; ethnic discrimination; negative emotionality; cannabis; cessation; motives for use; quitting michael j. zvolensky 1,2,3, bryce k. clausen4, ava a. jones1, rodrigo castillo-avilés1, jessica m. thai1, justin m. shepherd1 lucas bogiaizian5, brooke y. redmond 1,3, & lorra garey1,3 1department of psychology, university of houston 2department of behavioral science, the university of texas md anderson cancer center 3health institute, university of houston 4department of psychological and brain sciences, texas a&m university 5psychotherapeutic area of “asociación ayuda,” anxiety disorders clinic cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000335 volume 8, issue 3 perceived ethnic discrimination and negative emotional reactivity to minority stress: association with cannabis use processes among united states hispanic/latinx adults corresponding author: michael j. zvolensky, phd, university of houston, 3695 cullen blvd., room 126, houston, tx, 77204. phone: (713) 743-8056. email: mjzvolen@central.uh.edu cannabis, a publication of the research society on marijuana 39 the hispanic/latinx population represents one of the largest and fastest growing ethnic groups in the united states (us; u.s. census bureau, 2021). presently, there are over 62 million hispanic/latinx persons in the us, reflecting almost 50% of the total population growth in the country from 2010 to 2020 (u.s. census bureau, 2021). cannabis use rates have steadily increased across all racial/ethnic groups throughout the us (montgomery et al., 2022). there is limited study of the prevalence of cannabis use among hispanic/latinx persons although the work that does exist suggesting increasing rates of use (salas-wright et al., 2019). the available research suggests that while past cannabis use does not often differ between racial/ethnic groups (e.g., 10% prevalence), there is differential prevalence of cannabis use disorder (cud; wu et al., 2014). for instance, hispanic/latinx adults who use cannabis are at an increased likelihood of meeting criteria for past cud (19.5%) relative to non-hispanic/latinx white (13.5%) but not black (19.1%), native american (24.6%), or asian american (17.2%) adults (wu et al., 2016). historically, scientific literature focused on cannabis use and cud among the hispanic/latinx population has received less attention relative to other racial/ethnic groups (e.g., non-hispanic/latinx white, african american; martin-willett et al., 2022; montgomery et al., 2022), even though cannabis has historical roots to medicinal use in certain subpopulations of the hispanic/latinx community (e.g., curanderismo in the mexican folk tradition; cavender et al., 2011; padilla et al., 2001). available work also suggests that cannabis is used for a variety of reasons among hispanic/latinx persons, including coping with life stress, anxiety, and depression, as well as recreational and medicinal use (martin-willett et al., 2022). the experience of ethnic discrimination, or the unfair treatment based on one’s ethnicity, is a common and pernicious life experience among hispanic/latinx people living in the u.s. (cano et al., 2021a). there is empirical work suggesting that higher rates of ethnic discrimination among hispanic/latinx people evidences adverse effects on health and behavior (cano et al., 2021b), as well as substance use (andrade et al., 2021). however, only a limited number of investigations have focused on cannabis use in regard to this observed relationship (bakhtiari et al., 2020; montgomery et al., 2022; pro et al., 2018; walley et al., 2019). available work provides evidence that parallels the larger literature on ethnic discrimination, such that exposure to ethnic discrimination increases the risk for cannabis use (unger et al., 2016). theoretical models and research focused on ethnic discrimination suggest that discrimination may fuel more frequent and ingrained patterns of cannabis use for negative reinforcement reasons. due to ethnic discrimination being associated with higher levels of negative affect, individuals may be more prone to use cannabis to alleviate these aversive states (araújo & borrell, 2006; cano et al., 2016). from a negative reinforcement/mood regulation perspective (wycoff et al., 2018), individuals who identify as hispanic/latinx may encounter more discriminatory experiences, and these experiences may then contribute to more negative/unpleasant mood states. in an attempt to acutely alleviate/regulate these mood states, individuals may then turn to cannabis use. past research not specific to the hispanic/latinx community has supported this negative reinforcement model as a primary reason as to why individuals choose to engage in cannabis use (baker et al., 2004; wycoff et al., 2018). alternatively, and in a non-mutually exclusive manner, exposure to ethnic discrimination may increase the probability of cannabis use for acute positive-affect reasons (leventhal et al., 2017). overall, research in this domain among hispanic/latinx individuals is lacking, particularly as it relates to the effect of ethnic discrimination in regard to cannabis use processes that are theoretically associated with continued use due to additive stress (e.g., causing problems with relationships, medical problems, financial difficulties, legal problems). past empirical research has indicated that prolonged cannabis use is associated with multiple problems in physical, social, and mental domains of life, such as higher rates of mood disorders/psychotic disorders, cardiovascular risk and respiratory illness, higher risk of motor vehicle crashes, and financial difficulties, among others (connor et al., 2021; karila et al., 2014). however, research investigating cannabis use problems among hispanic/latinx individuals is lacking, as well as the relationship between experiencing ethnic discrimination and cannabis use problems. this lack of research hinders efforts to understand the cannabis use among hispanic/latinx adults 40 role of ethnic discrimination in the maintenance of cannabis use and its sequelae among this marginalized population. beyond ethnic discrimination, recent work has suggested that negative emotional reactivity to ethnic minority status stressors can impact psychological adjustment and self-regulatory processes (zvolensky et al., 2024). negative emotional reactivity reflects variation in the degree of affective response to minority stress. previous work suggests this construct is unidimensional as well as distinct from ethnic discrimination and other psychological constructs (e.g., subjective social status; zvolensky et al., 2024). there is limited but growing empirical literature that indicates negative emotional reactivity to ethnic minority stress is associated with substance use behavior. for example, one investigation found that elevated negative emotional reactivity to ethnic stress among hispanic/latinx persons who smoke combustible cigarettes is related to more severe symptoms when trying to quit (zvolensky et al., 2024). to date, no work has addressed the role of negative emotional reactivity to ethnic stress in terms of cannabis use in general or focused on the hispanic/latinx community specifically. reactivity to stress has often been linked to substance use via a coping mechanism, including reducing negative mood states, withdrawal, abstinence-related distress, and life stress (sinha, 2024). other research has highlighted substance use engagement for the purposes of producing increases in positive affect (stellern et al., 2023). for these reasons, an important next step would be to explore the role of negative emotional reactivity to ethnic minority stress cannabis use process, such as perceived barriers for reducing or quitting cannabis, motives for using cannabis, and severity of cannabis use problems. although somewhat speculative given the limited science on the topic, theoretically, perceived ethnic discrimination and negative emotional reactivity to ethnic minority stress may also interplay with one another to confer worse cannabis use and associated processes. theoretically, minority stress models emphasize multi-dimensions of vulnerability for substance use (lehavot & simoni, 2011). conceivably, hispanic/latinx persons experiencing higher degrees of ethnic discrimination and negative emotional reactivity to ethnic minority stress may be relatively more at risk for using cannabis due to the compounded risks inherent to these constructs. thus, the combination of ethnic discrimination and negative emotional reactivity to ethnic minority stress may create a psychologically based synergistic effect, intensifying symptoms (e.g., anxiety, depression, stress) that may promote cannabis use for multiple types of motives and contribute to problems related to use and challenges in reducing or quitting. the present investigation sought to test the main and interactive effects of perceived ethnic discrimination and negative emotional reactivity to minority stress in terms of cannabis use processes among hispanic/latinx adults in the u.s. it was hypothesized that in the context of one another, greater degrees of perceived ethnic discrimination and negative emotional reactivity to minority stress would be positively associated with perceived barriers for reducing or quitting cannabis, motives for using cannabis, and severity of cannabis use problems. further, it was hypothesized that there would be an interaction between perceived ethnic discrimination and negative emotional reactivity, such that higher levels of these two constructs would be associated with greater levels of the studied cannabis criterion variables. methods participants participants were recruited via qualtrics panels, an online data collection portal that can access potential participants across the u.s. through a myriad of recruitment channels. participants can be recruited through email lists, retail stores, and referrals. eligibility criteria for the study included endorsing current cannabis use (past month use), being between the ages of 18 and 65 years of age, self-identifying as hispanic or latino(a), and having access to a computer or mobile device. exclusion criteria included an inability to complete required self-report surveys, lack of proficiency in english, and not providing informed consent. in the current study, all participants (n = 521) identified as hispanic or latino(a). participants were on average 36.52 years of age (sd = 10.26) and 44.90% (n = 234) identified their sex assigned at birth as female. cannabis, a publication of the research society on marijuana 41 additionally, in terms of race, 5.2% (n = 27) identified as alaska native or american indian, 1.7% (n = 9) identified as asian, 11.7% (n = 61) identified as black or african american, 0.8% (n = 4) identified as native hawaiian or other pacific islander, 60.3% (n = 314) identified as white, 8.6% (n = 45) identified as two or more races, and 17.5% (n = 91) identified as ‘other’ racial group not previously mentioned. in terms of state residency, 161 (30.90%) participants resided in the southern u.s. (texas = 77, florida = 38, georgia = 13, north carolina = 9, south carolina = 7, tennessee = 4, alabama = 3, arkansas = 3, virgina = 3, louisiana = 2, kentucky = 1, oklahoma = 1), 188 (36.08%) participants resided in the western u.s. (california = 116, arizona = 15, nevada = 15, new mexico = 13, washington state = 11, oregon = 7, colorado = 5, utah = 5, idaho = 1), 105 (20.15%) participants resided in the northeast u.s. (new york = 42, new jersey = 20, pennsylvania = 14, maryland = 12, connecticut = 7, massachusetts = 7, maine = 1, rhode island = 1, vermont = 1), 66 (12.67%) participants resided in the midwest (illinois = 18, ohio = 14, indiana = 7, michigan = 7, wisconsin = 7, minnesota = 5, missouri = 3, iowa = 2, nebraska = 2, kansas = 1), and 1 participant resided in the pacific islands (alaska = 1). see table 1 for socio-demographic descriptive characteristics of the sample. table 1. breakdown of socio-demographic information (n = 521) variable n[m] %[sd] age [36.52] [10.26] biological sex male 287 55.1 female 234 44.9 annual income $0 $4,999 30 5.8 $5,000 $9,999 7 1.3 $10,000 $14,999 23 4.4 $15,000 $24,999 40 7.7 $25,000 $34,999 63 12.1 $35,000 $49,999 77 14.8 $50,000 $74,999 144 27.6 >$75,000 137 26.3 highest level of education less than high school 5 1.0 some high school 18 3.5 high school or high school equivalent 131 25.1 some college 108 20.7 associate’s degree 67 12.9 bachelor’s degree 110 21.1 master’s degree 72 13.8 doctoral degree 10 1.9 nativity united states 452 86.8 mexico 30 5.8 cuba 12 2.3 puerto rico 8 1.5 dominican republic 5 1.0 cannabis use among hispanic/latinx adults 42 venezuela 4 0.8 ecuador 2 0.4 guatemala 2 0.4 columbia 1 0.2 peru 1 0.2 central america (not specified) 1 0.2 south america/latin america (not specified) 1 0.2 spain 1 0.2 nicaragua 1 0.2 procedures potentially eligible participants with a qualtrics panels account were notified and sent basic information about the study. participants who expressed interest in the study were directed to the study participation link and provided informed consent. after providing informed consent, participants completed a self-report survey on qualtrics. the survey took approximately 60 minutes to complete. each participant was compensated with credit through their qualtrics panels account. a total of 527 surveys were completed. six surveys were removed due to inconsistent responses, resulting in a sample of 521 surveys. this study was approved by the institutional review board at the sponsoring institution. data was collected from june 2024 to august 2024. measures demographics questionnaire. participants reported sex (0  =  male, 1  =  female), race, ethnicity, age, educational level (1 = less than high school to 8 = doctoral degree), income (1 = $0 to 8 = >$75,000), and years residing in the us. age, sex, education, income, average number of cigarettes smoked per day, and number of years in the u.s. were included as covariates. alcohol use disorders identification (audit). the audit (saunders et al., 1993) is a 10-item self-report measure that was developed to assess alcohol consumption, drinking behaviors, and severity of alcohol use problems. items (e.g., “how often do you have a drink containing alcohol?”) are rated on various scales that are anchored to each specific item and are summed for a total score (range = 0–40), where higher scores indicate greater drinking behavior and severity of alcohol related problems. the audit total score can also be used to differentiate individuals without problems (< 7 for females and < 8 for males) from those with potential problems (≥ 7 for females and ≥ 8 for males) and identifies four ‘zones’ with increasing risk and intervention levels: zone 1 (below cut-off; 0–7), zone 2 (simple advice; 8–15), zone 3 (simple advice plus brief counseling and monitoring; 16–19), and zone 4 (referral to specialize for evaluation and treatment; 20–40; babor et al., 2001; higgins-biddle & babor, 2018). the audit total score was used as a covariate for the severity of alcohol use problems in the current investigation and demonstrated excellent internal consistency (α = .92). daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu). the dfaq-cu (cuttler & spradlin, 2017) is a 33item self-report measure of cannabis use, including primary mode of use, patterns of use, and amount of use. lifetime cannabis use frequency (coded: 1 = 1-5 times, 2 = 6-10 times, 3 = 11-50 times, 4 = 51-100 times, 5 = 101-500 times, 6 = 501-1000 times, 7 = 1001-2000 times, 8 = 20015000 times, 9 = 5001-10,000 times, 10 = more than 10,000 times) was determined for the current sample and utilized in the current study as a covariate. the dfaq-cu has demonstrated good reliability and predictive and discriminant validity (cuttler & spradlin, 2017). emotional reactivity to minority stress (erms). the erms (zvolensky et al., 2024) is a 15-item self-report measure designed to assess factors in negative emotional states experienced in response to minority-related racial and ethnic stressors. participants rate the degree to which they agree with each item (e.g., “when i feel unsafe because of my race/ethnicity, i become fearful.”) on a 5-point likert scale ranging from 0 (none) to 4 (much/very much). items are summed cannabis, a publication of the research society on marijuana 43 for a total score, where higher scores indicate greater emotional reactivity to racial and ethnic minority stress. for the current study, the erms was utilized as a predictor variable in all models and demonstrated excellent internal consistency (α = .97). perceived barriers for cannabis reduction and cessation scale (pbcrcs). the pbcrcs (zvolensky et al., in preparation) is a 19-item measure developed by the research team that assesses respondents' perceived barriers for cannabis cessation (e.g., “feeling in less control of you moods,” “miss the companionship of using marijuana,” “fear of failing to quit successfully”). the measure was informed by previous work on tobacco cessation (macnee & talsma, 1995), but the content of items was oriented toward cannabis use reduction and cessation. respondents were asked to report on the level of agreement they had with each statement (0 = not a barrier/not applicable to 3 = large barrier). the pbcrcs maintains a single-factor structure (zvolensky et al., 2018) and good construct validity. internal consistency for the pbcrcs in the present study was excellent (α = .95), and the pbcrcs was utilized as a criterion variable. see supplementary materials for the full scale. marijuana motives measure (mmm). the mmm (simons et al., 1998) is a 25-item questionnaire that assesses five primary motives for cannabis use, including enhancement of mood (e.g., “because it’s exciting”), coping with negative affect or stressors (e.g., “to forget my worries”), social enhancement (e.g., “it helps me enjoy a party”), social conformity (e.g., “to fit in with the group i like”), and expansion of experiential awareness (e.g., “to know myself better”). the sum of the means from the 5 subscales represents a total score. items are rated on a 5-point likerttype scale (1 = never/almost never to 5 = always/almost always). the mmm subscales were used in the current study as criterion variables (α range = .85 .90). marijuana problems scale (mps). the mps (stephens et al., 2000) is a well-established 19item self-report measure of negative social, occupational, physical, and personal consequences associated with cannabis use in the past 90 days. items are rated on a 3-point likert scale (0 = no problem to 2 = serious problem). scores can be calculated as either the total number of problems present (0 – 19) or a total score of the severity of problems present (0 – 38). as in past work (buckner & schmidt, 2008), internal consistency was excellent in the current sample (α = .96). for the current study, the severity of problems score was utilized as a criterion variable. analytic strategy data analyses were completed using ibm spss statistics (version 29). first, bivariate correlations among the measures were examined. additionally, three-step hierarchical multiple regression analyses were conducted for perceived barriers for cannabis cessation, cannabis motives, and cannabis problems. in the first step, covariates of age, sex, educational level, income, number of years in the us, severity of alcohol use problems, cannabis use frequency, and average number of cigarettes smoked per day were entered. in the second step, predictor variables of emotional reactivity to minority stress and perceived ethnic discrimination were mean centered and then entered. in the third step, an interaction term of emotional reactivity to minority stress and perceived ethnic discrimination was entered. to correct for multiple comparisons, an alpha level of .007 was used to determine statistical significance. data was first examined for outliers/influence, normality, etc. (e.g., linearity). to test for multicollinearity, variance inflation factor (vif) scores were calculated for each covariate/predictor, where vif scores > 5 indicated potential multicollinearity (kim, 2019). squared semi-partial correlations (sr2) were used as indices of effect size (interpreted as .01 = small, .09 = moderate, and .25 = large; cohen, 1988). results participant characteristics a breakdown of socio-demographic information is presented in table 1. of note, participants were on average 36.52 years of age (sd = 10.26) and 55.1% (n = 287) identified as male. in terms of cannabis use and other substances, participants on average reported using cannabis 3-4 times a week and were 20.43 (sd = 8.88) years of age when first trying cannabis. in terms of primary method endorsed cannabis use among hispanic/latinx adults 44 for ingesting cannabis, 28.0% (n = 146) identified this as joints, 26.9% (n = 140) identified blunts, 16.3% (n = 85) identified vaporizers, 12.3% (n = 64) identified edibles, 9.8% (n = 51) identified hand pipes, 4.6% (n = 24) identified bongs, 1.7% (n = 9) identified hookah, and 0.4% identified other methods. regarding polysubstance use, 41.1% (n = 214) reported currently smoking tobacco cigarettes, with 31.7% (n = 165) smoking tobacco cigarettes daily. in terms of alcohol consumption, 23% (n = 120) reported not drinking alcohol, 24% (n = 125) reported drinking monthly or less, 18.8% (n = 98) reported drinking 2-4 times a month, 23.8% (n = 124) reported drinking 2-3 times a week, and 10.4% (n = 54) reported drinking 4 or more times a week. descriptive statistics and bivariate correlations descriptive statistics and bivariate correlations are presented in table 2. see table 3 for the regression results. there were no problems related to outliers/influence, normality, etc. vif scores at all steps in all models did not exceed 5. of note, negative emotional reactivity to minority stress positively correlated with perceived barriers for cannabis reduction and cessation (r = .42), cannabis coping motives (r = .34), cannabis social motives subscale (r = .32), cannabis motives-conformity subscale (r = .35), and cannabis use problems (r = .44). moreover, perceived ethnic discrimination positively correlated with perceived barriers for cannabis reduction and cessation (r = .40), cannabis motives-social subscale (r = .31), cannabis motives-conformity subscale (r = .44), and cannabis problems (r = .51). hierarchical regression analysis and moderating effects negative emotional reactivity to minority stress was positively associated with all criterion variables except for cannabis use motives of conformity (p = .054). specifically, negative emotional reactivity to minority stress was positively associated with perceived barriers for cannabis reduction and cessation (b = 0.27, p <.001,), enhancement (b = 0.01, p <.001), social (b = 0.01, p <.001), coping (b = 0.02, p <.001), and expansion (b = 0.01, p = .004) motives, as well as cannabis use problems (b = 0.11, p <.001). perceived ethnic discrimination was only positively associated with perceived barriers for cannabis reduction and cessation (b = 2.21, p = .007), conformity motives (b = 0.27, p <.001), and cannabis use problems (b = 2.23, p <.001). these associations were statistically significant after controlling for multiple theoretically relevant covariates. there were no statistically significant interactions in any model . cannabis, a publication of the research society on marijuana 45 table 2. descriptive statistics and bivariate correlations between study variables (n = 521) variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1. agea - 2. sexa -.02 - 3. educationa .14** -.15** - 4. incomea .12** -.23** .54** - 5. years in the usa .86** -.003 .02 .06 - 6. alcohol use problemsa -.08 -.16** .20** .14** -.10* - 7. cannabis use frequencya .13** -.09* -.14** -.08 .16** -.001 - 8. cigarettes smoked per daya .16** -.07 .09* .08 .14** .13** .03 - 9. emotional reactivity to minority stressb -.13** -.07 .12** .06 -.10* .23** -.05 .07 - 10. perceived ethic discriminationb -.14** -.16** .14** .01 -.14** .38** -.06 .08 .67** - 11. perceived barriers to cannabis reduction and cessationc -.12** -.07 .07 .05 -.15** .27** .03 .03 .42** .40** - 12. cannabis motives enhancementc -.07 -.11* <.01 .03 -.03 .17** .28** .08 .22** .15** .34** - 13. cannabis motives socialc -.13** -.13** .09* .07 -.10* .25** .14** .09* .32** .31** .46** .74** - 14. cannabis motives copingc -.17** -.06 -.001 -.01 -.13** .18** .15** .10* .34** .29** .51** .65** .69** - 15. cannabis motives conformityc -.16** -.11* .22** .10* -.19** .40** -.12** .07 .35** .44** .55** .32** .57** .40** - 16. cannabis motives expansionc -.20** -.16** .10* .08 -.19** .23** .13** .08 .29** .29** .48** .66** .65** .66** .48** - 17. cannabis use problemsc -.13** -.16** .22** .09* -.15** .44** -.03 .05 .44** .51** .54** .21** .34** .33** .52** .34** - mean/n 36.52 234 4.69 6.05 34.77 8.00 6.39 2.96 21.55 2.26 25.19 3.57 3.20 3.43 2.42 3.15 8.99 sd/% 10.26 44.90% 1.60 1.95 11.20 9.16 2.32 7.02 16.85 1.08 15.73 1.01 1.08 1.04 1.21 1.14 9.71 note. **p < .01, *p < .05. a covariate; b predictor variable; c criterion; sex % listed as females (coded: 0 = male, 1 = female); education (1 = less than high school to 8 = grad school or more); income (1 = $0 to $4,999 to 8 = >$75,000); severity of alcohol use problems = alcohol use disorders identification test total score (higgins-biddle & babor, 2018; saunders et al., 1993); cannabis use frequency = number of times cannabis used in lifetime (1 = 1-5 times, 2 = 6-10 times, 3 = 1150 times, 4 = 51-100 times, 5 = 101-500 times, 6 = 501-1000 times, 7 = 1001-2000 times, 8 = 2001-5000 times, 9 = 5001-10,000 times, 10 = more than 10,000 times; cuttler & spradlin, 2017); emotional reactivity to minority stress = emotional reactivity to minority stress total score (zvolensky et al., 2024); perceived ethnic discrimination = perceived ethnic discrimination questionnaire lifetime exposure total score (brondolo et al., 2005); perceived barriers to cannabis reduction and cessation = perceived barriers to cannabis reduction and cessation scale total score (zvolensky et al., in preparation); cannabis motives enhancement, coping, social, conformity, and expansion = marijuana motives measure subscales (simons et al., 1998); cannabis use problems = marijuana problems scale (stephens et al., 2000). cannabis use among hispanic/latinx adults 46 table 3. hierarchical regression of hispanic/latinx cannabis use in interaction with perceived barriers to cannabis cessation, marijuana motives subscales: enhancement, social, coping, conformity, and expansion, and marijuana problems (n = 521) perceived barriers for cannabis reduction cessation b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.01 0.13 -0.07 .943 -0.26 0.24 <.001 sex -0.58 1.39 -0.42 .678 -3.31 2.15 <.001 education 0.20 0.52 0.39 .695 -0.81 1.21 <.001 income 0.14 0.41 0.33 .740 -0.67 0.94 <.001 years in the us -0.18 0.12 -1.57 .116 -0.41 0.05 .004 severity of alcohol use problems 0.42 0.08 5.53 <.001 0.27 0.57 .054 cannabis use frequency 0.36 0.30 1.22 .223 -0.22 0.94 .003 cigarettes smoked per day 0.03 0.10 0.30 .767 -0.16 0.22 <.001 .09 step 2 emotional reactivity to minority stress 0.27 0.05 5.41 <.001 0.17 0.36 .044 perceived ethnic discrimination 2.21 0.81 2.71 .007 0.61 3.81 .011 .14 step 3 emotional reactivity to minority stress x perceived ethnic discrimination -0.01 0.04 -0.16 .876 -0.08 0.07 <.001 < .001 cannabis motives – enhancement b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.02 0.01 -1.98 .048 -0.03 .0001 .006 sex -0.10 0.09 -1.18 .240 -0.28 0.07 .002 education 0.01 0.03 0.18 .857 -0.06 0.07 <.001 income 0.01 0.03 0.44 .657 -0.04 0.06 <.001 years in the us 0.01 0.01 0.78 .435 -0.01 0.02 .001 severity of alcohol use problems 0.02 0.01 3.23 .001 0.01 0.03 .018 cannabis use frequency 0.13 0.02 6.74 <.001 0.09 0.16 .078 cigarettes smoked per day 0.01 0.01 1.56 .119 -0.002 0.02 .004 .13 step 2 emotional reactivity to minority stress 0.01 0.003 3.89 <.001 0.01 0.02 .025 perceived ethnic discrimination -0.04 0.06 -0.77 .440 -0.15 0.07 .001 .03 step 3 cannabis, a publication of the research society on marijuana 47 emotional reactivity to minority stress x perceived ethnic discrimination -0.002 0.002 -0.64 .523 -0.01 0.003 .001 .001 cannabis motives – social b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.02 0.01 -2.47 .014 -0.04 -0.004 .010 sex -0.14 0.09 -1.51 .131 -0.33 0.04 .004 education 0.05 0.04 1.39 .166 -0.02 0.12 .003 income 0.01 0.03 0.36 .720 -0.04 0.06 <.001 years in the us 0.01 0.01 0.64 .524 -0.01 0.02 .001 severity of alcohol use problems 0.02 0.01 4.78 <.001 0.01 0.03 .040 cannabis use frequency 0.08 0.02 3.80 <.001 0.04 0.12 .025 cigarettes smoked per day 0.01 0.01 1.63 .105 -0.002 0.02 .004 .12 step 2 emotional reactivity to minority stress 0.01 0.003 3.67 <.001 0.01 0.02 .022 perceived ethnic discrimination 0.10 0.06 1.68 .095 -0.02 0.21 .004 .07 step 3 emotional reactivity to minority stress x perceived ethnic discrimination <0.01 0.003 -0.18 .861 -0.01 0.01 <.001 < .001 cannabis motives – coping b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.03 0.01 -2.96 .003 -0.04 -0.01 .015 sex -0.04 0.09 -0.41 .682 -0.22 0.14 <.001 education 0.01 0.03 0.40 .687 -0.05 0.08 <.001 income -0.01 0.03 -0.17 .866 -0.06 0.05 <.001 years in the us 0.01 0.01 0.61 .544 -0.01 0.02 .001 severity of alcohol use problems 0.02 0.01 3.23 .001 0.01 0.03 .018 cannabis use frequency 0.08 0.02 4.01 <.001 0.04 0.12 .028 cigarettes smoked per day 0.02 0.01 2.55 .011 0.004 0.03 .011 .10 step 2 emotional reactivity to minority stress 0.02 0.003 4.60 <.001 0.01 0.02 .034 perceived ethnic discrimination 0.08 0.06 1.43 .154 -0.03 0.19 .003 .09 step 3 cannabis use among hispanic/latinx adults 48 emotional reactivity to minority stress x perceived ethnic discrimination -0.02 0.003 -0.99 .323 -0.01 0.002 .002 .002 cannabis motives – conformity b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.01 0.01 -0.79 .428 -0.03 0.01 <.001 sex -0.11 0.10 -1.12 .265 -0.31 0.08 .002 education 0.12 0.04 3.13 .002 0.04 0.19 .015 income -0.02 0.03 -0.65 .514 -0.08 0.04 .001 years in the us -0.01 0.01 -1.28 .202 -0.03 0.01 .003 severity of alcohol use problems 0.05 0.01 8.56 <.001 0.04 0.06 .112 cannabis use frequency -0.04 0.02 -1.98 .048 -0.08 <0.01 .006 cigarettes smoked per day 0.01 0.01 0.99 .321 -0.01 0.02 .002 .22 step 2 emotional reactivity to minority stress 0.01 0.004 1.93 .054 <.01 0.01 .005 perceived ethnic discrimination 0.27 0.06 4.58 <.001 0.16 0.39 .029 .08 step 3 emotional reactivity to minority stress x perceived ethnic discrimination 0.004 0.003 1.58 0.12 -0.001 0.01 .003 .003 cannabis motives – expansion b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.02 0.01 -2.38 .018 -0.04 -0.004 .010 sex -0.22 0.10 -2.25 .025 -0.41 -0.03 .008 education 0.06 0.04 1.64 .102 -0.01 0.13 .004 income 0.01 0.03 0.43 .668 -0.04 0.07 <.001 years in the us -0.01 0.01 -0.64 .521 -0.02 0.01 <.001 severity of alcohol use problems 0.02 0.01 3.79 <.001 0.01 0.03 .024 cannabis use frequency 0.08 0.02 3.93 <.001 0.04 0.12 .026 cigarettes smoked per day 0.01 0.01 1.94 .053 <0.01 0.03 .006 .14 step 2 emotional reactivity to minority stress 0.01 0.004 2.89 .004 0.003 0.02 .013 perceived ethnic discrimination 0.11 0.06 1.84 .067 -0.01 0.23 .005 .05 step 3 cannabis, a publication of the research society on marijuana 49 emotional reactivity to minority stress x perceived ethnic discrimination -0.003 0.003 -0.92 .357 -0.01 0.003 .001 .001 cannabis use problems b se t p 95% bootstrapped ci sr2 r2/ r2change step 1 age -0.05 0.07 -0.69 .491 -0.19 0.09 .001 sex -1.57 0.79 -1.99 .047 -3.11 -0.02 .006 education 1.09 0.29 3.73 <.001 0.51 1.66 .021 income -0.32 0.23 -1.37 .171 -0.77 0.14 .003 years in the us -0.06 0.07 -0.89 .373 -0.19 0.07 .001 severity of alcohol use problems 0.42 0.04 9.73 <.001 0.33 0.50 .141 cannabis use frequency -0.01 0.17 -0.07 .944 -0.34 0.32 <.001 cigarettes smoked per day -0.003 0.06 -0.05 .957 -0.11 0.11 <.001 .24 step 2 emotional reactivity to minority stress 0.11 0.03 3.93 <.001 0.05 0.16 .019 perceived ethnic discrimination 2.23 0.46 4.90 <.001 1.33 3.12 .030 .13 step 3 emotional reactivity to minority stress x perceived ethnic discrimination 0.02 0.20 0.84 .400 -0.02 0.06 .001 .001 note. sex (coded: 0 = male, 1 = female); education (1 = less than high school to 8 = grad school or more); income (1 = $0 to $4,999 to 8 = >$75,000); severity of alcohol use problems = alcohol use disorders identification test total score (higgins-biddle & babor, 2018; saunders et al., 1993); cannabis use frequency = number of times cannabis used in lifetime (1 = 1-5 times, 2 = 6-10 times, 3 = 11-50 times, 4 = 51-100 times, 5 = 101-500 times, 6 = 501-1000 times, 7 = 1001-2000 times, 8 = 2001-5000 times, 9 = 5001-10,000 times, 10 = more than 10,000 times; cuttler & spradlin, 2017); emotional reactivity to minority stress = emotional reactivity to minority stress total score (zvolensky et al., 2024); perceived ethnic discrimination = perceived ethnic discrimination questionnaire lifetime exposure total score (brondolo et al., 2005); both emotional reactivity to minority stress and perceived ethnic discrimination were mean centered prior to analysis; perceived barriers to cannabis reduction and cessation = perceived barriers to cannabis reduction and cessation scale total score (zvolensky et al., in preparation); cannabis motives enhancement, coping, social, conformity, and expansion = marijuana motives measure subscales (simons et al., 1998); cannabis use problems = marijuana problems scale (stephens et al., 2000). cannabis use among hispanic/latinx adults 50 discussion the present investigation explored the singular and interactive effects of perceived ethnic discrimination and negative emotional reactivity to minority stress in terms of cannabis use processes among hispanic/latinx adults in the u.s. this work is important given the rising rates and negative effects of cannabis use among the hispanic/latinx population (salas-wright et al., 2019). results were partially consistent with the prediction. negative emotional reactivity to minority stress and perceived ethnic discrimination explained unique variance in terms of perceived barriers for cannabis reduction and cessation and cannabis use problems after accounting for theoretically relevant covariates. for cannabis use motives, negative emotional reactivity to minority stress offered statistically significant effects for all motives except for conformity, whereas perceived ethnic discrimination was the only predictor that contributed to conformity motives. the size of the observed effects ranged from small to medium across the analyses. the clinical significance of the overall results include the unique variance accounted for by the predictors compared to the covariates (abelson, 1985). notably, perceived ethnic discrimination and negative emotional reactivity to minority stress were positively related at the bivariate level, but shared only 44% of variance. thus, in the context of one another, there was empirical evidence of unique explanatory power for these factors for several cannabis use processes linked to the maintenance of this substance use behavior. this further demonstrates that while both predictors may appear similar in nature, they can be considered distinct constructs predicting unique variance independent of one another. future research could be usefully oriented on the mechanisms underlying the observed relations. it may be that higher degrees of negative emotional reactivity to minority stress and perceived ethnic discrimination, elicit greater emotion dysregulation, which in turn, is related to cannabis use for reasons such as coping and conformity; a process that would involve more ingrained patterns of use and perhaps more challenges in reducing or quitting (weiss et al., 2022). if supported in future research, culturally tailored interventions specifically aiming to increase and enhance emotion regulation skills, within the context of increased negative emotional reactivity to minority stress, could prove to help reduce cannabis use and problems among the hispanic/latinx population. in contrast, higher levels of negative emotional reactivity to minority stress may invoke the tendency to use cannabis to amplify positive affect states and experiences, including social, enhancement, and expansion motives. this perspective would be in line with reward sensitivity models of cannabis use (pacheco-colón et al., 2018). there was no evidence of a synergistic effect for perceived ethnic discrimination and negative emotional reactivity to minority stress for any of the studied cannabis variables. it is possible that the individual effects of these stressors were already substantial enough that their interaction did not yield an additive or multiplicative impact. future research is needed to isolate whether these factors interact with other sociocultural constructs (e.g., acculturative stress; yockey et al., 2020) among the hispanic/latinx population who use cannabis. there are potential clinical implications to the observed findings. regular cannabis use among the hispanic/latinx and other populations frequently elicits life impairment and a decreased quality of life (national academies of sciences et al., 2017; wu et al., 2014), prompting many persons to be motivated to reduce or quit using this substance (chauchard et al., 2013). the current research findings suggest that among the hispanic/latinx population who use cannabis, perceived ethnic discrimination and negative emotional reactivity to minority stress may represent important constructs associated with a myriad of cannabis-related constructs (e.g., motives for use, problems associated with use, barriers for quitting/reducing use). for this reason, there could be value in briefly screening the hispanic/latinx population for cannabis use in primary and urgent care settings and potentially referring those at risk to relevant health professionals, who can consider these culturally salient constructs to help provide better coping mechanism for minority stress. further, there may be utility in developing cannabis interventions for the hispanic/latinx population that provide psychoeducation about the relevance of these factors for the motivational bases of use, challenges in quitting, and severity of cannabis cannabis, a publication of the research society on marijuana 51 use problems. this kind of intervention work could also develop strategies, including cognitive and behavioral methods, that can help to decrease these forms of minority stress to facilitate change in cannabis use behavior. additionally, providing tailored services that are in-line with hispanic/latinx values, offering services in the language that is primarily spoken from the client, and bolstering more community-focused treatments could help decrease these forms of minority stress induced cannabis use behavior. there are several study limitations. first, due to the cross-sectional research methodology, directional and causal inferences cannot be made. building from this initial research on an understudied cannabis-using population, future work could utilize prospective methods that could help isolate the dynamic interplay between the studied constructs. second, we utilized self-report methods. given that a mono-method assessment approach can inflate method variance (kline et al., 2000), research could enlist a multi-method protocol in future efforts to study cannabis use among the hispanic/latinx population. third, the sample consisted of individuals who engaged in current cannabis use, by design, to help ensure a generalizable sample of individuals who use cannabis. however, the studied sample did not all have clinical cannabis use problems (e.g., cud). it may be fruitful for research to extend the present work to hispanic/latinx persons who use cannabis and are engaged in treatment for cannabis use problems. fourth, the present sample was comprised of persons who speak english, as a tactic to ensure comprehensive understanding of the self-report measures. we unfortunately do not know how many participants were excluded because of language proficiency. nonetheless, because language can influence health outcomes among the hispanic/latinx population (lozano et al., 2025), testing the generalizability of the findings to polylingual and spanish-speaking individuals would be advisable. finally, we modeled two theoretically relevant constructs in relation to cannabis use processes. although this is an important first step in an area of study with limited research, there could be utility in exploring other candidates in multi-risk models for cannabis use (e.g., acculturative stress; zamboanga et al., 2009). overall, the present investigation evaluated two relevant factors among hispanic/latinx adults who use cannabis in the u.s. results indicated that perceived ethnic discrimination and negative emotional reactivity to minority stress were related to specific cannabis use processes. the current findings suggest that among the hispanic/latinx population, screening for 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(2024). negative emotional reactivity to minority stress: measure development and testing. cognitive behaviour therapy, 53(1), 1-28. https://doi.org/10.1080/16506073.2023.226056 0 funding and acknowledgements: research reported in this publication was also supported by the national institute on minority health and health disparities (nimhd) of the national institutes of health (nih; u54md015946). the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. author note: the data and ideas presented in this manuscript to date have not been disseminated prior to publication in any conferences, listservs, or websites. data will be made available upon reasonable request. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 55 citation: zvolensky, m. j., clausen, b. k., jones, a. a., castillo-avilés, r., thai, j. m., shepherd, j. m., bogiaizian, l., redmond, b. y., & garey, l. (2025). perceived ethnic discrimination and negative emotional reactivity to minority stress: association with cannabis use processes among united states hispanic/latinx adults. cannabis, 8(3), 38–55. https://doi.org/10.26828/cannabis/2025/000335 brief report 1 ved abstract objective: sexual minority women (smw) have higher rates of cannabis use compared to heterosexual women, which may be partially attributed to lower harm perceptions. however, no study has examined if the association between harm perceptions and cannabis use is stronger for smw than heterosexual women. this study examined if sexual identity (smw vs. heterosexual woman) moderated the association between harm perceptions and past 30-day cannabis use among a sample of female young adults (18-25 years old). method: participants were 949 (29.8% smw; mean age = 24.33; 92.1% non-hispanic white) females (99.3% cisgender) recruited from amazon mechanical turk who reported weekly cannabis use. participants reported how many days they used cannabis in the past 30-days and how harmful they perceived cannabis to be to their health (not at all/slightly/somewhat harmful vs. very/extremely harmful). an analysis of covariance examined the study aim. results: a significantly larger percentage of heterosexual women perceived cannabis to be very/extremely harmful to their health than smw (45.2% vs. 22.6%). those who perceived cannabis to be very/extremely harmful reported more frequent cannabis use in the past-30 days. smw who perceived cannabis to be very/extremely harmful reported more frequent cannabis use relative to those who held lower harm perceptions; there were no significant differences for heterosexual women. conclusions: smw may perceive cannabis as harmful because they may be experiencing health consequences from frequent use. it may be important for interventions and public health campaigns to be tailored specifically to smw and include information about the potential harms of cannabis use. key words: = cannabis use; sexual minority women; harm perceptions rates of cannabis use among young adults are high, compared to older age groups, with recent estimates from the 2022 monitoring the future panel study showing that 28.8% of young adults ages 19 to 30 in the united states reported past month use (patrick et al., 2023). further, sexual minority women (smw) have higher rates of cannabis use than heterosexual women (ehlke et al., 2024; schuler & collins, 2020). specifically, results from the 2021 and 2022 national survey on drug use and health (nsduh) showed that smw were two to three times more likely than heterosexual women to report past year cannabis use (substance abuse and mental health services administration, 2023). sexual identity differences on cannabis use disparities are stronger and more stable for women than men (see dyar, 2022 for a review), indicating that smw are at greater risk of use than heterosexual women, and differences and changes in use for men are less distinct. the high rates of cannabis use among smw are concerning given the health consequences of use, such as psychological distress, cognitive impairment, and adverse respiratory outcomes (figueiredo et al., 2020; hall et al., 2016; russell et al., 2018). despite these notable health sarah j. ehlke1,2, samantha a. fitzer1, kendra n. rigney1 1department of psychology, old dominion university 2virginia consortium program in clinical psychology cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000273 volume 8, issue 1 exploring differences in cannabis use and harm perceptions among sexual minority and heterosexual females: a brief report corresponding author: sarah j. ehlke, phd, old dominion university, 5115 hampton blvd, mills godwin life sciences building room 130b. norfolk, virginia, 23529. email: sehlke@odu.edu cannabis, a publication of the research society on marijuana 2 consequences, some research indicates that compared to adolescents and older adults, young adults have low perceptions that cannabis is harmful to their health (levy et al., 2021; waddell, 2022). for instance, among a sample of young adults, they most often reported perceived risks unrelated to health (e.g., get into trouble, friends upset with you) and greater perceived benefits (e.g., feel high or buzzed, look cool) of using cannabis (nguyen et al., 2022). further, a recent study of young adults found that smw reported lower harm perceptions of cannabis relative to heterosexual women (romm et al., 2023). this finding is alarming given research that low harm perceptions of cannabis are related to greater use among young adults (nguyen et al., 2023; romm et al., 2023). thus, lower harm perceptions of use may be one explanation for why the rates of cannabis are higher for smw than heterosexual women. given the rapidly changing policy landscape of cannabis, there is an urgent need to identify reasons associated with increased cannabis use for smw to inform intervention and prevention programs, with the goal of reducing the rates of use and reducing health disparities among this population. perceived harms of cannabis are an important reason for use among young adults (nguyen et al., 2023) and are often lower than harm perceptions of tobacco products and alcohol (berg et al., 2015; hanauer et al., 2021; nguyen et al., 2023). thus, cannabis use may continue to increase without interventions that address the harms of this product, potentially creating larger disparities for groups that already use at elevated levels, such as smw. this study examined differences between cannabis harm perceptions and sexual identity (sexual minority vs. heterosexual) among a sample of young adult (ages 18 to 25) females who reported weekly cannabis use. additionally, to extend prior research, sexual identity was examined as a moderator of the relationship between cannabis harm perceptions and past 30-day cannabis use frequency. although this study used a female sample, without regard to gender identity, the term smw is used herein to describe the current sample given the extensive use of this term in the broader literature. it was hypothesized that smw would report lower cannabis harm perceptions than heterosexual women, which would be associated with greater cannabis use. methods participants and procedure participants were 949 (29.8% smw) young adult females recruited from amazon mechanical turk (mturk; amazon mechnical turk, n.d.) in february 2023 who completed a larger study about factors related to cannabis use. eligibility criteria included a) 18-25 years old, b) female, and c) report using cannabis some days (at least weekly) or every day in the past 30-days. mturk system and premium qualifications were also used to request participants who live in the united states, had a ≥95% approval rating, were 18-25 years old, and were female. participants were compensated $1 for completing the 12-15 minute survey. participants were on average 24.33 years old (sd = 1.33), primarily not hispanic white (92.1%), completed some college or higher (96.7%), and married (61.9%). in terms of gender identity, 99.3% identified as a woman, 0.6% as a man, and 0.1% as gender non-conforming. for more details about mturk qualifications, participant characteristics, and study procedures, see ehlke et al. (2024). study materials and procedures were approved by the university’s institutional review board. materials sexual identity was measured by asking participants, “how would you describe your sexual identity? would you say you are:” with response options of a) heterosexual, b) lesbian or gay, c) bisexual, d) pansexual, e) queer, f) another sexual orientation not listed, or g) don’t know/unsure. a single sexual identity variable was created where 0 = heterosexual (n = 666, 70.2%) and 1 = smw (all other sexual identities; lesbian/gay n = 3, 0.3%; bisexual n = 265, 27.9%; pansexual n = 11, 1.2%; queer n = 2, 0.2%; another sexual orientation n = 1, 0.1%; don’t know/unsure n = 1, 0.1%). to measure cannabis use frequency, participants reported the number of days in the past 30-days they used marijuana (range = 1-30; m = 12.93, sd = 7.47).1 lastly, harm perceptions were measured by asking participants, “how harmful do you think marijuana is to your health?” with response options of a) not at all harmful, b) slightly harmful, c) somewhat harmful, d) very harmful, or e) extremely harmful. cannabis use and harm perception among females 3 similar to prior research (cohn et al., 2023; sarvet et al., 2018), a binary cannabis use harm perception variable was created where 0 = not at all/slightly/somewhat harmful and 1 = very/extremely harmful. data analysis analyses were conducted in ibm spss statistics (version 28; ibm corp, 2021). past 30day cannabis use frequency was normally distributed with no outliers. chi-square analyses examined differences between sexual identity (smw vs. heterosexual) and cannabis harm perception (very/extremely harmful vs. not at all/slightly/somewhat harmful), and an independent samples t-test examined differences on cannabis use frequency.2 an analysis of covariance (ancova) examined if sexual identity moderated the association between harm perception and cannabis use frequency.3 results a greater percentage of heterosexual women (45.2%) than smw (22.6%) perceived that cannabis was very/extremely harmful to their health, χ2(1) = 42.78, p < .001. additionally, heterosexual women reported cannabis use on more days than smw, m = 13.56, sd = 6.98 vs. m = 11.45, sd = 8.37; t(451.79) = 3.72, p < .001, and those who perceived cannabis as very/extremely harmful to their health reported more frequent use in the past 30-days, relative to those who perceived cannabis as not at all/slightly/somewhat harmful, m = 14.39, sd = 7.32 vs. m = 12.03, sd = 7.43; t(943) = -4.78, p < .001. ancova results showed that smw who perceived cannabis as being very/extremely harmful to their health reported more frequent use in the past 30-days than smw who perceived cannabis as not at all/slightly/somewhat harmful, f(1,941) = 27.09, p < .001. however, there were no differences between harm perceptions and past 30-day cannabis use for heterosexual women, f(1,941) = 3.20, p = .320. see figure 1. figure 1. differences on past 30-day cannabis use frequency based on harm perceptions and sexual identity 13.10 10.23 14.12 15.67 0 2 4 6 8 10 12 14 16 18 heterosexual smw p as t 3 0 -d ay c an n ab is u se f re q u en cy not at all/slightly/somewhat harmful very/extremly harmful 1problematic cannabis use was measured in this study using the cannabis use disorder identification test – revised (cudit-r); however, the majority of the sample (98.6%) met criteria for hazardous use (cudit scores ≥8), possibly due to the eligibility criteria of at least weekly cannabis use. therefore, due to the overwhelming majority of the sample meeting the cutoff score for hazardous use, we did not include this variable in the current study. 2differences between smw and heterosexual women on cannabis use frequency has been examined in a previous publication from this dataset that examined route of cannabis administration; see ehlke et al., 2024. 3age, race (non-hispanic white, non-hispanic black, non-hispanic another race, and hispanic), and income were examined as potential covariates. however, these variables were not significant in the ancova model and results were identical when including and not including these potential covariates. thus, to present the most parsimonious model, the ancova results do not include these covariates. cannabis, a publication of the research society on marijuana 4 discussion this study examined cannabis harm perceptions among smw and heterosexual women, and their association with past 30-day cannabis use frequency. heterosexual women in the current study reported using cannabis on more days in the past 30-days, relative to smw, which is contrary to prior research (ehlke et al., 2024; schuler & collins, 2020). this may be attributed to the recruitment of only individuals who used cannabis frequently for the current study (see ehlke et al., 2024). consistent with prior research (romm et al., 2023), heterosexual women held greater perceptions that cannabis was harmful to their health, compared to smw. lower harm perceptions among smw may be due to social norms related to cannabis use within the sexual minority community (romm et al., 2023). in fact, prior research has found that sexual minority females perceive cannabis as more socially acceptable and that more peers use cannabis, relative to heterosexual women (romm et al., 2023). thus, these higher social norms among smw than heterosexual women may result in greater beliefs that cannabis is not harmful. contrary to prior research (nguyen et al., 2023; romm et al., 2023), among all participants in the current study, those who perceived cannabis as more harmful to their health reported more frequent cannabis use in the past 30-days. this may be attributed to our sample that only included females who reported cannabis use. perhaps participants in other studies that include non-users of the substance being examined have higher harm perceptions, but this may also influence (i.e., lower) the mean when examining frequency of use. conversely, a recent study of only cannabis users found greater cannabis harm perceptions were associated with less frequent use (florimbio et al., 2024). however, this study included males and females, which may have influenced the findings, given research showing that males perceive cannabis as less harmful than females (e.g., hellemans et al., 2019; levy et al., 2021). the current study used a large sample of only females, which may partially explain the different findings. studies examining harm perceptions should focus on subset analyses that include only users of the substance and separate males and females. additionally, prior research has found that greater cannabis harm perceptions are associated with a higher likelihood of problematic cannabis use (romm et al., 2024). unfortunately, problematic cannabis use was not examined in the current study given the high proportion of those who met criteria for hazardous use (see footnote 1). differences between smw and heterosexual women on this association between cannabis harm perceptions and problematic cannabis use should be explored in future research. the current study also extends previous research (romm et al., 2023) by revealing that smw who held higher cannabis harm perceptions reported more frequent cannabis use than smw with lower harm perceptions. these findings show that although some smw acknowledged cannabis was harmful to their health, they continued to use it more frequently than those with lower harm perceptions. this is contrary to prior research about cannabis harm perceptions (nguyen et al., 2023; romm et al., 2023) but is the first study to focus on sexual identity as a moderator of this association and smw specifically. smw with greater harm perceptions may be experiencing more health consequences because of frequent use. it is widely accepted that smw experience sexual minority stressors due to their sexual identity (meyer, 2003) and therefore may use cannabis to cope with these stressful experiences (khantzian, 1997). over time, the increased use of cannabis may result in health consequences and influence harm perceptions. interventions should be tailored for smw, specifically, given the elevated rates of use among this population (ehlke et al., 2024; schuler & collins, 2020). however, a recent review article found that the majority of interventions for sexual and gender minority individuals focused on sexual minority men and that there was a lack of programs for cannabis use (kidd et al., 2022). empirically evaluating cannabis use interventions for smw is also of critical importance (mcgeough, 2021). taken together, interventions to reduce cannabis use should be tailored for smw, incorporate harm perceptions related to use, and evaluated using scientific rigor through randomized controlled trial designs. findings from this study also showed that there were no differences between harm perceptions and cannabis use for heterosexual women. perhaps other factors influence cannabis cannabis use and harm perception among females 5 use for heterosexual women. as mentioned previously, the social norms surrounding cannabis may be different for heterosexual women due to the lower rates of use and subsequently less exposure to use among this population. romm et al. (2023) found that heterosexual females reported lower perceived social acceptability and peer cannabis use, relative sexual minority females. thus, these normative perceptions may also influence harm perceptions. although speculative, if heterosexual women have less exposure to other peers using cannabis, they may believe this behavior is less normative due to the harm it poses to one’s health. while addressing harm perceptions of cannabis is important for all groups, it may be less likely to lead to behavior change or have a lesser impact for heterosexual women, as compared to smw. limitations and future directions several limitations should be noted for the current study. this was a cross-sectional study, limiting the interpretation of causal inferences of cannabis use. future studies should use ecological momentary assessment (ema) designs to examine the momentary association between harm perceptions and cannabis use, and the fluctuation of harm perceptions at the daily level. all smw were grouped together due to the low representation of non-heterosexual identities. specifically, the majority of this sample identified as bisexual/pansexual (97.5%; i.e., bisexual+). understanding subgroup sexual identity differences, such as bisexual+ and monosexual identities (e.g., lesbian/gay). should be considered in future research. problematic cannabis use was not examined in the current study. mturk participants may have different (i.e., higher) rates of cannabis use. which influences problematic use. although mturk is commonly used to collect large samples of data, including examining differences on substance use based on sexual identity (benz et al., 2019; smout & benotsch, 2022), and samples are similar to community samples on demographic factors (burnham et al., 2018), results may not generalize to the larger population of females who use cannabis. additionally, future studies should expand findings to harm perceptions of other substances such as alcohol and tobacco and the co-use of products. comparisons between racial and ethnic minority individuals were not examined, given that the sample was predominantly non-hispanic white, and findings may not generalize to racial/ethnic minority populations. it is important for future research to consider the intersection of sexual orientation and racial/ethnic identity to understand the relationship between harm perceptions and cannabis use for populations with multiple marginalized identities. conclusions given the elevated rates of cannabis use among young adults in the united states, it is important to identify reasons for these increasing trends of use, particularly for health disparity populations such as smw. this was the first study to show that cannabis harm perceptions were associated with cannabis use for smw, but not heterosexual women. because findings showed that higher health harm perceptions of use were associated with cannabis use, it may be critical to disseminate information about the health effects of cannabis, particularly for smw, to reduce frequent cannabis use. references amazon mechanical turk. 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(2022). age-varying time trends in cannabis-and alcohol-related risk perceptions 2002–2019. addictive behaviors, 124, 107091. https://doi.org/10.1016/j.addbeh.2021.107091 funding and acknowledgements: this work was not funded. the authors have no conflicts of interest to report. data and materials from this study are available from the primary author upon request. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: ehlke, s. j., fitzer, s. a., & rigney, k. n. (2025). exploring differences in cannabis use and harm perceptions among sexual minority and heterosexual females: a brief report. cannabis, 8(1), 1-7. https://doi.org/10.26828/cannabis/2024/000273 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ research article 129 ved abstract objective: medical cannabis has emerged as a promising therapeutic option, but its market acceptance faces significant regulatory, societal, and scientific challenges. this study explores pharmaceutical business managers’ perspectives on marketing strategies, brand architecture, and the value proposition of medical cannabis, aiming to identify approaches to overcome these barriers and guide policymaking. method: semistructured interviews were conducted with 12 pharmaceutical managers to explore key challenges and strategies. results: key themes included the need for extensive scientific research, targeted communication to address stigma, effective marketing tactics, and long-term sustainability. participants stressed the importance of rigorous, disease-specific research to establish medical cannabis’ therapeutic efficacy and build trust with healthcare providers and patients. societal stigma was identified as a major barrier, with participants advocating for communication strategies that distinguish medical cannabis from recreational use and educate stakeholders. marketing strategies focused on creating a unique value proposition, strong brand identity, and adaptive approaches to meet the diverse needs of healthcare professionals, regulators, and patients. additionally, phased market entry strategies, beginning with pilot programs in regions with progressive regulatory environments, were recommended to pave the way for broader market expansion. conclusions: this study offers valuable insights into the marketing management and policymaking necessary for integrating medical cannabis into the pharmaceutical market. by addressing regulatory uncertainties, societal stigma, and scientific gaps, pharmaceutical companies can unlock the full potential of medical cannabis as a credible therapeutic product. these findings lay the groundwork for future research and policymaking to promote sustainable growth in the emerging medical cannabis market. key words: = medical cannabis; marketing strategy; brand architecture; value proposition; pharmaceutical market the global interest in medical cannabis as a therapeutic intervention has grown significantly in recent years, driven by its potential benefits in the management of conditions such as childhood epilepsy, spasticity in multiple sclerosis, chemotherapy-induced nausea and vomiting, christos ntais1,2, nikolaos kontodimopoulos3, and yioula melanthiou4 1healthcare management program, school of economics & management, open university of cyprus 2marketing department, school of business, university of nicosia 3department of economics and sustainable development, harokopio university 4department of communication and marketing, faculty of communication and media studies, cyprus university of technology cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000316 volume 8, issue 2 marketing management and policymaking for medical cannabis: overcoming barriers and shaping strategies corresponding author: christos ntais, md. open university of cypress, 2220 nicosia, cyprus. email: christos.ntais@st.ouc.ac.cy marketing medical cannabis 130 chronic non-cancer pain, and other disorders (bukowska, 2024; grimison et al., 2024; jeddi et al., 2024). however, despite the expanding body of evidence supporting its efficacy, the path to market entry for medical cannabis remains fraught with challenges. regulatory hurdles, societal stigma, and gaps in scientific evidence continue to impede its broader acceptance and integration into healthcare systems (ntais et al., 2023a; ntais et al., 2023b). these complexities underscore the need for robust marketing strategies and brand positioning to bridge the gap between therapeutic potential and consumer acceptance. pharmaceutical companies face unique challenges when entering the medical cannabis market. unlike traditional pharmaceutical products, medical cannabis operates within a patchwork of regulatory frameworks that vary across jurisdictions, influencing both product development and marketing efforts (ruheel et al., 2021; ryan et al., 2021). moreover, societal perceptions of cannabis, rooted in its recreational use and historical criminalization, present additional obstacles to brand acceptance (fehr et al., 2024; king et al., 2024). addressing these barriers requires an informed and nuanced approach to branding and value proposition development that aligns with the expectations of healthcare providers, patients, and regulatory bodies. this study examines the perspectives of pharmaceutical business managers regarding the marketing strategies, brand architecture, and value proposition for medical cannabis. by leveraging insights from semi-structured interviews with 12 pharmaceutical industry professionals, this research examines key themes, including the need for rigorous scientific research, the impact of stigma on brand positioning, and the strategic imperatives for product development and marketing. the selection of key topics for the interviews was guided by existing literature on medical cannabis marketing and branding, as well as the regulatory challenges faced by industry stakeholders. given that medical cannabis is positioned at the intersection of healthcare, business strategy, and policy, understanding how pharmaceutical companies navigate these complexities is crucial. business managers were selected as the primary participants because they play a central role in shaping the commercial trajectory of medical cannabis. their expertise in strategic decisionmaking, market positioning and regulatory navigation makes them well-suited to provide valuable insights into how medical cannabis can be successfully marketed and responsibly integrated into the healthcare landscape. by synthesizing business managers’ insights, this study offers actionable recommendations for overcoming barriers to market entry and fostering greater acceptance of medical cannabis. in doing so, it aims to contribute to the ongoing dialogue on how pharmaceutical companies can navigate the complex landscape of medical cannabis to deliver value while addressing regulatory and societal challenges. methods study design this study employed a qualitative research design to explore pharmaceutical business managers’ perspectives on marketing strategies, brand architecture, and value proposition for medical cannabis. semi-structured interviews were conducted to elicit in-depth insights, allowing participants to elaborate on their experiences and viewpoints. the study followed an inductive approach, using thematic analysis to identify recurring patterns and themes. participants twelve participants were recruited through purposive sampling, targeting pharmaceutical business managers with relevant expertise in marketing, product development, and strategic management within the healthcare and pharmaceutical sectors. recruitment efforts leveraged professional networks, industry conferences, and direct outreach to individuals known to be involved in medical cannabis-related discussions or projects. to ensure diverse representation, we considered participants from different organizational backgrounds and geographic locations, particularly from europe and north america, where regulatory frameworks and market dynamics vary significantly. eligibility criteria required participants to have a minimum of five years of managerial experience, ensuring cannabis, a publication of the research society on marijuana 131 that insights were drawn from professionals with substantial industry knowledge. no financial or material incentives were offered to participants. instead, participation was voluntary and individuals were informed about the study’s objectives and potential contributions to the evolving discourse on medical cannabis marketing and policy. this ethical approach helped ensure candid responses and maintained the integrity of the data collection process. data collection interviews were conducted between september 2022 and february 2023, lasting approximately 45-60 minutes each. participants were interviewed via video conferencing platforms to accommodate geographic diversity. a semistructured interview guide was developed based on the study objectives and existing literature on medical cannabis marketing and branding (table 1). key topics included: • perceived challenges in marketing medical cannabis • strategies for overcoming societal stigma • approaches to brand positioning and value proposition development • the role of scientific research in enhancing market credibility interviews were audio-recorded with participants’ consent and transcribed verbatim for analysis. all interviews were conducted in english language. table 1. topic guide section questions introduction -thank you for participating in this study. the purpose of this interview is to explore your perspectives on medical cannabis. your insights will inform marketing strategies and policymaking for medical cannabis. -your responses will be confidential, and you are free to withdraw at any time. therapeutic potential and research needs 1. from your perspective, how does the current body of research support the use of medical cannabis in treating specific conditions like chemotherapyinduced nausea and vomiting, multiple sclerosis, or chronic pain? 2.what research gaps do you believe are critical to address for wider acceptance by healthcare providers and patients? addressing societal stigma 3. how has societal stigma around cannabis affected your strategies for marketing or branding medical cannabis? 4. what role do you think education and targeted communication play in overcoming this stigma? developing a strong value proposition 5. how do you perceive the competitive landscape for medical cannabis compared to traditional pharmaceuticals? 6. what key components should a value proposition for medical cannabis highlight to differentiate it from recreational cannabis and traditional pharmaceuticals? 7. how can real-world evidence, such as case studies or testimonials, strengthen this value proposition? branding and marketing strategies 8. in building a brand identity for medical cannabis, which aspects do you think are most important to emphasize to healthcare professionals and patients? 9. how can marketing campaigns balance scientific accuracy with accessibility to diverse audience groups? marketing medical cannabis 132 10. how can marketing strategies be tailored to address the specific needs and concerns of patients? navigating regulatory challenges 11. what are the key obstacles you’ve faced in dealing with the regulatory framework for medical cannabis in your region? 12. how viable do you think phased market entry strategies, such as pilot programs, are for overcoming initial regulatory challenges? collaboration and policy advocacy 13. how do partnerships with government bodies, healthcare professionals and private organizations support the integration of medical cannabis into mainstream healthcare? 14. what role do you think healthcare endorsements play in establishing credibility for medical cannabis? 15. what role do pharmaceutical companies play in advocating for favorable regulatory policies for medical cannabis? 16. how can industry players contribute to public education campaigns to support policy changes? long-term market sustainability 17. what adaptive strategies are essential to maintain a competitive edge in the evolving medical cannabis market? 18. how can medical cannabis be integrated into established healthcare models, such as chronic care frameworks? 19. how can medical cannabis be positioned alongside other therapeutic options in treatment protocols? future outlook 20. in your view, how is the medical cannabis market likely to evolve over the next decade? 21. what regulatory or societal changes would you like to see to facilitate growth in this sector? conclusion -is there anything else you would like to add that we haven’t covered? -thank you for sharing your thoughts and experiences. your insights will contribute to ongoing research and strategic development. data analysis thematic analysis was conducted following the six-step framework proposed by braun and clarke (2006). initial coding was performed independently by two researchers to identify meaningful segments of text and discrepancies were resolved through discussion. codes were organized into broader themes, guided by both inductive insights and deductive categories derived from the interview guide. nvivo 14 software was used to facilitate data organization and analysis (lumivero, 2023). ethical considerations the study adhered to ethical research principles, including voluntary participation, cannabis, a publication of the research society on marijuana 133 informed consent and confidentiality. ethics approval was obtained from the university of nicosia research ethics committee (ref. no urec/2022/14 dated 19 july 2022), and participants were assigned aliases (bm1-bm12) to ensure anonymity. data were securely stored and accessible only to the research team. results demographics the sample included seven males (58%) and five females (42%), with ages ranging from 35 to 60 years (m = 46.8 years). participants represented organizations operating in europe (n = 9) and north america (n = 3), reflecting regions with varying levels of regulatory acceptance for medical cannabis. industry experience ranged from 8 to 25 years (m = 15.4 years), with specific involvement in medical cannabis ranging from 1 to 5 years. thematic axes medical cannabis as a therapeutic product participants expressed nuanced perspectives on the current status and potential of medical cannabis as a therapeutic product. while some were optimistic, they emphasized the need for further development and validation. bm1 stated, “cannabinoids have demonstrated their ability to treat several diseases effectively, with fewer side effects. however, more evidence is needed to establish reliability and broaden acceptance.” bm2 agreed, highlighting that “medical cannabis has shown promise for specific conditions, but targeted research is necessary to confirm its effectiveness across a wider range of indications.” a subgroup of respondents acknowledged the strides made in positioning medical cannabis but warned of challenges due to its fragmented development. bm4 remarked, “medical cannabis is on the cusp of becoming a credible therapeutic option, but additional research is required to transform it into a trusted standalone brand for serious illnesses.” bm5 echoed this sentiment: “cannabis has potential as a therapeutic option for many conditions, but the industry must demonstrate its safety and efficacy through rigorous validation to build trust among prescribers and patients.” other participants were more skeptical, noting the premature nature of cannabis’ medical applications. bm7 observed, “despite the emergence of various cannabis-based products worldwide, their multi-usage creates confusion among physicians and patients, undermining the credibility needed for medical cannabis to achieve a trusted status.” bm10 shared a similar concern, stating, “without sufficient primary and secondary data supporting its therapeutic properties, medical cannabis will struggle to move beyond its supplementary treatment role.” the need for extensive research across the board, participants emphasized the importance of extensive, disease-specific research to validate medical cannabis’ efficacy and safety. bm4 noted, “pharmaceutical products are held to high standards of validation, and medical cannabis must meet these requirements to gain acceptance. more focused clinical trials and longterm studies are essential.” bm7 emphasized the value of collaborative efforts, suggesting that, “partnerships between government bodies and private companies are necessary to fund and execute the large-scale studies required to unlock medical cannabis’ full potential.” several respondents highlighted specific research priorities. bm9 remarked, “detailed research is mandatory, given the complexity of cannabis’ active compounds. efforts should focus on isolating and testing these components to ensure accurate dosing and consistent efficacy.” bm1 suggested that “comprehensive clinical trials exploring medical cannabis’ effectiveness in conditions like cancer, glaucoma, and multiple sclerosis would go a long way in establishing its medical relevance.” the educational impact of disseminating research findings was also stressed. bm10 emphasized, “transparent communication of research results is critical to equipping healthcare providers with the confidence to prescribe cannabis-based therapies. this will facilitate its transition from an alternative therapy to a mainstream treatment option.” addressing stigma through strategic communication marketing medical cannabis 134 the stigma surrounding cannabis emerged as a significant barrier to its medical acceptance. participants identified strategic communication as a key tool in overcoming societal resistance. bm4 remarked, “managing the dissemination of data and framing it appropriately is crucial in mitigating negativity and skepticism surrounding medical cannabis.” bm7 elaborated, “physicians require solid scientific information to trust cannabis treatments. releasing credible evidence will help increase confidence among healthcare professionals and patients alike.” participants suggested that messaging should be tailored to specific audience segments. bm9 noted, “a targeted approach is essential. policymakers, healthcare providers, and patients each require customized messaging that addresses their unique concerns.” bm6 emphasized the value of professional endorsements, suggesting, “advocacy from trusted healthcare providers could accelerate the acceptance of medical cannabis among both patients and the wider public.” some participants highlighted the role of storytelling in destigmatizing cannabis. bm5 stated, “case studies showcasing successful medical cannabis treatments can humanize its benefits and provide relatable examples for skeptics.” bm10 added, “educational campaigns should focus on differentiating medical cannabis from its recreational counterpart, emphasizing its therapeutic applications,” marketing strategies participants recognized the importance of robust marketing strategies to navigate the challenges of stigma and misinterpretations. bm4 proposed, “a differentiated value proposition that highlights the functional and experiential benefits of medical cannabis will help position it effectively in the market.” bm10 suggested a focus on customer engagement, stating, “marketing strategies should prioritize addressing misconceptions while building trust through credible and transparent messaging.” branding was consistently highlighted as a critical component of success. bm7 remarked, “establishing a strong brand identity and image is vital, especially in the introductory stages. branding strategies must emphasize medical cannabis’ reliability, safety and efficacy.” bm11 recommended a multi-pronged approach, noting, “brand equity and line extension strategies can help enhance customer trust and establish medical cannabis as a legitimate therapeutic option alongside traditional pharmaceuticals.” some participants advocated for leveraging existing research and testimonials to bolster branding efforts. bm8 observed, “aligning branding strategies with validated research findings and real-world case studies will strengthen the value proposition of medical cannabis products.” bm5 added, “effective branding can help shift public perception, positioning medical cannabis as a credible medical treatment.” regulatory and social challenges the dual challenges of regulatory ambiguity and societal resistance were consistently identified as significant hurdles. bm7 noted, “the legal and stigmatized status of cannabis has created substantial barriers to market entry. strategic efforts are needed to align branding with regulatory requirements and public expectations.” bm10 suggested phased market entry strategies, stating, “launching pilot programs in regions with progressive regulatory environments could help establish credibility while paving the way for broader adoption.” participants also emphasized the importance of engaging healthcare professionals in overcoming resistance. bm6 remarked, “collaboration with physicians and other healthcare providers is essential to promote acceptance and build trust in cannabis-based therapies.” bm5 highlighted the role of advocacy, noting, “professional endorsements and partnerships with trusted medical organizations could help counter societal skepticism and accelerate regulatory approval processes.” long-term strategic approaches participants stressed the importance of adopting adaptive, long-term strategies to ensure the sustained growth of medical cannabis in the pharmaceutical market. bm4 suggested integrating cannabis into broader therapeutic frameworks, stating, “positioning cannabis products within chronic care models can help align them with existing healthcare paradigms cannabis, a publication of the research society on marijuana 135 and promote acceptance.” bm11 emphasized collaboration, remarking, “ongoing data-sharing initiatives between industry and regulators will foster a transparent and supportive ecosystem for medical cannabis.” market feedback was identified as a crucial factor in refining strategies. bm9 noted, “consumer insights and experiences must inform the development of marketing and branding efforts to ensure they remain relevant and effective in an evolving market.” bm8 highlighted the importance of flexibility, adding, “as perceptions and regulations shift, companies must be prepared to adapt their approaches to meet changing market demands.” insights on market readiness. participants expressed diverse views on market readiness, reflecting regional and cultural differences. bm6 observed, “market readiness varies significantly across regions, driven by differences in regulatory progress and societal openness.” bm10 cautioned against over-reliance on early adopters, stating, “while niche markets can serve as a foundation, a broader focus on mainstream patient populations is essential for long-term success.” bm3 added, “progressive regions that have embraced medical cannabis can serve as models for expanding into more conservative markets, but strategies must be tailored to local contexts.” logistical considerations were also highlighted. bm8 stated, “readiness involves more than public perception. stable supply chains, consistent quality assurance, and efficient distribution channels are critical to ensuring the successful integration of cannabis products into the healthcare system.” discussion this study highlights the complex interplay of scientific, societal, and strategic factors that shape the marketing and branding of medical cannabis. by analyzing the perspectives of pharmaceutical business managers, it offers a nuanced understanding of the challenges and opportunities inherent in the medical cannabis market. the findings align with existing literature while providing practical insights into how stakeholders can address barriers to market entry and foster acceptance of medical cannabis as a legitimate therapeutic option. participants recognized the therapeutic potential of medical cannabis, reinforcing its growing credibility. studies have demonstrated its efficacy in managing chronic pain, multiple sclerosis, and chemotherapy-induced nausea and vomiting (bukowska, 2024; grimison et al., 2024; jeddi et al., 2024). however, in line with the observations of jean-jacques et al. (2021), the need for condition-specific research emerged as a critical concern. managers highlighted the premature state of cannabis’ therapeutic development, echoing calls for intensified r&d to ensure clinical validation. this developmental uncertainty highlights a tension between optimism and skepticism. while some managers celebrated recent regulatory approvals and market entries as indicators of progress, others expressed concerns over limited data and inconsistent clinical trial outcomes. these findings suggest that to achieve broader adoption, medical cannabis must transition from being perceived as an alternative therapy to a mainstream medical option backed by rigorous evidence. the consensus among managers regarding the importance of research aligns with existing recommendations in the literature. diseasespecific clinical trials are essential for establishing efficacy and safety profiles for targeted medical conditions (cooper et al., 2021). collaborative efforts between government agencies and private companies could alleviate resource constraints and expedite research efforts (ellison et al., 2021). stigma emerged as a pervasive barrier to the acceptance of medical cannabis. societal attitudes often hinder its medical application (hulaihel et al., 2023). research indicates that patients undergoing treatment with cannabis-based medicines perceive stigma from various societal sectors, including government officials and medical professionals. this stigma can impede access to treatment and open communication with healthcare providers (troup et al., 2022). participants emphasized the importance of strategic communication in overcoming stigma. public education campaigns have been shown to shift perceptions and reduce negative biases (clobes et al., 2021). tailoring messages to specific stakeholders such as healthcare professionals, marketing medical cannabis 136 policymakers, and patients was identified as a critical strategy. a qualitative review highlighted the importance of targeted communication efforts, emphasizing the need for different approaches for different audiences (reid, 2020). additionally, endorsements from trusted healthcare providers could be instrumental in mitigating skepticism (ntais et al., 2023a). the study’s findings regarding differentiation and branding align with established marketing principles, emphasizing the importance of a clear value proposition (kotler & keller, 2016). managers stressed that branding strategies should highlight reliability, efficacy, and safety reflecting the cautious approach that healthcare providers and patients adopt toward new therapies. implementing multi-brand strategies can help address diverse therapeutic needs, a wellestablished practice in the pharmaceutical industry (ntais et al., 2023b). additionally, developing tailored messaging for each indication is crucial for successful multi-indication product launches (gores & scott, 2023). the focus on targeted campaigns and cultural sensitivity underscores the importance of adapting strategies to regional contexts, which is critical for international market expansion (prahalad & doz, 1987). regulatory ambiguity and societal resistance were identified as major hurdles for market entry. the complex and evolving regulatory landscape requires stakeholders to continually adapt to remain compliant and competitive (de souza et al., 2022). participants recommended phased market entry strategies, including pilot programs and collaboration with healthcare professionals, to build credibility and facilitate acceptance. for example, denmark’s medical cannabis pilot scheme has been instrumental in assessing the feasibility and impact of medical cannabis, with plans to expand into a fully legalized market (stevens, 2024). managers emphasized the need for long-term strategies to sustain market presence. integrating medical cannabis products into broader therapeutic frameworks aligns with chronic care models that prioritize patient-centric and holistic treatment approaches (wagner et al., 1996). additionally, data-sharing initiatives could foster transparency and build trust among regulators, healthcare providers and patients. the diverse perspectives on market readiness reflect the varying levels of acceptance and regulatory progress across regions. early adoption in progressive markets provides valuable blueprints for broader expansion, echoing findings from prior studies on innovation diffusion (rogers, 2003). however, participants cautioned against over-reliance on niche markets, stressing the importance of targeting mainstream patient populations to ensure sustained growth. while this study primarily focuses on marketing and management, policymaking remains an implicit and crucial element. regulatory ambiguity and evolving legal frameworks highlight the significant role policymakers play in shaping the medical cannabis market. addressing stigma through targeted communication further underscores the importance of public policy in fostering societal acceptance. effective policymaking around education and awareness campaigns could help reduce stigma. additionally, pilot programs and phased market entry strategies — often requiring collaboration with regulatory bodies — emphasize policymakers’ role in facilitating early commercialization. finally, the long-term strategic approaches for integrating medical cannabis into healthcare systems point to policymaking as key to the future growth and regulatory landscape of medical cannabis. market-driven recommendations this study offers actionable recommendations for pharmaceutical companies seeking to enter or expand in the medical cannabis market. key strategies include prioritizing disease-specific research to generate robust evidence, leveraging targeted communication campaigns to educate stakeholders and address stigma, developing a strong brand identity aligned with patient needs, and using phased marketing strategies to build trust and expand market reach. collaborative efforts with regulators, healthcare professionals, and other stakeholders are crucial in navigating the challenges and unlocking the therapeutic potential of medical cannabis. policy recommendations cannabis, a publication of the research society on marijuana 137 based on the data collected, this study underscores the following policy recommendations: establish clear and consistent regulatory guidelines. governments should create standardized regulatory frameworks that define medical cannabis’ legal status, quality control measures and prescribing protocols. this would reduce market uncertainty and encourage investment in research and development. support large-scale clinical research initiatives. policymakers should facilitate partnerships between pharmaceutical companies, healthcare institutions, and academic researchers to fund and conduct rigorous, disease-specific studies on medical cannabis’ efficacy and safety. develop physician training and education programs. medical cannabis should be incorporated into medical curricula and continuing professional development programs to ensure that healthcare providers are wellinformed about its therapeutic applications, dosing strategies and potential risks. implement public awareness campaigns to reduce stigma. policymakers, in collaboration with industry stakeholders, should develop targeted public health campaigns that emphasize the medical legitimacy of cannabis and differentiate it from recreational use. encourage pilot programs in progressive regulatory environments. governments should consider phased implementation strategies, such as pilot programs in jurisdictions with favorable regulatory conditions, to gather real-world evidence and refine best practices before broader market expansion. limitations and future research this research is subject to some limitations. while the sample size was relatively small, practical research suggests that a sample of 12 participants may be sufficient to reach data saturation within a relatively homogeneous population (boddy, 2016). however, a larger sample could have provided additional nuances. another limitation of this study is the consolidation of participant perspectives across different regulatory frameworks. while the study acknowledges that medical cannabis operates within a patchwork of regulations, responses from participants in different regions were analyzed collectively without extensive differentiation based on their specific regulatory environments. while regulatory landscapes differ, the overarching themes and strategic considerations — such as the need for scientific validation, stigma reduction, and adaptive branding — remained similar among all respondents. however, this approach may overlook nuanced regional differences in market dynamics, policy constraints, and stakeholder perceptions. additionally, the study does not provide detailed descriptions of the specific regulatory environments in which participants were operating, nor does it attempt to compare or contrast the perspectives of participants working in different jurisdictions. as a result, potential variations in how regulatory frameworks shape marketing strategies and industry challenges may not be fully captured. future research could adopt a comparative approach, providing a more granular understanding of the interplay between varying regulatory environments and market dynamics. additionally, future studies could explore the perspectives of other stakeholders, such as healthcare providers, patients, and policymakers, to provide a more comprehensive analysis. finally, a potential future research direction would be to focus participant recruitment within a specific region to gain a more in-depth understanding of the challenges and opportunities within a single market. conducting a region-specific study would allow for a more detailed analysis of the interplay between local regulations, consumer perceptions, and market strategies. this approach could also help identify best practices and region-specific barriers, offering targeted insights for policymakers, businesses, and healthcare professionals operating in that particular regulatory environment. conclusion this study sheds light on the strategic considerations pharmaceutical companies must address to successfully market medical cannabis. by examining the perspectives of business managers, the research identifies key challenges, including regulatory ambiguity, societal stigma, and insufficient scientific validation, which hinder market acceptance. it also highlights actionable strategies, such as the need for marketing medical cannabis 138 rigorous disease-specific research, targeted communication to address stigma, and adaptive branding and marketing approaches that emphasize reliability, efficacy, and safety. importantly, the findings reveal an intricate connection between marketing strategies, public perception, and 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(1996). organizing care for patients with chronic illness. milbank quarterly, 74(4), 511544. https://doi.org/10.2307/3350391 funding and acknowledgements: no funding was received to assist with the preparation of this manuscript. the authors declare that there are no potential conflicts of interest with respect to authorship and/or publication of this article. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: ntais, c., kontodimopoulos, n., & melanthiou, y. (2025). marketing management and policymaking for medical cannabis: overcoming barriers and shaping strategies. cannabis, 8(2), 129 140. https://doi.org10.26828/cannabis/2025/000316 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ marketing medical cannabis 140 research article 120 ved abstract objective: an increase in medical cannabis and prescribed cannabinoids use for chronic pain management has been observed in canada in the past years. this study aimed to: 1) describe clinicians’ perceived risk associated with the use of medical cannabis and prescribed cannabinoids for the management of chronic pain; and 2) identify sociodemographic and professional factors associated with perceived risk of adverse effects. method: a web-based cross-sectional study was conducted in quebec, canada in 2022. a convenience sample of 207 clinicians was recruited (physicians/pharmacists/nurse practitioners). they were asked to rate the risk of adverse effects associated with medical cannabis (e.g., smoke, or oil) and prescribed cannabinoids (e.g., nabilone) on a scale of 0 to 10 (0: no risk, 10: very high risk), respectively. multiple linear regression was performed to identify factors associated with perceived risk. results: average perceived risk associated with medical cannabis and prescribed cannabinoids were 5.93 ± 2.08 (median:6/10) and 5.76 ± 1.81 (median:6/10). factors associated with higher medical cannabis perceived risk were working in primary care (β = 1.38, p = .0034) or in another care setting (β = 1.21, p = .0368) as compared to a hospital setting. as for prescribed cannabinoids, being a pharmacist (β = 1.14, p = .0452), working in a primary care setting (β = 0.83, p = .0408) and reporting more continuing education about chronic pain (β = 0.02, p = .0416) were associated with higher perceived risk. no sex differences were found in terms of perceived risk. conclusions: considering the clinician’s experience provide insights on cannabis risk as these professionals are at the forefront of patient care when they encounter adverse effects. key words: = chronic pain; healthcare professionals; physician; pharmacist; nurse; factors medical cannabis is legal in canada since 2001 (gagnon, 2019) and can be used in the treatment of several conditions such as chronic pain (cp; most common reason of use), anxiety, and depression (kosiba et al., 2019). non-medical (recreational) cannabis has been legalized in canada since 2018 (government of canada., 2023), and has increased the accessibility of these products for the general population (clarke & fitzcharles, 2023; statistics canada, 2020). a recent meta-analysis concluded that medical cannabis was used for cp management by 67% of users (kosiba et al., 2019). in canada, approximately one third of people living with cp report using cannabis for pain management (medical or non-medical; godbout-parent et al., 2022), and 15-62% of people with cp self-medicate gwenaelle de cliffordfaugère1, adriana angarita-fonseca1, hermine lore nguena nguefack1, marimée godbout-parent1, claudie audet1, anaïs lacasse1 1département des sciences de la santé, université du québec en abitibi-témiscamingue (uqat) cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000263 volume 7, special issue 3 perceived risk of medical cannabis and prescribed cannabinoids for chronic pain: a cross-sectional study among quebec clinicians corresponding author: anaïs lacasse, ph. d., université du québec en abitibi-témiscamingue (uqat), 445 bd de l'université, rouyn-noranda, qc j9x 5e4, canada. phone: 819-762-0971 poste 2722. email: anais.lacasse@uqat.ca cannabis, a publication of the research society on marijuana 121 with cannabis (use of cannabis for therapeutic purposes without guidance; audet et al., 2024; ware et al., 2003). following non-medical cannabis legalization, an increase in medical cannabis (e.g., smoke, or oil) and prescribed cannabinoids (e.g., nabilone) use for cp management has been observed in canada in the past years (≤10% in pre-legalization (ste-marie et al., 2016; ware et al., 2003) vs. ≥30% in postlegalization (de clifford-faugère et al., 2023; godbout-parent et al., 2022)). medical cannabis and prescribed cannabinoids are considered a third-line treatment for cp (häuser et al., 2018; mu et al., 2017). the current scientific evidence on its efficacy and safety for cp management is limited (mcdonagh et al., 2022). medical cannabis and prescribed cannabinoids may provide short-term improvement for people living with neuropathic cp (häuser et al., 2018; mcdonagh et al., 2022). however, to our knowledge, midand long-term effects have not yet been investigated. to date, the international association for the study of pain (iasp) presidential task force and other national organizations do not recommend the use of cannabis and prescribed cannabinoids for cp management because of the lack of knowledge on efficacy and on shortand long-term safety (fitzcharles et al., 2019; haroutounian et al., 2021; nice, 2019). however, certain expert panels support the utilization of cannabis for pain management, provided that it is accompanied by cautious monitoring (busse et al., 2021). in recent years, qualitative and quantitative studies have focused on clinicians’ perceptions of medical cannabis use for cp including attitudes and beliefs (abo ziad et al., 2022; jacobs et al., 2019; karanges et al., 2018; kondrad & reid, 2013; narouze et al, 2020; ng et al., 2021; schauer et al., 2022; sharon et al., 2018; zolotov et al., 2018), knowledge (abo ziad et al., 2022; ebert et al., 2015; jacobs et al., 2019; karanges et al., 2018), clinical practices/ experience (carlini et al., 2017; ebert et al., 2015; schauer et al., 2022; sharon et al., 2018), training needs (carlini et al., 2017), perceived efficacy for cp management (cooke et al., 2019), and barriers/facilitators for prescribing cannabis (hachem et al., 2022; withanarachchie et al., 2023). previous studies focusing on the risk of adverse effects associated with the use of cannabis for cp highlighted that clinicians are most concerned with the risk of addiction, misuse, mental health risk, dizziness and sedation, as well as drug interaction (cooke et al., 2019; hachem et al., 2022; karanges et al., 2018; kondrad & reid, 2013; ng et al., 2021; withanarachchie et al., 2023). to our knowledge, no study, however, has focused on quantifying and comparing physicians, pharmacists and nurse practitioners' perceived risk associated with the use of medical cannabis. also, little is known about sociodemographic and professional factors associated with a higher perceived risk of medical cannabis and prescribed cannabinoids use for cp management. comparing the perceived risk of cannabis among physicians, pharmacists, and nurse practitioners, and understanding the factors predicting these perceptions, is relevant for tailoring continuing education and support tools to ensure a consistent and informed approach to cannabis management in healthcare. this study thus aimed to describe and compare physicians’, pharmacists’ and nurse practitioners’ perceived risk associated with the use of medical cannabis and prescribed cannabinoids for the management of cp. sociodemographic and professional factors associated with those perceived risk were also explored. we hypothesized that differences would be found between types of clinicians in terms of perceived risk associated with the use of medical cannabis and prescribed cannabinoids. we also expected factors such as sex at birth, continuing education, years of practice, and personal experience with chronic pain to be associated with the perceived risk. methods study design and population this study was conducted in the context of a larger initiative about perceived risk towards medications used for cp management (de cliffordfaugère et al., 2024). a web-based cross-sectional study was conducted from march 1 to may 28, 2022, in quebec (canada), and 207 clinicians (physicians, pharmacists, and nurse practitioners) were recruited. to be eligible, clinicians had to: 1) dispense and/or adjust prescriptions for the treatment of cp in their clinical practice, 2) hold a valid license, 3) practice in a canadian setting, and 4) be able to complete a questionnaire in french. the project has obtained ethical approval from the clinicians’ perceived risk of cannabinoids 122 research ethics board of université du québec en abitibi-témiscamingue (#2020-01–diallo, m.). recruitment clinicians were recruited through various web platforms held by quebec professional associations and research networks. the invitation to participate in the study was shared via associations’ and networks’ newsletters, but also on social media (facebook [meta inc, cambridge, ma]) and through emails sent by the team members (“snowball” sampling). in all dissemination platforms, the invitation contained the url to access the anonymous online questionnaire on the surveymonkey platform (surveymonkey inc, san mateo, ca). the landing page allowed for free and informed electronic consent. measured variables perceived risk of medical cannabis and prescribed cannabinoids. participants were asked to assign a score between 0 and 10 for the risk of adverse effects for medical cannabis and then prescribed cannabinoids, 0 representing no risk and 10 a very high risk (de clifford-faugère et al., 2024). the risk of adverse effects was defined in the questionnaire as organ-specific or systemic toxicity (gastrointestinal symptoms, central nervous system), medication interactions, physical/psychological dependence potential, abuse potential, insomnia, tolerance, increased pain perception over time (hyperalgesia), and memory or concentration problems. in quebec, nabilone is the only synthetic prescribed cannabinoids reimbursed by the public prescription drug insurance. medical cannabis is available through a medical authorization under the cannabis act in various forms such as dried marijuana or cannabis oil. participants’ characteristics. various sociodemographic and professional variables were measured in the web-based questionnaire. sociodemographic variables include sex at birth (female/male), gender identity (women, men, gender fluid, non-binary, trans man, trans woman, two-spirited, or none of these options), and region of residence (list of the 17 administrative regions in quebec). also, participants were asked if they or a loved one had cp (lacasse et al., 2017). professional variables included years of clinical practice (0-5/6-10/1120/≥20 years), type of practice (e.g., pain clinic, primary care, community pharmacy, hospital setting), self-identification as a cp treatment specialist (yes/no), comfort level in dispensing or adjusting prescriptions for cp treatment (010 scale, 0: very uncomfortable, 10: very comfortable), proportion of past year continuing education activities related to cp and its treatment (0 to 100%), and country of initial education (canada, north america excluding canada, south america, europe, asia, africa, oceania, antarctica). stasticial analysis descriptive statistics were used to describe participants’ sociodemographic and professional profile (means and standard deviations for continuous variables; numbers and proportions for categorical variables). clinicians’ perceived risk associated with medical cannabis and prescribed cannabinoids were described (median, interquartile range) by type of clinicians (nurse practitioners, physicians, and pharmacists). kruskall-wallis tests were then performed to investigate the difference between clinicians perceived risk. bivariable and multivariable linear regression models were used to identify participants’ sociodemographic and professional profile associated with perceived risk associated with medical cannabis and prescribed cannabinoids. crude and adjusted β, p values, and confidence intervals (ci) were reported. all independent variables to be included in the multiple linear regression analyses were identified based on a literature review and clinical considerations. based on the more recent recommendation, an a priori selection of variable was applied instead of other criticized selection techniques such as relying on bivariate regression analyses p values (sourial et al., 2019). multicollinearity was tested according to variance inflation factors (vifs), which were below 4.0 (vatcheva et al., 2016) for all variables included in the multivariable models (sex at birth was kept instead of gender identity as they differed in 0.96% of participants). all statistical analyses were cannabis, a publication of the research society on marijuana 123 performed using sas® version 9.4 (sas institute, cary, nc, usa). results participants’ sociodemographic and professional characteristics. in total 207 clinicians including 66 nurse practitioners, 83 physicians, and 58 pharmacists responded to the survey. table 1 presents participants’ characteristics. clinicians were mostly females (86.0%), many practising in primary care clinics (44.0%) and working in different regions of quebec (remote and near large urban centres; all administrative regions represented). most of them (95.7%) had an initial education in canada. the majority of our sample (74.9%) had more than 5 years of experience, and 10.6% of them considered themselves specialists in the treatment of cp. also, these clinicians felt an average of 6.1 ± 1.9 points of comfort (0: very uncomfortable, 10: very comfortable) in dispensing or adjusting prescriptions for the treatment of cp. regarding their continuing education activities in the past year, the average percentage of activities related to cp and its treatment was 23.4% ± 18.9. more than a quarter of clinicians (27.5%) reported living with cp and 37.2% had a loved one living with cp. table 1. professional’s and sociodemographic profile variables nurse practitioners (n = 66) physicians (n = 83) pharmacists (n = 58) total (n = 207) mean ± sd mean ± sd mean ± sd mean ± sd comfort level in dispensing or adjusting prescriptions for cp treatment (0-10 scale, 0: very uncomfortable, 10: very comfortable) 5.1 ± 1.8 6.4 ± 1.8 6.6 ± 1.8 6.1 ± 1.9 proportion of past year continuing education activities related to cp and its treatment* 18.6 ± 13.6 29.7 ± 23.8 20.5 ± 14.4 23.4 ± 18.9 n (%) n (%) n (%) n (%) sex at birth females 60 (90.9%) 75 (90.4%) 43 (74.1%) 178 (86.0%) males 6 (9.1%) 8 (9.6%) 15 (25.9%) 29 (14.0%) gender identity** women 60 (90.9%) 74 (89.2%) 43 (74.1%) 177 (85.6%) men other 6 (9.1%) 0 (0%) 9 (10.8%) 0 (0%) 14 (24.1%) 1 (1.7%) 29 (14.0%) 1 (0.5%) region of residence nonremote regions remote resource regions*** 56 (84.9%) 10 (15.1%) 72 (86.6%) 11 (13.4%) 47 (81.1%) 11 (18.9%) 175 (84.6%) 32 (15.4%) years in practice 0 – 5 12 (18.2%) 23 (27.7%) 17 (29.3%) 52 (25.1%) 6 – 10 11 – 20 21 and + 11 (16.7%) 32 (48.5%) 11 (16.7%) 18 (21.7%) 32 (38.6%) 10 (12.0%) 7 (12.1%) 24 (41.4%) 10 (17.2%) 36 (17.4%) 88 (42.5%) 31 (15.0%) type of practice setting primary care clinic hospital setting**** community pharmacy 48 (72.7%) 9 (13.6%) 0 (0.0%) 37 (44.6%) 27 (32.5%) 0 (0.0%) 6 (10.3%) 11 (18.9%) 41 (70.7%) 91 (44.0%) 47 (22.7%) 41 (19.8%) pain clinic 0 (0.0%) 9 (10.8%) 0 (0.0%) 9 (4.3%) local community services centre (clsc) 3 (4.5%) 4 (4.8%) 0 (0.0%) 7 (3.4) long-term care residence (chsld) 3 (4.5%) 0 (0.0%) 0 (0.0%) 3 (1.4%) other 3 (4.5%) 6 (7.2%) 0 (0.0%) 9 (4.3%) self-identification as a cp treatment specialist yes 2 (3.0%) 18 (21.7%) 2 (3.4%) 22 (10.6%) no 64 (97.0%) 65 (78.3%) 56 (96.6%) 185 (89.4%) living with cp clinicians’ perceived risk of cannabinoids 124 yes 25 (37.9%) 22 (26.5%) 10 (17.2%) 57 (27.5%) no 41 (62.1%) 61 (73.5%) 48 (82.8%) 150 (72.5%) having a loved one living with cp yes 31 (47.0%) 29 (34.9%) 17 (29.3%) 77 (37.2%) no 35 (53.0%) 54 (65.1%) 41 (70.7%) 130 (62.8%) country of initial education canada 65 (98.5%) 79 (95.2%) 54 (93.1%) 198 (95.7%) other 1 (1.5%) 4 (4.8%) 4 (6.8%) 9 (4.4%) note. * 4.8% of missing data. 0% for all other variables. ** gender identity differed from sex at birth for 0.96% of participants. *** revenu quebec defines remote resource regions as: bas-saint-laurent (region 01), saguenay–lacsaint-jean (region 02), abitibi-témiscamingue (region 08), côte-nord (region 09), nord-du-québec (region 10), gaspésie–îles-de-la-madeleine (region 11). non-remote regions are near a major urban centre. cp = chronic pain; sd = standard deviation. **** includes emergency department perceived risk among clinicians for medical cannabis and prescribed cannabinoids. perceived risk associated with medical cannabis and prescribed cannabinoids are presented for each type of clinician in table 2. the median and iqr range score for medical cannabis and prescribed cannabinoids were similar (both score at a median of 6/10). for medical cannabis, no statistically significant differences were found between nurse practitioners and physicians (p = .853), between nurse practitioners and pharmacists (p = .843), or between physicians and pharmacists (p = .966). for prescribed cannabinoids, nurse practitioners had a higher perceived risk median score compared to physicians (p = .039); no statistically significant differences were found between the other groups (nurse practitioners vs. pharmacists’ p = .535; physicians vs. pharmacists p = .175). table 2. risk perception by clinicians for medical cannabis and prescribed cannabinoids nurse practitioners (n = 66) physicians (n = 83) pharmacists (n = 58) total (n = 207) n median (iqr) n median (iqr) n median (iqr) n median (iqr) medical cannabis 58 6(3) 77 6(2) 55 6(2) 190 a 6(2.25) cannabinoids (nabilone) 59 6(3)b 78 5(3)b 57 6(2) 194 c 6(2) note. iqr: interquartile range a17 missing (8.2%) bkruskall-wallis’s test: significant difference between nurse practitioners vs. physicians (p = .039) c13 missing (6.3%) predictors of higher-risk perception by clinicians for medical cannabis and prescribed cannabinoids. bivariable and multivariable linear regression analyses aimed at identifying participants characteristic associated with perceived risk associated with medical cannabis and prescribed cannabinoids (one model for each) are presented in table 3. factors associated with higher perceived risk associated with medical cannabis were working in primary care clinics (adjusted β = 1.38, p = .0034) or another setting (adjusted β = 1.21, p = .0368; as compared to working in a hospital setting). for prescribed cannabinoids (nabilone), the analysis revealed that working in primary care clinic (adjusted β = 0.83, p = .0408), being a pharmacist (adjusted β = 1.14, p = .0452), and having a higher proportion of continuing education on cp and its treatment (adjusted β = 0.02, p = .0416) were associated with higher perceived risk. no sex differences were found in terms of perceived cannabis, a publication of the research society on marijuana 125 table 3. simple and multiple linear regression medical cannabis prescribed cannabinoids characteristics crude β p value 95% ci adjusted β p value 95% ci crude β p value 95% ci adjusted β p value 95% ci sex females (vs. males) 0.506 .2350 -0.332 1.344 0.748 .1169 -0.189 1.684 0.474 .2001 -0.253 1.202 0.661 .1061 -0.142 1.465 residing a remote region (vs. nonremote region) 0.339 .4286 -0.503 1.180 0.081 .8563 -0.805 0.968 0.279 .4533 -0.453 1.010 -0.055 .8872 -0.823 0.712 years of practice (vs. ≤5 years) 6 – 10 years -0.481 .2330 -1.275 0.312 -0.499 .3102 -1.466 0.469 -0.140 .6820 -0.815 0.5345 -0.114 .7853 -0.942 0.713 11 – 20 years 0.443 .1482 -0.159 1.043 0.154 .7119 -0.667 0.975 0.242 .3591 -0.277 0.760 0.073 .8419 -0.645 0.790 ≥21 years -0.590 .1660 -1.427 0.247 -0.914 .0815 -1.944 0.116 -0.351 .3304 -1.059 0.358 -0.593 .1802 -1.463 0.277 type of practice* (vs. hospital setting) primary care clinic 0.658 .0308 0.061 1.254 1.377 .0034 0.463 2.292 0.541 .0390 0.028 1.054 0.830 .0408 0.035 1.625 community pharmacy -0.167 .6534 -0.898 0.564 0.369 .5936 -0.992 1.730 -0.040 .9014 -0.668 0.589 -0.073 .8991 -1.200 1.055 other 0.339 .4341 -0.514 1.191 1.212 .0368 0.075 2.348 -0.112 .7666 -0.853 0.630 0.696 .1700 -0.301 1.693 type of clinicians (vs. physicians) nurse practitioners 0.173 .5986 -0.474 0.820 0.010 .9803 -0.814 0.834 0.633 .0245 0.082 1.184 0.576 .1086 -0.129 1.282 pharmacists -0.032 .9244 -0.689 0.626 0.841 .2096 -0.477 2.159 0.137 .6319 -0.426 0.700 1.138 .0452 0.024 2.253 specialist in cp management (yes vs. no) -0.084 .8624 -1.035 0.867 -0.189 .8035 -1.685 1.307 -0.809 .0478 -1.611 -0.008 -1.011 .1246 -2.305 0.282 living with cp (yes vs. no) 0.335 .3264 -0.336 1.006 0.290 .4358 -0.443 1.023 0.145 .6211 -0.431 0.720 0.067 .8319 -0.554 0.687 having a loved one living cp (yes vs. no) 0.132 .6736 -0.484 0.748 0.091 .7859 -0.570 0.752 0.178 .5085 -0.353 0.709 0.096 .7389 -0.472 0.665 comfort level with dispensing or adjusting prescriptions for cp treatment (0 to 10) 0.064 .4281 -0.094 0.222 -0.045 .6874 -0.267 0.176 -0.057 .4051 -0.193 0.078 -0.088 .3548 -0.275 0.099 proportion of continuing education activities related to cp and 0.006 .5052 -0.011 0.022 0.016 .1934 -0.008 0.040 -0.002 .8057 -0.016 0.012 0.021 .0416 0.001 0.042 clinicians’ perceived risk of cannabinoids 126 note. multicollinearity: for all variables included in the multiple linear regression model, variance inflation factors were bellow <4. cp: chronic pain, ci: confidence interval. * clinical setting was grouped to have a sufficient number of participants in each group. other settings are constituted of pain clinics, local community services centre, long-term care residence and other settings. its treatment (0 to 100%) country of initial education (canada vs. others) 0.978 .1688 -0.419 2.375 0.904 .2468 -0.632 2.440 0.926 .1566 -0.358 2.211 0.746 .3024 -0.677 2.169 cannabis, a publication of the research society on marijuana 127 discussion the present study conducted among clinicians in quebec, canada, aimed to describe perceived risk associated with the use of medical cannabis and prescribed cannabinoids for cp management and then to identify sociodemographic and professional factors associated with perceived risk. participating clinicians perceived a 6 out of 10 median risk of adverse effects associated with medical cannabis and prescribed cannabinoids used for cp management. type of practice setting, the type of clinicians and continuing education about cp were factors associated with perceived risk. prescribed cannabinoids our results show that prescribed cannabinoids such as nabilone, despite being approved by health canada, are not considered less risky than medical cannabis. there might be a prevailing societal or professional perception that medications like nabilone, despite approval, carry risk similar to medical cannabis. this perception could be influenced by historical stigma surrounding cannabis (brochu et al., 2019; zolotov et al., 2018). also, there may be limited strong evidence comparing the safety profiles of prescription cannabinoids and medical cannabis (mcdonagh et al., 2022). without robust evidence, clinicians might rely on personal experiences or anecdotal information, leading to varied perceptions of risk (daei et al., 2020, dawes & sampson, 2003). finally, we could think that health canada's approval of nabilone doesn't necessarily dictate clinicians' opinion. the regulatory approval process may focus on specific criteria related to efficacy and safety, but clinicians’ perception might be influenced by societal stigma associated with cannabis. types of practice setting results of this study highlights that working in primary care clinic compared to a hospital setting was associated with higher perceived risk of adverse effects for medical cannabis and prescribed cannabinoids. these differences are likely due to the numerous distinctions that exist between the primary care practice context versus the hospital setting. for example, primary care clinicians often manage chronic conditions over long periods, whereas hospital-based clinicians frequently deal with acute care (government of canada, 2024). additionally, interdisciplinary collaboration can vary greatly between these settings depending on organizational, team, and individual factors (wei et al., 2022). type of clinican it was expected that perceived risk of adverse effects with prescribed cannabinoids may vary according to the role and responsibilities of clinicians. in this study, pharmacists had a higher perceived risk towards prescribed cannabinoids than other clinicians. this could be explained by the role of the pharmacist in canada who is in charge of dispensing medications, and therefore may be more often exposed to adverse effects reported by patients (dassieu et al., 2022; khaira et al., 2020). for patients in the united states of america (usa), collaboration with their community pharmacist (high accessibility as compared to other primary care clinicians) makes them a preferred choice for pharmacological treatments-related issues (gonzalvo et al., 2012). also, pharmacists are the clinicians with the most knowledge about medications, their possible interactions, the mode of action of cannabinoids and their associated risk (dassieu et al., 2023), which may increase their perceived risk. a recent canadian study has highlighted that pharmacists found many challenges to monitor drug interactions with cannabis because of the lack of scientific research (dassieu et al., 2023). in quebec, pharmacists are considered experts in medication, and must complete a 4-year university course to ensure the appropriate use of medications. despite their extensive knowledge, the insufficient research on cannabis interactions limits pharmacists' ability to provide safe and effective guidance to patients, which could contribute to increasing their perceived risk. continuing education our results highlight that clinicians with the most continuing education about cp and its treatment have a higher perceived risk associated with prescribed cannabinoids use. these results may be explained by the possibility that continuous education exposes clinicians more to clinicians’ perceived risk of cannabinoids 128 the latest recommendations regarding the efficacy and safety of cannabis and cannabinoids. in fact, prominent international and national organizations do not recommend the use of cannabis and prescribed cannabinoids for cp management because of the lack of knowledge on efficacy and on shortand long-term safety (fitzcharles et al., 2019; haroutounian et al., 2021; nice, 2019). clinicians have the responsibility to ensure a safe use of treatments in a perspective of minimizing risk for the patient and increase shared decision-making (coronadovázquez et al., 2020; wilson et al., 2021). cannabis and cannabinoids are increasingly being used by people living with cp, both through medical and non-medical channels (audet et al., 2024; de clifford-faugère et al., 2023; godboutparent et al., 2022). given this trend, it is crucial for clinicians to be well-informed about the potential benefits and risk associated with these medications to support informed patient choices and enhance the safety of their treatment plans. regarding cp management, continuing education for clinicians is an integral part of the canadian action plan for pain recommendations (campbell et al., 2021), and it is essential for clinicians to keep their scientific knowledge up to date and improve patient health outcomes (campbell et al., 2021; cervero & gaines, 2015; samuel et al., 2021). it is important to note that in several studies of clinicians’ perceptions of cannabis use, continuing education is a clinical recommendation (carlini et al., 2017; hachem et al., 2022; karanges et al., 2018; kondrad & reid, 2013; ng et al., 2021). to this end, clinical practice guidelines and webinars appear to be the preferred way to reach physicians on the topic of cannabis (hachem et al., 2022). in canada, almost one third of clinicians (including physicians, nurses, and pharmacists) report not knowing the requirements for obtaining cannabis (hachem et al., 2022). other factors no association was found between the number of years of practice or the level of comfort in dispensing/adjusting prescriptions for cp treatment and the perceived risk of using cannabis and cannabinoids. this is surprising because it was expected that clinicians with more experience or greater comfort in managing chronic pain treatments would have different perceptions of the risk associated with cannabis and cannabinoids. these findings suggest that factors other than experience and comfort level may play a more significant role in shaping clinicians' risk perceptions. no sex differences were found in clinicians’ perceived risk of using cannabis and cannabinoids. recently, narouze et al. (2020) conducted a cross-sectional study in the usa highlighting that physicians have mostly attitudes in favor of medical cannabis use. similar to our results, they did not find an association between age, sex/gender, years of experience and attitudes in favor of medical cannabis (narouze et al., 2020). literature suggests that people living with cp have better knowledge and more positive attitudes towards other people living with cp than those without cp (lacasse et al., 2017). contrary to our expectations, living with cp or having a loved one living with cp were not associated with the perceived risk of medical cannabis or prescribed cannabinoids use among our participating clinicians. indeed, people living with cp are more aware of the challenges regarding cp treatment and may have tried medical cannabis (with or without experience of adverse effects), which could theoretically influence their perception. recommendations for research it seems relevant to continue research aiming to evaluate clinicians’ perceptions of the use of medical cannabis (effects and risk) as the prevalence of medical cannabis and prescribed cannabinoids is increasing in people living with cp. investigating the experiences of clinicians can provide new data on its usage and risk, particularly in subpopulations, such as women vs. men or <65 vs. ≥ 65 years old clinicians. indeed, these professionals are at the forefront of patient care when they encounter adverse effects (clarke & fitzcharles, 2023), and can provide relevant information to guide clinical research on the risk associated with cannabis use in pain management. thus, educational interventions could be conceptualized for the different clinicians to increase their knowledge about medical cannabis and prescribed cannabinoids for pain management (mode of action, indication, effects, risk of adverse effects). cannabis, a publication of the research society on marijuana 129 strengths and limitations with web surveys, it is not always possible to know who is responding, but several aspects of our methodology helped ensure that registered clinicians participated. these included the announcement of eligibility criteria in the invitations, confirmation of these criteria within the survey questions, and sharing the survey in dedicated groups on social media (e.g., associations, professional networks, and support groups for clinicians). the invitation was not broadly distributed on general public social media platforms. our sample was composed of different clinicians authorized to prescribe or adjust prescriptions in quebec and from both urban, remote and rural areas, and only 11% of cp specialists, supporting the external validity of our study. while cannabis regulation is federal, a previous study demonstrated that residing outside quebec was a predictor of cannabis initiation (ashoorion et al., 2023). additionally, healthcare and the organization of professional orders fall under provincial jurisdiction, highlighting the importance of specifically characterizing the context of quebec. however, our results may not be representative of all canadian prescribers and further studies could explore provincial differences. the cross-sectional design of the study limits assessment of causal relationships between participants characteristic and perceived risk associated with medical cannabis and prescribed cannabinoids. for example, an association between continuing education and a higher perceived risk of adverse effects with the use of prescribed cannabinoids was found in this study. however, the direction of the association cannot be defined, i.e., whether doing continuing education raises awareness and contributes to higher perceived risk, or whether those who had higher perceived risk at baseline are those who do more continuing education to better understand the risk. our participants were mostly identified as women (86%), which is not surprising, as women tend to participate in surveys more often than their men counterparts (becker, 2022; cull et al., 2005). although women were overrepresented among pharmacists (74% in our study vs 67% in quebec; ordre des pharmaciens du québec, 2023), this factor did not, however, emerge as associated with perceived risk of adverse events in the simple linear regression model. conclusion considering the increasing use of medical cannabis and prescribed cannabinoids for cp management and the lack of strong evidence towards their use for cp treatment, it seemed relevant to investigate perceived risk of adverse events. indeed, clinicians’ clinical practice is influenced by their own perceived risk. this study identified the type of practice setting, the type of clinicians and continuing education about cp as factors influencing perceived risk. shared decision-making between the different clinicians and individuals living with cp in all settings is crucial to ensure quality of care. references audet, c., bertrand, c., martel, m. o., pinard, a. m., bérubé, m., & lacasse, a. 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(2018). medical cannabis: an oxymoron? physicians’ perceptions of medical cannabis. international journal of drug policy, 57, 4-10. doi: 10.1016/j.drugpo.2018.03.025. funding and acknowledgements: this study was supported by the quebec network on drug research (réseau québécois de recherche sur les médicaments rqrm) which is itself funded by the fonds de recherche du québec— santé (frqs). study funding also came from the université du québec en abitibitémiscamingue’s foundation (fondation de l’université du québec en abitibitémiscamingue; fuqat) and partly from the canadian institutes of health research (cihr) (#pjt-461946). g.d.f. holds frqs and cihr postdoctoral scholarships. h.l.n.n. holds frqs and cihr doctoral scholarships. m.g.-p. holds a cihr doctoral scholarships. m.g.p. holds a frqs junior 2 research scholarship. we would like to thank all health care professionals who participated in the survey. also, special thanks to all professional and research organizations who accepted to disseminate our invitation: réseau de recherche sur les médicaments (rqrm), réseau stat, the societé québecoise de la douleur (sqd), the réseau québécois de recherche sur la douleur (rqrd) and its junior chapter (the réseau québécois des étudiant(e)schercheurs(euses) sur la douleur), the réseau-1 québec and its réseaux de recherche axée sur les pratiques de première ligne (rrappl), the association des anesthésiologistes du québec (aaq), the department of anesthesiology and pain medicine of université de montréal, various facebook support groups of physicians, pharmacists, and nurses, in addition to organizations that wished to remain anonymous. the chronic pain epidemiology chair under anaïs lacasse direction is funded by the fuqat, in partnership with local businesses: the pharmacie jean-coutu de rouyn-noranda (community pharmacy) and glencore fonderie horne (copper smelter). gwenaelle de cliffordfaugère, adriana angarita-fonseca, hermine lore nguena nguefack, marimée godboutparent, claudie audet, and anaïs lacasse do not have any conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: de clifford-faugere, g., angaritafonesca, a., nguefack, h. l. n., godbout-parent, m., audet, c., & lacasse, a. (2024). perceived risk of medical cannabis and prescribed cannabinoids for chronic pain: a cross-sectional study among quebec clinicians. cannabis, 7(3), 120–133. https://doi.org/10.26828/cannabis/2024/000263 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 164 ved abstract objective: legal cannabis dispensary employees (“budtenders”) are a significant resource for cannabis users. current research indicates that cannabis use may adversely impact mental health. public perception, however, is often inconsistent with this evidence, leading to increased use and disproportionate harm towards individuals with mental health disorders. this underscores the need for a deeper understanding of how budtenders may influence these perceptions. this preliminary cross-sectional survey assessed budtender perceptions and knowledge of cannabis use and its implications for mental health. method: researchers recruited budtenders (n = 46) from legal cannabis dispensaries (ontario cannabis stores) across the greater toronto (canada) area to participate in a 15-minute online survey. the survey collected non-identifying demographic data and responses about perceptions, education and customer interactions surrounding cannabis and mental health. results: we found that budtender perceptions (n = 46) of cannabis’ influence on mental health vary significantly based on symptomatology assessed, and often diverge from evidence-based knowledge. notably, 54.6% of budtenders rated cannabis as having a beneficial effect across the outcomes assessed, with sleep and depression most frequently perceived as beneficial. customers inquired about the mental health effects of cannabis at 21% of cannabis store visits. there was considerable variability in the sources from which budtenders derived their knowledge. conclusions: this study underscores significant gaps between budtender perceptions and scientific evidence regarding cannabis use and mental health. determining the impact of these perceptions is crucial for developing targeted, evidence-based educational interventions to mitigate the risks associated with recreational cannabis use. key words: = cannabis; mental health; public health; education cannabis has emerged as a central topic of public discourse, marked by shifts in legal frameworks, societal perspectives, use patterns, and health considerations. in 2021, an estimated 4.2% of the global population, aged 15-64 years, used cannabis, representing a 21% increase over the previous decade (united nations office on drugs and crime, 2023). this increase coincides with an expanding global landscape of nonmedical cannabis legalization (hasin & walsh, 2021; united nations office on drugs and crime, 2023). notably, following canada’s enactment of the cannabis act (bill c-45; cannabis act, 2018; cox et al., 2018) in 2018, cannabis use increased, with ~16% of canadians reporting past month use as of 2023 (hall et al., 2023; health canada, 2024; imtiaz et al., 2023). such legislative action corresponds to heightened frequency and initiation of cannabis use, as well as diminished perceived harm associated with use (cerdá et al., darby j. e. lowe1, cindy wang1, sergio rueda1,2, tony p. george1,2 1institute for mental health policy and research (imhpr), centre for addiction and mental health (camh) 2department of psychiatry, temerty faculty of medicine, university of toronto cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000292 volume 8, issue 2 budtender perceptions and knowledge of cannabis and mental health: a preliminary study corresponding author: tony george, md, frcpc, university of toronto; centre for addiction and mental health, 60 white squirrel way, room 109, toronto, ontario, canada. email: tony.george@camh.ca. cannabis, a publication of the research society on marijuana 165 2020; gali et al., 2021; gunadi et al., 2022; hall et al., 2023; hasin & walsh, 2021). in the context of mental health, observations of increased cannabis use and underestimation of associated risk are common. surveys within canada and the united states reveal that individuals who self-report poor mental health status or serious psychological distress are more likely to use cannabis (rotermann, 2020; weinberger et al., 2019). moreover, the perception of cannabis as a harmless and/or therapeutic option for managing mental health issues has become increasingly common (lowe et al., 2019; urits et al., 2020). data from the international cannabis policy study indicates that cannabis users commonly report alleviation of mental health symptoms, such as anxiety, depression, and trauma in association to use (leung et al., 2022; rup et al., 2022). further research reveals comparable motivations and contexts for cannabis use, including dissatisfaction with conventional treatment, using cannabis as a substitute for prescription medication, and the continued use of cannabis without consulting healthcare providers (aminilari et al., 2023; das et al., 2024). perceptions may be further complicated due to the nature of cannabis withdrawal which often presents with depression and anxiety, therefore blurring the lines between self-medication and withdrawal management (connor et al., 2022). moreover, the perception that cannabis offers mental health benefits is reportedly more common amongst individuals with a mental health disorder compared to those without (pacek et al., 2020; rup et al., 2022; sexton et al., 2016). despite the perceived benefits of cannabis for mental health, especially given the presumption of self-medication (hill et al., 2022; lowe et al., 2019), there is divergence from the current evidence. cannabis consists of over a hundred cannabinoids, including cannabidiol (cbd) and delta-9-tetrahydrocannabinol (thc; hall et al., 2019; lowe et al., 2019; national academies of sciences et al., 2017). most commonly, amongst cannabis users, research indicates increased risk for, and earlier onset of, psychosis and schizophrenia, as well as exacerbated symptom severity and worsened outcomes within this population (hasan et al., 2020; lowe et al., 2019; polkosnik et al., 2021; sorkhou et al., 2021). similarly, research highlights an association between cannabis use and a higher prevalence of depressive and manic symptoms in the general population, along with a higher risk of developing major depressive disorder and bipolar disorder, as well as poorer functional outcomes (sorkhou et al., 2024; tourjman et al., 2023). research investigating cannabis’ therapeutic effects for schizophrenia and depression is limited and primarily pertains to cbd administration, of which provides equivocal evidence (national academies of sciences et al., 2017). the evidence describing the association between cannabis use and ptsd and anxiety disorders is mixed. individuals not only use but are also prescribed cannabis for ptsd symptom alleviation; however, the lack of methodologically robust research, notably randomized controlled trials, indicates insufficient evidence for therapeutic effects in ptsd (bedard-gilligan et al., 2022; rodas et al., 2024). moreover, there is limited evidence to characterize the association between cannabis use and anxiety; however, preliminary findings indicate that regular cannabis use may be associated with the subsequent onset of anxiety symptoms, as well as a worsened prognosis among individuals diagnosed with an anxiety disorder (botsford et al., 2020; feingold et al., 2018; lowe et al., 2024). importantly, research investigating cannabis’ therapeutic effects for anxiety is similarly focused on cbd, with limited and equivocal findings (national academies of sciences et al., 2017). moreover, research shows that cannabis use is associated with poorer outcomes in sleep and cognition (edwards & filbey, 2021; hser et al., 2017; kroon et al., 2021; scott et al., 2018). thus, current research suggests that cannabis use may exacerbate symptoms and outcomes across a range of mental health disorders. public perceptions about cannabis and its effects on mental health often contradicts the evidence. moreover, research indicates that individuals who perceive fewer risks associated with cannabis are more likely to, and more frequently, use cannabis (florimbio et al., 2024; gali et al., 2021; han & shi, 2023; leos-toro et al., 2020; salloum et al., 2018). consequently, favorable perceptions of cannabis use on mental health may translate into increased use, with disproportionate harms to individuals with, or at high risk of, mental health disorders. this underscores the need for a comprehensive understanding of not only public perceptions of perceptions and knowledge of cannabis and mental health 166 cannabis, but also sources of knowledge and guidance that may shape these perceptions. legal cannabis dispensary employees in canada (i.e., “budtenders”) serve as a significant resource for cannabis users, particularly those who use recreationally (i.e. non-medical cannabis users). existing research from the united states shows that budtenders provide guidance to consumers on cannabis strains, administration methods, potential side effects and benefits for clinical symptoms, with recommendations made based on varied sources (carlini et al., 2022; haug et al., 2016; merlin et al., 2021). similar findings have been qualitatively described within the canadian context, of which individuals with mood and anxiety disorders commonly seek information from non-medical sources, including staff at cannabis stores (das et al., 2024). budtenders commonly perceive cannabis as beneficial and low-risk for various health concerns, including mental health disorders such as ptsd (bulls et al., 2023). moreover, amongst people with multiple sclerosis and chronic pain who use cannabis, budtenders are perceived as an essential source of guidance, ranking them above the internet, scientific publications, and medical professionals (boehnke et al., 2019; salter et al., 2022). thus, budtenders may play a crucial role in influencing cannabis product selection and use, relying on anecdotal evidence rather than scientific information (lange et al., 2023). a canadian cross-sectional survey found that 88% of budtenders and managers received questions about perceived medical use and/or benefits of cannabis, with over 90% of respondents receiving questions specifically related to whether cannabis could help with anxiety, depression or sleep (cameron et al., 2023). thus, there is a distinct research gap in budtender education, perceptions, and customer engagement, following non-medical cannabis legalization in canada. this preliminary study sought to assess budtenders’ perceptions and knowledge of cannabis use and mental health. the results of the survey provide important information on how budtenders may be shaping legal cannabis perceptions and use patterns, which can be used to inform public health strategies and educational efforts. methods study design the study employed an online, cross-sectional survey from september–november, 2023 in the greater toronto area (gta), ontario, canada. the inclusion criteria were individuals aged 19 years and older, proficient in english, employed at a legal cannabis retail store (“budtenders”) in the gta, and with access to an internet-connected device for survey participation. the research ethics board (reb) at the centre for addiction and mental health approved the study (reb#2023-046), and the alcohol and gambling commission of ontario (agco), the regulator of legal cannabis stores in the province of ontario, endorsed the study. the agco facilitated recruitment via email through its database of legal cannabis retail store managers and owners. the agco, on behalf of the principal investigator (tpg), sent recruitment emails that explained their role as solely aiding in connecting the research team with potential budtender participants. the emails also included a detailed project description, requirements (e.g., eligibility criteria), and information to be forwarded to participants (i.e., the study information, an invitation to participate, and an informed consent link). store managers and owners reviewed and distributed the information to their staff for participation at their discretion. participants first completed and submitted the consent form to provide informed consent. participants accessed the self-administered survey on redcap, which took approximately 15 minutes to complete. the survey collected all data without personal identifiers. participants learned about the research objectives and provided consent, and then were reassured of their anonymity before proceeding to the survey. after completing and submitting the survey, participants accessed a separate redcap form to receive renumeration ($10 egift card). study measures and analysis the survey included 42 items (see appendix 1), collecting data across multiple dimensions. the survey examined sociodemographic characteristics, including age, gender identity, race and ethnicity, education, and cannabis use history. the survey also assessed perceptions on the effects of cannabis on mental health and characteristics of customer interactions (e.g., (camh), 60 white squirrel way, room 312. toronto, ontario, canada, m6j 1h4 phone: (416) 535-8501 x 32662. email: tony.george@camh.ca cannabis, a publication of the research society on marijuana 167 frequency of mental health-related inquiries, budtender influence and responsibility), measuring all responses on likert scales. additionally, the survey assessed budtender knowledge sources. an extensive review of existing literature and validated instruments, where applicable, informed the development of all items, ensuring relevance and rigor. the data was analyzed from the completed surveys using ibm spss statistics (version 28.0). given the exploratory nature of this pilot study, we employed comprehensive descriptive statistics to characterize the data, including measures of central tendency (mean, median, mode) and dispersion (frequencies, percentages, standard deviations), as well as proportional analyses. results participant demographics a total of 46 participants provided informed consent. demographic characteristics are detailed in supplemental table 1. the sample was predominantly cisgender men (39.1%) and women (37.0%), with an average age of 35.4 years (sd = 14.0). the majority of participants identified as ‘white-north american’ (41.4%) or ‘whiteeuropean’ (19.0%). a significant portion (95.7%) had at least a high school education. notably, 71.7% of participants were cannabis users within the past six months. a minority reported cannabis use more than six months prior, and two individuals reported never using cannabis. due to incomplete responses to individual survey questions, the sample size analyzed varies across results (e.g., n = 40), and it is not a consistent subset of the original n = 46. therefore, demographic data are reported for the full sample for context. table 1. perceptions of cannabis’ effects on mental health (n = 40) mental health outcome extremely harmful % (n) somewhat harmful % (n) neither harmful nor beneficial % (n) somewhat beneficial % (n) extremely beneficial % (n) “i don’t know” % (n) mental health (thc) 2.5 (1) 12.5 (5) 32.5 (13) 22.5 (9) 12.5 (5) 17.5 (7) mental health (cbd) 0.0 (0) 2.5 (1) 17.5 (7) 25.0 (10) 40.0 (16) 15.0 (6) anxiety 0.0 (0) 10.0 (4) 15.0 (6) 47.5 (19) 17.5 (7) 10.0 (4) social anxiety 0.0 (0) 10.0 (4) 20.0 (8) 37.5 (15) 20.0 (8) 12.5 (5) depression 0.0 (0) 5.0 (2) 12.5 (5) 55.0 (22) 20.0 (8) 7.5 (3) ptsd 0.0 (0) 7.5 (3) 5.0 (2) 37.5 (15) 30.0 (12) 20.0 (8) psychosis 7.5 (3) 25.0 (10) 27.5 (11) 15.0 (6) 2.5 (1) 22.5 (9) schizophrenia* 15.4 (6) 20.5 (8) 25.6 (10) 15.4 (6) 23.1 (9) 0.0 (0) bipolar disorder 5.0 (2) 20.0 (8) 17.5 (7) 32.5 (13) 7.5 (3) 17.5 (7) eating disorders 0.0 (0) 5.0 (2) 7.5 (3) 42.5 (17) 30.0 (12) 15.0 (6) sleep 0.0 (0) 2.5 (1) 10.0 (4) 22.5 (9) 62.5 (25) 2.5 (1) cognition 7.5 (3) 20.0 (8) 40.0 (16) 22.5 (9) 5.0 (2) 5.0 (2) total 3.1 (15) 11.7 (56) 19.2 (92) 31.3 (150) 22.6 (108) 12.1 (58) note. *n = 36 (n = 2 missing responses). perceptions of the effects of cannabis on mental health budtender perceptions about the effects of thc and cbd on mental health were assessed on a 5-point likert scale from extremely harmful to extremely beneficial, including the option ‘do not know’. across the sample (n = 40), 67.5% and 97.5% of budtenders reported that thc and cbd, respectively, have effects on overall mental health ranging from neutral (i.e., ‘neither harmful nor beneficial’) to ‘extremely beneficial’ (table 1). a detailed analysis of budtender perceptions across specific mental health symptomatology is presented in table 1. notably, across the 10 variables that were assessed, 54.6% of the collective 399 responses were classified as somewhat or extremely beneficial. when considering the effects of cannabis on symptoms of depression, 75.0% of participants reported cannabis as somewhat or extremely beneficial, while only 5.0% of participants perceptions and knowledge of cannabis and mental health 168 reported any harmful effects. for symptoms of anxiety, beneficial effects were reported by 65.0% of participants, with 10.0% reporting harmful effects. in contrast, perceptions of cannabis’ effects on symptoms of psychosis and schizophrenia diverged from the predominantly beneficial views. when considering cannabis’ impact on psychosis, 32.5% of participants reported somewhat or extremely harmful effects and 27.5% reported neutral effects; 22.5% indicated a lack of knowledge. for schizophrenia, 35.9% of participants reported somewhat or extremely harmful effects, while 25.6% reported neutral and 38.5% reported somewhat or extremely beneficial effects. across the variables assessed, the effect of cannabis on sleep was most frequently perceived by budtenders as beneficial, with 85.0% of participants reporting a somewhat or extremely beneficial effect. only a minority reported neutral (10.0%) or somewhat harmful (2.5%) effects. customer engagement: general over the past 30 days, budtenders reported that 71.3% (sd = 22.8) of customer interactions involved requests for a product recommendation, with customers purchasing cannabis from recommendations 74.3% (sd = 21.4) of the time. the most frequent customer inquiries involved product potency (52.5%), followed by recreational motives (15.0%) and product strain (10.0%;figure 1). figure 1. most common questions (n = 40) customer engagement: mental health customer engagement about the effects of cannabis on mental health over the past 30 days was assessed using a 7-point likert scale from ‘never’ (i.e., 0% of the time) to ‘always’ (i.e., 100% of the time). proportional analysis was implemented to further characterize findings (table 2). across the variables assessed, the frequency with which customers engaged with budtenders about these topics was approximately 20.9% (sd = 20.7) of the time. customers inquired 24.0% (sd = 22.8) of the time about symptoms of depression and 34.0% (sd = 23.0) of the time about symptoms of anxiety. in contrast, customers inquired 8.5% (sd = 20.19) and 5.3% (sd = 12. 45) of the time, respectively, about symptoms of psychosis and schizophrenia. most frequently, customers inquired about cannabis’ effects on sleep approximately 59.3% (sd = 22.7) of the time. budtenders (n = 38) reported receiving questions that they felt were better suited for medical professionals 43.9% (sd = 25.5) of the time. cannabis, a publication of the research society on marijuana 169 table 2. past 30-day customer engagement regarding the effects of cannabis on mental health (n = 40) mental health outcome never % (n) rarely (<10% of the time) % (n) occasionally (~ 30% of the time) % (n) sometimes (~50% of the time) % (n) frequently (~70% of the time) % (n) usually (~90% of the time) % (n) always % (n) mean* (%) sd* anxiety 15.0 (6) 17.5 (7) 20.0 (8) 35.0 (14) 12.5 (5) 0.0 (0) 0.0 (0) 34.0 23.0 social anxiety 27.5 (11) 32.5 (13) 17.5 (7) 12.5 (5) 10.0 (4) 0.0 (0) 0.0 (0) 21.8 22.8 depression 25.0 (10) 30.0 (12) 15.0 (6) 22.5 (9) 7.5 (3) 0.0 (0) 0.0 (0) 24.0 22.8 ptsd 45.0 (18) 30.0 (12) 12.5 (5) 7.5 (3) 2.5 (1) 2.5 (1) 0.0 (0) 14.5 21.1 psychosis 80.0 (32) 5.0 (2) 2.5 (1) 10.0 (4) 2.5 (1) 0.0 (0) 0.0 (0) 8.5 20.2 schizophrenia 77.5 (31) 12.5 (5) 5.0 (2) 5.0 (2) 0.0 (0) 0.0 (0) 0.0 (0) 5.3 12.5 bipolar disorder 67.5 (27) 10.0 (4) 7.5 (3) 15.0 (6) 0.0 (0) 0.0 (0) 0.0 (0) 10.8 18.4 eating disorders 60.0 (24) 20.0 (8) 5.0 (2) 12.5 (5) 2.5 (1) 0.0 (0) 0.0 (0) 11.5 19.2 sleep 0.0 (0) 5.0 (2) 17.5 (7) 22.5 (9) 37.5 (15) 15.0 (6) 2.5 (1) 59.3 22.7 cognition 37.5 (15) 27.5 (11) 15.0 (6) 12.5 (5) 2.5 (1) 5.0 (2) 0.0 (0) 19.8 24.8 total 43.5 (174) 19.0 (76) 11.8 (47) 15.5 (62) 7.8 (31) 2.3 (9) 0.3 (1) 21.0 20.7 note. *proportional analyses were used to provide the mean (%) and standard deviation (sd) for each outcome. budtender knowledge and responsibility based on a 5-point likert scale from ‘not at all knowledgeable/responsible’ to ‘extremely knowledgeable/responsible’, budtenders were assessed on their perceived knowledge and responsibility about various cannabis-related topics and communications (table 3). a majority reported higher levels of knowledge on the psychological effects (66.7%) and physical effects (74.4%) of cannabis, as well as on the differences between thc and cbd (89.7%). the three primary sources of cannabis knowledge among participants were personal experience (84.6%), job training, such as the agco-approved training program cannsell (79.5%), and equal proportions between published research, cannabis industry resources, and word of mouth (66.7%; figure 2). figure 2. budtender sources of knowledge (n = 40). perceptions and knowledge of cannabis and mental health 170 regarding budtender perceived responsibility, 61.5% of budtenders felt moderately to extremely responsible for providing scientifically accurate information and 89.7% felt a similar level of responsibility for promoting safe cannabis use (table 3). table 3. budtender knowledge and responsibility (n = 39). perceived knowledge not at all knowledgeable % (n) slightly knowledgeable % (n) somewhat knowledgeable % (n) moderately knowledgeable % (n) extremely knowledgeable % (n) new products 2.6 (1) 10.3 (4) 15.4 (6) 35.9 (14) 35.9 (14) methods of consumption 0.0 (0) 2.6 (1) 7.7 (3) 38.5 (15) 51.3 (20) psychological effects 0.0 (0) 10.3 (4) 23.1 (9) 48.7 (19) 18.0 (7) physical effects 5.1 (2) 2.6 (1) 18.0 (7) 48.7 (19) 25.6 (10) legal regulations 0.0 (0) 0.0 (0) 7.7 (3) 41.0 (16) 51.3 (20) thc vs cbd 0.0 (0) 0.0 (0) 10.3 (4) 25.6 (10) 64.1 (25) perceived responsibility not at all responsible % (n) slightly responsible % (n) somewhat responsible % (n) moderately responsible % (n) extremely responsible % (n) evidence-based communication 7.7 (3) 2.6 (1) 28.2 (11) 25.6 (10) 35.9 (14) promoting safe use 0.0 (0) 0.0 (0) 10.3 (4) 5.1 (2) 84.6 (33) discussion to our knowledge, this is the first survey to study perceptions, education, and customer interactions among canadian budtenders in the context of recreational cannabis use and mental health. the findings suggest that majority of budtender perceptions regarding the effects of cannabis on mental health disorders and outcomes diverge from current scientific evidence. budtenders perceive cannabis to be beneficial towards depression, anxiety, and sleep; however, for psychosis and schizophrenia, perceptions were mixed between perceived harm and benefit. these findings align with previous research, characterizing trends, amongst dispensary staff and the general population, of lowered perceived harm and clinical benefits of cannabis (bulls et al., 2023; goodman & hammond, 2022; haug et al., 2016). importantly, these perceptions are in contrast with the growing scientific literature, which offers equivocal evidence supporting the benefit of cannabis across the assessed mental health disorders and outcomes (botsford et al., 2020; edwards & filbey, 2021; feingold et al., 2018; hasan et al., 2020; lowe et al., 2019; polkosnik et al., 2021; tourjman et al., 2023), highlighting a critical knowledge gap among budtenders. budtenders report primarily deriving their knowledge from personal experience, followed by formal job training and other diverse resources. moreover, budtenders report high levels of knowledge when considering the psychological effects of cannabis, suggesting perceived accuracy in their perceptions. the reliance on personal experiences to inform this understanding reflects previous research indicating dispensary staff often depend on knowledge sources, such as insights from past customer interactions and colleague recommendations (lange et al., 2023; merlin et al., 2021), suggesting a reliance on anecdotal information, which may contribute to the discrepancies between budtender perceptions and established scientific evidence. although customers inquired about the effects of cannabis on mental health, inquiries over the past 30 days predominantly focused on product potency, environmental/personal context (e.g., for watching a movie, to “chill out”), as well as strain characteristics, according to budtenders. this focus of topics reflects previous findings of which cannabis strains and pharmacological makeup (e.g., thc potency) were most commonly inquired by customers (cameron et al., 2023; haug et al., 2016). in this study, interactions regarding specific mental health outcomes were comparatively less frequent according to budtenders, occurring in less than 50% of interactions, with sleep-related inquiries being the most prevalent motive. nonetheless, budtenders reported fielding questions surrounding all assessed mental health disorders and outcomes, reflecting previous canadian cannabis, a publication of the research society on marijuana 171 research conducted by cameron et al. (2023), in which over 90% of budtenders and recreational dispensary managers received questions regarding anxiety, depression, and sleep. moreover, a significant number of budtenders received questions that reportedly would be more appropriately addressed by medical professionals, echoing previous findings (calcaterra et al., 2020; cameron et al., 2023; salter et al., 2022). budtenders not only address a wide range of questions about cannabis but also perceive having a significant influence over consumer behaviour, with over 70% of customers who received a product recommendation proceeding to purchase the recommended product according to budtenders. this is consistent with previous research, which suggests that cannabis users frequently rely on and act upon budtender recommendations (boehnke et al., 2019; das et al., 2024; salter et al., 2022). overall, our preliminary findings indicate that budtender perceptions of cannabis do not align with the current scientific evidence concerning its effects on mental health. furthermore, according to budtenders, customers confide in and are influenced by suggestions and guidance when selecting products. building upon previous research (dickson et al., 2018; haug et al., 2016; merlin et al., 2021), this study offers further evidence of potentially misleading guidance regarding the mental health effects of cannabis. notably, the majority of budtenders acknowledged their responsibility in providing scientifically accurate information and promoting safe cannabis use, which aligns with previous research (carlini et al., 2022). nonetheless, there exists a significant knowledge and education gap around cannabis’ influence on mental health. this complicates interactions with customers who frequently pose questions that budtenders are not legislatively permitted to address in canada due to the federal regulations under the canadian cannabis act, which mandates transparent, accurate, and non-promotional information without making any health-related claims (canadian cannabis survey, 2024). with customers frequently asking about these topics, such misinformation and restrictions might leave customers without clear guidance or, potentially, misinformed about the mental health implications of cannabis use—a situation that facilitates the quandary of budtenders acting as “proxy clinicians” in a commercial retail environment (calcaterra et al., 2020; lange et al., 2023). taken together, our findings highlight the critical need for standardized, accurate training programs for budtenders, which focus not only on product knowledge but also on the limitations and potential risks associated with communication about the health effects of cannabis. this study has limitations. first, the reliance on self-reported data introduces potential biases, as actual staff practices are unknown. second, the specificity of thc versus cbd was not assessed for each question due to the exploratory nature of the study, which may have overlooked nuances in perceptions and knowledge. instead, the term ‘cannabis’ was used to streamline the survey and reduce participant burden, while capturing broader perceptions. while the sample size was sufficient for exploratory analysis, there are limitations for the generalizability of findings to represent broader populations. most of the sample identified as cisgender and white, which further limits generalizability. moreover, the demographic focus on budtenders in the greater toronto area may not reflect observations within other regions with varied regulatory environments, such as quebec, in which commercial regulations are more restricted compared to ontario and the united states. additionally, the survey was distributed to the agco’s database of dispensary managers and owners, who autonomously decided whether to forward it to their staff (i.e., budtenders). this approach may introduce potential response bias, leading to unobserved differences between respondents and non-respondents, as well as between dispensaries associated with managers and owners who chose to forward the survey versus those who did not, further limiting generalizability. future research should aim to expand on this work by collecting data in larger and more demographically diverse populations to improve representativeness of the findings. moreover, it would be valuable to examine whether budtenders are recommending specific cannabis products for mental health disorders or outcomes, a practice that has been found in previous studies (haug et al., 2016), in order to reduce the gap between self-reported perception of customer interactions and actual staff practices. expanding the scope of research to include a broader array of perceptions and knowledge of cannabis and mental health 172 mental health disorders and outcomes and cannabis subtypes, such as sub-clinical symptoms like 'high stress' and the delineation between cbd-only and high-thc products, could also provide a more comprehensive understanding of health-related perceptions and interactions within dispensaries. furthermore, research into the effectiveness of specific educational interventions for budtenders could yield critical information on how to enhance knowledge for budtenders. such studies could ultimately inform best practices and guide policy development, ensuring that budtenders are equipped to provide accurate and safe advice to consumers. conclusions these preliminary findings shed light on budtender perceptions, education, and customer interactions related to cannabis use and mental health. with the increasing acceptance and use of cannabis, particularly as a form of self-medication for various mental health conditions, our findings emphasize the need for ongoing research, public health strategies, and improved educational efforts. future efforts should aim to bridge the gap between anecdotal evidence and scientific research, ensuring that budtenders and consumers can make informed decisions regarding cannabis use. references aminilari, m., busse, j. w., turna, j., & mackillop, j. 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(2019). serious psychological distress and daily cannabis use, 2008 to 2016: potential implications for mental health? drug and alcohol dependence, 197, 134-140. https://doi.org/10.1016/j.drugalcdep.2019.01.0 10 funding and acknowledgements: this study was supported in part by a university of toronto excellence award (utea) to ms. wang, and cihr operating grant pjt-190053 to dr. tp george. dr. tp george is co-principal editor for neuropsychopharmacology (npp), an official journal of the american college of neuropsychopharmacology (acnp). ms. dje lowe, ms. wang and dr. s rueda have no disclosures to report. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: lowe, d. j., wang, c., rueda, s., & george, t. p. (2025). budtender perceptions and knowledge of cannabis and mental health: a preliminary study. cannabis, 8(2), 164 176. https://doi.org10.26828/cannabis/2025/000292 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ perceptions and knowledge of cannabis and mental health 176 research article 150 ved abstract emerging research shows that many individuals commonly consume cannabis while gambling. however, individuals’ expectations for how cannabis consumption will impact their gambling behavior remain unknown. participants who gambled weekly (n = 472) were recruited from amazon mechanical turk and completed assessments of gambling behaviors, cannabis consumption, and expectations about the influence of cannabis on gambling. almost all participants (94%) screened positive for problem gambling. over half of participants (55%) reported lifetime cannabis consumption, and almost all those participants (99%) reported gambling under the influence of cannabis (guic) in the past month. most participants agreed with positive expectations of gambling; they expected that they would feel calmer when under the influence of cannabis (61.4%), that gambling would be more enjoyable (61.0%), and that their gambling skills would increase when guic (60.6%). at the same time, most participants also agreed with negative expectations of guic. they expected cannabis use would make them more careless (56.4%), more anxious (54.8%), and less able to concentrate (53.7%) while gambling. negative cannabis expectancies were significantly associated with the severity of cannabis consumption. both positive and negative cannabis expectancies were significantly associated with gambling problems and time spent gambling under the influence of cannabis. these findings indicate that expectations may influence the decision to consume cannabis and gamble simultaneously. this study contributes to the need for addressing cannabis expectations during treatment of gambling problems. key words: = cannabis; cannabis expectancies; acute cannabis use; gambling; problem gambling emerging research suggests that cannabis is commonly used while gambling (mcphail et al., 2020; mcgrath et al., 2023). gambling is defined by risking something of value in an event whose outcome is partly defined by chance (whelan et al., 2007). over three-quarters (76.9%) of adults report gambling within the past year (welte et al., 2015). nearly 50% of those who gamble at least once weekly also reported having used cannabis at least half of the time they gamble (mcphail et al., 2020). this finding is not surprising given that cannabis is the most consumed illicit psychoactive substance in the united states, with 20% of the population reportedly using cannabis within the past year (united nations, 2020). individuals’ expectations about how cannabis affects their gambling and gambling experience may be associated with engaging in these behaviors simultaneously – a research question that has not yet been examined. the present study explored expectations of acute cannabis consumption on gambling and their relation to gambling behaviors. acute cannabis consumption can influence psychomotor behaviors related to regulating behavior while gambling, such as short-term memory, learning, attention, and concentration (dellazizzo et al., 2022). while under the influence e. halle smith1, abby mcphail1, marcos lerma1, rory a. pfund1, & james p. whelan1 1university of memphis cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000231 expectations of how acute cannabis use affects gambling experiences and behaviors corresponding author: elizabeth h. smith, b.a., tennessee institute for gambling education & research, the university of memphis. 400 fogelman drive, memphis, tn 38152. email: gambling@memphis.edu. cannabis, a publication of the research society on marijuana 151 of cannabis, individuals often describe feelings of intoxication (desrosiers et al., 2015; hart et al., 2001a, 2001b; morrison et al., 2009a, 2009b). specifically, those who use cannabis often report a diverse assortment of positive and negative effects, such as relaxation, dizziness, happiness, and feeling withdrawn (green et al., 2003). these effects inform the perception of acute cannabis consumption while gambling. not only do these effects influence future use of cannabis and engagement in gambling (rotter et al., 1972; bandura, 1977; jones et al., 2001), but these effects also influence expectations of gambling under the influence of cannabis (guic) in a way that may also undermine an individual’s engagement in more cautious risk-taking, also known as responsible gambling. outcome expectancy theory defines expectancy as the experiences an individual anticipates before engaging in a behavior (rotter et al., 1972; bandura, 1977; jones et al., 2001). cannabis outcome expectancies classified six areas of cannabis use expectancies: cognitive and behavioral impairment, relaxation and tension reduction, social and sexual facilitation, perceptual and cognitive enhancement, global negative effects, and craving and physical effects (schafer & brown, 1991). broadly, cannabis expectations may be “positive” (relaxation and tension reduction, perceptual and cognitive enhancement, social and sexual facilitation) or “negative” (cognitive and behavioral impairment, global negative effects, craving and physical effects; anthenien et al., 2021; kristjansson et al., 2012). differences in cannabis expectancies have been found consistently between individuals who do and do not consume this drug. those who do not use cannabis may have more negative expectancies than people who use cannabis (kristjansson et al., 2012). in contrast, people who use cannabis are more likely to endorse positive expectancies for cannabis use than those who do not use cannabis. among people who consume cannabis at least three times a week, expectancies are a potential moderator of the relation between frequent use and motivations for use (anthenien et al., 2021). expectations such as these may have implications for gambling behaviors. research on the acute effects of alcohol consumption on gambling and risk-taking highlights the impact of individuals’ expectations about the effect of substance use on gambling. a meta-analysis review revealed that differences in risk-taking are driven by expectations about alcohol rather than the physiological effects of acute alcohol consumption (horn et al., 2022). to further investigate these expectations, horn et al. (2023) explored how individuals expect alcohol consumption to influence their gambling behaviors. the authors found that individuals expected alcohol to both positively and negatively influence their gambling. for example, they believed that drinking alcohol would make them more focused while gambling (positive expectation), and they believed that drinking alcohol would make them lose control and gamble carelessly (negative expectation). in the same study, alcohol expectancies were associated with higher scores of alcohol use problems and problem gambling severity. additionally, positive expectations were associated with higher rates of alcohol consumption while gambling. with the same sample as horn et al. (2023), this study examines whether similar findings appear among individuals who use cannabis. our primary aim was to explore how individuals who gamble frequently expect cannabis to affect their gambling. we also sought to examine how these expectancies aligned with the extant literature on cannabis outcome expectancies by examining the difference in positive and negative expectancies between those who do and do not guic. within individuals who guic, we explored whether expectations were associated with measures of cannabis usage and gambling behavior. finally, the relation between the percentage of time spent guic and cannabis expectations was explored. methods the same data were used in a previously published study on how participants’ expectations of the impacts of alcohol use on gambling were associated with gambling behaviors and problems. however, the current study was distinct in that it examined how participants’ expectations of the impacts of cannabis use on gambling were associated with gambling behaviors and problems. cannabis expectancy and gambling 152 participants participants were recruited via amazon mechanical turk (mturk) and eligible if they were united states residents, at least 18 years old, and self-reported that they gambled at least once per week (the duration of weekly gambling was not specified). the final dataset included 472 individuals with a mean age of 35.37 (sd = 10.18). the majority were male (58%), white (95%), heterosexual (67%), married (86%), and held bachelor’s degrees or higher (96%). sample characteristics can be found in table 1. table 1. demographic variables of whole sample, non-cannabis use sample, and cannabis use sample variable whole sample (n = 472) non-cannabis use subsample (n = 213) cannabis use subsample (n = 259) m(sd) m(sd) m(sd) t(df) p age 35.37 (10.18) 35.3 (10.6) 35.4 (9.8) 0.07 (470) .94 n (%) n (%) n (%) 𝒳2(df) p race 2.78(4) .60 caucasian 447 (95) 204 (96) 242 (93) african american 9 (2) 3 (1) 6 (2) asian american 8 (2) 4 (2) 4 (2) hispanic american 4 (1) 1 (1) 2 (1) american indian or alaskan native 7 (2) 1(1) 6(2) gender 0.51(1) .48 male 273 (58) 127 (60) 146 (56) female 199 (42) 86 (40) 113 (44) sexual orientation 45.1(4) <.001 heterosexual 317 (67) 176 (83) 141 (54) bisexual 145 (31) 35 (16) 110 (43) gay or lesbian 8 (2) 1 (1) 7 (3) prefer not to say 1(1) 1 (1) 0(0) prefer to self-describe 1(1) 0(0) 1(1) marital status 3.87(4) .425 married 406 (86) 182 (85) 224 (86) single, never married 46 (10) 21 (10) 25 (10) divorced/separated 17 (4) 10 (5) 7 (3) widowed 3 (1) 0 (0) 3 (1) education 25.04(7) <.001 less than high school 1 (1) 0 (0) 1 (<1) high school graduate 13 (3) 5 (2) 8 (3) some college 3 (1) 1 (1) 2 (1) associate degree 3(1) 2(1) 1(1) bachelor’s degree 335 (71) 174 (82) 161 (62) master’s degree or higher 117 (25) 31 (15) 86 (33) note. participants were able to self-identify within multiple categories. there were some missing demographic data. rows may not sum to total population pool. cannabis, a publication of the research society on marijuana 153 instruments demographics. participants were asked their age, gender, race/ethnicity, sexual orientation, relationship status, and education. current gambling behaviors. four items were used to assess current gambling behavior. items included “how many days per week do you gamble?”, “on an average gambling day, how many hours do you typically gamble?”, and “on an average gambling day, how much money did you wager?” the fourth question asked for a report of gambling activities they have engaged in over the last 12 months on a 7-point likert-type scale from not at all to daily. cannabis use. four items assessed cannabis use. one item asked, “have you ever consumed cannabis?” if respondents answered yes, they were asked, “in the past month, how many days did you consume cannabis?” participants answered with a number between 1 and 30. they were also asked to enter a number between 1 and 100 in answer to the question “in the past month, when you gamble, what percent of the time were you also under the influence of cannabis?” a final question asked, “during a typical session when you gambled under the influence of cannabis, how high are you?” participants rated their response on a 5-point likert-type scale from 1 = not at all high to 5 = extremely high. cannabis expectancies while gambling. items were derived from the alcohol expectancy questionnaire (brown et al., 1987) and the gamblers’ beliefs questionnaire (steenbergh et al., 2002). these items are provided in table 3. the following was assessed with three items each: perceptual and cognitive enhancement expectancies of cannabis use while gambling, cognitive impairment expectancies of cannabis use while gambling, relaxation and tension reduction expectancies of cannabis use while gambling, and negative expectancies of cannabis use while gambling. four items assessed expectancies of gambling beliefs with cannabis use while gambling. all items were measured on a 7-point likert-type scale with ratings from strongly disagree and strongly agree. cannabis use disorder identification testrevised (cudit-r; adamson et al., 2010). the cudit-r is an 8-item screening test that assesses an individual’s hazardous cannabis consumption habits over the past six months. items are rated from 0 to 4 and are summed up to compute a total score with a maximum of 32. among those who meet the cut-off score of 8, scores are classified as cannabis abuse (8-11) and cannabis dependence (12+; adamson et al., 2010). problem gambling severity index (pgsi, ferris & wynne, 2001). the pgsi was used to assess participants’ gambling behaviors over the past year. this measure contains nine items with responses indicated on a 4-point likert-type scale, ranging from 0 = not at all to 3 = often. item ratings are summed to yield a maximum score of 27. individuals are classified as being at high risk for gambling disorder if their score was 8 or greater (ferris & wynne, 2001). procedure following irb approval, those registered as mturk workers with a successful human intelligence task approval rate of 80% were invited to complete an anonymous questionnaire about gambling behaviors and expectations about how various substances impacted gambling behaviors (peer et al., 2014). after completing the survey, participants were provided with mental health resources, including phone numbers and websites for mental health and problem gambling services. data analytic plan the following statistical analyses were conducted using statistical package of social sciences (spss), version 28 (ibm, 2021). of the 502 who provided consent, 15 did not pass the embedded instructional manipulation checks (hauser & schwarz, 2016; oppenheimer et al., 2009). eleven were considered outliers on daily money wagered (3.00 < z < -3.00), and four provided inconsistent responses. frequency analyses were used to summarize cannabis consumption behaviors and gambling behaviors of the overall sample. using mplus, version 8 (muthén & muthén, 2017), an exploratory factor analysis (efa) with maximum likelihood estimation and oblique geomin rotation was conducted on cannabis expectancy items. parallel analyses (horn, 1965) – comparing the generated eigenvalues from the actual data to normally distributed random data eigenvalues – and scree plots were used to cannabis expectancy and gambling 154 determine the number of factors to retain. items with loadings < 0.32 or loadings across factors ≥ 0.32 were excluded from further analysis (tabachnick & fidell, 2007). the efa was repeated with the remaining set of items. once the number of factors was determined, composite scores were computed to run further analyses. factorial analysis was conducted to explore how these cannabis expectancies items aligned with the cannabis expectancies literature. participants who used cannabis were compared with participants who did not use cannabis on the resulting factors and individual items with independent t-tests to assess how these expectancies fit into the broader literature. pearson correlations were used to see whether the level of agreement with each expectancy item was associated with the percentage of time spent consuming cannabis while gambling. lastly, excluding those who did not consume cannabis, multiple linear regressions were conducted to predict the percentage of time spent guic, pgsi score, and cudit-r score. predictors included both positive and negative cannabis expectancies while gambling. results sample characteristics participants reported gambling an average of 4.31 days (sd = 1.75) per week, spending 10.11 hours per gambling episode (sd = 6.20), and spending $413 usd (sd = $1,378) per episode. 94% percent (n = 444) evidenced problem gambling on the pgsi (m = 16.37, sd = 5.09). for demographics of the whole sample and those who endorsed cannabis use, see table 1. about half the participants (55%, n = 259) reported lifetime cannabis use, and 99% of those participants (n = 256) endorsed cannabis use in the past month. only 3 of the 259 (1%) participants who reported cannabis consumption reported not having guic. those who reported lifetime cannabis consumption showed increased risk of problem gambling on the pgsi (m = 17.05, sd = 4.38) in comparison to those who did not consume cannabis (m = 15.52, sd = 5.76; t(468) = 3.28, p = .001). for comparisons of gambling behaviors between those who consume cannabis and those who do not, see table 2. table 2. gambling behaviors of those who use cannabis and those who do not non-cannabis use (n=213) cannabis use (n=259) m(sd) m(sd) t df p gambling days per week 4.21(1.76) 4.40(1.74) 1.15 470 .25 gambling hours per day 8.54(5.55) 11.41(6.42) 5.13 470 <.001** average dollars gambled 448.15(1241.30) 383.41(1483.00) 0.51 470 .62 pgsi 15.52(5.76) 17.05(4.38) 3.28 468 .001** n (%) n (%) 𝒳! df p no risk 12(5.6) 2(0.8) 13.24 3 .002* low risk 7(3.3) 1(0.4) moderate risk 3(1.4) 3(1.2) high risk 191(89.7) 253(97.7) note. pgsi = problem gambling severity index. the reported categories coincide with modified categories on the pgsi identified by currie et al., (2013). the chi-square test was conducted with a fisher’s exact test as some observed cell-groups had a count less than 5. *denotes significance at p < .05. **denotes significance at p < .001. those in the subsample of participants reporting cannabis use reported consumption at an average of 14.25 (sd = 7.38) days a month. of those who reported lifetime cannabis use, participants held an average cudit-r score of 17.19 (sd = 6.57), with 81.4% (n = 259) classified as experiencing cannabis dependence. on average, those who endorsed guic reported that they were under the influence of cannabis about 48% (sd = 26.10) of the time that they gambled in the last month. on a scale of 1-5 describing how high they usually feel, these individuals reported having an average score of 3.37 (sd = 1.00). expectancy dimensions the whole sample was included when examining dimensions of cannabis expectancies in order to understand the relation between these cannabis expectancies and gambling. results from parallel cannabis, a publication of the research society on marijuana 155 analysis and a scree plot suggested a two-factor structure (horn, 1965). an efa was then conducted, and two factors were retained. eigenvalues for these factors were 8.69 and 1.44. the two-factor solution explained 68% of the variance. the first factor, positive expectations, explained 58% of the variance and the second factor, negative expectations, explained 10% of the variance. using the factor loadings summarized in table 3, expectations showed that participants who used cannabis showed stronger positive expectancies (m = 4.68, sd = 1.17) compared to participants who did not use cannabis (m = 3.76, sd = 1.49), t(397.69) = 7.41, p < .001, d =.70. those participants who consumed cannabis also showed significantly greater negative expectancies (m = 4.55, sd = 1.34) of cannabis’ impact on their gambling behavior compared to those who did not use cannabis (m = 3.83, sd = 1.55), t(421.07) = -5.35, p < .001, d = -.50. table 3. exploratory factor analysis factor loadings items m(sd) factor loadings i ii i am more focused… 4.29 (3.20) 0.824 -0.130 i feel more confident… 4.21 (3.14) 0.874 -0.101 i am better at gambling… 4.24 (3.04) 0.816 -0.008 it is more enjoyable… 4.30 (3.02) 0.836 -0.027 i cannot concentrate… 4.25 (3.14) -0.003 0.775 i am not alert… 4.14 (3.14) -0.109 0.903 i am indecisive… 4.23 (2.89) 0.008 0.809 i feel calm… 4.32 (2.94) 0.763 0.046 i am less tense… 4.22 (3.14) 0.684 0.152 i lose control and become careless… 4.29 (3.15) 0.038 0.773 i feel anxious… 4.25 (3.14) 0.047 0.758 i feel more impulsive… 4.27 (2.78) 0.571 0.276 i win more… 4.29 (3.18) 0.704 0.142 my skills increase… 4.33 (2.86) 0.738 0.046 i have more luck… 4.23 (2.83) 0.743 0.038 i lose less… 4.22 (3.10) 0.572 0.209 note. bold indicates factor item loaded onto the strongest. i = positive expectancy; ii = negative expectancy. all items are written as “________ when i gamble under the influence of cannabis” and have been shortened above to simplify presentation. items are displayed in the order they were presented to participants. after adopting a bonferroni correction to control for type 1 error, independent samples t-tests were used to compare individual expectancy items of participants who guic and participants who did not. all comparisons were significant (all ps < 0.001), with participants who guic endorsing all expectancy items more strongly than participants who did not (see table 4). expectancies for how cannabis affects gambling frequency analysis showed that over 50% of participants who used cannabis showed some degree of agreement with every expectancy item. most of the cudit-r items had modest positive correlations with both positive and negative expectancy items (rs = 0.21-0.28, ps < .003; table 5). all positive expectancy items were endorsed with some degree of agreement by at least 52.1% of the sample. the three most endorsed positive expectancies were “i feel calm when i guic” (61.4%), “it is more enjoyable to guic” (61.0%), and “my skills increase when i guic” (60.6%). most participants who used cannabis reported some agreement that they were more focused (60.3%) and that they felt they won more (57.5%) when guic. all negative expectancy items were endorsed with some degree of agreement by at least 52.5% of the sample. the three most endorsed negative expectancies were “i lose control and become careless when i guic” (56.4%), “i feel anxious when i guic” (54.8%), and “i cannot concentrate when i guic” (53.7%; figure 1). the linear regression predicting cudit-r score based on positive and negative expectancies was statistically significant, f(2, 256) = 12.31, p < 0.001, adjusted-r2 = 0.081. negative cannabis expectancies were significantly associated with a higher cudit-r score (b = .17, p = .04), and positive expectancies were not significantly associated with cudit-r score (b = .08, p = .08; table 6). cannabis use expectancies and problem gambling all expectancy items, positive expectancies, and negative expectancies were positively correlated with pgsi scores (rs = 0.22 0.43, ps < .001; table 5). the linear regression predicting pgsi score based on expectancies was statistically significant, f(2, 256) = 31.89, p < 0.001, adjusted-r2 = 0.193. both positive (b = .06, p = .048) and negative (b = .21, p < .001) cannabis expectancies significantly predicted higher pgsi scores. cannabis expectancy and gambling 156 table 4. independent samples t-test comparing participants who did and did not guic items non-guic (n=216) guic (n=256) m(sd) m(sd) t df p i am more focused… 3.74 (1.84) 4.76 (1.61) 6.36 429.87 <.001 i feel more confident… 3.65 (1.93) 4.68 (1.48) 6.42 399.81 <.001 i am better at gambling… 3.69 (1.88) 4.7 (1.47) 6.46 402.69 <.001 it is more enjoyable… 3.69 (1.84) 4.81 (1.47) 7.17 409.53 <.001 i cannot concentrate… 3.84 (1.88) 4.6 (1.6) 4.67 425.09 <.001 i am not alert… 3.81 (1.84) 4.42 (1.67) 3.76 439.71 <.001 i am indecisive… 3.79 (1.73) 4.59 (1.59) 5.18 442.38 <.001 i feel calm… 3.79 (1.82) 4.76 (1.49) 6.24 414.08 <.001 i am less tense… 3.61 (1.82) 4.74 (1.56) 7.15 425.00 <.001 i lose control and become careless… 3.85 (1.92) 4.66 (1.56) 4.94 414.30 <.001 i feel anxious… 3.88 (1.84) 4.57 (1.65) 4.23 436.33 <.001 i feel more impulsive… 3.8 (1.71) 4.67 (1.53) 5.79 435.81 <.001 i win more… 3.75 (1.88) 4.75 (1.56) 6.27 417.95 <.001 my skills increase… 3.9 (1.79) 4.69 (1.51) 5.11 422.15 <.001 i have more luck… 3.79 (1.76) 4.61 (1.52) 5.38 428.93 <.001 i lose less… 3.77 (1.81) 4.6 (1.63) 5.21 436.62 <.001 note. all statements are worded as “__________ when i gamble under the influence of cannabis.” table 5. correlations between cannabis expectancies while gambling and percentage of time spent consuming cannabis while gambling and cudit-r and pgsi scores time spent guic cudit-r score pgsi score i am more focused… .21** .23** .30** i feel more confident… .19* .24** .25** i am better at gambling… .13 .18 .27** it is more enjoyable… .21** .19* .27** i cannot concentrate… .15 .21** .31** i am not alert… .20* .19* .32** i am indecisive… .18* .26** .36** i feel calm… .20* .16 .29** i am less tense… .19* .16 .33** i lose control and become careless… .26** .27** .41** i feel anxious… .18 .21** .39** i feel more impulsive… .21** .21** .32** i win more… .25** .23** .33** my skills increase… .27** .17 .22** i have more luck… .16 .25** .29** i lose less… .20* .23** .35** positive expectancies .27** .27** .38** negative expectancies .24** .28** .43** note. all statements are worded as “__________ when i gamble under the influence of cannabis.” for all expectancy items, n = 259 *denotes significance at p < .003 **denotes a finding that was significant at p < .001. supplemental tables 1-3 offer the linear regressions predicting pgsi score, cudit-r score, and time spent guic for individual items. cannabis, a publication of the research society on marijuana 157 table 6. linear regressions of positive or negative cannabis expectancies predicting pgsi score, cudit-r, and percentage of time using cannabis while gambling b se p predicting pgsi score positive cannabis expectancies while gambling .06 .03 .048* negative cannabis expectancies while gambling .21 .05 <.001** predicting cudit-r score positive cannabis expectancies while gambling .08 .05 .077 negative cannabis expectancies while gambling .17 .08 .040* predicting percentage of time spent gambling under the influence of cannabis positive cannabis expectancies while gambling .46 .20 .021* negative cannabis expectancies while gambling .33 .34 .333 note. model fits: pgsi:  f(2, 256)=31.89, p < .001 with adjusted r2=0.193. cudit-r:  f(2, 256)=12.31, p < .001 with adjusted r2=0.081. time spent guic:  f(2, 255)=10.31, p < .001 with adjusted r2=0.068. *denotes significance at p < .05 **denotes a finding that was significant at p < .001. the individual items that comprised each variable in the model are presented in tables 4 and 5. figure 1. participants’ percent agreement with expectations regarding how cannabis impacted gambling behavior note. all items are written as “________ when i gamble under the influence of cannabis” and have been shortened above to simplify presentation. the order of questions is presented as mostly likely to agree to least likely to agree rather than the order of presentation to participants. cannabis use expectancies and time guic most negative and positive cannabis expectation items (62%) were modestly and positively correlated with guic (rs = 0.21-0.27, ps < .003; table 5). the linear regression predicting the percentage of time spent guic was statistically significant, f(2, 255) = 10.31, p < 0.001, adjusted-r2 = 0.068. positive cannabis expectancies significantly predicted a higher percentage of time spent guic (b = .46 p = .021), and negative expectancies were not significantly associated (b = .33, p =.333; table 6). 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 i have more luck … i am not alert … i am indecisive … i cannot concentrate … i feel anxious … i am better at gambling … i lose control and become careless … i feel more confident … i am less tense … i lose less … i feel more impulsive … i win more … i am more focused … my skills increase … it is more enjoyable to… i feel calm … strongly disagree disagree somewhat disagree neither agree nor disagree somewhat agree agree strongly agree cannabis expectancy and gambling 158 discussion given the reported co-occurrence of gambling and cannabis consumption, this study aimed to examine individuals’ expectations of the effect of cannabis consumption on gambling. cannabis expectancy theory (anthenien et al., 2021; kristjansson et al., 2012; schafer & brown, 1991) indicates that peoples’ experience with cannabis will inform what outcomes they expect will follow consumption. in this sample of participants who almost all screened positive for problem gambling, who on average gambled four days per week, “positive” and “negative” dimensions underlie individuals’ reported cannabis expectancies. six areas of cannabis expectancies have been identified within the literature (schafer & brown, 1991). consistent with the broader cannabis expectancy literature, this two-factor structure of positive and negative expectations broadly categorizes the six areas into positive and negative expectancies. positive expectations include relaxation and tension reduction, perceptual and cognitive enhancement, and social and sexual facilitation. negative expectations include cognitive and behavioral impairment, global negative effects, and craving and physical effects (anthenien et al., 2021; kristjansson et al., 2012) both positive and negative expectations have implications for gambling behaviors, experiences, and performances. those who used cannabis held stronger positive cannabis expectations than those who did not use cannabis. in contrast to previous findings, participants who used cannabis also held significantly stronger negative expectancies than participants who did not use cannabis. when the expectancy results were examined on an item level, those who used cannabis endorsed significantly stronger agreement with all cannabis and gambling expectancies than participants who did not use cannabis, with no significant difference found in the proportion of participants endorsing positive or negative expectancy items. there are several possible explanations for this unique finding. first, the current sample predominately reported clinically significant levels of both cannabis use and gambling harms. approximately 94% were identified as at high risk for gambling disorder, and 81.4% of those participants were classified as experiencing cannabis dependence. prior research into cannabis expectancies has primarily focused on non-clinical samples, resulting in a call for more research into expectancies in individuals with more severe cannabis usage (anthenien et al., 2021). the clinical nature of this sample may not reflect the general population of those who gamble or consume cannabis recreationally. however, the current sample reveals a strength of this dataset as it provides greater insight into the experiences of individuals with both cannabis use disorder and gambling disorder – a group that would benefit from greater attention to help develop responsible gambling policies and treatment protocols (mcgrath et al., 2023; mcphail et al., 2020). another reason why the current findings may differ from the findings of previous research is methodological differences. this study prioritized examining a range of cannabis expectancies as they relate to gambling. for this reason, we elected to use items from the alcohol expectancy questionnaire (brown et al., 1987) and the gamblers’ beliefs questionnaire (steenbergh et al., 2002), although the majority of cannabis expectancy literature uses the marijuana effect expectancy questionnaire (meeq), either in its original (schafer & brown, 1991) or brief form (torrealday et al., 2008). although both methodological approaches capture both positive and negative expectations of cannabis use, our selected approach prohibited us from assessing the “craving and physical effects” domain of items on the meeq. instead, our approach prioritized the following domains of cannabis use expectancies: cognitive and behavioral impairment, relaxation and tension reduction, perceptual and cognitive enhancement, and global negative effects (schafer & brown, 1991). future studies should seek to understand how the craving and physical effects items relate to gambling behaviors. consistent with the research on cannabis expectancies, participants who used cannabis reported a mixture of positive and negative cannabis expectancies, with all items endorsed by 50-62% of the sample (anthenien et al., 2021; kristjansson et al., 2012). among the expectancy items, the top five most endorsed items overall were positive expectancies. while guic, individuals reported feeling calmer (61.4%), finding gambling more enjoyable (61.0%), believing that their skills increased (60.6%), cannabis, a publication of the research society on marijuana 159 feeling more focused (60.2%), and feeling that they won more (57.5%). the three most endorsed negative expectancies were “i lose control and become careless when i guic” (56.4%), “i feel anxious when i guic” (54.8%), and “i cannot concentrate when i guic” (53.7%). increases in negative cannabis expectancy effects predicted an increased cudit-r score. this finding could reflect greater awareness of the negative impacts of cannabis use generally among the individuals with increased problems, especially when engaging in a specific task. increases in both positive and negative cannabis expectancies were significantly associated with increased gambling problems. as the participants showed both positive and negative expectations of cannabis consumption on gambling, these findings indicate that individuals do not have extreme unidirectional expectations about cannabis consumption. because of this, these findings are novel in that they are the first to identify the specific expectations (both positive and negative) about the effect of cannabis consumption on gambling behavior. this warrants future examination, as these findings may reflect a broader relation between cannabis attitudes generally and increased gambling behavior or may be indicative of a missing moderating variable (e.g., whether cannabis expectancies motivate cannabis use while gambling), as suggested by anthenien and colleagues (2021). stronger positive cannabis expectancies were associated with an increased proportion of time spent gambling under the influence of cannabis. this is in line with the broader expectancy theory that an individual is more likely to engage in an activity that they believe will have a positive outcome. however, this finding also highlights the importance of assessing how an individual who guic believes that cannabis affects their gambling behavior, as increased percentages of time spent guic have been associated with greater gambling problems (mcphail et al., 2020). the implication for clinicians is the assessment for cannabis use when seeing an individual for gambling disorder, and visa-versa. the belief that using cannabis while gambling increases luck or gambling ability is particularly problematic and could produce an overall increase in both problematic gambling and cannabis use. there is currently no research on how to best treat individuals with a gambling disorder and comorbid cannabis use disorder (dowling et al., 2016; pfund et al., 2023). the current study stresses the importance of developing more effective regulations and treatments for this population. a potential limitation of this study was the use of a convenience crowdsourced sample. consistent with our sample, mturk samples have been found younger, less employed, and more politically liberal than the general united states population (goodman & paolacci, 2017). although mturk samples have been increasingly prominent within psychological research, they have also shown an increase of low-quality data (chmielewski & kucker, 2020). researchers have noted mturk samples have been at risk for noise from bad data and bots; this risk may be exacerbated by the length and nature of the research task (webb & tangney, 2022). at the same time, research has found that mturk may be useful and appropriate for collecting samples of individuals who gamble frequently and who consume cannabis (kim & hodgins, 2017). the national spread of the mturk sample is additionally appropriate to gauge cannabis consumption since the legalization status of cannabis across different states has not been associated with cannabis consumption behaviors (mcphail et al., 2024). the current study was also limited in that expectations of cannabis on gambling did not explore types of cannabis ingestion such as dabbing, vaping, smoking, or edible consumption. for example, emerging adults perceive dabbing and vaping cannabis as conferring more risk than smoking cannabis occasionally (florimbio et al., 2023). depending on their methods of cannabis ingestion, participants may carry different expectations of how cannabis influences their gambling. finally, the sample of the study was limited to participants screening positive for cannabis dependence who held a mixture of positive and negative expectations. consistent with other literature, individuals with cannabis dependence hold both positive and negative expectations (connor et al., 2011; schafer & brown, 1991). however, future research is needed to understand whether individuals without cannabis dependence hold both positive and negative expectations and whether the associations among expectations, cannabis problems, gambling problems, and gambling cannabis expectancy and gambling 160 behavior replicate in samples without cannabis dependence. in conclusion, this study provided a potential explanation for why some individuals might use cannabis and gamble simultaneously – they expected that guic made gambling more enjoyable, helped them focus while gambling, feel calmer, and have greater skills. at the same time, this study provided a potential explanation for why some individuals might not use cannabis and gamble simultaneously – they expected that guic made them more careless, anxious, and unfocused. together, these findings further highlight the importance of how individuals expect substance use to influence their gambling behavior, as negative expectations were associated with higher cannabis severity, and both positive and negative expectancies were associated with greater problem gambling severity. future research is needed to 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(2007). problem and pathological gambling. hogrefe & huber publishers. funding and acknowledgements: this work was partially supported by funding from the tennessee department of mental health and substance abuse services. the content is the sole responsibility of the authors and does not necessarily represent the official views of the state of tennessee. no authors have competing interests. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ research article 177 ved abstract objective: while cannabis use is common among people with hiv (pwh), there have been few studies examining the association of use with health outcomes among pwh. we aimed to evaluate the association between cannabis use and bothersome physical and mental health symptoms using both self-report and a direct biomarker for cannabis use. method: the medications, alcohol and substance use in hiv study (mash) is a cross-cohort study focused on polypharmacy and substance use among pwh. participants were enrolled from october 2018 to may 2022 in the swiss hiv cohort study (shcs), kaiser permanente northern california (kpnc) hiv cohort, and 7 sites (atlanta, ga; bronx, ny; washington, dc; houston, tx; los angeles, ca; new york, ny; and nashville, tn) in the veterans aging cohort study hiv (vacshiv). participants submitted self-reported information on the presence/absence of symptoms in the prior 4 weeks, along with bothersome level, using the hiv symptom index, which is comprised of 20 symptoms commonly reported in pwh, including fatigue, diarrhea, fever, anxiety, and weight loss, among others. concurrent self-reported substance use information was also collected, and participants provided nail clippings to be tested for cannabis use. we used logistic regression models, adjusted for age, sex, race/ethnicity, and cohort, to examine associations of self-report and biomarker-identified cannabis use with self-reported bothersome symptoms. results: the analytic sample included 1,226 pwh who were predominantly male (85%), non-white (64%), with an average age of 57 years; 20% tested positive for cannabis use, and 23% reported recent cannabis use. agreement between self-report and biomarker cannabis use was substantial (agreement 89%, kappa = 0.67). put together, 27% either reported cannabis use or tested positive. of the 20 symptoms included in the hiv symptom index, 19 were more prevalent at a bothersome level among those with cannabis use compared to those without. in adjusted models, the patterns of association remained for both self-reported and biomarker-confirmed cannabis use, and they aleksandra wrona1,2, amy c. justice1,2, janet p. tate1,2, christopher t. rentsch1,2,3, kirsha s. gordon1,2, farah kidwai-khan1,2, michael j. silverberg4, derek d. satre4,5, vincent c. marconi6,7,8, suzanne m. ingle9, jonathan a. c. sterne9, matthias cavassini10,11, kendall bryant12, kathleen a. mcginnis1,2 1va connecticut healthcare systems 2department of internal medicine, yale university school of medicine 3london school of hygiene and tropical medicine 4division of research, kaiser permanente northern california 5department of psychiatry and behavioral sciences, university of california, san francisco 6atlanta va healthcare system 7emory university school of medicine 8rollins school of public health, emory university 9population health sciences, bristol medical school, university of bristol 10lausanne university hospital and university of lausanne, switzerland 11swiss hiv cohort study 12national institute on alcohol abuse and alcoholism cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000269 volume 8, issue 1 cannabis use and selfreported bothersome symptoms in people with hiv cannabis, a publication of the research society on marijuana 178 were particularly substantial for memory, depression, anxiety, and nausea. conclusions: cannabis use was common among pwh and was associated with a number of bothersome symptoms. while cannabis use may be used to treat loss of appetite, nausea/vomiting, and weight loss, the associations of cannabis use with depression, anxiety, and memory loss are concerning and deserve investigation. key words: = cannabis; biomarker; bothersome symptoms; hiv; agreement cannabis legalization has become increasingly common across the united states, leading to greater access and use among the general population, including people with hiv (pwh; hasin et al., 2022). however, the health impacts of cannabis use, particularly among those with underlying conditions such as hiv, are not well understood given its complex mechanisms of action (volkow et al., 2014). cannabis use has been associated with several physical and psychological symptoms. physical symptoms commonly associated with smoking cannabis use include respiratory complaints, such as coughing, wheezing, and phlegm (national academies of sciences et al., 2017; tetrault et al., 2007), along with increased rates of pneumonia and other respiratory infections (volkow et al., 2014). the effects of cannabis use on blood pressure are unclear, and associations remain inconsistent (alshaarawy & elbaz, 2016; goyal, awad, et al., 2017; vallée, 2023). cannabis use has also been associated with cognitive changes, including mild to moderate impairments in memory and attention (bourque & potvin, 2021; gabrys, robert & porath, 2019). additionally, cannabis use has been linked to depression and anxiety; however, the direction of the association is not well understood (feingold & weinstein, 2021; gorfinkel et al., 2020; stoner, ,2017; volkow et al., 2017). hiv/aids is a qualifying condition in all states with medical cannabis programs. findings have been mixed as to whether cannabis use is associated with antiretroviral therapy (art) use and adherence, which is crucial for hiv management (costiniuk et al., 2019; montgomery et al., 2019; vidot et al., 2017; zhang et al., 2018). while cannabis use has been shown to provide relief from various hiv-related symptoms, including pain, anxiety, and poor appetite (andreae et al., 2015; ellis et al., 2009; goyal, singla, et al., 2017; mack & joy, 2000; woolridge et al., 2005), it has also been associated with other features that negatively impact quality of life for pwh, such as cognitive impairment (cristiani et al., 2004), breathing problems (lorenz et al., 2019), and impairments in host defense (roth et al., 2002; turcotte et al., 2016; wenger & crothers, 2019), although more studies are needed in these areas. pwh are frequently screened for self-reported bothersome symptoms in clinical and research settings in order to evaluate patient well-being and quality of life. these screenings are often conducted in the context of their hiv diagnosis and not for particular substance use; a prior study found that bothersome symptoms were more common among people who use alcohol among both people with and without hiv (bahji et al., 2023). potential bothersome symptoms include common physical (fatigue, aches/pains, nausea) and mental health (depression, anxiety) symptoms experienced by pwh. given that medical outcomes such as viral load and cd4 count are commonly addressed in medical settings, screening for symptoms most commonly associated with hiv diagnosis helps capture outcomes that are more relevant to the patient experience. symptoms identified as increasingly bothersome were more highly associated with outcomes and clinical severity than just “any level of symptom” (justice, holmes, et al., 2001). moreover, since hiv symptoms may decrease patient quality of life and interfere with antiretroviral medication adherence, effective symptom management can greatly improve overall patient well-being. among the general u.s. population, nonmedical past-year cannabis use grew from 10% to 13% among adults from 2002 to 2014 (azofeifa, 2016; carliner et al., 2017). use is greater among young adults: according to the nih monitoring the future study, a nationally representative corresponding author: kathleen mcginnis, drph, ms, va connecticut healthcare system, 11acsl-g, 950 campbell avenue. west haven, connecticut 06516. phone: (810) 387-3211 ext. 13541. email: kathleen.mcginnis3@va.gov. https://www.zotero.org/google-docs/?henzuk https://www.zotero.org/google-docs/?henzuk https://www.zotero.org/google-docs/?oswoe3 cannabis associated with symptoms in pwh 179 sample of over 32,000 students across the united states who self-reported their substance use from february to june 2021, 43% reported past-year use compared to 17% in 2011 (national institute on drug abuse, 2022). however, studies have found that cannabis use has been increasing across other age groups as well, including among older adults (han & palamar, 2020). according to one 2022 nih study, past-year cannabis use was reported by 44% of adults ages 19 to 30, and by 28% of adults ages 35 to 50, representing the highest recorded cannabis endorsement over a 10year period (national institute on drug abuse, 2023; patrick et al., 2023). cannabis use is overall lower in europe compared to the united states, but prevalence of use has nevertheless increased by over 25% since 2010 (manthey et al., 2021; espad group, 2020). according to the european monitoring centre for drugs and drug addiction, past-year cannabis use among european adults aged 15 to 64 was 8% overall (european monitoring centre for drugs and drug addiction, 2023). compared to the nih monitoring the future study, the 2019 european school survey project on alcohol and other drugs study showed that lifetime use among 15and 16year olds, while less than the us, was still over 25% in countries such as the czech republic, italy, and latvia (espad group, 2020). cannabis use among u.s. military veterans has increased over the past decade following the trends of the general population. nearly 12% of veterans used cannabis in the past 6 months in a 2021 study, compared to 9% in 2014 (davis et al., 2018; m. l. hill et al., 2021). cannabis is often used to treat symptoms of post-traumatic stress disorder (ptsd), such as sleep problems and anxiety, as well as chronic pain associated with military service. reports on the benefits of cannabis use on ptsd are largely anecdotal (hill et al., n.d.); however, high-quality randomized controlled trials comparing cannabis use to a placebo group among individuals suffering from ptsd have been sparse (rehman et al., 2021). in one study of 150 participants in 2020, those using thc-dominant cannabis reported a greater reduction in ptsd symptom severity over the course of a year compared to the control group who did not use cannabis (bonn-miller et al., 2022). given the increasing use of cannabis (cash et al., 2020), that hiv is a qualifying condition for medical cannabis use, and the association of cannabis use with both cognitive and physical changes, there is a need to better understand the relationship between cannabis use and bothersome symptoms among pwh. with the success of art on hiv suppression, pwh are living longer with a better quality of life. pwh are now entering middle and later age, and the study of this population and the modifying effects hiv has on a host of other age-related health issues has only begun to be explored. the veterans aging cohort study (vacs) is one of the largest cohorts of pwh in the world. we sought to evaluate the association between cannabis use and bothersome symptoms among aging pwh in vacs along with two non-veteran cohorts in northern california (kaiser permanente) and in switzerland (the swiss hiv cohort study). while self-reported data on substance use is frequently employed in research, it can result in underreporting due to social desirability bias. comparing factors associated with cannabis use based on self-report to a validated biomarker can strengthen such findings. in this paper, we aimed to 1) evaluate the association between cannabis use and bothersome symptoms using both selfreport and a direct biomarker for cannabis use and 2) examine whether patterns of associations between cannabis use and bothersome symptoms differed when using self-reported vs. biomarkerconfirmed cannabis use. methods study design the medications, alcohol, and substance use in hiv (mash) study is a multi-site cross-sectional study focused on polypharmacy and substance use in pwh. pwh on antiretrovirals (arvs) were enrolled from october 2018 to may 2022 from the kaiser permanente northern california (kpnc) hiv cohort (silverberg et al., 2020), swiss hiv cohort study (shcs; scherrer et al., 2022), and 7 sites (atlanta, ga; bronx, ny; washington, dc; houston, tx; los angeles, ca; new york, ny; and nashville, tn) of the vacs-hiv (justice et al., 2006). participants completed in-depth confidential surveys, including questions on substance use and the hiv symptom index (justice, holmes, et al., 2001), provided salivary samples, nail clippings, and blood spots for https://www.zotero.org/google-docs/?41rscp https://www.zotero.org/google-docs/?hlz0qu cannabis, a publication of the research society on marijuana 180 substance use assessment, all at the time of study enrollment. the study was approved by the internal review boards (irb) for the department of veterans affairs (va), yale university, kpnc, and the swiss hiv cohort study. due to va regulations and our ethics agreements, the analytic data sets used for this study are not permitted to leave the va firewall without a data use agreement. this limitation is consistent with other studies based on va data. measures cannabis use. cannabis use was measured in two ways: a self-report questionnaire and a validated biomarker. self-reported questionnaires were given to all participants in the study across the three cohorts. in the swiss cohort, questionnaires were translated into french and then back-translated in order to maintain and validate original meaning. participant cannabis use was captured by selecting an answer to the following: “for each of the following drugs, please fill in the option that best indicates how often in the past 12 months you used each drug.” a multiple choice selection included “have never tried,” “no use in last year,” “less than once a month,” “1-3 times per month,” “1-3 times per week,” 4-6 times a week,” and “every day.” positive self-reported cannabis use was defined as using marijuana 1-3 times per month or more frequently, because this cutoff had the best agreement with biomarkerconfirmed cannabis use. biomarker-confirmed cannabis use was ascertained using nail samples. cannabinoid presence in nail samples can be detected up to 6 months after cannabis use and thus is more appropriate for identifying chronic rather than occasional use (cobo-golpe et al., 2021; shu et al., 2015). specimens were sent to the united states drug testing laboratories, inc. (usdtl) and were initially tested using a 5 pg/mg immunoassay cutoff point to test for the drug metabolite carboxy thc. preliminary immunoassay testing may yield false negative and positive results due to structurally similar compounds found by testing surfactants (antunes et al., 2023). for tests presumed positive by immunoassay, a second portion of the nail specimen was prepared for confirmation. using mass spectrometry, quantitative values were generated and the applicable 0.02 pg/mg cutoffs were applied in order to determine whether the specimen was positive or negative for cannabinoids. mass spectrometry is the gold standard for confirmatory analyses due to its high degree of specificity and ability to quantify substance amounts (loos et al., 2016). using a combination of both the immunoassay and mass spectrometry techniques, usdtl is able to capture reliable and accurate measurements of various substances within biologic specimens. hiv symptom index. the hiv symptom index developed by justice et al. in 2001 (justice, holmes, et al., 2001) is a commonly used selfreport instrument to assess the presence and severity of bothersome symptoms within the past 4 weeks. it has demonstrated good reliability and validity and has been employed in various clinical and research settings to measure the effectiveness of interventions, monitor symptom burden, and improve patient care (wang et al., 2022; zuñiga et al., 2020). the symptoms within the index are not unique to hiv and were derived from previous quality-of-life indices used by clinicians to evaluate overall patient well-being (anderson & testa, 1994; stephens et al., 1997a; wilson & cleary, 1995). the hiv symptom index is comprised of 20 items regarding common symptoms experienced by pwh, including fatigue, diarrhea, fever, anxiety, and weight loss, among others (figure 1). participants in the mash study were asked to provide one of the following five responses for each symptom: “i do not have this symptom,” “i have this symptom,” along with one of the following: “it doesn’t bother me,” “it bothers me a little,” “it bothers me,” or “it bothers me a lot.” for this study, we created a variable for each symptom representing having the symptom and being at least “a little” bothered, similar to previously established thresholds (bahji et al., 2023; justice, chang, et al., 2001). demographic and other substance use variables. age, sex, race and/or ethnicity, education, other substance use (listed below), and hiv mode of acquisition (e.g. men who have sex with men, injection drug use) variables were collected on the patient self-report survey. additionally, variables for recent use of other substances were based on biomarkers: cotinine from saliva (>20 ng/ml) for smoking/tobacco use, phosphatidyl ethanol (peth) from bloodspots (>20 ng/ml) for at least moderate alcohol use, and cannabis associated with symptoms in pwh 181 metabolites of cocaine, amphetamine, and opioid use from fingernail clipping table 1. demographic characteristics of mash (n = 1,226) cannabis use self-report or biomarker variable combined n = 1,226 yes n = 337 no n = 889 mean age in years (sd) 56.8 (12.0) 56.3 (12.2) 57.0 (11.9) male, n (%) 1,039 (85%) 305 (91%) 734 (83%) race/ethnicity, n (%) black white hispanic other/unknown 553 (45%) 447 (36%) 176 (14%) 50 (4%) 158 (47%) 124 (37%) 47 (14%) 8 (2%) 395 (44%) 323 (36%) 129 (15%) 42 (5%) education, n (%) <high school high school graduate some college college graduate 141 (12%) 338 (28%) 377 (31%) 370 (30%) 35 (10%) 91 (27%) 107 (32%) 104 (31%) 106 (12%) 247 (28%) 270 (31%) 266 (30%) hiv risk group, n (%) msm* idu** msw/wsm*** other/unknown 672 (55%) 133 (11%) 402 (33%) 19 (2%) 206 (61%) 50 (15%) 78 (23%) 3 (1%) 466 (52%) 83 (9%) 324 (37%) 16 (2%) cannabis use, n (%) neither self-report or biomarker self-report only biomarker only both self-report and biomarker 889 (73%) 90 (7%) 49 (4%) 198 (16%) other substance use (biomarker), n (%) tobacco alcohol cocaine amphetamines opioids 427 (35%) 375 (31%) 164 (13%) 79 (6%) 50 (4%) 175 (52%) 119 (35%) 61 (18%) 29 (9%) 24 (7%) 252 (28%) 256 (29%) 103 (12%) 50 (6%) 26 (3%) cohort, n (%) 1 2 3 442 (36%) 267 (22%) 517 0(42%) 85 (25%) 103 (31%) 149 (44%) 357 (40%) 164 (18%) 368 (41%) note. *men who have sex with men, **injection drug use, ***men who have sex with women / women who have sex with men analysis demographic characteristics, cannabis measures, and biomarker measures for other substances were summarized. agreement between self-report and biomarker-confirmed cannabis use was evaluated using cross tabulation and kappa statistics. we also evaluated the association between biomarker-confirmed cannabis use and other substance use with chi-square statistics. for each symptom, the proportion with a reported bothersome symptom was calculated by cannabis use and evaluated graphically for both self-report and biomarker-confirmed cannabis use. we used logistic regression models, adjusted for age, sex, race and/or ethnicity, and cohort to examine adjusted associations of bothersome symptoms with self-report (at least monthly) and biomarkeridentified cannabis use. for this sample of 1,226 with 337 who use cannabis, power of 80 and alpha cannabis, a publication of the research society on marijuana 182 = 0.05, we are sufficiently powered to detect absolute differences ranging from 6% to 9% for bothersome symptoms that range in prevalence from 10% to 50%. as a sensitivity analysis, we also ran the logistic regression models using selfreported cannabis use at least weekly in place of at least monthly. results demographic charateristics we identified 1,226 participants across the three cohorts who had survey and biomarker data available. participants were mostly male (85%), black (45%), with a mean age of 57 years (table 1). over 30% used alcohol (31% had peth >20 ng/ml) and tobacco (35% had cotinine >20 ng/ml). other substance use was less common; based on biomarkers, 13% had recent use of cocaine, 6% amphetamines, and 4% opioids (table 1). figure 1. bothersome symptoms by recent cannabis use (n = 1,226) *note. statistically significant at p < .05 cannabis self-report vs. biomarker cannabis use was common based on both selfreported at least monthly use (288 participants, 23%) and biomarker (247 participants, 20%) measures. combined, 337 (27%) either endorsed cannabis use or had a positive biomarker test. of those who reported cannabis use in the past month, 198 (69%) had a positive cannabis biomarker. of those with a positive cannabis biomarker, 80% also self-reported cannabis use at least monthly. the kappa statistic (0.67) indicated substantial agreement. in comparing agreement of the biomarker-confirmed measure with multiple self-reported frequency cut points (at least weekly, at least monthly, at least yearly, ever), agreement was best, based on kappa statistics, with at least monthly use (appendix table 1). cannabis associated with symptoms in pwh 183 cannabis and other substance use other substance use was more common among those with a positive cannabis biomarker test compared to those without, particularly tobacco (136, 56% vs. 291, 30%), cocaine (51, 21% vs. 113, 12%), amphetamines (23, 9% vs. 56, 6%), and opioids (21, 9% vs. 29, 3%) the same was true to a lesser extent for alcohol (83, 34% vs. 292, 30%) and fentanyl (3, 1.2% vs. 6, 0.6%) comparing those with and without a positive cannabis biomarker test. bothersome symptoms by cannabis use bothersome symptoms were common; over 40% reported being at least a little bothered by symptoms related to mental health (memory, depression, anxiety) and physical health (sleep, fatigue, body changes, joint pain, and numbness). for both measures of cannabis use, those with cannabis use were more likely to report bothersome symptoms than those without (for 19 of the 20 symptoms), and the patterns of associations between cannabis use and bothersome symptoms were similar for both (figure 1). only the way a person perceives their body to look bothersome symptom was less likely among those with cannabis use compared to those without. additionally, 9 of the 20 symptoms were found to be statistically significantly more likely among those with cannabis use compared to those without (p < 0.05) for both the self-reported and biomarker measures. these included all the mental health symptoms (memory, depression, anxiety), symptoms related to gastro-intestinal issues (nausea, appetite, diarrhea) and other physical health issues (weight loss, numbness in the hands/feet). based on the odds ratios and 95% confidence intervals generated from logistic regression models adjusted for age, gender, race/ethnicity, and cohort, those with cannabis use were more likely to have symptoms than those without for the majority of the 20 symptoms. the most substantial associations were related to anxiety (self-report: 1.45 [1.10, 1.90]; biomarker: 1.51 [1.13, 2.01]), nausea (self-report: 1.58 [1.06, 2.34]; biomarker: 1.50 [1.00, 2.26]), depression (selfreport: 1.23 [0.94, 1.62]; biomarker: 1.44 [1.08, 1.91], and memory loss (self-report: 1.42 [1.08, 1.87]; biomarker: 1.41 [1.05, 1.87]; table 2). patterns were similar when using the at least weekly (instead of at least monthly) self-reported cannabis use variable in sensitivity analyses, although the association became stronger between cannabis use and four bothersome symptoms: appetite, body image, breathing, pain, and hair loss. overall, patterns were similar between the models using self-reported and biomarkerconfirmed cannabis use, but there were some marked differences. for example, in certain instances, biomarker-confirmed cannabis use was more strongly associated with bothersome symptoms, as in the case of appetite (biomarker: 1.71 [1.19, 2.45]; self-report: 1.35 [0.94, 1.94]) and weight loss (biomarker: 1.55 [1.11, 2.17]; selfreport: 1.22 [0.87, 1.71]). conversely, self-reported cannabis use was substantially associated with fever, chills, or sweats (1.71 [1.22, 2.39]) whereas the biomarker was much less pronounced (1.26 [0.88, 1.80]; table 2). table 2. association of cannabis use with hiv symptoms from adjusted logistic regression models adjusted odds ratio (95% ci)* symptoms self-report biomarker trouble remembering 1.42 (1.08, 1.87) 1.41 (1.05, 1.87) felt sad, down, or depressed 1.23 (0.94, 1.62) 1.44 (1.08, 1.91) felt nervous or anxious 1.45 (1.10, 1.90) 1.51 (1.13, 2.01) difficulty falling or staying asleep 1.23 (0.93, 1.62) 1.28 (0.96, 1.71) cannabis, a publication of the research society on marijuana 184 fatigue or loss of energy 1.31 (0.99, 1.72) 1.22 (0.91, 1.62) feeling dizzy or light headed 1.28 (0.95, 1.71) 1.26 (0.93, 1.71) nausea or vomiting 1.58 (1.06, 2.34) 1.50 (1.00, 2.26) loss of appetite or change in the taste of food 1.35 (0.94, 1.94) 1.71 (1.19, 2.45) diarrhea or loose bowel movements 1.22 (0.88, 1.68) 1.00 (0.71, 1.42) problems with weight loss or wasting 1.22 (0.87, 1.71) 1.55 (1.11, 2.17) fever, chills, or sweats 1.71 (1.22, 2.39) 1.26 (0.88, 1.80) pain, numbness, or tingling in the hands or feet 1.34 (1.02, 1.77) 1.33 (1.00, 1.78) headache 1.11 (0.82, 1.51) 1.14 (0.83, 1.57) bloating, pain, or gas in your stomach 1.05 (0.79, 1.41) 0.99 (0.73, 1.35) changes in body looks (fat deposits/weight gain) 0.77 (0.58, 1.02) 0.89 (0.67, 1.19) cough or trouble catching breath 1.26 (0.94, 1.71) 1.16 (0.84, 1.59) muscle aches or joint pain 1.23 (0.93, 1.61) 1.17 (0.88, 1.56) problems with having sex (lack of interest/satisfaction) 1.04 (0.79, 1.38) 0.97 (0.73, 1.31) skin problems, such as rash, dryness, or itching 0.99 (0.74, 1.32) 0.96 (0.70, 1.30) hair loss/changes in the way your hair looks 1.16 (0.82, 1.65) 1.11 (0.77, 1.60) *models adjusted for age, gender, race and ethnicity, and cohort discussion in this large sample of pwh drawn from three health system-based cohorts, recent cannabis use was reported or detected in over 20% of study participants. bothersome symptoms were very common, with eight of the twenty symptoms being reported in at least 40% of participants. cannabis use was associated with an increased likelihood for most of the 20 bothersome symptoms in the hiv symptom index. while the associations of self-reported and biomarker-confirmed cannabis use with symptoms were not identical, the overall patterns were similar. agreement between self-reported and biomarker-confirmed cannabis use was good. because both measures can identify some degree of use that the other measure might not, we cannot necessarily conclude that one measure is better than the other. the biomarker can detect chronic use up to six months prior but may not identify use that is only occasional, whereas occasional use can be identified if it is selfreported. similarly, chronic use that was more than thirty days ago and within the past six months could be identified with the biomarker, but the survey items were not asked in a way to capture use in the past six months. because of these issues, in some situations in which maximum identification is desired, it might be useful to combine the self-reported and biomarker-confirmed measures. the cohorts used in this study tended to be comprised of older individuals (average age of 57 cannabis associated with symptoms in pwh 185 years) and were overwhelmingly male (85% overall). additionally, a large portion of the study was made up of veterans from the vacs. however, strengths of this study include that it is racially/ethnically and geographically diverse, and both non-veterans and veterans were included. further, the frequency of cannabis use is similar between our study to trends found outside of this population (espad group, 2020; national institute on drug abuse, 2023; manthey et al., 2021; patrick et al., 2023). while there may be limited generalizability to other settings, kaiser permanente and the va represent two of the largest hiv providers in the united states, and individuals enrolled in the swiss hiv cohort study are generalizable to other pwh in europe. analyses were cross-sectional, and we were not able to evaluate causality between cannabis use and bothersome symptoms. in some cases, cannabis was likely being used to self-medicate for symptoms that already existed. in other cases, cannabis use could have been causing or exacerbating bothersome symptoms. for example, we found that those who used cannabis were more likely to have gastrointestinal-related symptoms, and this may be due to the use of cannabis to treat loss of appetite, nausea/vomiting, and weight loss (goyal, singla, et al., 2017). consistent with prior research (feingold & weinstein, 2021; gorfinkel et al., 2020; stoner, 2017; volkow et al., 2017), we found cannabis use to be associated with depression, anxiety, and memory loss; this is concerning and deserves further investigation because while cannabis may be used to treat these symptoms, we are unable to evaluate the direction of causality in this study. we found that those who use cannabis are more likely to drink alcohol and smoke cigarettes, which may also have an effect on reporting of bothersome symptoms. future research should explore whether polysubstance use plays a role in the association between cannabis use and bothersome symptoms. additionally, future studies should consider reasons for smoking/consuming cannabis and whether they perceive their cannabis/substance use as the cause for bothersome symptoms. conclusion cannabis use was common among pwh and was associated with many bothersome symptoms for both self-reported and biomarker-confirmed cannabis use measures. while cannabis may be used to treat a variety of symptoms including loss of appetite, nausea/vomiting, weight loss, anxiety, and depression, the associations of cannabis use with deleterious mental health outcomes are concerning and deserve investigation to better establish temporal relationships. although selfreported and biomarker-based cannabis measures capture slightly different aspects of cannabis use, there was high agreement between the two measures and their associations with bothersome symptoms were similar; 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(2020). biomarkers panels can predict fatigue, depression and pain in persons living with hiv: a pilot study. applied nursing research, 52, 151224. https://doi.org/10.1016/j.apnr.2019.151224 funding and acknowledgements: this work was supported by the national institute on alcohol abuse and alcoholism grants: u10-aa013566, u01-aa026224, u01-aa020790, u24-aa020794, u01-aa026209, and u01 aa026230. vm has received funding support from emory center for aids research (p30ai050409) for work related to this manuscript. vm has received investigatorinitiated research grants (to the institution) and consultation fees from eli lilly, bayer, gilead sciences, merck, and viiv. mc’s institution received research grants and expert opinion fees from gilead and msd. the remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. the content is solely the responsibility of the authors and does not necessarily represent the official views of the veterans affairs or the national institutes of health. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: wrona, a., justice, a. c., tate, j. p., rentsch, c. t., gordon, k. s., kidwai-khan, f., silverberg, m. j., satre, d. d., marconi, v. c., ingle, s. m., sterne, j. a. c., cavassini, m., bryant, k., & mcginnis, k. a. (2025). cannabis use and self-reported bothersome symptoms in people with hiv. cannabis, 8(1), 177-190. https://doi.org/10.26828/cannabis/2025/000269 issue date: february 1, 2025 https://creativecommons.org/licenses/by/4.0/ cannabis, a publication of the research society on marijuana 190 research article 41 ved abstract objective: cannabis has become more available in canada since its legalization in 2018. many individuals who use cannabis also use alcohol (co-use), which can be used either at the same time such that their effects overlap (simultaneous use) or at different times (concurrent use). though studies have identified predictors of co-use relative to single-substance use, less is known about the predictors of specific types of co-use. the present study examined the mental health and dispositional predictors of simultaneous relative to concurrent use of the two legal substances (cannabis and alcohol) among adults in canada. method: canadian adults reporting past-year use of both cannabis and alcohol (n = 1,761) were recruited from academic prolific and six canadian universities. participants completed online self-report measures of demographic characteristics, cannabis and alcohol co-use, mental health symptoms, impulsivity, and personality traits. results: binary logistic regression analyses revealed that when independent variables were each examined individually, greater severity of depression, anxiety, ptsd, and adhd symptoms; greater negative urgency and lack of premeditation; and greater impulsivity each predicted an increased likelihood of reporting past-year simultaneous use relative to concurrent use. when independent variables were grouped into three separate models (mental health, impulsivity, and personality variables), greater anxiety symptom severity, adhd symptom severity, negative urgency, and sensation seeking were each uniquely associated with an increased likelihood of simultaneous relative to concurrent use. conclusions: individuals with elevated anxiety and adhd symptoms, as well as negative urgency and sensation seeking, may be more inclined to engage in simultaneous use to self-medicate and achieve greater symptom reduction. future studies may examine the directionality of these relations and motives (e.g., coping) that may differentiate simultaneous and concurrent use. key words: = cannabis; alcohol; co-use; simultaneous alcohol and marijuana (sam); comorbidity; legalization jenna l. vieira1, sophie g. coelho2, lindsey a. snaychuk1, nassim tabri3, samantha j. dawson4, david c. hodgins5, matthew t. keough2, n. will shead6, hyoun s. kim1, 5 1department of psychology, toronto metropolitan university 2department of psychology, york university 3department of psychology, carleton university 4department of psychology, university of british columbia 5department of psychology, university of calgary, calgary 6department of psychology, mount saint vincent university cannabis 2024 © author(s) 2024 researchmj.org 10.26828/cannabis/2024/000256 volume 7, special issue 3 mental health and dispositional predictors of simultaneous versus concurrent cannabis and alcohol use in a canadian context corresponding author: hyoun s. kim, ph.d., department of psychology, toronto metropolitan university, 350 victoria street, toronto, on, m5b 2k3 state, phone: (416) 979-5000 ext. 552624. email: andrewhs.kim@torontomu.ca cannabis, a publication of the research society on marijuana 42 cannabis was legalized for non-medical use in canada in october 2018 (cannabis act, 2018). the legalization of cannabis introduced increased availability of cannabis and greater perceptions of its social acceptability (health canada, 2022), potentially contributing to rising prevalence rates of use. indeed, cannabis use prevalence among canadian adults rose from 22% in 2017 to 27% in 2022 (health canada, 2022), and as of 2019, cannabis was noted as the most used drug in the country (health canada, 2023). alcohol is also one of the most used legal substances in canada, with 76% of canadians reporting having consumed alcohol in the past year in 2019 (health canada, 2023). notably, a substantial proportion of individuals engage in co-use of cannabis and alcohol, a phenomenon whereby both substances are used either at different times (i.e., concurrent use) or the same time and with overlapping effects (i.e., simultaneous use) (bravo et al., 2021; yurasek et al., 2017). although cannabis use and alcohol use are each independently associated with negative consequences (pearson, 2019; white & hingson, 2014), these harms are amplified among those who engage in co-use (yurasek et al., 2017). indeed, the relative risks of couse versus single-use of cannabis and alcohol are welldocumented (jackson et al., 2020; sokolovsky et al., 2020; thompson et al., 2021; waddell, 2021), with simultaneous use generally associated with greater negative outcomes relative to concurrent use (bravo et al., 2021; jackson et al., 2020; linden-carmichael & wardell, 2021a; looby et al., 2021; thompson et al., 2021; yurasek et al., 2017). the existing literature has revealed specific consequences associated with different patterns of couse when examined at the betweenand within-person levels. at the between-person level, individuals who engage in simultaneous use have been found to experience more substance-related harms, including problems in social, occupational, financial, and physical domains relative to those who engage in alcohol use only and concurrent use (lee et al., 2022; subbaraman & kerr, 2015). moreover, those who engage in simultaneous use are more likely to engage in risky driving relative to those who engage in alcohol use only, cannabis use only, and concurrent use (subbaraman & kerr, 2015). the within-person consequences of co-use relative to single-substance use are less clear, and few studies have distinguished between simultaneous and concurrent use. however, select daily diary studies have indicated that relative to single-substance use days, days on which cannabis and alcohol are used simultaneously are associated with greater heavier alcohol use (ito et al., 2021; lee et al., 2020) and greater negative substance-related consequences (lindencarmichael et al., 2020; sokolovsky et al., 2020; wardell et al., 2024), as well as with specific consequences such as poorer sleep quality (graupensperger et al., 2021), greater next-day negative affect (linden-carmichael et al., 2021b), risk for sexual assault (read et al., 2021), and impaired driving (drohan et al., 2023; patrick et al., 2021). although there is evidence supporting elevated negative consequences of simultaneous relative to concurrent use, particularly at the between-person level, less research attention has been devoted to understanding risk factors for simultaneous relative to concurrent use. some studies have examined cannabis and alcohol use indicators (e.g., frequency, quantity) and sociodemographic characteristics (e.g., age, gender) as predictors of simultaneous relative to concurrent use (hatch et al., 2023; sokolovsky et al., 2020; subbaraman & kerr, 2015). however, there is a dearth of research examining the mental health and dispositional factors that distinguish simultaneous from concurrent use, particularly in jurisdictions where both cannabis and alcohol are legal for recreational use. single-use of cannabis and alcohol have been linked to symptoms of various common mental health conditions, such as anxiety (grant et al., 2015; kedzior & laeber, 2014; single et al., 2022), depression (langlois et al., 2021; mchugh & weiss, 2019), posttraumatic stress disorder (ptsd; kevorkian et al., 2015; lane et al., 2019), and attentiondeficit/hyperactivity disorder (adhd; francisco et al., 2023; rooney et al., 2012). greater depressive symptoms are also associated with greater simultaneous and concurrent use among adults (midanik et al., 2007). importantly, previous longitudinal studies suggest that the relations between mental health symptoms and use of these substances appear to be bidirectional and mutually reinforcing, whereby pre-existing mental health conditions lead to elevated risk of problematic cannabis and alcohol use (bell & britton, 2014; mcgee et al., 2002; ummels et al., 2022) and vice versa (bellos et al., 2016; mcgee et al., 2002; ummels et al., 2022). however, the extent to which mental health symptoms may predict engagement in simultaneous versus concurrent use is unclear. it is possible that symptoms of various mental health conditions may be stronger predictors of simultaneous relative to concurrent cannabis and alcohol use. according to the self-medication hypothesis, substance use is often motivated by a desire predictors of simultaneous versus concurrent use 43 to obtain relief from negative affect, such as anxiety and depression (khantzian, 1997). individuals with more severe mental health symptoms may therefore be more inclined to use multiple substances at the same time and with overlapping effects in an effort to seek greater relief from their combined effects. several dispositional characteristics have also been identified as robust predictors of both cannabis and alcohol use independently. these include dimensions of trait impulsivity, such as negative and positive urgency, sensation seeking, lack of premeditation, and lack of perseverance (coskunpinar et al., 2013; vanderveen et al., 2016). regarding co-use, greater sensation seeking, negative urgency, and positive urgency have been linked to greater likelihood of engaging in both simultaneous (salguero et al., 2022; stamates et al., 2023) and concurrent use (daros et al., 2021; waddell et al., 2021). however, most studies have generally examined these constructs in relation to just one type of co-use or to single-substance use. two other dispositional characteristics, hopelessness and anxiety sensitivity, have been identified as influential risk factors for substance use (woicik et al., 2009) and are positively associated with single use of both cannabis and alcohol (baines et al., 2016; newton et al., 2016). though also likely to play a role in co-use of these two substances, the extent to which they predict engagement in simultaneous versus concurrent use has not yet been tested. given the legality and consequent widespread availability of both cannabis and alcohol in canada, many individuals may be likely to use these substances simultaneously or concurrently. there is a need to identify the characteristics that may render certain individuals more likely to engage in simultaneous versus concurrent use, given that simultaneous use poses greater risk for harms (linden-carmichael & wardell, 2021a; yurasek et al., 2017). moreover, previous research has identified differences between individuals who use legal substances relative to illegal substances in demographic and personality characteristics (fearn et al., 2016; novais et al., 2016), suggesting that legal context is an influential factor in substance use patterns. therefore, there is a need to examine risk factors for co-use of cannabis and alcohol in a legal context wherein both substances are widely available. the present study seeks to address this gap by examining the extent to which various common mental health symptoms and dispositional characteristics predict likelihood of engaging in simultaneous relative to concurrent cannabis and alcohol use in a large, combined sample of universityattending and community-dwelling canadian adults. given the dearth of existing research regarding mental health and dispositional predictors of simultaneous relative to concurrent use, the present research was exploratory in nature. however, given that simultaneous cannabis and alcohol use appears to be associated with more severe negative consequences than concurrent use (lee et al., 2022; lindencarmichael et al., 2021b; patrick et al., 2021; subbaraman & kerr, 2015; sznitman et al., 2023), we expected that certain variables that have been linked to substance use severity more broadly may be more strongly predictive of simultaneous relative to concurrent use. therefore, the risk factors investigated were informed by the broader substance use literature; specifically, we examined mental health symptoms (i.e., depression, anxiety, social anxiety, posttraumatic stress, and attention-deficit/hyperactivity) and dispositional characteristics (i.e., impulsivity, hopelessness, anxiety sensitivity, and sensation seeking) that, in prior studies, have exhibited positive associations with the intensity of both alcohol (baines et al., 2016; castillo-carniglia et al., 2019; coskunpinar et al., 2013) and cannabis use (hasin & walsh, 2021; moreno-mansilla et al., 2021; paulus et al., 2018; rinehart & spencer, 2021). methods participants and procedures the current study combined data from two subsamples: (1) a community subsample (n = 1089) of canadian adults recruited from academic prolific, an online crowdsourcing platform; and (2) a student subsample (n = 3193) of undergraduate psychology students recruited from psychology student research pools at six canadian universities (toronto metropolitan university, york university, carleton university, university of british columbia, university of calgary, and mount saint vincent university). eligibility criteria for participants in both subsamples were (i) residing in canada; and (ii) being of legal drinking age in their respective jurisdiction. to increase confidence in the validity of community participant data, eligibility criteria were preset in the study recruitment notice using age and country of residence filters provided by academic prolific, ensuring that only eligible individuals were able to access the study survey. moreover, participants were asked at the end of the survey to indicate whether they cannabis, a publication of the research society on marijuana 44 provided high-quality responses and whether they answered questions honestly; if they responded “no” to either of these items, their data were excluded from analyses. of the initial 5990 participants (n = 1088 community; n = 4902 student) who enrolled in the study, 2144 participants (n = 429 community; n = 1715 student) reported past-year use of both cannabis and alcohol. 382 participants (n = 57 community; n = 325 student) reporting past-year cannabis and alcohol use were excluded due to failing attention checks or not confirming having provided honest, high-quality responses to all items, and one additional student participant was excluded due to missing data on items assessing simultaneous use, resulting in a final analytic sample of n = 1761 (n = 372 community; n = 1389 student). characteristics of each subsample are reported in table 1. compared to student participants, community participants were older and more educated and were more likely to identify as male (versus female), more likely to identify as men, less likely to identify as women, more likely to identify as white, less likely to identify as south asian, more likely to be currently employed, and more likely to be in a relationship (versus single). community participants also reported greater hopelessness and lower anxiety symptom severity, ptsd symptom severity, adhd symptom severity, negative urgency, positive urgency, lack of premeditation, sensation seeking, and impulsivity. study procedures received ethical approval from the research ethics board at each participating institution. all participants were required to read through a detailed consent form and provide their informed consent prior to accessing the study survey, in which they were informed that they could withdraw their consent at any time and leave any questions blank while still receiving participation credit. given the online nature of the study, participants were given an unlimited amount of time to read through the consent form and were encouraged to contact the principal investigator via email to ask any questions about the study and their participation. participants were asked to voluntarily select one of two response options: 1) “i consent to participate in this research;” or 2) “i do not consent to participate in this research.” only those who consented were subsequently directed to complete the study questionnaire. the 45-minute online questionnaire included measures of demographic characteristics, addictive behaviours, mental health, and other psychological variables. participants received $7.75 cad (community) or course credit (student) following completion of the online questionnaire. measures demographic characteristics. participants reported their age, gender, sex assigned at birth, race/ethnicity, highest level of education, and sexual orientation (see tables 1 and 2). ‘ cannabis and alcohol use. participants reported whether they had used cannabis in the past year, and if so, during what proportion of their cannabis use occasions they also used alcohol such that the effects of the two substances overlapped. next, they reported whether they had used alcohol in the past year, and if so, during what proportion of their alcohol use occasions they also used cannabis such that the effects of the two substances overlapped. response options for both questions were not at all, some of the time, most of the time, and every time. for analyses, participants were assigned to one of two groups: (1) a simultaneous use group, describing participants who used both cannabis and alcohol in the past year and reported any past-year use of the two substances with overlapping effects; or (2) a concurrent use group, describing participants who had used both cannabis and alcohol in the past year but reported never, in the past year, having used the two substances with overlapping effects. mental health variables. the depression and anxiety subscales from the 21-item depression, anxiety, and stress scale (dass-21; henry & crawford, 2005) were used to assess depressive and anxiety symptom severity; the seven ordinal items comprising each subscale were summed and multiplied by two to obtain subscale scores (a = .91 and a = .83) for depression and anxiety, respectively, in our sample). social anxiety symptom severity was assessed using the social interaction anxiety scale (sias; mattick & clarke, 1998), consisting of 20 ordinal items that were summed to obtain scores (a = .94). the short posttraumatic stress disorder rating interview (sprint; connor & davidson, 2001) was used to assess posttraumatic stress disorder (ptsd) symptom severity; scores were the sum of the eight ordinal items (a = .92). attention-deficit/hyperactivity disorder (adhd) symptom severity was assessed using the adult adhd self-report scale (asrs; kessler et al., 2005), consisting of six ordinal items that were summed to obtain scores (a = .79). predictors of simultaneous versus concurrent use 45 table 1. characteristics of the community and student subsamples community sample (n = 372) student sample (n = 1389) na n (%) na n (%) x2 df p sex 371 1389 33.86 1.00 < .001 male 130 (34.95) 284 (20.45) female 241 (64.78) 1105 (79.55) gender 372 1389 39.00 –b < .001 woman 236 (63.44) 1051 (75.67) man 127 (34.14) 273 (19.65) nonbinary 7 (1.88) 48 (3.46) transgender 0 (0) 2 (0.14) trans woman 1 (0.27) 1 (0.07) trans man 1 (0.27) 10 (0.72) other 0 (0) 4 (0.29) race/ethnicity 372 1389 62.78 8.00 < .001 black 8 (2.15) 52 (3.74) east asian 41 (11.02) 180 (12.96) latinx or hispanic 10 (2.69) 67 (4.82) middle eastern 7 (1.88) 51 (3.67) south asian 22 (5.91) 191 (13.75) southeast asian 13 (3.49) 82 (5.9) white 248 (66.67) 627 (45.14) indigenous 10 (2.69) 30 (2.16) other 13 (3.49) 109 (7.85) sexual identity 372 1389 12.13 –b .096 straight/heterosexual 259 (69.62) 909 (65.44) gay 6 (1.61) 25 (1.8) bisexual 51 (13.71) 270 (19.44) pansexual 16 (4.3) 57 (4.1) asexual 10 (2.69) 16 (1.15) lesbian 12 (3.23) 41 (2.95) queer 17 (4.57) 60 (4.32) other 1 (0.27) 11 (0.79) highest level of education 372 1389 597.42 3.00 < .001 high school diploma or less 28 (7.53) 430 (30.96) some post-secondary education but no college or university degree 96 (25.81) 818 (58.89) college diploma or university degree (bachelors) 187 (50.27) 139 (10.01) cannabis, a publication of the research society on marijuana 46 post-graduate work or degree 61 (16.4) 2 (0.14) employment status 372 1389 788.59 2.00 < .001 not working 67 (18.01) 649 (46.72) working part-time 78 (20.97) 704 (50.68) working full-time 227 (61.02) 36 (2.59) relationship status 372 1389 102.81 1.00 < .001 single 160 (43.01) 991 (71.35) in a relationship 212 (56.99) 398 (28.65) age 372 31.40 (9.21) 1389 20.46 (3.66) 22.42 402.90 < .001 dass-21 depression score 372 13.49 (10.19) 1388 13.50 (10.18) -0.02 584.98 .987 dass-21 anxiety score 372 8.77 (7.82) 1388 11.20 (8.48) -5.23 625.16 < .001 sias total score 372 34.30 (17.03) 1389 34.63 (16.34) -0.33 567.28 .741 sprint total score 371 10.41 (7.91) 1381 11.49 (8.05) -2.33 592.41 .020 asrs total score 372 8.87 (4.41) 1388 9.83 (4.69) -3.65 614.28 < .001 supps-p negative urgency score 372 2.40 (0.68) 1384 2.49 (0.68) -2.31 581.45 .021 supps-p positive urgency score 372 1.88 (0.65) 1384 2.06 (0.65) -4.74 588.15 < .001 supps-p lack of premeditation score 372 1.81 (0.56) 1382 1.97 (0.56) -4.66 584.25 < .001 supps-p lack of perseverance score 372 1.87 (0.56) 1384 1.93 (0.54) -1.80 575.90 .073 supps-p sensation seeking score 372 2.40 (0.69) 1381 2.60 (0.67) -5.06 576.27 < .001 surps hopelessness score 372 15.55 (4.36) 1385 15.02 (3.79) 2.14 530.75 .033 surps anxiety sensitivity score 372 13.25 (2.44) 1385 13.50 (2.51) -1.73 597.36 .085 surps impulsivity score 372 10.42 (2.62) 1385 11.00 (2.66) -3.78 592.94 < .001 surps sensation seeking score 372 14.24 (3.58) 1385 15.45 (3.56) -5.79 582.60 < .001 note. m = mean; sd = standard deviation; dass-21 = depression, anxiety, and stress scale; sias = social interaction anxiety scale; sprint = short posttraumatic stress disorder rating interview; asrs = adult adhd self-report scale; adhd = attention deficit hyperactivity disorder; supps-p = short uppsp impulsive behavior scale; surps = substance use risk profile scale. total scores for multi-item scales were obtained only for participants who completed all items. bolding denotes statically significant (p < .05) group differences; a bonferroni adjustment was used to control for type i error inflation in post hoc pairwise comparisons following statistically significant chi-square tests. adenotes number of participants with complete data for each variable; bno degrees of freedom reported as p value simulated (with 2000 replications) due to small expected value. predictors of simultaneous versus concurrent use 47 dispositional variables. five domains of impulsivity (negative urgency, positive urgency, lack of premeditation, lack of perseverance, and sensation seeking) were assessed using the short upps-p impulsive behavior scale (supps-p; cyders et al., 2014); subscale scores were the mean of the four items comprising each subscale (as = .67-.80). the substance use risk profile scale (surps; woicik et al., 2009) was administered to assess four personality risk factors for substance use: hopelessness (seven items), anxiety sensitivity (five items), impulsivity (five items), and sensation seeking (six items); items comprising each subscale were summed to obtain subscale scores (as = .67-.88). data analysis data were analyzed using a series of binary logistic regression models. in each model, the dependent variable was the likelihood of reporting past-year simultaneous use relative to past-year exclusive concurrent use (referent category). first, we specified each mental health and dispositional variable as an independent variable in separate models. next, mental health and dispositional variables were specified as simultaneous independent variables in three models to examine their unique effects on likelihood of simultaneous use relative to concurrent use; specifically, the mental health variables (depressive symptom severity, anxiety symptom severity, social anxiety symptom severity, ptsd symptom severity, and adhd symptom severity) were specified as independent variables in model 1, to examine the extent to which symptoms of various common mental health disorders may be uniquely associated with likelihood of engaging in one type of co-use relative to the other. the five supps-p impulsivity domains (negative urgency, positive urgency, lack of premeditation, lack of perseverance, and sensation seeking) were specified as independent variables in model 2, and the four surps risk factors (hopelessness, anxiety sensitivity, impulsivity, and sensation seeking) were specified as independent variables in model 3. the supps-p and surps measures were entered as independent variables in separate models due to overlap between domains of the supps-p and the impulsivity subscale of the surps. for each of these three models, we obtained adjusted p values that controlled for the model-wise false discovery rate, reducing risk for type i error inflation. in all models, we controlled for a subsample indicator (0 = community, 1 = student), age (in years), and sex (0 = male, 1 = female), race (0 = white, 1 = non-white, sexual identity (0 = straight/heterosexual; 1 = lesbian, gay, bisexual, queer+), and relationship status (0 = single, 1 = in a relationship).1 the binary logistic regression models were fit using iteratively reweighted least squares estimation. the proportion of participants who were missing data on one or more scale items ranged from 0–0.57% across variables; however, when participants had data on 80% or more of the items comprising a given scale, their missing item values were prorated using available items, resulting in variable-level missingness ranging from 0–0.51%. to include data from participants with partially missing data on independent variables, missing data were handled using multiple imputation via the multiple imputation by chained equations (mice) approach; predictive mean matching was used to impute missing values for continuous variables, and logistic regression was used to impute missing values for binary variables. all models were fit separately to each of 50 imputed datasets, after which estimates were pooled. all analyses were conducted in r (r core team, 2022) using the mice, misty, stats, and tidyverse packages (r core team, 2022; van buure & groothuis-oudshoorn, 2011; wickham et al., 2019; yanagida, 2022). data and code for analyses are available at https://osf.io/9dq53/. results table 2 presents characteristics of the full sample and of each co-use group. one thousand and ninetyseven participants (62.29%) reported past-year simultaneous use, and 664 participants (37.71%) reported past-year concurrent use. results of binary logistic regression models with each independent variable of interest in a separate model are shown in table 3. in these models, greater depressive, anxiety, ptsd, and negative urgency, positive urgency, lack of premeditation, and sensation seeking on the supps-p; and greater impulsivity and sensation seeking on the surps were each significantly associated with an increased likelihood of simultaneous use relative to concurrent use. 1gender was not included in models as a covariate due to high overlap with sex, and employment status and highest level of education were not included in models as covariates due to high overlap with subsample. cannabis, a publication of the research society on marijuana 48 table 2. characteristics of the full sample and of participants reporting past-year concurrent use and past-year simultaneous use full sample (n = 1761) concurrent use (n = 664) simultaneous use (n = 1097) na n (%) na n (%) na n (%) sex 1760 663 1097 male 414 (23.51) 140 (21.08) 274 (24.98) female 1346 (76.43) 523 (78.77) 823 (75.02) gender 1761 664 1097 woman 1287 (73.08) 504 (75.9) 783 (71.38) man 400 (22.71) 133 (20.03) 267 (24.34) nonbinary 55 (3.12) 23 (3.46) 32 (2.92) transgender 2 (0.11) 0 (0) 2 (0.18) trans woman 2 (0.11) 2 (0.3) 0 (0) trans man 11 (0.62) 2 (0.3) 9 (0.82) other 4 (0.23) 0 (0) 4 (0.36) race/ethnicity 1761 664 1097 black 60 (3.41) 24 (3.61) 36 (3.28) east asian 221 (12.55) 103 (15.51) 118 (10.76) latinx or hispanic 77 (4.37) 37 (5.57) 40 (3.65) middle eastern 58 (3.29) 27 (4.07) 31 (2.83) south asian 213 (12.1) 98 (14.76) 115 (10.48) southeast asian 95 (5.39) 36 (5.42) 59 (5.38) white 875 (49.69) 293 (44.13) 582 (53.05) indigenous 40 (2.27) 9 (1.36) 31 (2.83) other 122 (6.93) 37 (5.57) 85 (7.75) sexual identity 1761 664 1097 straight/heterosexual 1168 (66.33) 444 (66.87) 724 (66) gay 31 (1.76) 11 (1.66) 20 (1.82) bisexual 321 (18.23) 112 (16.87) 209 (19.05) pansexual 73 (4.15) 26 (3.92) 47 (4.28) asexual 26 (1.48) 15 (2.26) 11 (1) lesbian 53 (3.01) 19 (2.86) 34 (3.1) queer 77 (4.37) 32 (4.82) 45 (4.1) other 12 (0.68) 5 (0.75) 7 (0.64) highest level of education 1761 664 1097 high school diploma or less 458 (26.01) 174 (26.2) 284 (25.89) some post-secondary education but no college or university degree 914 (51.9) 323 (48.64) 591 (53.87) predictors of simultaneous versus concurrent use 49 college diploma or university degree (bachelors) 326 (18.51) 135 (20.33) 191 (17.41) post-graduate work or degree 63 (3.58) 32 (4.82) 31 (2.83) employment status 1761 664 1097 not working 716 (40.66) 262 (39.46) 454 (41.39) working part-time 782 (44.41) 304 (45.78) 478 (43.57) working full-time 263 (14.93) 98 (14.76) 165 (15.04) relationship status 1761 664 1097 single 1151 (65.36) 438 (65.96) 713 (65) in a relationship 610 (34.64) 226 (34.04) 384 (35) age 1761 22.77 (6.96) 664 22.73 (6.75) 1097 22.80 (7.09) dass-21 depression score 1760 13.49 (10.18) 663 12.51 (10.16) 1097 14.09 (10.15) dass-21 anxiety score 1760 10.69 (8.40) 663 9.66 (8.19) 1097 11.30 (8.47) sias total score 1761 34.56 (16.48) 664 34.51 (16.75) 1097 34.59 (16.32) sprint total score 1752 11.26 (8.03) 661 10.62 (8.04) 1091 11.65 (8.01) asrs total score 1760 9.63 (4.65) 663 8.98 (4.72) 1097 10.02 (4.56) supps-p negative urgency score 1756 2.48 (0.68) 662 2.41 (0.66) 1094 2.51 (0.69) supps-p positive urgency score 1756 2.02 (0.65) 662 1.99 (0.67) 1094 2.04 (0.64) supps-p lack of premeditation score 1754 1.93 (0.57) 659 1.90 (0.56) 1095 1.96 (0.57) supps-p lack of perseverance score 1756 1.91 (0.55) 662 1.90 (0.56) 1094 1.92 (0.54) supps-p sensation seeking score 1753 2.56 (0.68) 660 2.48 (0.67) 1093 2.60 (0.68) surps hopelessness score 1757 15.13 (3.92) 663 14.98 (3.82) 1094 15.22 (3.98) surps anxiety sensitivity score 1757 13.45 (2.49) 663 13.32 (2.46) 1094 13.52 (2.51) surps impulsivity score 1757 10.88 (2.66) 663 10.68 (2.71) 1094 10.99 (2.62) surps sensation seeking score 1757 15.19 (3.59) 663 14.82 (3.48) 1094 15.42 (3.64) note. m = mean; sd = standard deviation; dass-21 = depression, anxiety, and stress scale; sias = social interaction anxiety scale; sprint = short post-traumatic stress disorder rating interview; asrs = adult adhd self-report scale; adhd = attention deficit hyperactivity disorder; supps-p = short upps-p impulsive behavior scale; surps = substance use risk profile scale. total scores for multi-item scales were obtained only for participants who completed all items. adenotes number of participants with complete data for each varable. cannabis, a publication of the research society on marijuana 50 table 3. results of binary logistic regression models predicting likelihood of simultaneous use relative to concurrent use with each independent variable of interest in a separate model model variable or estimate se p iv of interest: depressive symptom severity dass-21 depressive symptom severity 1.02 0.02 0.01 0.001 subsample (0 = community, 1 = student) 1.33 0.29 0.16 0.073 age 1.00 0.00 0.01 0.660 sex (0 = male, 1 = female) 0.75 -0.29 0.12 0.016 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.00 0.00 0.11 0.990 relationship status (0 = single, 1 = relationship) 1.05 0.04 0.11 0.684 iv of interest: anxiety symptom severity dass-21 anxiety symptom severity 1.03 0.03 0.01 < 0.001 subsample (0 = community, 1 = student) 1.28 0.25 0.16 0.122 age 1.01 0.01 0.01 0.488 sex (0 = male, 1 = female) 0.71 -0.34 0.12 0.005 race (0 = white, 1 = non-white) 0.68 -0.38 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 0.98 -0.02 0.11 0.831 relationship status (0 = single, 1 = relationship) 1.02 0.02 0.11 0.871 iv of interest: social anxiety symptom severity sias social anxiety symptom severity 1.00 0.00 0.00 0.853 subsample (0 = community, 1 = student) 1.31 0.27 0.16 0.094 age 1.00 0.00 0.01 0.719 sex (0 = male, 1 = female) 0.76 -0.28 0.12 0.024 race (0 = white, 1 = non-white) 0.68 -0.39 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.05 0.05 0.11 0.641 relationship status (0 = single, 1 = relationship) 1.03 0.03 0.11 0.789 iv of interest: ptsd symptom severity sprint ptsd symptom severity 1.02 0.02 0.01 0.002 subsample (0 = community, 1 = student) 1.28 0.25 0.16 0.119 age 1.00 0.00 0.01 0.795 sex (0 = male, 1 = female) 0.72 -0.33 0.12 0.008 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.00 0.00 0.11 0.997 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.743 iv of interest: adhd symptom severity asrs adhd symptom severity 1.05 0.05 0.01 < 0.001 subsample (0 = community, 1 = student) 1.28 0.24 0.16 0.130 age 1.00 0.00 0.01 0.614 sex (0 = male, 1 = female) 0.71 -0.34 0.12 0.005 race (0 = white, 1 = non-white) 0.68 -0.38 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 0.98 -0.02 0.11 0.823 relationship status (0 = single, 1 = relationship) 1.02 0.02 0.11 0.863 iv of interest: supps-p negative urgency supps-p negative urgency 1.27 0.24 0.07 0.001 subsample (0 = community, 1 = student) 1.31 0.27 0.16 0.091 age 1.01 0.01 0.01 0.588 sex (0 = male, 1 = female) 0.75 -0.28 0.12 0.020 race (0 = white, 1 = non-white) 0.66 -0.41 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.01 0.01 0.11 0.915 relationship status (0 = single, 1 = relationship) 1.03 0.03 0.11 0.814 iv of interest: supps-p positive urgency supps-p positive urgency 1.17 0.15 0.08 0.049 predictors of simultaneous versus concurrent use 51 subsample (0 = community, 1 = student) 1.29 0.26 0.16 0.108 age 1.00 0.00 0.01 0.616 sex (0 = male, 1 = female) 0.77 -0.26 0.12 0.036 race (0 = white, 1 = non-white) 0.66 -0.41 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.05 0.05 0.11 0.665 relationship status (0 = single, 1 = relationship) 1.03 0.03 0.11 0.794 iv of interest: supps-p lack of premeditation supps-p lack of premeditation 1.22 0.20 0.09 0.026 subsample (0 = community, 1 = student) 1.29 0.25 0.16 0.115 age 1.00 0.00 0.01 0.649 sex (0 = male, 1 = female) 0.74 -0.30 0.12 0.016 race (0 = white, 1 = non-white) 0.67 -0.39 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.04 0.04 0.11 0.722 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.745 iv of interest: supps-p lack of perseverance supps-p lack of perseverance 1.13 0.12 0.09 0.186 subsample (0 = community, 1 = student) 1.31 0.27 0.16 0.094 age 1.00 0.00 0.01 0.703 sex (0 = male, 1 = female) 0.75 -0.28 0.12 0.021 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.05 0.05 0.11 0.664 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.737 iv of interest: supps-p sensation seeking supps-p sensation seeking 1.29 0.25 0.08 0.001 subsample (0 = community, 1 = student) 1.24 0.22 0.16 0.173 age 1.00 0.00 0.01 0.637 sex (0 = male, 1 = female) 0.84 -0.18 0.13 0.151 race (0 = white, 1 = non-white) 0.67 -0.41 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.09 0.09 0.11 0.415 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.718 iv of interest: surps hopelessness surps hopelessness 1.02 0.02 0.01 0.146 subsample (0 = community, 1 = student) 1.32 0.28 0.16 0.079 age 1.00 0.00 0.01 0.734 sex (0 = male, 1 = female) 0.76 -0.27 0.12 0.026 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.03 0.03 0.11 0.805 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.705 iv of interest: surps anxiety sensitivity surps anxiety sensitivity 1.04 0.04 0.02 0.055 subsample (0 = community, 1 = student) 1.31 0.27 0.16 0.086 age 1.00 0.00 0.01 0.636 sex (0 = male, 1 = female) 0.73 -0.32 0.12 0.010 race (0 = white, 1 = non-white) 0.68 -0.39 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.03 0.03 0.11 0.750 relationship status (0 = single, 1 = relationship) 1.02 0.02 0.11 0.840 iv of interest: surps impulsivity surps impulsivity 1.05 0.05 0.02 0.007 subsample (0 = community, 1 = student) 1.30 0.26 0.16 0.101 age 1.01 0.00 0.01 0.601 sex (0 = male, 1 = female) 0.77 -0.27 0.12 0.029 race (0 = white, 1 = non-white) 0.66 -0.42 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.04 0.04 0.11 0.696 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.718 cannabis, a publication of the research society on marijuana 52 iv of interest: surps sensation seeking surps sensation seeking 1.05 0.05 0.01 0.002 subsample (0 = community, 1 = student) 1.25 0.22 0.16 0.167 age 1.00 0.00 0.01 0.609 sex (0 = male, 1 = female) 0.82 -0.20 0.12 0.109 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 < 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.06 0.06 0.11 0.565 relationship status (0 = single, 1 = relationship) 1.04 0.04 0.11 0.707 note. or = odds ratio; se = standard error; iv = independent variable; dass-21 = depression, anxiety, and stress scale; lgbq+ = lesbian, gay, bisexual, queer+; sias = social interaction anxiety scale; sprint = short post-traumatic stress disorder rating interview; ptsd = posttraumatic stress disorder; asrs = adult adhd self-report scale; adhd = attention deficit hyperactivity disorder; supps-p = short upps-p impulsive behavior scale; surps = substance use risk profile scale. bolding indicates statistical significance at a = .05. results of binary logistic regression models with each independent variable of interest combined into three separate models are shown in table 4. in the model with all mental health variables as independent variables (model 1), greater anxiety symptom severity, social anxiety symptom severity, and adhd symptom severity were each significantly and uniquely associated with an increased likelihood of simultaneous use relative to concurrent use, although the association of anxiety symptom severity with likelihood of simultaneous use relative to concurrent use was no longer statistically significant after correcting for the false discovery rate. in the model with all impulsivity facets as independent variables (model 2), greater negative urgency and sensation seeking were each significantly and uniquely associated with an increased likelihood of simultaneous use relative to concurrent use. in the model with all personality risk factors as independent variables (model 3), greater sensation seeking was significantly and uniquely associated with an increased likelihood of simultaneous use relative to concurrent use. table 4. results of binary logistic regression models predicting likelihood of simultaneous use relative to concurrent use with independent variables of interest combined into three models model variable or estimate se p padj model 1: mental health variables as ivs of interest dass-21 depressive symptom severity 1.00 0.00 0.01 0.652 0.896 dass-21 anxiety symptom severity 1.02 0.02 0.01 0.036 0.079 sias social anxiety symptom severity 0.99 -0.01 0.00 0.009 0.025 sprint ptsd symptom severity 1.01 0.01 0.01 0.497 0.782 asrs adhd symptom severity 1.04 0.04 0.01 0.002 0.010 subsample (0 = community, 1 = student) 1.22 0.20 0.16 0.225 0.412 age 1.00 0.00 0.01 0.718 0.878 sex (0 = male, 1 = female) 0.71 -0.34 0.13 0.007 0.025 race (0 = white, 1 = non-white) 0.67 -0.40 0.10 <0.001 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 0.98 -0.02 0.11 0.832 0.916 relationship status (0 = single, 1 = relationship) 1.02 0.02 0.11 0.875 0.875 model 2: impulsivity facets as ivs of interest supps-p negative urgency 1.28 0.24 0.09 0.008 0.029 supps-p positive urgency 0.90 -0.10 0.10 0.303 0.476 supps-p lack of premeditation 1.11 0.10 0.11 0.340 0.468 supps-p lack of perseverance 1.12 0.11 0.11 0.293 0.537 supps-p sensation seeking 1.31 0.27 0.08 0.001 0.006 subsample (0 = community, 1 = student) 1.25 0.22 0.16 0.168 0.369 predictors of simultaneous versus concurrent use 53 age 1.01 0.01 0.01 0.505 0.617 sex (0 = male, 1 = female) 0.81 -0.22 0.13 0.088 0.243 race (0 = white, 1 = non-white) 0.66 -0.42 0.10 <0.001 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.04 0.04 0.11 0.745 0.745 relationship status (0 = single, 1 = relationship) 1.05 0.05 0.11 0.666 0.732 model 3: personality risk factors as ivs of interest surps hopelessness 1.02 0.02 0.01 0.198 0.330 surps anxiety sensitivity 1.04 0.04 0.02 0.073 0.182 surps impulsivity 1.03 0.03 0.02 0.203 0.290 surps sensation seeking 1.05 0.05 0.02 0.002 0.008 subsample (0 = community, 1 = student) 1.27 0.24 0.16 0.137 0.273 age 1.01 0.01 0.01 0.460 0.575 sex (0 = male, 1 = female) 0.79 -0.23 0.13 0.068 0.228 race (0 = white, 1 = non-white) 0.66 -0.41 0.10 <0.001 0.001 sexual identity (0 = straight/heterosexual, 1 = lgbq+) 1.01 0.01 0.11 0.927 0.927 relationship status (0 = single, 1 = relationship) 1.05 0.05 0.11 0.635 0.706 note. or = odds ratio; se = standard error; padj = adjusted p value after correcting for the false discovery rate; iv = independent variable; dass-21 = depression, anxiety, and stress scale; sias = social interaction anxiety scale; sprint = short post-traumatic stress disorder rating interview; ptsd = posttraumatic stress disorder; asrs = adult adhd self-report scale; adhd = attention deficit hyperactivity disorder; lgbq+ = lesbian, gay, bisexual, queer+; supps-p = short upps-p impulsive behavior scale; surps = substance use risk profile scale. bolding indicates statistical significance at a = .05. discussion the present study sought to elucidate the mental health and dispositional predictors of simultaneous relative to concurrent cannabis and alcohol use in a canadian context, wherein both substances are legal for recreational use. when independent variables were examined individually, more severe depression, anxiety, ptsd, and adhd symptoms; greater overall impulsivity; and greater negative urgency, positive urgency, sensation seeking, and lack of premeditation were each associated with a greater likelihood of reporting simultaneous relative to concurrent use. when independent variables were grouped into three models (mental health, impulsivity, and personality traits), anxiety symptoms, adhd symptoms, negative urgency, and sensation seeking remained significant predictors of simultaneous relative to concurrent use. symptoms of various common mental health disorders, including those of anxiety and adhd, were expected to predict greater simultaneous relative to concurrent cannabis and alcohol use. in line with the self-medication hypothesis of substance use (khantzian, 1997), individuals with elevated symptoms of these disorders may be inclined to use substances to cope with and reduce the intensity of their symptoms––a goal they may expect to be more rapidly achieved if they use multiple substances at the same time for their additive effects. indeed, the findings that both anxiety and adhd symptoms predicted greater simultaneous relative to concurrent use in the present study appear to support this notion. moreover, cross-fading motives, which refer to using cannabis and alcohol at the same time to enhance the effects of each substance, are frequently endorsed by individuals who engage in simultaneous use (patrick et al., 2020). individuals with elevated anxiety symptoms may be drawn to use both cannabis and alcohol due to their perceived anxiolytic effects (gilman et al., 2008; sharpe et al., 2020). cannabis is often used to relax (patrick et al., 2016) and to cope with distress (ouellette et al., 2022), and some report a subjective decrease in anxiety following use (cuttler et al., 2018). alcohol is also often consumed for its tension-reducing properties (abrams et al., 2021; pabst et al., 2014), and its acute impairment of cognitive processes such as inhibitory control and attention (field et al., 2010) may be sought by some individuals to aid in temporarily disengaging from worry and anxiety. cannabis, a publication of the research society on marijuana 54 individuals with elevated adhd symptoms may similarly engage in simultaneous cannabis and alcohol use to reduce distress associated with their symptoms (smith et al., 2002). indeed, some individuals with adhd report experiencing enhanced positive mood following substance use (mitchell et al., 2017) and using substances to be perceived as “normal” and to achieve a greater sense of social belongingness (nehlin et al., 2014). existing evidence suggests potential additive effects of cannabis and alcohol (yurasek et al., 2017), with simultaneous use producing greater subjective relief than alcohol-only use (waddell et al., 2023). thus, consistent with the selfmedication hypothesis (khantzian, 1997), simultaneous use may be particularly attractive to individuals with elevated anxiety and adhd symptoms as a tool for managing their distress. several dimensions of impulsivity were also explored as risk factors for simultaneous relative to concurrent use in the present study, with negative urgency and sensation seeking identified as significant predictors. individuals high in sensation seeking tend to endorse a need to seek novel, risky, and exciting experiences (lynnelandsman et al., 2011) and may thus be inclined to fulfill this need by combining cannabis and alcohol use to achieve enhanced or intensified psychoactive effects (i.e., cross-fading motives; patrick et al., 2020). on the other hand, individuals high in negative urgency may be inclined to combine cannabis and alcohol use to obtain greater relief from the negative affect they are experiencing in the moment. this possibility is aligned with findings of a previous study indicating that the daily-level relationship between quantity of cannabis and alcohol consumed was stronger for individuals high but not low in negative urgency, suggesting that participants with elevated levels of this trait may be more likely to use these substances simultaneously for their complementary effects (daros et al., 2022). that these two facets of impulsivity were each associated with a greater likelihood of simultaneous relative to concurrent cannabis and alcohol use also appears to be consistent with the broader co-use literature. previous work has identified a positive association between both sensation seeking (waddell et al., 2021) and negative urgency (rothstein et al., 2023) with co-use, though these studies did not differentiate between simultaneous and concurrent use. findings of the present study suggest that these facets of impulsivity may be particularly influential in the decision to use cannabis and alcohol at the same time rather than separately. given that individuals with elevated anxiety and adhd symptoms appear to be at greater risk of engaging in simultaneous use, they may benefit from psychoeducation, perhaps involving information about potential motives for and consequences of simultaneous use, mental health symptoms (e.g., anxiety, adhd), and more adaptive strategies for coping with distress associated with these symptoms (mckee, 2017). this information may help individuals to be better informed about their decision to engage (or not engage) in simultaneous use. elements of cognitive-behavioural therapy may also be integrated to help clients to implement effective coping and emotion regulation strategies that reduce their likelihood of engaging in simultaneous use to manage distress (mckee, 2017). dialectical behaviour therapy (dbt; linehan, 2015) skills may be a beneficial addition for individuals who endorse elevated sensation seeking and negative urgency, as they have been shown to lead to reductions in impulsivity among individuals with substance use disorders (cavicchioli et al., 2023). given the relatively small effect sizes observed for these predictors, however, future research should seek to replicate the present findings to provide greater support for these recommendations. interestingly, none of the other dimensions of impulsivity tested in the present study— including positive urgency, lack of premeditation, and lack of perseverance—were identified as significant predictors of simultaneous versus concurrent use when included alongside other predictors. it is particularly interesting that negative, but not positive, urgency significantly predicted greater likelihood of simultaneous relative to concurrent use, as this suggests that simultaneous use may be more strongly influenced by negative than positive emotion. this is consistent with several studies in the broader substance use literature, which have found that negative urgency is a stronger predictor of problematic alcohol use (willie et al., 2022) and alcohol use consequences than is positive urgency (grimaldi et al., 2014). in addition to the null findings related to several predictors of simultaneous versus concurrent use 55 facets of impulsivity, neither anxiety sensitivity nor hopelessness significantly differentiated simultaneous use from concurrent use. it is possible that these dispositional traits contribute to cannabis use and alcohol use (baines et al., 2016; newton et al., 2016; woicik et al., 2009) and to co-use in general, but do not differentiate between specific types of co-use. however, this interpretation is speculative and warrants empirical testing. limitations our cross-sectional design precludes causal inferences. longitudinal data are needed to confirm the directions of associations observed. further, concurrent use was broadly defined as having used both cannabis and alcohol within the past year. whether results would generalize to narrower definitions of concurrent use (e.g., use of both within the same month, week, or day) remains unknown. our focus on two community samples may also limit the generalizability of results to clinical samples of adults seeking treatment for cannabis or alcohol use problems. in particular, there are known limitations associated with online research panel data sources such as academic prolific, including concerns regarding data quality, financial incentives motivating the provision of inaccurate data, and difficulty generalizing results due to discordance between characteristics of the sample and those of the broader population of interest (borodovsky, 2023; chandler et al., 2022). importantly, however, academic prolific has been found to yield higher-quality data relative to other frequently used online research panels such as amazon’s mechanical turk, as evidenced by academic prolific participants being more likely to pass attention checks, provide meaningful answers, and adhere to instructions (douglas et al., 2023). nonetheless, the present study should be replicated in more representative samples recruited from various sources to provide additional confidence in its findings. conclusions in sum, this study extends prior research on cannabis-alcohol co-use by examining factors differentiating individuals reporting simultaneous use from those reporting exclusively concurrent use. results suggest that higher anxiety and adhd symptom severity increase 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4(2), 184–193. https://doi.org/10.1007/s40429-017-0149-8 funding and acknowledgements: no funding was received to assist with the preparation of the manuscript. the authors declare that there are no potential conflicts of interest with respect to authorship, and/or publication of this article. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: vieira, j. l., coelho, s. g., snaychuk, l. a., tabri, n., dawson, s. j., hodgins, d. c., keough, m. t., shead, n. w., & kim, h. s. (2024). mental health and dispositional predictors of simultaneous versus concurrent cannabis and alcohol use in a canadian context. cannabis, 7(3), 41–60. https://doi.org/10.26828/cannabis/2024/000256 issue date: december 12, 2024 https://creativecommons.org/licenses/by/4.0/ research article 33 ved abstract background: with cannabis legal in nearly half of u.s. states, important concerns about the public health impact remain, particularly for states yet to legalize. the present study, using data collected in the initial phase of cannabis legalization in missouri, examined predictors of the intention to initiate (in the cannabis naïve) and increase use (in those with past-year use) in a representative sample of missouri college students. methods: data (ncannabisnaïve = 2,716; ncannabisuse = 1,591) were collected from 25 missouri college campuses. four pre-registered multilevel models examined the associations of theory-driven predictors with the intention to initiate cannabis use and to increase use. results: 33.4% of all students surveyed reported past-year cannabis use, 9.9% of cannabis naïve students reported intending to initiate cannabis use, and 22% of those with previous cannabis use reported intending to increase cannabis use. multilevel modes found that being gay or lesbian (aor = 3.03; ci = [1.72, 5.34]), bisexual (aor = 3.52; ci = [2.41, 5.14]), or queer (aor = 2.51; ci = [1.71, 3.69]) was associated with intending to initiate use, while greater flourishing (aor = 0.98; ci = [0.96, 0.99]) was associated with decreased odds of intending to initiate use. endorsing more cannabis motives (aor = 1.13; ci = [1.08, 1.19]), age of first use (aor = 1.09; ci = [1.03, 1.15]), and being gay or lesbian (aor = 2.19; ci = [1.27, 3.76]) were associated with intending to increase use. endorsing more cannabis-related negative consequences was associated with intending to decrease use (aor = 0.91; ci = [0.89, 0.94]). discussion: multiple theory-driven factors were associated with intending to initiate or increase cannabis use following legalization. future research should examine how intentions to change cannabis use translate to actualized behavior following legalization and factors that may create increased risk for minoritized sexual identities. key words: = cannabis; cannabis legalization; motives; cannabis frequency; sexual orientation to date, nearly half of the united states has legalized recreational cannabis use for adult use (24 states plus the district of columbia; reuters, 2023) and there is increasing public support for legalization (chiu et al., 2022). legalization has benefits, including increased tax revenue, reducing justice system burden, and offsetting black market sales (gunadi & shi, 2022; kavousi et al., 2022). it also holds important public health considerations, such as concerns about increased ian a. mcnamara1, jamie e. parnes2,3, khrystyna stetsiv1, melissa nance1, jake sauer1, kayleigh greenwood4, joan p. masters4, & ryan w. carpenter1 1department of psychology, university of notre dame 2center for alcohol and addiction studies, brown university school of public health 3e. p. bradley hospital 4missouri partners in prevention, university of missouri cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000286 volume 8, issue 2 missouri college students’ intentions towards initiating or changing cannabis use in a shifting legal landscape corresponding author: ian mcnamara, m.a., university of notre dame, corbett family hall, 18931 moose krause circle, notre dame, indiana, 46556. phone: (574) 631-6650. email: imcnamar@nd.edu cannabis, a publication of the research society on marijuana 34 use, cannabis use disorder (cud), and related harms (e.g., intoxicated driving; hall & lynskey, 2016; hopfer, 2014; monte et al., 2015; parnes et al., 2017). this is especially the case among young adults, an age group that already reports the highest rates of cannabis use and cud (center for behavioral health statistics and quality, 2023). in states that have legalized recreational cannabis, studies have examined changes in cannabis use, cud, cannabis beliefs, and intoxicated driving, among others. cross-sectional studies on young adults in the united states have mostly found increased cannabis use, although results have been mixed regarding changes to frequency (bae & kerr, 2020; kerr, bae, phibbs, et al., 2018; kerr et al., 2017; kerr, ye, et al., 2018; mennis et al., 2023; o’grady et al., 2022; parnes, bravo, et al., 2018; wallace et al., 2020). longitudinal young adult studies have also documented increases in use, particularly among those with previous cannabis use; the extent of these changes have varied by state (barker & moreno, 2021; smart & pacula, 2019; zellers et al., 2023). studies also noted greater increases in young adult use among those with recent heavy alcohol use (kerr et al., 2017) and past-year depression (mennis et al., 2023), as well as women (bae & kerr, 2020) and those over the legal purchasing age (i.e., 21 years old; bae & kerr, 2020). more broadly, poor social relationships and greek life affiliation are risk factors for young adult cannabis use (kerr et al., 2017; vidal et al., 2022). beyond use, young adult research has also founded increases in acceptance of use and decreases in perceptions of risk (barker & moreno, 2021; mennis et al., 2023; wallace et al., 2020), despite post-legalization increases in negative cannabis-related consequences (estoup et al., 2016; parnes et al., 2017). given findings, policymakers and stakeholders in states that have yet to legalize likely want to know how legalizing would impact their state, especially among high-risk groups (e.g., young adults). one way to predict legalization’s future impact is by examining intentions to initiate or increase use at the time of or closely following legalization. given that intentions to use cannabis are associated with greater use in both the short (waddell et al., 2023) and long term (ito et al., 2015), identifying predictors of these intentions is crucial for determining who may be most impacted by cannabis legalization. moreover, identifying riskrelated intentions can inform targets for cannabis interventions (e.g., marijuana echeckup to go; riggs et al., 2018). several factors are associated with greater intentions to use, including stronger cannabisrelated social norms (i.e., acceptability and commonality of use in one’s social network), greater past-month alcohol use, and younger age (cohn et al., 2017; sandhu et al., 2019). greater current cannabis use frequency was also associated with intentions to increase use following legalization (clarke et al., 2018; cohn et al., 2017; sandhu et al., 2019), though one study (cui et al., 2023) did not find this association. worse self-reported mental health was also related to greater intentions around cannabis use following legalization (sandhu et al., 2019). sexual minorities, especially bisexual individuals, often report higher rates of cannabis use (parnes et al., 2017), though cui et al. (2023) did not find that they reported greater intentions to use after legalization. despite known sex and gender differences in cannabis use and consequences (e.g., greaves & hemsing, 2020), findings on intentions to use following legalization are more ambiguous with results varying by country (cui et al, 2023; sandhu et al., 2019). the current study as u.s. recreational legalization expands, initially resistant states have begun passing such laws. compared to early adopting states, which often had pre-existing higher use rates and more permissive norms (schuermeyer et al., 2014), the context and effects of legalization may differentially impact these more hesitant states. given that the effects of legalization appear to vary across states (bailey et al., 2023; barker & moreno, 2021; smart & pacula, 2019), it is a public health priority to continue examining the potential effects of legalization, particularly in less studied states. this large, cross-sectional study of missouri college students examined factors related to intentions to initiate or change cannabis use with the recent legalization of cannabis in the state in 2023. descriptively, we will present a depiction of cannabis use presently and over the past decade. we calculate rates of use and non-use over the cannabis use intentions during legalization 35 past decade, frequency of use for students in the past year and month, rates of substance co-use with cannabis, and current perceived descriptive norms of cannabis use. beyond this, building from existing work, we had two sets of primary hypotheses, one set predicting the intention to initiate cannabis use following legalization, and the second set predicting, among those already using cannabis, the intention to change cannabis use following legalization. first, we hypothesized that, among cannabis-naïve college students, greater descriptive norms, greater recent alcohol use, prior binge drinking, and being over 21 years old would be associated with a greater likelihood of intention to initiate cannabis use following legalization. second, we hypothesized that, among college students who previously used cannabis, greater descriptive norms, greater cannabis and alcohol use, prior binge drinking, more cannabis use motives, and greater cannabis consequences would positively predict intentions to increase consumption following legalization. additionally, we proposed two secondary models that examined factors previously associated with cannabis use, but less clearly linked to changes in use intentions. first, we examined whether not previously using cannabis due to illegality, level of self-perceived fulfillment (flourishing), self-report of mental health disorders, age, gender, race, sexual orientation, greek life affiliation, and sports participation were related to intentions to initiate cannabis use following legalization among cannabis-naïve college students. second, we examined whether age of cannabis initiation, methods of use, level of self-perceived fulfillment (flourishing), self-report of mental health disorders, age, gender, race, sexual orientation, greek life affiliation, and sports participation were related to intention to increase cannabis use following legalization among students with prior use. methods transparency and openness hypotheses and analyses, including specific predictors and outcomes, unless labeled exploratory, were pre-registered (https://osf.io/97gb2). we report how we determined our sample size, all data exclusions, and all measures in the study. participants and procedures the missouri assessment of college health behaviors (machb) survey is administered by partners in prevention (pip), a coalition of 25 public and private colleges and universities within missouri (takenaka & greenwood, 2022). this retrospective, self-report survey is emailed to undergraduate students at participating schools at the beginning of each spring semester. the number of students emailed at each school depends on the size of the institution, with 25% of students contacted at schools with more than 4,000 students, 1,000 students at schools with between 1,000-3,999 students, and all students at schools with fewer than 1,000 students. data were collected via campuslabs from 2007 until 2022 and via qualtrics starting in 2022. the annual sample size varied, ranging between 11,178 in 2015 and 5,817 in 2023 (mn = 9,225.91). pip targets a representative, proportional sample across most missouri institutions of higher education each year (see wray et al., 2021 for more information). due to limited resources, recruitment efforts focused on initial recruitment of a random sample and not on ensuring that actual respondents were representative of the missouri college student population. however, demographics of the 2023 survey were similar to publicly available information on the population of missouri college students (u.s. department of education, 2023). based on aggregate data, respondents to the 2023 machb survey were 58.1% female, 41.8% male, 80% white, 8.6% black, 7.5% asian, and 6.1% hispanic. in comparison, respondents to the 2019 survey were 59% female, 40% male, 84% white, 9.9% black, 5.3% asian, and 4.6% hispanic. according to the integrated postsecondary education data system (ipeds) from the national center for education statistics (nces), in 2022, the student body of missouri institutions participating in the machb survey was 58.1% female and 41.9% male, 63.9% white, 9.7% black, 4.2% asian, and 5.9% hispanic (u.s. department of education, 2023). while this suggests that the machb may have oversampled white students, note that the ipeds reports race and ethnicity as mutually exclusive, such that students who were https://osf.io/97gb2 cannabis, a publication of the research society on marijuana 36 considered hispanic were not considered white or other races, and included categories such as “two or more races” and “u.s. non-resident.” descriptive analyses used data from the 20122013 school year through the 2022-2023 school year. primary analyses regarding intentions to use cannabis following legalization used 20222023 school year data. data collection extended from february 1, 2023 to march 18, 2023, while the legislation took effect on december 8th, 2022, the first legal cannabis sale occurred on february 3, 2023 (ballentine, 2023).1 we used all available data (total n = 5,817; n = 2,716 cannabis naïve; n = 1,591 with prior use), excluding participants (n = 1,399; prior cannabis use = 346; cannabis naïve = 460; no data on any cannabis use = 593) that elected not to respond to our outcome variables and graduate students (n = 101), due to inconsistent inclusion and our focus on undergraduate students. cannabis naïve participants were majority white (78.3%), 21.7% were students of color, majority female (61.0%), 36.3% male, and 4.3 gender minorities, with a mean age of 20.17 (sd = 1.85). cannabis using participants were majority white (80.7%), 19.3% were students of color, majority female (58.2%), 35.3% male, and 9.6 gender minorities, with a mean age of 20.69 (sd = 1.99). intention to change cannabis consumption. participants who had ever used cannabis responded to a single item about their intention to change their cannabis use following legalization. five response options were provided: “much less”, “a little less”, “the same amount”, “a little more”, and “much more”. independent variables binge drinking. participants were asked, “think over the past 30 days. how many times have you binge drank?” and defined binge drinking as: “male 5 or more drinks within a 2-hour period; female 4 or more drinks within a 2-hour period.” participants responded with a number between 0 and 30. due to infrequent endorsement, responses were dichotomized to either no binge drinking (0) or any binge drinking (1) in the previous 30 days. alcohol use frequency. participants were asked “please indicate the number of days you drank in the past 30 days.” response options were “i did not drink in the past 30 days” (i.e., 0 days), each integer between 1 and 20 days, or “20 or more days,” and this was treated continuously. cannabis use frequency. participants were asked, “how many days have you used cannabis (any type) in the past 30 days?” response options were, “i did not use cannabis in the past 30 days,” each integer between 1 and 20 days, and “more than 20,” and this was treated continuously. descriptive cannabis use norms. participants were asked “how often do you think the typical student on your campus uses marijuana/cannabis?” response options were, “never,” “1-6 times a year,” “1-2 times a month,” “12 times a week,” “3 or more times a week,” or “daily.” cannabis use motives. participants were asked, “which of the following are contributing factors to your decision to use marijuana/cannabis?” and checked all options, a total of 16 potential options, that applied (see supplemental table 3). although people may use cannabis for different reasons, we were primarily interested in the overall strength of participants’ motivation to use cannabis. for this reason, we calculated a sum of the number of endorsed motives (ɑ = .68). the 16 items were derived from previously validated measures and the factors of cannabis use motives identified in their research. these factors are enhancement, conformity, expansion, coping, and social (zvolensky et al., 2007), and medical, relatively low risk, boredom, and experimentation (lee et al., 2009). cannabis-related consequences. participants were asked, “how often in the past 12 months have you experienced the following as a result of using marijuana/cannabis?” eight items included were: “been arrested for dui/dwi,” “felt in a fog, sluggish, tired, or dazed the morning after using,” “felt very sick to my stomach or thrown up,” “performed poorly on a test or assignment,” “missed class,” “attended class after using marijuana/cannabis,” “had a blackout after using marijuana/cannabis heavily (i.e. could not remember hours at a time),” and “had trouble sleeping.” response options ranged from 0 = 0 times, 1 = 1 times, 2 = 2 times, 3 = 3-5 times, 4 = more than 5 times. responses were summed to create a count variable representing total 1over the period of data collection, only existing facilities licensed to sell cannabis for medical reasons were allowed to sell recreational cannabis and could only do so after converting their license. cannabis use intentions during legalization 37 consequences experienced (ɑ = .67). items were derived from the core institute’s survey on college student alcohol and drug use (presley et al., 1994). methods of cannabis use. participants were asked, “when you have used marijuana/cannabis in the past 12 months, how often have you used in the following ways?” methods included smoked, edible, vaporized, and concentrate. response options ranged from 0 = “i did not use in the past year,” to 5 = “daily.” scores for each item were dichotomized to represent any usage of that method, then summed to create a count variable representing the number of different ways in which an individual consumed cannabis. reasons not to use. participants that reported no previous cannabis use were asked, “which of the following are reasons that you choose not to use cannabis?” given our focus on legalization, we only examined the option, “because it is against the law/policy.” responses were dichotomous, indicating endorsement (1) or non-endorsement (0). flourishing. the flourishing scale (diener et al., 2010) is an 8-item measure indicating selfperceived fulfillment (e.g., “my social relationships are supportive and rewarding”). responses were measured on a 7-point likert scale ranging from “strongly disagree” to “strongly agree” and summed to create a minimum score of 8 and maximum of 56 (ɑ = .92). past year mental health disorders. participants were asked to check all mental health disorders they had experienced in the previous 12 months that had been diagnosed by a mental health or medical professional. diagnoses with an endorsement rate greater than 5% were included in analyses as dichotomous variables, indicating diagnosis (1) or non-diagnosis (0). included disorders were depression disorders, eating disorders, sleeping disorders, post-traumatic stress disorder (ptsd), anxiety disorders, and panic disorders. age. age was assessed with response options of integers from 18 through 24 and a final category of 25 or older. two variables were created: one, a dichotomous variable representing below legal age (i.e., 20 or younger) or being of legal age (i.e., 21 or older), and a second continuous age variable. year in school. response options ranged from 1 (freshman) to 5 (five or more years, i.e., super senior). sexual orientation. sexual orientation was assessed with nine response options: bisexual/biromantic, gay, lesbian, straight/heterosexual, queer, questioning, asexual/aromantic, pansexual, and other (please specify). we generated dichotomous variables based on response rates and related identities: gay and lesbian; bisexual; queer (queer, questioning, asexual/aromantic, or pansexual); and straight/heterosexual. gender. participants could check all that applied of five response options: woman, man, transgender, genderqueer/non-conforming (e.g., genderfluid, third-gender, agender), and selfidentify. due to limited endorsement of gender minority identities, we created dummy-coded dichotomous variables for: women, men, and gender minority (e.g., transgender, genderqueer). race and ethnicity. due to the university’s ethics board’s constraints, we were only provided with whether a student identified as a person of color (1) or white (0). extracurricular activities. students were asked, “in which of these campus activities or organizations are you currently involved? (check all that apply).” greek-life affiliation and sports participation were coded as dichotomous variables, indicating involvement (1) or non-involvement (0). data analysis descriptive statistics were calculated using ibm spss satistics (version 28.0), all analyses were conducted in rstudio 4.2.2 (r core team, 2022). multilevel models accounted for the nested structure of the data (i.e., students within schools). we used multilevel logistic models to predict intentions to initiate cannabis use using the "lme4" package (bates et al., 2015) and multilevel ordinal models to predict intentions to change consumption using the "ordinal" package (christensen, 2023). we estimated two separate models for each outcome, one examining our primary hypotheses and one examining our secondary hypotheses. in the multilevel logistic models estimating effects on intention to initiate cannabis the primary predictors were: greater perceived descriptive norms of cannabis use, endorsing binge drinking status, greater alcohol use frequency in the past 30 days, and legal age status (i.e., 21 or older). the secondary predictors were endorsing, “because it is against the cannabis, a publication of the research society on marijuana 38 law/policy” as a reason for not using cannabis, score on the flourishing scale, mental health diagnoses, age, gender, race, sexual orientation, greek life affiliation, and sports participation. in the multilevel ordinal model estimating effects on intention to change cannabis use, the primary predictors were greater frequency of cannabis use in the past 30 days, greater number of cannabis use motives endorsed, greater perceived descriptive norms of cannabis use, endorsing binge drinking status, greater alcohol frequency in the past 30 days, and cannabis related consequences. the secondary predictors were age of first cannabis use, methods of cannabis use, score on the flourishing scale, mental health diagnoses, age, gender, race, sexual orientation, greek life affiliation, and sports participation. in primary models, we considered p ≤ .05 significant. given less available evidence supporting secondary hypotheses, we considered p ≤ .01 significant in secondary models to avoid type 1 errors. models were estimated using restricted maximum likelihood (reml). to examine the possible impact of missing data, models were repeated using full information maximum likelihood estimation in mplus 8.7 (muthén & muthén, 1998-2023). as results did not meaningfully differ, we present findings from reml models. parameter estimates were exponentiated to calculate adjusted odds ratios (aor). intraclass correlations (iccs; i.e., a ratio of betweenand within-school variance) were low across each model (icc = .01-.05), indicating minimal variance between schools. nevertheless, we estimated random intercepts and slopes, as research indicates that iccs as low as .01 can increase type 1 error in nested data if nesting is not accounted for (musca et al., 2011). for all models, we retained only significant random slopes. this led to the inclusion of random slopes in the secondary model predicting intention to increase use for gender identity, sexual orientation, race, and extracurricular participation. in all other models, results did not differ based on random slopes inclusion. results descriptive statistics (trends between 20132023) to contextualize results for intentions to use cannabis following legalization, we present overall trends in cannabis use in the machb data going back to 2013. past-year cannabis use by missouri college students increased from 22.9% of students in 2013 to 34.5% in 2023 (figure 1). cannabis use prevalence increased most between 2016 and 2017 (δ = 5.2%) and between 2022 and 2023 (δ = 6.7%). perceived descriptive norms generally increased from 2013-2023 (supplemental table 4). data on the co-use of other substances with cannabis was collected beginning in 2020 (supplemental table 5). the most common substance that students reported co-using with cannabis was alcohol (63.8% endorsed). figure 1. past-year cannabis use prevalence in missouri college students from 2013 to 2023 note. important dates in missouri cannabis legal policy are presented as red dashed vertical lines. cannabis use intentions during legalization 39 descriptive statistics (year 2023) about one-third of the sample (33.4%, n = 1,591) endorsed past-year cannabis use, of which, 5.3% reported near daily use (n = 251). past-year cannabis use frequencies were largely similar across demographic groups, although gender minority (e.g., 10.6%, n = 30 using daily), compared to cisgender (e.g., 4.8-5.5%, n = 231 using daily), and students over 21 (e.g., 7.3%, n = 143 using daily), compared to underage (e.g., 3.8%, n = 143 using daily) appeared to use more frequently (supplemental table 1). among people who endorsed past-year cannabis use, about a third (30.8%, n = 485) did not use in the past month, about half (52.4% n = 826) used between 1-20 days (m = 5.56, sd = 5.55), and 16.8% (n = 265) used more than 20 days. supplemental table 2 shows past-month cannabis use frequencies by race, gender, and legal age status. the most endorsed cannabis motives were to relax (78.1%; n = 1,229) and to have fun with friends (59.7%; n = 939; supplemental table 3). among individuals who did not use cannabis, 9.9% (n = 269) endorsed intending to try cannabis following legalization, while 90.1% (n = 2,447) endorsed no intent. intent frequency was similar across demographic groups (table 1), though a higher proportion of gender minority students (27%, n = 31), when compared to cisgender, reported intent to initiate use table 1. endorsed intentions to initiate or change cannabis use following legalization intention to initiate cannabis use n (%) intention to change cannabis use n (%) yes no much less a little less the same amount a little more much more total 269 (9.9) 2,447 (90.1) 75 (5.0) 51 (3.4) 1,042 (69.6) 273 (18.2) 57 (3.8) race student of color 54 (9.3) 529 (90.7) 13 (4.6) 11 (3.9) 197 (70.1) 48 (17.1) 12 (4.3) not a student of color 212 (10.1) 1,896 (89.9) 60 (5.0) 39 (3.2) 842 (69.6) 224 (18.5) 45 (3.7) gender male 99 (10.1) 882 (89.9) 23 (4.4) 20 (3.8) 371 (70.9) 85 (16.3) 24 (4.6) female 151 (9.2) 1,497 (90.8) 47 (5.4) 25 (2.9) 604 (69.6) 163 (18.8) 29 (3.3) gender minority 31 (27.0) 84 (73.0) 8 (5.6) 7 (4.9) 90 (62.5) 34 (23.6) 5 (3.5) legal age status under 21 180 (10.1) 1,606 (89.9) 42 (5.4) 24 (3.1 542 (69.3) 148 (8.9) 26 (3.3) over 21 89 (9.6) 841 (90.4) 33 (4.6) 27 (3.8) 500 (69.8) 125 (17.5) 31 (4.3) note. gender categories (female, male, gender minority) were coded as binary variables (yes/no) for analyses, and participants who endorsed multiple categories could be included in both (e.g., female and gender minority). cannabis, a publication of the research society on marijuana 40 among those who previously used cannabis, the majority (69.6%; n = 1,042) intended to continue using the same amount, 8.4% (n = 126) intended to use less, and 22% (n = 330) intended to use more in response to legalization. in contrast, students were also asked about their general intentions to change cannabis use. of those with past-year cannabis use, 30.5% (n = 460) reported that they were either currently trying to use less cannabis (16.8%; n = 253), were ready to try using less cannabis (2.8%; n=43), or were thinking about trying to use less cannabis (10.8%; n = 164). the remainder, 69.5% (n = 1,050), reported that they saw no need to change their cannabis use. the number of participants reporting no need to change their cannabis use has increased from 59% in 2019, 61% in 2020, 64% in 2021, and 66% in 2022, to the present 69.6%. regression analyses intention to initiate cannabis use. in the primary model (n = 2,716; table 2), none of the predictors (perceived cannabis norms, binge drinking, alcohol use frequency, legal age) were associated with the intention to initiate cannabis use. in the secondary model (table 3), being gay or lesbian (aor = 3.03; ci = [1.72, 5.34]), bisexual (aor = 3.52; ci = [2.41, 5.14]), or queer (aor = 2.51; ci=[1.71, 3.69]) were associated with increased odds of intended initiation relative to being straight/heterosexual. greater flourishing (aor = 0.98; ci = [0.96, 0.99]) was associated with decreased odds of intended initiation. other predictors were not significant. table 2. logistic multilevel regression showing the associations between primary predictors and the intention to initiate cannabis use following legalization intention to initiate cannabis use m (sd) n (%) odds ratios ci p cannabis descriptive norms 2.02 (1.33) -1.07 0.96 – 1.18 .237 binge drinking -373 (14.3)a 1.34 0.89 – 2.03 .163 alcohol frequency 1.43 (2.93) -1.04 0.99 – 1.09 .149 legal age status -930 (34.2) b 1.08 0.81 – 1.45 .587 note: ci = 95% confidence intervals; a n (%) of those meeting criteria for binge drinking; b n (%) of those meeting legal age status. table 3. logistic multilevel regression showing the associations between secondary predictors and the intention to initiate cannabis use following legalization intention to initiate cannabis use m (sd) n (%) odds ratios ci p cannabis’ legal status -745 (28.1)a 0.82 0.59 – 1.15 .253 flourishing 44.73 (9.13) -0.98 0.96 – 0.99 .006 depression disorders -375 (14.2) 0.94 0.60 – 1.48 .794 eating disorders -87 (3.3) 1.31 0.64 – 2.69 .457 sleep disorders -117 (4.4) 0.78 0.38 – 1.60 .501 anxiety disorders -656 (24.9) 1.22 0.83 – 1.80 .300 cannabis use intentions during legalization 41 ptsd -98 (3.7) 1.07 0.53 – 2.17 .857 panic disorders -113 (4.3) 0.78 0.39 – 1.54 .474 age 20.17 (1.85) -1.03 0.95 – 1.12 .432 female -1,648 (61.0) 0.74 0.54 – 1.01 .060 gender minority -115 (4.3) 0.89 0.50 – 1.58 .685 student of color -583 (21.7) 0.94 0.65 – 1.35 .735 lesbian or gay -91 (3.4) 3.03 1.72 – 5.34 <.001 bisexual -223 (8.4) 3.52 2.41 – 5.14 <.001 queer -282 (10.6) 2.51 1.71 – 3.69 <.001 greek affiliation -276 (10.2) 1.44 0.88 – 2.38 .151 athletic involvement -541 (20.3) 0.89 0.60 – 1.31 .546 note. ci = 95% confidence intervals; p-values of less than .01 are considered significant to account for the more exploratory nature of the secondary analyses; a n (%) are not using cannabis due to its legal status. intention to increase cannabis use. in the primary model (n = 1,591; table 4), endorsing more cannabis motives was associated with greater odds of intending to increase cannabis use (aor = 1.13; ci = [1.08, 1.19]), and endorsing more consequences was associated with lower odds of intending to increase cannabis use (aor = 0.91; ci = [0.89, 0.94]). in the secondary model (table 5), age of first cannabis use (aor = 1.09; ci = [1.03, 1.15]) and being gay or lesbian (aor = 2.19; ci = [1.27, 3.76]) were associated with greater odds of intending to increase cannabis use. other predictors were not significant. table 4. ordinal multilevel regression showing the associations between primary predictors and the intention to increase cannabis use following legalization intention to increase cannabis use m (sd) n (%) odds ratios ci p binge drinking -829 (52.1)a 0.93 0.71 – 1.21 .575 cannabis descriptive norms 2.49 (1.16) -0.98 0.89 – 1.09 .732 alcohol frequency 4.83 (4.61) -1.01 0.98 – 1.04 .576 cannabis frequency 6.45 (8.06) -0.99 0.98 – 1.01 .385 cannabis motives 5.13 (2.89) -1.13 1.08 – 1.19 <.001 cannabis consequences 2.73 (4.36) -0.91 0.89 – 0.94 <.001 note. ci = 95% confidence intervals; a n (%) of those meeting criteria for binge drinking. cannabis, a publication of the research society on marijuana 42 table 5. ordinal multilevel regression showing the associations between secondary predictors and the intention to increase cannabis use following legalization intention to increase cannabis use m (sd) n (%) odds ratios ci p age of first cannabis use 17.61 (2.29) -1.09 1.03 – 1.15 .003 cannabis use methods 2.66 (1.14) -1.00 0.89 – 1.12 .988 depression disorders -453 (29.0) 0.97 0.70 – 1.34 .856 eating disorders -118 (7.5) 0.92 0.58 – 1.46 .721 sleep disorders -134 (8.6) 0.82 0.52 – 1.28 .376 anxiety disorders -629 (40.2) 1.29 0.96 – 1.73 .091 ptsd -136 (8.7) 0.67 0.43 – 1.05 .083 panic disorders -145 (9.3) 1.00 0.64 – 1.55 .996 flourishing 43.1 (9.15) -1.00 0.99 – 1.02 .767 age 20.69 (1.99) -0.99 0.93 – 1.06 .769 female -920 (58.2) 0.80 0.56 – 1.14 .217 gender minority -152 (9.6) 0.64 0.37 – 1.11 .111 student of color -305 (19.3) 0.96 0.68 – 1.37 .825 lesbian or gay -120 (7.6) 2.19 1.27 – 3.76 .005 bisexual -331 (21.1) 1.47 0.96 – 2.23 .074 queer -335 (21.3) 1.68 1.13 – 2.51 .011 greek affiliation -312 (19.6) 1.22 0.84 – 1.79 .298 athletic involvement -306 (19.5) 0.99 0.70 – 1.42 .976 note. ci = 95% confidence intervals; p-values of less than .01 are considered significant to account for the more exploratory nature of the secondary analyses. discussion the present study extends research on factors associated with intentions to initiate or increase cannabis use following recreational legalization. descriptive findings indicate that cannabis use prevalence among a representative sample of missouri college students increased 66.23% from 2013 to 2023 (figure 1). nearly 10% of cannabis naïve students reported intentions to initiate use following legalization, particularly students who identified as sexual minorities or were lower in flourishing. additionally, 22% of students with prior cannabis use reported intending to increase their use. greater intentions to increase use were reported among those with more cannabis use motives, fewer cannabis consequences, older age of first cannabis use, and a gay or lesbian sexual orientation. regression results indicated that sexual minority students were significantly more likely to intend to initiate use following legalization relative to straight students, and gay and lesbian and queer students were more likely than other students to intend to increase their cannabis use following legalization. while some previous cannabis use intentions during legalization 43 research has indicated that young adults’ actual changes in cannabis use are not associated with sexual orientation (bae & kerr, 2020) and that the intentions to use of sexual minority young adults are similar to those of heterosexual individuals (cui et al., 2023), others have indicated that some sexual minority identities use cannabis more frequently in recreational states (parnes et al., 2019). thus, this study adds to a somewhat mixed literature on the impact of legalization amongst sexual minority students. the regression results for sexual minority status may potentially relate to the fact that our sample was drawn from missouri, a state with historically lower support of and greater discrimination toward sexual minorities (henrion, 2016; mcelroy et al., 2015; watson et al., 2021). experiencing greater sexual minorityrelated stress (e.g., stigma, discrimination) is associated with cannabis and other substance use (goldbach et al., 2015; mereish et al., 2023), but sexual minorities living in less supportive places may also be less likely to engage in illicit activities due to disproportionate police contact (rice et al., 2021; schwartz et al., 2022). thus, by reducing the possibility of legal consequences, legalization in a state like missouri may result in a greater increase in intentions amongst sexual minority students than in other states. if accurate, the current findings may have implications for other states hesitant to legalize cannabis, as many of these states have lower support of sexual minority status (e.g., as indicated by lower support for gay marriage; spetz et al., 2019). particularly given the large effect sizes (aor of 1.68 – 3.03), indicating not just a significant effect but an increased likelihood as much as three times greater than the usual odds, it is important for future research to better explicate the relationship between sexual and gender minority status with changes in cannabis use, and the more distal effects that changes in use have for these populations. further, as more states legalize, intervention and prevention efforts in these states should ensure that they tailor content for sexual minority populations (e.g., addressing sexual minority-related discrimination and stress). cannabis motives are established predictors of greater frequency and quantity of cannabis consumption (e.g., votaw & witkiewitz, 2021). our findings from regression models extend prior research, suggesting that having more reasons for using cannabis, regardless of the specific motives, is associated with greater intentions to increase use following legalization. legalization-related increased acceptability and availability (wallace et al., 2020) may ultimately promote increased use among individuals with more motivations to use cannabis. although we focused on the overall number of motives endorsed, future research should differentiate the associations of unique motives and intentions to escalate use, particularly given prior research showing some motives (e.g., coping motives) are more strongly linked to consequences (espinosa et al., 2023). motivations for use can be modified and, as legalization continues, it may be particularly valuable for intervention efforts to focus on helping people find alternative positive activities to meet their needs (correia et al., 2010). given the effect size for cannabis motives (aor = 1.13) indicating an increased likelihood of 13% relative to usual odds, interventions focused on cannabis motives may be advantaged by expanding to target other mechanisms in conjunction to motives. findings from regression models indicate that participants who endorsed more negative consequences were more likely to report planning to reduce their use. this potentially suggests that students who reported more consequences had some awareness that they might benefit from reducing their use, which may have had a particular link to legalization. this is a potentially encouraging finding for cud prevention efforts, as it indicates that undergraduates experiencing greater harms from cannabis, which may reflect increased risk for cud, do not see legalization as carte blanche to increase use. even though legalization reduces the risk of certain consequences (e.g., misdemeanor charges for possession), others persist (e.g., missing class). additionally, schools may continue to enforce policies against cannabis use on campus. nevertheless, with the reduction in legal consequences, legalization may offer opportunities for prevention efforts to focus conversations around more personal experiences of both positives and negatives of use, which may ultimately be more effective than the specter of legal consequences (urbanoski, 2010). descriptively, participants who reported an intention to change their cannabis use were largely more likely to intend to increase their use cannabis, a publication of the research society on marijuana 44 compared to decrease (22% vs 8.4%). however, participants who intended to increase their use largely indicated they only intended to increase their use “a little” compared to “a lot” (18.2% vs 3.8%), while those who intended to decrease their use generally intended to use “much less” compared to “a little less” (5.0% vs 3.4%). given the response scale, understanding exactly what these categories translate to in daily life and for each participant is unclear. however, nearly three times the number of people intended to increase their consumption, an additional 13.6%, which matches the rate of cannabis naïve people intending to initiate cannabis use. future research might be well suited to explore profiles of cannabis use following legalization to better understand which factors explain different approaches to use change. in contrast to previous research, regression results suggest that cannabis use frequency was not associated with intending to increase use (cohn et al., 2017; cui et al., 2023; kerr et al., 2017; wallace et al., 2020). past research has had mixed findings on changes in use frequency following legalization (bae & kerr, 2020; cohn et al., 2017; kerr, bae, phibbs, et al., 2018; kerr et al., 2017; kerr, ye, et al., 2018; parnes, smith, et al., 2018; sandhu et al., 2019), and many students in our study intended to continue using cannabis at the same frequency. combined, our findings suggest that many students who use cannabis may already be using at their desired use frequency, independent of legalization. older age of first cannabis use was associated with intentions to increase use in regression models. on the surface, this might seem to contradict findings that earlier first use is associated with more frequent use, consequences, and cud (han & palamar, 2018; millar et al., 2021; richmond-rakerd et al., 2017). perhaps people who started at an older age are still considering their preferred use frequency, whereas people who started younger may have more experience and become more set in their use patterns. in contrast, being of legal age was a nonsignificant predictor of cannabis use intentions. paired with our findings also indicating that endorsing legality as a reason to not use was not associated with an increased likelihood of intending to initiate cannabis use, it is possible that those who have not begun cannabis use by 21 have other reasons for that choice. contrary to hypotheses, although consistent with cohn et al., (2017), binge drinking and alcohol use frequency were unrelated to intentions around cannabis use. though alcoholcannabis co-use is common and associated with problems and consequences (subbaraman & kerr, 2015), the legal status of cannabis may not be a major factor for why some people drink alcohol but do not use cannabis. more research is needed to understand what leads some young adults to use both substances versus only one. perceived cannabis descriptive norms were also not associated with intentions, diverging from the findings of cui et al. (2023). this may, in part, be due to the fact that we only had a single item gauging perceptions of typical student cannabis use. more proximal reference groups (e.g., friend rather than typical student) may have been more informative (napper et al., 2016). a more finegrained assessment might help elucidate associations between norms and cannabis intentions. additionally, not using cannabis due to its illegal status was not a significant predictor of initiating cannabis use following legalization. it’s possible that this is a result of non-users having a constellation of reasons, rather than a singular reason, for avoiding use. for example, they may also be worried about negative consequences on their professional or academic work. thus, even with legalization imminent, they may have no plans to initiate cannabis use. strengths and limitations missouri is part of a region historically hesitant toward cannabis legalization (spetz et al., 2019) and, thus, the results, from a large representative student sample recruited from the breadth of missouri institutions of higher education, may hold important insights for the future as legalization continues. data collection was also timely, occurring immediately preceding and concurrent to the first recreational cannabis sales in missouri and prior to wide availability of recreational cannabis. there were also limitations. first, our data are cross-sectional. while this limits the ability to determine direction of effect for some variables (e.g., cannabis use motives), for others, such as sexual orientation, this limitation is of lesser importance. second, the machb survey was initially designed to inform higher education cannabis use intentions during legalization 45 policy, and not for research purposes. however, available data suggest that the obtained sample was representative in terms of race, ethnicity, and sex when compared to the population of missouri college students. third, due to limits set by the irb, specific racial and ethnic demographic information was unavailable (except in aggregate), and we were unable to assess differences across these groups, as was preregistered. as noted by spetz and colleagues (2019), there are clear racial and ethnic differences between states with earlier legalization and those with later legalization, future research should examine this more thoroughly. while the political climate of missouri as a largely conservative state with two mid-major democratic leaning cities makes these findings more generalizable to similar states, they may also be less generalizable to states or countries with dissimilar political environments. due to limited endorsement rates, we collapsed pansexual, asexual, queer, and questioning identities into one category (“queer”), despite known differences in substance use among these identities (scroggs et al., 2023). fourth, the survey design artificially constrained age above 24 to “25 and older,” and cannabis and alcohol use frequency greater than 19 days to “20 or more days.” these ceilings may have limited our ability to detect differences at the higher end of these scales, which limits generalizability for those groups. fifth, while the items that make up the cannabis motives and consequences measures in the present study are derived from scales that have undergone validation (e.g., lee et al., 2009), as constructed, the variables used in our analyses have not undergone psychometric testing and validation. our purpose, rather than to measure a shared construct, was to create an inventory of possible reasons one might use cannabis. given their reliability in the current sample was somewhat low, if one wanted to draw conclusions about constellations of motives, further research would require either validated measures to assess these constructs or a focus on the psychometric properties of the included items. sixth, given the cross-sectional nature of the data and the timing of data collection, we cannot determine the causality of legalization in behavior change. likewise, it is possible that participants’ answers about changing their cannabis use may have reflected reasons for behavior change beyond specifically those related to legalization. for example, it is developmentally normative for a portion of students to initiate or increase cannabis use during this time regardless of reason. it is possible that some participants reported their general intentions to use and not those specifically tied to legalization. reducing, but not removing, this concern, an additional item included in the survey asked about general intention to change cannabis use among those who reported cannabis use. among cannabis-using participants, 30.5% of participants reported either considering, planning, or having reduced their cannabis use, only 8.4% of the sample reported planning to use cannabis less due to legalization. given the distinct difference in response rate, this suggests that participants reported on their legalizationspecific intentions. nevertheless, we cannot rule out the possibility that some participants, especially those who were cannabis-naïve, may have reported on their general intentions to use cannabis. additionally, while intentions are a critical component of behavior and behavior change, we did not assess actual changes in cannabis use following legalization. future research will be needed to fully explicate the relationship of the variables in this study with actual changes in cannabis use for missouri college students. finally, there was a large spike in cannabis prevalence in 2023. while recreational cannabis was not widely available during the 2023 survey, it is possible that the anticipation of legalization prompted an increase in cannabis use or willingness to disclose use. however, this large shift is also congruent with the general trend of increasing cannabis use (hasin, 2018; samsha, 2023). further, a sizable minority of respondents reported intentions to initiate use or increase their use, suggesting that we captured a meaningful percentage of students who were contemplating, but had not yet, changed their cannabis use in response to legalization. conclusion with the legalization of recreational cannabis, a meaningful percentage of missouri college students reported an interest in increasing or initiating cannabis use. multiple theory-driven factors were associated with either intending to initiate or increase cannabis use in the wake of cannabis, a publication of the research society on marijuana 46 legalization. with expanding legalization, future research should seek to better understand how changing normative perceptions shift cannabis expectancies and motivations for use. given that sexual orientation was associated with cannabis intentions, future work should prioritize understanding mechanisms driving the observed disparities. while our study focused on cannabis use intentions, future research is necessary to 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(2007). marijuana use motives: a confirmatory test and evaluation among young adult marijuana users. addictive behaviors, 32(12), 3122–3130. https://doi.org/10.1016/j.addbeh.2007.06.010 funding and acknowledgements: the national institutes of health supported the authors’ efforts (f32da054718, k99da057994, pi: parnes; k23aa029729, pi: carpenter). the authors do not have any conflicts of interest to declare. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: mcnamara, i. a., parnes, j. e., stetsiv, k., nance, m., sauer, j., greenwood, k., masters, j. p., & carpenter, r. w. (2025). missouri college students’ intentions towards initiating or changing cannabis use in a shifting legal landscape. cannabis, 8(2), 33 50. https://doi.org/10.26828/cannabis/2025/000286 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/ research article 89 xved abstract objective: cannabis use is common among adolescents. limited research has examined how specific cannabis use behaviors may differentially increase cannabis use disorder (cud) risk. method: data were from two waves of a prospective cohort of southern california adolescents who used cannabis in the past six months (n = 420; fall 2022, spring 2023). multivariable logistic regression models were used to examine the association of each cannabis use behavior at baseline (number of modes of cannabis administration used, product type used first and most often, cannabinoid formulation used most often, past 30-day frequency, quantity) with probable cud at a six-month follow-up (measured using the cannabis abuse screening test), adjusting for sociodemographic factors, other substance use, and probable cud at baseline. results: most adolescents (69.8%) used >1 mode of cannabis in the past six-months; concentrates (vaped or dabbed) were the product type used most often (37.5%). greater odds of cud were observed for each additional cannabis product used in the past 6 months (vs. only one; adjusted odds ratio [aor] range = 2.83-4.13; ps < .05), and for frequent past 30-day cannabis use (10+ days/month vs. 1-2 days/month; aor = 2.87, 95%ci = [1.31,6.27]). no other cannabis behaviors or characteristics were associated with cud in adjusted models. conclusions: frequent past-month cannabis use and using multiple modes of administration were predictors of probable cud. in addition to monitoring the overall presence of adolescent cannabis use, these results demonstrate the importance of raising awareness about specific use behaviors associated with cud risk among youth, particularly in regions with well-developed cannabis markets. key words: = cannabis; adolescents; cannabis use disorder; youth; cannabis use cannabis use is highly prevalent among adolescents in the united states (u.s.), with 29% of u.s. 12th graders reporting past-year use in 2023, and 12% of all 12th graders reporting daily use for more than a month (miech et al., 2023). adolescent cannabis use is linked to various adverse health outcomes, including an increased risk of mental health disorders (onaemo et al., 2021), disruptions in working memory (schweinsburg et al., 2008) and brain claire a. walsh1,2, nikki jafarzadeh1,2, reid c. whaley1,2, dae hee han1,2, adam leventhal1,2, eric r. pedersen2,3, jessica barringtontrimis1,2, & alyssa f. harlow1,2 1department of population and public health sciences, university of southern california keck school of medicine 2institute for addiction science, university of southern california keck school of medicine 3university of southern california, keck school of medicine, department of psychiatry and behavioral sciences cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000323 volume 8, issue 3 cannabis products and use patterns associated with cannabis use disorder symptoms among youth in southern california corresponding author: jessica barrington-trimis, phd, university of southern california, 1845 n soto street los angeles, california 90032. email: jtrimis@usc.edu cannabis, a publication of the research society on marijuana 90 development (jacobus & tapert, 2014), and alterations in cognitive functioning that may have a greater impact compared to cannabis use during adulthood (quinn et al., 2008). individuals are also at a higher risk of developing cannabis use disorder (cud) when cannabis use is initiated during adolescence compared to adulthood (winters & lee, 2008). cud is characterized by problematic use of cannabis and can lead to clinically significant impairment, distress, or cooccurrence with mental health disorders like mood or anxiety disorders (hasin & walsh, 2020; gendy et al., 2023; onaemo et al., 2021; zaman et al., 2015). cud cases often become evident during youth and young adulthood (kosty et al., 2017). for example, among adolescents aged 12-17 who have ever used cannabis, the prevalence of pastyear cud was 16% in 2015-2017 pooled data (han et al., 2019). there is limited information on more recent trends among youth. following legalization of recreational cannabis for adults, the prevalence of cud increased from 2.2% to 2.7% among adolescents residing in states where recreational cannabis is legal (cerdá et al., 2020). yet, there is a dearth of data available to explain such increases. such data are critically needed to identify cannabis use behaviors and products that may increase the risk of cud among adolescents to inform interventions and potential regulation of cannabis products to protect youth. legalization of cannabis for adult use in multiple u.s. states has expanded the range of products available on the market, many of which appeal to youth (goodman et al., 2019; tan et al., 2022). although adolescents cannot purchase cannabis legally, the proliferation of cannabis commercialization may make access to novel products, such as vape devices, easier through informal channels or third-party purchasing. youth residing in states with adult-use cannabis legalization report that cannabis is more accessible post-legalization (harpin et al., 2018). despite these changes to the cannabis market, few studies have attempted to characterize use behaviors within adolescent populations, including frequency of use, number of administration methods, preferred products (including which product types are tried first and used most often), or quantities of cannabis used per use session. such data are needed to understand the impact of these factors on cud among youth. existing research indicates that certain cannabis use behaviors and product types may elevate the risk of problematic use and cud. greater frequency, quantity, and different product types have each been associated with adverse outcomes such as cud risk or psychological distress. prior studies suggest a possible dose-response relationship between cannabis use frequency and cud (leadbeater et al., 2019); however, much of the research regarding the effects of cannabis use frequency is outdated (chen et al., 1997) and not reflective of products currently on the market, many of which contain higher potency levels than in the past. cannabis vaping is also becoming more common as a route of administration among adolescents (keyes et al., 2022), yet research on its effects compared to other routes of administration is lacking. emerging evidence shows that among adolescents who use cannabis, those who vape tend to use cannabis more frequently than those who exclusively use other routes of administration (mitchell et al., 2024), and that cannabis vaping is associated with psychological distress (mattingly et al., 2024). however, the risk profile of using cannabis concentrates, including vapes or dabs, compared to other commonly used routes of administration (e.g., edibles or flower) remains unknown. in addition to product types, quantity may differentially contribute to cud risk; adolescents may be more sensitive to the effects of cannabis compared to adults, with smaller quantities leading to more pronounced acute cognitive effects (murray et al., 2022) and a higher likelihood of developing cannabis dependence compared to adults (chen et al., 1997), establishing dose-dependent impairments. however, little is known about how different cannabis use behaviors within adolescents, including frequency, types of products used, and average use quantities (e.g., joints or vape sessions per day), relate to cannabis-related risks, including cud. the current study assessed patterns of cannabis use among adolescents in southern california within the context of a highly developed, legal commercialized cannabis market for adults. we examined a wide range of cannabis use behaviors among a sample of youth reporting past 6-month cannabis use at baseline, including routes of administration, frequency of use, and quantity of use within a given use session. we cannabis & cud in youth 91 then estimated the association of cannabis use behaviors with the risk of probable cud six months later. we hypothesized that (1) higher past-month frequency and greater average quantities of cannabis use in the past month would be associated with greater odds of probable cud at follow-up, and (2) youth using cannabis through multiple modes of administration (vs one) or concentrate products as their most-used product type (vs edibles or flower) would demonstrate greater odds of cud at follow-up. methods participants data were from two waves of a prospective cohort study of southern california high school students. in the fall semesters of 2020 and 2021, the study recruited 9th grade students from eleven schools across five southern california counties (graduating class of 2024 and class of 2025). students completed self-administered, online surveys at school twice each academic year (once per semester) with questions on substance use and behavioral health. the current study used data from the fall 2022 survey as baseline (september – december 2022), and the spring 2023 survey as follow-up (january – may 2023) when participants were in 10th/11th grade. we chose to analyze these waves because they introduced more detailed questions about specific cannabis product types into the survey. the timing of the surveys was also such that cannabis had been legal and available for adult purchase for approximately 5 years (i.e., first licensed recreational dispensaries opened in california in january 2018). additional information pertaining to study recruitment procedures is detailed elsewhere (harlow et al., 2022). participants were eligible for the current study if they reported past 6-month cannabis use at baseline and had non-missing data on all baseline covariates and the outcome at follow-up. of the 3,831 participants who completed the baseline survey, 456 (12%) used cannabis during the past 6 months at baseline and had complete covariate data; of these, 420 (92%) had outcome data at follow-up and constituted the analytic sample. we used listwise deletion for missing data on specific cannabis use behaviors. prior studies indicate that listwise deletion performs similarly (and sometimes better) than multiple imputation in the case of covariate-adjusted regression models (pepinsky, 2018). measures predictors, cannabis use behaviors. in this survey, participants reported past 6-month and past 30-day frequency of the following four modes of use: smoking, edibles, vaping, or cbd or hemp products (i.e., modes of use not including thc). we assessed the number modes of use (coded 1-4), and past 30-day use frequency using the highest value across modes (0 days, 1-2 days, 3-9 days, 10+ days). among those who reported any past six-month cannabis use, participants reported the product they used first at the age of onset and product they used most often: blunts, joints/dry pipes, bongs, goods, drinks, dry flower vapes, vape pens, dabs, tinctures, topicals, capsules, or another products not listed. we created the following collapsed categories by product type: vaped concentrates [vape pens, dabbing], plant material/flower [blunts, joints/dry pipes, bongs, dry flower vapes], edibles [food or drinks], or other [tinctures, topicals, capsules, or another product not listed]. participants also reported cannabinoid formulation used most often in the past 30-days (mostly cbd, mostly thc, a mix of thc and cbd, or don’t know). finally, we assessed average use quantity in the past 30 days for smoking and vaping, with an item querying the average number of joints/bowls smoked per use day among those who used flower. among those who vaped, two items assessed the average number of times vape was used per day, and number of hits taken per use session. in our addition to our primary predictors of cannabis use behaviors, we included additional cannabis use variables for descriptive purposes, including from where youth obtained cannabis (select all that apply: self-grown, free from someone, buy from someone, buy from an inperson dispensary without a medical card, an online dispensary, a delivery service, buy from a dispensary with a real medical card, buy from a dispensary with a fake medical card, other), locations where they used cannabis (select all that apply: at home, on or near school campus including specific places on school campuses for those who used cannabis at school, friend/family cannabis, a publication of the research society on marijuana 92 member’s home, restaurants, outdoor public spaces, indoor public spaces, in a vehicle, at work, other), and who they primarily used cannabis with (mutually exclusive: alone, with friends, siblings/cousins, other family members, significant other, co-workers, other). outcome, cannabis use disorder (cud). probable cud was assessed using the cannabis abuse screening test (cast), a previously validated measure used to screen for cannabisrelated disorders (el malki et al., 2024; legleye, 2018). the cast was administered at baseline and follow-up to all participants who endorsed past 6-month use of any cannabis. the cast includes six questions related to problematic use in the past six months: using cannabis before midday, using cannabis while alone, having memory problems while using cannabis, having friends/family suggest that cannabis use should be cut down or stopped, unsuccessful attempts to quit or reduce use, and problems related to using cannabis (e.g., arguments or problems at school or work). each of the six questions are rated on a 5point scale capturing the frequency each problem was experienced in the past six months (0 = never, 1 = rarely, 2 = sometimes, 3 = quite often, 4 = very often). following clinical cutoff points identified in a prior reliability and validity study of the cast with dsm-iv cud in a sample of adolescents (legleye et al., 2011), the present study used a score of 4+ as a binary cutoff point representing probable past six-month cud. covariates. the following sociodemographic characteristics collected at baseline were included: gender identity (male or masculine, female or feminine, transgender or nonbinary, decline to answer), race (asian, white, multiracial, another race), ethnicity (hispanic, not hispanic), highest parental educational attainment ( < high school, high school, some college, college graduate, advanced degree, don’t know, decline to answer), perceived financial status (pretty well off, about average, financially struggling/in poverty, it varied), and sexuality (heterosexual, gay/lesbian, bisexual/pansexual, another identity, decline to answer). we also included any past 30-day use of nicotine products (including cigarettes, e-cigarettes, iqos, snus, pouches, gum/lozenges, cigars, or cigarillos) or alcohol (yes/no) at baseline as covariates. finally, in the adjusted model examining the number of cannabis modes used, we additionally adjusted for product type used most often (including a missing category), given the potential conceptual overlap between primary product type and use of multiple modes statistical analysis first, we generated descriptive statistics of covariates and all cannabis use variables. logistic regression was used to assess the association between cannabis use behaviors at baseline with probable cud at follow-up. we fit unadjusted models, followed by models adjusting for demographic characteristics, baseline probable cud status, and baseline past 30-day nicotine or alcohol use. unadjusted odds ratios (ors), adjusted odds ratios (aors), and 95% confidence intervals (cis) are reported. for variables with a natural order, we chose the lowest category as the reference group. when selecting the reference group for product type variables, we chose edibles based on our a-priori hypothesis that edibles would be associated with lower odds of probable cud as compared to concentrates or flower. similarly, for cannabinoid formulation used most often, we selected ‘mostly cbd’ as the reference group because we hypothesized it would also be associated with the lowest likelihood of probable cud. we conducted a sensitivity analysis examining associations between cannabis use behaviors at baseline and each of the six cast items, individually, at follow-up. all analyses were conducted using sas 9.4 software (sas institute inc., 2017). results sample characteristics among adolescents who reported cannabis use in the past 6-months at baseline, approximately half (51.4%) identified as female (table 1). most participants identified as hispanic (53.1%), or white (25.5%). most identified as heterosexual (58.8%), with an appreciable proportion identifying as bisexual or pansexual (24.8%). parental education was distributed across all categories, and a plurality expressed their perceived socioeconomic status as about average (46.4%). cannabis & cud in youth 93 table 1. sociodemographic characteristics and substance use behaviors of adolescents who used cannabis in the past six months at baseline (n = 420) characteristic n (col %) sociodemographic characteristics gender identity male or masculine 152 (36.2) female or feminine 216 (51.4) transgender or non-binarya 39 (9.3) prefer not to disclose 13 (3.1) race/ethnicityb american indian or alaska native 9 (2.1) asian 31 (7.4) black or african american 10 (2.4) native hawaiian or pacific islander 7 (1.7) white 107 (25.5) hispanic or latinx 223 (53.1) multi-racial 30 (7.1) another race 3 (0.7) sexual identity straight/heterosexual 247 (58.8) gay or lesbian 14 (3.3) bisexual or pansexual 104 (24.8) another sexual minorityc 44 (10.5) prefer not to disclose 11 (2.6) highest parental educational attainment <high school 43 (10.2) high school graduate 64 (15.2) some college 83 (19.8) college graduate 119 (28.3) advanced degree 93 (22.1) don’t know 11 (2.6) prefer not to disclose 7 (1.7) perceived socioeconomic status pretty well off financially 96 (22.9) about average 195 (46.4) financially struggling or in poverty 39 (9.3) it varied 90 (21.4) baseline substance use behaviors past 30-day cannabis use yes 282 (67.1) no 138 (32.9) probable cud yes 141 (33.6) no 279 (66.4) past 30-day nicotine use yes 170 (40.5) no 250 (59.5) past 30-day alcohol use yes 207 (49.3) no 213 (50.7) note. aincludes those who identified as transgender male, transgender female, or gender variant/non-binary, or another gender identity not listed. bin regression models, race was collapsed to the following categories: asian, white, multiracial, another race. cincludes those who identified as asexual, queer, questioning, or another sexual identity not listed. cannabis, a publication of the research society on marijuana 94 of our sample of adolescents reporting past 6month cannabis use at baseline, most (67.1%) also reported past 30-day cannabis use, and 33.6% screened positive for probable cud at baseline. a majority of the sample also reported past 30-day nicotine use (59.5%) or alcohol use (50.7%). cannabis use behaviors nearly one-third (30.2%) of participants used only one type of cannabis product in the past six months, while 24.8% used two, 20.5% used three, and 24.5% used all four types (smoking, vaping, edibles, and cbd/hemp; table 2). cannabis concentrates, including vape pens or dabs (vs flower, edibles, or other), were the product type most commonly used first (33.0%), and also the product type used most often in the past 6 months (37.5%). among those reporting use of edibles most often, nearly all used food-based products (e.g., gummies, baked goods), and within the concentrate group, almost all reported using vape pens rather than dab rigs (e-table 2). use of plant material/flower was more evenly distributed across blunts, joints, bongs, and vaporizers. probable cud prevalence at follow-up varied across specific product types, with the highest observed among bong users (46.7%) and the lowest among those using topicals or capsules (≤15%). table 2. association between cannabis behaviors at baseline and probable cud at follow-up (n = 420) characteristic baseline total (n, col %) probable cud at follow-up (n, row %) model results unadjusted adjusteda or (95% ci) aor (95% ci) 420 (100) 100 (23.8) among all past 6-month users at baseline: number of modes used in the past six monthsb, n = 420 1 mode 127 (30.2) 11 (8.7) ref ref 2 modes 104 (24.8) 24 (23.1) 3.16 (1.47, 6.82) 2.67 (1.13, 6.28) 3 modes 86 (20.5) 27 (31.4) 4.83 (2.24, 10.4) 3.41 (1.41, 8.27) 4 modes 103 (24.5) 38 (36.9) 6.17 (2.95, 12.9) 4.37 (1.82, 10.5) product type first used, n = 315 edibles 74 (23.5) 22 (29.7) ref ref plant material/flower 92 (29.2) 28 (30.4) 1.03 (0.53, 2.02) 0.98 (0.45, 2.11) concentrates 104 (33.0) 34 (32.7) 1.15 (0.60, 2.19) 0.94 (0.44, 1.98) other 57 (18.1) 9 (15.8) 0.44 (0.19, 1.06) 0.58 (0.22, 1.50) product type used most often in the past 6 months, n = 315 edibles 57 (18.1) 14 (24.6) ref ref plant material/flower 87 (27.6) 26 (29.9) 1.31 (0.61, 2.79) 0.65 (0.26, 1.63) concentrates 118 (37.5) 44 (37.3) 1.83 (0.90, 3.71) 1.07 (0.47, 2.46) other 53 (16.8) 8 (15.1) 0.55 (0.21, 1.43) 0.48 (0.16, 1.39) among past 30-day users at baseline cannabinoid formulation used most often in the past 30 days, n = 347 mostly cbd 38 (11.0) 8 (21.1) ref ref mostly thc 109 (31.4) 43 (39.5) 2.44 (1.02, 5.83) 1.62 (0.61, 4.28) a mix of thc and cbd 36 (10.4) 15 (41.7) 2.68 (0.96, 7.45) 1.74 (0.56, 5.43) don’t know 164 (47.3) 25 (15.2) 0.67 (0.28, 1.64) 0.67 (0.25, 1.77) cannabis & cud in youth 95 note. aadjusted for race/ethnicity, highest parental education, gender identity, sexuality, financial status, baseline cud, past 30-day nicotine use, past-30 day alcohol use. badditionally adjusted for product type used most often. most participants answered “don’t know” to the cannabinoid formulation they used most often in the past 30-days (47.3%), followed by mostly thc (31.4%). overall, stress/anxiety was the most commonly endorsed reason for using cannabis, followed by sleep (figure 1). endorsement of use for stress/anxiety or sleep was more common among adolescents using mostly thc or a mix of thc and cbd, compared to those using mostly cbd. in contrast, chronic pain was more frequently reported as a reason for use among those using mostly cbd or a thc/cbd mix than among those using mostly thc. figure 1. reasons for using cannabis by cannabinoid formulation used most often (n = 347)a note. aresponse options are not mutually exclusive past 30-day use frequency, n = 282 1-2 days 120 (42.6) 19 (15.8) ref ref 3-9 days 76 (27.0) 24 (31.6) 2.45 (1.23, 4.89) 1.45 (0.65, 3.21) 10+ days 86 (30.5) 43 (50.0) 5.32 (2.78, 10.2) 2.87 (1.31, 6.27) combustible cannabis: no. joints, blunts, bowls smoked per use day in the past 30 days, n = 213 1 per day 130 (61.0) 31 (23.8) ref ref 2 per day 37 (17.4) 17 (45.9) 2.72 (1.27, 5.82) 1.81 (0.75, 4.37) 3 per day 29 (13.6) 13 44.8) 2.60 (1.13, 5.98) 1.15 (0.44, 3.02) 4+ per day 17 (7.4) 6 (35.3) 1.74 (0.60, 5.10) 0.64 (0.18, 2.28) vaped thc: no. times vape device picked up per use day in the past 30 days, n = 191 1 per day 95 (49.7) 26 (27.4) ref ref 2 per day 35 (18.3) 12 (34.3) 1.39 (0.60, 3.18) 0.73 (0.28, 1.90) 3 per day 25 (13.1) 15 (60.0) 3.98 (1.59, 9.97) 2.01 (0.70, 5.77) 4+ per day 36 (18.8) 16 (44.4) 2.12 (0.96, 4.71) 1.10 (0.43, 2.79) vaped thc: no. puffs taken before putting device away in the past 30 days, n = 196 1 puff 48 (24.5) 10 (20.8) ref ref 2 puffs 54 (27.6) 22 (40.7) 2.61 (1.08, 6.32) 1.41 (0.50, 3.96) 3 puffs 60 (30.6) 26 (43.3) 2.91 (1.23, 6.89) 1.17 (0.42, 3.22) 4+ puffs 34 (17.3) 13 (38.2) 2.35 (0.88, 6.28) 0.91 (0.29, 2.89) 69.7 45.9 22.9 8.26 12.8 6.4 15.6 72.2 47.2 19.4 25 11.1 5.6 11.1 39.5 29 5.3 23.7 7.9 2.6 21.1 49.4 20.7 8.5 5.5 6.1 1.2 36.6 0 20 40 60 80 100 stress/anxiety sleep nausea or appetite chronic pain post-traumatic stress other physical problems none of these p e rc e n t (% ) mostly thc (n = 109) a mix of thc& cbd (n = 36) mostly cbd (n = 38) don't know (n = 164)mostly thc (n = 109) a mix of thc & cbd (n = 36) mostly cbd (n = 38) don’t know (n = 164) cannabis, a publication of the research society on marijuana 96 among those who used cannabis in the past 30 days, 42.6% reported infrequent past 30-day use (1-2 days), 27.0% moderate use (3-9 days), and 30.5% frequent use (10+ days). of those who smoked plant material/flower in the past 30 days, most participants (61.0%) smoked one joint/bowl per an average use day. of those who vaped in the past 30 days, half (49.7%) used their vape device once per use day on average, while another 50.3% used their vape device >1 time per day. additionally, a quarter (24.5%) of participants who vaped in the past 30 days took one hit per use session on average; the other three-quarters took multiple hits per use session. most youth obtained cannabis products for free from someone they know (51%), followed by purchasing from someone directly (27%) or purchasing from an online delivery service (5%) (figure 2). youth most commonly used cannabis either at home (40%) or at a friend or family members home (39%; figure 3a). among those who used cannabis at school (n = 71), restrooms (77%) or immediately outside of school buildings (41%) were the most common use locations (figure 3b). participants typically used cannabis either with friends (56%) or alone (27%; figure 4). figure 2. locations where youth obtain cannabisa (n = 420) note. aresponse options are not mutually exclusive. figures 3a & 3b. locations where youth use cannabisa (a) overall (n=420) and (b) among those who use on campus, specific on-campus location (n = 71) note. aresponse options are not mutually exclusive. 51 27.1 5.2 4.1 3.6 1.9 1.9 0.5 6.9 0 20 40 60 80 100 free from someone buy from someone buy from delivery service buy from inperson dispensary without medical card self-grown buy from online dispensary buy from dispensary with real medical card buy from dispensary with fake medical card other p e rc e n t (% ) source 40.2 39.1 23.8 16.9 15.2 6.4 4.5 1.4 5 0 20 40 60 80 100 at home friend or family member's home outdoor public spaces on or near school campus in a vehicle indoor public spaces restaurants or other food service locations at work other p e rc e n t (% ) 76.1 40.8 18.3 15.5 11.3 11.3 8.5 7 8.5 0 20 40 60 80 100 restrooms immediately outside of school buildings sports fields or courts locker room gymnasium classrooms hallways cafeteria or outdoor eating area other p e rc e n t (% ) cannabis & cud in youth 97 figure 4. who youth are usually with whenusing cannabis (n = 420; %) associations of cannabis use behaviors with cud using multiple modes of cannabis (vs. only one) was associated with increased odds of probable cud at follow-up, with greater odds observed with increasing numbers of modes of use (two modes [vs. one] aor = 2.67, 95% ci = [1.13, 6.28]; three modes [vs. one] aor = 3.41, 95% ci = [1.41, 8.27]; four modes [vs. one] aor = 4.37, 95% ci = [1.82, 10.5]; table 2). use of cannabis on 10 or more days (vs. 1-5 days) was also associated with greater odds of probable cud in adjusted models (aor = 2.87, 95% ci = [1.31, 6.27]). several other cannabis use behaviors were associated with higher odds of probable cud in unadjusted, but not adjusted models; these included using mostly thc (vs. mostly cbd), higher frequency of smoking combustible cannabis (e.g., 2–3 times per day), vaping thc three times per day (vs. once), and taking 2–3 puffs per use (vs. one puff). type of product used first was not significantly associated with probable cud at follow-up, nor was product type used most often. sensitivity analysis the associations between baseline cannabis behaviors and individual cast items at follow-up were largely non-significant, with a few exceptions (e-table 1). using multiple modes of cannabis in the past six months (vs. one) was associated with an increased likelihood of using cannabis while alone or experiencing problems with work/school from cannabis use. higher past 30-day use frequency (10+ days vs. 1-2) was associated with unsuccessful attempts to quit or reduce use and experiencing problems with friends/work/school due to use. . discussion alone 27% friends 56% siblings or cousins 9% other family members 2% significant other 2% co-workers 1% other 3% cannabis, a publication of the research society on marijuana 98 this study describes cannabis use behaviors among southern california youth, and the relationship between various cannabis use behaviors and the odds of probable cud six months later. our findings indicate that greater number of modes of use and frequent (10+ days) past 30-day use were associated with greater odds of probable cud, while other behaviors (type of product used, quantity of use) were not associated with later problematic use after accounting for baseline cud. using more than one mode of cannabis within the past six months at baseline was a strong predictor of probable cud at follow-up and of specific cud symptoms (using while alone and experiencing problems due to using cannabis), with increased risk with an increase in the number of modes of use. this finding is especially concerning, considering that over two thirds of youth who used cannabis within the past six months in this sample endorsed using multiple modes. because type of product used most often was not associated with probable cud, we conclude that use of multiple products concurrently may be a stronger indicator of cannabis-related consequences among youth than specific product preference. previous studies have similarly found that most adolescents who use cannabis engage in poly-product use (leal & moscrop-blake, 2024). while research on the health outcomes of poly-product use is still limited, such patterns may compound risks, as different modes of use carry unique consequences (russell et al., 2018; schauer et al., 2020). therefore, it is important to monitor these trends among adolescents and provide education on the distinct risks associated with each mode of use. consistent with our hypotheses, we observed an association between cannabis use frequency and the likelihood of developing probable cud. this association remained significant even after accounting for baseline cud, suggesting that frequency of cannabis use may play a unique role in increasing the risk of developing cannabisrelated problems beyond the influence of preexisting cud symptoms. these findings are in line with prior research identifying cannabis use frequency as having a strong association with mental health problems among adolescents (leadbeater et al., 2019; shanahan et al., 2021), and highlights that frequency may be an important marker or identifier for youth at increased risk of developing new cud. the associations of cannabis use frequency with cud are important, given that over a fifth of our sample who used any cannabis within the past six months reported frequent past-month cannabis use, and that daily cannabis use is rising among adolescents in the u.s (miech et al., 2023). additionally, because our findings on quantity were not significant after adjusting for baseline probable cud, this relationship might be largely explained by pre-existing cud symptoms. therefore, the observed associations for quantity in the unadjusted models may not reflect an effect of increased cannabis use on developing cud, but rather a continuation of already present symptoms. our finding that most-used product type was not associated with probable cud contrasts with our hypothesis that concentrate use would be associated with a higher risk of probable cud compared to other product types. this also differs from research on adult cannabis use, which indicates that high-potency products (such as concentrates) are linked to a quicker progression to cud (arterberry et al., 2019), and that frequent concentrate use is associated with more severe cud symptoms compared to nonconcentrate users (bidwell et al., 2018). additionally, prior research has shown that even within a single product category, modes of administration (e.g., vaping vs. smoking flower) can result in differing pharmacokinetics and subjective effects (cooper et al., 2009; spindle et al., 2018). in contrast, our findings suggest that adolescents may be particularly vulnerable to developing cud when experimenting with multiple modes of administration within a short period. nonetheless, given the risks associated with high potency products among adults, it remains crucial to monitor their impact among youth, as these patterns may adversely impact the developing adolescent brain over time. continued monitoring of high potency product use among youth is especially important, since in our sample, concentrates were both the product type most adolescents used first and the most-used product type overall. this popularity reflects a change in product use, which for many years reflected combustible cannabis products were the most popular (hammond et al., 2020). this preference may be partially driven by the fact that some cannabis & cud in youth 99 adolescents reported using cannabis on school grounds, particularly in school restrooms, likely due to the concealability and rapid effects of concentrate products such as vape pens. while our findings regarding associations between cannabinoid formulation and cud symptoms were not statistically significant, the high proportion of adolescents who responded “don’t know” when asked about the cannabinoid content of the cannabis product they used most often highlights a meaningful concern. a lack of awareness about cannabinoid formulations may stem from several factors, including shared product use among peers (over half of participants in this sample endorsed using with friends), discarded product packaging containing cannabinoid content, or unclear or inconsistent labeling. this issue reflects a broader challenge in adolescent, and even adult, cannabis use, where individuals frequently lack accurate knowledge of the potency or cannabinoid composition of the products they consume. because both dose and cannabinoid profile play important roles in determining acute and long-term effects of cannabis, including the risk of developing cud, this knowledge gap may increase vulnerability to adverse outcomes. improved product labeling standards, especially those that make cannabinoid content more visible and understandable to consumers, could help young people make more informed decisions and potentially reduce risk. this study has several limitations. first, all measures are self-reported, which may lead to misclassification of variables, particularly underreporting of cannabis. second, while the cast was used as a proxy for probable cud, it is not a direct measure of dsm-defined cud. the cast is designed to assess cannabis-related problems and disorders (legleye, 2018), with a cutoff indicating probable cud (legleye et al., 2011) rather than a definitive diagnosis. also, despite examining a range of cannabis use behaviors, our study did not include specific measures of product potency, which could influence cannabis-related outcomes and is an important future direction for subsequent studies. we controlled for baseline probable cud to account for pre-existing cannabis-related problems at the study’s outset with the assumption that it preceded the cannabis use behaviors we assessed as predictors and therefore served as a confounder. however, there remains the possibility of residual confounding from cannabis use behaviors initiated prior to the baseline as well as from other unmeasured lifestyle factors that could influence subsequent cannabis use patterns. additionally, quantity of cannabis use was only assessed for smoking and vaping; data on quantity or dose were not collected for edibles or other non-inhalable products, which limits our ability to evaluate patterns of use across all product types. finally, our study design utilized wave 5 of the parent study as the baseline to capture cannabis use during a critical developmental period in late high school, a time when cannabis use becomes significantly more common among youth (miech et al., 2023). nevertheless, potential selection bias must be considered due to participants lost to follow-up by this stage and the restriction of analyses to those with complete outcome data at the follow-up wave. conclusions this study demonstrates the importance of understanding specific patterns of cannabis use among adolescents, rather than focusing solely on the general presence of cannabis use. our findings reveal links between past-month use frequency and number of modes used in the past 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(2008). likelihood of developing an alcohol and cannabis use disorder during youth: association with recent use and age. drug and alcohol dependence, 92(1–3), 239–247. https://doi.org/10.1016/j.drugalcdep.2007.08.0 05 zaman, t., malowney, m., knight, j., & boyd, j. w. (2015). co-occurrence of substance-related and other mental health disorders among adolescent cannabis users. journal of addiction medicine, 9(4), 317–321. https://doi.org/10.1097/adm.00000000000001 38 funding and acknowledgements: this work was supported by the national cancer institute (nci) under award number r01ca229617. the authors have no conflicts of interest to declare. ethics statement: parental consent and student assent were obtained prior to data collection. the university of southern california institutional review board approved this study. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. issue date: november 03, 2025 citation: walsh, c. a., jafarzadeh, n., whaley, r. c., han, d. h., leventhal, a., pedersen, e. r., barrington-trimis, j., & harlow, a. f. (2025). cannabis products and use patterns associated with cannabis use disorder symptoms among youth in southern california. cannabis, 8(3), 89– 102. https://doi.org/10.26828/cannabis/2025/000323 https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 152 abstracts from the 2025 scientific meeting of the research society on marijuana july 18-20, 2025 special section editors: lauren micalizzi, ph.d. kyra farrelly, m.a. stephanie penta, m.a. keynote addresses extending reach: technology-supported cannabis interventions in the green wave era erin bonar, ph.d. (university of michigan) cannabis legalization in canada: the good, the bad and the ugly james mackillop, ph.d. (michael g. degroote centre for medicinal cannabis, mcmaster university) all abstracts were peer-reviewed by (in alphabetical order): sophie g. coelho (york university), bradley t. conner (colorado state university), kyra n. farrelly (york university), lauren micalizzi (brown university), jamie e. parnes (brown university; bradley hospital), stephanie m. penta (toronto metropolitan university), kristina t. phillips (kaiser permanente hawaii, center for integrated health care research; kaiser permanente bernard j. tyson school of medicine, department of health systems science), jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. papers & posters the relationship between cannabis and alcohol use with sexual assault, suicidal behaviors, and posttraumatic stress symptoms: a network analysis leslie a. brick (brown university) grisel garcía-ramírez (prevention research center) ruschelle leone (university of colorado) amanda k. gilmore (georgia state university) introduction. cannabis remains a widely consumed substance and in tandem with the changing legal landscape surrounding its use, it has often been used to relieve symptoms of depression, anxiety, and posttraumatic stress disorder (ptsd). elevated rates of cannabis use and dependence are consistently reported among individuals with trauma exposure and ptsd. one form of trauma exposure commonly experienced by young adults in college settings is sexual assault cannabis 2025, 8(3), 116-225. © author(s) 2025 researchmj.org 10.26828/cannabis/2025.03.001 conference abstracts 153 (sa). sa is associated with more severe ptsd symptoms, higher levels of negative beliefs and emotions, and suicidal ideation and attempt. selfmedication with cannabis and other substances may serve to alleviate symptoms of stress and trauma, however, it can lead to biological changes in the stress response system. thus, complex relations between traumatic stress and cannabis use may exist in which cannabis is used to reduce negative affect, relieve distress, and other symptoms, while disrupting the inhibitory role of the stress response system. we sought to test a theoretical model in which cannabis use is linked with maladaptive coping behavior (i.e., using to decrease negative mood) resulting in a dysregulation of the stress response (i.e., heightened arousal). specifically, we hypothesized that, after controlling for the effects of alcohol use, sa severity, and suicidality, cannabis use would be associated with lower symptoms of negative mood and cognition, higher arousal, and higher suicidality. methods. undergraduate college students (n=2160; 68% women, 31% men; 42% white, 20% black, and 15% latinx) between the ages of 18-25 years old (m=20.08, sd=1.58) participated in a research study on alcohol and health risk behaviors. participants reported on demographics, hours of cannabis use per week, number of alcoholic drinks consumed weekly, sa severity, suicidal behaviors, and posttraumatic stress symptoms. gaussian graphical models were used to model the conditional relations between cannabis use, alcohol use suicidality, sa severity, and severity scores for the four ptsd clusters based dsm-5 (assessed using the pcl-8) (1.intrusions, 2.avoidance of trauma reminders, 3.negative mood and cognitions, and 4.arousal and reactivity). non-parametric bootstrapping with 3,000 samples was used to evaluate the stability and accuracy of edge weights and centrality measures. results. after bootstrapping, the estimated network revealed that ptsd clusters were positively correlated with each other, with the strongest edges between negative mood and cognitions, and arousal and reactivity as well as between avoidance and intrusion symptoms. those who reported using cannabis more hours per week reported higher scores on suicidality, more severe arousal and reactivity symptoms, and less severe negative mood and cognition symptoms. higher suicidality was associated with negative mood and cognitions. while drinks per week was associated with greater sa severity, the edges connecting these to the rest of the network were not robust during bootstrapping and they were not connected to any other variables. conclusions. findings were consistent with our hypothesized model, in which cannabis use was associated with lower severity of negative mood and cognitions (consistent with a model of self-medication) and was associated with and higher suicidality and higher arousal and reactivity symptoms (consistent with stress-dysregulation). cannabidiol vs placebo for persistent post-surgical pain following total conference abstracts 154 knee arthroplasty (cannabis tka): a multicentre randomized pilot trial jason w. busse (mcmaster university) breanne flood (research institute of st. joseph's hamilton) kim madden (mcmaster university) behnam sadeghirad (mcmaster university) vahid ashoorion (mcmaster university) emmanuel olaonipekun (royal college of surgeons in ireland) amit atrey(st. michael's hospital) vickas khanna (mcmaster university) anthony adili (mcmaster university) background: total knee arthroplasty (tka) is a common surgery for endstage knee osteoarthritis that typically provides improvement in function and pain; however, 1 in 4 patients develop persistent post-surgical pain (ppsp). higher peri-operative pain and anxiety is associated with a greater risk of ppsp. cannabidiol (cbd) is a nonpsychoactive cannabinoid that has shown anti-inflammatory and anxiolytic properties. we conducted a pilot trial to assess the feasibility of a definitive randomized trial of oral cbd to prevent ppsp after tka, which we prospectively registered on clinicialtrials.gov (nct03825965). methods: we conducted a two-centre, concealed, blinded randomized pilot study of patients undergoing tka. we used central randomization to allocate patients to receive mpl-001 (an oral 25:1 cbd:thc formulation in oil [50mg/ml cbd: 2mg/ml thc]; donated by medipharm labs) or placebo, in addition to standard care, and followed for 6-months. patients were instructed to take study medication for 4 weeks before surgery, titrating from 25mg/day up to a maximum of 125mg/day based on individual response, and 6-weeks after surgery. patients experiencing pain at 6-weeks had the option to continue their study treatment for up to 6months post-surgery. the goals of our pilot study were to determine if we could recruit 40 patients over 6months, have 75% of patients comply with 75% of their study doses, and follow ≥85% of enrolled patients at 6months. our secondary outcomes were ppsp, opioid use, pain interference, physical and emotional function, return to functioning, sleep, and adverse events (aes). results: following an initial set-up period during which we enrolled 10 patients, we successfully recruited 29 additional participants from two sites in hamilton and toronto canada over 6 months. two patients were not eligible for surgery and were excluded postrandomization, leaving 37 participants in the analysis. three participants decided against use of the study drug and withdrew before surgery, two withdrew after surgery (1 cited study burden, 1 did not want the study drug), and two participants were lost to follow-up. the mean age of enrolled participants was 66 (sd 9.4), most were female (76%) and had never used cannabis (81%). at baseline, 49% met criteria for moderate to severe insomnia, 19% for depression symptoms, and 43% for anxiety symptoms. of patients randomized to cbd, 53% took ≥75% of study doses, and of patients randomized to placebo, 35% took ≥75% of study doses. followconference abstracts 155 up ranged from 89% at the postoperative visit to 81% at 6-months. at 3-months follow-up, 41% in the placebo arm (7 of 17) reported cpsp, and 13% in the cbd arm (2 of 15). at 6-months follow-up, 19% in the placebo arm (3 of 16) reported cpsp, and 14% in the cbd arm (2 of 14). there were 18 treatment-related aes in the cbd group (in 11 patients) and 21 in the placebo group (in 12 patients), most of which were gastrointestinal. discussion: our results suggest that modifications to our study protocol will be required to ensure feasibility of a definitive, multi-centre trial of cbd versus placebo to reduce cpsp among tka patients. for the definitive trial, we will expand participant recruitment to additional centres and implement strategies to optimize participant adherence to the study treatment and follow-up. for example, switching from oil drops to a capsule formulation. exploring cannabis use motivation when controlling for sensation seeking personality type across mental and physical health concerns endometriosis sexual health highlighted brenna a. carter (colorado state university) bradley. t. conner (colorado state university) the inaccessibility of treatment for mental and physical health concerns in the united states has prompted an increase in self-medication in general adult populations, particularly in conjunction with growing legal markets for cannabis products, leading to increased interest in the underlying motivations for cannabis consumption among individuals actively experiencing mental and physical health concerns. prior literature has identified a link between sensation seeking personality types with multiple cannabis use motives. however, prior research evidence is limited by a lack of exploration around delineating the role of non-impulsive sensation seeking personality traits from the associated motivational factors in adult populations due to sample focus on adolescents and emerging adults. this set of analyses explored initial distinction between sensation seeking as a personality trait and underlying motives for cannabis use among a variety of mental and physical health concerns with the goal of establishing additional future directions among these domains in adult populations. this is a secondary data analysis of an adult community sample evaluating cannabis and alcohol co-use, collected via prolific. this dataset was selected due to its extensive list of mental health and physical health concerns included. initial analyses were a series of chisquare dependency tests between the marijuana motives questionnaire (mmq) and past 12-month experience of all included mental and physical health concerns surveyed. all pairings that yielded a significant dependency pattern were rerun as a zero-inflated poisson multiple regression including the sensation seeking personality type scale (sspt) to control for the influence of personality. in the majority of pairs, the introduction of sspt sufficiently controlled for the dependency pattern between the conference abstracts 156 health concern and mmq. select analysis pairs maintained significance even with the control, suggesting that the underlying motive did have a unique relationship with the health concern. the only remaining significant predictions of health concerns after sspt inclusion were coping motives predicting anxiety concerns and enhancement motives predicting endometriosis. the remaining significant associations were found in the two control conditions, with the mental health control group maintaining a significant coping motivation and the physical health control group maintaining a significant socialization motive when controlling for sspt. the results also replicated severe multicollinearity between sensation seeking personalities and both expansion and enhancement motives. while the relationship between anxiety and coping motives have been welldocumented in the literature, the relationship between endometriosis and enhancement motives may be an interesting direction for further research. established literature linking the two has primarily focus on cannabis's role in coping with the chronic pain and uterine symptoms, highlighting the relationship between endometriosis, gut microbiome, and the endocannabinoid system. however, our analyses suggest that there may also be a link between experiential enhancement alongside those same mechanisms. given consideration of enhancement motives and experiences of sexuality, exploring the role of cannabis in a dual copingenhancement motivation structure within a condition known to induce painful sexual experiences may be a fruitful avenue of inquiry on leveraging the endocannabinoid system's functioning within individuals diagnosed with endometriosis to promote sexual health and comfort. psychosocial correlates of transitions from single-substance to polysubstance use among adolescents: results from a national survey grace chung (university of new mexico health sciences center) lillian walker (university of new mexico health sciences center) eunice kim (university of new mexico) sam swift (university of new mexico health sciences center) laura nellums (university of new mexico health sciences center) verlin joseph (university of new mexico health sciences center) background: adolescents are particularly vulnerable to polysubstance use, with studies indicating that early cannabis initiation increases the likelihood of later polysubstance use. there is mixed research with respect to parental involvement and adolescents' mental health and, relatedly, behavioral outcomes, such as cannabis and polysubstance use. some adolescent groups appear to benefit from greater parental involvement, while others appear to benefit from less. in the context of adolescents who use cannabis, it is unclear whether greater or lesser parental involvement promotes or prevents the transition from cannabis use to polysubstance conference abstracts 157 use. as such, we aimed to understand the prevalence of exclusive cannabis, tobacco, or electronic nicotine products (enp) use and identify psychosocial predictors of transitions to polysubstance use. methods: data are from wave 5 (december 2018november 2019) and wave 6 (march 2021-november 2021) of the adolescent cohort (ages 12-17) from the population assessment of tobacco and health study. adolescents reporting past 30day use of combustible tobacco, enp, or cannabis at wave 5 were included in the analysis. weighted proportions at wave 5 were calculated for exclusive past 30-day combustible tobacco, enp, and cannabis use. weighted logistic regression was used to identify predictors associated with transitions from exclusive tobacco or enp use at wave 5 to polysubstance use (tobacco/enp and cannabis) at wave 6, including demographics, having a weekend curfew, and mental health. results: the proportion of exclusive combustible tobacco use was 6.4% (20/343), the proportion of exclusive enp use was 45.1% (150/343), and the proportion of exclusive cannabis use was 21.3% (78/343). the transition to polysubstance use occurred among 17.9% (4/20) of tobacco-only users, 21.8% (31/150) of enp-only users, and 15.4% (11/78) of cannabis-only users. adolescents reporting worse mental health (or = 2.43, 95% ci: 1.08-5.45) compared to 12 months ago were significantly more likely to transition from exclusive tobacco or enp use to polysubstance use than those reporting improvements. adolescents with a weekend curfew had significantly reduced odds of transitioning from exclusive tobacco or enp use to polysubstance use (or = 0.39, 95% ci: 0.16-0.95), compared to adolescents without a weekend curfew. conclusions: adolescents who initially used only enp or tobacco often transitioned to polysubstance use (cannabis combined with enp or tobacco), with notably higher rates observed among enp-only users. we found that poor mental health was associated with an increased likelihood of transitioning to polysubstance use, suggesting the need for addressing youth mental health as a preventive measure. additionally, weekend curfews were identified as a potential protective factor against polysubstance use. further research examining the interplay between adolescent substance use, mental health, and preventive policies is warranted. advancing assessment of delta-9tetrahydrocannabinol (thc) and cannabidiol (cbd) use across different forms of cannabis with ecological momentary assessment sophie coelho* (york university) sergio rueda (centre for addiction and mental health, university of toronto) matthew t. keough (york university) jeffrey d. wardell (york university, centre for addiction and mental health, university of toronto) *student award winner background: there is a critical need for methods of assessing cannabis use that quantify consumption of delta-9tetrahydrocannabinol (thc) and other cannabinoids (e.g., cannabidiol [cbd]), in turn permitting aggregation across conference abstracts 158 cannabis products of varying forms and potencies. this paper describes the development of a novel ecological momentary assessment (ema) approach to assess total thc and cbd consumption across different forms of cannabis, which permits calculation of standard (five-milligram) thc units consumed. further, we examine the feasibility of this approach and provide preliminary data on the predictive validity of thc use estimates by examining their associations with acute cannabis-related consequences. method: participants (n = 42; mean age 25 years, 59.52% women) were young adults (ages 18-34 years) who reported using thc-containing cannabis three or more times per week and using two or more forms of cannabis in a typical week. participants attended a baseline study visit with a research assistant (via videoconference), during which they were oriented to the ema protocol and trained in reporting cannabis quantities and cannabis thc and cbd contents. following the study visit, participants completed a 14-day ema protocol, which involved completing surveys immediately prior to cannabis use that assessed the quantities, thc content, and cbd content of various forms of cannabis to be used in the current session. items used formspecific units for quantities and cannabinoid content, with units selected to match those typically displayed on the labels of cannabis products available through the legal cannabis market. participants also uploaded photos of the cannabis product labels when available. surveys were also administered at fixed times throughout the day (85% completion rate) to assess acute cannabis-related consequences. results: participants completed a total of 786 pre-cannabis surveys, of which 79.39% and 77.35% contained sufficient information to calculate total thc and cbd (in milligrams), respectively. high agreement was observed between participant-entered thc and cbd contents and those shown in corresponding photos of cannabis product labels. aggregating across all products used, participants reported using an average of 141.41 (sd = 224.62, range = 0.00å -2000.00) milligrams of thc (i.e., 28.28 standard units) and 7.53 (sd = 34.87, range = 0.00-484.22) milligrams of cbd per day. multilevel models revealed that participants were more likely to report acute negative consequences following sessions when their estimated thc use was higher than their typical thc use. at the between-person level, participants reporting more thc use on average across sessions were less likely to report negative consequences overall. conclusions: results support the feasibility of this novel ema approach for measuring thc and cbd consumption, which involves administering items that are tailored to the specific form of cannabis being used in the moment. we also observed preliminary evidence for the predictive validity of thc consumption assessed using this approach in predicting acute negative cannabis-related consequences. continued refinement of this approach may advance understanding of dose-response relations between cannabis use and harms in observational research. conference abstracts 159 where there's smoke: estimating access to legal cannabis in massachusetts through objective and subjective measures alexander m. colby (commonwealth of massachusetts) graelyn humiston (commonwealth of massachusetts) hailey pensky (commonwealth of massachusetts) victoria edwards (commonwealth of massachusetts) julie k. johnson (commonwealth of massachusetts) aim: to examine geographic patterns of cannabis retailer density and subjective cannabis purchasing trends in massachusetts. background: cannabis has been available to medical patients for nearly a decade, with the first medical-use dispensary (registered marijuana dispensary (rmd); later medical marijuana treatment center (mtc) opening in june 2015, and adult-use dispensaries opening in november 2018. understanding the distribution of these cannabis retailers is integral to understanding the 'saturation' of the cannabis market in massachusetts. in the current study we estimate the density of dispensaries across massachusetts and contextualize this data using the experience of residents through the international cannabis policy study (icps). methods retail density: we use the number of retailers per 100,000 population in each county to estimate their overall prevalence. population estimates were derived from the 2023 american community survey released in march 2024. the number of rmd/mtc priority and general/other priority retailers was derived from licensing data on the massachusetts cannabis control commission's open data catalog. icps: we use data from the 2019-2023 waves of the international cannabis policy study (icps) to investigate the subjective experience of massachusetts residents (n = 11,635). we use the percent of cannabis products purchased legally to explore how reported purchasing trends have changed over time and how they differ across counties. the county of residence for respondents was derived from their self-reported city of residence in cases where an exact match was available from the u.s. census bureau's 2023 population estimates for massachusetts cities and towns. an exact match was found for 82.94% of responses (9,650:11,635). barnstable, dukes, and nantucket counties were collapsed with bristol and plymouth into one 'southeast and cape counties' region, and berkshire, franklin, and hampshire were collapsed with hampden county into the 'western counties'; both cases were due to small sample sizes for 2023 (ns<10). results retail density: among all retailers, berkshire (18.92), hampshire (16), and nantucket (13.85) had the highest prevalence per 100,000 population. trends were different, however, when observing only retailers licensed under rmd/mtc priority, with nantucket (6.92), hampshire (6.77) and dukes (4.80) having the highest prevalence of rmd/mtc priority retailers per 100,000 population. icps: the reported percentage of cannabis purchased from conference abstracts 160 legal sources by respondents increased from 60.78% of all purchases in 2019 (n = 612) to 84.15% in 2023 (n = 626). in the most recent 2023 sample, respondents from the southeastern and cape counties were the most likely to source from the legal market at 90.9% (n=110) in 2023, compared to suffolk county respondents who sourced products from the legal market 78% of the time (n=64). conclusions access to cannabis in the southeastern counties appears to have improved since this data was last calculated for rsmj 2022 (colby et al., 2022), with the southeastern and cape counties having the highest percentage of legal purchases, and dukes county having the third highest retail density. future research should consider how more fine-grained analyses at the municipal or even census tract level can be leveraged for a more refined understanding of cannabis access in massachusetts. cannabis use & driving under the influence among canadian youth robert colonna (centre for addiction & mental health) liliana alvarez (western university) michael bauer (western university) andrew johnson (western university) alexander crizzle (university of saskatchewan) isabelle gelinas (mcgill university) jeffrey holmes (western university) background since the legalization of recreational cannabis in canada, concerns have grown regarding cannabis use among youth and driving under the influence of cannabis (duic). preventing youth from engaging in duic remains a top public health priority, as it increases the risk of collisions and has become more common than alcohol-impaired driving. moreover, young novice drivers are at the highest risk for crashes, even when not impaired by alcohol or drugs, underscoring the importance of prevention. understanding the factors that influence young drivers' involvement in duic is vital for developing effective prevention strategies. objective this cihrfunded study aimed to identify the prevalence of cannabis use, duic, and the individual and social determinants of duic among canadian youth aged 14 to 24. methods an anonymous online survey was conducted with a national sample of young canadian drivers (n=2651; mean age 19.7 years; 52% female). recruitment occurred between july 2023 and june 2024 through social media posts, paid advertisements, and targeted outreach at various colleges/universities. the survey assessed demographics, cannabis use, duic behaviours, riding experiences, knowledge and credibility of the law, personal attitudes, and social norms. ordinal logistic regression was used to identify the determinants of future duic intention. results overall, 84.5% (2241) reported lifetime cannabis use, 79% (2094) had used it in the past year, and 33.5% (750) reported daily use. nearly half of current users (53%; 1109 of 2094) indicated a history of duic, with 29.3% (615) doing so in the past 30 days. additionally, 30.8% (818) expressed intent to engage in duic in the next year. regression analyses conference abstracts 161 identified 13 determinants of duic intention, including past 12-month cannabis use, the number of days using cannabis in the past 30 days, past duic experiences, duic combined with alcohol, riding with an adult (over 25) who was duic, decisions regarding being a passenger with someone duic, perceptions of how many friends and peers engage in duic, beliefs about how many hours after cannabis use it is safe to drive, and personal beliefs that duic is acceptable, safe, not morally wrong, and/or not dangerous. conclusions a significant number of young canadians currently use cannabis and engage in duic. these findings provide critical insights into the individual and social determinants of duic, offering guidance for future interventions aimed at reducing duic and promoting safer cannabis use. addressing these determinants through targeted, evidence-based strategies could play a pivotal role in lowering duic prevalence and fostering safer driving behaviours among canadian youth. at-risk cannabis use prevalence and associations among elective surgical patients richard davies (michigan medicine) xintong ju (michigan medicine) estevan pena (michigan medicine) jake solka (michigan medicine) maureen a. walton (michigan medicine) frederick blow (michigan medicine) kelley kidwell (michigan medicine) anne c. fernandez (michigan medicine) purpose. preoperative cannabis use is linked to preand post-surgical complications including higher pain and increased opioid use. cannabis use disorder (cud) is associated with a higher incidence of myocardial infarction and a modest increased risk of perioperative morbidity and mortality. using screening data collected from an ongoing clinical trial, we examined cannabis use patterns across surgical services to assess prevalence and identify potential atrisk demographic groups. methods. we analyzed preoperative screening data collected during recruitment between 2/20/2024-2/10/2025. patients scheduled for elective non-cancer surgery within 7-9 weeks were identified using electronic health records (ehrs) and invited to complete an online screening survey assessing alcohol, cannabis, tobacco, illicit drug use, and perceived health. alcohol use was assessed using the audit-c, a validated 3-item screening tool that measures frequency and quantity of alcohol consumption over the past 2 months. based on established criteria, scores were categorized as low-risk (04) or at-risk (5+). cannabis and other substance use frequency over the past 12 months was categorized as "at-risk" (weekly or daily use) or "low-risk" (monthly or less). based on substance use patterns, participants were classified into four mutually exclusive groups: no risk, cannabis risk only, cannabis + other substance (alcohol/drug) use risk, and noncannabis substance use risk. chisquared tests and one-way anova were used to compare demographic characteristics across these four conference abstracts 162 groups. logistic regression was then used to identify factors independently associated with at-risk cannabis use. results. participants (n=2,688) were categorized into four groups: no risk (72.4%, n=1,945), cannabis risk only (9.5%, n=255), cannabis + other substance use risk (5.5%, n=147), and non-cannabis substance risk only (12.7%, n=341). participants in the atrisk cannabis use groups were significantly younger (44.1-43.2 years) than non-cannabis substance use risk and no risk groups (51.4-52.8, p <.001). non-cisgender participants were overrepresented in at-risk cannabis use groups (21.6% cannabis risk only, 12.2% cannabis + other substance) versus overall (7.9%, p<.001). multivariable logistic regression confirmed younger age (or=0.97 per year, 95% ci: 0.96-0.97), male sex (or=1.34, 95% ci: 1.05-1.70), non-cisgender identity (aor=1.94, 95% ci: 1.37-2.72), and worse perceived health scores (or=1.45, 95% ci: 1.29-1.62) were independently associated with at-risk cannabis use. conclusion. at-risk cannabis use was reported in 15% of preoperative patients, underscoring the need for comprehensive preoperative screening. the findings indicate that at-risk cannabis use is more likely among younger, male, and non-cisgender individuals, as well as those with worse perceived health. tailored screening approaches that consider both general and population-specific risk factors may help identify patients who would benefit from targeted interventions to prevent surgical complications. the effects of cannabis on cognition and subjective experience in older adults patricia di ciano (centre for addiction and mental health) bernard le foll (centre for addiction and mental health) sampson zhao (centre for addiction and mental health) patrick byrne (ministry of transportation of ontario) yoassry elzohairy (ministry of transportation of ontario) jeffrey brubacher (university of british columbia) michael mcgrath (ministry of transportation of ontario) bruna brands (health canada) cheng chen (centre for addiction and mental health) wei wang (centre for addiction and mental health) pamela kaduri (centre for addiction and mental health) christine wickens (centre for addiction and mental health) tarek rajji (centre for addiction and mental health) aims: the impact of cannabis on cognition is believed to be mediated by delta-9-tetrahydrocannabinol (thc). adults over the age of 65 years are the fastest growing group of cannabis users, but there are few studies of the acute effects of cannabis in this population. methods: the present observational study aimed to determine the effects of cannabis on tests of verbal learning and memory (verbal free recall), executive function and information processing (trail making test) and functional vision and visual attention (useful field of view conference abstracts 163 (ufov)). blood thc levels were also measured and correlated with cognitive measures. results: healthy participants aged 65-79 (31 in total; 21 male) were invited to smoke their own preferred legally purchased cannabis in the lab. participants chose to smoke cannabis with an average thc content of 18.7%. performance on the trail making test versions a and b were impaired 60 minutes after smoking cannabis, compared to the no cannabis condition. for the percent retained in the verbal free recall, the cannabis condition was significantly higher than the no cannabis condition, but this was apparent as a reversal in performance decrement that emerged over the day. naturalistic doses of cannabis produced robust increases in ratings of drug experience. at 60 minutes, increased blood thc was associated with improved performance on a subtask of the ufov, while at 210 minutes only the dose of cannabis used was related to performance on the ufov. at 210 minutes, there was a positive correlation between potency of thc and slower performance on more complicated versions of the trail making test. conclusions: these results suggest that older adults who use cannabis may experience slightly impaired cognition after using cannabis, and there is no definite relationship to dose, potency, and blood thc. changes in cannabis attitudes and perceptions in the five years following recreational legalization in canada: findings from an observational cohort study of community adults amanda doggett (mcmaster university) kyla belisario (mcmaster university) andré j. mcdonald (mcmaster university) jane de jesus (mcmaster university) emily vandehei (mcmaster university) jessica gillard (mcmaster university) laura lee (mcmaster university) james mackillop (mcmaster university) background: social acceptability and perceived risks/benefits are key attitudinal factors that influence substance use, and a major concern about cannabis legalization is an increase in more favourable attitudes ultimately leading to greater cannabis misuse. this study investigated perceptions of cannabis acceptability and risks/benefits over the 5 years following legalization in canada, the first g7 nation to have legalized cannabis nationally, in a longitudinal observational cohort of community adults. methods: participants (60 % female, median age = 29, 48% reporting cannabis use pre-legalization) were non-clinical adults from the general community who were assessed up to 11 times from september 2018 to october 2023 (mean waves = 9.9). overall temporal attitudinal changes and whether changes were moderated by pre-legalization cannabis use status were examined. results: significant increases over time were present for social acceptability of any recreational cannabis use (or [95% ci]: 1.06 [1.05, 1.07]) and trying cannabis (1.02 [1.01, 1.03]), while acceptability of medical cannabis use decreased (0.95 [0.94, conference abstracts 164 0.96]). meanwhile, regular cannabis use was perceived as riskier (0.97 [0.96,0.98]) and addiction potential was perceived as greater (0.94 [0.93, 0.95]) over time. health-related benefits of cannabis were significantly less likely to be endorsed over time, while there were significant increases in perceived risks, including exacerbating stress, anxiety, and depression; exacerbating existing medical conditions; and disrupting sleep. moderator analyses found participants not using cannabis pre-legalization showed significantly steeper increases towards greater social acceptability of occasional and regular use, and less steep increases in endorsement of cannabis-related risks. conclusions: shifting social acceptability of cannabis postlegalization in canada is paralleled by increases in perceived health-related risks and decreases in benefits. continued surveillance of attitudinal changes following legalization in canada is warranted to inform the impacts in the largest national legal cannabis jurisdiction as well as other jurisdictions considering regulatory reform. subjective stress and diurnal salivary cortisol in adults with frequent cannabis use julia donner* (oregon state university) megan campbell (oregon state university) jahnavi nanwani (oregon state university) mckenzie meyer (oregon state university) anita cservenka (oregon state university) *student award honorable mention introduction: several studies indicate that the hypothalamic-pituitaryadrenal (hpa) axis, the major neuroendocrine system that responds to stress, is dysregulated by substance use. however, little is known about diurnal hpa axis response in individuals who use cannabis frequently (cu). the rise of cortisol in the morning, known as the cortisol awakening response (car) is thought to be critical for mobilizing the body to meet the challenges of the day and is believed to be a reliable marker for individual differences in hpa axis activity. a recent study of young adults who used cannabis found a blunted car, suggesting that cannabis use may be associated with hpa axis dysregulation, which could contribute to continued substance use. the purpose of this study was to investigate differences in the car between adult cu and healthy controls (hc) and determine whether cannabis use status moderates the relationship between subjective stress and cortisol levels. methods: 39 cu (3 days of cannabis use/week in the past year; cannabis use in the past month) and 43 hc (1/month cannabis use in the past year; no past month cannabis use; 50 lifetime cannabis use occasions) collected daily saliva samples at awakening, 30 minutes post awakening and in the evening on two consecutive weekdays and provided subjective stress at each collection time on a scale of 0 (no stress) to 10 (high stress). cortisol immunoassays quantified salivary cortisol levels, which were averaged for morning, 30 min post awakening, and conference abstracts 165 evening across the two days. independent samples t-tests examined group differences in the car (mean 30 min post awakening mean awakening cortisol). multiple linear regressions were conducted to determine the association between average subjective stress and average cortisol levels at each collection time with group status entered as a moderator in the analyses. results: there were no significant differences in the car between cu and hc (p=0.23). the model examining the main effect of subjective stress at awakening, group, and their interaction in relation to awakening cortisol levels was significant (r2=0.14, p=0.007). there was a main effect of subjective stress being positively related to cortisol levels (p=0.001), a main effect of group (p=0.047), such that cu had higher cortisol at awakening than hc, and a trend-level interaction (p=0.093), illustrating a stronger relationship between subjective and physiological levels of stress in hc relative to cu. for the second model (r2=0.12, p=0.016), there was a main effect of subjective stress 30 min post awakening being positively related to cortisol levels (p=0.003), no main effect of group (p=0.193), and a trend-level interaction (p=0.072) similar to that noted above. the third model examining the effects of subjective evening stress, group, and their interaction in relation to evening cortisol levels was not significant. conclusions: these findings suggest that subjective stress during the morning was significantly related to salivary cortisol, with cu having greater awakening cortisol levels relative to hc. trend interactions indicating a dissociation between subjective and physiological stress in cu may suggest a dysregulation of their hpa axis functioning and warrants further research. detecting cannabis use reduction through biochemical verification of urinary cannabinoids: an exploratory, aggregated analysis characterizing cannabinoid decay ashley n. dowd (medical university of south carolina) nathanial l. baker (medical university of south carolina) brian neelon (medical university of south carolina) rachel l. tomko (medical university of south carolina) kevin m. gray (medical university of south carolina) aimee l. mcrae-clark (medical university of south carolina, ralph h. johnson va medical center) erin a. mcclure (medical university of south carolina) introduction: cannabis use is prevalent and appears to be increasing in the united states (us) and globally. concurrently, there is a decreased perception of harm associated with cannabis use and more interest in reduction as a treatment outcome, rather than abstinence. however, datadriven cannabis reduction metrics using objective urinary cannabinoids and/or self-report is lacking. this gap must be addressed to inform public health and clinical recommendations regarding cannabis harm reduction. measurement of urinary cannabinoids, along with detailed and standardized self-reported cannabis use conference abstracts 166 quantification, is necessary to determine the amount of reduction that may be beneficial for an individual. using aggregated data from cannabis use disorder (cud) trials, the aims of this analysis were to; 1) determine if decreases in self-reported cannabis use (50% in frequency and/or 75% in amount; based on our prior work) correlate with a decrease in urinary cannabinoids, and 2) characterize the decay in urinary cannabinoids in participants who reduce cannabis use to determine an individual cut-off metric indicating significant reduction. our hypotheses are that; 1) withinsubject changes in weekly urinary cannabinoids versus baseline will be positively correlated with changes in self-reported cannabis use over the same period, and 2) the decay model in weekly urinary cannabinoids will differentiate those that reduced use versus not. methods: this exploratory aggregated analysis of seven cud treatment trials include individual studies conducted within us academic medical centers and community substance use treatment settings and led by the investigative team at the medical university of south carolina. participants with weekly self-reported cannabis use and urinary cannabinoid measurements through week 6 were included (n=471 of 920 total) and were classified as; 1) significantly reducing cannabis use (50% in frequency and/or 75% in amount; n=220) or, 2) no selfreported reduction (n=251). linear mixed effects regression models were used to evaluate correlations in selfreported reduction and corresponding urinary cannabinoids. random coefficient models with linear and quadratic polynomial time terms were utilized to estimate the slope of change in cannabinoids. results: participants self-reporting significant cannabis use reduction had significantly lower urinary cannabinoids relative to those who did not reduce (p<.001). among participants who reduced their cannabis use significantly (50% reduction in use days and 75% reduction in amount), average urinary cannabinoids decreased by up to 50% from baseline levels. the overall model and parameter estimates for urinary cannabinoid decay during treatment were statistically non-significant (p's>.3). decay in urinary cannabinoids was modified by baseline levels, such that participants with higher baseline cannabinoids showed a significant liner and quadratic change in urinary cannabinoids over time. conclusions: this analysis provides important information on the potential role of urinary cannabinoid measurement to detect cannabis use reductions. on average, urinary cannabinoids differed between those with and without selfreported, significant cannabis use reduction (50% average decrease). however, decay models did not yield a cut-off value that could be used for individuals to detect significant cannabis reduction. urinary cannabinoids are a reliable measurement of cannabis exposure, though individual-based biochemical verification of reduction will require further work to establish. posttraumatic stress disorder and alcohol and cannabis co-use: conference abstracts 167 characterizing the relationship in a sample of treatment-seeking adults kyra n. farrelly (york university, centre for addiction and mental health) anthony c. ruocco (centre for addiction and mental health, university of toronto) ahmed n. hassan (centre for addiction and mental health, university of toronto) daniel felsky (centre for addiction and mental health, university of toronto) shannon lange (centre for addiction and mental health, university of toronto) yuliya nikolova (centre for addiction and mental health, university of toronto) thomas prevot (centre for addiction and mental health, university of toronto) etienne sibille (centre for addiction and mental health, university of toronto) erica vieira (centre for addiction and mental health, university of toronto) daphne voineskos (centre for addiction and mental health, university of toronto) lena c. quilty (centre for addiction and mental health, university of toronto) jeffrey d. wardell (york university, centre for addiction and mental health, university of toronto) background: posttraumatic stress disorder (ptsd) may be a risk factor for co-use of alcohol and cannabis, as the synergistic psychoactive effects of the two substances might provide greater relief from trauma-related distress compared to single substance use. however, no studies have examined ptsd as a predictor of co-use (above and beyond single substance use) in a clinical population. this study examined the associations between ptsd diagnostic status and alcoholcannabis co-use behavior, as well as the co-occurrence of alcohol use disorder (aud) and cannabis use disorder (cud), in individuals seeking treatment for aud and/or cud. we also examined how primary substance use disorder (sud) moderated these associations. method: this study utilized baseline data from a larger study of adults seeking sud treatment. the present study consisted of a subsample of 75 individuals (mage = 38.24, 65% male) seeking treatment for their alcohol and/or cannabis use, who reported at least one cannabisalcohol co-use day in the past two months and endorsed a lifetime criterion a traumatic life event. participants completed a clinical interview to assess past month ptsd diagnostic status, past year diagnostic status for aud and cud, and a timeline follow back interview assessing substance use over the past 60-days. primary sud was determined by the diagnosis with the greatest number of symptoms (i.e., aud or cud). results: a series of regression analyses (controlling for sex and age) were run with ptsd diagnostic status (n=23 with ptsd) as the independent variable and primary sud (n= 34 aud, n= 41 cud) as the moderator. ptsd was associated with consuming more standard drinks on co-use days, controlling for drinks consumed on alcohol-only days (b=10.24, p<.001), conference abstracts 168 and there was a significant interaction between ptsd and primary sud (b=10.26, p<.001). further probing of the interaction revealed that ptsd was only associated with heavier drinking on co-use days for those whose primary sud was aud (b=10.25, p<.001). ptsd was also associated with using more cannabis flower on co-use days (b=0.89, p< .01), but this relationship was not moderated by primary sud, and it was no longer significant when controlling for use on cannabis-only days (p=.45). further, ptsd was not associated with frequency of co-use days (p=.27). finally, results of a multinomial regression analysis found that ptsd was not associated with greater odds of having comorbid aud/cud (n=34), compared to audonly (n=21, or=0.87, p=.83) or cudonly (n=20, or=1.18, p=.79). conclusions: individuals meeting criteria for ptsd whose most severe sud was aud engaged in heavier drinking on days that they also consumed cannabis than on alcoholonly days. findings reveal a potential complementary effect of alcohol and cannabis use for individuals with ptsd and who have more symptoms of aud than cud. in contrast, heavier cannabis use on co-use days among people with ptsd was accounted for by heavier cannabis use on cannabis-only days, suggesting individuals with ptsd may engage in heavier cannabis use overall. future studies should examine whether interventions targeting alcohol-cannabis co-use may be beneficial among individuals with ptsd who are seeking treatment for their alcohol use. poly-cannabis and poly-tobacco couse: associations with rurality and chronic health conditions bethany shorey fennell (university of kentucky) cherell cottrell-daniels (health choice network) significance: evidence suggests tobacco and cannabis couse (couse) is associated poorer health outcomes, yet little is known about how different types of couse (single use vs. poly use) may influence chronic health conditions. further, rural populations have often been overlooked in investigations of co-use and should be included as evolving cannabis policy expands access in the u.s. methods: we describe co-use and chronic health conditions among us adults who use tobacco recruited nationally online (n=4013). of these, 2058 (51.3%) co-used cannabis in the last month. associations of rurality are examined using the index of relative rurality (irr; 0=most urban, 1=most rural). results: on average, participants were 47.55 (sd=16.39) years old, cis-gender men (50.1%) or women (49.0%), were primarily non-hispanic white (58.6%) or black (22.0%), and, were from all 50 us states and dc and on average were urban area-dwelling (irr=.22, range =.02-.67). participants who coused were slightly more urban than those who did not (.21 vs. .23, p<.001). among adults who co-used, 22.1% used one tobacco and one cannabis product (single use co-use, su), 10.8% (222) used multiple tobacco products and one cannabis product (tobacco poly use, tpu), 26.8% (551) used one conference abstracts 169 tobacco product and multiple cannabis products (cannabis poly use, cpu), and 40.3% (827) used multiple tobacco and cannabis products (dual poly use, dpu). dpu was overrepresented among urban participants (44.8%), su was overrepresented (25.0%) and polycannabis use (cpu & dpu) was underrepresented among peri-urban participants, and cpu was overrepresented among rural participants (30.4%). dpu were more likely to report lifetime diagnoses of anxiety (54%, p<.001), cancer (6.4%, p=.02), depression (48%, p<.001), & ptsd (18%, p<.001). cpu reported more chronic pain (26%, p=.03), anxiety (53%, p<.001), depression (47%, p<.001), & ptsd (18%, p<.001). tpu reported more diabetes (17%, p=.03) and su were less likely to report anxiety (39%, p<.001) and asthma than other groups (14%, p=.003). overall, su (27%) and tpu (26%) were more likely to report no chronic health conditions (vs. 19% cpu & 20% dpu, p=.006) conclusion: this research suggests poly-cannabis and polytobacco use varies by rurality and that prevalence of chronic mental and physical conditions differs within these groups. specifically, polycannabis use was common across all levels of rurality/urbanicity while poly-tobacco use was more common among urban and per-urban participants and single tobacco use was common among rural participants. additionally, reporting any chronic health condition was more common among dpu and cpu, with approximately half reporting anxiety and depression as well as high levels of ptsd. future work and tobacco reduction or cessation interventions should further explore how rurality and co-use product choice may impact health outcomes. a qualitative examination of motives, expectancies, and consequences for cannabis use among women with posttraumatic stress disorder reagan e. fitzke (university of colorado colorado springs) brigitta m. beck (university of colorado colorado springs) colin t. mahoney (university of colorado colorado springs) numerous studies have explored substance use following traumatic experiences via the self-medication model, which posits that individuals use substances to cope with traumarelated psychosocial sequelae (e.g., posttraumatic stress disorder [ptsd], negative affect, depressive, or anxiety symptoms). most research in support of this model has investigated motives for, and effects of, alcohol use; however, the literature is still limited regarding differential motives, expectancies, and effects of other substance classes in response to traumatic events, including cannabis use. the current study is a secondary analysis of qualitative data from women (n = 48) with interpersonal trauma histories (e.g., intimate partner violence, sexual assault) and ptsd symptoms to understand and elucidate motives, expectancies, and consequences of recreational cannabis use in relation to trauma-related psychopathology. participants reported using cannabis to reduce anxiety symptoms, gain new conference abstracts 170 perspectives on traumatic experiences (i.e., trauma processing and assimilation), and as a harm reduction replacement or alternative for heavy alcohol use. as far as consequences of cannabis use to cope with psychological symptoms, women disclosed higher frequency and quantity of use, higher tolerance, and use of stronger routes of administration (e.g., engaging in use of concentrates instead of flower or edibles). these findings have an etiological impact for the use of cannabis among women trauma survivors within the context of the selfmedication model, as well as clinical implications for measurement-based care of this population, and policy efforts on the prescribed use of cannabis for ptsd. preliminary findings from a pilot mobile health iintervention for emerging adults with cannabis use autumn rae florimbio (university of michigan) devin c. tomlinson (university of michigan) maureen a. walton (university of michigan) erin e. bonar (university of michigan) maya campbell (university of michigan) susobhan ghosh (harvard university) pei-yao hung (university of michigan) lauren zimmermann (university of michigan) susan murphy (harvard university) mark w. newman (university of michigan) inbal nahum-shani (university of michigan) lara n. coughlin (university of michigan) background: cannabis use prevalence in the united states is highest among emerging adults (eas; aged 18-25 years) compared to other age groups. early interventions that are both innovative and accessible are needed, especially given increased cannabis potency and potential for experiencing consequences among eas. mobile health (mhealth) interventions, including just-in-time adaptive interventions (jitais), offer promising tools for reducing cannabis use and associated consequences among eas by delivering real-time personalized support. to address this need, we developed an mhealth app aimed at reducing cannabis use among eas. we describe the acceptability and feasibility findings of a pilot trial. we also present preliminary findings on changes in cannabis use. methods: we used social media advertisements to recruit 122 eas who reported regular cannabis use (3 or more times per week) and some motivation to change their use. study assessments included a baseline survey, twice-daily in-app surveys, a post-intervention survey, and a 2-month follow-up. during the 30-day intervention period, eas were randomized twice per day to receive an intervention message or not; intervention messages focused on future goal-oriented behavior, alternative substance-free activities, and affect regulation strategies. inapp features included a digital reward card that revealed a small incentive (ranging between $0.50-$3.00) for completing daily surveys and life conference abstracts 171 insights graphs that visually displayed participants' daily survey responses. acceptability items (rated on a 1-10 scale) included helpfulness of the app, likelihood of recommending the app to others, and ratings of inapp features (reward cards, life insights graphs); we also asked about the amount of messages received. we used paired wilcoxon tests to evaluate the effect of the app on cannabis use (i.e., number of days using cannabis in the past month) post-intervention and at the 2-month follow-up compared to baseline cannabis use. results: participants (n=122; 53.3% female sex; 73.5% white, 9.9% black, 5.0% asian, 10.7% other) indicated they would recommend the app to others (m=7.1, sd=2.2). participants found the app helpful overall (m=6.2, sd=2.3). the assessment of individual app components indicated high acceptability of the reward card incentives (m=8.1, sd=2.0) and lower acceptability of the life insights graphs (m=5.5, sd=2.6). most participants reported they received the right amount of messages (62.5%), while 21.4% would have preferred more and 16.1% would have preferred fewer messages. the intervention was feasible as indicated by the twice-daily in-app survey completion rate of 76.9%. importantly, there was a significant reduction in the number of past-month cannabis use days from baseline (m=24.8) to post-intervention (m=22.9; p=.002) and 2-month followup (m=21.7; p<.001). conclusion: the mhealth intervention app was feasible for eas to use, and eas rated the app and its features positively overall. preliminary results showed the number of past-month cannabis use days reduced over time, providing support for further testing of mhealth interventions in promoting behavior change in eas. applying qualitative results to inform a novel cannabis brief intervention for emerging adults: a case report study kathryn s. gex (musc) shannon phillips (musc) benjamin o. ladd (washington state university) christine m. lee (university of washington) kevin m. gray (musc) rachel l. tomko (musc) background: frequent cannabis use and cannabis use disorder are increasingly prevalent among emerging adults (18-25). brief interventions for preventing problematic use are critical, yet cannabis brief interventions demonstrate mixed efficacy in reducing use and problems due to use. novel approaches are needed to improve efficacy. approach: to inform development of novel intervention content and approaches, qualitative interviews were conducted with 12 emerging adults (50% cis-women, 33% cis-men, 17% non-binary) from the community. emerging themes focused on motives for use as well as perceptions of problematic use and consequence severity. although participants overwhelmingly indicated their primary reason for use was to relax/unwind to cope with everyday stress, other motives also were endorsed, indicating a variety of conference abstracts 172 unique reasons for use. while severity of personal consequences from cannabis use were perceived as relatively low, participants perceived high frequency use, dependence, and impairment in everyday life as indicators of problematic use. we integrated these themes with existing theory and research to develop a 2session cannabis brief intervention that uses motivational interviewing and emphasizes personal values and goals while targeting motives for cannabis use. the goal of the brief intervention is to motivate behavior change, whether by facilitating taking steps in an already identified plan or recognizing that their use pattern is creating or could create problems. to reduce the impact of cannabis use on quality time spent in valued life areas, session 1 provides feedback on motives for use and time spent in valued life areas to promote discussion of values and goals. session 2 complements session 1 by providing cognitive behavioral strategies tailored to the individual's reasons for using cannabis with the goal of improving contextbased decision-making regarding cannabis use. case studies: three emerging adults (2 cis-women, 1 cisman) have received the novel brief intervention as part of a small openlabel trial (target n=6) and completed follow-up out to 1-month. each participant had slightly different presentations of cannabis use and motives. for example, session 1 feedback for one participant primarily discussed use to help with sleep, whereas for another participant it primarily discussed use for enjoyment and out of boredom. although session 2 structure and approach was generally the same, the content in terms of cognitive and behavioral strategies differed for each individual. although reporting overall low motivation to change, two of the three participants reported increases in "taking steps" towards change on the stages of change readiness and treatment eagerness scale (socrates). one reported little-to-no change in "taking steps" but reported increased "recognition" of a potential problem with their use and decreased "ambivalence" about their use at the post-session assessment. on an 11point scale (0, not at all, to 10, very much), all participants rated the intervention highly overall (m=9.0), in its interestingness (m=8.0), personal relevance (m=8.7), usefulness (m=8.3), and effectiveness in changing how they use cannabis (m=7.7). these initial cases are encouraging and support continuation of the open-label trial which will be followed by a randomized pilot trial. characterization of the salivary metabolome from cannabis and tobacco users: biochemical insights to drug dependence risk claire gillespie* (mcmaster university) meera shanmuganathan (mcmaster university) philip britz-mckibbin (mcmaster university) iris balodis (mcmaster university) *student award honorable mention cannabis and nicotine are two of the most widely used drugs of abuse globally, posing significant harms from conference abstracts 173 smoke exposures, especially from couse, including chronic disease burden and/or cognitive impairment. current methods for the assessment of nicotine or cannabis dependence rely on standardized questionnaires, such as the fagerstrom test for nicotine dependence (ftnd), and the cannabis use disorder identification test (cudit), which are prone to bias and misreporting. there is a need for a more objective and non-invasive approach for the assessment of polysubstance use and drug dependence which can exacerbate mental health conditions particularly among high-risk patients. herein, we introduce a comprehensive approach to characterize the salivary metabolome from a diverse group of participants recruited for a psychosocial stress study divided into cohorts of selfreported never smokers (n=16), cannabis only (n=29) and mixed cannabis and tobacco users (n=17). we verify tobacco smoking and cannabis use habits while assessing drug dependence risk when compared to self-reports, including the impact of substance co-use (30% reporting mixed use). metabolomics is an emerging field in functional genomics which encompasses the analysis of low molecular weight metabolites in complex biological samples, including exogenous compounds from environmental exposures. previous reports have proposed that the salivary metabolome may provide unique insights into behavioral responses to psychological stress using a convenient non-invasive biofluid. a targeted and nontargeted analysis of polar aqueous metabolites, including salivary nicotine, cotinine, and hydroxycotinine was performed using capillary electrophoresis-mass spectrometry (ce-ms) under positive and negative ionization modes with full-scan data acquisition. salivary nicotine levels identified two participants with misreported tobacco use, which further correlated with self-reported nicotine dependence scores. salivary phytocannabinoid content, including cannabidiol, 9-tetrahydrocannabinol, and their metabolites were further quantified using reversed-phase liquid chromatography-mass spectrometry (lc-ms), and compared to selfreported modes of consumption and cannabis use dependence scores. the differential impact of drug use patterns on salivary metabolome and lipid profiles will be explored to better understand the deleterious effects of mixed cannabis and tobacco use, which may also allow for more objective assessment of nicotine dependence and/or cannabis use disorder. this work will provide new biochemical insights into drug dependence and health risks relevant to vulnerable canadian adults in an era of recreational cannabis legalization. monitoring changes in the new jersey cigar market following cannabis legalization: implications for blunt use allison m. glasser (rutgers institute for nicotine and tobacco studies) kevin r.j. schroth (rutgers institute for nicotine and tobacco studies) cristine d. delnevo (rutgers institute for nicotine and tobacco studies) andrea c. villanti (rutgers institute for nicotine and tobacco studies) conference abstracts 174 cigars are used to create blunts, which are disproportionately used by people who experience health disparities. preliminary studies report greater availability of blunt wraps and cigarillos co-marketed with cannabis in states with legalized cannabis, highlighting the growing potential harm of tobacco and cannabis co-use. this study assessed the relationship between the opening of adult-use cannabis retail outlets in new jersey (nj) and cigar sales by characteristics of products sold (flavor, package size, brand). nielsen convenience store data on cigar sales in nj were obtained for 12 quarters (01/02/2021 to 09/03/2023). halfway through this period (04/21/2022), legal sales of cannabis began in the state. joinpoint analyses determined inflection points in time when linear trends in the quarterly percent change (qpc) in sales shifted. over the full period, 6.0% of tobacco sales (6.2% prevs. 5.8% post-retail period, p<0.001) were for cigar products. beginning during the quarter when cannabis retail outlets opened, sale of alcohol-flavored cigars (19.1% of cigar market share) declined (qpc: -7.4%, 95% ci: -11.3, -5.0) compared to a pre-retail increase (qpc: 2.8%, 95% ci: 0.7, 5.8). fruit-flavored cigar sales declined during the first year of cannabis sales by 5.0% (95% ci: -6.4, -3.2) but rebounded over the study's last two quarters (qpc: 3.9%, 95% ci: 1.0, 6.4). other/conceptflavored (e.g., "green envy", "kush") cigars' proportion of the flavored cigar market share (3.7% to 6.7%, p<0.001) almost doubled from the preto postretail period. following initial sale of cannabis, sale of 2-3-pack cigars dropped by 3.0% (95% ci: -4.1, -1.6) until one year later, then rebounded by 2.6% (95% ci: 0.1, 4.6) over the last two quarters. sales for 5-packs dropped by 6.5% (95% ci: -7.8, -5.0) from when cannabis sales began to one year later. while sale of packs with 20+ cigars were low (2.6% of cigar market share), sales gained a 24.8% increase in units sold (95% ci: 4.4, 49.3) one year after cannabis sales began compared to a prior decline. backwoods (qpc: -11%, 95% ci: -12.0, -9.4) and white owl brand cigar (qpc: -14.2%, 95% ci: 18.6, -8.9) sales declined during the year after sales began. sale of game cigars (8.5% of market share) increased by 6.1% (95% ci: 2.3, 8.1) starting one year after sales began. black & mild cigars gained 2.3% (95% ci: 1.1, 3.4) of the cigar market share after sales began through the end of the study period. sale of some traditional cigar flavors (e.g., alcoholic drinks, fruit) and cigars in 2-3 and 5-packs declined after cannabis retail sales opened, while sale of concept-flavored cigars and larger packs increased. sale of some cigarillo brands commonly used for blunts declined post-cannabis retail, while sale of black & mild, commonly used to smoke tobacco, increased. for cigars often used for blunts, there was some evidence of a rebound in sales one year after cannabis sales began as the number of retail outlets increased. alternative cannabis products, including pre-rolled blunts, available in legal cannabis retail outlets, may be displacing the use of cigar products to roll blunts. conference abstracts 175 evaluating diverse impacts of recreational cannabis legalization in michigan jason e. goldstick (university of michigan) philip stallworth (university of michigan) keara sullivan (university of michigan) maureen a. walton (university of michigan) kipling m. bohnert (michigan state university) emily dove-medows (university of michigan) erin e. bonar (university of michigan) introduction: michigan citizens voted in november 2018 to legalize recreational cannabis for cultivation, sale, and consumption for those ages 21 and older. michigan became the 10th state and the first in the midwest to enact such a measure and the retail market subsequently opened in december, 2019. to gain a broad sense of the potential impacts of recreational legalization in michigan across healthrelated indicators, we evaluated data over time from a variety of sources (e.g., healthcare utilization, staterepresentative surveys, etc.). methods: we gathered data from administrative and community partners (e.g., department of health/human services) and publicly available sources (e.g., national survey on drug use and health) to characterize the following preand post-recreational legalization: state cannabis use prevalence, cannabis-related toxicology in suicide and homicide deaths, cannabis-related emergency department utilization, and cannabis use among expectant and post-partum mothers. findings are descriptive and represent time periods that vary; demographic trends within each data source will be reported. results: in the most recent data (20212022), 18.5% of michigan residents reported past-month cannabis use, an increase of over 150% from 7.2% since 2002-2003. the post-legalization rate remains greater than what is found in the midwest and the nation. among michigan suicide decedents receiving cannabis toxicology testing, the proportion testing positive for cannabis was relatively stable from 2016 (21.0%) to 2018 (23.0%). this proportion increased annually, reaching a peak of 35.0% in 2021, prior to declining to 25.0% in 2022. regarding michigan homicide victims tested, the proportion testing positive for cannabis decreased prior to recreational legalization, but starting in 2018 has increased steadily to a peak of 64.0% in 2022. ed visits for cannabis poisoning climbed after recreational legalization to 7.3 per 100,000, though have leveled off across 2019-2021; youth <15 accounted for the largest increase (10.4% to 16.4% of visits). most expectant mothers do not use cannabis in the months before, during, or after pregnancy. for 20212022, 74.4% of michigan expectant mothers did not use cannabis before, during, or after pregnancy; this rate is lower than the 86.7% reported in 20162017. conclusions: with the opening of a legal recreational market in michigan several indicators of health and well-being are being monitored for change. notably, the retail market opened just prior to the covid-19 pandemic, which likely impacted conference abstracts 176 health and well-being indicators concurrent with the data examined. key findings reflect increases in cannabis found in the toxicology testing of homicide and suicide decedents, with a more recent decline in positive cannabis toxicology in suicide decedents. also, there has been an increase in cannabis use among pregnant and post-partum mothers. ed visits related to cannabis poisoning increased initially, but appear to have leveled off. there is a need, however, for continued evaluation of these indicators over time as numerous forces can impact outcomes (e.g., potency, price, outlet density). current findings point to the possible benefit of public health efforts to mitigate cannabis use among potentially vulnerable populations, such as those experiencing mental health symptoms, those who are pregnant or planning to become pregnant, and youth. the role of coping flexibility in the association between depression and anxiety symptoms and risk of problematic cannabis use among young adults bella m. gonzález-ponce (university of extremadura) alberto parrado-gonzález (university of huelva) josé carmona-márquez (university of huelva) adrian j. bravo (william & mary) fermín fernández-calderón (university of huelva) background and aims: depression and anxiety are well-documented risk factors for problematic substance use, including cannabis. according to the self-medication hypothesis, individuals experiencing distress may turn to cannabis use as a maladaptive coping strategy. however, coping flexibility, which refers to the ability to adjust coping strategies to situational demands, may help mitigate this risk. research suggests that individuals with greater coping flexibility demonstrate better psychological adjustment and are less likely to use substances for emotional regulation. for instance, studies on alcohol consumption show that those with greater coping flexibility adopt more adaptive coping mechanisms, reducing their need for substance use as a means of emotional regulation. in this vein, the present study examined the moderating role of coping flexibility in the relationship between anxiety, depression, and cannabis use disorder symptoms among young adults in spain. methods: this study is part of the psicocann project, a longitudinal study that used targeted sampling to recruit a community sample of 612 young adults in spain aged 18-25 who reported cannabis use in the pastmonth. among the 612 participants, 505 (31.9% female, mage = 21.25; sd = 2.17) completed follow-up measures three months later. at baseline, participants completed the coping flexibility scale (cfs-8) and the depression, anxiety and stress scale21 (dass-21). at follow-up, cannabis use disorder symptoms were assessed using the cannabis use disorder identification test (cudit). two simple moderation models were conducted using the process macro in spss 29.0. sex, age, and university status were included as covariates. conference abstracts 177 results: findings showed that coping flexibility moderated the relationship between anxiety (interaction é¿ = å|0.034, p = .004) and depressive symptoms (interaction é¿ = å|0.021, p = .024) on cannabis use disorder symptoms. specifically, the positive relationships between depression/anxiety symptoms on cannabis use disorder symptoms was weakest among individuals reporting higher coping flexibility. for example, within the depression model the relationship between depressive symptoms and cannabis use disorder was non-significant at higher levels of coping flexibility (é¿ = 0.14, p = .060). conclusions: our results suggest that coping flexibility serves as a protective factor, reducing the impact of anxiety and depression may have on problematic cannabis use among young adults who use cannabis. individuals with high coping flexibility may be less likely to use cannabis as a coping mechanism, as they may engage in alternative strategies to manage distress. these findings highlight the potential for interventions incorporating coping flexibility training to help decrease problematic cannabis use in this population. cannabis policy and product safety: implications for patients and consumers in the u.s. symone griffith (arizona state university) kendra conrow (arizona state university) marisa kreider (stantec) maxwell leung (arizona state university) while cannabis legalization continues to advance, considering the health and safety of patients requires urgent attention to contamination risks. in particular, the opportunistic infection risk and neurological side effects associated with fungal contaminants and pesticide residues in cannabis have raised safety concerns in recent years. while the public health regulation of cannabis is often compared to alcohol, alcohol production in the u.s. has robust quality and safety controls at the state and federal levels. these quality and safety controls were prompted by the history of severe health effects of moonshine consumption on consumers. since cannabis is often marketed as a beneficial product for those with certain medical conditions, there is a need for closer regulation. yet, while cannabis is regulated by many states, the regulations are inconsistent. no uniform safety regulation is applied for the patient populations in the u.s. in this presentation, we would like to address the question of how scientists, regulators, doctors, and other stakeholders can help improve the safety of cannabis for medical and recreational use, given the risks apparent in the current lack of federal involvement and research. first, a multi-stakeholder regulatory framework is needed under the leadership of the federal government and state agencies. like many federalstate partnerships such as medicaid, the federal government sets the 'floor' or the minimum requirements/baseline level for healthcare coverage, and the states can set the 'ceiling' or any additional coverages that they may conference abstracts 178 deem appropriate for their constituents. similarly in the context of cannabis, federal involvement as well as multiple stakeholders is crucial to shape a comprehensive regulatory system. as the federal government has yet to change its stance on cannabis, state agencies should play a key role in developing contaminant action levels that are risk-based, clear, and transparent. second, the contradictory nature of current cannabis state and federal policies needs to be addressed. a schedule i drug is defined as having a high potential for abuse, no currently accepted medical use, and a lack of accepted safety for use under medical supervision. this, in contrast to states' medical qualifying conditions is confusing for consumers and physicians alike and can lead to higher rates of misuse, abuse, and lack of communication between patients and providers. lastly, federal investment is needed in cannabis safety research. the u.s. federal agencies such as the nih, fda, epa, and usda are not funding cannabis safety research, partly due to the current federal stance on cannabis as a schedule i substance. current cannabis research primarily focuses on abstaining from use, its effect on adolescent development and addiction, and evaluating it as a drug of abuse. we recommend that the u.s. federal agencies allocate funding to study contaminants, develop sterilization technology, improve patient education, and incentivize solutions for safer cannabis production. these changes in the science and technology policy of cannabis will play a pivotal role in promoting cannabis safety. the effect of number of dispensaries on cannabis consumption among high school students in colorado mohammad i. habib (colorado state university) cole scott (colorado state university) maggie vanbuskirk (colorado state university) bradley t. conner (colorado state university) background: cannabis markets are growing and there are generally mixed findings on the effects of increased number of retail markets. research does suggest that greater number of cannabis dispensaries are associated with increased consumption. however, it is still relatively unknown how the number of dispensaries affects high potency cannabis use and cannabis use among adolescents, and whether the type of dispensary (recreational or medical) has any effect. high potency cannabis use is of importance because it is commonly associated with increased risk of experiencing negative outcomes from cannabis use, such as cannabis use disorder. in this study, we aim to determine if cannabis use frequency and high potency cannabis use frequency differ by the number of dispensaries or by dispensary type. method: data in this study were obtained from the healthy kids colorado survey. high school aged youth (n = 10,379) completed a survey asking about their past 30-day frequency of cannabis use and frequency of high potency (i.e., "wax") use. students were separated into regions based on county groupings. data on the number and type of conference abstracts 179 dispensaries for each county and subsequently each region in colorado were obtained from the publicly available licensed list of dispensaries on the colorado government's website. data were collected from students at randomly selected public high schools in the state of colorado. to determine if total number of dispensaries influenced either cannabis use frequency, a multilevel logistic regression among all students was tested followed by a multilevel negative binomial regression among those who used cannabis. similar models were conducted for wax use and for the number of recreational/medical dispensaries. data were analyzed using r version 4.4.1. results: the total number of dispensaries, recreational dispensaries, or medical dispensaries were not associated with an increase in the log-odds of reporting past 30-day cannabis use (b=0.08, 95%ci: -0.03,0.20; b=0.09, 95%ci: 0.02, 0.2; b=0.06, 95%ci: -0.05,0.19, for total, recreational, and medical respectively), nor was the total number of dispensaries associated with increased past 30-day frequency (b=0.004, 95%ci: -0.05,0.06; b=0.01, 95%ci: -0.04,0.06; b=-0.07, 95%ci:0.06,0.05, for total, recreational and medical respectively). we observed the same pattern with the relation between the number of total, recreational, and medical dispensaries and log-odds of reporting any past 30-day wax use (b=0.07, 95%ci: -0.09,0.09; b=0.01, 95%ci: -0.08, 0.10; b=-0.01, 95%ci: 0.10,0.08, for total, recreational, and medical respectively) and with past 30day wax frequency (b=-0.02, 95%ci: 0.11,0.07; b=-0.01, 95%ci: -0.10,0.08; b=-0.03, 95%ci:-0.12,0.06, for total, recreational and medical respectively). conclusions: these data suggest that the number of dispensaries, either recreational or medical, have little to no effect on cannabis use frequency or high potency cannabis use among high school aged students in colorado. more research is needed to determine if distance to the nearest dispensary or dispensary advertising practices have different effects on adolescent cannabis consumption, and future studies should account for pre-filled cannabis cartridges. measuring cannabis use and cannabis use disorder among people with hiv, by age, sex, race and ethnicity and sexual or gender minority status, using biomarker, self-report and icd codes danielle f. haley (boston university school of public health) amy justice (va connecticut healthcare systems, yale university school of medicine) ziming xuan (boston university school of public health) rachel sayko adams (boston university school of public health) michael silverberg (kaiser permanente northern california) adam trickey (bristol medical school, university of bristol) derek satre (university of california, san francisco and kaiser permanente northern california) kaku so-armah (boston university school of medicine) suzanne ingle (bristol medical school, university of bristol) conference abstracts 180 farah kidwai-khan (va connecticut healthcare systems and yale university school of medicine) matthew p. fox (boston university school of public health) aleksandra wrona (va connecticut healthcare systems, yale university school of medicine) rob j fredericksen (university of washington school of medicine) kathleen mcginnis (va connecticut healthcare systems, yale university school of medicine) introduction. nationallyrepresentative samples estimate cannabis use and cannabis use disorder (cud) to be at least three times greater among people with hiv (pwh) vs. those without. pwh use cannabis for pain, stress reduction, and hiv-related symptoms, but may be at elevated risk for adverse cannabis-associated outcomes due to multimorbidity, physiologic frailty, and polypharmacy. while characterizing benefits and risks of cannabis use among pwh is critical, cannabis use is not routinely captured in healthcare systems and may be subject to bias. we compared cannabis use based on a biomarker, self-report, and cannabis use disorder diagnostic codes using a multi-cohort study of pwh, overall and by age, sex, race and ethnicity, and sexual or gender minority status (sgm). methods. the medications, alcohol and substance use in hiv study is a cross-cohort study examining polypharmacy and substance use among pwh enrolled for a single visit between 2018-2022. participants reported cannabis use on a confidential survey and provided nail clippings for immunoassay and mass spectrometry testing. two of the three cohorts provided electronic health records (ehr), supporting investigation of cud diagnosis using international classification of diseases, tenth revision, clinical modification (icd-10-cm) codes (f12*, t40.711*). we examined: 1) kappa statistics comparing the biomarker (gold standard) to self-reported monthly (or more) cannabis use (n=1,226) and 2) overlap between cannabis use (biomarker or self-report) and a cud diagnosis within 2 years (n=705 participants with ehr). we did this overall and by age, sex, race and ethnicity, and sgm status. results. participants (n=1,226) were mostly male (85%), non-white (64%), and sgm (60%). mean age was 57 years. twenty three percent self-reported cannabis use and 20% had a positive biomarker. self-reported and biomarker cannabis measures showed substantial agreement (kappa = 0.67 overall; 0.600.72 by subgroups). among participants with ehr, 32% selfreported cannabis use and/or had a positive biomarker; of those, 21% had a cud diagnosis. white non-hispanic participants were more likely to use cannabis than black non-hispanic or hispanic participants (39% vs. 32% and 30%) but less likely to have diagnosed cud (14% vs. 22% and 27%). participants aged >60 were less likely to use cannabis than participants aged <60 (30% vs. 35%), but more likely to have a diagnosed cud (23% vs. 19%). women were less likely to use cannabis than men (23% vs. 33%) and to have a diagnosed cud (11% vs. 21%). sgm were more likely to report cannabis use than non-sgm (34% vs. 29%) and to conference abstracts 181 have a diagnosed cud (21% vs. 19%). conclusion. cannabis use and cud is common among pwh, including those aged 60, and can be reliably captured by self-report. as has been previously demonstrated for alcohol use disorder, non-white adults may be over-screened and diagnosed for cud relative to white adults. unbiased methods for identifying cannabis use in ehr, such as patient queries and innovations involving natural language processing should be explored so that both positive and negative impacts of cannabis use on health, especially among older individuals in care, can be better understood. cannabis use disorder diagnosis among people with and without hiv, by sex and race/ethnicity, 2000-2022 danielle f. haley (boston university school of public health) kaku so-armah (boston university school of medicine) amy justice (va connecticut healthcare systems, yale university school of medicine) derek satre (university of california, san francisco and kaiser permanente northern california) farah kidwai-khan (va connecticut healthcare systems and yale university school of medicine) ziming xuan (boston university school of public health) rachel sayko adams (boston university school of public health) michael silverberg (kaiser permanente northern california) matthew p. fox (boston university school of public health) adam trickey (bristol medical school, university of bristol) suzanne m. ingle (bristol medical school, university of bristol) aleksandra wrona (va connecticut healthcare systems, yale university school of medicine) kathleen mcginnis (va connecticut healthcare systems, yale university school of medicine) introduction. systematic reviews and meta-analyses estimate 20-30% of people using cannabis have a cannabis use disorder (cud). however, data are lacking that characterize cud over time and among groups historically underrepresented in cannabis research (e.g., women, racialized minorities, people with hiv). to evaluate cud trends, we examined cud diagnoses from 2000-2022, by hiv status, race/ethnicity, and sex, in a large, demographically-matched cohort of people with hiv (pwh) and without (pwoh). methods. this analysis includes electronic health records from ~180,000 individuals in the veterans aging cohort study-hiv, a national us cohort of pwh matched 1:2 to pwoh using data from 2000-2022. annual cud diagnosis was determined by dividing the number with a cud international classification of diseases-clinical modification (icd) code each year by number with at least one outpatient icd code in each year. we examined trends by sex, race/ethnicity, and hiv status graphically and with multivariable logistic regression models. results. demographic characteristics were comparable for pwh (n=58,959) vs. pwoh (n=126,413): 45% black non-hispanic; 35% white non-hispanic; 7% hispanic; conference abstracts 182 3% women. the mean age was 48 years. twenty percent of pwh and 17% of pwoh had a cud diagnosis from 2000-2002. the percent with diagnosed cud was highest for black nonhispanic pwh, black non-hispanic pwoh, and hispanic pwh over time. cud diagnoses increased in all subgroups and were consistently higher among pwh than pwoh over time (odds ratio=1.14 [95% confidence interval [ci]=1.10-1.18]). cud diagnoses increased from 2000 to 2022 for pwh and pwoh, respectively, from 4.6% to 6.8% (pwh) and 4.1% vs. 5.6% (pwoh) among black nonhispanic, from 2.4% to 4.4% (pwh) and 2.2% to 3.4% (pwoh) among white non-hispanic and from 3.3% to 5.4% (pwh) and 2.0% to 3.4% (pwoh) among hispanic. in adjusted models, among both pwh and pwoh, individuals who identified as black non-hispanic were more likely to have a cud diagnosis (pwh or=1.72 95%, ci=1.62-1.83; pwoh or=1.77, 95% ci=1.69-1.85) than individuals identifying as white non-hispanic. among pwh only, those identifying as hispanic were more likely to have a cud diagnosis than those who were white non-hispanic pwh (or=1.28, 95% ci=1.14-1.43). among pwh and pwoh, cud diagnoses increased from 2000 to 2002 from 3.6% to 4.9% (pwh) and 1.9% to 3.2% (pwoh) for females and 3.4% to 5.7% (pwh) and 3.0% to 4.5% (pwoh) for males. in adjusted models, for pwh there was no difference in the likelihood of having a cud diagnosis by sex (or=1.01, 95% ci=0.87-1.18). however, among pwoh, females were 50% less likely to have a cud diagnosis than males (or=0.50, 95% ci=0.43-0.57). conclusion. cud diagnoses increased dramatically among all subgroups over time and were higher among pwh. cud diagnoses were more common among black non-hispanic and hispanic individuals; this warrants further exploration to determine whether there may be differences in screening by race/ethnicity. universal screening and treatment advances are needed, as is research characterizing patterns and modalities of cannabis use, cud, and potential harms and benefits of cannabis use. combined marijuana and ssri use: effects on romantic relationships sadie e. harper (division of mathematics and natural sciences, brescia university) jonathan e. dudko (division of mathematics and natural sciences, brescia university) abstract: despite the increased prevalence of marijuana and ssri use among college students, limited research has examined their combined impact on romantic relationships. in 2022, 40.9% of college students reported marijuana use, and psychiatric prescriptions among this demographic increased by 42% compared to 2015-2019. given that college provides a formative environment for romantic relationships-evidenced by reports that up to 50% of tinder users are of traditional college age-understanding how substance use affects relationship satisfaction is critical. we used the couples satisfaction index (csi-32), an accepted clinical tool, along with conference abstracts 183 supplemental questions for group sorting to identify potential relationship impacts correlated with combined use of marijuana and ssri medications. we recruited both traditional and non-traditional college students from two universities in western kentucky and southern indiana to participate in an anonymous online survey. a kruskal-wallis test was conducted using preliminary data to examine the differences in relationship satisfaction rates between four groups: combined use, marijuana only, ssris only, and no use. no significant differences were identified (é‘ = 2.47, p = 0.481, df = 3). median csi-32 scores appeared highest in the no use (137.5; n = 16) and ssri only (132; n = 4) groups, with lower scores for marijuana only (119; n = 10) and combined-use (110.5; n = 4) groups. while no definitive conclusions can be drawn from this preliminary data, it is interesting to observe the apparently higher scores achieved by those in the no use and ssri only categories. notably, both groups of participants that reported marijuana use scored lower than the groups without marijuana use. additionally, the median value for the combined use group approached the threshold for "notable relationship dissatisfaction" (csi-32 scores falling below 104.5). while these findings remain inconclusive due to the limited sample size, they highlight the need for future research exploring the potential effects of ssri and marijuana use on romantic relationships. additional analyses considering frequency of use, relationship length, and mental health status may provide greater clarity on how these substances influence relationship satisfaction. associations between the retail marijuana environment and youth sources of marijuana in 40 california cities kirsten helgeson (pacific institute for research and evaluation) mallie j. paschall (pacific institute for research and evaluation) joel grube (pacific institute for research and evaluation) objective: to investigate youth sources of marijuana and their associations with local marijuana retail environments in 40 california cities. methods: survey data were obtained from 1,082 15-to-20-year-olds in 40 california cities in 2023-2024. survey questions asked participants who reported using cannabis in the past year to report their frequency of obtaining it from each of seven sources(1) a retail cannabis store, (2) a home delivery service, (3) an unlicensed dealer, (4) someone they know who is 21 or older, (5) someone they know who is under 21, and from home either (6) with or (7) without their parents' permission-over that same 12-month period. a list of licensed cannabis retailers was obtained from the california department of cannabis control, and a list of unlicensed dispensaries was compiled from systematic internet searches. counts of licensed delivery services available to each city were obtained from controlled weedmaps searches. a series of multilevel logistic regression models were conducted with participants who reported past-year conference abstracts 184 marijuana use (n = 400). participants' city of residence was treated as a random effect, and having acquired marijuana from each source (no, yes) were the dependent measures. citylevel densities of licensed and unlicensed cannabis storefront retailers and numbers of licensed delivery services were used as predictors, along with cityand participant-level demographic characteristics. results: the most commonly reported sources of marijuana were "from someone you know who is 21 or older" (65.3%) and "from someone you know who is under 21" (64.5%), followed by "from a dealer not at a cannabis store" (50.1%). the next most common responses were "from home without your parents' permission" (35.1%) and "at a retail cannabis store" (34.3%). the least commonly reported sources were "from home with your parents' permission" (23%) and "from a home delivery service" (19%). licensed cannabis storefront density was positively associated with participants' obtaining marijuana from a home delivery service (or = 1.19, p = 0.021) and a dealer (or = 1.15, p = 0.035). no other local retail environment measures were significantly associated with youth cannabis sources in any of the models. city-level socioeconomic status was positively associated with respondents' obtaining cannabis from a retail store (or = 1.71, p = 0.047), as were participants' age (or = 1.38, p = 0.007) and being male at birth (or = 2.38, p = 0.001). participants' age was positively associated with obtaining marijuana from someone 21 or older (or = 1.48, p < 0.001) and from home with their parents' permission (or = 1.42, p = 0.011). age was negatively associated with obtaining marijuana from someone under 21 (or = 0.75, p = 0.014). none of the predictors were significantly associated with obtaining marijuana from home without the parents' permission. conclusions: the findings of this study suggest that youth aged 15-to-20 primarily obtain cannabis through someone they know around their age and that a city's density of licensed cannabis retailers may be related to their obtaining cannabis through two other sources: from a home delivery service and from a dealer. body dissatisfaction, ruminative thinking, and cannabis use and consequences javeira hernandez puelma (william & mary) hanna pazo vargas (william & mary) katherine a. berry (university of wyoming) luke herchenroeder (george washington university) alison looby (university of wyoming) adrian j. bravo (william & mary) stimulant norms and prevalence 2 (snap2) study team (university of wyoming) cannabis is the second most used substance among college students in the united states. national survey data suggests that 39.5% of college students used cannabis in the past year, and 26.1% used it in the past month. cannabis use is a significant health concern among college students, as it is associated with a variety of psychological, academic/occupational, conference abstracts 185 and physical health consequences. research indicates that body dissatisfaction may contribute to risky health behaviors, including cannabis use. the present study examined whether rumination facets (problemfocused thoughts, counterfactual thinking, repetitive thoughts, anticipatory thoughts) serve as potential mechanisms indirectly linking body dissatisfaction to cannabis use and related consequences in college students. specifically, we tested whether higher body dissatisfaction relates to greater cannabis-related negative consequences via greater ruminative thinking and cannabis use quantity. college students (n=1,535; mage=19.39; 71.9% female; 60.7% white) from six u.s. universities who endorsed past-month cannabis use completed measures of body dissatisfaction, rumination, and cannabis outcomes. our estimated path model (i.e., body dissatisfaction -> rumination facets --> cannabis use quantity --> cannabis-related problems) showed one significant double-mediated association. specifically, higher body dissatisfaction was positively associated with greater cannabis problems via greater endorsement of problem-focused thoughts and greater cannabis use quantity (indirect b =0.012; 99% cis=0.005, 0.022). these findings suggest that individuals experiencing body dissatisfaction may ruminate more (particularly engaging in problem-focused thoughts), which in turn may lead to more cannabis use and, subsequently, more cannabisrelated problems. our findings align with prior research indicating that body dissatisfaction is a risk factor for cannabis use, and problem-focused thoughts may increase the risk of engaging in maladaptive coping strategies (particularly substance use). overall, these results highlight the relevance of rumination and cannabis use as potential factors in linking body dissatisfaction to cannabis-related problems among college students. intervention efforts targeting ruminative thinking, such as cognitivebehavioral strategies aimed at reducing problem-focused thoughts, may be advantageous in mitigating cannabis-related harms among students with high body dissatisfaction. medicinal versus recreational cannabis use stigma: examining associations between indicators of stigma, use behaviours, and negative outcomes ryan hooshiar* (york university) annabelle moore (york university) kyra n. farrelly (york university) nicolle fox (york university) matthew t. keough (york university) jeffrey d. wardell (york university, centre for addiction and mental health, and university of toronto) *student award winner background: despite the increasing prevalence of cannabis use and more liberal cannabis policies, cannabis use remains stigmatized in some contexts. perceived stigma surrounding cannabis use has been associated with negative outcomes such as decreased healthcare access. past studies have focused on perceived stigma among people exclusively engaging in conference abstracts 186 medicinal cannabis use (mcu) or recreational cannabis use (rcu), despite a growing population engaging in both mcu and rcu, especially among young adults. the goal of this study was to examine whether young adults engaging in both mcu and rcu perceive different levels of disapproval for their mcu versus their rcu and whether they are more or less comfortable disclosing their mcu versus their rcu to others. the study also examined how both mcu and rcu stigma (operationalized as discomfort disclosing and perceived disapproval of cannabis use) relate to route of cannabis administration and cannabis problem severity. method: data came from a pilot ecological momentary assessment (ema) study of young adults (ages 18-34) who reported engaging in both mcu and rcu (n= 43; 74% female). the current analyses focused on measures administered in the online baseline survey preceding the ema, including items assessing participants' discomfort disclosing and perceived disapproval of their mcu and rcu for various referent groups (e.g., family, friends, etc). for the analyses, discomfort and disapproval items (rated on 5-point scales) were averaged across all referent groups for both mcu and rcu. additionally, participants completed measures of cannabis use behaviours, including primary route of administration (dichotomized as smoking vs nonsmoking), and cannabis problem severity. results: a dependent samples t-test indicated no significant within-person difference in discomfort disclosing mcu (m=2.75, sd=0.85) versus rcu (m=2.79, sd=0.92), t(42)=0.56, p=.58. however, a separate dependent samples t-test indicated participants perceived greater disapproval of their rcu (m=3.00, sd=0.61) than their mcu (m=2.79, sd=0.56), t(42)=-3.29, p=.002. mixed ancovas indicated no significant interaction between reason for use (mcu vs. rcu) and primary route of administration (smoking vs. nonsmoking) on discomfort disclosing, f(1, 41)=0.01, p=.93, np2<0.01, or perceived disapproval, f(1, 41)=0.41, p=.52, np2<0.01. however, there was a main effect of route of administration on discomfort, f(1, 41)=15.04, p<.001, np2=0.14, such that individuals who reported primarily using non-smoking routes of administration had greater discomfort disclosing cannabis use (collapsed across mcu and rcu). multiple linear regressions showed that discomfort disclosing and perceived disapproval of mcu and rcu were not statistically significant predictors of cannabis problem severity indices (all p>.05). conclusion: results indicate that despite similar levels of comfort disclosing mcu and rcu, young adults perceived more disapproval from others for their rcu than their mcu. while route of administration did not moderate differences between mcu and rcu in stigma indicators, the fact that young adults primarily using non-smoking methods felt greater discomfort disclosing cannabis use overall justifies further investigation given that it contradicts smoking stigma literature. the nonsignificant associations between cannabis use stigma indicators and cannabis problem severity may have resulted from low conference abstracts 187 power due to small sample size, pointing to the need for larger samples in future research. outlook of the massachusetts medical cannabis program eight years after adult-use legalization and implementation graelyn humiston (commonwealth of massachusetts) alexander m. colby (commonwealth of massachusetts) hailey pensky (commonwealth of massachusetts) victoria edwards commonwealth of massachusetts) kate fiske (commonwealth of massachusetts) andrew carter (commonwealth of massachusetts) julie k. johnson (commonwealth of massachusetts) background as adult-use cannabis approval grows, states pass laws to enact and implement legalization measures. cannabis markets change rapidly, and it remains an ongoing question how medical cannabis programs fare after adult-use cannabis is implemented. regulatory agencies must proactively monitor many indicators for market health, which differ for adult-use and medical markets. medical markets, by definition, exist to provide patients with a medicine; if these markets are not closely monitored, patients may lose access to that medicine. methods we evaluated massachusetts' medical use of marijuana program through five metrics: total sales, units sold, registered patients, registered clinicians, and medical treatment centers (mtcs). registered patients, clinicians, and mtcs are reported in cannabis control commission (ccc) monthly public meetings. registered patients are reported as "total patients (active patients)." medical and adultuse sales data are available on the ccc's open data catalog. we calculated inflation using the u.s. bureau of labor statistics cpi inflation calculator. we used r, microsoft excel, and tableau for data cleaning and analysis. results registered patients rose from 64,351 (57,285) in january 2019 to a peak of 104,960 (99,108) in january 2022, then decreased 19.7% to 87,719 (82,820) in february 2025. this most recent total remains 22.8% (24.6%) higher than the 67,742 (62,459) reported in march 2020, before the adult-use market temporarily closed due to the covid19 pandemic. the number of medical providers peaked in february 2025, with 334 physicians (+21.3% since march 2020), 124 nurse practitioners (+39.5%), and 7 physicians' assistants (none in march 2020). there were 97 mtcs reported as operating in february 2025, a 10.3% decrease from the peak of 107 in 2024, but a 38.1% increase from 60 in march 2020. medical market sales peaked at $269m in 2021 and fell to $162m in 2024. january 2025 saw $11.7m in sales ($9.5m in february 2020 dollars), a 27.7% decrease from the $12.2m transacted in february 2020. by contrast, the adult-use market grew from $55.4m in february 2020 to $132.9m in january 2025 ($108.2m in february 2020 dollars, a 48.8% increase). units sold decreased from a peak of 6.3m in 2022 to 5.6m in 2024, conference abstracts 188 but remain above pre-pandemic levels, with 419k units sold in january 2025, a 45.3% increase from 288k in february 2020. prices have decreased for all products in both medical and adult-use markets. buds, for example, decreased from $11.22/gram in the medical market in february 2020 to $4.62/gram in january 2025 ($3.76/gram in february 2020 dollars, a 66.5% decrease). discussion these metrics paint a complex picture of the state of massachusetts' medical market, which has shrunk by some measures since its peak, but whose peak was partly fueled by a steep increase in registered patients during the adult-use market closure in marchmay 2020. sales in dollars and units sold diverge due to the decrease in product prices, which is an unsurprising trend with the increased number of mtcs and adult-use establishments. these metrics reveal that maintaining mtc financial sustainability and patient registrations amid competition from adult-use establishments are key concerns for regulators. the impact of cannabis retail availability on cannabis and mental health outcomes among medicaid recipients in wa state helen ippolito (washington state institute for public policy) this paper examines the impact of cannabis retail availability on cannabis and mental health-related outcomes including diagnoses, treatment, ed visits, hospitalizations, and psychotropic drug prescriptions. using individual-level medicaid claimant data on participants aged 12 to 64 from washington state between 2013-2023, we take advantage of the staggered opening of retailers across the state in a difference-in-differences estimation framework-this allows us to estimate if, on average, healthcare outcomes change with proximate cannabis retail openings. retail availability is primarily measured as an average drivetime of 20-minutesresults are qualitatively robust to alternative measures of access. overall, among legal-aged adults, we find that residing in a locale with a nearby cannabis retailer leads to roughly a 2-7% increase in the prevalence of cannabis use disorder diagnoses (cud), cannabis-related hospitalizations, ed visits, inpatient treatment, and outpatient treatment. in addition, we find that retail availability leads to an increase in the co-occurrence of cud-or cud-related hospitalization or treatment-and mental health diagnoses including depression and psychosis. impacts are increasing with hospital access, and in the years following the advent of legalization. evidence is mixed regarding the relationship between cannabis-related outcomes and the prevalence of select psychotropic drug prescriptions. the size of the impact of retail availability differs across race, with the largest impact, at over 10%, observed among asian recipients, followed by hispanic and native american recipients. subgroup analyses further reveal that relatively larger effects are observed among recipients with a diagnosed disability, and there is little variation in effects across sex. when examining outcomes conference abstracts 189 for youth and under-aged adults, evidence suggests co-occurring cud and select mental health diagnoses increase with retail availability. fungal and illicit drug contaminants in blackand gray-market cannabis in arizona and california, 2023 2024 maxwell leung (arizona state university) albert rivera (arizona state university) mike grommes (desert tox, llc) thomas cahill (arizona state university) cannabis has been legalized in 39 states and washington, d.c. for medical or recreational use. yet, the illicit market including unlicensed production (i.e., black market cannabis) within a legalized state and products that failed compliance testing in the gray market accounts for the majority of the u.s. cannabis market at 76 billion dollars as compared to the legal market at only 30 billion dollars in 2022. the contamination level of blackand gray-market cannabis is largely unknown. in this study, we surveyed the production environment and contaminant sources of illicit cannabis. maricopa county sheriff's office (mcso)'s high intensity drug trafficking areas task force conducted 37 seizures between 2023 and 2024. while 90% of seized cannabis in arizona was estimated to come from california, a few grow operations were discovered locally in arizona. stressed cannabis plants were found in improperly managed grow operations with standing water and algal growth. water damage and black mold were found on the ceiling, walls, and doors of the illicit sites. additionally, illicit cannabis products were packaged in unkempt bench areas. next, we examined 20 aspergillus and fusarium mycotoxins and 3 metabolites in black and grey market cannabis seized by law enforcement in arizona and california. mcso, together with u.s. postal inspection services, seized a total of 118 blackand gray-market cannabis dried flower samples between 2023 and 2024. using sciex 5500 qtrap lc-ms-ms with a matrixmatched calibration of hemp flower, we detected mycotoxins and fungal metabolites in 1 in every 6 illicit cannabis flower samples (i.e., 16%), including fusarenon-x (10 samples; 500-1,700 ppb), diacetoxyscirpenol (one of the federally designated biological select agents and toxins; 3 samples; 276-297 ppb), and deepoxydeoxynivalenol (a microbial metabolite of deoxynivalenol, also known as vomitoxin; 2 samples; 316-876 ppb). only one sample contained one of the five mycotoxins (i.e., aflatoxin b1, b2, g1, and g2 and ochratoxin a) regulated in the legal market. further analyses are underway to test for the presence of illicit drug contaminants including cocaine, fentanyl, and psilocybin in the blackand graymarket cannabis samples. cannabis social equity initiatives among us states with legal nonmedical cannabis retail: a review and recommendations cassidy r. loparco (george washington university) rishika chakraborty (george washington university) conference abstracts 190 morgan speer (george washington university) y. tony yang (george washington university) carla j. berg (george washington university) background: cannabis legalization continues to expand in the us. several states have enacted laws/policies to advance social equity (se). we documented cannabis-related se policies in the 24 states that have legal non-medical cannabis retail. methods: state cannabis-related se laws/policies (promotion in industry participation among disproportionately-impacted communities, community reinvestment, criminal justice reform) as of december, 2024 were independently identified using on lexisacademic, westlaw, heinonline, state-specific legislative websites, and other relevant documents by two coders who underwent an iterative content and thematic analysis. results: se programs related to cannabis licensure were present in 20/24 states (83%); of these, 60% reserved a number/percent of for se applicants. regarding se licensure eligibility, most states (65%) required majority ownership in the business and had criteria that considered whether applicants and/or their family were ever arrested/convicted for cannabisrelated offenses (80%), residence in disproportionatelyimpacted/disadvantaged areas (80%), and/or applicants' income/wealth (50%). most states with se programs provided se applicants/licensees with technical assistance, training, and opportunities for reduced application and licensing fees (65%). all 24 states had cannabis taxes on retail sales, ranging from 5-20%; 8 states (33%) also had excise taxes. most states (58%) distributed cannabis-related revenue to substance education/prevention/treatment (ranging from 5-72%); one-third (33%) distributed funds for equity-related purposes. over half of states (63%) had cannabis-related expungements. discussion: while cannabis-related se initiatives were present (e.g., reserved licenses, training, allocation of tax revenue, expungements), several states could benefit from implementing or expanding these programs. future research is needed to monitor and evaluate these se programs. cannabis and derived cannabis use, motives, and consequences among us young adults: findings from a crosssectional mediation study cassidy r. loparco (george washington university) yuxian cui (george washington university) matthew e. rossheim (university of north texas health science center) rishika chakraborty (george washington university, washington) morgan speer (george washington university) julia chen-sankey (rutgers university) patricia a. cavazos-rehg (washington university) carla j. berg (george washington university) background: since the 2018 agricultural improvement act, derived intoxicating cannabis products (dicps) conference abstracts 191 emerged as largely unregulated products; meanwhile, traditional cannabis use has increased. to inform effective prevention, research is needed to assess differences in motives for using cannabis only versus both cannabis and dicps, as well as userelated consequences. methods: we analyzed survey data (june-november 2023) from 4,031 us young adults ages 18-34 (average age=26.9; 63.9% white; 59.0% female; aiming for ~50% pastmonth cannabis use). the analytic sample included participants reporting past-month cannabis use (n=1,968). two cross-sectional mediation models were conducted to examine: 1) cannabis use motives (social/cognitive enhancement and coping) in relation to use-related consequences (psychophysiological and sociobehavioral) via use category (cannabis-only vs. cannabis-dicp couse) and 2) consequences in relation to use category via use motives. results: overall, 54.4% reported cannabis-only use and 45.6% reported cannabis-dicp co-use. greater enhancement and coping motives were associated with cannabis-dicp co-use (vs. cannabisonly use). regarding model #1, lower cannabis coping motives and cannabisdicp use (vs. cannabis-only use) were associated with greater psychophysiological and sociobehavioral consequences, and the associations between coping and enhancement motives and psychophysiological and sociobehavioral consequences were indirectly mediated via cannabis-dicp co-use. for model #2, lower psychophysiological and greater sociobehavioral consequences were associated with greater coping and enhancement motives, greater sociobehavioral consequences was associated with higher odds of cannabis-dicp co-use (vs. cannabisonly use), and psychophysiological and sociobehavioral consequences were indirectly associated with cannabisdicp co-use through enhancement and coping motives. conclusions: considering the risks associated with cannabis and dicp use, future intervention and prevention efforts should focus on the observed associations to reduce risk. snapchat ai as an information source on delta-8 thc cassidy r. loparco (george washington university) kayla k. tillett (university of north texas health science center) ayyüce begüm bektaş (memorial sloan kettering cancer center) matthew e. rossheim (university of north texas health science center) carla j. berg (george washington university) introduction: snapchat is a prominent social media site among youth. in april 2023, snapchat released an aipowered chatbot that was automatically implemented on all accounts. given the apparent ease in communicating with this feature, youth may use it as an information source. methods: while snapchat purports to block results for drug keywords, it is unclear the extent to which this type of content is blocked. in august 2024 january 2025, we asked snapchat ai questions related to delta8 thc, a derived psychoactive conference abstracts 192 cannabis product that has been rapidly rising in popularity in the us and has limited regulations. qualitative responses were independently coded into thematic categories. results: the ai prompted individuals to ask followup questions, which largely drove the themes. themes included general information (similarity to delta-9 thc but with a purported lower potency; relaxing/euphoric effects; legality), use motives (pain relief, anti-nausea, appetite stimulation, anxiety reduction), potential consequences (dry mouth, red eyes, increased heart rate, drowsiness, contaminated products, inaccurate labeling), retail availability, and product recommendations. responses did not provide supporting citations. while the ai did not block results related to delta-8 thc, it did block results pertaining to 'weed' and 'thc'. discussion: snapchat ai is a plausible information source about delta-8 thc among youth. no citations were provided to support claims made by the ai, which portrayed delta-8 thc use favorably, as having benefits and low risks from use. findings have policy implications, including restricting or regulating this type of content particularly relating to claims without supporting scientific evidence. cannabis and alcohol use and co-use in black young adults’ daily life: leveraging personalized geospatial data p. priscilla lui (university of washington) zachery z. willett (university of washington) nia jones (university of washington) devin e. banks (washington university in st. louis) latrice montgomery (university of cincinnati college of medicine) kevin m. king (university of washington) background: one in four black young adults uses cannabis monthly. in recent years, black individuals have seen rising cannabis use and cannabis use disorder rates and continue to face disproportionately negative health and legal consequences. these concerns are particularly pronounced among individuals who concurrently use cannabis and alcohol. cannabis and alcohol use are influenced by environmental factors including opportunities to use, the substances’ availability, and social contexts. to examine these contextual influences, research integrating geospatial data has focused on aggregated, area-level and cross-sectional analyses, but these have not been well integrated into daily life studies. linking zip-coded geospatial data with self-reported quantitative and qualitative data can deepen insight into personal and environmental contexts of cannabis and alcohol (co-)use in young people’s daily life. method: data were from 110 black young adults (ages 18-30, m=22.9) in an ongoing study conducted in seattle, washington. washington state legalized recreational cannabis use in 2012. eligibility criteria included weekly cannabis and/or alcohol use, scoring below thresholds for hazardous use on select cudit-r or conference abstracts 193 audit items, and not seeking treatment for cannabis/alcohol use disorder. most participants identified as non-immigrant black/african american (75.5%); 47.3% were ciswomen, 12.7% non-binary, and 50.0% were full-time students. study procedures included an inperson visit to complete baseline surveys, two online daily diary survey assessments, and a virtual semistructured interview. participants reported the locations for each cannabis use or drinking occasion. corresponding geospatial data were examined in the context of licensed cannabis and alcohol vendors to estimate zip-level availability of each substance. geospatial data also were analyzed alongside participants’ qualitative responses to contextualize when, where, and with whom they used these substances. results & conclusion: across 2 weekend days, 76.0% of participants reported using cannabis and/or alcohol. among the 24 individuals who used both substances, 45.8% engaged in simultaneous co-use. participants who used cannabis reported intoxicated in 93.3% of use occasions (nj = 144), with a median duration of intoxication of 75 minutes (range=1600). participants reported drunk in 78.0% of drinking occasions (nj = 82), with a median duration of intoxication of 70 minutes (range=1-420). we recorded 59 unique zip codes where participants used cannabis and/or drank. per zip code, we found a median of one (range=0-8) licensed cannabis vendor, 39 establishments licensed to serve alcohol on-premise (range=0-217), and 23 (range=0-54) licensed to sell alcohol for off-premise consumption. coupled with their qualitative interview data, we observed that participants tended to use cannabis alone and close to home (median distance=0.38 miles), with only 33.1% of occasions taking place in the company of others. by contrast, participants tended to drink while among others in 78.3% of the occasions. they tended to report drinking further from home (median distance=2.33 miles). we demonstrated the feasibility of a multi-modal data collection approach integrating geospatial information to examine participants’ idiographic patterns and contexts of cannabis and alcohol use. research implications were discussed for integrating personalized geotemporospatial data into daily life research in a population at risk for hazardous cannabis and alcohol (co-)use, and practical implications for just-in-time interventions. associations between mental health symptoms, cannabis use problems, and cannabis use motives in a diverse sample of community young adults andrea m. maxwell* (mcmaster university) molly l. garber (peter boris centre for addictions research, mcmaster university) laura reid marks (center for translational behavioral science, florida state university) conference abstracts 194 kyla belisario (peter boris centre for addictions research, mcmaster university) james g. murphy (university of memphis) james mackillop (peter boris centre for addictions research, mcmaster university) *student award winner objective: cannabis use disorder occurs concurrently to heightened levels of other mental health symptoms, such as depression, anxiety, and posttraumatic stress symptoms. existing research has primarily focused on coping motives (i.e., using cannabis to manage/relieve unpleasant emotional symptoms) to explain these relationships, but limited research has examined these pathways in young adult samples. furthermore, studies exploring these relationships among racialized groups (i.e., non-white individuals) is scarce. this is especially important due to well-documented health disparities faced by racialized individuals. thus, the primary aims of this study were to (1) explore and characterize relationships between cannabis use problems, motives, and mental health symptoms, (2) examine possible indirect effects of cannabis use motives on the relationship between cannabis use problems and mental health symptoms, and (3) examine possible differences in these relationships among racialized young adults. methods: this study utilized baseline data from a larger longitudinal study of young adults with high-risk substance use (n = 761; m age = 21.9; %f = 50.3; %white = 58.2) in hamilton, ontario, canada and memphis, tennessee, usa. participants completed assessments related to cannabis use problems, cannabis use motives, and symptoms of depression, anxiety, and posttraumatic stress. first, bivariate correlations and hierarchical linear regression were performed to investigate and characterize relationships between study variables. then, indirect effect analyses were performed to elucidate the possible mechanistic influence of cannabis use motives. finally, moderated indirect effect analyses were performed to examine the possible moderating role of racial identity (trichotomized as white, nonblack people of colour [nbpoc], and black). results: regression analyses revealed significant associations between cannabis use problems and coping (é¿ = 0.43, p <.001), enhancement (é¿ = 0.15, p<0.001), and expansion (é¿ = 0.10, p=0.014) motives. the overall indirect effect analyses revealed significant indirect effects via coping (unstandardized effects= 0.04-0.12) and expansion (unstandardized effects= 0.01-0.02) among all mental health measures. when racial identity was included as a moderator, the indirect effects through coping remained significant, but only for the white (unstandardized effects = 0.050.19) and nbpoc groups (unstandardized effects = 0.04-0.11). conclusion: overall, results generally support a negative reinforcement pathway to concurrent cannabis use problems and mental health symptoms, where these relationships are at least partially explained via coping motives. however, conference abstracts 195 results revealed surprising betweengroup differences among racialized individuals, highlighting the need for future research exploring the cannabis use motives and mental health outcomes specifically among individuals with diverse racial identities. smoke, sip, sleep, repeat: investigating daily-level bidirectional relationships between separate and simultaneous alcoholcannabis use and sleep annabelle moore* (york university) sophie g. coelho (york university) christian s. hendershot (university of southern california) jeffrey d. wardell (york university, centre for addiction and mental health, university of toronto) *student award honorable mention background: sleep problems are common among young adults, and both alcohol and cannabis are known to impact sleep. given the high prevalence of simultaneous alcoholcannabis use in this population, there is a need to clarify the mixed findings in existing research regarding the combined effects of alcohol and cannabis use on sleep. while studies suggest that the effects of alcohol and cannabis on sleep may depend on the level of use and/or dependence, this has not been thoroughly explored in the context of simultaneous use. this study examined daily relationships between simultaneous use (versus cannabisonly, alcohol-only, and no use) and key sleep indices (i.e., subjective sleep quality, sleep duration, and bedtime), exploring the moderating role of substance use problem severity. method: young adults (n = 151; 64% female; mage = 22.07) completed 21 consecutive daily morning surveys (89.12% compliance) in a smartphone app assessing prior-day alcohol use (number of drinks) and cannabis use (grams of cannabis flower, hits of concentrates, and servings of edibles and cannabis beverages), bedtime, wake time, and subjective sleep quality. alcohol and cannabis problem severity were assessed at baseline using the alcohol use disorders identification test (audit; saunders et al., 1993) and cannabis use disorder identification test-revised (cudit-r; adamson et al., 2010), respectively. results: multilevel models (with days nested within participants) indicated that participants reported worse sleep quality and shorter sleep duration on alcohol-only use days relative to simultaneous use and no-use days (ps <.001.026). participants reported similar subjective sleep quality and sleep durations on cannabis-only and simultaneous use days, but cannabisonly use days were associated with better sleep quality relative to no use (p <.001). the same pattern of differences between simultaneous and singlesubstance use days were observed even when controlling for quantities of alcohol and cannabis consumed. further, alcohol problem severity moderated several associations. for example, controlling for quantities consumed, individuals with greater alcohol problem severity went to bed earlier (b = -0.63, se = 0.17, p = <.001) on simultaneous use days relative to conference abstracts 196 alcohol-only days, whereas those with lower alcohol problem severity went to bed later on simultaneous use days compared to cannabis-only days (b = 0.50, se = 0.13, p = <.001). models examining reverse associations (i.e., impacts of sleep variables on next-day likelihood of simultaneous or single substance use) did not reveal any significant associations. conclusion: young adults' sleep appears to be more disrupted when they use alcohol on its own than when they use alcohol with cannabis. this effect is especially evident among those with greater alcohol problem severity, who experience more pronounced sleep disturbances associated with alcohol use. in contrast, those with lower alcohol problem severity tended to have later bedtimes on simultaneous use days compared to cannabis-only days. as contextual factors may also contribute to differences in sleep outcomes across simultaneous use and single substance use days, further research on the factors that explain these differences is warranted. future studies should examine simultaneous use among people with sleep disorders to inform sleep interventions. characterizing the cascade of care for cannabis use disorder in the u.s.: treatment gaps and barriers to care using the 2022-2023 national survey on drug use and health matthew g. myers* (michigan state university) kipling m. bohnert (michigan state university) *student award winner research question: cascade of care frameworks describe patient utilization at various stages of care. in addiction medicine, they help identify discontinuities across the care continuum in the detection and treatment of substance use disorders. such frameworks have illustrated gaps in care for those with alcohol and opioid use disorders; however, a cannabis use disorder (cud) cascade of care model has not been examined. here, we use nationally representative data to describe utilization of care among those with cud. secondarily, we explore perceived barriers of treatment. method and analysis: we aggregated 2022 and 2023 national survey on drug use and health data to identify a representative sample of us adults (unweighted n=91,528). the presence and severity (mild, moderate, severe) of past-year cud was assessed using diagnostic and statistical manual of mental disorders 5th edition criteria. among those with cud, we estimated conditional past-year prevalences of 1) healthcare utilization, 2) a drug use discussion with a healthcare provider among those who utilized healthcare, and 3) receipt of outpatient cannabis use treatment among those discussing their drug use with a provider. among a subsample of those with untreated cud (unweighted n=408), we examined prevalences of perceived barriers for treatment. all results are stratified by severity of cud and are nationally representative of us adults. this work is deemed non-human subjects by the michigan state university institutional review board. results: the weighted prevalence of cud was 6.8% (95%ci:6.6, 7.1). mild, conference abstracts 197 moderate, and severe cud were present in 3.8% (95%ci:3.6, 4.0), 1.8% (95%ci:1.7, 1.9), and 1.2% (95%ci:1.1, 1.3) of u.s. adults, respectively. healthcare utilization was common among those with mild (78.4%; 95%ci:76.1, 80.7), moderate (76.3%; 95%ci:73.7, 79), and severe cud (79.5%; 95%ci:76.2, 82.8). among those with past-year healthcare utilization, discussing drug use with a healthcare provider was common, and prevalences of such discussions did not differ between those with mild (75.2%; 95%ci:71.8, 78.5), moderate (76.4%; 95%ci:72.4, 80.3) or severe (76.7%; 95%ci:72.3, 81) cud. the conditional prevalences of receiving outpatient treatment for cannabis use were rare among those with mild (1.7%; 95%ci:0.7, 2.8), moderate (4.8%; 95%ci:1.8, 7.9) or severe (11.3%; 95%ci:7.3, 15.3) cud. among those with untreated cud, 73.5% (95%ci:63.6, 83.4) did not receive treatment because they thought they could handle the issue on their own. the majority of those with untreated cud also reported not receiving treatment for the following reasons: it cost too much (57.9%; 95%ci:48.2, 67.6), they were not ready to start treatment (55.4%; 95%ci:45.7, 65.2), they didn't know where to get treatment (52.4%; 95%ci:44.6, 60.3), and they were not ready to stop use (51.5%; 95%ci:41.6, 61.4). conclusion: although adults with cud commonly utilize health care and discuss their drug use with providers, very few ultimately receive treatment for cud. it may be important to consider expanded screening and referral efforts for individuals in care settings that have the capacity to treat cud. additionally, healthcare systems may improve engagement in cud treatment by addressing treatment barriers commonly perceived by patients. examining the associations between cannabis use and indicators of cognition in a longitudinal cohort study of emerging adults peter najdzionek (mcmaster university) amanda doggett (mcmaster university) kyla belisario (peter boris centre for addictions research) james murphy (university of memphis) james mackillop (mcmaster university & peter boris centre for addictions research) background: frequent cannabis use is known to diminish cognitive functions such as attention, working memory, and inhibition. there's a current lack of research evaluating how cognition is affected by age-related reductions in cannabis use. our study employed a longitudinal cohort model to assess cannabis use and cognition in an emerging adult sample. methods: 691 young adults (mean age 21.4 years, 47.75% male) were assessed every 8 months across 3 timepoints. participants reported their cannabis use frequency (via the alcohol, smoking, and substance involvement screening test), and engaged in the following cognitive-behavioral tasks: numeric digit span, go/no-go inhibition task, and a monetary delay discounting paradigm. random intercept crossconference abstracts 198 lagged panel models were used to determine the longitudinal relationship between cannabis use frequency and each of the cognitive measures. results: while go/no-go and delay discounting revealed no crosslagged effects with cannabis use, there was a negative relationship between forward digit span and cannabis frequency [b = -0.203, p = 0.035; b = 0.230, p = 0.043], such that decreases in cannabis use led to increased forward digit span capacity. conclusions: finding demonstrated that reductions in cannabis use frequency led to better performance on the forward digit span task 8 months later. as digit span forward is a proxy for attention, future research examining the relationship between cannabis & cognition should focus on attentional measures. a longitudinal test of health-related psychological theories in explaining avoidance of driving under cannabis influence alberto parrado-gonzález (university of huelva) nehemías romero-pérez (university of huelva) bella m. gonzález-ponce (university of extremadura) adrian j. bravo (william & mary) fermín fernández-calderón (university of huelva) background and aims: driving under the influence of cannabis is a prevalent high-risk behavior. identifying factors that predict the avoidance of this behavior can be approached through various psychosocial theories that have demonstrated their usefulness in explaining health behaviors, such as the theory of planned behavior (tpb), the protection motivation theory (pmt), and the health belief model (hbm). this study aimed to longitudinally analyze the explanatory capacity of these models in avoiding driving under the influence of cannabis. methods: data were obtained from the psicocann project, a longitudinal study with an initial sample of 612 young people (aged 1825) recruited from the community, all of whom reported cannabis use in the past month. 82.5% completed a threemonth follow-up. for this analysis, participants who reported having driven a vehicle in the past 30 days at both baseline and follow-up assessments were included, resulting in a final sample of 167 young adults (female = 31.7%, mage = 21.70, sd = 2.06). the baseline questionnaire assessed constructs (e.g., attitudes, self-efficacy) of the three tested theories (i.e., tpb, pmt, and hbm). in both assessments, the frequency with which participants reported avoiding driving under the influence of cannabis in the past month was measured using an item from the protective behavioral strategies for marijuana scale. path analysis models were used to evaluate the explanatory power of the original models. then, past behavior was included as a control variable to further establish the predictive ability of the models. all analyses controlled for sex and age. results: all models showed adequate fit indices. the tpb and pmt explained a greater proportion of the variance in avoiding driving under the influence of cannabis (53.3% and 53.2%, respectively), while the hbm conference abstracts 199 explained 29.1%. when past behavior was included as a control variable, the explained variance increased for all models: 59.0% in tpb, 58.9% in pmt, and 54.3% in hbm. the results indicated that in both the tpb and pmt, intention was the only significant predictor of behavior. in tpb, a more favorable attitude toward protective behavior was associated with a greater intention to avoid driving under the influence of cannabis. in pmt, higher levels of self-efficacy, perceived vulnerability, and perceived efficacy were associated with a greater intention to avoid driving under the influence of cannabis. in hbm, a higher perception of vulnerability was directly associated with a greater frequency of behavior avoidance. conclusions: findings suggest that all three models are useful in explaining the avoidance of driving under the influence of cannabis, with tpb and pmt demonstrating greater explanatory power. these results could contribute to the design of more effective interventions aimed at reducing this risky behavior. demographic and clinical factors associated with recreational cannabis use in female psychiatric outpatients with suicidal ideation and healthy controls anna patterson (university of illinois chicago) anisha nagpal (university of illinois chicago) ashley ross (university of illinois chicago) jordan barone (university of illinois chicago) hafsah tauseef (university of illinois chicago) jaclyn ross (university of illinois chicago) natania crane (university of illinois chicago) tory eisenlohr-moul (university of illinois chicago) background: given the widespread legalization of recreational cannabis across the united states, it is crucial to examine sociodemographic, affective, and behavioral factors associated with cannabis use to identify at-risk populations. female individuals exhibit a faster transition from first use to problem use than their male counterparts1. further, suicide is a leading cause of death in reproductiveaged female individuals, with rates in this group showing the steepest increases in recent years2,3. considering these co-occurring trends, there exists an urgent public health need to identify characteristics of female recreational cannabis users with suicidality to inform prevention and intervention efforts. methods: demographic, clinical diagnostic, and daily psychiatric symptom and substance use data from baseline and washout phases across three randomized controlled trials were analyzed. data was primarily collected after the legalization of recreational cannabis in illinois. female individuals were recruited for pastmonth suicidal ideation (si) or as healthy controls with no history of si. results: of 257 participants, 140 (54%) reported cannabis use. participants with si only and si with a history of suicide attempt were more likely to use conference abstracts 200 cannabis than healthy controls (or=5.23, p=0.005; or=3.20, p<0.001, respectively). sexual minority status also positively predicted cannabis use (or=2.69, p=0.001). cannabis use frequency did not differ significantly between the three groups (si only, si with history of suicide attempt, and healthy controls). cannabis use frequency was also higher in those of a sexual minority. finally, cannabis use frequency does not appear to be associated with daily affect nor passive and active si in our sample. conclusion: in a sample of reproductive-aged female participants, those with past-month suicidal thoughts were more likely to use cannabis than controls, though cannabis use was not significantly associated with suicide attempt. frequency of use did not differ between groups. future work is needed to examine this relationship longitudinally within subject. overall, our study serves to guide clinicians and researchers on the demographic and clinical correlates of cannabis use at a crucial time when recreational cannabis use, cud, and suicide attempt rates are increasing in the female population. college marijuana beliefs, harm reduction strategies, and marijuana outcomes: a cross-national study hanna pazo vargas* (william & mary) javiera hernandez puelma (william & mary) adrian j. bravo (william & mary) cross-cultural addictions study team (william & mary) *student award winner within the college student alcohol literature, college alcohol beliefs (i.e., the belief that drinking alcohol is an important part of the college experience) has been shown to be a robust risk factor for excessive alcohol use and problems (bravo et al., 2018). more recently, researchers have found that college marijuana beliefs (i.e., the belief that using marijuana is an important part of the college experience) is a unique robust predictor of marijuana-related outcomes (i.e., marijuana user status, frequency of use, marijuana-related consequences) among u.s. college students (pearson et al., 2018). in exploring mechanisms, one prior study found that lower use of protective behavioral strategies (pbs) links greater college alcohol beliefs to problematic alcohol use (bravo et al., 2017); however, limited research has examined whether marijuana pbs use links college marijuana beliefs to marijuana outcomes, particularly across diverse cultural contexts. the present study examined the associations between college marijuana beliefs, marijuana pbs use, and marijuana-related outcomes among college students from six different countries. participants included 906 college students (64.8% female; mean age = 20.58) from six countries (i.e., usa, argentina, spain, south africa, england, and canada) who regularly consume marijuana within a typical week and completed measures of college marijuana beliefs, marijuana pbs, marijuana use quantity, and marijuana-related consequences. within our estimated path model (i.e., college marijuana beliefs → marijuana conference abstracts 201 pbs → marijuana quantity → marijuana-related consequences), findings revealed that stronger endorsement of college marijuana beliefs was positively associated with lower use of marijuana pbs, which in turn was associated with greater marijuana quantity (indirect b = .11; 99% ci = 0.07, 0.16) and more marijuana-related consequences (indirect b = .08; 99% ci = 0.05, 0.12). additionally, a significant doublemediation effect was found such that greater endorsement of college marijuana beliefs was associated with more marijuana-related consequences via lower use of pbs and greater marijuana quantity (indirect é¿ = .02; 99% ci = 0.01, 0.04). importantly, this double-mediated effect was supported within a longitudinal model among a subsample of participants from our analytic sample (n = 251). specifically, greater endorsement of college marijuana beliefs was associated with less pbs use 3 months later, which in turn was associated with greater cannabis quantity and negative marijuana-related consequences 3 months later (indirect é¿ = .04; 99% ci = 0.01, 0.11). these findings highlight the importance of addressing college marijuana beliefs and promoting marijuana pbs use to mitigate the impact of heavy marijuana use among college students, particularly in culturally diverse settings. understanding these differences is essential for developing culturally tailored prevention strategies that promote healthier marijuana use habits and reduce marijuana-related harm among college students. acute cannabis-related alterations in fmri global brain connectivity during performance of a simulated driving task godfrey d. pearlson (yale university/institute of living) shashwath a. meda (institute of living) michael c. stevens (yale university/institute of living) introduction: cannabis is associated with dose-related decrements in specific driving abilities. global brain connectivity (gbc) mapping is an fmri analysis method that usefully quantifies network integration between different brain regions by summing the strength of functional connectivity between every fmri measurement in the brain and all other points.these high-definition gbc maps then can be directly compared in cannabis dose challenge studies to learn which brain regions might be relatively disconnected as a consequence of drug use and related to cannabis-impaired driving. methods: in this placebo-controlled, doubleblind, counterbalanced, randomized trial, n=33 regular cannabis-using adults aged 19-38 (27% female) underwent a placebo-controlled cannabis challenge. on separate days, participants received 0.5 gm of either cannabis (~12.5% thc flower) or placebo, via paced inhalation from a volcano vaporizer. 45 minutes after acute dosing, participants' brain activity was assessed using fmri while performing a 3-part, 30-minute simulated driving paradigm implemented on a realtime technologies, inc. (sim vehicle lt conference abstracts 202 platform; this included lane-keeping, car following, and overtaking tasks. gbc was implemented on data collected during the entire 30 minutes of driving. permutation analysis of linear models (palm) neuroimaging software implemented a paired t-test contrasting placebo versus active cannabis gbc maps, using 5000 permutations, threshold-free cluster enhancement (tfce) and false discovery rate (fdr) control over whole-brain multiple comparisons. to identify links between brain connectivity and driving behavior, we used a multi-set canonical correlation analysis (mcca) combined with joint independent component analysis (joint ica) to fuse and decompose gbc maps and 19 driving behaviors derived from the driving scenarios. paired t-tests assessed dose-related differences in the resulting joint components loading coefficients. results: gbc after active cannabis was significantly reduced in many sub-cortical brain regions. impaired network connectivity was particularly prominent in left hippocampus, bilateral cerebellum and bilateral thalamus, but extended to include lesser aspects of bilateral caudate, putamen, and brainstem. no drug effects on cortical gbc survived fdr corrections. however, diffusely widespread cortical disconnectivity was detected at less stringent, exploratory p<.05 uncorrected thresholds. diminished cortical gbc deficits were most dense in visual cortex, motor and supplementary motor area (sma), and right lateral prefrontal cortices. data fusion analysis characterizing associations between gbc and driving behavior drug effects identified a 12-component solution as most optimal. among these components, component 8 demonstrated significant hypoactivity in sma, frontal, and visual areas (z = 2.12; p < 0.04). this correlated with reduced lane-keeping steering reversal rate behavior (z = 2.04; p < 0.05) on the active dose. additionally, component 6 revealed increased standard deviation of lateral position (sdlp) at the active dose, associated with a regional network involved in attention, visual processing, and sensory integration. conclusion: this study establishes the first links between impaired driving and drug effects on large-scale brain network function. we observed that acute cannabis use exerts strong effects on how strong and widespread subcortical regions co-engage with the rest of the brain, with less strong evidence for comparable cortical effects. moreover, these neural changes were shown to be related to aspects of the participant's driving performance. exploring daily predictors and harms of cannabis and alcohol co-use among transgender and gender diverse adults who drink stephanie m. penta* (toronto metropolitan university) alexandra uhrig (toronto metropolitan university) jeffrey d. wardell (york university, university of toronto, centre for addiction and mental health) sarah s. dermody (toronto metropolitan university) *student award winner background: aside from combinations with tobacco, cannabis and alcohol are conference abstracts 203 the most commonly co-used substances in north america. understanding cannabis and alcohol co-use is important because it is associated with experiencing more substance-related harms than single substance use. emerging evidence suggests that transgender and gender diverse (tgd) adults experience a disproportionate impact from cannabis and alcohol use and co-use and corresponding harms compared to cisgender adults. this disparity is likely due to the everyday stressors that tgd people encounter due to their minoritized gender identities, termed gender minority stress (gms). very little research has examined the relationships between cannabis and alcohol co-use, substancerelated harms, and gms and resilience in tgd populations. the current study employed ecological momentary assessment (ema) to explore daily associations between these variables among tgd adults. method: this secondary analysis included 100 canadian tgd adults (m = 27.88 years, sd = 7.64) who reported typically drinking alcohol at least once per week. among the participants, 22% identified as transmasculine, 27% as transfeminine, and 49% as gender diverse (e.g., nonbinary, gender fluid). for 21 days, participants completed daily ema surveys capturing their past-day substance use (i.e., alcohol and cannabis use frequency, number of standard drinks consumed, and types of cannabis consumed), substancerelated harms (e.g., engaging in risky behaviors, interpersonal conflicts, and hangover symptoms), and gms and resilience. to explore daily-level associations between these variables, we applied generalized linear mixed models (glmm). results: across all participants, 330 alcohol-only days, 282 cannabis-only days, and 124 co-use days were reported. on alcohol use days, the mean number of standard drinks consumed was 3.16 (sd = 2.64). on cannabis use days, participants used cannabis flower, concentrates, edibles, beverages, and more than one form of cannabis on 53.98%, 23.51%, 1.49%, 1.49%, and 19.94% of days, respectively. glmm results revealed that, on days when participants coused, they experienced more substance-related harms than on alcohol-only days (irr = 1.42, p = .008). despite this, on days when participants co-used, they did not consume significantly more standard drinks (irr = 1.06, p = .516) than on alcoholonly days. participants also did not experience significantly more gms or resilience on co-use days than on alcohol-only (gms: or = 0.89, p = .301; resilience: or = 0.87, p = .327) or cannabis-only days (gms: or = 1.00, p = .976; resilience: or = 0.91, p = .406). conclusions: these findings raise additional concerns about the impacts of cannabis and alcohol co-use on the health and wellbeing of tgd adults. the results suggest that co-use is associated with experiencing more substance-related harms than alcoholonly use, which suggests that cannabis may worsen harms for tgd adults who drink. this is an important finding, given that participants endorsed high levels of cannabis use, including using more than one form of cannabis on one fifth of all cannabis use days. the results of this study may be used to inform tailored harm-reduction policy conference abstracts 204 and intervention efforts for tgd adults. methods for exploring cannabis discussions on reddit: leveraging machine learning and large language models chanda phelan kane (brown university) xiangyu tao (rutgers university) jim samuel (rutgers university) kristina jackson (rutgers university) jane metrik (brown university) objective this project explores methods using machine learning and large language models (llms) for analyzing large-scale cannabis-related discussions on reddit, with a focus on therapeutic topics such as sleep and pain. method we collected posts and comments from 16 cannabis subreddits (e.g. /r/trees, /r/cannabis, /r/petioles) and three health-related subreddits (r/sleep, r/anxiety, r/chronicpain), comprising a corpus of over 60,000 posts and over 450,000 comments. for the cannabis-related subreddits, we used keyword filtering to select the subset of posts and comments likely to be about therapeutic effects of cannabis; for health-related subreddits, keyword filtering produced text likely to be about cannabis. we employed a multi-method natural language processing (nlp) approach to investigate thematic patterns and sentiment: word frequency analysis, topic modeling using latent dirichlet allocation (lda) and chatgpt 4.o, and sentiment analysis using traditional machine learning libraries and chatgpt 4.o. results initial word frequency analysis provided a highlevel view of commonly used terms but lacked the granularity to capture health-related content. we then used lda to identify latent thematic structures in the text. lda helped highlight recurrent discussion areas, such as cannabis's perceived benefits for sleep, experiences with withdrawalrelated insomnia, and the development of tolerance. to improve the interpretability of lda results, we used chatgpt 4.o to generate humanreadable summaries of topics. while lda was valuable for modeling large corpora and identifying patterns, interpretation remained subjective and sensitive to preprocessing decisions and model parameters topic modeling by chatgpt produced detailed, easily interpretable themes, but as interpretative tools llms can lack transparency and may introduce subjective biases. finally, we conducted sentiment analysis to assess user perceptions of cannabis's effectiveness for sleep. both traditional machine learning libraries and chatgpt sentiment analyses revealed a spectrum of sentiment, highlighting both positive and negative experiences. sentiment analyses are limited by the accuracy of their sentiment libraries when applied to cannabis-related text. each method offered distinct strengths: word frequency analysis was fast and accessible; lda revealed deeper topic structures; and gpt-assisted interpretation and sentiment analysis added context and nuance. however, challenges included the limitations of keyword filtering, the interpretability of unsupervised models like lda, and the potential biases introduced by using llms for annotation and conference abstracts 205 interpretation. conclusions this work is part of an ongoing exploration of the role of ai in cannabis research. we present this abstract to foster conversation about how nlp and llms can support, but also complicate, interpretation in substance use research. open questions remain about best practices, limitations, and opportunities for responsible integration of these tools into substance use research contexts. the saferr just-in-time adaptive intervention for diverse young adults who co-use cannabis and alcohol kristina t. phillips (kaiser permanente hawaii center for integrated health care research; kaiser permanente bernard j. tyson school of medicine) michael m. phillips (university of hawai'i at manoa) mark a. prince (university of southern california) kara tsuzaki (kaiser permanente hawaii center for integrated health care research) catherine erickson (kaiser permanente hawaii center for integrated health care research) michael d. stein (boston university) introduction: approximately onefourth of young adults engage in simultaneous use of cannabis and alcohol (i.e., use of both substances with overlapping effects), leading to more negative consequences than use of either alone. to prevent substance use disorder (sud), an intervention that targets harm reduction or protective behavioral strategies (pbs) may prove beneficial. current pbs interventions are primarily designed for college students, with limited opportunities for community-recruited young adults. just-in-time adaptive interventions (jitais) offer one mechanism for delivering pbs in a mobile and accessible format. the smartphone app for effectively reducing risk (saferr) is a new jitai being tested in an ongoing clinical trial. the aim of the current presentation is to describe the saferr study design and explore feasibility and preliminary findings. method: young adults aged 18-30 who endorsed recent simultaneous use of cannabis and alcohol were recruited from a large integrated healthcare system and screened online. eligible and interested participants completed informed consent and a virtual training session. participants were randomly assigned to one of eight study conditions as part of a fractional factorial design. they completed a baseline assessment and five weeks of ecological momentary assessment (ema). all participants completed an introduction module that included psychoeducation, personalized feedback, and goal-setting; those assigned to a jitai intervention condition received intervention content for four weeks. although the trial is ongoing, exploratory analyses focused on initial feasibility (response rate) and change in pbs use and cannabis and alcohol frequency over the follow-up period (one-week, one-month, and 3month). changes in past 30-day alcohol/cannabis use and pbs for alcohol/cannabis were examined using a series of linear mixed effects models. for count outcomes, quasi-poisson conference abstracts 206 models were utilized. results: fortythree young adults have enrolled in the study. participants reported a mean age of 24.95 (sd=2.94; range=20-30), were predominantly female (74%), and endorsed white (41.9%), native hawaiian or pacific islander (27.9), asian (11.6%), filipino (2.3%), black (2.3%), or more than one race (14%). of the 43 participants who enrolled, 29 have fully completed the protocol. signal-contingent ema response rate over the 5-week study period was 68%. from baseline to the 3-month follow-up across all participants, there was a significant increase in pbs for both alcohol and cannabis. the effect was small to medium sized for alcohol (beta=.24) and small for cannabis (beta=.17). both past 30-day alcohol and cannabis use reduced. days of alcohol use were not significantly different from the baseline to 3-mo follow-up (beta=-.16), but cannabis significantly changed (beta=-.14 cannabis). conclusions: a preliminary examination of the saferr intervention suggests that the protocol is feasible and trending in the expected direction on outcomes, with increases in pbs use, and decreases in alcohol and cannabis use frequency. additional participants will allow for a more nuanced examination of outcomes across the different study conditions. poly-substance use of cannabis, alcohol and nicotine among hawai'i youth: insights from the 2019, 2021, and 2023 youth risk behavior survey (yrbs) michael m. phillips (university of hawai'i at mnoa) fran woodworth (university of hawai'i at mnoa) mika d. thompson (university of hawai'i at mnoa) john r. massey (university of hawai'i at mnoa) substance use among adolescents remains a significant public health concern, with cannabis, alcohol, and nicotine being the most commonly used substances. we utilized hawaii yrbs 2019, 2021, 2023 data to assess the rates of cannabis, alcohol, and nicotine coand poly-substance use among hawai'i high school (hs) students, including sexual and gender minorities, race/ethnicity, rurality, mental health status, including depression and self-harm. the youth risk behavior survey (yrbs) provides critical data on the prevalence, patterns, and trends for substance use, informing prevention and intervention efforts. cannabis use prevalence for hawai'i hs students ranged from 17.2% for 2019, 12.0% for 2021, and 14.0% for 2023, and a combined 14.3% (95% ci: 13.3%, 15.4%) across all three data collection periods. a growing trend, females had a significantly higher co-use prevalence for cannabis-alcohol (8.9% to 6.4% for males) and cannabisnicotine (10.8% to 8.2% for males). of the 4 counties in hawaii, all 3 counties having higher rurality (>94%) generally had statistically higher prevalence for cannabis, co-use, and poly-use of all three compared to honolulu county (rurality, 63%). when examining race/ethnicity: japanese, filipino, and other asian hs students had statistically lower conference abstracts 207 prevalence for cannabis use, co-use and poly-use compared to white, native hawaiian and individuals with other race/ethnicities. hs students who identify as transgender (21.9%, 95%ci: 15.6-29.8) had significantly higher prevalence of cannabis use compared to their cisgender peers (14.0%, 95%ci: 12.9-15.1) and a general trend of higher coand polyuse, but not statistically different. when exploring the association between mental health, depression, and self-harm, there was a statistically significant trend across the board of higher prevalence for cannabis, coand poly-substance use, with sometimes double and triple the rate. demographic disparities emerged in the hawaii data for cannabis use along with coand polyuse, with differences in use patterns by sex, race/ethnicity, rurality of counties, gender identity, and with mental health, depression, and selfharm. perceived harm associated with cannabis has decreased among youth, potentially contributing to continued use. meanwhile, nicotine consumption has risen lately due to the popularity of e-cigarettes and vaping devices (19.3% compared to combustible usage at 3.8% for hawaii hs students from 2019-2023). the yrbs data highlight that a substantial percentage of adolescents who use e-cigarettes also report concurrent use of cannabis, raising concerns about poly-substance use and long-term health effects. additionally, others have found yrbs findings to suggest that youth engaging in substance use are more likely to participate in other risky behaviors, including unprotected sexual activity and impaired driving. the analysis underscores the importance of continued public health efforts, including education campaigns, stricter regulations, and prevention programs tailored to address evolving trends in youth substance use. the increasing prevalence of vaping and shifting attitudes toward cannabis necessitate adaptive strategies to mitigate risks and promote healthier behaviors among adolescents. by leveraging yrbs data, policymakers and educators can develop targeted interventions to reduce substance use and associated risks among young populations. trajectories of e-cigarette and cannabis co-use and dependence among multiethnic young adults pallav pokhrel (university of hawaii at manoa) kristina t. phillips (kaiser permanente) michael m. phillips (university of hawaii at manoa) crissy t. kawamoto (university of hawaii at manoa) thaddeus a. herzog (university of hawaii at manoa) background: little is known about ecigarette and cannabis co-use patterns among young adults over time or how dependence evolves over time compared to exclusive use. this study sought to determine patterns of exclusive and co-use of cannabis and ecigarettes over time in terms of latent classes, and to compare the trajectories of e-cigarette and cannabis dependence across the classes. conference abstracts 208 methods: multiethnic [~65% asian american, native hawaiian or pacific islander (nhpi)] young adults from hawaii were surveyed at six timepoints in six-month intervals between mid-2021 and mid-2024. the present analyses are based on a subsample (n=1305 at baseline; m age=25.0, sd=2.2; 57% women) who reported e-cigarette and/or cannabis use in the past 30 days at least once across the six survey timepoints. couse was defined as any use of cannabis and e-cigarette in the past 30 days. repeated measures lca was conducted to examine the patterns of e-cigarette and cannabis use and couse over the six time-points. latent growth curve (lgc) modeling was used to examine the trajectories of ecigarette and cannabis dependence within each class. results: a model with the following 4 latent classes (entropy=.91) best fit the data: stable moderate cannabis-only (smc) use (prevalence: 32%), stable high ecigarette-only (she) use (16%), stable high co-use (shco; 14%), and stable low use of either (sle) or both substances (38%). older age was associated with higher likelihood of membership in the smc class compared with the sle class. cigarette smoking at baseline was associated with higher likelihood of membership in each of the three other classes compared with membership in the sle class. relative to being white, being east asian, filipino, or nhpi reduced the likelihood of membership in the smc class and increased the likelihood of membership in the she class compared to membership in sle class. similarly, relative to being white, being east asian or filipino reduced the likelihood of membership in the shco class, but no significant difference was found between white and nhpi for shco membership. on average, individuals in the smc class showed a significant rate of increase in cannabis dependence initially (linear slope=.14, p=.009) that tended to level off later (quadratic slope=-.02, p=.03). similarly, on average, individuals in the she class showed a steep initial rate of increase in e-cigarette dependence (linear slope=.32, p<.0001), which later tended to level off (quadratic slope=.06, p=.001). cannabis dependence showed no significant rate of change in the shco class; however, e-cigarette dependence showed a steep initial increase in the class (linear slope=.53, p<.0001) followed by slower or declining rate of change later (quadratic slope =-.07, p=.01). conclusions: these data suggest that prolonged co-use of cannabis and ecigarettes may increase e-cigarette dependence but not necessarily cannabis dependence. future studies may need to examine the potential role of cannabis use in increasing nicotine dependence. in addition, some demographic groups such as whites and nhpis have increased risk for couse of cannabis and e-cigarettes. prevention interventions may benefit from targeting these vulnerable groups. cannabis as an economic driver in post-legalization economies: lessons for botswana from the u.s. and canada conference abstracts 209 question jaden ramontsho (university of michigan) cannabis legalization in the united states and canada has demonstrated substantial economic benefits, including job creation, increased tax revenues, and industry expansion. this paper explores how botswana could leverage similar opportunities by legalizing and regulating cannabis as part of its economic diversification efforts. botswana's economy remains heavily reliant on diamond mining, but high youth unemployment and the need for agricultural innovation highlight the potential of cannabis as an alternative growth sector. by examining economic benefits, challenges related to social equity, and public health considerations in postlegalization economies, this study provides policy recommendations tailored to botswana's unique socioeconomic landscape. the economic potential of cannabis legalization is evident in north america, where the u.s. cannabis industry generated $13.6 billion in 2020, with projections exceeding $41 billion by 2025. similarly, canada's cannabis sector contributed $8.26 billion to the economy in 2020 and employed over 151,000 individuals. legalization in botswana could attract investment, create employment, and enhance agricultural productivity. however, for these benefits to be realized, it is crucial to establish effective regulatory structures that ensure fair access to economic opportunities, particularly for marginalized groups. cannabis legalization has raised significant social equity concerns, as historically marginalized communities have faced disproportionate legal and economic barriers to participation in the industry. in the u.s., only 19% of cannabis businesses are owned by black and minority entrepreneurs, and gender disparities persist, with women comprising 37% of the workforce. to address these issues, countries such as the u.s. and canada have implemented social equity programs, such as the cannabis opportunity reinvestment and expungement (core) act, which provides grants and training to underrepresented groups. botswana could adopt similar policies to ensure that legalization benefits all segments of society, particularly women, youth, and lgbtq+ entrepreneurs. despite the economic opportunities, cannabis legalization poses public health challenges. studies indicate increased cannabis use among youth in legalized states, although legalization has also reduced youthrelated arrests and expulsions, benefiting marginalized students. additionally, concerns about impaired driving and mental health risks require careful regulatory measures. botswana must implement harmreduction strategies, including public education campaigns, thc potency regulations, and mental health support services, to mitigate potential negative effects. for botswana to successfully integrate cannabis into its economy, a well-structured policy framework must balance economic benefits with public health safeguards and social equity considerations. key recommendations include implementing inclusive licensing conference abstracts 210 policies, creating targeted funding for marginalized entrepreneurs, developing responsible taxation structures, and investing in research to monitor legalization's long-term effects. by drawing lessons from the u.s. and canada, botswana can establish a sustainable cannabis industry that fosters economic growth while ensuring social justice and public health protection. this study underscores that cannabis legalization, if implemented thoughtfully, can serve as a catalyst for economic diversification and social equity in botswana. however, success depends on proactive policymaking that incorporates international lessons while addressing local economic and social realities. keywords: cannabis legalization, economic development, comparative analysis, botswana, job creation, regulatory framework, u.s., canada are blunt-specific messages effective? an experimental study among us youth who smoke or are susceptible to cigars leah m. ranney, phd, ma (university of north carolina at chapel hill) rime, jebai, phd (boston university) michael jetsupphasuk, phd (university of north carolina at chapel hill) sarah d. kowitt, phd, mph (university of north carolina at chapel hill) kristen l. jarman, msph(university of north carolina at chapel hill) sonia a. clark, mha (university of north carolina at chapel hill) adam o. goldstein, md, mph (university of north carolina at chapel hill) james f. thrasher, phd, ma, ms (university of south carolina) jennifer cornacchione ross, phd (boston university) background: the use of cigars for blunts (i.e., which are hollowed-out cigars filled with cannabis) is well documented. various product features of cigars, such as flavors, low cost, accessibility, and perforated (easy to open) wrappers, make it easy for youth and young adults to create blunts. blunts pose significant health risks because the combined use of tobacco and cannabis exacerbates health risks. messaging intended to reduce cigar use among youth does not specifically address the risks of using cigars to smoke blunts. this study assessed the efficacy of a blunt-specific message compared to traditional tobacco and cigar messages. methods: participants were a sample of 506 us youth (ages 15-20) recruited from april through june 2023 from qualtrics. eligible participants include those who reported past 30day or ever use of little cigars or cigarillos (lccs) or were classified as susceptible to using lccs. we conducted a between-subjects experiment embedded into an online survey where participants were randomized to 1 of 3 messages presented in a white box with black text: 1) "tobacco use causes oral, lip, and tongue cancer" (tobacco message); 2) "cigar smoking can cause lung cancer and lung disease" (cigar message); or 3) "blunts contain conference abstracts 211 nicotine and tobacco, even if you remove the tobacco filler" (blunts message). after the participants viewed the message, they reported perceived message effectiveness (pme) measured over three questions, "how much does this message: 1) make you worry about what smoking blunts will do to you?; 2) make you think smoking blunts is a bad idea?; and 3) discourage you from smoking blunts?", measured from 1, "not at all", to 5 "a great deal". secondary outcomes included thinking about risks using the same 5-point response scale; risk perceptions measured from 1, "no harm", to 4, "a lot of harm", self-reported learning measured from 1, "not at all", to 7, "very much"; and new knowledge measured "yes" or "no". we assessed differences in outcomes between conditions using linear or logistic regression models depending on whether the outcome was continuous or binary. results: most participants were men or boys (56.1%), white (59.3%), and heterosexual (67.8%). past 30-day lcc use was 32%, ever lcc use was 20.6%, and 47.4% never used lccs but were susceptible. over half of the participants reported smoking part or all of a cigar with marijuana in it (51.9%). participants were more likely to have learned new knowledge when they received the blunt message compared to the tobacco (or: 3.09, 95% ci [1.88, 5.07]) or the cigar (or: 1.93 [1.22, 3.03]) messages. selfreported learning was also higher for the blunt message compared to the tobacco message (beta= 0.57, [0.13, 1.02]). no other differences in outcomes between conditions were statistically significant at the 0.05 level. conclusions: blunt-specific messaging can increase self-reported learning and knowledge about blunts containing nicotine and tobacco among youth who use cigars and cigars as blunts. larger sample sizes and a range of messages are necessary to identify effective blunt messages that promote accurate risk perceptions for future research in this area. the problems posed by the lack of racial diversity in cannabis use disorder clinical trials mallet r. reid (department of family medicine, michigan state university) omayma alsharaawy (department of family medicine, michigan state university) blake reynolds (department of family medicine, michigan state university) jacqueline cape (department of family medicine, michigan state university) zara ahmed (department of family medicine, michigan state university) hashim ali (department of family medicine, michigan state university) background: approximately 6.8% of us adults experience cannabis use disorder (cud) in their lifetime. notably, the rates of cud vary as follows: 3.0% among multiracial people, 2.3% among american indian/alaska natives (ai/an), 2.2% among black people, 1.6% among latines, 1.3% among white people, and 0.8% among asians. additionally, ai/an, black, and latine people are more likely to experience moderate conference abstracts 212 and severe cud compared to white people. thus, several groups of people of color (poc) have a higher prevalence of cud and endure more severe clinical presentation than white people. importantly, people often seek therapy to address substance use disorders (sud) like cud. however, evidence indicates that sud treatments are less effective for poc compared to white people. therefore, poc must be well represented in cud clinical trials to ensure research is generalizable and effective for all. objective: to investigate the racial diversity of cud behavioral health interventions. methods: we systematically searched for interventions undertaken in the us without date restrictions. we searched pubmed and psycinfo using key terms, following prisma guidelines. we uploaded 384 articles into covidence, a systematic review data management software, and screened articles by title, abstract, and full text. we included studies of behavioral health interventions conducted in the us among adults (18 years) that only addressed cud and were published in peer-reviewed journals. after screening, we included 12 studies in our review. results: since 1994, 1,933 adults have participated in behavioral intervention trials for cud. most participants were white (61.1%), followed by black (11.1%), latine (9.2%), multiracial/other (2.1%), and asian (0.3%). additionally, 71.1% were males. four author groups failed to report the demographic characteristics of participants of color, yet they reported the demographic characteristics of white participants. additionally, one group collapsed participants of color in their study as "minorities." finally, our search suggests that 0 indigenous adults have been included in cud behavioral intervention trials. conclusions: people of color are severely underincluded in cud behavioral intervention trials despite having higher prevalence rates and more severe cud than white people. this poses serious concerns for the generalizability and applicability of the findings for cud research. it may mean that those who experience and suffer from cud the most are least likely to have their needs met by research. additionally, it impacts researchers' ability to conduct metaanalyses examining cud treatment effectiveness by race. further, approximately one-third of researchers reporting race/ethnicity fail to meet the national institutes of health and other organizations' basic guidelines regarding racial inclusion and reporting standards established since the mid-1990s. for instance, grouping all people of color as "minorities" or "other" belies researchers' ability to reach meaningful conclusions about the effects of interventions by race/ethnicity. overall, the dominance of white men in cud research is undeniable. it should serve as a call to action for researchers to consider equity as well as efficacy and effectiveness in their trials. exploring the gateway theory: emotion regulation, cannabis use, and increased risk of alcohol and conference abstracts 213 tobacco initiation following trauma in adolescence gillian rossmann (brown university, rhode island hospital) shaquanna brown (brown university, the miriam hospital) nicole r. nugent (brown university, rhode island hospital) leslie a. brick (brown university) substance use behaviors, such as cannabis, tobacco, and alcohol use, often emerge during adolescence, a critical period for cognitive and emotional development. the gateway theory suggests early cannabis use may increase the likelihood of later substance use. this theory emphasizes the importance of identifying psychological and behavioral factors that contribute to the initiation of substance use in adolescence. emotion regulation difficulties and impairments in executive functioning are known to be heightened during this developmental stage and may play a role in shaping substance use outcomes. this study analyzes preexisting data from a longitudinal study that investigated the development of ptsd in adolescents 13-18 years of age following admittance to the emergency department following a traumatic event. the data were collected over a nine-month period through self-report surveys and clinical diagnostic interviews. this secondary analysis examines the relationship between substance use and emotion regulation difficulties at baseline within the emergency department and at nine months (n =191). the adolescent alcohol and drug involvement scale (aadis) and the difficulties in emotion regulation scale (ders) were used to assess substance use and emotion dysregulation. substance use was categorized into those who never used and those who have used at least once in their lifetime, both baseline and month nine timepoints and analyses focused specifically on the highest endorsed substance (i.e., tobacco, alcohol, and cannabis). about thirteen percent (12.6) of youth reported lifetime tobacco use, 20.9% reported lifetime alcohol use, and 29.3% reported lifetime cannabis use at baseline, with an additional 4.2%, 7.3%, and 7.9% initiating tobacco, alcohol, and cannabis use at month nine, respectively. both the ders total score and subscores were analyzed with the substance use variables using logistic regression modeling. initial findings indicated that lifetime cannabis use at baseline increased the odds of initiating tobacco (p = 0.025) or alcohol (p = 0.048) use during the nine months following hospital discharge. greater difficulties in overall emotion regulation at baseline increased the odds of initiating cannabis use (p = 0.012) at 1.11. further analysis with ders subscores indicated that greater difficulties in goal directed behavior and impulsivity both increased odds of lifetime cannabis use (p = 0.014, p = 0.007 respectively). these findings suggest that youth who indicate higher levels of emotion regulation difficulties are more likely to report initiating cannabis use after a traumatic event. the predictive relationship between cannabis use and an increased odds of initiating alcohol conference abstracts 214 or tobacco use indicates that early cannabis use may increase susceptibility to other substances, consistent with the hypothesis of the gateway theory. additionally, difficulties in goal directed behavior and impulsivity are significant predictors of cannabis use, suggesting that those with impaired executive functioning may be more likely to use substances. these findings emphasize the importance of considering both emotional and cognitive factors in substance use prevention, particularity during adolescence. using large language models to identify and extract medicinal cannabis use data from electronic medical records in a us academic health system johannes thrul (johns hopkins university) nic dobbins (johns hopkins university) cerina dubois (johns hopkins university) clarissa madar (johns hopkins university) paul nagy (johns hopkins university) mark dredze (johns hopkins university) ryan vandrey (johns hopkins university) background: medicinal cannabis use is widespread, with over 5.5 million registered patients in state-regulated programs in the u.s. alone. significant gaps remain regarding patient-level health outcomes associated with medicinal cannabis use, including challenges related to capturing detailed use patterns in national health surveys. electronic medical records (emrs) represent a potentially rich data source providing detailed clinical insights into medicinal cannabis use and associated health outcomes. however, medicinal cannabis use is inconsistently coded in emrs. clinical natural language processing (nlp) approaches are uniquely suited to extract information from unstructured text and turn it into structured data. hence, the objective of this study is to use nlp to extract cannabis-related information from free-text provider notes in emrs in the johns hopkins health system (jhhs). methods: in partnership with the jhhs data trust, we extracted approximately 2.1 million clinical notes from over 800,000 patients. initially, patients were selected based on frequently reported health conditions for medicinal cannabis (i.e., chronic pain, mood and anxiety disorders, autism, epilepsy) and records were identified by cannabis-related diagnostic keywords. utilizing openai's large language models (llms) hosted within a secure, hipaa-compliant azure environment, we developed and refined preprocessing routines and classification schemas through iterative examination and syntactic pattern analysis of clinical notes. our llm-output data schema systematically captures detailed information including cannabis use status (medicinal or recreational), registration in medical cannabis programs, cannabis use disorder diagnoses, and conditions such as cannabis hyperemesis syndrome. additional granular data extracted will include subjective effects of conference abstracts 215 cannabis use, quantity, frequency, and route of administration, product type, cannabinoid chemotype, treatment indications, and reported health consequences. llm-generated outputs were validated and refined using a specifically developed annotation tool and results were used to iteratively revise and improve the llm-output data schema. results: our preliminary processing flagged approximately 1.5 million clinical notes with a high likelihood of documenting cannabis use. by the time of the conference, detailed structured outputs from these emrs will have been processed through our refined llm-based nlp approach, enabling granular analysis of cannabis use characteristics in our study population, including medicinal versus recreational use, frequency, product types, cannabinoid chemotypes, and routes of administration. this comprehensive dataset will provide robust insights into patterns of medicinal cannabis use, patient demographics, clinical contexts of use, and associated health outcomes. conclusions: integration of advanced nlp methods with emrs significantly enhances our ability to capture and analyze detailed cannabis use information in clinical populations. identification of medicinal cannabis use within emrs supports robust longitudinal, case-control, and other observational studies, including comparison to matched non-cannabis using controls, which are essential for investigating the health effects of medicinal cannabis use. this study will provide a tool to evaluate the health impact of medicinal cannabis on a health systems scale, which can ultimately inform clinical decisionmaking and public health policy. the scalability of this approach is substantial through working with the observational health data sciences and informatics (ohdsi) community, which will allow us to collaborate with over 300 data partners worldwide with over 950 million unique patients for future analyses. cannabis safety considerations and informed decision making by cancer patients morgan tisdall (arizona state university) symone griffith (arizona state university) iris balodis (mcmaster university) deirdre querney (city of hamilton's alcohol, drug & gambling services) allison rosenthal (mayo clinic) mahmoud siyam (hamilton health sciences) robert kirchoff (mayo clinic) maxwell leung (arizona state university) with the increased availability and social acceptance of cannabis, cancer patients are increasingly considering its use to alleviate cancer symptoms (i.e., cancer pain) as well as chemotherapy-related side effects. although the perceived benefits of cannabis use in cancer populations are common, there is little discussion of cannabis safety issues specific to cancer patients in the peer-reviewed literature. to support informed symptom management with cannabis use in this patient population, we reviewed three primary types of health conference abstracts 216 risk: adverse effects and misuse, drug interactions, and product safety concerns. cancer patients, due to compromised health, are particularly vulnerable to cardiovascular, respiratory, and psychiatric effects that could arise from shortor longterm cannabis use. potential drug interactions with common chemotherapeutic medications may result in adverse drug events and poor health outcomes. additionally, the inconsistent quality and labeling of cannabis products pose an additional risk due to contaminants like fungi and other microbial contaminants. informed decision-making by cancer patients including the "start low and go slow" dosing method to prevent supratherapeutic doses and proactive recognition of misuse patterns and thorough communication with healthcare providers may reduce the risk of cannabis associated adverse effects. encouraging safety-conscious behaviors, including scrutinizing product certifications and considering safer consumption methods, are also important safety recommendations. as legalization efforts for medicinal cannabis continue, the findings from this review provide the basis for cannabis safety education in cancer care, which in turn will reduce the health risk associated with cannabis use in cancer symptom management. cannabis use in adults over 50: patterns of use and self-reported side effects kara tsuzaki (kaiser permanente hawaii center for integrated health care research) kathryn l. pedula (hawaii permanente medical group, kaiser permanente hawaii) catherine erickson (kaiser permanente hawaii center for integrated health care research) kristina t. phillips (kaiser permanente hawaii center for integrated health care research, kaiser permanente bernard j. tyson school of medicine) introduction: cannabis use among adults aged 50 and older has increased despite this population's heightened vulnerability for health-related conditions and use of medications for chronic illnesses. as cannabis is legalized across the u.s., corresponding changes in societal perceptions surrounding cannabis use have contributed to this rising trend. there is a need to better understand older adults' patterns of cannabis use and unintended effects to decrease susceptibility for harm. the current study reports on cannabis-related side effects and explores the relationship between side effects, form of cannabis used, and symptoms of cannabis use disorder (cud) among adults aged 50 and older who use thc-based cannabis products. method: participants were recruited using targeted email outreach to patients aged 50 and older. patients reporting recent cannabis use within the past 30 days via an online screener were invited to complete a comprehensive online survey that included questions assessing demographics, cannabis use patterns (e.g., form, method of ingestion, quantity), cannabis-related side effects, and symptoms of cud conference abstracts 217 using the cannabis use disorders identification test-revised (cuditr). results: participants (n = 342) were 42.4% female, with an average age of 65.8 (sd = 8.7), and predominantly white (68.4%), native hawaiian or pacific islander (nhpi; 12.9%), or asian (8.2%). overall, 84.1% of participants reported at least one side effect out of 22 possible, with an average of 3.1 (sd = 2.3). the most commonly reported side effects included dry mouth (74.2%), dry eyes (37.1%), and forgetfulness (42.3%). of note, many participants experienced psychological symptoms such as anxiety (26.6%) and paranoia (23.3%), and physical symptoms such as dizziness (28.1%) and unsteadiness (27.6%). participants who endorsed smoking as their primary method of cannabis ingestion (n=192) were more likely to report having at least one side effect compared to those using other methods (p = .0004). significantly greater numbers of participants who smoked reported experiencing dry mouth (p = .005), breathing problems (p = .004), feeling agitated/upset (p =.016), and feeling forgetful (p = .021). the distribution of cudit-r scores were examined in quartiles; as cudit-r scores increased, the number of side effects also increased in a dose-response manner (p=.002). side effects did not differ with varying amounts of cannabis quantity. multiple logistic and linear regression models tested the impact of demographics, cannabis frequency/patterns, other substance co-use, and cudit-r scores on any/number of endorsed side effects. younger age (p = .0002) and greater cudit-r score (p < .0001) were associated with a greater number of side effects. smoking cannabis (or = 3.99, p < .0001) and greater cudit-r score (or = 1.1, p = .05) were associated with at least one side effect. conclusions: our findings suggest that older adults who use cannabis are experiencing cannabis-related problems and side effects. more research is needed to better understand the impact of cannabis on older adult health. because older adults are more susceptible to various health conditions and cognitive decline due to the natural aging process, it is imperative to develop targeted education and harm reduction approaches specific to this population. patient-physician communication about cannabis: an initial exploration of reasons for nondisclosure in adults over 50 kara tsuzaki (kaiser permanente hawaii center for integrated health care research) kathryn l. pedula (hawaii permanente medical group, kaiser permanente hawaii) catherine erickson (kaiser permanente hawaii center for integrated health care research) kristina t. phillips (kaiser permanente hawaii center for integrated health care research, kaiser permanente bernard j. tyson school of medicine) introduction: the increasing prevalence of cannabis use in adults over 50 raises concerns about open patient-physician communication, particularly as this population ages conference abstracts 218 and experiences medical issues that could be impacted by cannabis use. this presentation aims to assess 1) patient disclosure of cannabis use to their physician, 2) reasons for not disclosing cannabis use, and 3) patient characteristics associated with nondisclosure. methods: patients over 50 were recruited from an integrated healthcare system in a medical cannabis state and screened online for past month cannabis use. eligible participants were invited to complete a comprehensive online survey covering cannabis use (including frequency, methods of ingestion, and problem cannabis use or cudit-r score), discussions with their physician about cannabis use, and-if they had not disclosed their usereasons for non-disclosure. two independent raters coded these openended responses, agreeing on discrepant codes. results: participants (n=367) were 43% female, with an average age of 65.9 (sd=8.6), and predominantly white (67.9%), native hawaiian or pacific islander (12.3%), or asian (9.3%). almost half of the sample (47%) was retired. participants reported using a range of cannabis products; however, the majority (59.9%) reported primarily using thc-based flower, followed by edibles (16.7%). most participants (56.7%) reported smoking as their primary method of ingestion, followed by oral consumption (22%). participants used cannabis for a mean of 18.7 days (sd=11.5) in the past 30 days. of the full sample, 333 participants (91%) reported having a regular physician; of those, 179 (53.8%) disclosed their cannabis use to their provider. demographic variables were not associated with disclosure, but those who disclosed their use had a higher cudit-r score (m=8.3, sd=4.7) compared to those who did not (m=6.5, sd=4.2; p=.0007). of the 154 participants who did not disclose their use, 54.6% either agreed or strongly agreed that their physician would judge them, 40.9% wondered if it would affect their medical treatment, and 34.6% were concerned that it might affect medications prescribed to them. participants provided 88 additional open-ended reasons with 20 discrepant codes requiring consensus explaining why they had not disclosed their use. five themes emerged: 1) legality and fear of consequences (n=22), 2) irrelevance or didn't feel it was necessary (n=31), 3) never had an opportunity to discuss (n=21), 4) privacy and reluctance for cannabis to be specified in their medical record (n=15), and 5) other (n=26). conclusion: patient acknowledgement of cannabis use among this sample of older adults in a state without legal recreational cannabis highlights underlying reasons for non-disclosure that point to the need for improved patientprovider communication. patients who endorsed greater cannabis problems were more likely to disclose their use, which may be associated with a need for more cannabis-related medical care. overall, participants expressed some hesitancy to disclose and fear of judgement. further research is needed to understand the nuances of patientphysician communication to promote open discussion. conference abstracts 219 cannabinoid neuroprocessing and retina: disruptions, dysfunctions, and impairment of iprgc denise a. valenti (immad llc) holly kailher (immad llc) purpose: cannabinoids and marijuana in particular have been identified as disrupting dopaminergic neuroprocessing. among these are the retinal and visual pathways. the goal of this presentation is to relate the latest research and resulting hypothesis related to the marijuana induced disruptions of the retina and subsequent impairment of visual functions. the emphasis will be on those functions and visual responses that are essential to the task of driving. methods: the data and information were derived from the laboratory and field work of impairment measurement marijuana and driving (immad) through national institute of justice funded research; 15pnij-22-gg04417-ress and literature reviews undertaken to further validate research findings. the research was performed under an irb approved protocol that allowed for opportunistic dosing of healthy volunteers under the age of forty. opportunistic dosing is when a volunteer consumes their own legal adult use product. immad's protocol had the volunteer come to the laboratory for consent process, drug screening, questionnaires and undosed research testing. volunteers informed staff when and where they would be consuming their own legal adult use products and volunteers were then brought into the lab by shared ride. the only criteria for the products was it must be inhaled and no dabbing products. we measured retinal function using a virtual reality goggle system (for which immad holds the marijuana utility patent) displaying seventeen small ten degree striped squares across the central forty degrees of visual field, one at a time and each eye separately. the stripes were of fixed temporal flip but variable contrast. the volunteer pressed a bluetooth button each time they saw the stripes. results: immad laboratory identified disruptions and dysfunctions in retinal processing that correlates in location to the dopaminergic dependent intrinsically photosensitive retinal ganglion cells. data are being further analyzed to determine how significant these disruptions and dysfunctions are in contributing to impairment to drive. conclusions: undertaking research on a drug that is schedule i presents significant barriers. further research is necessary with fully controlled dosing using precisely controlled cannabis and marijuana products. an example is the contribution nicotine makes to retinal neuroprocessing. this is a variable when inhaled blunts (tobacco wrapped marijuana) products are used. better consistency and control is available if volunteers are provided with products. development of the cannabis use questionnaire (cuq): a comprehensive measure of cannabis use behavior ryan vandrey (johns hopkins university) cerina dubois (johns hopkins university) conference abstracts 220 clarissa madar (johns hopkins university) johannes thrul (johns hopkins university) justin strickland (johns hopkins university) nicholas schlienz (roswell park comprehensive cancer center) alan budney (dartmouth college) heather jackson (realm of caring) marcel bonn-miller (charlotte's web) background: the legalization of cannabis for therapeutic and nontherapeutic purposes has resulted in a substantial increase in the diversity of cannabis-based products available for retail sale. these products vary by intended route of administration, formulation, chemotype and dose. laboratory research shows that these variables impact pharmacokinetics and pharmacodynamics. a consequence of the evolution of this industry is that there are no longer valid assessments of cannabis use behavior that capture the variety of marketed products. to meet this need, the cannabis use questionnaire (cuq) was developed as a comprehensive measure of cannabis use behavior. methods: cannabis product surveillance was conducted for online and retail marketplaces to establish product categories, which included differentiation by route of administration, formulation, and chemotype. a structure was developed to minimize participant burden using branching logic and the questionnaire programmed into both redcap and qualtrics platforms. units of measure were determined for each product type based on intended route of administration and package content labeling to quantify consumption for each retail category. the survey was first deployed in an observational study and feedback obtained from participants using a variety of cannabis products for medicinal purposes. the measure was then refined and is currently undergoing test-retest validation with volunteers being administered the questionnaire across 2 time points, separated by 1 week. an algorithm is also being developed from controlled human laboratory data to quantify inhaled thc and cbd exposure based upon puff topography data. results: participants report which of 9 distinct product categories a given cannabis product they use falls: flower, e-liquid, concentrates, oils/tinctures, edibles, topicals, suppositories, pharmaceuticals, or they can specify another unlisted product type. data on predominant chemical composition of the product (e.g., thc-dominant, cbd-dominant, balanced thc/cbd, or minor cannabinoid-dominant), as well as, for inhaled products, whether the product was smoked or vaporized is reported. the dose of thc, cbd, and/or the dominant minor cannabinoid is also reported. analyses of test-retest results is pending completion of ongoing data collection and is expected well before the conference. conclusions: the cuq is the most comprehensive tool for quantitatively measuring cannabis use behavior and can be utilized in a broad array of research contexts. branching logic is used to minimize the burden on the participant. the authors are willing to share the redcap or qualtrics program with conference abstracts 221 any researcher interested in using the measure. widespread adoption of this tool will help integration and comparison of data from different sources. association between plasma thc/cbd and chronic pain outcomes: early results from a prospective cohort of older adults with chronic musculoskeletal pain yan wang (university of florida) kimberly t. sibille (university of florida) zhigang li (university of florida) rene przkora (university of florida) siegfried o.f. schmidt (university of florida) margaret c. lo (university of florida) jost klawitter (university of colorado) robert l. cook (university of florida) background: quantifying cannabis use via self-report is often challenging given the diversity of products (e.g., routes of administration, cannabinoids profile). blood tests for cannabinoids and their metabolites provide an objective measure of cannabis use that can enhance research rigor. this study leverages plasma cannabinoids/metabolites test over time in a prospective cohort to examine the long-term effects of medical cannabis (mc) on older adults with chronic pain. method: we analyzed data from 97 participants (mean age = 65 9.4, 66% female) as part of an ongoing prospective cohort that recruits and follows older adults (50 years or older) with chronic pain for one year, as some initiate mc (mc group) and others do not (control group) with a planned enrollment ratio at 3:1. blood samples were collected at baseline, 3, 6, 9, and 12 months to test for 17 cannabinoids and cannabinoid metabolites. at each time point, self-reported chronic pain severity was assessed by the brief pain inventory (bpi), and pain interference was measured by the 4item promis pain interference short form. available data (collected so far as data collection is still ongoing) were analyzed to examine whether the presence of plasma thc/cbd and related metabolites is associated with lower chronic pain severity and interference at 3-, 6-, 9and 12-month follow-ups. results: based on completed study visits, 35 out of 97 participants tested positive for plasma thc/cbd or related metabolites at 3 months, 22/72 tested positive at 6 months, 10/53 at 9 months, and 10/49 at 12 months (total n differed because not everyone finished all study visits yet). those who initiated mc use had slightly higher baseline pain severity (5.83 3.22 vs. 5.38 3.76) and interference (63.8 7.3 vs. 61.6 7.2) than those who did not use mc. the presence of thc and its metabolites in plasma was associated with lower selfreported "worst pain", "least pain", and "average pain" scores at 3, 6, 9, and 12 months, and lower pain interference at 12 months (58.3 9.3 for thc positive group vs. 61.1 8.2 for thc negative group, p < .01). however, the presence of cbd and its metabolites in plasma was not associated with either lower pain severity or interference at all time points. in terms of reductions in pain severity and interference, the presence conference abstracts 222 of plasma thc/metabolites trended towards greater reduction in overall bpi average score (1.85 1.62 for thc positive group vs. 0.51 2.61 for thc negative group, p = .062) and reduction in pain interference score (9.63 9.60 vs. 0.87 7.54, p < .01) at 12-month follow-up. conclusions: although sample sizes are small and findings are preliminary, data suggest that consuming mc products containing thc reduce pain severity and interference among older adults, while cbd didn't show a direct benefit on these outcomes. more research leveraging blood test as an objective measure of cannabis use is needed to further investigate the differentiating effects of thc, cbd, and other cannabinoids on various health outcomes. early insights from the nontherapeutic research on cannabis framework in canada raymond yang (health canada) sophie-anne lamour (health canada) yasmina medjamia (health canada) joseph antony (health canada) austin mayers hanan abramovici since december 2022, canadian researchers wanting to conduct clinical research studies for nontherapeutic purposes with legally available cannabis products regulated under the cannabis act can apply for a cannabis research licence under the non-therapeutic research on cannabis (ntrc) framework. health canada implemented this risk-based framework to inform public health and public safety measures, facilitate public education, and inform and support policy decisions. the objective of this work is to examine the types of ntrc studies that have been submitted by cannabis research licence applicants between december 2022 and december 2024. studies under the ntrc framework are classified into three risk categories: category 1 (lower risk) for consumer preference studies; category 2 (medium risk) for studies involving healthy participants where the mode of consumption and amount of cannabis consumed are similar to their usual consumption habits; and category 3 (higher risk) for studies involving additional risk factors such as participants with comorbidities, higher-doses of cannabis, novel cannabinoids, or combining cannabis with other substances or health products. application requirements vary based on the risk category: the higher the risk category, the more information required to be submitted to health canada for review. applicants must submit two to three documents for scientific review depending on the risk category. for category 2 and 3 studies, applicants are required to submit the cannabis research and evidence dossier (cred), which documents safety evidence drawn from peer-reviewed literature, and the research protocol, which outlines the study objectives, methodology, participant eligibility, dosing, and safety measures. for category 3 studies, they must also submit the informed consent form(s), which explains the risks of participating in a study to the participants. additionally, the conference abstracts 223 cannabis used in the study is required to meet good production practices (gpp) as mandated by the cannabis act and its regulations. from december 2022 to december 2024, health canada received a total of 126 applications, including 104 category 1, 4 category 2, and 18 category 3. research topics for category 2 and 3 studies were diverse and included studies on smoking topography, cognitive function, impacts on driving, and the safety of high-potency thc products. the participants were healthy, with about two-thirds being occasional cannabis consumers, and the remaining third being regular cannabis consumers. cannabis was administered through inhalation (vaping and smoking) in 13 studies, and orally in 9 studies. the cannabinoids under study included thc (6), cbd (3), and their combinations (13). additionally, one study included thc, cbd, cbg, and cbn. all the category 1 applications were from industry, whereas most applications (16) for category 2 and 3 studies came from academic institutions. the ntrc framework opens a new and important path to conduct critically needed research to gather evidence on the effects and risks associated with the use of cannabis products by canadians for non-therapeutic purposes. this evidence will help further our understanding of the public health and public safety impacts of cannabis legalization and regulation in canada, help inform lower-risk use, enhance public education and awareness and help inform policy decisions. symposia symposium title: assessing the relative reinforcing value of cannabis among dispensary patrons using novel behavioral economic tools chair: elizabeth r. aston (brown university school of public health) discussant: james mackillop (mcmaster university) evolving cannabis legality has yielded significant increases in cannabis accessibility and purchase. this has resulted in availability of novel cannabis formulations likely accompanied by changes in normative perceptions of peer cannabis use. behavioral economic approaches to the study of cannabis use integrate tools from economics and psychology to explain the degree to which one values cannabis relative to other reinforcers (i.e., cannabis demand). measurement of demand for cannabis has been highly effective in the detection of excessive substance valuation, and indices of demand for cannabis are robust predictors of cannabis misuse, consequences, and cannabis use disorder. these presentations will examine cannabis demand among those who use cannabis using novel measures that have been developed in response to the changing landscape of cannabis availability, use, and purchase. the presenters will comment on public health implications of cannabis demand assessment and the importance of tailoring behavioral economic measures in the face of continuously developing policy. dr. conner will present data on product conference abstracts 224 purchasing and cannabis demand collected from cannabis dispensary patrons. dr. aston will present results from work validating a novel behavioral economic purchase task for high potency concentrates among those with experience using concentrates. dr. prince will present findings from work using a novel marijuana purchase task designed to assess normative perceptions of cannabis demand among recreational dispensary patrons. dr. mackillop will synthesize the results from these investigations by discussing the promise of adapting marijuana purchase tasks to evolve with the transforming cannabis environment in the context of fluctuating cannabis policy. talk 1: testing the marijuana purchase task in the real world: assessing its predictive validity and utility in identifying problematic cannabis use among dispensary patrons bradley t. conner (colorado state university) elizabeth r. aston (brown university school of public health) mark a. prince (university of southern california) background: a drug's relative reinforcing value is a powerful determinant of its misuse. relative drug value (i.e., demand) can be measured via hypothetical measures known as behavioral economic purchase tasks, wherein respondents indicate how much drug they would purchase and consume across escalating prices. the current studies focused on the marijuana purchase task (mpt), developed to measure the reinforcing nature of cannabis. little research to date has tested the external validity and utility of the mpt when administered outside of the lab. method: the goal of this study was to determine whether the mpt, administered in a real-world setting by collecting data from participants recruited while standing in line in a legal recreational cannabis dispensary in colorado, was predictive of cannabis use and symptoms of cannabis use disorder (cud). discriminate validity was tested via examining whether indices of cannabis demand predicted alcohol use. data came from 140 individuals (age m = 30.6 sd = 11.5, women = 50.7%, self-reported race white = 91.9%, 16.4% hispanic/ latine) who reported recent cannabis use. upon dispensary exit, participants provided information on demographics, cannabis use history, and cannabis products purchased that day, and completed self-report questionnaires including the mpt and the selfreported symptoms of cannabis use disorder questionnaire. results: with respect to products purchased, 29.1% of the sample reported purchasing concentrated cannabis products (e.g., vape cartridge, wax, shatter), 18.6% reported purchasing edible products, and 67.1% reported purchasing flower products (product purchases were not mutually exclusive). five indices of cannabis demand were obtained from the mpt: intensity consumption at zero cost; omax maximum expenditure on cannabis; pmax price associated with omax ; breakpoint price suppressing consumption of cannabis to zero; and elasticity the conference abstracts 225 rate of consumption decline with increasing cost. pmax significantly positively and elasticity significantly negatively predicted number of days in the past 30 that participants reported using cannabis (p < 0.05 & 0.001, respectively). intensity significantly positively predicted estimated grams of cannabis used in a typical cannabis use week (p < 0.001). omax and breakpoint significantly positively predicted cud symptom count (p < 0.001 & 0.05, respectively). cannabis demand indices were not significantly associated with past 30-day alcohol use. conclusions: these findings indicate that the mpt administered in real-world settings has both predictive and discriminate validity and may be a good assessment tool to determine who is at most risk for developing cud symptoms. moreover, this is the first study to assess cannabis demand among those reporting recent dispensary purchases. future research is needed to replicate these findings in other settings and among other samples, specifically those who endorse cannabis use but do not obtain cannabis from a dispensary (e.g., growers, those who purchase from unregulated sources). importantly, findings from the present investigation indicate that the mpt may be a valuable tool to use in the field to aid in determining those at greatest risk for cannabis misuse and progression to cud. talk 2: initial validation of the high potency concentrate purchase task elizabeth r. aston (brown university school of public health) mark a. prince (university of southern california) bradley t. conner (colorado state university) background: evolving cannabis legalization has dramatically altered the landscape of cannabis use in the united states. while flower remains the most commonly used formulation, those who use cannabis often experiment with and adopt use of other formulations, including high potency concentrated cannabis products which contain extremely high thc levels. the relative value (demand) one places on cannabis is a key indicator of risk for misuse and cannabis use disorder (cud) escalation. cannabis demand can be assessed via a marijuana purchase task (mpt), which reflects the interplay between cannabis price and its consumption. traditional single-commodity mpts were designed to assess demand for flower and thus do not permit assessment of demand for other formulations. this study assessed high potency concentrate demand using a novel high potency concentrate purchase task (hpcpt). methods: participants were recruited outside a retail cannabis dispensary in colorado. upon dispensary exit, participants provided demographic and cannabis use information, and completed the hpcpt, mpt, marijuana consequences questionnaire, positive outcomes of cannabis use scale, and self-reported symptoms of cannabis use disorder. participants who endorsed concentrate experience (n = 93; 50% female, mean [sd] age = 36 [13], mean [sd] pastmonth cannabis use days = 28 [7]) were conference abstracts 226 included in analyses. five demand indices were obtained from the hpcpt: intensity (consumption at zero cost), omax (maximum expenditure), pmax (price associated with omax), and breakpoint (price suppressing demand to zero). bivariate correlations were run between hpcpt and mpt demand indices to assess convergent validity. subsequent correlations were run among concentrate demand indices and cannabis use outcomes. divergent validity was examined by dividing the sample according to self-reported cud symptoms and examining concentrate demand as a function of group. results: for participants with complete hpcpt and mpt data, concentrate demand indices were significantly correlated with their flower demand index counterparts (rs = .313-.821, ps < .01). omax (r = -.259, p = .012), pmax (r = .350, p < .001), and breakpoint (r = .243, p = .019) were significantly related to marijuana use days. intensity was significantly related to self-reported cud symptoms (r = .217, p = .036) and positive cannabis-related consequences (r = .295, p = .004). no concentrate demand indices were associated with negative consequences. participants with more cud symptoms exhibited signicantly greater breakpoint (mean = 63.82, sem = 6.25) and pmax (mean = 38.55, sem = 5.30) than participants with fewer self-reported cud symptoms (mean = 41.79, sem = 4.99, p < .001; mean = 28.60, sem = 4.50, p = .031). conclusions: these results provide initial support for convergent and divergent validity of the hpcpt, demonstrating its sensitivity to demand for concentrates as a function of increasing cost, and its ability to differentiate between those with varying degrees of self-reported cud symptoms. associations between concentrate demand and negative cannabis-related consequences were not observed, however, negative cannabis consequence measures were not developed to assess concentratespecific consequences. future work can further improve upon this promising measure by using qualitative methods to tailor task components to the nuances of cannabis concentrates. talk 3: normative perceptions of peer cannabis demand characteristics mark a. prince (university of southern california) bradley t. conner (colorado state university) elizabeth r. aston (brown university school of public health) background: marijuana purchase tasks (mpts) are hypothetical measures that offer an efficient way to assess cannabis' relative reinforcing value (i.e., demand). such tasks ask participants to report on the amount of cannabis they would purchase across a range of prices. data from the mpt can be used to generate a set of demand indices including intensity (i.e., amount of cannabis one would consume if it were free), omax (i.e., the maximum amount one is willing to pay for cannabis), pmax (i.e., the price associated with omax), breakpoint (i.e., price at which one is no longer willing to purchase cannabis), and elasticity (i.e., rate of decline in cannabis purchase with increasing conference abstracts 227 cost). two open questions concern whether individuals assume that their peers' cannabis purchasing behavior is similar to their own, and whether one's own motivations for using cannabis are associated with their perceptions of other's cannabis demand. methods: participants were recruited while standing in line in a legal recreational cannabis dispensary in colorado; those with valid cannabis demand data (n = 137) were included in analyses. this was the first study to adapt the mpt to ask participants: "how much marijuana do you think a typical user would purchase and use at different price levels?" in addition to this normative perception-based purchase task, participants were also asked to complete the mpt about their own purchasing behavior, as well as the marijuana motives measure. we hypothesized that those with conformity motives would be more likely to believe others' cannabis purchasing behavior to be similar to their own. results: with the exception of omax, participants' own demand indices were nearly identical to demand indices generated from their perceptions of others' purchasing behavior. participants perception of others' cannabis demand generated higher omax values than their own omax values (omax-personal = 135.19, omax-other = 178.11). correlations between personal demand indices and perceptions of others' demand indices were large and statistically significant (omax r = .776, pmax r = .671, breakpoint r = .752, intensity r = .731, elasticity r = .899). in addition, social motives were associated with normative perceptions of omax (r = .221), and conformity motives were associated with normative perceptions of all demand indices with the exception of elasticity (omax r = .471, pmax r = .360, breakpoint r = .228, intensity r = .200, elasticity r = -.049). conclusions: based on the focus theory of normative conduct, it is likely that participants' beliefs about others' purchasing behavior influenced their own purchasing behavior. the higher omax generated from perceptions of other's purchasing behavior suggests that participants believe others would spend more on cannabis than they would themselves. subsequent work should aim to collect a large normative sample of cannabis demand data to determine whether purchasing behavior normative beliefs are exaggerated in a similar way to normative perceptions about others' substance use behavior. if the same exaggerated normative beliefs exist, normative re-education interventions could be developed to correct misperceptions potentially leading to safer buying practices. symposium title: what are the implications of cannabis intentions? exploring planned and unplanned use chair: lindy k. howe (brown university) discussant: rachel l. gunn (brown university) exceeding one's planned amount of substance use may be an indicator of impaired control, a key criterion in the diagnostic and statistical manual of mental disorders (dsm-5) for substance use disorders. as such, conference abstracts 228 examining the relationship between planned and unplanned use and related outcomes is essential. explored primarily in the context of alcohol thus far, there remains limited understanding of how planned versus unplanned use, and related constructs, operates with cannabis. this symposium will include four ecological momentary assessment (ema) studies aimed at addressing this gap. nicolle fox (clinical psychology phd student, york university) will present findings on the longitudinal associations between measures of impaired control over cannabis and daily experiences of unplanned cannabis use and difficulty limiting cannabis use, highlighting how these predict cannabis use and negative consequences at the day level. alexander sokolovsky (assistant professor, brown university) will present data on the predictors and consequences of forgoing planned cannabis use in a sample of individuals that use both alcohol and cannabis. holly boyle (assistant professor, yale university) will present data from a daily survey study of young adults examining the relationship between day-level cannabis use intentions and willingness and use (i.e., hours high), subjective high, and related consequences. lindy howe (postdoctoral fellow, brown university) will present findings of intentions in predicting perinatal cannabis use and describe preliminary data on motivations behind planned and unplanned use. this symposium deepens our understanding of how intentions shape cannabis use across a variety of populations and could potentially inform future interventions. talk 1: understanding impaired control over cannabis in daily life: unplanned use versus difficulty limiting use nicolle fox (york university) christian s. hendershot (university of southern california) kyra n. farrelly (york university) annabelle moore (york university) jeffrey d. wardell (york university; institute for mental health policy research; university of toronto) background: impaired control (ic) over cannabis, a feature of cannabis use disorder involving failed attempts to limit use, is linked with heavier consumption and negative consequences. there is limited research on ic over cannabis, and no studies have examined whether elevated ic is associated with perceived difficulty limiting cannabis use in daily life or whether this proximally predicts greater use and consequences. further, ic may be a risk factor for unplanned cannabis use (i.e., using without prior intention), which could partially explain the link between elevated ic and increased cannabis use and consequences. this study investigated whether unplanned cannabis use and perceived difficulty limiting cannabis assessed at the day level mediated associations between ic over cannabis and cannabis use and consequences over one year. methods: participants were 133 young adults (ages 19-24; 65% female) from a larger ecological momentary assessment (ema) study of alcohol conference abstracts 229 and cannabis co-use. participants completed 21 days of ema surveys in three bursts (i.e., baseline, 6-month, 12-month; n=2115 total observations). prior to each burst, participants completed a measure assessing attempts to control cannabis during the past 6 months and perceived ic over cannabis (taguba et al., 2022). participants then completed daily morning surveys (89-92% compliance across bursts) assessing their intention to use cannabis that day along with their previous days' cannabis use (forms and grams of flower). unplanned use was operationalized as using on days when no intention to use was indicated on the preceding morning survey (26% of use days). items assessing difficulty limiting cannabis use the prior day (endorsed on 5% of use days), and acute negative cannabis consequences were also included. results: a multilevel structural equation model with cannabis use days (level 1) nested within burst (level 2) nested within participants (level 3) revealed significant day-level relationships between difficulty limiting cannabis (but not unplanned cannabis use) and both increased cannabis use [95%ci: 0.041, 0.150] and greater acute negative consequences [95%ci: 0.198, 0.542]. at the burst level, withinperson increases in attempts to control cannabis use over the past 6 months were associated with more unplanned cannabis use days during the ensuing ema burst [95%ci: 0.018, 0.107], and within-person increases in perceived ic over cannabis predicted greater endorsement of difficulty limiting cannabis on subsequent daily surveys [95%ci: 0.032, 0.132]. increases in perceived ic reported prior to a given ema burst were indirectly linked to increased use and consequences during that burst, mediated by difficulty limiting use during the burst (95% cis did not contain zero). conclusion: perceived ic over cannabis predicted greater use and consequences in the daily lives of young adults, mediated by greater endorsement of difficulty limiting cannabis on daily surveys. more attempts to control cannabis use were linked to more unplanned use, but unplanned use was not associated with heavier use and consequences at the daily level. findings suggest that changes in ic over one year are linked to changes in daily cannabis use patterns and consequences, and point to strategies for improving control over cannabis use as a future research direction. talk 2: forgoing planned cannabis use: daily correlates and alcohol use outcomes of cannabis non-use when use was planned in a heavy drinking young adult sample alexander w. sokolovsky (brown university) lindy k. howe (brown university) rachel l. gunn (brown university) background: intentions are a crosscutting antecedent of behavior across theoretical models of health behavior, including models of substance use. while research has examined the links between planned cannabis use and cannabis-related outcomes at the person level in cross-sectional and conference abstracts 230 longitudinal observational or treatment outcome studies, research examining the daily correlates of cannabis use intentions remains limited. early work has found that daily cannabis use intentions (i.e., planned cannabis use) are associated with spending a greater number of hours high, although not with increased negative consequences. critically, with the increasing legalization of cannabis use, there has also been a widespread increase in the co-use of alcohol and cannabis. research on such co-use has found that cannabis can act both as a substitute and as a complement to alcohol, with different findings observed for different research questions. in light of this complexity and as substance use intentions are often a prime target for intervention, especially in just-in-time-adaptive intervention (jitai), understanding the impact of forgoing planned cannabis use and identifying predictors of such non-use is critical in determining whether cannabis use intentions could be targeted to indirectly reduce daily alcohol use and what mechanisms may facilitate such intervention. in this secondary analysis, we examine the antecedents and outcomes of forgoing planned cannabis use in a sample of young adults who drink heavily. methods. young adults (n=107; mage=23.3; 55% female) completed a baseline survey and completed 28 days of ecological momentary assessment (ema) comprising random, substance, and morning surveys. to examine antecedents of forgoing planned cannabis use, we fit generalized linear mixed models regressing forgoing (ref: enacting) planned cannabis use onto prior-day positive and negative alcohol and cannabis use consequences and morning alcohol and cannabis craving. to examine the outcomes of forgoing planned cannabis use, we fit linear mixed effects models regressing total number of drinks and positive and negative alcohol consequences onto forgoing (ref: enacting) planned cannabis use. all models covaried age, sex, and everyday discrimination experiences. results. participants indicated planned cannabis use on 1,458 days, of which they forwent use on 144 days (9.9%). none of the examined antecedents (prior day positive and negative alcohol and cannabis consequences, morning alcohol and cannabis craving) were significantly associated with forgoing (versus enacting) planned cannabis use that day. forgoing planned cannabis use was associated with consuming significantly fewer total drinks (est = -1.18, se = 0.31, p <.001) on a given day but was not associated with fewer positive or negative alcohol consequences. conclusion. although this preliminary examination did not identify significant antecedents of forgoing planned cannabis use, we did observe a significant protective effect of forgoing planned cannabis use on daily alcohol consumption. targeting planned cannabis use in jitai could serve to indirectly reduce alcohol use outcomes among heavy-using young adults. future research in this and other studies could examine daily social, contextual, and behavioral patterns that may better predict forgoing planned cannabis use and act conference abstracts 231 as mechanisms to reduce the enactment of daily cannabis use intentions. talk 3: daily cannabis use intentions and willingness: implications for use, subjective high, and related outcomes holly k. boyle phd (yale school of medicine) oksana k. ellison phd (yale school of medicine) jennifer e. merrill, phd (brown university) expanding legalization of recreational cannabis use in the us has been associated with increased prevalence of use and cannabis use disorder in young adults, but the decision-making process of engaging in cannabis use is understudied. the prototype willingness model suggests that level of intentions (i.e., plans) and willingness (i.e., one's openness to engage in a behavior if an opportunity presents itself) are both important predictors of substance use behavior. we tested whether the level of intention (i.e., plans) for cannabis use predicted (a) number of hours high, (b) subjective high, (c) one's evaluation of that high, and (d) cannabis-related consequences at the day-level. on cannabis use days when young adults did not have clear plans to use cannabis, we also explored whether increased willingness predicted cannabis use behavior. eighty-four young adults (ages 18-29) who reported simultaneous alcohol and cannabis use (59% female, 66% white) completed 30 days of daily surveys. each day, participants reported whether they intended to use cannabis (0 strongly disagree 4 strongly agree). if they did not have clear plans (i.e., did not respond strongly agree), they were asked to report their willingness to use cannabis (0 strongly disagree 4 strongly agree). they also reported substance use, number of hours high, consequences (16 positive and 21 negative consequences), subjective level of high (0 not at all 6 extremely), and evaluation of the high (i.e., how enjoyable/pleasant was that 0 not at all 6 extremely). across 647 cannabis days, 14.5% were unplanned. participants strongly agreed to having intentions to engage in cannabis use on 17.6% of days. the average level of intentions to engage in cannabis use was 2.08 (sd=1.29). on days young adults did not have clear plans to use cannabis, their average level of willingness to use cannabis was 2.41 (sd=1.19). multilevel models controlling for sex, age, weekend vs. weekday, day in study (1-30), and alcohol use revealed increased number of hours high on days when participants had increased intentions to use cannabis (err=1.06, 95% [ci=1.01-1.11]). days of increased intentions predicted increased subjective high (err=1.04, 95% [ci=1.02-1.08]), but not one's evaluation of that high. on days young adults did not have clear plans to use cannabis, increased willingness to use cannabis did not predict number of hours high, but did predict increased subjective high (err=1.03, 95% [ci=1.00-1.07]) and more positive evaluation of that high (err=1.05, 95% [ci=1.03-1.07]). both intentions conference abstracts 232 and willingness were unrelated to positive and negative consequences. on the majority of cannabis use days, young adults reported some level of intentions and willingness to use cannabis. level of intentions to use cannabis positively predicted number of hours high and subjective high suggesting increased intentions for cannabis use may be a risk factor for heavier use. willingness to engage in cannabis use was related to increased high and evaluating the experience as more enjoyable/pleasant potentially reinforcing future use. day-level intentions and willingness may be important intervention targets for reducing adverse cannabis use in young adults. talk 4: intentions to use cannabis during pregnancy: preliminary ecological momentary assessment data lindy k. howe (brown university) lauren micalizzi (brown university) rachel l. gunn (brown university) background. perinatal cannabis use is a significant public health concern, as it is linked to adverse maternal and neonatal outcomes. despite growing evidence of the risks associated with prenatal cannabis exposure, many individuals continue to use cannabis, often to manage symptoms such as nausea, anxiety, or pain. the theory of planned behavior (tpb) suggests that behavioral intentions are reliable and critical predictors of substance use. while intentions and subsequent behavior (planned/unplanned use) have been widely studied in nonpregnant populations, research on its application to prenatal cannabis use is limited. the current project presents preliminary data from an ongoing pilot ecological momentary assessment (ema) study on perinatal (i.e., pregnancy and postpartum) cannabis use to: a) assess the prevalence of planned vs. unplanned cannabis use in pregnancy and postpartum; b) evaluate the association between daily intentions and subsequent use, and how this may differ between pregnancy and postpartum; and c) explore motives associated with daily planned vs. unplanned cannabis use. methods. pregnant participants (n=20, mage=30.15) reporting current cannabis use were recruited to complete two 14-day ema bursts (one in pregnancy [n=20], one 6-weeks postpartum [n=15]) measuring daily cannabis use, motives, and intentions. planned use days were defined as morning endorsement of plans to use cannabis that day and reporting of subsequent use, while unplanned use days are those in which no morning intentions were endorsed, but cannabis was later endorsed. results. planned use was prevalent in both pregnancy and postpartum (60.8% and 46.7%, respectively), followed by planned nonuse (21.2% and 37.6%), unplanned use (9.2% and 9.1%), and foregoing plans to use (8.8% and 6.7%). generalized linear mixed models indicated that intentions to use cannabis were significantly associated with daily use (or=5.78, p<.001). no main effect of perinatal phase (pregnancy vs. postpartum) on daily use was observed (or=0.48, p=0.10), nor was there an interaction between perinatal phase conference abstracts 233 and intention on daily use (or=1.23, p=0.75). in the full sample, there were 25 unplanned days and 350 planned use days. for both planned and unplanned use days, common reported motives were "to relax" (plan/unplan=64%), "to relieve pain" (unplan=41, plan=44%), and "to sleep better" (unplan=31, plan=32%). some motives were more common on planned use days relative to unplanned use days, including "to increase appetite" (plan=30% vs unplan=4%) and "to feel less anxious'" (plan=36% vs. unplan=20%), while "to enjoy the effects" was more common on unplanned use days relative to planned use days (unplan=44% vs. plan=26%). discussion. results demonstrate preliminary applicability of the tpb to perinatal cannabis use. similar to non-perinatal samples, intentions were found to be associated with use in both pregnancy and postpartum. the endorsement rates of cannabis motives on planned vs. unplanned days reveal that physical management needs (e.g., appetite, pain) were associated with planned rather than unplanned use, suggesting individuals may anticipate these motives. in contrast, relaxation and pain relief were commonly reported on both planned and unplanned days. larger samples are needed to further explore these relationships. symposium title: ensuring cannabis policies aren't half baked: pairing policy with science. chair: julie k. johnson (commonwealth of massachusetts) discussant: julie k. johnson (commonwealth of massachusetts) cannabis is illegal at the federal level, hindering research, including medicinal research, and leaving stateenacted legalization and medical programs with many scientific unknowns. regulators often write policy and patients consume cannabis in the absence of verified research and data. as emergencies like the recent cannabis testing inaccuracies show, these research gaps can contribute to major regulatory challenges and potential harm to consumers, patients, and industry workers. as the science on cannabis progresses, it becomes even more important that we understand how research informs policy, regulation, and implementation, ensuring policy evolves with the science. regulatory and medicinal science are urgently needed to help guide adult-use and medical-use cannabis policy. however, research being conducted often does not reflect the most urgent regulatory science needs, and typically does not account for the nuance that exists in the cannabis policy landscape across the u.s. combining regulatory knowledge and data with research expertise can fill gaps around bestpractices for regulating an industry as safely and equitably as possible. this panel brings cannabis regulators and state and academic researchers together to discuss applied cannabis research at the intersection of changing cannabis policies, medical research, and sustaining cannabis programs. each panelist brings specialized knowledge in an area of policy or conference abstracts 234 medicinal research in new york, minnesota, utah, and massachusetts. the goal of this symposium is to (1) provide insight into regulatory science ("applied cannabis policy"); (2) provide examples of scientific findings from regulatory and research-based collaboration, and (2) discuss urgent research needs for evidence-based cannabis policy. talk 1: evaluation and analysis of patient & practitioner experiences in the nys medical cannabis program kaitlin kosinski (new york state office of cannabis management) alexandria wilkins (new york state office of cannabis management) nakesha abel (new york state office of cannabis management) cannabis regulators play a crucial role in shaping the cannabis industry by monitoring market trends and developing data-driven programs, policies, and rules that protect public health and safety. the introduction of adult-use markets in states that previously had medical-only programs has led to a significant decline in the number of medical cannabis patients nationwide. regulators are uniquely positioned to analyze these trends and develop strategies to better support medical cannabis patients in an evolving landscape. in 2023, the new york state office of cannabis management (ocm) administered a patient and practitioner experience survey to assess the state's medical cannabis program. certifying practitioners in the program (n=265) provided feedback on their experiences and clinical perceptions of medical cannabis effectiveness. medical cannabis patients were surveyed in 2023 (n=10,781 respondents) and 2024 (n=5,456 respondents) sharing insights on product usage, costs, travel time to medical dispensaries, and reasons for leaving the medical program. the analysis identified key patterns based on patient age, household income, medical conditions, and veteran status. the surveys provided valuable data on the program's evolution as ny works to develop a robust equity driven adultuse cannabis market. the findings helped ocm establish priorities for expanding medical cannabis access and informed key recommendations for strengthening medical cannabis programs nationwide. talk 2: benefits of medical cannabis in patients with autism spectrum disorder registered to the minnesota medical cannabis program grace m. christensen (minnesota department of health office of medical cannabis) david rak (minnesota department of health office of medical cannabis) emma matthes (minnesota department of health office of medical cannabis) the endocannabinoid system is hypothesized to play a role in behavioral functioning, leading to interest in cannabis as a therapeutic agent for patients with autism spectrum disorder (asd). however, there are few studies of cannabis and symptoms of asd. this study aims to estimate symptom relief among conference abstracts 235 patients in the minnesota medical cannabis program qualified for asd. asd was introduced as a qualifying condition for the minnesota medical cannabis program in august 2018. a cohort was created from patients who enrolled in the program between august 1st, 2018, and july 31st, 2023. patient registry data was aggregated for the cohort, including medical cannabis product purchasing and patient self-evaluation (pse) data. patients are required to fill out a pse prior to every medical cannabis purchase, which includes questions about eight standard symptoms and side effects. improvements in anxiety, depression, and disturbed sleep were of greatest interest to the study given the relative prevalence of these symptoms in this patient group. we calculated proportions of patients who achieved 30% symptom relief within four months of starting the program, as well as those who were able to maintain 30% symptom relief for at least four months. we compared symptom relief and product purchasing trends between pediatric (< 18 years old) and adult (18+ years old) patients. 1,381 patients enrolled in the minnesota medical cannabis program for asd and purchased medical cannabis during the study period. medical cannabis product purchasing trends differed by age group. pediatric patients primarily purchased enteral products with balanced or cbddominant cannabinoid profiles. in contrast, adult patients primarily purchased high thc cannabinoid products. patient symptom relief changes were similar between age groups. survey data included scores of eight different symptoms. of those symptoms surveyed, anxiety was the most commonly reported symptom among patients with asd. overall, 88.4% (n = 1,219) of asd patients reported moderate to severe anxiety scores before making their first medical cannabis purchase. of those patients, 58.6% reported 30% improvement in their anxiety score within four months of starting the program. overall, approximately 36.0% were able to both achieve 30% reduction and maintain it for at least four months. depression and disturbed sleep scores were similarly improved, with 43.7% and 39.1% of patients, respectively, able to both achieve 30% score reduction and maintain it for at least four months. during the study period, 20% of patients reported experiencing side effects. of those side effects, almost three quarters were reported to be mild. this is the first observational study of its kind to assess changes in symptoms in asd patients enrolled in a state medical cannabis program. medical cannabis may be beneficial for some asd patients and appears to be generally well-tolerated. further research must be conducted to better understand the effectiveness of cannabis to treat symptoms of asd. medical cannabis programs are a valuable data source to investigate these hypotheses and help set health care practitioners' expectations on what their asd patients may experience in a real-world setting. talk 3: a literature review of state medical cannabis program evaluations conference abstracts 236 lirit franks (university of utah school of medicine) gerald cochran (university of utah school of medicine) carter reeves (university of utah school of medicine) michael a. incze (university of utah school of medicine) clinton j. hardy (university of utah school of medicine) adam j. gordon a. taylor kelley background: the use of medical cannabis (mc) is increasing across the united states, with operational mc programs in 38 states and washington d.c. each state has varying program regulations and practices due to a lack of systematic guidance. evaluations are useful to determine the safety and efficacy of state mc programs; however, not much is known about whether and how states evaluate their programs. examining state mc program evaluations to date could inform state governments, mc program officials, and health providers about effective approaches and provide recommendations for future program evaluations. summary: we conducted a narrative literature review of state mc program evaluations, including peer-reviewed manuscripts, reports produced by independent evaluators within state governments, and reports produced by third-party evaluators. after searching pubmed, apa psychinfo, medline, embase, scopus, google scholar, state mc program websites, and requesting unpublished or in-progress evaluations from national and international mc researchers, we narrowed our search to 304 abstracts initially screened. seven evaluations met inclusion criteria. there were three overarching themes between the evaluations: 1) evaluation characteristics, including design and methodology of evaluations; 2) program experience, including perceptions of patients and healthcare providers; and 3) assessment of cannabis use, including patterns and frequency of use, self-reported efficacy for qualifying medical conditions, and investigation of risk factors applicable to mc use. we identified that goals and methods for conducting state mc evaluations differed greatly, but key factors were shared in evaluations with results that were more comprehensive and quantitatively rigorous. these include reliance on independent evaluators not associated with the state, a focus to measure specific stated goals, and inclusion of assessment of issues universal to mc use (including safety, misuse, and access). we also recommend that future evaluations utilize standardized and validated survey instruments, include comparison cohorts, and create a plan to minimize bias. key messages: a minority of states operating mc programs have conducted formal evaluations of their program and, within those, approaches differed greatly. however, common themes were also present, which can inform future efforts to conduct state evaluations. evaluation through independent partners not associated with the state government may provide a preferential strategy to ensure meaningful results and valuable data. talk 4: conference abstracts 237 a seven-year snapshot of the adultuse and medical-use cannabis industry in massachusettswhat can revenue and costs tell us about overall industry health? julie k. johnson (commonwealth of massachusetts) alexander m. colby (commonwealth of massachusetts) hailey pensky (commonwealth of massachusetts) victoria edwards (commonwealth of massachusetts) graelyn humiston (commonwealth of massachusetts) background: as of march 2025, 39 states have enacted medical cannabis laws and of these, 24 states have additionally enacted adult-use cannabis laws. massachusetts enacted medical-use cannabis in 2012 and adult-use cannabis in 2016. massachusetts law includes a robust research agenda pursuant to m. g. l. c. 94g, åò 17 to understand different trends following cannabis legalization, includuding a market analysis of the legal marketplace. methods: this surveillance study extracted statecollected cannabis industry data from november 2018, when adult-use retail was implemented, to april 30, 2024. this study assessed key indicators of industry health, including revenue, market share, and price (by weight and by unit, where applicable). data cleaning was conducted in rstudio and microsoft excel, and descriptive statistics and data visualizations were computed using r, microsoft excel, and tableau. results: adult-use market sales totaled $6.06b, including $524m in january-april 2024. buds accounted for 42.2% of sales, followed by vape cartridges (18.4%), pre-rolls (15.0%), infused edibles and beverages (14.7%), and concentrates (7.6%). year-overyear sales increased most from 2018 to 2019 (537%), and least from 2022-2023 (5%), with a slight uptick again from 2023-2024 (7%). the price per gram of adult-use cannabis, calculated as a monthly average, fell from $14.09 in november 2018 to $5.36 in april 2024. the price per ounce of adult-use cannabis similarly fell from $401.50 in 2018 to $153.73 in 2024, both reflecting 62% decreases. medical market sales totaled $1.27b, including $66.6m in january-april 2024. buds accounted for 45.6% of sales, followed by infused edibles and beverages (15.3%), and vape products (14.6%). year-over-year sales increased from 2018-2021, then decreased for the first time from 20212022 (-13%), with the trajectory continuing to 2023-2024 (-16%, comparing january-april). discussion: the adult-use and medical-use cannabis markets in massachusetts followed similar trends from november 2018 to april 2024. buds were the highest selling products across both markets, making up the largest share of both the adult-use (42%) and medical-use (46%) markets over the study. trends were also similar between markets for the next largest products, with vape cartridges making up 18% of adult-use sales and 15% of medical sales, and infused edibles making up 14% and 15% of adult-use and medical-use sales, respectively. year-over-year changes in total sales show that the adult-use market continues to grow, although the pace of growth has declined, while the conference abstracts 238 medical-use market experienced peak sales in 2021 and has declined since. some decreases are expected as the market saturates across the commonwealth and as more east coast states implement adult-use cannabis legalization and become operational. it is critical for regulators to monitor industry metrics and enact policies to balance market forces to ensure industry health, as marketbased corrections may be necessary. symposium title: beyond the high: advancing the science of cannabis impairment chairs: jane metrik (brown university) nicholas j. bush (brown university) discussant: jane metrik (brown university) as cannabis use has become more prevalent, the ability to detect cannabis-induced impairment is increasingly critical for public health and safety. controlled research provides clear evidence that é¢tetrahydrocannabinol (thc) acutely impairs psychomotor functions, which are essential for driving performance, thereby increasing the risk of accidents and injuries. however, reliable objective methods for identifying impairment are lacking. most prior research has focused on inhaled cannabis in relation to driving and psychomotor functioning, but products vary widely in cannabinoid formulation and composition. understanding impairment from various cannabis formulations (e.g., edibles) and co-use patterns (e.g., with alcohol consumption) is essential for developing effective detection methods. this symposium introduces innovative methods and technologies for detecting cannabis psychomotor impairment. in a series of four talks, researchers will present findings based on objective behavioral assessments, including field sobriety tests, driving simulation, druid tablet-based testing, and mobile sensor technology measuring cannabis-induced changes in gait and balance. studies range in laboratory and field-based methods, distinguish cannabis-induced effects from alcohol, and characterize acute impairment across different formulations, including flower and edibles, as well as key cannabinoids (thc and cannabidiol). the discussion will focus on how these technologically advanced methods can be used for real-time impairment detection, helping individuals make informed decisions to avoid high-risk behaviors such as impaired driving. talk 1: evaluating detection methods for impairments from oral cannabis ("edibles"), alcohol, and their combination lakshmi kumar (johns hopkins university school of medicine) c. austin zamarripa (johns hopkins university school of medicine) spencer lin (johns hopkins university school of medicine) mckenna klausner (johns hopkins university school of medicine) denis antoine (johns hopkins university school of medicine) conference abstracts 239 thomas marcotte (university of california san diego, center for medicinal cannabis research) daniel roche (university of maryland school of medicine) elise weerts (johns hopkins university school of medicine) ryan vandrey (johns hopkins university school of medicine) tory spindle (johns hopkins university school of medicine) introduction: oral cannabis products (or "edibles") are increasingly popular and often co-used with alcohol, yet controlled research on their combined effects is limited. though validated methods exist for detecting alcoholinduced impairment (i.e., breathalyzers and standardized field sobriety tests [sfsts]), no analogous tests have been validated for cannabis. this human laboratory study characterized the acute impairing effects of cannabis edibles and alcohol (alone and combined) and evaluated impairment detection methods, including simulated driving performance, sfsts, a novel behavioral task (the druid), and blood thc levels. methods: healthy adults (n=21) completed seven, latinsquare-ordered, double-blind, doubledummy sessions. in each session, participants ingested a brownie containing whole plant cannabis (18% thc concentration) for a 10 or 25mg total thc dose, or a placebo brownie (0mg thc) and, 45 mins later, drank an alcoholic (target breath alcohol concentration, bac: 0.05%) or placebo (0.0% bac) beverage. a positive control session with alcohol consumed to 0.08% bac and placebo brownie consumed was also completed. assessments, collected before and for 7.5 hrs after cannabis use, included subjective drug effects, simulated driving performance, sfsts, the druid (tablet-based impairment test), and blood thc/metabolites pharmacokinetics. driving performance was evaluated on several individual tasks and at a global composite impairment score by integrating individual outcomes (e.g., lane weaving, speed deviation). results: cannabis and alcohol alone produced dose-dependent increases in subjective impairment and global driving impairment, and alcohol (0.05% bac) combined with 10mg or 25mg thc produced additive effects. 25mg thc + 0.05% bac produced comparable driving impairment to alcohol alone at 0.08% bac. at active doses, driving impairment peaked 3.5 hrs post-cannabis dosing (2.5 hrs postalcohol) and subsided by 7.5 hrs. at 10mg thc alone and 0.05% bac alone, participants' perceived impairment did not differ from placebo, but they displayed driving impairment. sfst impairment was consistently and strongly detected at 0.08% bac alone. sfsts also detected impairment at 25mg thc, 10mg thc + 0.05% bac, and 25mg thc + 0.05% bac, though to a lesser degree than at 0.08% bac, but not in other conditions. druid scores distinguished placebo from active doses but showed no differences between active doses (e.g., similar scores at low and high cannabis doses). on average, thc concentrations increased dosedependently; alcohol did not alter thc conference abstracts 240 or thc metabolite pharmacokinetics. conclusions: findings highlight the additive impairing effects of cannabis and alcohol on driving, even at bac levels below the legal limit. despite additive effects, blood thc levels were very low on average and did not differ between cannabis-only versus cannabis/alcohol conditions, suggesting blood thc is a poor proxy for impairment, unlike bacs. notably, participants often underestimated their impairment, particularly at lower thc doses and 0.05% bac. while sfsts effectively detected impairment at 0.08% bac, they were less sensitive to cannabis-alone and cannabis/alcohol conditions at 0.05% bac. additionally, although the druid differentiated active doses from placebo, it showed limited ability to distinguish between active doses. these findings emphasize the need for better impairment detection tools and further research to inform law enforcement strategies for identifying polysubstance-impaired individuals. talk 2: acute cannabis use and motor impairment: effects on postural sway in individuals with frequent and infrequent use margy y. chen (department of psychology and neuroscience, university of colorado boulder) angela d. bryan (department of psychology and neuroscience, university of colorado boulder) brian l. tracy (department of health and exercise science, colorado state university) l. cinnamon bidwell (department of psychology and neuroscience, university of colorado boulder; institute of cognitive science, university of colorado boulder) cannabis use is becoming increasingly common, raising safety concerns related to its impact on motor coordination, balance, and driving performance. however, research on how acute cannabis use affects motor balance remains limited. this study examined impairment of standing postural stability in individuals who use cannabis flower infrequently (n = 129) and frequently (n = 194). participants were randomly assigned to purchase and use a thc-dominant, thc+cbd, or cbd-dominant product from a partnered dispensary. postural stability was assessed before and after ad libitum use under three conditions: eyes open (eo), eyes closed (ec), and eyes closed with head tilted back (echb). postural fluctuations were measured using acceleration sensors on a hip-mounted smartphone. greater fluctuations in acceleration indicated impaired balance. postural stability was assessed before and immediately after use for infrequent cannabis flower users. frequent cannabis flower users were assessed before, immediately, and 1 hour after use. among infrequent flower users, eo, ec, and echb postural sway significantly increased after use (p < .05). the thc-dominant group showed greater eo sway than the cbddominant group acutely post-use (t = 2.147, p = .034). the thc-dominant group also showed significantly greater increase in eo sway acutely after use (t = 2.1, p = .037) while the thc+cbd (t = 1.818, p = .070) and conference abstracts 241 cbd-dominant group (t = .647, p = .519) did not. among frequent users, eo sway showed a linear trend (p = .012) increasing after use while ec and echb sway followed a quadratic trend (p < .05), with initial impairment that improved from acute to 1-hour post-use. this trend was primarily driven by the thcdominant group (t = 4.516, p < .001) and was not observed in the thc+cbd (t = .129, p = .897) or cbddominant (t = -.024, p = .981) groups. additionally, a significant time by group interaction emerged (t = 3.70, p < .001) for ec sway. simple effect tests indicated that the thcdominant group had significantly greater ec sway than others acutely post-use (t = 3.965, p < .001) and 1hour post-use (t = 2.324, p = .021), with no group differences in ec sway before use (ps > .230). across infrequent and frequent users, results replicated prior findings that using thc-dominant products increases postural sway and impairs balance. frequent users showed significantly higher eo postural sway than infrequent users (t = 3.073, p = .002) acutely post-use, though no differences emerged for ec or echb sway (ps > .367). this suggests frequent users may experience greater impairment in tasks requiring visual input but not in conditions with reduced sensory feedback. these findings demonstrate that acute cannabis use impairs balance, with thc-dominant products producing greatest impairment, while cbd appears to have no such effect. the observed differences between frequent and infrequent users highlight the need for individualized impairment assessments. future research should refine cannabis impairment testing methods by focusing on medium difficulty postural control tasks (e.g., ec sway), which may offer a more sensitive and proprioception-focused measure of cannabis-induced motor impairment. talk 3: gait in the wild: smartphone-based detection of recent cannabis use in natural environments nicholas j. bush (center for alcohol and addiction studies, brown university school of public health) ana abrantes (behavioral medicine and addictions research, butler hospital, providence ri; alpert medical school of brown university) clifford lindsay (university of massachusetts chan medical school) jane metrik (center for alcohol and addiction studies, brown university school of public health, providence va medical center) background: delta-9tetrahydrocannabinol (thc) use has been associated with alterations in ambulatory and motor functions (i.e., gait), such as increased postural sway and disrupted balance. however, accessible, objective, and ecologically valid methods for assessing cannabisinduced gait alterations remain a critical gap. this is particularly concerning given the rising prevalence of cannabis use globally and the significant public safety implications, especially considering increasing rates of driving under the influence of cannabis. while our previous laboratory-based findings have conference abstracts 242 demonstrated an ability to classify cannabis intoxication using sensors in smartphone devices accurately, there is limited research examining thcinduced gait changes in naturalistic environments. methods: this study investigated the feasibility of utilizing mobile sensor technology to classify cannabis intoxication during a prompted walking task. ten individuals (mage=33.5; 72.7% female) who reported regular cannabis use (at least five times weekly via vaporization or inhalation in the past month) participated in a 7-day ecological momentary assessment (ema) protocol. throughout this period, participants received prompts via their smartphones to complete brief surveys regarding their cannabis use. immediately following each survey, participants were instructed to complete a 30-second walk at their natural pace with their smartphones in their pockets (nwalks=249). data was collected at 100 hz from the smartphone's accelerometer and gyroscope sensors. walks were classified as intoxicated if they occurred within a one-hour window, plus the time spent inhaling cannabis. gait features were extracted from the smoothed and filtered accelerometer (motion) and gyroscope (rotation) sensor data. a logistic regression model was used to classify walks with recent cannabis use (nwalks=116) and walks without recent cannabis use (nwalks=133). the model fit was assessed by comparing a null model (intercept only) to a full model with gait features. results: the model demonstrated statistically significant discriminatory performance in classifying intoxicated versus nonintoxicated walks (δχ²=101.16, p<.001). the model achieved a nagelkerke r2 of .45 and an overall classification accuracy of 75.1%. further analysis revealed a sensitivity of .72, a specificity of .78, and a precision of .74. the area under the curve (auc) model was .85, indicating good discriminatory ability. standardized coefficient analysis revealed that recent cannabis use is associated with reduced predictability of vertical motion and increased asymmetry in overall movement. conclusion: these findings provide preliminary evidence supporting the feasibility of utilizing mobile sensorbased gait analysis in naturalistic settings for the objective assessment of cannabis-related ambulatory impairment. the achieved classification accuracy, coupled with the high auc, suggests that smartphone-derived gait features hold promise as indicators of thc intoxication. in addition, these results provide preliminary support that cannabis-induced gait changes may be characterized by less predictable and coordinated vertical gait patterns. this research has the potential to contribute to the development of accessible and ecologically valid tools for roadside impairment detection, consumer health monitoring, and clinical evaluations of cannabisrelated motor deficits. future considerations for machine learning models to utilize the model's identified features to build predictive models will be discussed. talk 4: conference abstracts 243 naturalistic observation of cannabis and alcohol-related gait impairments: evidence from ambulatory assessment in young adults rachel l. gunn (brown university) nicholas j. bush (brown university) nathan didier (brown university) jane metrik (brown university, providence va medical center) with increasing national rates of cannabis use, behavioral impairments associated with heavy cannabis use are a significant public health concern (e.g., cannabis-impaired driving). further, rates of simultaneous alcohol and cannabis use (i.e., so that the effects overlap) are also on the rise and laboratory work suggests additive impairment on cognitive and behavioral tasks when cannabis is used in combination with alcohol (relative to either substance alone). in line with these behavioral outcomes, cross-sectional and naturalistic studies have shown that simultaneous alcohol and cannabis use is associated with more substance-related consequences. laboratory studies are necessarily limited in dose and form of cannabis administered, as well as amount of alcohol administered, relative to naturalistic patterns of use in young adults. the present study utilized a smartphone-based walking task to assess gait impairment in simultaneous, alcohol-only, and cannabis-only events in a 28-day observational ambulatory assessment study of young adults (n=115). participants completed the walking task during a follow-up assessment administered 60 minutes after a userinitiated substance use report (alcohol and/or cannabis). the walking task instructed participants to walk in a straight line for 20 steps, and uses smartphone motion sensors (accelerometer and gyroscope at 100hz) to assess postural sway and gait features. events were coded as alcohol (n=231), cannabis (n=297), or simultaneous use (n=155) based on self-report. task data were preprocessed using rolling mean smoothing, outlier detection and butterworth bandpass filter. the magnitude of acceleration was calculated as the square root of the sums of squares. time domain (e.g., skewness and autocorrelation), frequency domain (e.g., peak spectral energy) and behavioral (e.g., step cadence) features were calculated. generalized linear mixed effects models were used to examine differences in gait features between event type (cannabis v. alcohol and cannabis v. simultaneous use), controlling for person-level (height, weight, sex) and time-varying (study day, subjective intoxication) covariates. regarding mixed effects models on behavioral features, we found significant differences between cannabis and simultaneous events on two behavioral features: steps taken (est=.95, p=.002) and cadence (est=.04, p=.002), suggesting more steps and slower cadence in simultaneous use events relative to cannabis-only events. regarding frequency domains, alcohol-only events were positively associated with greater spectral energy (est=.85, p=.03) relative to cannabis-only events, suggesting greater motion conference abstracts 244 fluctuations. regarding time domains, the standard deviation; (est=.003, p=.01) and autocorrelation (est=.01, p=.007) of the acceleration were positively associated with alcohol events relative to cannabis events, reflecting greater variability and predictability in the motion. associations between subjective intoxication and all task outcomes were non-significant. overall, results suggest that gait features captured via behavioral tasks in the field during substance use events can distinguish these events, and in particular that simultaneous use events reflect increased behavioral (i.e., step cadence) features of intoxication relative to cannabis-only events. future work should incorporate these specific gait features into machine learning models to detect changes in gait associated with alcohol, cannabis and simultaneous use for mobile health interventions. symposium title: the intersection of neurodevelopmental conditions and cannabis use chair: lauren micalizzi (brown university) discussant: alison looby (university of wyoming) growing evidence suggests that individuals with neurodevelopmental conditions-such as autism spectrum disorder (asd) and attentiondeficit/hyperactivity disorder (adhd)are at elevated risk for cannabis use and related harms. this symposium explores the complex interplay between neurodevelopmental traits and cannabis use across multiple levels of analysis. the first presentation examines cannabis expectancies among adolescents and young adults with asd, revealing that those with cannabis experienceparticularly for therapeutic purposesreport stronger positive and weaker negative expectancies than their nonusing peers. the second presentation investigates adhd symptom severity as a moderator of the link between frontostriatal connectivity and cannabis use patterns, identifying unique neurobiological vulnerabilities that may influence cannabis use trajectories. the third presentation explores cannabis-related consequences among college students with adhd, showing that both diagnosed and undiagnosed students meeting the clinical threshold face heightened risks, reinforcing the importance of integrated screening and intervention. the fourth presentation highlights how impulsive tendencies and momentary adhd symptom fluctuations predict unplanned cannabis use and increased consumption during treatment, emphasizing the value of addressing adhd symptoms alongside cannabisfocused interventions. the discussant brings expertise in cannabis use predictors and consequences among those with neurodevelopmental disorders, and will integrate these findings, offering insights for future research and clinical applications. talk 1: marijuana use and expectancies among adolescents and young adults with autism spectrum disorder conference abstracts 245 lauren micalizzi (brown university) becky smith (rutgers university) anthony spirito (brown university) stephen j. sheinkopf ( university of missouri) kristina m. jackson (rutgers university) autism spectrum disorder (asd) is a neurodevelopmental condition characterized by social communication challenges and repetitive behaviors. while preliminary research has demonstrated use of marijuana among individuals with asd, including use for therapeutic reasons, little is known about marijuana expectancies — beliefs about the substance's positive and negative effects. these beliefs may influence patterns of use and associated outcomes, emphasizing the need for further investigation in youth with asd. n = 266 adolescents and young adults with asd (mage = 19.34 [minimum = 12, maximum = 24]; 47.9% female; 87.5% white; 12.9% hispanic) selfreported their lifetime marijuana use, therapeutic use, and marijuana expectancies using the marijuana effects expectancies questionnairebrief. this measure yields a total expectancy score as well as subscale scores for positive expectancies (e.g., "marijuana helps a person relax and feel less tense") and negative expectancies (e.g., "marijuana generally has bad effects on a person"). correlational analyses were conducted to explore associations between positive and negative expectancies, as well as between ever use of marijuana and expectancies. six one-way anovas were conducted to examine mean differences in overall, positive, and negative expectancies by: (a) lifetime cannabis use status; and (b) lifetime therapeutic use. approximately one-third of the sample (n = 84; 31.6%) reported lifetime marijuana use, and 12% reported therapeutic marijuana use. positive and negative expectancies were significantly negatively associated (r = -.16, p = .02). ever-use of marijuana was positively associated with positive expectancies (r = .41, p < .001) and negatively associated with negative expectancies (r = -.16, p = .01). group comparisons revealed significant differences in expectancy patterns between those who reported lifetime use and those who did not. specifically, participants with lifetime cannabis use endorsed significantly higher overall expectancies (f(1,264) = 15.13, p < .001), with a mean score of 3.81 compared to 3.52 among nonusers. positive expectancies were significantly higher among those who had used cannabis (m = 4.03) relative to those who had not (m = 3.20; f(1,264) = 54.37, p < .001). moreover, individuals with lifetime cannabis use reported significantly lower negative expectancies (f(1,264) = 6.60, p = .01), with a mean of 3.58 compared to 3.85 among never users. there were no significant differences in positive, negative, or total expectancies across those who did versus did not endorse lifetime therapeutic use. overall, individuals with lifetime cannabis use reported greater overall and positive expectancies, as well as lower negative expectancies compared conference abstracts 246 to their non-using peers. these findings suggest that treatment and prevention programs might require distinct types of communication and content for young persons with asd depending on both their lifetime marijuana use history. talk 2: the neurobehavioral correlates of adolescent cannabis use and adhd symptoms sarah a. thomas (brown university) emily olenik (e.p. bradley hospital) sarah k. ryan (e.p. bradley hospital) meghan a. gonsalves (providence va medical center) jodi gilman (mass general hospital center for addiction medicine) jane metrik (brown university) anthony spirito phd (brown university) cannabis is frequently used by adolescents, with 26% of u.s. 12th graders reporting past-year cannabis use (cu). although adolescents' reasons for using substances vary, one common motive is to cope with psychiatric symptoms, consistent with the self-medication hypothesis. alternatively, certain psychiatric conditions characterized by increased reward sensitivity and impulsivity may predispose individuals to engage in activities like substance use. attention deficit hyperactivity disorder (adhd) has been linked to adolescent cu, with some individuals believing that cu helps them concentrate. neurobiologically, adhd symptoms are attributed to dysfunctional frontostriatal circuitry. at the same time, regular adolescent cu may impact brain development in these circuits, increasing the risk of addiction. therefore, understanding the biobehavioral relationship between adolescent cu and adhd symptoms is crucial to support prevention and intervention efforts. we evaluated the connection between adolescent cu and adhd symptoms using self-reports, interviews, and mri in 75 adolescents aged 14-17 (mean age=15.55 [sd=1.13]; 59% female biological sex; 35% sexual or gender minority; 2.67% asian, 9.33% biracial, 10.67% black/african american, 6.67% other, 69.33% white; 25.68% hispanic), grouped by < five lifetime cannabis episodes ("control"; n=44) and >11 lifetime episodes ("cannabis teen"; n=31). adolescents reported on lifetime and recent cu, reasons for cu; completed interviews characterizing past 90-day cu; and an mri resting-state scan. adolescents and their caregivers provided information on adolescent mental health, including dsmoriented adhd symptoms, from which age/sex-normed t-scores were derived (achenbach youth self-report and child behavior checklist). the cannabis group included 14 adolescents who met or exceeded the adhd clinical cut-off based on selfreport or parent-report, whereas the control group had 5 adolescents exceeding clinical cut-off. compared to controls, the cannabis group exhibited significantly greater adhd symptoms via self-report (t=-2.32, p=.024), and parent-report (t=-4.05, p<.001). adolescent-reported adhd symptoms were significantly associated with daily hours high (r=.35, p= 0.003), with reasons for cu of "coping" ("to conference abstracts 247 forget your problems"; "because you were depressed"; "to escape from your life"; r=.52, p<.001), and inversely with reasons for cu of "availability" ("it is readily available"; "you can get it for free"; "it is there"; r=-.38, p=.019). parent-reported adolescent adhd symptoms were marginally associated with a sleep motive (r=.28, p=.086). for a subset with highquality neural data (n=39 controls; n=28 cannabis teens), the association between left caudate/right orbital frontal connectivity and cu sessions during the measurement period depended on the severity of adolescent-reported adhd symptoms (b=0.01, p<.001), controlling for age and nicotine use: adolescents 1 sd below average adhd symptom severity exhibited a negative association between brain connectivity and cu sessions (b=-0.09, p=.007), whereas adolescents 1 sd above average adhd symptoms showed a positive association (b=0.06, p=.026). in conclusion, adolescents with cu have more adhd symptom severity than control adolescents. the link between sessions of cu and frontostriatal circuitry depended on level of adhd symptoms. more severe adhd symptoms were associated with a coping motive. understanding how adolescent cu relates to the severity of adhd symptoms is essential for exploring the role of selfmedication and determining effective symptom management strategies that minimize harm during brain development. talk 3: differences in cannabis outcomes among college students with varying adhd diagnostic histories, clinical thresholds, and symptom presentations katherine a. berry (university of wyoming) allison k. macht (trinity college) laura j. holt (trinity college) alison looby (university of wyoming) attention-deficit/hyperactivity disorder (adhd) is linked to increased cannabis use and related consequences among college students. however, most research has focused on students that have been formally diagnosed with adhd by a mental health care provider, leaving an important gap in understanding whether similar cannabis-related risks exist among students who currently meet the diagnostic threshold for adhd (i.e., five or more symptoms of inattentive and/or hyperactive/impulsive symptoms) but have never received a formal diagnosis. this study examined whether cannabis frequency, quantity, and consequences differed based on adhd diagnostic history and diagnostic threshold. additionally, among students currently meeting the diagnostic threshold for adhd (regardless of prior diagnosis), we examined whether students with different adhd symptom presentations differed in the aforementioned cannabis outcomes. college students (n=1500, mage=19.36, 59.6% white nonhispanic, 73.8% female) from six u.s. universities who reported past-month cannabis use completed an online conference abstracts 248 survey assessing adhd symptoms, adhd diagnosis history, and cannabis use frequency, quantity, and consequences. participants were categorized into four groups: no prior diagnosis and not meeting the clinical threshold for adhd (i.e., no diagnosis/no threshold; 64.2%), lifetime adhd diagnosis but not currently meeting the clinical threshold (i.e., diagnosis/no threshold; 8.4%), lifetime adhd diagnosis and currently meeting the clinical threshold (i.e., diagnosis/threshold; 9.7%), and no prior adhd diagnosis but currently meeting the clinical threshold (no diagnosis/threshold; 17.7%). three analysis of covariance (ancova) models examined group differences in outcomes, controlling for biological sex. in the cannabis use models, students with diagnosis/no threshold reported greater cannabis frequency and quantity than those with diagnosis/threshold and those with no diagnosis/no threshold. additionally, students with no diagnosis/threshold reported greater cannabis frequency and quantity than those with no diagnosis/no threshold. for cannabis consequences, students meeting the threshold for adhd (with or without a diagnosis) reported greater cannabis-related consequences than those who did not meet the diagnostic threshold. students with and without a diagnosis of adhd but meeting the clinical threshold for adhd did not significantly differ on cannabis consequences. next, among students meeting the clinical threshold for adhd (n=411), we examined differences by adhd symptom presentation (inattentive: 47.9%, hyperactive-impulsive: 15.1%, combined: 37.0%). ancovas demonstrated significant group differences in cannabis quantity, such that students with a combined adhd presentation reported greater cannabis consumption than those with an inattentive presentation. no significant differences emerged when examining the cannabis frequency or consequences models. overall, these findings highlight the need for more comprehensive mental health screening among college students who use cannabis and exhibit clinically significant adhd symptoms, regardless of their formal diagnosis history or specific adhd symptom profile. given that students currently meeting the diagnostic threshold for adhd reported greater cannabisrelated consequences, but not greater use or frequency, relying solely on use metrics to assess perceived problematic cannabis use may be insufficient, as these students are more likely to experience adverse consequences from use in general. intervention efforts could include early screening for both adhd and cannabis use, as well as integrating adhd symptom management with cannabis use interventions, particularly for students with a combined adhd presentation. talk 4: trait vs. state adhd symptoms and cannabis use during adolescent and young adult cannabis treatment jamie e. parnes (brown university & bradley hospital) conference abstracts 249 robert miranda jr. (brown university & bradley hospital) rationale: adolescent and young adult (aya) cannabis use is linked to several deleterious outcomes (e.g., dependence, lower achievement). attention-deficit/hyperactivity disorder (adhd), characterized by symptoms of inattention (adhd-i) and hyperactivity (adhd-h), confers risk for cannabis use and cannabis use disorder (cud) and may influence responsiveness to cannabis treatment. some research indicates that individuals with adhd use cannabis to self-medicate their symptoms, while other studies suggest cannabis may exacerbate symptoms-especially among aya. however, whether and how adhd influences use during aya cannabis treatment remains untested. we hypothesized that impulsive tendencies may promote unplanned cannabis use and greater quantities of cannabis consumption among aya with adhd. methods: to this end, we tested how trait-level adhd-i and adhd-h symptoms captured via a gold-standard diagnostic interview and state-level momentary fluctuations in these tendencies (i.e., difficulty concentrating, hyperactivity, boredom) measured via ecological momentary assessment (ema) relate to unplanned cannabis use, cannabis grams used, cannabis intoxication, and using more cannabis than planned. aya (n = 65) participated in pharmacotherapy plus motivational enhancement and cognitive behavioral therapy intervention. at baseline, aya received a formal adhd assessment. during the intervention, aya completed 42 days of ema measuring affect and cannabis-related variables. we used multilevel modeling (mlm) to examine if adhdi and adhd-h symptoms moderated the association between intentions to use cannabis (reported in the morning) and actual cannabis use (odds of use, grams used, intoxication level, using more than planned) later the same day. we also used mlm to examine if adhd-i and adhd-h symptoms moderated the association between momentary adhd symptoms (personcentered) immediately prior to using and cannabis use. results: adhd-h moderated associations between intentions to use and cannabis grams, while adhd-i and adhd-h were unrelated to odds of cannabis use, intoxication level, and using more than planned. planned use was related to greater grams consumed, but as adhd-h symptoms increased, the difference in grams from planned versus unplanned use became negligible. results from the momentary symptoms models found that adhd-h symptoms were positively related to cannabis grams (irr = 1.18) and moderated the association between hyperactivity symptoms and intoxication level. at low levels of momentary hyperactivity, relative to their own average, adhdh positively related to intoxication. conversely, at high levels of hyperactivity, adhd-h negatively related to intoxication; at mean levels of hyperactivity there was no association between adhd-h and intoxication. lastly, boredom was related to lower odds of using more than planned (aor = .89). conference abstracts 250 conclusions: overall, results suggest that there are trait and state level associations between adhd symptoms and cannabis use during aya cannabis treatment. these findings suggest that aya with adhd may benefit from concurrent adhd and cannabis treatment. symposium title: understanding budtender practices, customer behaviors, and the use of artificial intelligence in mixed methods cannabis research chair: eric r. pedersen (keck school of medicine, university of southern california) discussant: mark a. prince (keck school of medicine, university of southern california) the rapid growth of the legal recreational cannabis market has made dispensaries an essential environment in which to conduct mixed methods research on customer purchasing and retail staff selling behavior. this symposium presents research examining how cannabis is sold, purchased, and understood within retail settings, with a focus on budtender influence (e.g., recommendations), promotion and use of high-potency thc products, and use of artificial intelligence (ai) to assist in generating codes and themes in qualitative research. through interviews with 20 budtenders and 60 young adult cannabis users in the cannabis annex (the cannex) -a fully stocked mock dispensary researchers examined how budtender recommendations shape consumer decision-making. the first talk explores budtenders' selling behavior, with a focus on how harm reduction strategies are discussed with customers. findings highlight both the potential and limitations of such messaging in dispensaries. the second talk focuses on the sale and perception of high-potency thc products. using mixed methods, researchers analyzed how budtenders sell these products and why customers purchase them, revealing key themes related to potency labeling, consumer trust, and sales tactics. the third talk describes the potential utility of ai in qualitative cannabis research. using interview data obtained from budtenders and young adults, researchers compared human-coded thematic analysis with ai-assisted coding using a large language model. findings suggest ai can enhance efficiency in processing large datasets, but human oversight is necessary to ensure conceptual validity. together, these studies provide insights into cannabis retail dynamics, consumer decision-making, and the evolving role of ai in research. talk 1: budtender harm reduction in a mock dispensary environment: strengths and future considerations ireland m. shute (keck school of medicine, university of southern california) megan e. brown (keck school of medicine, university of southern california) bethany a. gray (colorado state university) angeles sedano (keck school of medicine, university of southern california) conference abstracts 251 grace earner (university of southern california) isaac bernstein (university of southern california) olivia newell (university of southern california) john r. monterosso (university of southern california) mark a. prince (keck school of medicine, university of southern california) eric r. pedersen (keck school of medicine, university of southern california) as of 2024, there were approximately 15,000 dispensaries across the united states for medicinal and/or recreational cannabis. recreational cannabis alone amassed 32 billion dollars in sales in 2024, indicating a demand for cannabis from regulated retail outlets. high frequency of use, however, is associated with adverse physical, mental, and interpersonal consequences. harm reduction techniques, or protective behavioral strategies, are behaviors one can use before, after, or during cannabis use that may reduce an individual's experience of cannabis-related consequences. although consumers often seek and receive advice from cannabis dispensary staff during visits to dispensaries, it is unclear whether staff present customers with harm reduction strategies in these retail cannabis environments. twenty budtenders and 60 young adult cannabis users participated separately in semi-structured interviews in a mock dispensary environment to discuss their cannabis selling (budtenders) and purchasing (young adults) behaviors, which we examined with thematic analysis and survey data. harm reduction strategies emerged as a post-hoc theme; thus, we sought to better understand how suggestions and recommendations from budtenders may be influential within the dispensary environment. in this mixed methods study, we investigated the harm reduction messages and strategies that retail dispensary staff (i.e., "budtenders") may present to customers during their interactions. as in prior literature, most young adults (72%) reported learning about products in dispensaries by asking budtenders about their personal recommendations and about individual product effects. nearly half (48%) found budtender recommendations at least moderately important when deciding to buy a cannabis product. given this potential influence of budtender suggestions and recommendations, we sought to examine the harm reduction strategies that budtenders may be discussing with customers in the context of these within-dispensary interactions. harm reduction themes emerged among the budtenders relating to (a) sales methodology (e.g., product dissuasion, such as limiting purchasing high thc or concentrated products for nave users), (b) advice about use behavior (e.g., recovering from overconsumption or preparing for recovery), and (c) establishing budtender-customer relationships (e.g., acknowledging advice is anecdotal and limitations of expertise, such as encouraging consultation with medical professionals). young adult interviews revealed themes related to avoiding conference abstracts 252 specific products (e.g., not purchasing vapes if concerned about using too often), limiting overconsumption (e.g., use of ratioed cbd products instead of products solely containing thc), and prioritizing purchases associated with positive use experiences (e.g., purchasing products they have used before and feel comfortable using). these results can help researchers and policymakers better understand harm reduction messaging within retail cannabis environments. doing so can help address potential misinformation related to harm reduction and identify content areas that can be enhanced for the creation of future trainings and science-based educational materials to help consumers implement harm reduction strategies that will work best for them when choosing to use cannabis. talk 2: a mixed methods study exploring insights and behaviors related to the sale of high potency thc products among customers and budtenders megan e. brown (keck school of medicine, university of southern california) ireland m. shute (keck school of medicine, university of southern california) bethany a. gray (colorado state university) angeles sedano (keck school of medicine, university of southern california) grace earner (university of southern california) madison moore (university of southern california) seth houghton (university of california, santa cruz) john r. monterosso (university of southern california) mark a. prince (keck school of medicine, university of southern california) eric r. pedersen (keck school of medicine, university of southern california) the legalization of cannabis for recreational sale and possession in the united states has raised concerns about products that contain elevated levels of thc (i.e., high-potency thc products). frequent use of these products, especially among young adults, has been linked to negative outcomes such as increased risk for cannabis use disorder, early onset of psychosis, and adverse psychological effects like anxiety and paranoia. additionally, these products are associated with acute cognitive impairment and an increased risk of tolerance and withdrawal. highpotency thc products are widely available in recreational cannabis dispensaries, with cannabis flower now averaging over 20% thc (compared to about 12% in 2012), and concentrated products, like oils and concentrates, reaching up to 99% thc. additionally, reports of inflated thc levels suggest that cannabis companies list higher thc concentrations as a marketing strategy. consumer demand for these products continues to rise, as past studies have found that many believe they offer a "better high," despite the associated risks. while existing literature has explored consumer preferences, no known studies have conference abstracts 253 examined how frontline cannabis dispensary staff (i.e., budtenders) sell high-potency thc products or provided detailed insights into consumer motivations for purchasing such products. the present mixed-methods study examined the general selling and purchasing behaviors of cannabis products in a mock dispensary. twenty budtenders and 60 young adult cannabis users participated in separate semi-structured interviews that explored their insights and behaviors related to the sale and purchase of cannabis products. the interviews and surveys also included inquiries about the sale and purchase of high-potency thc products. during their interview, budtenders answered questions about how they would sell various types of cannabis products, which included three high-potency thc products (i.e., a cannabis flower product, a vape, and a concentrate). young adults were interviewed after completing a simulated shopping experience where they were given a budget of $100 to purchase products in the mock dispensary. interview and survey data related to high-potency thc products were selected for data analysis. survey data revealed that 62% of young adult participants consider thc percentage important when making purchasing decisions, 41% buy high-potency thc products for their value, and 72% are at least somewhat confident in the accuracy of labeled thc concentrations. thematic analysis of budtender interviews revealed key themes regarding their sales methods for high-potency thc products, their views on labeled thc percentages, and their insights into why customers buy these products. similarly, thematic analysis of the young adult interviews highlighted key motivations driving consumer purchases of high-potency thc products, including the desire to get the maximum value for their purchase. the findings provide valuable information about the discussion surrounding high-potency thc products, both from budtenders' and consumers' perspectives, as well as how these products are marketed and sold in retail dispensaries. this study could help advise policymakers as they develop strategies to reduce the potential harm associated with highpotency thc products. talk 3: comparing ai-assisted and personcoded methods of thematic analyses: understanding how cannabis is sold and purchased in california dispensaries bethany a. gray (colorado state university) megan e. brown (keck school of medicine, university of southern california) ireland m. shute (keck school of medicine, university of southern california) eric r. pedersen (keck school of medicine, university of southern california) mark a. prince (keck school of medicine, university of southern california) background: marijuana purchase tasks (mpts) are hypothetical measures that offer an efficient way to assess cannabis' relative reinforcing value (i.e., demand). such tasks ask conference abstracts 254 participants to report on the amount of cannabis they would purchase across a range of prices. data from the mpt can be used to generate a set of demand indices including intensity (i.e., amount of cannabis one would consume if it were free), omax (i.e., the maximum amount one is willing to pay for cannabis), pmax (i.e., the price associated with omax), breakpoint (i.e., price at which one is no longer willing to purchase cannabis), and elasticity (i.e., rate of decline in cannabis purchase with increasing cost). two open questions concern whether individuals assume that their peers' cannabis purchasing behavior is similar to their own, and whether one's own motivations for using cannabis are associated with their perceptions of other's cannabis demand. methods: participants were recruited while standing in line in a legal recreational cannabis dispensary in colorado; those with valid cannabis demand data (n = 137) were included in analyses. this was the first study to adapt the mpt to ask participants: "how much marijuana do you think a typical user would purchase and use at different price levels?" in addition to this normative perception-based purchase task, participants were also asked to complete the mpt about their own purchasing behavior, as well as the marijuana motives measure. we hypothesized that those with conformity motives would be more likely to believe others' cannabis purchasing behavior to be similar to their own. results: with the exception of omax, participants' own demand indices were nearly identical to demand indices generated from their perceptions of others' purchasing behavior. participants' perception of others' cannabis demand generated higher omax values than their own omax values (omax-personal = 135.19, omax-other = 178.11). correlations between personal demand indices and perceptions of others' demand indices were large and statistically significant (omax r = .776, pmax r = .671, breakpoint r = .752, intensity r = .731, elasticity r = .899). in addition, social motives were associated with normative perceptions of omax (r = .221), and conformity motives were associated with normative perceptions of all demand indices with the exception of elasticity (omax r = .471, pmax r = .360, breakpoint r = .228, intensity r = .200, elasticity r = -.049). conclusions: based on the focus theory of normative conduct, it is likely that participants' beliefs about others' purchasing behavior influenced their own purchasing behavior. the higher omax generated from perceptions of other's purchasing behavior suggests that participants believe others would spend more on cannabis than they would themselves. subsequent work should aim to collect a large normative sample of cannabis demand data to determine whether purchasing behavior normative beliefs are exaggerated in a similar way to normative perceptions about others' substance use behavior. if the same exaggerated normative beliefs exist, normative re-education interventions could be developed to correct misperceptions potentially leading to safer buying practices. symposium title: conference abstracts 255 recipe vs. results: comparing cannabinoid formulations in legalmarket cannabis edibles using an integrative within-subjects and double-blind approach to measuring dose-response chair: emma e. smith (colorado state university) discussant: n/a due to federal limitations on cannabis research, few studies have examined the relations between the pharmacokinetic and pharmacodynamic properties of cannabis edibles, limiting our understanding of cannabis doseresponse and intoxication effects. additionally, prior research often lacked true placebo conditions, reducing internal reliability and control. this series of studies addresses these limitations by integrating biological, subjective, and behavioral measures to examine how cannabinoid formulation influences intoxication experience, physiological effects, and cognitive function over time. all subjective and objective data were collected with pharmacokinetic markers across standard, fast-acting, and placebo edibles in a mobile laboratory setting using a randomized, placebo-controlled, counterbalanced, double-blind, crossover observational study design. this combination of internal and external validity was possible through partnering with a local vertically integrated cannabis business. researchers observed participants (n = 20, within-subjects) before and for 5 hours after selfadministering three distinct standardized cannabis edible formulations: (1) "regular" (10mg thc), (2) "fast-acting" (10mg thc), and (3) placebo (terpene only, 0mg thc). study products were third-party tested by a state-regulated lab for consistency before distribution via a local dispensary. study products produced by industry partners were tested by a 3rd party state-regulated lab for consistency in active compounds prior to participant distribution via local dispensary. during observation, participants completed data collection at thirteen time points that consisted of blood sample collection, self-report measures, and behavioral tasks. this symposium aims to take integrative approaches to characterizing the doseresponse qualities of edible cannabis over time in terms of blood concentration, perceived intoxication, vital markers, and cognitive impairment. talk 1: pharmacokinetic differences between fast-acting, standard, and placebo cannabis edibles bradley t. conner (colorado state university) emma e. smith (colorado state university) samuel m. dicecco (colorado state university) kira l. sturgess (colorado state university) hollis c. karoly (university of colorado, anschutz medical campus) gregory dooley (colorado state university) natalie akagi (colorado state university) charles villanueva (azuca, inc.) conference abstracts 256 michael hennesy (wana brands, llc.) introduction. edibles have become the second-most used cannabis product in legal u.s. states, wherein 64% of cannabis consumers reported using edibles within the past year. among expansions to the legal cannabis industry are the newly marketed "fastacting" edible compounds, which may address many of the issues associated with edible use related to overdose and dose management. conventional cannabis edibles typically contain extracted cannabinoids, primarily 9tetrahydrocannabinol (thc). when ingested, thc is processed through the digestive system and undergoes firstpass metabolism in the intestine and liver prior to entering the systemic circulation. in this process, thc converts to 11-hydroxy-9-thc (thcoh), which further oxidizes to 11carboxy-9-thc (thc-cooh). this process results in low oral bioavailability, delayed onset of effects, and prolonged duration of action. micro-encapsulation technology, such as in the formulation from azuca, inc. used in this study, involves enclosing small particles of active substances, such as thc, with a protective coating. this encapsulation process often involves materials like polysaccharides, proteins, or lipids. micro-encapsulates can be engineered to protect active ingredients from enzymatic degradation in the gastrointestinal tract, enhance solubility, and regulate the release of these compounds, thereby improving absorption and increasing bioavailability upon consumption. this study aimed to systematically compare the pharmacokinetic properties of thc analytes in a standard, fast-acting, and placebo edible using a randomized, placebocontrolled, 3-way counterbalanced crossover observational study. the study hypothesized that fast-acting edibles would reach peak concentration significantly faster than standard and placebo edibles. materials & methods. participants (n=20) completed a 3-arm within-subjects designed study to test hypotheses. the three arms were ingestion of a (1) fast-acting edible, (2) a standard edible, and (3) a thc terpene-derived placebo edible that was indistinguishable from the two thc-containing edibles. blood plasma was analyzed for the presence of thc, thc-oh, and thc-cooh. the pharmacokinetic parameters tested were time to max concentration (tmax), maximum concentration (cmax), terminal half-life (t1/2), and area under the curve (auc). as data were non-normally distributed and participants were not randomly selected, non-parametric wilcoxon signed rank tests were used to analyze the data. alpha was set to 0.05 for all analyses. results. results supported study hypotheses in that tmax for the fast-acting edible occurred, on average, 30 minutes earlier than the tmax for the standard edible for thc, fast-acting compared to placebo (z=-3.1, p<.001), fast-acting compared to standard (z=-3.5, p<.001), and standard compared to placebo (z=2.4 p<.001), and for thc-oh, (z=-4.0 p<.001), and standard compared to placebo (z=-4.0 p<.001). there were no other significant differences between conference abstracts 257 the fast-acting and standard edibles; however, both significantly differed from the placebo across all pharmacokinetic parameters. discussion. the results indicate that the micro-encapsulation technology used to create the fast-acting edible enabled analyte concentrations to peak significantly faster than the standard and placebo edibles. the delayed onset of intoxication associated with edible cannabis products may be a risk factor for overconsumption, as individuals may increase their dose while waiting to feel the effects; however, the fastacting preparation may reduce this risk. talk 2: characterizing differential doseresponse qualities of varying cannabinoid formulations: a synthesis of intoxication intensity, experience quality, and biological markers emma e. smith (colorado state university) bradley t. conner (colorado state university) samuel m. dicecco (colorado state university) kira l. sturgess (colorado state university) gregory dooley (colorado state university) introduction. among the most popular legal-market available cannabis product categories (i.e., flower, extract), cannabis edibles present the most significant challenges when it comes to dosing management (i.e., selftitration) and are linked to a higher incidence of adverse effects from unintentional overconsumption. delayed onset of perceived intoxication with edible cannabis is a potential risk factor for overconsumption, as individuals may increase their dose before perceiving initial effects. relatedly, high variability in the way that thc is prepared for ingestion (i.e., method of administration, formulation of cannabinoids) can impact the onset and intensity of intoxication, further complicating the individual's ability to anticipate ideal dosing. while biological markers (i.e., blood cannabinoid concentration) across time between fast-acting and standard edibles suggest a promising advance in addressing overconsumption issues, little is known about perceptual or experiential differences that may accompany these varying pharmacokinetic profiles. this study systematically compared dose-response characteristics of intoxication intensity and experience quality with pharmacokinetic markers across standard, fast-acting, and placebo edibles in a mobile laboratory setting using a randomized, placebocontrolled, counterbalanced, doubleblind, crossover design. we hypothesized that fast-acting edibles would reach peak subjective intoxication significantly faster than the standard formulation and would descend from peak intoxication earlier as a result. concurrently, we postulated that at peak blood concentrations, there will be no significant differences in overall subjective intoxication intensity or quality between the regular and fastacting edibles. methods. participants (n=20) completed a 3-arm withinsubjects designed study to test conference abstracts 258 hypotheses using (1) a fast-acting edible, (2) a standard edible, and (3) a thc terpene-derived placebo edible that was indistinguishable from thccontaining edibles. participants provided blood samples and completed the subjective high assessment (shas) self-report measure before and at 12 time points after edible selfadministration. we tested blood plasma for thc, thc-oh, and thccooh, and the pharmacokinetic parameter tested was time to max concentration (tmax). we used wilcoxon signed rank tests to compare the differences in intoxication across time points, at tmax, and between the highest peaks in quality and intoxication (éø=.05). results. pairwise comparisons across identical time points showed no significant differences between intoxication intensity ratings for fast-acting and regular edibles; however, the fastacting edibles showed significantly higher perceived intoxication quality at 30 minutes post-ingestion. when comparing intoxication intensity and quality at tmax for both active thc edibles, the standard edible (tmax=60min) had significantly higher intoxication intensity (z=-2.45, p=.014) and intoxication quality ( z=-2.88, p=.004) than the fast-acting (tmax=30min) edibles. no significant differences were found between active edibles in overall global intoxication intensity and quality when comparing totals over the 5-hour session. discussion. these findings suggest a more intense perceived onset of effects in the standard edible during peak blood concentration, accompanied by greater reported intoxication quality, compared to the fast-acting edibles at their peak blood concentration. while fast-acting edibles did not necessarily create discomfort during peak intoxication, it appears that the cost associated with quicker perceived edible intoxication onset may be that the enhancing and ameliorative effects associated with intoxication are blunted compared to standard edibles. talk 3: differential responses in vital markers to regular vs. fast-acting cannabis edibles formulations kira l. sturgess (colorado state university) samuel m. dicecco (colorado state university) emma e. smith (colorado state university) bradley t. conner (colorado state university) introduction: current research on objective markers of intoxication (i.e., blood pressure, heart rate, temperature) while under the influence of cannabis is minimal. our study attempts to add to this body of work by examining changes in blood pressure, heart rate, and temperature throughout the administration, intoxication, and voiding processes associated with the consumption of a fast-acting cannabis edible, a standard cannabis edible, and a placebo edible. we hypothesized that blood pressure, heart rate, and temperature would significantly differ throughout the administration, intoxication, and voiding processes for the fast-acting and standard edibles compared to the conference abstracts 259 placebo edibles. methods: 20 participants completed all three arms of the within-subjects design. blood pressure, heart rate, and temperature were measured at each blood draw. we analyzed data using non-parametric wilcoxon signed rank tests and friedman's tests. alpha was set to .05 for all analyses. results. post ingestion of the cannabis edible, we observed significant temperature changes compared to baseline. at maximal thc concentration, as detected in the blood analyses, the change in temperature for the standard edible was significantly higher than for the fast-acting edible. this trend is also present 15 (z = -2.33, p = .020) and 30 minutes in (z = -2.16, p = .031). this pattern reverses as participants voided the cannabinoids such that, at 120 minutes, the fast-acting edible was significantly lower than the standard edible (z = -2.24, p = .025). further, significant changes in blood pressure occur at 240 minutes post-ingestion. essentially, changes in blood pressure over time post-ingestion for the standard edible (z = -2.88, p = .004) and the fast-acting edible (z = -2.36, p = .019) were significant compared to b, indicating similar vasodilatory effects in both standard and fast acting edibles. at 10 and 15 minutes, significant observed changes in heart rate occurred for both the standard edible condition (z = -2.66, p = .008) and the fast-acting edible condition (z = 3.07, p = .002). most notably, the standard edible (60 minutes) and fastacting (30 minutes) produce similar cardiovascular effects at peak concentration. the standard edible produced a noticeable jump in heart rate at 90 minutes compared to the baseline (z = -3.55, p = <.001). similarly, the fast-acting edible had the same effects at 60 minutes (z = 2.32, p = .021). discussion. the results indicate similar objective levels of intoxication across both regular and fast-acting edibles, with only slight differences in temperature across conditions. these findings suggest body temperature spikes faster for standard edibles and drops earlier than for fast-acting formulations. fastacting edibles are slower to impact body temperature at maximal concentration and on the descent, potentially due to differences in the digestive processing of fast versus regular-acting edibles. this information provides insight into the biological and pharmacological effects of cannabis, furthering our knowledge of physiological responses to cannabis edible products. to further understand the potential medicinal and therapeutic utility of cannabis, future research must continue to investigate the physiological effects of cannabis intoxication specific to legal-market available products. talk 4: cannabinoids and cognitions: behavioral impacts of acute cannabis edible intoxication on cognitive performance over time using an impairment detection app samuel m. dicecco (colorado state university) emma e. smith (colorado state university) kira l. sturgess (colorado state university) conference abstracts 260 bradley t. conner (colorado state university) introduction. acute cannabis consumption has previously been associated with impaired cognition in multiple domains, including confusion, concentration, and time dilation (i.e., inaccurately perceiving the passage of time). less is known about the time course of these impairments, particularly across different cannabis product formulations. methods: in our observational assessment of edible cannabis products, we measured behavioral and subjective reporting of impairment at multiple time points comparing the effects of a 10mg "standard" edible, a 10 mg "fast-acting" edible with tmax at 30 minutes before the standard edible, and a placebo edible product. impairment was measured behaviorally through the druid app and the subjective high assessment scale for cognitive impairment. as data were nonnormally distributed, we did not randomly select participants and conducted non-parametric analyses. we used wilcoxon signed-ranks tests to compare the differences in impairment across the same time points, tmax time points, and between the highest peaks of each variable. results: overall, for the fast-acting edible compared to the standard edible, there were significant differences in druid behavioral impairment, where the fast-acting product was still higher in impairment later into the time course (p < .05). for self-reported impairment, the fast-acting product had a significantly lower reported distorted sense of time than the standard product at tmax (p < .05). the fast-acting product was also associated with significantly lower difficulty concentrating closer to tmax (p < .01), but greater difficulty concentrating near the end of the time course for the products (p < .05). when comparing the overall time course as compared to the placebo condition, druid behavioral impairment lasted longer for the fast-acting product (p < .05). however, self-reported impairment was shorter for the fastacting product when considering selfreported clumsiness (p < .05), distorted sense of time (p < .05), and feelings of floating (p < .05). discussion: across all of the previously mentioned variables, there was no difference from the maximally reported effects in terms of magnitude, implying each product hits the maximum effect at some point during the time course, just at different times. from these results, for most effects it appears that self-reported impairment may be ending earlier for some cognitive effects in the fast-acting product but may actually be later when measuring impairment through behavioral means. this has potential implications for the risk of impairment when individuals no longer personally feel impaired, or issues with the method of behavioral measurement of impairment. further investigation into different means of cannabis administration and the time course of various cognitive impairment, as well as differences between behaviorally measured and self-reported impairment is thus warranted. research article 33 ved abstract objective: simultaneous alcohol and cannabis use (i.e., marijuana, [sam], using alcohol and cannabis so effects overlap) is associated with increased consumption and consequences compared to single-substance use. sam use prevalence is increasing, yet there is heterogeneity in use patterns among those engaging in sam use, which may lead to differential consequences. method: this study drew on daily data to characterize latent profiles of cannabis, alcohol, and sam use patterns and to test class differences on related consequences after 3 months among college students engaging in sam use (77.08% white, 51.67% female). class indicators were 10 person-level substance use variables derived from repeated daily surveys. results: results yielded a three-class solution: heavy alcohol, cannabis, and sam (heavy use, n = 105); heavy alcohol-light cannabis (n = 75); and light alcohol-heavy cannabis (n = 60). there were significant person-level differences between classes on all substance use indicators (e.g., quantity and frequency of alcohol, cannabis, and sam) but not sex or race/ethnicity. at 3-month follow-up, the heavy use class endorsed more sam consequences than the other classes. the heavy use class did not differ on alcohol or cannabis consequences compared to the heavy alcohol-light cannabis or light alcohol-heavy cannabis classes, respectively. the light alcohol-heavy cannabis class endorsed the fewest alcohol consequences. the heavy alcohol-light cannabis class endorsed the fewest cannabis consequences. conclusions: findings highlight distinct patterns of co-use and their association with consequences at follow-up. heavy alcohol or cannabis use was associated with consequences for that substance, but heavy use of only one substance was not indicative of sam-specific consequences. key words: = simultaneous use; cannabis; alcohol; latent class analysis simultaneous alcohol and cannabis (i.e., marijuana [sam]) use refers to the use of both substances such that the effects overlap. sam use is particularly prevalent among college-aged individuals (i.e., 18 – 22 years; terry-mcelrath & patrick, 2018; white et al., 2019) with a large, nationally representative sample finding that approximately one-quarter of college students enrolled in 4-year universities endorse lifetime sam use (mccabe et al., 2021). further, 54% of college students endorsing past-year alcohol use and 73% of those endorsing past-year alcohol and cannabis use report at least one occurrence of sam use in the past year (patrick & lee, 2018; white et al., 2019). importantly, the prevalence of sam use increases as the frequency of heavy episodic drinking (i.e., consuming 4 or more drink for females and 5 or more drinks for males a session; hed) and cannabis use increase (miech et al., 2018), suggesting that increased alcohol, cannabis, and sam use patterns are related. jordan a. gette1, alexander w. sokolovsky2, rachel l. gunn2, holly k. boyle2, kristina m. jackson2, & helene r. white1 1center of alcohol and substance use studies, rutgers, the state university of new jersey, piscataway, new jersey 2center for alcohol and addiction studies, brown university, providence, rhode island cannabis 2024, volume 7 (1) © author(s) 2024 researchmj.org 10.26828/cannabis/2023/000184 latent classes of simultaneous alcohol and cannabis use and associations with consequences using daily data corresponding author: jordan gette, ph.d. rutgers, the state university of new jersey, 607 allison road, piscataway, nj 08854. phone: (848):445-8195. email: jordan.gette@rutgers.edu. cannabis, a publication of the research society on marijuana 34 as rates of sam use increase, individuals are at increased risk of incurring negative consequences of use. compared to singlesubstance use, sam use is associated with greater frequency of both alcohol and cannabis use, greater consequences of use, greater functional impairment (see lee et al., 2022 and yurasek et al., 2017 for reviews), and increased risk of mental health symptoms (thompson et al., 2021). within persons studies comparing sam use to alcoholonly use have found that sam use is related to increased number of consequences, alcohol quantity, and alcohol and cannabis frequency (jackson et al., 2020; lee et al., 2020; lindencarmichael et al., 2020). comparing sam to concurrent use (i.e., use of cannabis and alcohol such that the effects do not overlap), those reporting sam use endorse more cannabis consequences and greater quantity and frequency of both alcohol and cannabis use (looby et al., 2021). of note, however, those endorsing sam use did not significantly differ on cannabis consequences or cannabis frequency and quantity compared to those reporting cannabis-only use (looby et al., 2021). though there are differences in outcomes between sam and concurrent use, it is worth noting that the majority of alcohol and cannabis co-use is sam (patrick et al., 2019; sokolovsky et al., 2020; subbaraman & kerr, 2015), highlighting the importance of understanding specific patterns of this type of couse. taken together, these findings indicate that there may different patterns of risk for individuals based on their unique cannabis, alcohol, and sam use patterns. the role of alcohol and cannabis use behavior in sam outcomes though studies have established that increased sam use is associated with negative outcomes, it is important to consider how quantity and frequency of alcohol and cannabis use independently influence these relations. extant work comparing single-substance use and co-use have included frequency and/or quantity as covariates with inconsistent outcomes. within (lee et al., 2020; lipperman-kreda et al., 2017; mallet et al., 2019; sokolovsky et al., 2020) and some between-person designs have found that relations between sam use and outcomes (e.g., consequences, driving under the influence) are attenuated or even eliminated when frequency of individual substance use is controlled for (cummings et al., 2019). however, other work has found that sam use incurs increased risk for adverse cannabis and alcohol outcomes after controlling for single-substance use (jackson et al., 2020; patrick et al., 2019; subbaraman & kerr, 2015), frequency and baseline problems (briere et al., 2011). in addition to frequency, quantity may also impact relations between sam and outcomes. among college students, relations between sam use and negative consequences were greatest among those who engaged in hed during event-level sam use occasions compared to lower alcohol quantities (mallett et al., 2019). of note, these authors found that heavy drinking was associated with increased consequences and that this pattern did not differ as a function of whether the person used cannabis simultaneously. similarly, metrik et al. (2016) found that sam use with heavy drinking, but not moderate drinking, was associated with increased likelihood of unprotected sex. among those endorsing sam use, there were similar consequence endorsement on alcohol-only days as compared to sam days (sokolovsky et al., 2020). these findings suggest that differences in consequences may be most attributable to drinking patterns (i.e., quantity and frequency) as opposed to cannabis use patterns. there are several possible explanations for the above patterns. first, college students may be more inclined to attribute negative consequences of sam use to alcohol alone (jackson et al., 2020) despite laboratory tasks demonstrating greater functional impairment with sam use than alcoholor cannabis-only use (downey et al., 2013; yurasek et al., 2017). additionally, it could be that ordering effects matter. at the person-level, days with cannabis-initiated sam use were associated with increased cannabis consumption but decreased alcohol consumption; however, ordering effects were not related to day-level consequences (gunn et al., 2021). cross-sectionally, karoly et al. (2022) found that on co-use days, an increase in cannabis-initiated days was associated with fewer alcohol consequences, whereas an increase in alcohol-initiated days was associated with fewer cannabis consequences. as can be seen, there is clear heterogeneity in patterns of alcohol, cannabis, and sam use among those engaging in sam use. quantity and latent classes of simultaneous alcohol and cannabis use 35 frequency of individual substance use at the eventand person-level differentially relate to experiences of consequences; however, associations between use patterns and outcomes have yielded inconsistent results. notably, much of the extant literature on sam use and outcomes has utilized variable-centered approaches in which analyses test coarse relations between variables (laursen & hoff, 2006). an alternative method for elucidating relations between sam use patterns and outcomes is to employ a personcentered approach wherein the focus is on parsing out typologies or patterns of multiple indicators to create classes or categories. use of a personcentered approach allows for examination of how these patterns of use may relate to risk of consequences more holistically, rather than examining relations between specific use variables (e.g., quantity, frequency) as they relate to consequences. latent class analysis (lca) accounts for individual differences in use at the person-level to determine unique patterns of use (i.e., classes) that then can be used to compare differences in outcomes. importantly, though it is well-established that sam use is associated with greater risk of incurring negative consequences at the eventor day-level, individuals tend to have a pattern of alcohol, cannabis, and sam use that may be evident by looking at their behavior over time and that is predictive of long-term consequences. to date, two studies of sam use have utilized class analyses to examine patterns of alcohol and cannabis co-use. first, in a sample of adolescents, patrick et al. (2018) identified a four-class solution of alcohol and cannabis use: sam hed, sam without hed, concurrent alcohol and cannabis-only, and alcohol-only. being in either sam class was associated with increased likelihood of additional substance use and conduct problems and this relationship was stronger for the sam with hed group. importantly, though sam use was an indicator in the class solution, their analyses were not specific to those endorsing sam use. given the evidence supporting increased risk of adverse outcomes among those endorsing sam, it is crucial to understand unique patterns of use within a population that engages in sam. to that end, using the same sample as the present study, lanza et al. (2022) found a fiveclass solution: frequent cannabis-focused sam use, frequent alcohol-initiating sam use, heavydrinking infrequent sam use, moderate sam use, and light infrequent sam use. classes primarily showed differences in frequency of sam use and alcohol behaviors. of note, however, consequences were included as a class indicator rather than an outcome variable for class membership. as such, it is unclear to what degree the classification of sam use among college-aged students was driven by the consequences of such use as opposed to use patterns themselves. use of lca to examine typologies of cannabis, alcohol, and sam use could serve to provide nuanced understanding of how individual patterns of substance use over time among individuals who engage in sam use relate to experiences of long-term consequences. current study the purpose of the present study is to characterize patterns of sam use based on alcohol, cannabis, and sam behaviors (e.g., quantity, frequency) and investigate if these classes are associated with experiences of alcohol, cannabis, and sam consequences at 3-month follow-up. as the reviewed literature demonstrates, when included as covariates, alcohol quantity and frequency impact relations between sam use and consequences (e.g., lee et al., 2020; lipperman-kreda et al., 2017; mallet et al., 2019) and when participants are stratified by alcohol quantity, individuals engaging in hed appear at greater risk for adverse outcomes (e.g., mallett et al., 2019; metrik et al., 2016; patrick et al., 2018). notably, much of the extant work examines eventor day-level consequences. however, understanding individuals’ patterns of use over a longer period of time adds to our understanding of how specific cannabis, alcohol, and sam behaviors may impact consequences over time. it could be that there are individuals who engage in high frequency use of one substance with occasional use of the other substance and, thus, may differentially experience consequences of use. to that end, we hypothesized that distinct classes would emerge based on quantity and frequency of alcohol, cannabis, and sam use. further, it was hypothesized that individuals with the heaviest use of both alcohol and cannabis in addition to greatest sam use frequency would experience the greatest risk for consequences. cannabis, a publication of the research society on marijuana 36 methods participants participants were college students in a multisite study assessing simultaneous cannabis and alcohol use. data collection took part in four stages. baseline data were collected in the fall of 2017 and follow-up assessments were completed approximately three months later (see white et al., 2019 for details). following the baseline survey, individuals who reported at least one sam use occasion in the past 3-months were invited to participate in a daily survey study. of those eligible, 89% (n = 284) participated, completing two bursts of up to five surveys per day over 28 consecutive days following the baseline and 3month follow-up surveys (see stevens et al., 2020 for details). data for the present study utilized a subsample of individuals who completed the baseline survey, first daily burst, and the 3-month follow-up survey to establish temporal precedence between class solutions (i.e., daily data) and consequences at the follow-up survey (n = 240). at baseline, participants included in the analyses had a mean age of 19.9 years and the majority of participants self-identified as non-hispanic white (77.1%) and female (51.7%). all procedures were approved by the coordinating university’s institutional review board. measures baseline measures. demographic variables were collected at baseline. participants reported on their race using census categories. additionally, ethnicity was coded such that 0 = not hispanic/latinx and 1 = hispanic/latinx. due to limited endorsement, a binary race/ethnicity variable was created (0 = non-hispanic white). sex assigned at birth was coded as 0 = male, 1 = female. age was treated as a continuous variable. daily survey items. participants completed up to five surveys per day over 28 days during the first burst. due to technical difficulties on the first two days of daily data collection, the first burst was limited to 26 days of daily survey data. because lca requires categorical indicators, variables were aggregated to the person-level such that dichotomous indicators in the final data represented any instance of the behavior for a participant across all study days while categorical indicators represented participants’ quartile in a continuous variable averaged across all observations. ten variables were included as latent class indicators. class indicators were selected to capture a range of behaviors associated with experiences of consequences including quantity and frequency of use as well as substance-specific indicators associated with negative outcomes such as heavy drinking, use of multiple cannabis forms in a day, and ordering of alcohol and cannabis on sam occasions. for alcohol variables, cut-offs for dichotomization were selected based on niaaa guidelines for high-risk drinking with variables created to reflect both hed (4+ drinks for men, 5+ drinks for women) and severe impairment (i.e., estimated blood alcohol concentration [ebac] ≥ .16; niaaa, 2022). to account for eventand day-level variability, categorical variables were derived to reflect average quantity and frequency of alcohol, cannabis, and sam use using quartiles to create cut-off points. alcohol variables included ebac ≥ .16 on any use day (0 = no, 1 = yes); any hed on an alcoholonly day (0 = no, 1 = yes), any hed on any sam day (0 = no, 1 = yes), average drinks per drinking day (0 = ≤ 4, 1 = 4.01 – 6.00, 2 = > 6), and proportion of use days with any alcohol use (0 = .00 .25, 1 = .26 = 50, 2 = .51 .75, 3 = .76 – 1.00). cannabis variables included average cannabis uses per use day (0 = 1.00 – 2.00, 1 = 2.01 – 4.00, 2 = > 4), use of two or more cannabis forms on any cannabis-use day (0 = no, 1 = yes), and proportion of use days with any cannabis use (0 = .00 .25, 1 = .26 = 50, 2 = .51 .75, 3 = .76 – 1.00). sam variables included frequency of sam use (0 = 1 – 2 days, 1 = ≥ 3 days) and proportion of sam use days initiated with alcohol (0 = .00 .25, 1 = .26 = 50, 2 = .51 .75, 3 = .76 – 1.00). for the present study, sam use was defined as occasions in which alcohol and cannabis were used within a 3-hour (180 minute) period. using this operationalization, approximately 90% of co-use days were sam use days. in addition to the class indicators, classes were compared on an additional seven person-level exploratory (auxiliary) variables. items included as exploratory were selected to further capture potential differences in substance use patterns between groups without influencing the class estimations. four categorical items were created to examine person-level proportions of days with no alcohol or cannabis use; use days with any latent classes of simultaneous alcohol and cannabis use 37 alcohol use; use days with any cannabis use; and use days with sam use (0 = .00 .25, 1 = .26 = 50, 2 = .51 .75, 3 = .76 – 1.00). though proportion of total days was included as a class indicator, proportion of use days with differing substances used may provide additional nuanced information on alcohol, cannabis, and sam patterns. further, to examine consistency in quantity of alcohol and cannabis use, three continuous variables were created, examining standard deviations in daily drinks per drinking day, day-level loose leaf quantity on days with any loose-leaf cannabis use among those endorsing flower use, and day-level cannabis concentrates quantity on days with concentrate use. given the exploratory nature of standard deviations of substance use, inclusion of these markers of variability as exploratory variables allowed for examination of these variables as continuous rather than creating categorical ranges of standard deviations in quantity and frequency of use that would be required for an lca model. follow-up measures. past 3-month alcohol, cannabis, and sam consequences were assessed via a follow-up survey approximately three months post-baseline. consequences were from a measure collapsing items across from the brief young adult alcohol consequences questionnaire (byaacq; kahler et al., 2005) and the brief marijuana consequences questionnaire (bmacq; simons et al., 2012), resulting in 28 total items. items were presented such that individuals endorsed whether they experienced a consequence and if so, if they attributed the consequence to alcohol, cannabis, and/or sam. participants were able to select multiple attributions per consequences resulting in three individual total consequences scores for alcohol, cannabis, and sam. this approach has demonstrated good internal consistency with alpha values ranging from .87 to .88 (see jackson et al., 2020). values for each consequence attribute type ranged from 0 to 28 with higher scores representing more problems. both the byaacq and b-macq have demonstrated good internal consistency with college students (kahler et al., 2005; simons et al., 2012). analytic approach indicators were included in a latent class analysis using mplus version 7.31 (muthen & muthen 1998 – 2017). classes were determined using the maximum likelihood with robust standard errors (mlr) with 200 random starts. model fit was evaluated using akaike’s information criterion (aic), the bayesian information criterion (bic), and the sample-size adjusted bic (bicadj), with lower values indicating better fit and entropy with higher values indicating better fit. in addition, the sample size of each class was taken into consideration (o’donnell et al., 2017; shanahan et al., 2013). upon determination of the optimal class solution, differences between classes on class indicators and additional variables of interest (e.g., demographics, proportion of use days with any alcohol or any cannabis use) were compared using the method initially developed by bolck, croon, and hagenaars (bch method; bolck et al., 2004; asparouhov & muthen, 2021). lastly, using the training weights (i.e., latent variables accounting for measurement error in the indicators) derived from the class analysis, class membership was used to predict the number of consequences using the approach developed by asparouhov and muthen (2021). results comparison of class solutions specifying 1 – 6 classes found that the 3-class solution evinced the best fit to the data based on the aic, bic, bicadj and log likelihood replication (see table 1). table 1. latent class analysis model fit indices number of classes aic bic adjusted bic entropy 1 3095.706 3137.473 3099.436 2 2935.228 3022.244 2943.000 .82 3 2818.021 2950.286 2829.835 .89 4 2790.998 2968.511 2806.853 .84 5 2795.679 3018.440 2815.576 .86 6 2800.379 3068.388 2824.317 .90 cannabis, a publication of the research society on marijuana 38 this solution resulted in an entropy of .89, suggesting good distinction among classes. though the four-class solution yielded a lower aic, coverage of classes was poor (i.e., class 4 only comprised 2% [n = 5] of total sample). as such, the three-class solution was selected as it maximized fit and entropy metrics while also permitting better coverage across classes. the heavy alcohol, cannabis, and sam (hereafter referred to as “heavy use”) class (n = 105) was made up of individuals endorsing heavy and frequent use of alcohol, cannabis, and sam. additionally, on sam use days, these individuals were equally likely to initiate with alcohol or cannabis. the light alcohol-heavy cannabis class (n = 60) contained individuals endorsing infrequent, low quantity alcohol use but frequent, higher quantity of cannabis use, use of multiple cannabis forms and moderate sam endorsement typically initiated with cannabis. conversely, the heavy alcohollight cannabis class (n = 75) comprised individuals with heavy, frequent alcohol use, infrequent, low quantity cannabis use, and relatively low endorsement of sam use, which was predominately alcohol-initiated (see table 2 and figure 1).1 table 2. latent class indicator endorsement rates and alcohol, cannabis, and sam consequences at follow-up for the full sample and the latent classes indicator full sample n = 240 heavy alcohol, cannabis, and sam n = 105 light alcoholheavy cannabis n = 60 heavy alcohol-light cannabis n = 75 ebac ≥ .16 on ≥ 1 day no .329 .075 .923 .213 yes .671 .925 .077 .787 hed on an alcohol only day no .239 .234 .538 .082 yes .761 .766 .462 .918 hed on a sam day no .188 .020 .427 .231 yes .812 .980 .573 .769 average drinks per drinking day ≤ 4 .342 .086 .865 .283 4.01 – 6.00 .333 .400 .135 .397 > 6 .325 .514 .000 .320 average daily cannabis sessions on cannabis use days 1.00 – 2.00 .250 .083 .187 .530 2.01 – 4.00 .388 .269 .546 .427 ˃ 4.00 .362 .649 .268 .043 frequency of sam use 1 – 2 .438 .233 .440 .717 3+ .562 .767 .560 .283 1class analyses were conducted using all available survey days with a total of 5863 survey days across 240 participants. to ensure class solutions were not impacted by missing surveys within days, class analyses were conducted on a subsample comprised of days with only 100% coverage (i.e., no two sequential missed prompts resulting in missing reporting periods; 75.61% of total survey days). this resulted in 4480 survey days across 209 participants. the class solution for the full coverage only subsample closely approximated the solution for the full sample. both analyses resulted in a three-class solution with similar endorsement proportions for each indicator by class. as such, the results for the full sample are presented. latent classes of simultaneous alcohol and cannabis use 39 multiple forms of cannabis on a use day no .567 .295 .565 .942 yes .433 .705 .435 .058 proportion of use days with any alcohol use .00 .25 .171 .204 .329 .000 .26 .50 .300 .454 .366 .037 .51 .75 .221 .247 .214 .191 .76 – 1.00 .308 .095 .091 .773 proportion of use days with any cannabis .00 .25 .117 .000 .018 .355 .26 .50 .129 .016 .000 .386 .51 .75 .158 .107 .194 .200 .76 – 1.00 .596 .876 .788 .058 proportion of sam days with alcohol first .00 .25 .296 .350 .433 .113 .26 .50 .179 .200 .255 .090 .51 .75 .175 .288 .118 .064 .76 – 1.00 .350 .161 .194 .733 mean (sd) alcohol consequences at 3-month follow-up 7.44 (5.07) 8.05 (5.4) 5.23 (3.49) 8.06 (5.09) mean (sd) cannabis consequences at 3-month follow-up 6.11 (4.39) 6.71 (4.60) 7.63 (4.05) 3.85 (3.36) mean (sd) sam consequences at 3-month follow-up 4.49 (4.17) 5.41 (4.45) 3.71 (4.47) 3.51 (2.75) figure 1. latent class indicator endorsement by class 0 0.5 1 1.5 2 2.5 3 eb ac > .1 6 hed on an al cohol-o nly d ay hed on a s am da y ave rag e drin ks > 50 % al cohol us e d ay s >5 0% alc ohol initia ted sa m ave rag e ca nnab is s ess ions mult iple ca nna bis fo rm s > 50 % ca nnab is u se days > 3 sa m days heavy use light alcohol-heavy cannabis heavy alcohol-light cannabis cannabis, a publication of the research society on marijuana 40 next, classes were compared to determine if they significantly differed on each of the class indicators (see table 3). the heavy use class had the highest proportion of individuals with at least one day of ebac ≥ .16, any hed on a sam day, three or more sam use days, and use of two or more cannabis forms. additionally, this class had a greater average number of drinks per drinking day and more cannabis uses per cannabis day than the heavy alcohol-light cannabis or light alcohol-heavy cannabis classes. the light alcohol-heavy cannabis class had the lowest proportion of individuals with at least one day of ebac ≥ .16, hed on an alcohol-only day, and hed on a sam day. the heavy alcohol-light cannabis class endorsed the highest proportion of hed on an alcohol-only day and the highest rates of alcohol-initiated sam use, but the lowest proportion of individuals with three or more sam use days and use of two or more cannabis forms. in addition to the class indicators, several additional variables were compared between classes. these variables included: proportions of days with no substance use and proportion of use days with any alcohol use, any cannabis use, and sam use (person-level); degree of variation (i.e., standard deviations at the day-level) in alcohol (number of drinks) and cannabis quantity (loose leaf and concentrates); and demographics (personlevel; see table 3). table 3. comparisons of means on latent class indicators and additional variables by class indicator heavy alcohol, cannabis, and sam light alcoholheavy cannabis heavy alcohollight cannabis ebac ≥ .16 on ≥ 1 daya,b,c .966 .014 .803 hed on an alcohol only daya,b,c .768 .444 .922 hed on a sam daya,b,c .998 .541 .770 average drinks per drinking daya,b,c 1.489 0.026 1.038 average daily cannabis sessions on cannabis use daysa,b,c 1.604 1.074 0.465 frequency of sam usea,b,c 1.786 1.546 1.267 multiple forms of cannabisa,b,c .734 .411 .036 proportion of sam days with alcohol initiationb,c 1.225 1.058 2.477 proportion of use days with any alcohol useb,c 1.221 1.033 2.779 proportion of use days with any cannabis usea,c 2.889 2.791 0.891 proportion of no use daysa,b,c .265 .370 .607 proportion of use days with sam usea,b 0.765 0.507 0.419 average standard deviation in drinks per drinking dayb,c 4.378 1.564 3.388 average standard deviation in loose leaf quantity on use daysb,c .662 .472 .150 average standard deviation in concentrate quantity on use daysb,c 3.859 3.081 0.627 agea 19.68 20.20 19.88 note. bold indicates variable was an indicator in the latent class analysis. a = classes 1 and 2 significantly differ, b = classes 1 and 3 significantly differ, c = classes 2 and 3 significantly differ. there were no significant differences on sex or race/ethnicity between classes. latent classes of simultaneous alcohol and cannabis use 41 due to the exploratory nature of these variables and in order to maximize parsimony of the class solution, these variables were not included as class indicators, but were entered as additional variables to facilitate comparison without influencing the class solutions. the heavy use class had the lowest proportion of no use days and the heavy alcohol-light cannabis use class had the highest proportion. however, on use days, the heavy alcohol-light cannabis class had the greatest proportion of days with any alcohol use and the lowest proportion of days with any cannabis use. regarding standard deviations in day-level quantity of use, the light alcoholheavy cannabis use demonstrated the lowest deviations in typical drinks per drinking day (i.e., greatest consistency) but the heavy alcohol-light cannabis class had the lowest standard deviations in both day-level cannabis flower use and concentrate quantity. the classes did not differ on sex, race/ethnicity, but the light alcoholheavy cannabis class was older than the heavy use class. class membership and consequences there were several significant differences in the three types of consequences at 3-month followup as a function of class membership (see table 2 for means and standard deviations). compared to the heavy use class, the light alcohol-heavy cannabis class endorsed significantly fewer alcohol and sam consequences but did not differ on cannabis consequences (see table 4). the heavy alcohol-light cannabis class endorsed fewer cannabis and sam consequences, but similar rates of alcohol consequences compared to the heavy use class. lastly, compared to the light alcohol-heavy cannabis class, the heavy alcohol-light cannabis class endorsed significantly more alcohol consequences but fewer cannabis consequences. however, these classes did not differ on sam consequences at follow-up.2 table 4. number of consequences as a function of class membership alcohol consequences cannabis consequences sam consequences b p b p b p heavy use (ref) v. light alcohol-heavy cannabis -2.776 .003 0.889 .264 -1.667 .040 heavy use (ref) v. heavy alcohol-light cannabis 0.004 .997 -2.839 <.001 -1.830 .026 light alcohol-heavy cannabis (ref) v. heavy alcohol-light cannabis 2.780 .006 -3.729 <.001 -0.163 .860 race/ethnicity (ref = nonhispanic white) -0.158 .848 0.663 .379 0.912 .256 sex (ref = male) 0.490 .490 -0.322 .605 0.667 .322 age -0.033 .906 -0.124 .624 0.043 .877 2ordinal logistic models are presented for all consequence outcomes. however, cannabis consequences evinced skewed distribution (mean = 3.3, sd = 41) with zero-inflation (n = 292, 31.5%). as such, zero-inflated poisson models were conducted for cannabis consequences. similar to the ordinal regressions, the heavy use class did not significantly differ from the light alcohol-heavy cannabis class on cannabis consequences (b = .90, p = .55). however, differences between the heavy use and heavy alcohol-light cannabis classes (b = -2.19, p = .08) and light alcohol-heavy cannabis and heavy alcohol-light cannabis classes (b = -1.29, p = .27) were no longer significant. cannabis, a publication of the research society on marijuana 42 discussion the primary purpose of the present work was to examine typologies of alcohol and cannabis use among individuals engaging in sam use and how class membership relates to consequences at 3month follow-up. latent classes analysis yielded a three-class solution: heavy use, heavy alcohollight cannabis, and heavy cannabis-light alcohol. broadly, these classes suggest that amongst those engaging in sam use, there are individuals who primarily engage in frequent cannabis use but less frequent and heavy alcohol use. conversely, there is a group of individuals demonstrating a pattern of heavy alcohol use with infrequent, light cannabis use. notably, over onethird of the sample demonstrated a pattern of heavy, frequent alcohol, cannabis, and sam use. classes were differentially related to alcohol, cannabis, and sam consequences at follow-up. the heavy use class was associated with more sam consequences. as might be expected, the light alcohol-heavy cannabis use class endorsed the fewest alcohol consequences, whereas the heavy alcohol-light cannabis class endorsed the fewest cannabis consequences. experience of alcohol related consequences at follow-up was similar between the heavy use and heavy alcohol-light cannabis classes, suggesting that heavier alcohol involvement (e.g., high bac, hed) was driving the association between substance use behaviors and a broad assessment of consequences. as well, cannabis consequences were similar between the heavy use and the light alcohol-heavy cannabis classes, suggesting that greater quantity and frequency of cannabis use was most indicative of cannabis consequences at follow-up. taken together, these findings demonstrate that along with increased sam use, substance-specific behaviors (e.g., alcohol quantity, cannabis quantity) are important in understanding risk of incurring alcohol, cannabis, and sam consequences. importantly, risk of sam consequences appears to be specifically tied to frequent sam use or heavy use of both substances, as heavy use of alcohol-alone or cannabis-alone was not associated with increased risk of sam consequences at follow-up. this pattern is somewhat discrepant from work examining event-level sam use and subsequent consequences that found heavy alcohol use during a sam occasion was associated with increased sam consequences (metrik et al., 2016; sokolovsky et al., 2020) and that this pattern held regardless of event-level cannabis use (mallett et al., 2019). understanding broader patterns of use could serve to inform just-in-time interventions. for example, if an individual engages in a pattern of use closely aligned with the light alcoholheavy cannabis class (i.e., infrequent, low quantity of alcohol use but frequent, higher quantity of cannabis use, multiple forms and moderate sam use) reports an increase in alcohol consumption, that could serve as a catalyst for engaging the individual in brief intervention. an important aspect of the present work was the use of daily data to predict experiences of consequences at 3-month follow-up rather than predicting event-specific consequences. individuals may report consequences differently depending on timeframe or context. for example, there may be consequences that individuals do not attribute to a particular use event (e.g., changes in cognitive or academic performance) but that they report experiencing when reflecting on a broader timeframe. similarly, individuals may be more accurate at reporting more acute events at the eventor day-level (e.g., affect changes) compared to broadened timeframes. as such, future work should aim to parse out how eventlevel alcohol and cannabis use on sam occasions relate to acute consequences compared to aggregate patterns. additionally, use of cognitive interviews could provide nuanced information on how individuals interpret, subjectively evaluate, and respond to consequences items at differing time intervals (e.g., event-level v. 3-months) and for specific substances (e.g., freeman et al., 2022; merrill et al., 2020; patrick & maggs, 2011). future work should also examine how class membership relates to event-level consequences and how these relations are impacted by contextual variables. for example, jackson et al. (2021) found that event-level motives, presence of peers, and peer use resulted in different rates of alcohol, cannabis, and sam use. as such, understanding under what contexts individuals in these classes are at increased risk of adverse outcomes could aid in refinement of intervention and prevention efforts. in addition to contextual variables, drinker identity and cannabis user identity may also be indicative of alcohol, cannabis, and sam patterns among those latent classes of simultaneous alcohol and cannabis use 43 engaging in co-use. extant work highlights that drinker identity (i.e., how closely one views drinking as part of their self-concept) is associated with increased alcohol use and subsequent consequences (lindgren et al., 2016a; lindgren et al., 2016b), and increased cannabis user identity is associated with more cannabis problems (blevins et al., 2018). understanding the extent to which individuals view themselves as a “drinker,” “cannabis user,” or both could aid in understanding distinct patterns of alcohol, cannabis, and sam use in the context of co-use. further, identifying more strongly as a user of alcohol or cannabis could have implications for sam ordering effects (e.g., someone with a high alcohol user identity and low cannabis user identity may be more likely to initiate sam with alcohol). in addition to frequency and quantity of use, the present work examined differences in standard deviations in daily quantity of alcohol and cannabis use (i.e., lower standard deviations are indicative of more consistent quantities of use). interestingly, results found that heavy use was associated with greater standard deviations in use compared to light use; for example, the heavy use and heavy alcohol-light cannabis classes had greater standard deviations in typical number of drinks than the light alcohol-heavy cannabis class. though this finding needs to be replicated, it indicates that variability in use may be a unique factor associated with subsequent outcomes. for example, individuals who drink less frequently and in lower quantities may be intentionally limiting their drinks or may experience the physiological effects of alcohol at lower quantities than those drinking more frequently. however, as an individual engages in more frequent or heavier use, they may not be as conscious of their number of drinks or may need to drink higher quantities to experience the effects of alcohol. another potential explanation for this pattern could be that individuals may continue to use until a desired effect is achieved (e.g., feeling intoxicated; coping with stress) and that those using a substance more frequently may have a wider range of motives for use, and thus, have greater variability in their quantities (stevens et al., 2021). it may also be that more frequent alcohol users have greater variability because they drink on weekdays and weekends, which results in more inconsistency in quantity, whereas primary cannabis users may drink more exclusively on weekends mostly in the same quantities. finally, heavier users have a higher range of drinking and thus mathematically deviations can be greater. the classes derived in the present work appear largely driven by heavy single-substance use (i.e., greater quantity and frequency) or heavy alcohol, cannabis, and sam use. this is somewhat discrepant from previous class models of alcohol, cannabis, and sam use (patrick et al., 2018; lanza et al., 2022). in their analyses, lanza et al., (2022) found a five-class solution with classes driven by the frequency of sam use (i.e., frequent, moderate, and infrequent), order of initiation on sam occasions, and presence of heavy drinking. cannabis use behavior was largely unrelated to class estimation in that analysis. this discrepancy could be due in large part to the inclusion of consequences in the class estimation rather than use of consequences as an outcome variable (as in the present study), particularly given the tendency to endorse fewer cannabis consequences or to attribute sam consequences predominately to alcohol (jackson et al., 2021). beyond elucidating unique sam profiles and risk patterns, the present findings inform prevention and intervention considerations for alcohol and cannabis co-use. notably, heavy use of a single substance was indicative of consequences for that substance, but risk was not increased between substances, suggesting some specificity of risk. as such, tailoring prevention and interventions for emerging adults engaging in sam use should take into consideration whether the individual has a primary substance of choice, and if so, modify content to emphasize the primary substance. for example, interventions aimed at increasing use of protective behavioral strategies targeting the primary substance(s) could be effective in reducing negative consequences of use (e.g., riggs et al., 2018), particularly when delivered in potentially highrisk use contexts (e.g., university game days, edwards et al., 2020). there is limited work examining specific interventions aimed at sam use and extant work has found that alcohol interventions do not tend to influence cannabis use, further highlighting a need for increased work evaluating sam and cannabis-focused interventions for emerging adults that co-use substances (see lee et al., 2022 for review). for cannabis, a publication of the research society on marijuana 44 individuals with any co-use, it is important that both substances are addressed in the context of clinical interventions to mitigate risks (metrik et al., 2018). limitations and future directions the strengths of this study include the use of a multisite sample responding to multiple daily surveys and robust analyses that facilitated investigating person-level indicators of substance use patterns aggregated from within-person behavior. despite the strengths of this work, several limitations exist. first, analyses focused exclusively on alcohol and cannabis use and did not control for the use of other substances (e.g., nicotine products) as class indicators. work by mallet and colleagues (2017) suggests that using alcohol with any second substance (e.g., cannabis, nicotine, cocaine) results in increased risk of negative outcomes and as such, future work should aim to determine how relations between consequences and alcohol and cannabis co-use patterns are impacted by use of additional substances. further, though daily surveys are associated with increased accuracy of alcohol and cannabis use self-report (freeman et al., 2022), individuals tend to overestimate their quantity of cannabis use and underestimate their alcohol use quantity (prince et al., 2018; shultz et al., 2017). as such, future works should aim to replicate these findings using multimethod assessment (e.g., wearable measures, direct observation). follow-up consequences were asked about the preceding three months and, thus, there was some overlap with the period of the daily survey assessment. at follow-up, alcohol, cannabis, and sam consequences were presented as dichotomous items. as such, this work determined relations between patterns of co-use and total number of types of consequences (e.g., blackout, hangover), but not frequency or type of consequences. it could be that some individuals experience a broader range of consequences but infrequently, whereas others may experience a more restricted range of consequences but more frequently. further, differentiating between acute (e.g., impaired coordination) and less acute (e.g., academic difficulties) consequences of use is an important consideration for future research on couse patterns. lastly, the sample included college students who were predominately white and may not be representative of a more diverse young adult population. conclusion among those reporting sam use, there are distinct patterns of cannabis, alcohol, and sam use that differentially relate to negative substance use consequences at follow-up. consistent with prior work, increased sam use in conjunction with heavy, frequent alcohol and cannabis use is associated with increased sam consequences. importantly, heavy use of a single substance is indicative of consequences for that substance but is not associated with increased risk of sam consequences. as such, among individuals who endorse sam use, but demonstrate a pattern of primarily using cannabis or primarily using alcohol, intervention and prevention efforts may be most successful by targeting the primary substance rather than both substances in tandem or simultaneous use. further, given that greater standard deviations in quantity of use varied between classes, exploring how use of individual substances vary between events and days could serve as an important marker for just-in-time interventions. references asparouhov, t., & muthén, b. 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(2017). co-use of alcohol and cannabis: a review. current addiction reports, 4, 184 –193. http://dx .doi.org/10.1007/s40429-017-0149-8 funding and acknowledgements: the writing of this paper was supported in part by nida grants r01da040880 (mpis: jackson, white) and k08da048137 (pi: sokolovsky), and niaaa grant k08aa027551 (pi: gunn). training support was provided to holly boyle (niaaa t32aa007459, pi: miranda). points of view in this document are those of the authors and do not necessarily represent the official position or policies of the national institutes of health. the funding sources had no role in the analysis or interpretation of the data, the preparation of this manuscript, or the decision to submit the manuscript for publication. the authors declare no conflicts of interest. copyright: © 2024 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. https://creativecommons.org/licenses/by/4.0/ special section conference abstracts 177 abstracts from the 2024 scientific meeting of the research society on marijuana july 19th-21st, 2024 special section editor lauren micalizzi, ph.d. keynote addresses trauma cue reactivity paradigms as a tool for studying affective and cognitive mechanisms contributing to ptsd – cannabis use disorder comorbidity sherry h. stewart (dalhousie university) cannabis for medical purposes and chronic pain: a clinical practice guideline jason w. busse (michael g. degroote centre for medicinal cannabis, mcmaster university) all abstracts were peer-reviewed by (in alphabetical order): sophie g. coelho (york university), bradley t. conner (colorado state university), kyra n. farrelly (york university), lauren micalizzi (brown university), jamie e. parnes (brown university; bradley hospital), stephanie penta (toronto metropolitan university), kristina t. phillips (kaiser permanente hawaii, center for integrated health care research; kaiser permanente bernard j. tyson school of medicine, department of health systems science), jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto). all abstracts below were approved and voluntarily submitted for publication in cannabis by the presenting or contact author. papers, posters, & panels cannabis treatment outcomes across health conditions: a systematic review of sex differences in clinical trials cannabis 2024, volume 7 (2) © author(s) 2024 researchmj.org doi: 10.26828/cannabis/2024.02.001 conference abstracts 178 joseph antony (health canada) george mammen (health canada) austin mayers (health canada) sophie-anne lamour (health canada) hanan abramovici (health canada) background: sex-based differences in response to cannabis treatment for various conditions have not received attention, despite knowing that sexand gender-related factors are involved in health effects and biological mechanisms. a systematic review will identify, evaluate, and summarize the findings of all relevant individual studies on sex-based differences in treatment response. methodology: a search of the databases, embase (197426 october 2023), medline (1946-26 october 2023), and ebm-reviews cochrane central register of controlled trials (up to september 2023) resulted in 1052 studies on sex and gender analysis in a therapeutic context. outof-scope literature was excluded to include only randomized clinical trials (rcts), published between 1973 and 2023, for data extraction. results: screening of published literature examining the influence of patients' sex on the therapeutic efficacy of cannabis and cannabinoids resulted in diverse study types such as retrospective, prospective observational, clinical survey, case series, archival datasets, observational/quasi-field experimental research, and cross-sectional assessments. because the quality of evidence in these non-randomized studies is generally poor, only evidence from rcts were included in this systematic review; 10 rcts consisting of 813 patients met the inclusion criteria for this review. except for three rcts investigating pain, and two rcts on cannabis use disorder (cud), the remaining five rcts examined five different conditions. there were no sex differences in the three rcts that examined pain. similarly, one rct on cud showed sex differences whereas the other did not. males with autism spectrum disorder, chronic tic disorder, and heroin use disorder showed improvement in disease symptoms. females, on the other hand, showed improvement only among those with cancer-related anorexia-cachexia syndrome relative to placebo. conclusion: analysis of data relevant to sex differences, regardless of whether the primary outcome of the study was met, showed improvement in disease symptoms among males and females. however, these findings were inconclusive because of the unequal number of males and females in the treatment arms. the apparent sex differences seen in this systematic review need to be interpreted with caution. statistically significant sex differences identified in the 10 rcts may be due to chance or bias, instead of true heterogeneity of treatment-disease associations or of treatment effects. systematically testing the evidence on marijuana (stem) chelsea ayers (va portland health care system) beth shaw (oregon health & science university) snehapriya yeddala (oregon health & science university) shannon robalino (oregon health & science university) shauna durbin (oregon health & science university) conference abstracts 179 rachel ward (va portland health care system) devan kansagara (va portland health care system and oregon health & science university) background: with continuing legalization in the u.s. and internationally, more patients are using or interested in using cannabis for health conditions. meanwhile, many clinicians are not counseling patients on the health effects of cannabis and most patients source this information from elsewhere (e.g., internet, cannabis dispensaries). limited evidence regarding cannabis health effects (e.g., relatively few randomized controlled trials, lack of standard measures), and a rapidly changing research and policy landscape, leave healthcare professionals without definitive guidance on how to counsel patients. yet clinicians need to be prepared to have evidence-informed discussions about cannabis use. additionally, highquality research is needed to improve knowledge regarding cannabis health effects. methods: the systematically testing the evidence on marijuana (stem) project is an independent, methodologically rigorous, and up-todate resource (cannabisevidence.org) that synthesizes what is known from research and what is left to learn about the health effects of cannabis. using best-practice approaches to living systematic reviews and guided by a technical expert panel comprised of individuals with cannabis-related clinical and research expertise, stem aims to: 1. empower clinicians to have evidence-based discussions about cannabis use with patients 2. identify research gaps and highlight ongoing research to help researchers design high-yield studies that advance the field of clinical cannabis research results: since the launch of the website in january 2022 stem has: • completed and maintained 6 living systematic reviews, including cannabis use in pregnancy and cannabis for posttraumatic stress disorder. each review features a full report, a highlevel summary, and a visual abstract so that readers can find the level of detail that fits their needs • developed 13 clinical briefs, on topics ranging from "patient experiences when visiting dispensaries" to "cannabis and sleep" • garnered 44,082 page views by 12,555 unique users • provided a variety of other resources related to cannabis and health pertinent to researchers and clinicians, including: a summary of basic cannabis information (e.g., terminology, pharmacology), a searchable database of ongoing studies of cannabis-related research, guidance on the conduct of cannabis-related research in the us, an interactive map of cannabis legal status and key cannabis use statistics by us state, an updated collection of curated highquality news articles relevant to our audience, an opportunity for clinicians to earn continuing medical education credits after reviewing the website. conclusions: stem is an innovative approach to help address gaps in knowledge and resources on the health effects of cannabis for clinicians and researchers. the stem team is continuing to seek ways to further engage with researchers and clinicians through ongoing studies and collaborations with the ultimate goal of conference abstracts 180 supporting clinicians to have evidencebased discussions about cannabis use with patients that support shared decision-making and improve patient outcomes. cannabis and adhd symptoms in emerging adulthood: a within-person analysis camara azubuike (university of toronto) alexandra shifrin (university of toronto) abby l. goldstein (university of toronto) background: emerging adults (ages 1825) have higher rates of cannabis use and cannabis consequences relative to other age groups. attention deficit hyperactivity disorder (adhd) has been identified as an important correlate of increased cannabis use and cannabis consequences among emerging adults (bidwell et al., 2014; mochrie et al., 2020). prior studies have primarily explored the link between cannabis use and history of adhd symptoms, leaving a gap in our understanding of associations between cannabis use and adhd symptoms in daily life. this study aims to bridge this gap by investigating the real-time relationship between adhd symptoms and cannabis-related outcomes using ecological momentary assessment (ema). objective: this research utilized ema to explore whether immediate challenges with attention and other adhd symptoms are linked to heightened cannabis use and its negative outcomes among emerging adults. methods: the study involved 81 emerging adults aged 19-25 (mean age = 22.01, sd = 2.08; 46% identified as female) who reported using cannabis on average 15.74 days (sd = 9.51) in the month prior to the study. participants first completed a baseline survey on their cannabis use and adhd symptoms. they then completed short surveys three times daily over two weeks, reporting on their cannabis use (yes/no), any negative outcomes from use (e.g., difficulty starting tasks), and attention-related difficulties (e.g., focusing issues). hierarchical linear modeling was employed to examine the within-person link between adhd symptoms and cannabis outcomes. results: on average, participants reported using cannabis 10.18 times (sd = 8.77) and experiencing 2.64 (sd = 2.02) negative outcomes per use. the most frequently reported adhd symptoms were attention-related issues, focusing difficulties, and restlessness. although adhd symptoms were not associated with cannabis use directly, a positive withinperson association was found between adhd symptoms and cannabis consequences. specifically, when adhd symptoms were more pronounced than usual, participants reported more negative consequences from cannabis use. this association was even stronger among individuals with higher overall adhd symptoms. conclusions: these findings underscore a nuanced relationship between adhd symptoms and the adverse effects of cannabis use. while previous research has shown that individuals with adhd are more prone to cannabis use and its related negative outcomes, our study reveals that these associations manifest more acutely at the moment, conference abstracts 181 with negative consequences intensifying during periods of increased attentional difficulties. notably, many negative outcomes associated with cannabis use, such as diminished motivation, mirror adhd symptoms, suggesting that cannabis may worsen existing attentional challenges. further research is needed to elucidate the dynamics of this relationship fully and to develop targeted strategies for mitigating the adverse effects linked to the concurrent presence of adhd and cannabis use. bud talks: knowledge translation materials to reduce cannabis harms in older adults iris balodis (mcmaster university) older adults are now the fastest growing age group of cannabis users. with cannabis’ legalization in many areas, there is a growing interest in older adult populations to understand the effects of this drug. people often use cannabis for pain, sleep, or mood and anxiety problems. these problems tend to increase with age and are the main reasons why older adults try cannabis. the popular media is filled with unscientific and inaccurate information about cannabis. recent canadian research shows a large increase in the number of older adults presenting in the emergency room for cannabis poisonings. the current presentation describes a knowledge translation (kt) project, through the centre for medicinal cannabis research (cmcr) at mcmaster university for developing materials to target misinformation and reduce cannabis harms in older adults. this project aims to provide evidence-based, clear and accessible information about cannabis. this presentation will describe the knowledge mobilization program and the development of ‘bud talks’: person-friendly, clear and evidence-based materials for older adults. as part of the kt process, the team engaged with older audiences, pharmacists and other specialists to understand their knowledge needs around cannabis. the content development focused on issues specific to older adults, including health risks and polypharmacy. there is also information on cannabinoids, druginteractions and dosing guidelines. the materials emphasize the importance of having an open ‘bud talk’ with a doctor and provide questions to ask that can help guide the discussion. there is a disconnect between the developments in the scientific evidence and the perceptions of risk with cannabis. knowledge mobilization products, developed through collaborations between researchers and those at the front lines of healthcare, are crucial for bringing accurate and useful information to the public. this bud talk for older adults enhances understanding about cannabis and speaks to their unique needs, questions and concerns. an innovative model? exploring how uruguay designed its cannabis supply system through hybridisation rachel barry (university of bath) as far as domestic presentation and wider international perspective, conference abstracts 182 uruguay is often portrayed as a trailblazer for its distinctive approach to cannabis regulation, which avoids the mistakes and failures of other cannabis supply precedents. the dominant explanation for the model's distinctiveness is uruguay's longstanding state interventionist culture, which served to constrain the transfer of more libertarian features of cannabis policies found in other jurisdictions. yet, since the direct transfer or imitation of one international model to another context is rarely feasible or desirable, some form of adaptation is likely to occur, as policymakers attempt to make international precedents compatible with global pressures, domestic institutions, or a combination of the two. to fully understand the extent of international distinctiveness of uruguay's cannabis regulation, it is critical to investigate not only the content of the new policies but also how the transfer process came about or was constrained. in this regard, to what extent can international pressures explain uruguay's distinctive model of state-regulated cannabis supply? drawing on analysis of documents, fieldwork observations, and 43 semistructured interviews with policymakers, advocates, health professionals, and the commercial sector, this paper explores the complex interplay between global influences and domestic factors in shaping the development of uruguay's cannabis regulation through the lens of hybridisation. hybridisation is understood in a variety of ways, but for the purposes of this study, it refers to the combination of elements from policies found in two or more political contexts to develop an approach best suited to local conditions. transfer processes and outcomes were evaluated in terms of dolowitz and marsh's typology, which lists a range of degrees: copying, emulation, hybridisation, and inspiration. the primary foci of analysis were the processes by which contextual factors shaped the decision (or not) to transfer certain aspects of policy approaches to cannabis in other countries to uruguay based on the perceptions and strategic actions of policymakers involved in these processes. the analysis demonstrates that uruguay's distinctive approach to state-regulated cannabis supply can be understood as a form of 'hybridisation' in which aspects of policy models in other countries were selected, blended, and adapted to the unique political and legal features of uruguayan society. this led to the development of an innovative approach that nevertheless reflects elements found in existing cannabis supply systems. this blending of cannabis policy innovations with the domestic context was carried out in very specific ways, based on concerns to reconcile the specific contents of the legislation with the policies of argentina and brazil and the preferences of the us government as the regional hegemon. while there was greater latitude over aspects of regulation involving domestic considerations, uruguayan officials were very cautious and conservative in the more constrained space of high politics or where cannabis regulation intersects with broader security dimensions of drug policy. the uruguayan case suggests that national policy space to develop cannabis conference abstracts 183 regulation in other contexts is likely to be constrained in areas where such regulation interacts with those of other powerful states. cannabis use frequency impacts youth use of alternative tobacco products in an experimental tobacco marketplace mariel s. bello (center for alcohol and addiction studies, brown university school of public health) suzanne m. colby (center for alcohol and addiction studies, brown university school of public health) rachel n. cassidy (center for alcohol and addiction studies, brown university school of public health) significance: co-use of cannabis and tobacco products is more prevalent than single use of these substances among u.s. adolescents. populationbased studies demonstrate that cannabis use is associated with cigarette smoking initiation, progression, and lower cessation among youth who smoke. laboratory evidence also suggests that cannabis use increases cigarette reward and reinforcement in young people; however, no studies have examined cannabis use frequency as a potential driver of demand for alternative tobacco products among youth who use multiple tobacco products. this study used a well-validated experimental tobacco marketplace (etm) to explore whether demand for alternative tobacco products differed by past 30-day cannabis use frequency among adolescent smokers who also used other tobacco products. methods: after baseline exposure to study-provided research cigarettes varying in nicotine content, 49 adolescents aged 15-20 (m age=18.9) who smoked cigarettes daily and also used at least ≥1 tobacco product completed a timeline follow-back interview assessing past 30-day cannabis use and an etm assessing the demand for tobacco products. effects of exposure to cigarettes varying in nicotine content did not differ at baseline; thus, we focused on whether patterns of alternative tobacco product use differed by cannabis use frequency, given high rates of cannabis use in this sample. 8 participants were never cannabis users (0 days), 11 were nondaily users (1-29 days), and 30 had used cannabis daily (30 days). in the etm, participants were asked to make hypothetical purchases of nicotine products as though they were making real tobacco purchases for the week. the etm consisted of 8 trials, across which the price per study cigarette increased ($0.12, $0.25, $0.50, $1, $2, $4, $8, and $16), while the price of alternative products remained the same. alternative tobacco products included combustible (i.e., little cigars, cigarillos) and non-combustible (i.e., juul, smokeless tobacco, disposable ecigarettes, e-liquids, and nicotine replacement therapy) products to simulate real-world availability. results: as the price of study cigarettes increased, cigarette purchasing decreased in the overall sample. demand for alternative tobacco products differed by cannabis use frequency, such that daily cannabis users purchased a higher overall conference abstracts 184 number of milligrams of nicotine relative to other cannabis use groups. rates of purchase for combustible products were consistently highest among daily cannabis users, followed by participants who never used cannabis, and lowest among participants who used cannabis non-daily. rates of purchase for non-combustible products were highest among daily cannabis users compared to non-daily and never users. conclusions: higher rates of purchasing of alternative tobacco products among daily cannabis users relative to non-daily or never users are consistent with data suggesting that cannabis use may be associated with greater tobacco exposure among young people. findings showing no differences in sources of nicotine (i.e., combustible or non-combustible) across cannabis use frequency suggest that heavy cannabisusing adolescents who smoke may be as amenable to shifting their tobacco use behaviors towards primarily noncombustible sources of nicotine as noncannabis using adolescents. future studies assessing co-use patterns of tobacco and cannabis among youth may inform efforts that shift use behaviors towards non-combustible sources and quitting. anxiety symptoms and coping-withanxiety motives serially mediate the link between psychotic-like experiences and cannabis-related problems in emerging adult cannabis users haley c. r. bernusky (dalhousie university, york university) philip g. tibbo (dalhousie university) patricia j. conrod (universite de montreal) fakir m. yunus (dalhousie university) matthew t. keough (york university) kara d. thompson (st. francis xavier university) marvin d. krank (university of british columbia) allyson f. hadwin (university of victoria) sherry h. stewart (dalhousie university) many canadian emerging adults between the ages of 18-25 years use cannabis, with 60% of past-three-month users reporting having experienced at least one cannabis-related problem (i.e., adverse social/legal/psychological/health consequences of use). while psychoticlike experiences (ples) and cannabis problems overlap, little is known about the mechanisms explaining this link. one hypothesis is that ples are distressing and give rise to anxiety, which emerging adults then attempt to cope with via an increase in cannabis use, which, in turn, increases their risk for developing cannabis-related problems. we tested a chainedmediational model to determine if anxiety symptoms and coping-withanxiety motives for cannabis use sequentially mediated the association between ples and cannabis-related problems in a sample of emerging adult undergraduates who currently/recently use(d) cannabis (i.e., within the past three months). furthermore, we tested a conditional process model which evaluated for moderation of the serial conference abstracts 185 mediation model by biological sex assigned at birth (e.g., male/female). emerging adults who had recently used cannabis (n = 413; mean [sd] age = 19.1 [1.5] years; 71.9 % female) were recruited from five universities across canada to provide cross-sectional, selfreport survey data in the fall semester of 2021. demographics were collected, along with data obtained from validated measures of ples, anxiety, coping-withanxiety motives for cannabis use, and cannabis-related problems. path analyses were conducted using mplus, the results of which provided support for the hypothesized chained mediational indirect effect observed from ples to anxiety symptoms to coping-with-anxiety motives for cannabis use to cannabis-related problems (b = 0.027, 95 % bootstrap ci = [0.012, 0.050]). no direct effect was found (p = .698), suggesting that the ples-to-cannabis-related problems association is fully explained by anxiety and coping-with-anxiety motives for cannabis use. inconsistent with hypotheses, the conditional process analysis revealed that the observed mediation did not depend on biological sex (95 % cis crossed zero); therefore, anxiety and cannabis coping-withanxiety motives explain the link between ples and cannabis problems in emerging adults regardless of the sex that they were assigned at birth. results highlight that anxiety and coping-with-anxiety motives for cannabis use may potentially be important targets for intervention among current/recent cannabis-using emerging adults with ples, which, in turn, could possibly prevent the development or worsening of cannabisrelated problems. an examination of alcohol and cannabis protective behavioral strategies among simultaneous, concurrent, alcohol-only, and cannabis-only users katherine a. berry (university of wyoming) alison looby (university of wyoming) harm reduction research team both simultaneous alcohol and cannabis (i.e., marijuana; sam) and concurrent alcohol and cannabis (i.e., marijuana; cam) use are prevalent among college students and associated with an increased risk of negative substancerelated consequences. prior work has found that students who report higher use of alcohol and cannabis protective behavioral strategies (pbs) report lower consumption and negative consequences. however, research has not yet examined if alcohol and cannabis pbs use differs among sam and cam users. thus, the purpose of the current study was to examine how sam, cam, and single-drug users differ on alcohol and cannabis pbs use. participants were 3471 college students (mage = 19.43; 69.5% female; 57.2%; white non-hispanic) from twelve united states universities who reported past-month alcohol and/or cannabis use (39.2% sam, 11.5% cam, 44.5% alcohol-only, 4.9% cannabis-only). participants completed measures of alcohol and cannabis pbs and demographics via an online survey. two analysis of covariance (ancova) models were conducted to examine conference abstracts 186 differences on alcohol and cannabis pbs separately by past-month user status, controlling for sex assigned at birth. the overall cannabis model was significant (f(2, 1753) = 4.706, p = .009, h2r = .01). examination of parameter estimates indicated that cam users reported significantly greater cannabis pbs use than sam users (b = -3.80, 95% ci = [6.26, -1.33], t(2) = -3.02, p = .003). cannabis-only users did not differ from cam nor sam users on cannabis pbs use. the overall alcohol model was also significant (f(2, 3079) = 38.49, p = <.001, h2r = .04). parameter estimates indicated that alcohol-only users reported significantly greater alcohol pbs use than cam (b = -2.63, 95% ci = [-4.82, -0.45], t(2) =-2.36, p = .018) and sam (b = -6.49, 95% ci = [-7.94, -5.04], t(2) = -8.77, p <.001) users. in addition, cam users reported significantly greater alcohol pbs use than sam users (b = -3.86, 95% ci = [-6.09, -1.63], t(2) = -3.39, p <.001). results indicated that sam and cam users can be importantly differentiated by alcohol and cannabis pbs use. given that sam users reported engaging in both alcohol and cannabis pbs use less frequently than cam users, intervention efforts designed to reduce sam-related consequences may benefit from promoting both alcohol and cannabis pbs use. specifically, it may be advantageous to provide sam users with psychoeducation about the utility of implementing both cannabis and alcohol pbs to mitigate the additive harms associated with both cannabis and alcohol use when they are consumed during the same occasion. considering that cannabis-only users did not differ from sam and cam users on cannabis pbs use, additional efforts may be needed to increase cannabis pbs use among sam, cam, and cannabis-only users. examining the potential impact of recreational cannabis legalization on individuals receiving treatment for substance use disorder: an interrupted time series study emily britton (homewood research institute) radia taisir (homewood research institute) yelena chorny (homewood health centre) james mackillop (homewood research institute; st. joseph's healthcare hamilton; michael g. degroote centre for medicinal cannabis research; peter boris centre for addiction research) jean costello (homewood research institute) objective: the present research evaluated the impact of legalizing recreational cannabis among individuals with substance use disorders (sud) who may already use cannabis at high rates. methods: using an interrupted time series study design, we evaluated the potential impact of legalization among individuals seeking treatment for sud within a hospital-based treatment setting in guelph, ontario. we examined 2,925 individuals who entered the treatment program between april 2017 and december 2021. we performed segmented regression analyses using both the date of cannabis legalization and the date of edibles legalization as the interruption conference abstracts 187 time point. we also performed stratified analyses to examine potential sex differences. results: we found no significant changes in the prevalence of cannabis use or readiness to quit using cannabis following legalization with either of the interruption time points. however, there was evidence of increasing cud severity post-edibles legalization. stratified analyses also suggested possible sex differences in readiness to quit over time. conclusions: results point to some small but potentially important impacts of recreational cannabis legalization among individuals with sud that may only continue with time. nevertheless, there is a need to continue to monitor cannabis use trends to understand any potential lagged effects. cannabis protective behavioral strategies and eating disorder symptoms: a closer look at muscular dysmorphia and cannabis use disorder among male and female college students megan e. brown (university of southern california) ireland m shute (university of southern california) keegan buch (university of southern california) stuart b. murray (university of southern california) mark a prince (colorado state university) eric r. pedersen (university of southern california) symptoms of eating disorders (ed) (e.g., making oneself sick, loss of control when eating, significant weight loss in a short period, feelings that food dominates one's life) have been identified as risk factors for problematic cannabis use across males and females. past studies show mixed results regarding sex differences in cannabis use among ed samples, but many studies focused on samples of those with eds do not include muscular dysmorphia (md) – a risk factor for ed across sex, and especially for males. greater use of cannabis protective behavioral strategies (cpbs) has been established as a protective factor against cannabis use disorder (cud) in college student samples. few studies have examined ed symptoms and cpbs; available studies did not find a relationship between the two constructs. sex differences in cpbs use among those who endorse ed symptoms have yet to be explored in detail. the present study investigated the moderating effect of ed symptoms, including md, on the relationship between cpbs and cud among male and female college students. the sample consisted of college students who used cannabis in the past year (n = 578; 76% female). all participants completed measures of cpbs (the protective behavioral strategies for marijuana scale), the cudit (cud-identification test), and the scoff questionnaire (a 5-item screener to detect ed symptoms). an additional item was added to evaluate md, which was examined individually. separate regression analyses were conducted with the sample overall and then for males and females separately. with cudit as the outcome, the models included either total scoff scores or md separately as moderators. conference abstracts 188 depression and generalized anxiety (i.e., correlates of eds) were included as covariates in all models (as assessed by the 8-item patient health questionnaire and the 7-item generalized anxiety disorder scale). greater use of cpbs was significantly associated with lower cudit scores among the whole sample. the scoff significantly moderated the relationship between cpbs and cud among the whole sample, such that participants with higher reported ed symptoms demonstrated significantly lower cudit scores when they used more cpbs, compared to participants who reported fewer ed symptoms. when examining sex separately, greater scores on the scoff functioned as a significant moderator for males only. when the md item was included in the models instead of the scoff, the md item moderated the relationship between cpbs and cud among the whole sample, such that participants who endorsed md symptoms demonstrated significantly lower cudit scores when they used more cpbs, compared to participants who did not endorse the md item. when examining sex separately, the md item was a significant moderator for both males and females. this study highlights the importance of cpbs as a harm reduction method in college students who use cannabis and report symptoms of eds. specifically, analyses highlight cpbs as a protective factor for males who present with a high amount of ed symptoms and for both males and females who endorse md symptoms. personality traits as mediators in the association between adverse childhood experiences and cannabis consequences: a cross-national examination among college students from six countries megan e. brown (university of southern california) laura mezquita (universitat jaume i) mark a. prince (colorado state university) adrian j bravo (william and mary) generós ortet (universitat jaume i) maria ibáñez (universitat jaume i) cross-cultural addictions study team impulsivity and childhood trauma exposure have been previously associated with increased cannabis use and negative consequences. studies have also found that impulsivity traits (i.e., positive urgency, negative urgency, sensation seeking, lack of perseverance, and lack of premeditation) mediate the association of adverse childhood experiences (ace) with later cannabis use. whether these results can be generalized across countries is unknown. moreover, past research has not considered the big five personality traits (i.e., emotional stability, extraversion, conscientiousness, agreeableness, and openness) in the relationship between aces and cannabis consequences. thus, the present study aimed to explore whether different impulsivity traits and big five personality traits mediate the relationship between a wide variety of ace's and negative cannabis consequences among college students from six countries (united states, conference abstracts 189 spain, argentina, canada, united kingdom, and south africa) as well as whether the mediational model was invariant across countries. a sample of 2,481 college student cannabis users (mean age = 20.12; 67.9% female) completed an online survey. they completed a measure of cannabis use frequency, the brief marijuana consequences questionnaire, the adverse childhood experiences international questionnaire, and personality measures including the upps-p and the big five personality test. mediation and moderation analyses were performed, controlling for cannabis frequency and sex. analyses revealed that negative urgency and emotional stability mediated the association between the frequency of ace's and cannabis consequences, such that higher ace scores were associated with higher negative urgency and lower emotional stability (i.e., higher neuroticism) which were in turn associated with more cannabis consequences. moderation analyses revealed that results were invariant across countries. this study replicates extant research linking aces with later cannabis use problems through negative emotionality-related impulsivity traits and suggests that these results could be generalized across college students from different countries. interventions for those who experience ace's might focus on impulsive, neurotic behaviors to lessen or even prevent negative cannabis consequences. cannabis use, consequences, and protective behavioral strategies among sexual and gender minority college students keegan buch (university of southern california) ireland m. shute (university of southern california) megan e. brown (university of southern california) reagan e. fitzke (university of colorado colorado springs) mark a. prince (colorado state university) eric r. pedersen (university of southern california) sexual and gender minority (sgm) individuals report increased levels of cannabis use when compared to their non-sgm counterparts. some studies have pointed to this trend in young adult/college student sgm populations as well, and this is of particular importance given the already-elevated risk for cannabis use among the general young adult population. cannabis use has been associated with several negative consequences, especially for college students; consequences may range from academic-related problems to more potentially severe consequences such as driving while high. although little research has investigated the prevalence of cannabis-related consequences among sgm college students, related literature has indicated sgm students' increased risk for alcohol-related consequences. thus, it is reasonable to consider the rate at which sgm students may experience cannabis-related consequences. similarly, protective behavioral strategies for marijuana use (pbsm) have been shown to be negatively conference abstracts 190 associated with cannabis use and consequences among young adults, and very few studies have explored their use among the sgm college student population. if sgm college students are indeed at increased risk of cannabis use and consequences when compared to non-sgm college students, it is important to investigate their endorsement of pbsm usage and how this may relate to their cannabis use and related problems. in this exploratory cross-sectional study, using a convenience sample of 1,014 (25.9% sgm) college students, we examined sgm students' endorsement of past year and past 30-day cannabis use, days of cannabis use in the past 30 days, cannabis use disorder (cud) symptoms, cannabis-related consequences, and pbsm usage. participants completed an online survey assessing past year and past 30-day cannabis use, past 6-month cud symptoms on the cannabis use disorder identification test (cudit), past 30-day cannabis-related consequences on the brief marijuana consequences questionnaire (bmacq), and pbsm usage. chi-square tests revealed that sgm participants were significantly more likely than non-sgm participants to endorse any past year (p < .001) and any past 30-day (p = .008) cannabis use. independent samples ttests revealed that sgm participants had significantly higher sum scores on the cudit (p < .001) as well as significantly higher amounts of cannabis-related consequences (p = .005) but did not differ from non-sgm participants in their pbsm usage. using two separate linear regression models with cannabis consequences and cudit scores as outcomes, we found that sgm status and pbsm usage associated with consequences and cudit scores, such that sgm participants had significantly greater consequences and higher cudit scores, and higher pbsm use significantly associated with lower consequences and cudit scores. there were significant interaction effects for sgm status and pbsm usage, such that sgm participants with low pbsm usage reported the highest consequences and cudit scores, whereas high pbsm usage protected against consequences and higher cudit scores regardless of sgm status. these findings provide novel insights into the cannabis use behaviors, consequences, and pbsm usage of sgm college students. future work is needed to further investigate the relationship between pbsm use and cannabis behaviors among sgm college students and explore other potential correlates of hazardous cannabis use in this population. cannabis use timing and motives: when you get high depends on why you get high brenna a. carter (colorado state university) siena ho shue (colorado state university) paige strait (colorado state university) hollis c. karoly (colorado state university) bradley t. conner (colorado state university) introduction: previous studies demonstrate the prevalent nature of cannabis use and its typical association with adverse physical health, mental conference abstracts 191 health, and daily-functioning outcomes. contrastingly, cannabis is often endorsed, and in some states prescribed, as an option for supplementing primary health concern treatment and coping with pain. considering the potential intersection between utilization of cannabis for varied motives and the timing-specific nature of influence in day-to-day functioning, it is imperative that we investigate the connection between motivations and consumption timing to elicit greater insight into areas of intervention and support. particularly, this study looks at how the endorsed motivation for cannabis use predicts the time patterns of cannabis consumption during the day. methods: this study is a secondary data analysis conducted on a community sample collected through prolific, comprised of 410 adults regarding cannabis and alcohol use. analyses consist of a series of multiple regressions testing the marijuana motives questionnaire (mmq) as a predictor of time-block consumption. time blocks were comprised of fourhour periods beginning at midnight and spanning each day of the week, resulting in a range from 0-7 modelled continuously for each time block. results: our study results supported our theory that different endorsed motives for cannabis consumption would predict different patterns of consumption timing during the day. during the time periods of 12am-4am, 8am-12pm, and 12pm-4pm, the coping motive demonstrated a significant positive relationship (p < 0.005). the 4am-8am period showed no significant association with any motive (p > 0.05). the 4pm-8pm period was associated with a significant increase in consumption among those endorsing coping and enhancement motives (p < 0.001) and a significant negative relationship with those endorsing a conformity motive (p < 0.001). the 8pm12am period showed a significant positive association with the coping, enhancement, and expansion motives (p < 0.05). discussion: the results of our study suggest that an individual's cannabis consumption across a typical 24-hour period can be predicted based on differences in motivation for cannabis use. as anticipated, individuals who endorse using cannabis to cope demonstrated a significant increase in cannabis use across all time blocks except the 4am-8am period, with elevated betas during typical working hours in the united states. impact of cannabis use during adolescence and young adulthood on academic achievement: a systematic review and meta-analysis of observational studies olsen chan (university of toronto) ahad daudi (mcmaster university) david ji (mcmaster university) mathias wang (mcmaster university) jeremy p. steen (mcmaster university) parsia parnian (mcmaster university) crystal li (mcmaster university) annie xiong (mcmaster university) wei zhang conference abstracts 192 (mcmaster university) luciane cruz lopes (university of sorocaba) james mackillop (mcmaster university) jason w. busse (mcmaster university) li wang (mcmaster university) background: cannabis, also referred to as marijuana, is one of the most commonly used psychoactive drugs around the world with an increasing trend in its use among adolescents and young adults. cannabis use during adolescence and young adulthood may affect academic achievement; however, the findings varied across studies and the magnitude of association remains uncertain. objectives: to evaluate the impact of cannabis use on academic achievement using systematic review and meta-analysis. methods: we searched cinahl, embase, medline, psycinfo, pubmed, scopus, and web of science up to november 2023 for observational studies examining the association of cannabis use with academic outcomes. paired reviewers independently screened the titles/abstracts and full texts, assessed the risk of bias, and extracted data using standardized and pilot-tested data collection forms. we used random-effects model for metaanalyses of three or more studies, and fixed effects models for meta-analyses of two studies. we tested the a priori hypotheses for subgroup analyses and sensitivity analysis. results: sixtythree studies that included 438,329 individuals proved eligible for review. moderate-certainty evidence showed cannabis use during adolescence and young adulthood probably results in increased school dropout rate (odds ratio [or] 1.72 [1.45-2.04]), higher school absenteeism (or 2.31 [1.763.03]), less likelihood of completing high school (or 0.50 [0.33-0.76]), and decreased university enrollment (or 0.72 [0.60-0.87]) with an absolute risk reduction (arr) or increase (ari) ranging from 8% to 14%. low-certainty evidence showed significant association with lower school grades (or for grade b and above 0.61, 95% ci = [0.52-0.71]), lower postsecondary degree attainment (or 0.69 [0.62-0.77]), and unemployment (or 1.50 [1.15-1.96]) with arr/ari ranging from 6% to 8%. very low certainty evidence showed no significant association with grade retention (or 1.41, 95% ci = [0.97 to 2.03]). subgroup analyses with moderate credibility showed worse academic outcomes for frequent users than infrequent users. conclusions: cannabis use during adolescence and young adulthood, particularly more frequent use, is associated with worse academic outcomes, including decreased high school graduation and university enrollment, and increased school dropout and absenteeism. associations between e-cigarette marketing exposure and vaping nicotine and cannabis among u.s. adults, 2021 julia chen-sankey (rutgers institute for nicotine and tobacco studies) kathryn la capria (rutgers institute for nicotine and tobacco studies) allison glasser conference abstracts 193 (rutgers institute for nicotine and tobacco studies) alisa a. padon (public health institute) meghan b. moran (johns hopkins bloomberg school of public health) kimberly g. wagoner (wake forest university school of medicine) kristina m. jackson (rutgers robert wood johnson medical school) carla j. berg (george washington university milken institute school of public health) introduction: vaping has become an increasingly common method for consuming nicotine and cannabis, a trend potentially influenced by ecigarette marketing. however, little is known about the influence of e-cigarette marketing on cannabis vaping behaviors. this study examined the associations between e-cigarette marketing exposure and nicotine and cannabis vaping behaviors among adults. methods: this cross-sectional study included a u.s. nationally representative sample of adults (≥18 years) from the wave 6 survey of the population assessment of tobacco and health (path) study, conducted from march to november 2021. we used multinomial logistic regressions to examine the associations between past 30-day e-cigarette marketing exposure (overall and by ten marketing channels) and past 30-day vaping behavior (sole and dual-vaping of nicotine and cannabis) overall and stratified by age. the models controlled for sociodemographics, physical and mental health statuses, and substance use factors. results: the study included 30,516 respondents (48.0% male and 63.9% non-hispanic white). overall, 52.0% of respondents reported past 30day e-cigarette marketing exposure, and 89.8%, 5.6%, 3.2%, and 1.4% reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dualvaping, respectively. multinominal logistic regression results show exposure to e-cigarette marketing was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [arr], 1.31; 95% confidence interval [ci], 1.091.57) and dual-vaping versus no vaping (arr, 1.26; 95% ci, 1.01-1.57). stratification analysis found these associations among those aged 18-24 and 25-34 years but not older adults (≥35 years). those exposed to e-cigarette marketing also had increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (arr, 1.28; 95% ci, 1.04-1.58). stratification analysis found this association only among those aged 18-24 years. e-cigarette marketing exposure via several channels (retail stores, billboards, events, newspapers/magazines) was associated with increased odds of reporting solecannabis vaping. discussion: among a nationally representative sample of u.s. adults in 2021, those who were exposed (versus not exposed) to ecigarette marketing were about 1.3times more likely to report solecannabis vaping compared to those who reported no vaping or sole-nicotine vaping. those exposed were also about 1.3-times more likely to report dualvaping behaviors compared to those who reported no vaping. importantly, conference abstracts 194 such associations appeared to be mainly driven by young adults aged 18-24 and 25-34 years, and no associations were found between e-cigarette marketing exposure and sole-nicotine vaping overall or among any age groups. greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in such marketing restrictions for cannabis may contribute to the continued influence of e-cigarette marketing on cannabis vaping. continued monitoring and evaluation of the cannabis industries' marketing practices and their influence is critically needed to inform regulatory actions aimed at minimizing the public harm of cannabis product use. research is also needed to develop more specific measures that disentangle marketing exposure for nicotine versus cannabis vape products and to examine whether the impacts of e-cigarette marketing on vaping behavior show product use specificity or generalize across product categories. exploring associations between cannabis exposure and neuropsychological functioning in people living with hiv: effects of lifetime, 12-month, and 30-day use victoria o. chentsova (san diego state university/university of california san diego joint doctoral program in clinical psychology) thomas d. marcotte (university of california san diego) jennifer e. iudicello (university of california san diego) j. hampton atkinson (university of california san diego) igor grant (university of california san diego) mariana cherner (university of california san diego) the hiv neurobehavioral research center (hnrc) group and the center for medicinal cannabis research (cmcr) group (university of california san diego) background: despite advancements in antiretroviral therapy (art) and subsequent improvements in health outcomes of people living with hiv (plwh), concerns persist regarding risk of impairment in neuropsychological (np) functioning in this population. hiv infection can lead to neuroinflammation, neural injury, increased sensitivity to the effects of opportunistic infections and substance use, and subsequently risk for neurocognitive impairment (nci). concurrently, cannabis use has become increasingly prevalent, particularly in plwh, prompting inquiries into its potential impact on np function. research is emerging that regular cannabis exposure may be antiinflammatory and associated with better np functioning in plwh. on the other hand, recent cannabis exposure may acutely affect np test performance, confounding its chronic effects. the current study explores relationship between several cannabis exposure parameters and np functioning in plwh who currently use cannabis. methods: participants included 561 plwh from studies at the hiv neurobehavioral research program between 2003 and 2018 (18-74 years old, 85% male, 46.5% white nonhispanic, 74% on art) who used cannabis in the last 30-days and had conference abstracts 195 no current (30-day) substance use disorder diagnoses (excepting cannabis). np test performance was summarized across a comprehensive test battery as a demographically corrected global deficit score (gds; higher scores indicate worse np performance; 41.0% of sample impaired at gds≥0.5). independent regression models examined associations between the gds and individual parameters of cannabis exposure obtained via timeline follow-back interview (i.e., age of first use, days since last use, days of use, quantity, and density [average daily quantity],) across the lifetime, past 12-month, past 30-days, in addition to any past 24 hour exposure. reading level (wrat reading) and nadir (lowest ever) cd4 cell count were included as covariates. exploratory regression analyses were repeated for domain-specific performance deficits (verbal fluency, executive functioning, speed of information processing [sip], learning, recall, attention/working memory, and motor ability). all analyses were evaluated against a type-i error rate of 0.05 without multiple comparison adjustment. results: there were no significant associations between gds and cannabis exposure for any period, including use within 24 hours of testing (n=225). in examining deficits in specific np domains, worse sip performance was associated with lower 30-day density (f(1, 544)=5.50, p=0.019), 12-month quantity (f(1, 544)=5.37, p=0.021), and 12-month density (f(1, 544) = -1.98, p=0.048). worse verbal fluency was associated with lower 30-day quantity (f(1, 543) = 3.90, p=0.049) and 30-day density (f(1, 543) = 4.82, p=0.029). finally, worse motor function was associated with lower 30-day quantity (f(1, 541) = 4.62, p=0.032). conclusion: consistent with emerging findings, we found no evidence of deleterious effects of cannabis exposure over the lifetime, 12-months, or 30-days on overall np functioning among plwh. lower recent use (12-month and 30-days) was weakly associated with worse performance on limited domains requiring speeded test performance, perhaps reflecting neuroprotective effects. future research may examine these associations on epochs of increased hiv immunologic vulnerability, such as during periods of immunosuppression (e.g., nadir cd4) or worse viral control (e.g., peak viral load), as these may result in increased sensitivity to effects of cannabis. opioids & cannabis: pain in the outpatient setting thomas a. clobes (california state university channel islands) matthew kraybill (cottage health) sean himbebaugh (california state university channel islands) bryce jones (cottage health) madison jaskolka (cottage health) background: pain is the primary reason people seek medical care and chronic pain affects approximately 100 million people in the united states. chronic pain is associated with substantial costs conference abstracts 196 to individual patients as well as health care systems and the broader economy. it is a leading cause of disability and individuals struggling with chronic pain have substantially increased medical costs, lost productivity, reduced quality of life, and increased risk for substance abuse. opioids have been commonly prescribed to patients with pain, even though there is growing evidence of opioid misuse, abuse, and addiction. while offering some pain relief, there has also been an exponential increase in mortality directly related to opioid use. in 2021, the number of people who died from opioid-related overdoses was 6 times more than in 1999 (centers for disease control and prevention, 2022). the current opioid crisis has driven a search for alternative pain treatments that are both efficacious and safer, with cannabis becoming increasingly recommended for patients with chronic pain. objectives: this study aimed to compare cannabis users and noncannabis users with regard to the daily dose and total dose of opioid medications prescribed when presenting to the emergency department (ed) and urgent care (uc) with pain symptoms. the hypothesis guiding this project, given the changes in opioid prescribing patterns in states with legal access to cannabis, was that daily and total opioid dose would be lower in patients with chronic pain presenting to the ed/uc who disclose cannabis use to their healthcare provider. design & methods: a retrospective patient records extraction design was utilized for this study. in coordination with cottage health research institute, key variables have been extracted from patient records (between the years of 2021 and 2023) from both the ed/uc sites of cottage health. the data extraction focused on patients whose primary complaint includes “pain” and or a medical condition in which pain is a main symptom. an independent samples ttest was used to compare the outpatient prescription dose of opioids prescribed by ed/uc clinicians between the two groups of patients with pain symptoms: cannabis users and non-cannabis users. the protocols for this study were reviewed and approved by the institutional review board at cottage health (approval 23-35xs). outcome/results/conclusions: the results of this project, while statistically significant, were not what was hypothesized. the hypothesis was that daily and total opioid dose would be lower in patients with chronic pain presenting to the ed/uc who disclose cannabis use to their healthcare provider. the findings of this project are not consistent with that hypothesis. in fact, the results were the opposite: patients who disclosed cannabis use were prescribed significantly higher daily and total doses of opioids. this project sought to evaluate the impact of cannabis-use disclosure on opioid prescribing from patients with chronic pain presenting to the ed/uc. patients who disclosed cannabis use received significantly higher daily (m = 5.15 for cannabis users, m = 4.65 for other patients, p < .0003) and total doses of opioids (m = 15.64 for cannabis users, m = 14.06 for other patients, p < .001). further research needs to explore the reasons for these prescribing patterns and better understand the need, or lack conference abstracts 197 thereof, to adjust opioid doses for patients who use cannabis. five years in: an updated look at demographics of the massachusetts cannabis industry alexander m. colby (cannabis control commission, commonwealth of massachusetts) graelyn humiston (cannabis control commission, commonwealth of massachusetts) hailey pensky (cannabis control commission, commonwealth of massachusetts) samantha doonan (new york university grossman school of medicine) julie k. johnson (cannabis control commission, commonwealth of massachusetts) background: many state-led legalization policy designs include equity initiatives to help rectify past harms of historical and disproportionate criminal justice enforcement of drug policy on black and hispanic populations, but the effects of equity policies and programs remain unclear. in massachusetts (ma), multiple equity provisions encourage general diversity and inclusivity in the new industry workforce without a predetermined outcome to reach. in the first 18 months of cannabis legalization in ma, the workforce skewed white and male, specifically in seniority roles, which have greater capacity to create generational wealth (doonan et al., 2022). in the current study, we reassess industry diversity in a now-maturing market. methods: all statistics were computed in r version 4.3.1. descriptive statistics were calculated to compare the demographics of the industry from april 2020 to the updated totals from june 2023. we use a type iii anova constructed using the 'psych' package (revelle, 2024) to determine whether the main effects of race and gender, as well as their interaction, are significant. we then used logistic regression (constructed with the 'stats' package installed with core r) to predict the likelihood an agent assumed a senior role from their race/ethnicity and gender, where 'white' and 'male' were used as reference groups. results: as of june 2023, the entire industry was 70% white (14,482/20,753) and 63% male (13,074/20,753), compared to 75% white and 65% male in 2020. senior-level agent positions were 77.4% (11,816/17) white and 74% male (2,562/3,444) in 2023, compared to 84% white (337/403) and 82% male in 2020. the state at large, per the 2023 census, was 79.4% white (alone), and 49% male. type iii anova revealed that the main effects of both race (f(5,1) = 269.36) and gender (f(2,1) = 186.99) were both significant (ps < .001), as was the interaction between race and gender, f(10,1) = 26.43, p = .003. in comparison to white agents, black (b = -.625, 95% ci = [.827, -.432]) and hispanic/latino (b = .941, 95% ci = [-1.151, -.741]) agents were less likely to assume a senior role (ps < .001), where asian agents were more likely to assume a senior role (b = 1.032, 95% ci = [.790, 1.272]) than white agents (p < .001). females were less likely (b = -.650, 95% ci = [-.746, .556]) to assume a senior role than males (p < .001). however, interactions between race and gender were conference abstracts 198 significant only in the case of black agents, where black females were more likely to assume a senior role than black males (b = .708, 95% ci = [.358, 1.051], p < .001). conclusions: although the employment demographics of the massachusetts cannabis industry remained predominantly white and male in 2023, there is now greater representation of black, hispanic, and female agents both in senior and nonsenior roles, in comparison to april 2020. these results highlight the utility of continuously monitoring industry demographics to assess gradual changes to the industry and to assist regulators in identifying inequities and adapting evidence-based initiatives to ensure cohorts disproportionally impacted by cannabis prohibition benefit from legalization. exploring "wake-and-bake" practices and problematic cannabis use in older adults juliamaria coromac-medrano (university of colorado colorado springs) elizabeth anquillare (university of colorado colorado springs) adrianna c. neiderman (university of colorado, colorado springs) rachel e. thayer (university of colorado, colorado springs) background: research indicates that young adults who reported more frequent "wake-and-bake" use (i.e., using cannabis shortly after waking up) endorsed more cannabis use disorder symptoms, but little is known about this effect in older adults who use cannabis (oacu). this study explored the number of hours that passed between waking up and first use of cannabis among oacu, weekly use frequency, and scores on cannabis use disorder screening. methods: this study utilized items assessing weekly cannabis use frequency and the number of hours that passed between waking and first use of cannabis from the daily sessions, frequency, age of onset, and quantity of cannabis use inventory (dfaq-cu). waking use was coded according to four categories: i do not use cannabis at all, within 1 hour of waking up, between 19 hours of waking up, and between 9-18 hours of waking up. weekly cannabis use frequency was measured as 0 days, 1-2 days, 3-4 days, 5-6 days, and 7 days out of the past week. one-way anova analyses were performed to examine the relationship between these patterns of use and cannabis use disorder identification test-revised (cudit-r) score. results: this sample included 52 oacu ages 60+ (m = 67.98, sd = 5.77; 50% = female; 90% = white). number of hours awake until first cannabis use was significantly associated [f(3,47) = 4.17, p = .01] with cudit-r score such that oacu who used cannabis within one hour of waking up endorsed more problematic use (m = 15.63, sd = 5.37) compared to those who first used cannabis between 9-18 hours of waking up (i.e., in the afternoon or evening; m = 9.10, sd = 6.25). additionally, weekly frequency was significantly associated with problematic use [f(4,47) = 3.22, p = .02]. oacu who used cannabis all days of the past week generated higher scores on the cudit-r (m = 13.58, sd = 6.92) compared to those who used conference abstracts 199 cannabis 1-2 days of the past week (m = 8.09, sd = 4.01). conclusions: these findings suggest that similar to younger adults, oacu are more likely to endorse problematic cannabis use if they begin using earlier in the day. however, adults over the age of 65 may no longer be working or have daily structure relative to younger adults (i.e., in the context of use disorder screening items that focus on failing to meet responsibilities, caring for children, etc.), and it will be important for future research to examine which symptoms of problematic use have the most utility in understanding this specific population. future research could also explore possible motivations, such as recreational or medicinal reasons, for why oacu use cannabis at a particular time of day. individuals' values and preferences regarding medical cannabis for chronic pain: a descriptive qualitative study hanson cummings (mcmaster university) moizza zia ul haq (mcmaster university) amne dargham (mcmaster university) nauman shekel (mcmaster university) jason w. busse (mcmaster university, michael g degroote centre for medicinal cannabis research) andrea j. darzi (mcmaster university) elizabeth alvarez (mcmaster university, centre for health economics and policy analysis) background: cannabis for select medical purposes has been legal in canada since 2001 and recreationally since 2018. medical cannabis has emerged as a management option for chronic pain; however, the relative value that patients place on its benefits and harms remains uncertain. this study aimed to explore the values and preferences of people living with chronic pain (plwcp) regarding medical cannabis for chronic pain to inform development of a clinical practice guideline. methods: we conducted a descriptive qualitative study using indepth interviews with plwcp. we asked participants about how they weighed the benefits and harms of cannabis use, the barriers and facilitators faced in the use of medical cannabis, the decisions made regarding routes of administration and types of products used, the sources where cannabis was obtained, and the sources of information regarding cannabis for chronic pain. following both deductive (based on the interview guide) and inductive (guided by the data) approaches, we developed concepts and themes related to the values and preferences of plwcp on their use (or avoidance) of medical cannabis for chronic pain. results: we interviewed 52 plwcp, including 40 current medical cannabis users, 10 previous users, and 2 non-users. there was variability around reasons plwcp chose to use medical cannabis, including ineffective pain management from other strategies or perception of cannabis as a safer option to pain medications, such as opioids. perceived benefits of medical cannabis among current users included relief from pain, better sleep, and conference abstracts 200 improved mental health. reasons for discontinuing use of medical cannabis included lack of improvement in pain or sleep or undesirable side effects. perceived barriers or facilitators to use included social acceptability, availability or access, cost, and attitudes and knowledge among healthcare providers. most plwcp who used cannabis therapeutically reported the need for experimentation to determine what cannabis products, routes, and doses worked for them. cannabinoid (cbd)dominant products were reported to result in minimal adverse events (e.g., physical or mental impairment) compared to tetrahydrocannabinol (thc)-dominant products. participants noted different routes of cannabis use including oral routes that provided longer-lasting pain relief with a slower onset and inhaled routes that had a more rapid onset with shorter-lived effects. there was also variability in where participants found information on medical cannabis, including medical and recreational cannabis vendors, medical cannabis clinics, and online sources. participants valued professional expertise and lived experiences to support their choices. conclusion: participants' decisions around using medical cannabis for chronic pain were varied, which suggests these decisions are sensitive to individuals' values and preferences. this emphasizes the importance of shared decision-making between plwcp, their careers, and healthcare professionals to ensure productive conversations and appropriate education and consideration of benefits, harms, barriers, and facilitators. the role of cannabis, opioids, and clinical factors in mild cognitive impairment (mci) among older adults with hiv jason s. defelice (university of florida) mark k. britton (university of florida) eric c. porges (university of florida) gladys e. ibañez (florida international university) charurut somboonwit (university of south florida) robert l. cook (university of florida) ronald a. cohen (university of florida) joseph m. gullett (university of florida) background: older people with hiv (pwh) may be at increased risk of abnormal cognitive aging, including mci. mci has two subtypes: amnestic (amci) primarily involving memory loss and associated with progression to alzheimer's disease (ad) and nonamnestic (namci) affecting domains beyond memory. however, the link between mci subtype and clinical and behavioral factors remains unclear. for instance, although cannabis use is common among pwh, and emerging evidence indicates that lifetime and present cannabis use may exert beneficial cognitive effects in older adults with hiv through reductions in systemic inflammation, its specific association with mci status in pwh is unknown and may differ based on cannabis use characteristics (e.g., age of onset, frequency, and duration of use). therefore, the purpose of the current conference abstracts 201 study was to identify potential associations between substance use, hiv clinical and health-related factors, and mci subtype in a diverse sample of older adults with hiv. methods: our sample consisted of 56 older adults with hiv (age range: 59-77, m = 64.3, sd = 4.43; 57% female; 64% black) enrolled in a larger study of cannabis use and clinical outcomes in pwh. participants completed a neurocognitive battery as well as the functional activities questionnaire (faq), which evaluates impairment across activities of daily living. two neuropsychologists assigned consensus diagnoses (amci/namci/unimpaired) based on available data. age, duration of hiv, years of education, and antiretroviral therapy adherence (≥ 95%/<95%) were assessed by self-report. the composite international diagnostic interview substance abuse module (sam) was administered to assess lifetime and current symptoms of dsm-5 cannabis use disorder. age of onset was operationalized categorically (nonuser/<25/≥25), as was frequency of use (nonuser/daily/less than daily). among cannabis users, duration of use was reported in days, weeks, months, and years. lifetime exposure to cocaine, alcohol, and opioids was quantified using the kreek-mchugh-schlugerkellogg scale (kmsk). associations between mci subtype and substance use/clinicodemographic variables were assessed with chi-squared tests and kruskal-wallis tests. results: twenty participants (36%) met clinical criteria for amci, while 21 (38%) met clinical criteria for namci. thirty-two participants (57%) reported lifetime use of cannabis (55%, 71%, and 40% of those classified as amci, namci, and unimpaired, respectively). mci subtype was not associated with current cannabis use (p = 0.17), age of onset of heaviest period (p = 0.13), frequency of use during heaviest period (p = 0.076), nor duration in years of heaviest use period (p = 0.60). however, mci status was associated with duration of hiv (h(2) = 8.26, p = 0.016, η2 = 0.19) and lifetime opioid exposure (h(2) = 7.82, p = 0.020, η2 = 0.11); post hoc dunn tests revealed amci was associated with a longer time since diagnosis and with greater exposure to opioids relative to namci and unimpaired groups. conclusion: over half of our participants reported lifetime cannabis use. however, we observed no statistically significant association between any aspect of cannabis use and mci. results suggest that duration of hiv (independent of age) and lifetime opioid exposure are associated with memory impairment among older pwh, potentially increasing progression to ad. perceived effectiveness of cannabis use for pain management in people living with hiv: an observational pilot study nicole dimitrova (york university) sophie g. coelho (york university) joel d. katz (york university; university of toronto) sergio rueda (university of toronto; centre for addiction and mental health, toronto) jeffrey d. wardell conference abstracts 202 (york university; university of toronto; centre for addiction and mental health, toronto) background: many people living with hiv (plwh) experience pain. drugs that are commonly used for pain management include opioids, which are associated with a high risk for substance use disorder, overdose, and adverse effects. research shows that cannabis may have analgesic properties, making it a popular alternative for pain management. however, few studies have examined the perceived effectiveness of cannabis for managing pain among plwh, specifically. moreover, no studies to our knowledge have examined changes in pain intensity from preto postcannabis-use in the daily lives of plwh. therefore, the goal of this study was to examine pain intensity ratings before and after cannabis use to determine whether plwh perceive cannabis to have an effect on their pain in their daily lives. methods: data were drawn from a pilot ecological momentary assessment (ema) study of cannabis use among plwh (wardell et al., 2022), in which surveys were administered via a smartphone application before and after each cannabis use for a 14-day period. the current analytic sample were the subsample of participants reporting pain on one or more pre-cannabis surveys (n = 18, 67% male, 67% white). pre-cannabis surveys inquired about motivations for cannabis use and pain intensity (from 1 = mild to 5 = severe). post-cannabis surveys, prompted one hour after pre-cannabis surveys, reassessed pain intensity and assessed the routes of cannabis administration used. results: across all participants, 279 pre-cannabis surveys were completed, and 240 (86%) of the prompted post-cannabis surveys were completed. for the analyses, we calculated each participant’s average pre-cannabis and average post-cannabis pain intensity scores across all cannabis use events reported during the 14-day period. a mixed analysis of variance (anova) revealed statistically significant within-person reductions in average pain intensity scores from precannabis (m = 3.10, sd = 0.86) to postcannabis (m = 1.56, sd = 0.90), f(1, 16) = 61.78, p < 0.01. further, there was a significant interaction between time (preversus post-cannabis) and primary route of administration (oral versus inhaled), f(1, 16) = 7.93, p = 0.012. although both groups (those who primarily inhaled cannabis and those who primarily ingested cannabis orally) showed statistically significant pre-topost-cannabis reductions in pain intensity, the reductions were greater among participants who typically inhaled cannabis (difference score = 1.94) relative to participants who typically administered cannabis orally (difference score = 0.77). conclusion: results showed that plwh reported reductions in pain an hour after using cannabis, suggesting that they perceived it to be useful in managing their pain. findings also show that there were differences in how much pain relief was reported based on the route of administration, but dosage was not measured making it unclear whether the effect is truly dependent upon the route. moreover, the timing of the postcannabis survey (one hour after use) conference abstracts 203 poses a limitation for examining the effects of oral cannabis, which may take more than an hour to peak. given the small sample size for this pilot study, analyses should be replicated with larger samples of plwh to enhance power and generalizability, and multilevel modeling should be applied to examine daily-level associations in future larger studies. evaluating the impact of canadian cannabis legalization on cannabis use outcomes in emerging adults: comparisons to a us sample via a natural experiment amanda doggett (peter boris centre for addictions research, department of psychiatry and behavioural neurosciences, mcmaster university) kyla belisario (peter boris centre for addictions research, department of psychiatry and behavioural neurosciences, mcmaster university) andré j. mcdonald (peter boris centre for addictions research, department of psychiatry and behavioural neurosciences, mcmaster university) scott t. leatherdale (school of public health sciences, university of waterloo) james g. murphy (department of psychology, the university of memphis, memphis, tn, usa) james mackillop (peter boris centre for addictions research, department of psychiatry and behavioural neurosciences, mcmaster university) background: federal legalization of cannabis in canada marked a significant policy shift, but a challenge of understanding the subsequent changes is the absence of a counterfactual control group. while legalization is an intervention that is unfeasible to evaluate using a randomized control trial design, advanced statistical techniques can employ quasi-experimental designs using natural experiments. this study evaluates the impact of cannabis legalization in a longitudinal cohort of canadian emerging adults by comparing changes over time to changes in a non-legal control jurisdiction in the united states. methods: two samples of emerging adults from hamilton, ontario and memphis, tennessee were followed longitudinally in 4-month intervals from april 17, 2017 to march 11, 2020, with three pre-legalization and four post-legalization assessments. doubly robust difference-in-difference (did) estimation was used to assess whether cannabis legalization impacted cannabis use frequency or cannabisrelated consequences in the hamilton sample over time. the impact of cannabis legalization on alcohol use and alcohol-related consequences was also assessed to serve as a counterfactual comparison. cohort differences were adjusted within did estimation using propensity score approaches. results: against a general trend of decreasing use over time, the did estimation revealed significantly greater cannabis use frequency approximately 6-months post legalization (att: 0.2245 (0.0154, conference abstracts 204 0.4336)), and approximately one year post legalization (att:0.3091 (0.0473, 0.5709)) in the hamilton sample compared to memphis sample. similarly, cannabis-related consequences were also greater in the hamilton sample at each of these time points (att: 0.0.7610 (0.0797, 1.4423), (att: 1.0396 (0.1864, 1.8928)). counterfactual alcohol measures showed no impact of legalization at any time point. conclusions: findings suggest that cannabis legalization was associated with a shallower reduction in cannabis use frequency and adverse consequences in the hamilton sample compared to the memphis control. although the magnitude of these impacts was small, this may suggest the start of diverging cannabis trajectories. given that effects of legalization are hypothesized to be longerrather than shorter-term, further monitoring of the impacts of cannabis legalization is certainly warranted. a naturalistic study of cannabis use and sleep among young adult females: a pilot study using wearable sleep data emily a. doherty (oklahoma state university center for health sciences) hannah appleseth (oklahoma state university) quinn leffingwell (oklahoma state university center for health sciences) susette a. moyers (oklahoma state university center for health sciences) erica k. crockett-barbera (oklahoma state university center for health sciences) julie m. croff (oklahoma state university center for health sciences) background: while a common motivation for cannabis use is as a sleep aid, evidence has been mixed on cannabis’s effect on sleep. however, much of this research has relied on selfreported sleep or has been conducted in a sleep lab. wearable device measured sleep may offer advantages, allowing for objective sleep measures over longer periods of time in a naturalistic environment. cannabis's effect may be particularly relevant among females, given similar rates of cannabis use and reports of greater sleep disturbance compared to males. females have historically been underrepresented in substance use research in part to avoid addressing menstrual cycle changes. objective: this pilot study sought to explore the relationship between cannabis use and wearable device measured sleep over the menstrual cycle in young adult females, assessing the feasibility of larger-scale measurement. methods: this study is a secondary analysis of data from a randomized controlled trial investigating the effects of methyl-folate supplementation in young adult females. females, age 18-25, that reported an episode of binge drinking (>4 drinks) in the previous 2-weeks were eligible for participation. study participation began on approximately the 7th day of their menstrual cycle and took place over 14 days. at baseline, participants completed questionnaires assessing demographics, past month conference abstracts 205 cannabis use, sleep quality and menstrual cycle. sleep and cannabis use were measured prospectively via oura ring and daily interviews, respectively. participants on hormonal birth control and those who failed to report cannabis use at least once during the study period were removed from analysis. for each participant a visualization of daily cannabis use, sleep metrics, and countbased menstrual cycle phase were created to facilitate data exploration. results: participants (n = 8) ranged from having a past month cannabis use frequency from daily to 2-3 times a month. over the study period, participants used cannabis an average of 4.63 days (sd = 4.66), reporting an average subjective high of 6.22 (sd = 1.98) on a 0-10 scale with 10 being the "highest". participants reported past month subjective sleep quality ranging from very poor to fairly good. on nights following cannabis use, participants spent an average of 14.35% (sd = 8.91) of sleep in rem relative to 17.45% (sd = 9.07) on nights without cannabis use. after cannabis use participants had 20.61 (sd = 27.91) minutes of sleep onset latency compared to 11.82 (sd = 8.55) minutes on nights following no cannabis use. conclusions: a number of factors should be considered when examining the effect of cannabis use on objective sleep measurements among a sample of young adult females. larger scale longitudinal studies of cannabis use and wearable device measured sleep that incorporate menstrual cycle phase (consideration of study timing/duration and assay measures to corroborate menstrual cycle phase) are needed. accounting for polysubstance use, as well as accurate measurement of quantity, method, and timing of cannabis use will enhance study design. cannabis use among emerging adults in us states with and without legal cannabis sales using the international cannabis policy study (icps) wave 4 2021 data cara drake (university of nevada, reno, usa) jennifer l. pearson (university of nevada, reno, usa) kristen clements-nolle (university of nevada, reno, usa) sung-yeon park (university of nevada, reno, usa) peter reed (university of nevada, reno, usa) laura crosswell (university of nevada, reno, usa) elle wadsworth (rand europe) david hammond (university of waterloo, canada) background/purpose: cannabis legalization laws have contributed to changes in the us social and policy landscape. while the largest proportion of cannabis use is among emerging adults (eas) aged 18-25 years compared to people younger and older (samhsa, 2022), the effect of adult-use legalization on cannabis behaviors among eas is less clear. the purpose of this study was to understand the association between legalization (adultuse legal sales status) and cannabis use behaviors among eas who were under (18-20 years old) and over (21-25 years old) the legal age to purchase cannabis. methods: using 2021 international cannabis policy study (icps) wave 4 us data (n = 3,467), eas' cannabis use conference abstracts 206 frequency, cannabis products, multiproduct use, source, and source legality were described. among eas who used cannabis in the past 12-months (p12m), logistic and linear regression models were used to understand the associations between cannabis use behaviors and state legality (legal: states with adult-use retail sales; nonlegal: states with no adult-use retail sales) among eas under and over the legal age to purchase cannabis. results: among all eas, 33% consumed cannabis in the p12m and half reported never consuming. among eas who were p12m users, dried flower had the highest frequency of use (121 days in the p12m [95% ci: 112.1, 130.0]), the majority used between 1-3 cannabis products, and they obtained 68.1% (95% ci: 65.4, 70.8) of their cannabis from legal sources. after adjusting for sociodemographic and substance use behaviors, eas who were 21+ years old in legal states had greater odds of p12m use (aor: 1.38; 95% ci: 1.01, 1.87) and lowered odds of obtaining cannabis from family/friends (aor: 0.70; 95% ci: 0.53, 0.93) and dealers (aor: 0.32; 95% ci: 0.24, 0.43) compared to over-age eas in non-legal states. compared to eas under age 21 in non-legal states, eas in legal states were more likely to obtain cannabis from dispensaries (aor: 1.96; 95% ci: 1.23, 3.13). eas under age 21 reported obtaining 21.6% (95% ci: 9.86, 33.38) and eas over age 21 reported obtaining 26.3% (95% ci: 20.45, 32.12) more cannabis from legal sources in legal vs. non-legal states. additionally, under-age eas in legal states who used cannabis concentrates used them on around 28 more days (95% ci: 5.68, 51.06) in the p12m than under-age eas in non-legal states conclusions: living in a state with adult-use legal cannabis sales was associated with cannabis use behaviors among eas under and over the legal age of purchase. under-age eas' increased reports of dispensary use and use of cannabis concentrates in legal states are concerning, due to adverse health effects from the use of high-potency cannabis products. these findings highlight the need for further investigation into under-age dispensary access and understanding of the drivers of increased concentrates use among young people. just-in-time adaptive intervention (jitai) for young adults using cannabis and alcohol: initial development and qualitative feedback catherine erickson (kaiser permanente hawaii) kara tsuzaki (kaiser permanente hawaii) michael m. phillips (university of hawaii) mark a. prince (colorado state university) trent l. lalonde (state of colorado) jonathan lai (kaiser permanente hawaii) michael d. stein (boston university) kristina t. phillips (kaiser permanente hawaii) simultaneous use of cannabis and alcohol in young adults is common and can be symptomatic of more serious problems compared to the use of either substance alone. just-in-time adaptive interventions (jitais) offer a new way to reach individuals vulnerable to conference abstracts 207 substance use disorder through the use of mobile technology (e.g., smartphone apps). by combining ecological momentary assessment (ema) and programmed algorithms, jitai decision rules can be adjusted to facilitate the delivery of intervention content in a particular moment when participants might need encouragement, strategies, or feedback. the current presentation describes the development of a new jitai called smartphone app for effectively reducing risk (saferr), which was designed for young adults engaging in simultaneous cannabis and alcohol use. to guide the delivery of saferr intervention tips focused on protective behavioral strategies (pbs) and craving reduction, participants are sent signal-contingent ema prompts three times per day. they are also asked to complete event-based ema messages prior to and following cannabis or alcohol use. depending on the participant's study condition, intervention tips are delivered daily and/or are triggered based on ema responses focused on craving, presence in settings where cannabis or alcohol use occurs, or social context. the saferr intervention also includes an introduction module with psychoeducational information about cannabis and alcohol, personalized feedback, and goal setting. before implementing a clinical trial, an abbreviated version of saferr was piloted with the target population. participants were recruited from kaiser permanente hawaii, a large healthcare system, and asked to complete one-week of ema and an abbreviated version of the intervention. following their participation, they were asked to complete brief surveys and a qualitative interview to provide feedback on satisfaction, usability, perceived helpfulness, goal attainment, intervention implementation, and engagement. pilot participants included two males and four females who were white or native hawaiian/pacific islander, and their ages ranged from 19 to 28 years. retention in the pilot was high (83.3%; one dropout) and the average signalcontingent ema response rate over the one-week pilot was 77%. participants who completed the intervention enjoyed the app-based delivery and rated saferr as easy to use (3.2 out of 4). most participants engaged with the intervention tips in a timely fashion (i.e., within one hour). all participants completed the introduction module and rated the quality of the content as satisfactory or greater (2.6 out of 4). few technological issues arose when downloading the app or navigating the intervention, with ratings of good usability. qualitative feedback provided additional insight, with most participants reporting increased awareness about antecedents of their cannabis and alcohol use, such as mood, social contexts, or environmental setting. overall, participants rated saferr as acceptable, with high satisfaction. an overview of how participant feedback was used to adapt the final version of the intervention will be discussed. a clinical trial of the saferr intervention is ongoing and will examine the impact of saferr on the use of pbs and negative consequences related to cannabis and alcohol use. conference abstracts 208 the impact of cannabidiol (cbd) placebo on neural responses to an acute stressor mikaela a. ethier-gagnon (dalhousie university) robin n. perry (dalhousie university) jessica liebmann (dalhousie university) sherry h. stewart (dalhousie university) sean p. barrett (dalhousie university) background and purpose: a growing body of evidence has suggested that cannabidiol (cbd) may be a promising treatment candidate for stress and anxiety disorders. given that cbd is not associated with any overt psychoactive effects, cbd's therapeutic effects might be significantly influenced by expectancy (placebo) effects. however, the extent to which cbd's non-pharmacological factors contribute to its therapeutic properties remains unclear. our group has previously shown that cbd expectancy alone is sufficient to impact subjective, physiological, and endocrine markers of stress and anxiety. however, it is unclear to what extent these findings reflect altered neural activity. cbd is believed to modulate stressand anxiety-related neural substrates such as the activity of the anterior cingulate cortex (acc) and the ventromedial prefrontal cortex (vmpfc). both brain regions are implicated in the top-down regulation of the amygdala during stress-related processing. using the same dataset as the current study, cbd expectancy was demonstrated to reduce functional connectivity between the amygdala and acc. however, the potential involvement of the vmpfc in stress reduction following cbd placebo remains unexplored. the current investigation aimed to assess the independent effects of cbd expectancy on amygdala resting state functional connectivity (rsfc) with the vmpfc following acute stress. methods: using a between-subject, repeated measures design, healthy adults (n = 32, 47% female) were randomly assigned to receive accurate (n = 17; told cbdfree) or inaccurate (n = 15; told cbd) instructions regarding the cbd content of a cbd-free oil received sublingually during one experimental session. resting state functional connectivity was assessed at baseline and following a stress task (serial subtraction with negative feedback). during post-stress rsfc measurement, participants were erroneously informed that they would need to complete a second more difficult version of the counting task following brain activity measurements. this mild deception was implemented to distinguish between acute and anticipatory stress and anxiety, and to prolong task-induced stress. outcomes were examined with ancova. subjective state was also measured at several timepoints and was analyzed with marginal linear models. results: cbd expectancy (vs. cbd-free expectancy) was associated with attenuated rsfc between the left amygdala and right acc (p = 0.049). there were no other significant differences in rsfc between groups. for subjective state, a significant main effect of time was identified for stress, anxiety (p < 0.001), and energy (p = conference abstracts 209 0.032). however, there were no significant main effects of expectancy or expectancy by time interactions. posthoc analysis of the time main effect using pairwise comparisons revealed significantly increased stress (p < 0.001) and anxiety (p < 0.001) following acute stress relative to other timepoints across conditions. additionally, participants in the told cbd condition reported decreased stress (p = 0.017), and anxiety (p = 0.021), from baseline to oil administration, and significantly decreased stress (p = 0.024) and anxiety (p = 0.017) from post-anticipation to recovery. conclusion: cbd expectancy effects may be sufficient to alter stress and anxiety-related neural responses associated with its therapeutic properties. specifically, amygdala-acc connectivity may be particularly sensitive to cbd placebo effects. further research is warranted to replicate these findings in larger samples, and to examine the interactive effects of cbd's pharmacological and expectancy effects on stressand anxiety-related neural processing. avoiding driving under the influence of cannabis: a longitudinal study testing the theory of planned behavior and an extended model including social norms fermín fernández calderón (university of huelva, spain) josé carmona márquez (university of huelva, spain) adrian j. bravo (university william and mary) claudio vidal giné (asociación bienestar y desarrollo, energy control, spain) bella m. gonzález ponce (university of huelva, spain) carmen díaz batanero (university of huelva, spain) background and aims: cannabis consumption impairs driving and is associated with increased motor vehicle crashes. preventative interventions aimed at reducing driving-related injuries among people who use cannabis may benefit from the identification of the factors predicting the avoidance of driving under the influence of cannabis (duic). this study aimed to: 1) examine the predictive value of the theory of planned behavior (tpb) over the avoidance of driving under the influence of cannabis (duic) among young adults in the community, and 2) examine the added explanatory value of social norms (descriptive, personal, and moral norms). methods: as part of an ongoing longitudinal study (project psicocann), we used targeted sampling procedure to access a community sample of 612 young adults (18-25 years), who informed past-month cannabis use and completed baseline questionnaires. most (82.5%, n = 505) completed a 3-month follow-up assessment. according to the aims of this study, we selected those participants who endorsed past-month driving at baseline and responded to the follow-up survey (analytic sample: n = 211, females = 32.7%; m age = 21.6 [sd = 2.01]). participants completed measures of the tpb (i.e., attitude, injunctive norm, behavioral control, self-efficacy, intention) at baseline regarding the cannabis-protective behavior "avoiding driving after cannabis use" at follow-up. moreover, they completed baseline measures of conference abstracts 210 descriptive, personal (i.e., personal approval of other’s duic) and moral norms of duic. two hierarchical linear regression models were conducted, both including past behavior (i.e., avoiding duic at baseline), gender, age and past-month frequency of cannabis use as covariates. in the first model, intention to avoid duic (dependent variable) was regressed onto covariates (step 1), tpb constructs (step 2), and descriptive, personal, and moral norms (step 3). in the second model, avoiding duic was regressed onto covariates (step 1), behavioral control and selfefficacy (step 2), and intention (step 3). results: the explained variance (adjusted r2) in the first model (intention as dependent variable) was 81.3%. attitude, self-efficacy, personal and moral norms were identified as predictors of intention to avoid duic (p < .05). adding social norms to the tpb constructs resulted in a 2.4% increase in explained variance (p < .01). in model 2 (avoiding duic as dependent variable), the explained variance was 56.2%, and only intention (neither behavioral control nor self-efficacy) was identified as a significant predictor of avoiding duic. conclusions: our findings support the utility of one of the most prominent theories of human behavior, the tpb, as an explanatory model for avoiding duic. they are also consistent with previous research showing the relevance of personal and moral norms for behaviors morally censored like risky driving-related behaviors. our results may inform preventative interventions aimed at reducing potential driving-related harms among people who use cannabis. in particular, in light of our findings, it is recommended to target personal and moral norms towards duic, and attitudes, self-efficacy, and intentions to avoid duic. note: project psicocann (pid2020-118229rb-i00), funded by miciu/aei/10.13039/501100011033 (pi, fernández-calderón). correspondence to: fermin.fernandez@dpces.uhu.es the predictive value of the theory of planned behavior over cannabis use frequency among young adults who use cannabis: adding past behavior and habit within the framework of dual-process models fermín fernández calderón (universidad de huelva) alberto parrado gonzález (universidad de huelva) josé carmona márquez (universidad de huelva) lucía vélez pérez (universidad de huelva) adrian j. bravo (william & mary) óscar m. lozano rojas (universidad de huelva) background and aims: the theory of planned behavior (tpb) has consistently been shown to be one of the most useful conceptual frameworks in explaining alcohol consumption. however, longitudinal research testing the explanatory value of the tpb over the frequency of cannabis use among young adults is scarce. as a social cognition theory, the tpb assumes that human behavior is determined by rational/deliberative processes (e.g., intentions). however, within the framework of dual-process models, it has been shown that nonconference abstracts 211 conscious/automatic processes (e.g., habits) can enrich the explanatory value of the tpb. we aimed to longitudinally examine: 1) the predictive power of the tpb over the frequency of cannabis use among a community sample of young adults and 2) test an extended tpb model that includes the effects of past cannabis behavior and habit over the intention to use cannabis and cannabis use frequency. methods: using a targeted sampling procedure, we accessed a baseline community sample of 612 young adults (18-25) reporting past-month cannabis use. from these, 505 (82.5%) participated in a 3-month follow-up, comprising the analytic sample (females = 39.0%; m age = 20.99 [sd = 2.13]). participants reported on their past month frequency of cannabis use at baseline (i.e., past behavior) and past 3-month frequency of cannabis use at follow-up (follow-up behavior). baseline measures also included the tpb constructs (attitude, injunctive norm, behavioral control towards cannabis use; self-efficacy to refuse cannabis; and next 3-month intention to use cannabis) and habit strength for cannabis use (also measured at followup). two path analysis models were conducted to predict past 3-month frequency of cannabis use at follow-up. model 1 included the tpb constructs while controlling for gender, age, quantity of cannabis used, and past cannabis behavior. model 2 also included: a) a path from past cannabis behavior to habit at baseline, b) a path from habit at baseline to intention at baseline and to habit at follow-up, and c) a path from habit at follow-up to frequency of cannabis use at follow-up. gender, age, and quantity of cannabis used were also controlled in model 2. results: model 1 explained 65% of the variance in intention and 70% of the variance in follow-up cannabis behavior. attitudes and injunctive norms were associated with intention, while intention was associated with follow-up cannabis behavior. in model 2, the explained variance was 65% for intention and 72% for follow-up cannabis behavior. similarly to model 1, in model 2 attitude and injunctive norm were associated with intention, while intention was associated with follow-up cannabis behavior. moreover, in model 2, there significant effects of past cannabis behavior on baseline habit, of baseline habit on follow-up habit, and of follow-up habit on follow-up behavior. conclusions: our findings may be useful to inform interventions aimed at minimizing the potential harms of cannabis use. cannabis vaping and perceived harm: exploring the impact on cannabis use frequency among young adult females samantha a. fitzer (old dominion university) kendra l. rigney (old dominion university) sarah j. ehlke (old dominion university) cannabis vaping is becoming an increasingly popular route of administration for cannabis, especially among youth and young adults. despite the negative health consequences of cannabis vaping (e.g., e-cigarette or vaping associated lung injury [evali]), young adults continue to describe cannabis vaping as a safer and healthier conference abstracts 212 alternative to combustible forms of cannabis administration. recent research supports that perceived risk of cannabis-related harms differs by route of administration using an emergency department sample of emerging adults. however, it is unknown how the perceived level of cannabis harm and use of cannabis vape devices influence cannabis use frequency. this study examined if cannabis vaping moderated the association between cannabis harm perceptions and past 30-day cannabis use frequency. a sample of 949 young adult females (18-25 years old; m age=24.33) who reported using cannabis at least weekly were recruited in february 2023 from amazon mechanical turk for a larger study interested in examining cannabis attitudes and beliefs among sexual minority and heterosexual females. premium qualifications were used to request participants who live in the united states and had an approval rating of 95% or higher. participants were compensated $1 for completing the 12-15-minute survey. participants reported on how many days they used cannabis and indicated if they vaped cannabis in the past 30-days. participants also reported how harmful they believe cannabis is to their health (1=not at all harmful to 5=extremely harmful). a moderation analysis examined if past 30-day cannabis vaping (0=no, 1=yes) moderated the association between cannabis harm perceptions and past 30-day cannabis use frequency. on average, participants reported using cannabis on 12.93 days (sd = 7.47) and over a quarter of participants (25.9%) reported vaping cannabis in the past 30-days. those who vaped cannabis used on more days (m = 14.37) than those who did not (m = 12.43; p < .001). those who did not vape cannabis and who reported greater perceived harm to their health had higher levels of past 30-day cannabis use than those who did not vape cannabis with lower levels of perceived harm (p = .015). there were no differences for participants who reported vaping cannabis (p = .881). results indicate that young adult females who have not vaped cannabis in the past 30-days experience a stronger association between cannabis harm perceptions and past 30-day cannabis use frequency. participants who report cannabis use, but not cannabis vaping may have higher harm perceptions because they may be experiencing more health problems (e.g., bad cough, trouble catching breath) due to using combustible forms of cannabis administration (e.g., blunts). regardless, participants reporting cannabis vaping are consuming cannabis more frequently, putting them at higher risk for poly-product use and cannabis use disorder. as such, those who vape cannabis remain an important group to target for interventions to reduce the negative health effects of use, such as evali and acute lung injury, and mitigate the harms of frequent cannabis use. gender differences in cannabis use frequency, severity, and consequences among trauma survivors reagan e. fitzke (university of colorado colorado springs) kaylin muller conference abstracts 213 (university of colorado colorado springs) colin t. mahoney (university of colorado colorado springs; lyda hill institute for human resilience) medical and recreational cannabis use are increasing among trauma survivors, potentially as attempts to mitigate negative posttraumatic sequelae, including symptoms of posttraumatic stress disorder (ptsd). though cannabis may acutely mitigate symptoms of ptsd, it may exacerbate ptsd symptoms over time and increase the likelihood of developing cannabis use disorder (cud). moreover, men and women trauma survivors differ in their likelihood of experiencing specific traumatic events; for instance, women are at greater risk for sexual violence than men, which confers greater risk for ptsd as compared to other trauma types (e.g., serious motor vehicle accidents, military combat, natural disasters). prior research has also indicated that men are more likely to engage in cannabis use to cope with ptsd symptoms, as compared to women, who may use more adaptive coping strategies instead of using cannabis. additional research is needed to further disentangle differences in cannabis use frequency, severity, and consequences among men and women trauma survivors. the current study used a multivariate analysis of variance (manova) controlling for ptsd severity to investigate differences between college men (n = 44) and women (n = 114) trauma survivors' cannabis use frequency (average days per week), cannabis use severity (cannabis use disorder identification test scores; cudit), combined alcohol and cannabis severity (i.e., co-use; a composite score of the cudit and alcohol use disorder identification test), and cannabis-related consequences (short inventory of problems revised; modified to assess cannabis use). men in the sample most commonly reported transportation accidents (55.2%) and physical assault (36.8%) as traumatic events. women also commonly reported transportation accidents (57.9%), as well as sexual assault (40.5%) and other unwanted sexual experiences (60.8%). manova results indicated that men reported significantly higher cannabis use frequency (m = 3.86, sd = 2.82) than women (m = 2.60, sd = 2.66; f = 7.32, p = .008), higher cudit scores (m = 6.70, sd = 5.70) than women (m = 4.22, sd = 4.29; f = 8.98, p = .003), higher co-use severity (m = 13.59, sd = 6.26) than women (m = 9.82, sd = 6.21; f = 14.27, p < .001), and more cannabis-related consequences (m = 5.00, sd = 7.30) than women (m = 2.92, sd = 5.10; f = 5.94, p = .02). ptsd emerged as a significant covariate in the model for co-use severity and cannabis use consequences, but not for cannabis use frequency or severity. findings suggest that although women may endorse severe types of trauma, women trauma survivors may be less likely to engage in hazardous cannabis use than men trauma survivors. thus, there is a pronounced need for consistent screening practices for cannabis use and probable cud diagnoses among men trauma survivors in particular across clinical settings. in addition, ptsd may perpetuate alcohol and cannabis co-use conference abstracts 214 severity and cannabis consequences, suggesting integrative interventions (e.g., trauma-focused components within substance use interventions) may attenuate negative cannabis userelated outcomes among trauma survivors, especially for men. mindfulness profiles and substance use outcomes among college students folly folivi (william & mary) adrian j. bravo (william & mary) cross-cultural addictions study team marijuana continues to be one of the most prevalent and heavily endorsed substances on college campuses today (johnston et al., 2022). marijuana is associated with negative consequences such as driving under the influence, aggressive behavior (i.e., physical fights, property damage), missing schoolwork, and trouble sleeping (bravo et al., 2019; jackson et al., 2020). one protective factor that has been identified to lower problematic marijuana use among this at-risk population is mindfulness. though studies have found links between mindfulness and lower marijuana use and consequences, research on their relationships heavily relies on variablecentered statistical approaches (e.g., multiple regression, factor analysis, structural equation modeling). however, variable-centered approaches tend to only examine associations between a single mindfulness facet and related outcomes, and they assume that samples represent a homogenous population. within the mindfulness literature, several studies have used latent profile analyses (lpa; a personcentered approach that identifies distinct homogenous subgroups within a population based on continuous indicators, collins & lanza, 2009) to identify subpopulations of individuals on mindfulness facets. prior research has found strong relationships between mindfulness profiles and psychological health outcomes such as well-being, self-regulation, and attachment (e.g., bravo et al., 2016). however, research on whether mindfulness profiles differ on marijuana use outcomes is limited. the present study identified distinct profiles of trait mindfulness among 771 college students (66.8% female; 75.7% white, non-hispanic) who endorsed using marijuana in the past 30 days and completed the five facet mindfulness questionnaire (baer et al., 2006). a lomendell-rubin adjusted likelihood ratio test and bch method test on mplus 8.8 was used to determine the number of latent classes and to test the equality of means across the latent classes on marijuana outcomes. lpa results revealed four distinct mindfulness profiles: non-judgmentally aware (n = 92; 11.93%), judgmentally observing (n = 130; 16.86%), low mindfulness (n = 450; 58.37%), and high mindfulness (n = 99; 12.84%). the non-judgmentally aware group were high on non-judging of inner experience (z = 1.38) and acting with awareness (z = 1.42), but very low on the observing facet of mindfulness (z = −1.71). the judgmentally observing group were the highest on observing (z = 1.04), but very low on non-judging of inner experience (z = −1.76) and acting with awareness (z = −1.42). the low mindfulness group were relatively low on every facet of mindfulness conference abstracts 215 (−0.30<zs<.04). finally, the high mindfulness group were moderately high on all facets of mindfulness (0.67<zs<1.49). in examining mean differences, we generally found that the high mindfulness and non-judgmentally aware groups had the most adaptive marijuana outcomes (i.e., lower marijuana-related problems, cud symptoms, and social, coping, conformity, and expansion motivations) and did not differ from each other except on expansion motives (higher for the high mindfulness group). in contrast, the judgmentally observing group had the most maladaptive marijuana outcomes (i.e., higher marijuana-related problems, cud symptoms, and social, coping, conformity, and expansion motives to use marijuana). the low mindfulness group typically endorsed greater marijuana outcomes than the high mindfulness and non-judgmentally aware groups. these findings suggest that future mindfulness-based interventions targeting problematic marijuana use in college students should consider these mindfulness profiles to improve the efficacy of such interventions. characterization of the salivary metabolome from cannabis and tobacco users: biochemical insights to drug dependence risk claire gillespie1 meera shanmuganathan1 zachary kroezen1 philip britz-mckibbin1,3 iris balodis2,3 (1department of chemistry and chemical biology, mcmaster university 2department of psychiatry and behavioural neurosciences, mcmaster university 3centre for medicinal cannabis research, department of psychiatry, mcmaster university) cannabis and nicotine are two of the most widely used drugs of abuse globally, posing significant harms from smoke exposures, especially from couse, including chronic disease burden and/or cognitive impairment. current methods for the assessment of nicotine or cannabis dependence rely on standardized questionnaires, such as the fagerstrom test for nicotine dependence (ftnd), and the cannabis use disorder identification test (cudit), which are prone to bias and misreporting. there is a need for a more objective and non-invasive approach for the assessment of polysubstance use and drug dependence which can exacerbate mental health conditions particularly among high-risk patients. herein, we introduce a comprehensive approach to characterize the salivary metabolome from a diverse group of participants recruited for a psychosocial stress study (35% with diagnosed psychiatric co-morbidities) divided into cohorts of self-reported never smokers (n=11, 27.3:72.7 m:f, avg age 32, avg bmi 24.9), cannabis only (n=34, 50:50 m:f, avg age 39.9, avg bmi 26.4) and mixed cannabis and tobacco users (n=17, 42:58 m:f, avg age 36.2, avg bmi 25.5). we verify smoking status and assess drug dependence risk when conference abstracts 216 compared to self-reports, including the impact of substance co-use (30% reporting mixed use). metabolomics is an emerging field in functional genomics which encompasses the analysis of low molecular weight metabolites in complex biological samples, including exogenous compounds from environmental exposures. previous reports have proposed that the salivary metabolome may provide unique insights into behavioral responses to psychological stress using a convenient non-invasive biofluid. a targeted and nontargeted analysis of metabolites from unstimulated saliva samples was performed using capillary electrophoresis-mass spectrometry (ce-ms) and liquid chromatographymass spectrometry (lc-ms) under positive and negative ionization modes with full-scan data acquisition. multivariate and univariate statistical analyses of diluted saliva filtrate resulted in the identification of biomarkers associated with smoking status when comparing self-reported non-smokers, cannabis only and mixed cannabis-tobacco users. salivary nicotine, thiocyanate, cotinine, nornicotine and myosine were investigated as biomarkers of tobacco smoke exposure when comparing cannabis-tobacco users with cannabis only participants and non-smokers. salivary nicotine was used as an unambiguous marker of tobacco smoking and helped identify nonsmoker and cannabis users who selfreported as non-tobacco smokers. furthermore, risk assessment for nicotine dependence was evaluated by correlating salivary nicotine concentrations with self-reported nicotine dependence scores. work is underway to confirm cannabis users by measuring salivary phytocannabinoid content, including cannabidiol, ∆9tetrahydrocannabinol, and related metabolites, which will be compared to self-reported modes of consumption and cannabis use dependence scores. lastly, the differential impact of drug use patterns on salivary metabolome profiles will be explored to better understand the deleterious effects of mixed cannabis and tobacco use, as well as specific cannabis use patterns. this work provides a timely study which will contribute new biochemical insights into drug dependence and health risks relevant to vulnerable canadian adults, co-morbid with a high prevalence of mental health conditions, in an era of recreational cannabis legalization. disparities in blunt use at the intersection of multiple social identities among us adults allison m. glasser (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa) jessica k. jensen (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa) kymberle l. sterling (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa) andrea c. villanti (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa) conference abstracts 217 background: blunts – cigars with the tobacco filling replaced or mixed with cannabis – incur greater potential health risks than other forms of cannabis due to exposure to additive health harms of tobacco and cannabis and disparate patterns of use in certain subgroups. blunts are primarily used by populations who suffer disproportionately from tobaccoattributable death and disease in the us, such as people with low income and who experience mental health conditions. blunts are chiefly used by people who identify as black/african american (b/aa); therefore, b/aas are at greatest risk for the health effects of blunt use. additionally, b/aas who belong to more than one group susceptible to blunt use may be at increased risk for harm. applying an intersectionality lens, the objective of this study was to describe patterns of blunt use among us adults with multiple identities associated with greater risk for health disparities. methods: using nationally representative data on us adults (n = 30,516) from wave 6 (2021) of the population assessment of tobacco and health (path) study, we assessed the association between current blunt use (smoke any type of cigars only as blunts every day or some days) and race (b/aa vs. non-b/aa) + mental health (pastyear symptoms of internalizing and externalizing disorders) and socioeconomic status (past-year receipt of public financial assistance). population and replicate weights were used to adjust for complex study design characteristics. separate multivariable logistic regression models assessed differences in combined intersectional positions on blunt use, stratified by age (young adults [yas] 18-34 vs. adults 35+ years). reference categories included those with joint advantage (non-b/aa + no or low (1-3) internalizing/externalizing symptoms; non-b/aa + no public financial assistance). results: 8.4% of yas and 1.4% of adults 35+ reported current use of blunts in 2021. identifying as b/aa, having 4+ symptoms of internalizing and/or externalizing disorders, and receiving public financial assistance were all independently significantly associated with increased odds of current blunt use across age groups (ps < 0.05). the magnitude of the effect of identifying as b/aa or receiving public assistance on blunt use was greater among adults 35+ years (b/aa: aor = 4.57, 95% ci = 3.58-5.84; assistance: aor = 2.59, 95% ci = 1.91-3.50) than among yas (b/aa: aor = 2.09, 95% ci = 1.80-2.43; assistance: aor = 1.41, 95% ci = 1.20-1.64). compared with the joint advantage groups, those identifying as b/aa who received public assistance (yas: aor = 3.08, 95% ci = 2.36-4.03; adults 35+: aor = 11.21, 95% ci = 7.7816.16) and those identifying as b/aa and reporting internalizing symptoms (yas: aor = 3.50, 95% ci = 2.68-4.57; 35+: aor = 5.18, 95% ci = 2.88, 9.32) or externalizing symptoms (yas: aor = 2.86, 95% ci = 2.02-4.05; 35+: aor = 6.12, 95% ci = 3.28-11.42) all had greater odds of using blunts. conclusions: a greater proportion of b/aa adults who either received financial assistance or experienced mental health conditions reported currently using blunts than jointly advantaged groups. while the magnitude of some disparities may be conference abstracts 218 greater among older adults, disparities persist across ages, and blunt use is highest among yas. findings emphasize the importance of examining how multiple social identities intersect and shape blunt use patterns among us adults. intersectionality-informed interventions to reduce blunt use could improve health equity. effects of an adult-use cannabis law on blunt and other cannabis use in new jersey young adults allison m. glasser (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa) andrea c. villanti (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa; department of health behavior, society and policy, rutgers school of public health, piscataway, nj, usa) daniel gundersen (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa; robert wood johnson medical school department of general internal medicine, new brunswick, nj, usa) kevin schroth (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa; department of health behavior, society and policy, rutgers school of public health, piscataway, nj, usa) mary hrywna (rutgers institute for nicotine & tobacco studies, new brunswick, nj, usa; department of health behavior, society and policy, rutgers school of public health, piscataway, nj, usa) background: growing evidence suggests that cannabis laws are followed by no change or small increases in cannabis use among young adults (yas) following implementation of cannabis laws. few studies have assessed the impact of adult-use cannabis laws following full implementation after retail outlets have opened. in addition, no studies have assessed the impact of these laws on use of blunts cigars with the tobacco filling replaced or mixed with cannabis. in new jersey (nj; united states), adult-use cannabis became legal in february 2021, and retail outlets opened in april 2022. the objective of this study was to assess the impact of adult-use cannabis retail outlets opening in nj on any cannabis use by yas and by type of cannabis use, including use of blunts. methods: using data on nj yas (18-23 years) from the policy communication and evaluation (pace) nj study, we compared the prevalence of ever and past 30-day use of cannabis, specific cannabis sub-types (dried flower, edibles, oral capsules/drops, vaping, drinks, concentrates, hash, tinctures, and topicals), and blunt use (smoked a cigar every day or some days and reported using cigars "to smoke marijuana (i.e., as blunts)") before (waves 1-3 [march/june 2021 to october/november 2021], n = 1,439) and after (wave 4 [june/july 2022], n = 1,127) cannabis adult-use retail outlets opened. separate logistic regression models, controlling for race/ethnicity and income, assessed differences in pre (reference) and post-retail sales for each outcome of interest. we explored moderation by age due to the legal age of sale (<21 vs. 21+). results: ever and past 30-day cannabis use among nj conference abstracts 219 yas was higher in the post-retail sales period than pre-policy period (ever: 56.5% vs. 46.4%, p < 0.001; past 30-day: 24.7% vs. 21.4%, p = 0.039). in regression models, the odds of ever cannabis use were 51% higher (95% ci = 30%-76%) and past 30-day use 20% higher (95% ci = 0%-43%) in the postretail period. by type, ever use of dried flower (post vs. pre: 43.0% vs. 36.1%; aor = 1.35; 95% ci = 1.16-1.58), ever edible use (post vs. pre: 44.2% vs. 34.2%; aor = 1.54; 95% ci = 1.32-1.79), and past 30-day edible use (post vs. pre: 11.2% vs. 8.5%, p = 0.015; aor = 1.34; 95% ci = 1.05-1.71) were higher in the post-retail sales period, while the use of other product types did not differ. there was also no difference between the prevalence of pre(3.9%) and post (3.4%) retail sales period blunt use (aor = 0.87; 95% ci = [0.57-1.35]). for all pre/post differences, moderation analyses revealed greater effect sizes among those aged 21+ years compared to those <21 years. conclusions: ever and past 30-day cannabis use increased among nj yas in the three months after adult-use cannabis retail outlets opened, with greater odds of using cannabis edibles and dried flower. blunt use remained low over both timepoints; sample characteristics or measurement of blunt use may underestimate prevalence or mask changes. although increases were seen among all yas, they were greatest among those of legal age to purchase cannabis. continued monitoring of cannabis use and heterogeneity across product types will be needed over longer follow-up periods in nj and other states legalizing tripping on weed: a pilot study for understanding cannabis and hallucinogen co-use bethany gray (colorado state university) mark a. prince (colorado state university fort collins) bradley t. conner (colorado state university) while research on the co-use of cannabis with other substances, such as alcohol and tobacco, has helped illuminate the complexity of use outcomes for each substance, there is little to no research examining the co-use of cannabis and hallucinogens. with changing legislation in oregon and colorado and bills being entertained in massachusetts and kentucky, legal access to hallucinogens for recreational and medicinal use is increasing. oregon and colorado have already legalized recreational use of both cannabis and psilocybin, opening the door to legal couse of both substances. currently, researchers and clinicians are unable to make evidenced-based recommendations regarding co-use, as there are no existing definitions of what might constitute problematic co-use and there is scant research examining potential contraindications of cannabis and psilocybin. our aim in the present study was to begin to understand the effects of co-use of cannabis and psilocybin. we recruited 419 participants from reddit.com to complete anonymous, self-report surveys pertaining to psilocybin use metrics, use benefits, and undesirable use consequences. one participant was excluded due to failing attention checks. conference abstracts 220 we used quasi-poisson count regression on the remaining data (n = 418) to explore whether co-use of psilocybin and cannabis impact one's likelihood of experiencing beneficial or undesirable consequences from their psilocybin use. co-use was determined by asking participants to indicate from a list which substances they used/ used to use at the same time as psilocybin. undesirable and beneficial use outcomes were determined with scales developed for this study. results indicated that co-use of psilocybin and cannabis was associated with a higher incidence of experiencing undesirable psilocybin use consequences (irr = 1.25, p = .02) when compared to the number of negative use consequences reported by those who did not endorse cannabis and psilocybin co-use. interestingly, we also observed that psilocybin and cannabis co-use was associated with more psilocybin use benefits when compared to the positive use outcomes reported by participants who did not endorse cannabis and psilocybin co-use (irr = 1.07, p < .001). that those who engage in co-use indicate benefit from this co-use may also indicate the potential for increasing rates co-use of these substances as legislation in states across the united states continues to evolve. more research is needed to better understand the relationships between cannabis use, psilocybin use, their concurrent use, and what strategies people might use to minimize their risk of experiencing negative use outcomes while maximizing their likelihood of experiencing use benefits. cannabis use in parkinson's disease: patient access to medical cannabis and physician perspective on product safety symone griffith (arizona state university) kendra conrow (arizona state university) michael go (university of pennsylvania) mindy mcentee (arizona state university) raminta daniulaityte (arizona state university) majia nadesan (arizona state university) mathew swinburne (university of maryland) holly shill (barrow neurological institute) maxwell leung (arizona state university) the rate of medical cannabis use has increased in parallel with the number of states legalizing its use. parkinson's disease (pd) patients are of particular concern due to their higher cannabis use rate than in the general us population (25-40% pd patient cannabis users vs. ~18% in the general population), as well as their susceptibility to environmental contaminants in cannabis, including pesticides, toxic elements, solvents, microbes, and mycotoxins. in order to address the complex nature of this industry, we examined the changes in pd-related qualifying conditions in the u.s. from 2019 to 2023. we also conducted an online survey to gain insight into the knowledge, risk perceptions, and opinions regarding medical cannabis and contamination issues from physicians who treated pd conference abstracts 221 patients. the number of states including pd-related qualifying conditions increased over the past 5 years from 28 to 36 states. these conditions included pd (increasing from 14 to 16 states), muscle spasms (14 to 24), anxiety (1 to 5), and pain (17 to 35). state-by-state comparisons revealed high variability in the language used to describe the different qualifying conditions. online surveys were sent out to 45 neurologists and movement disorder specialists who primarily treated pd patients. the response rate was 44% from nine states (az, ca, fl, ma, mn, wi, pa, il, and nm). when asked if they were aware of any contaminants in cannabis products, we found that 67% of the physicians were unaware of any contaminants commonly found in cannabis and only 22%, 11%, and 11% of them were aware of pesticide, toxic element, and solvent contaminants, respectively. in their free-text opinion response on future policy changes to reduce the health risk of contaminant issues, "lack of regulation" and "comorbidities and pd prognosis" were identified as the two most common themes (15% for both). these results point to the need for further regulatory deliberation regarding risks and susceptibility to cannabis contaminants. additionally, education is needed to inform physicians on cannabis safety issues. further research will identify the implementation strategies to reduce contaminant exposure and protect patient health. making sense of population trends in adolescent cannabis use and emotional concerns: strengthening, staying the same, or weakening? jillian halladay (mcmaster university) matthew sunderland (university of sydney) cath chapman (university of sydney) ruth repchuck (mcmaster university) katholiki georgiades (mcmaster university) angela boak (university of toronto) hayley a. hamilton (university of toronto) maree teesson (university of sydney) tim slade (university of sydney) background: across high-income countries, adolescent emotional concerns (e.g., depression, anxiety, distress, and suicidality) have starkly increased while common substance use (e.g., alcohol, cannabis, and smoking) has generally declined. it is unclear if and how these population trends are related to one another, including how the co-occurrence of these concerns has been changing over time. methods: first, we developed the intersect framework, a dataand youth-driven approach to explore the intersection between trends in substance use and emotional concerns. second, applying this framework, we employed weighted poisson regression with robust standard errors to examine joint trends in psychological distress (as measured with the kessler-6) and past month cannabis use using repeated representative surveys of grade 7-12 conference abstracts 222 students across ontario, canada from 2013-2019. results: the framework presents three hypotheses including strengthening of co-occurrence or the "hardening" hypothesis, staying the same or the "consistency" hypothesis, and weakening or the "decoupling" hypothesis. six existing studies from the us, uk, and norway (covering trends between 2002 and 2018) have shown mixed results with respect to temporal trends in co-occurring cannabis use and emotional concerns among adolescents; two found strengthening, three consistency, and one weakening of associations over time. in ontario, psychological distress approximately doubled while the prevalence of cannabis remained relatively stable during the observation period. analysis of ontario data provided further support for the consistency hypothesis. notably, there was a consistent positive relationship between psychological distress and cannabis use over time, with these rates higher for elementary compared to secondary students (pr_elem = 2.68 [99% confidence interval 1.71-4.19]; pr_sec = 1.35 [99% confidence interval 1.17-1.57]). conclusion: the intersect framework seeks to guide the conceptualization, evaluation, and understanding of changes in the cooccurrence of substance use and emotional concerns over time, including outlining a research agenda informed by pre-existing research and youth perspectives. applying this framework to examine trends in ontario students, the magnitude of recent increases in psychological distress appears to be similar for adolescents who do and do not use cannabis use. however, cannabis use remains important to assess and address alongside distress. further work is needed to replicate and identify the mechanisms driving these trends over time. guiding cannabis researchers and regulators through complex industry testing standards and data graelyn b. humiston (cannabis control commission, commonwealth of massachusetts) alexander m. colby (cannabis control commission, commonwealth of massachusetts) hailey pensky (cannabis control commission, commonwealth of massachusetts) julie k. johnson (cannabis control commission, commonwealth of massachusetts) background: cannabis is illegal at the federal level, hindering federal research and best regulatory practices. this leaves a heterogenous patchwork of policies nation-wide, including testing, whose safety effects are unknown. massachusetts (ma) has implemented public cannabis industry testing guidance and data. ma tracks industry data via an inventory control system ("seed-to-sale") platform, where extensive procedural knowledge is required to extract and clean the data for use in research to evaluate product safety. this poster will present ma potency and microbial testing data to illustrate how industry data may be used to assess safety, with a focus on testing data validity and reliability, and summarize recommendations for academic researchers who seek to analyze state testing data. methods: conference abstracts 223 data included four test types: ∆-9 thc %, thca %, total thc %, and total yeast and mold (tym; reported in colony-forming units per gram or cfu/g). we computed descriptive statistics for total thc and tym in r version 4.3.0, using 'dplyr' (1.1.4) for descriptive statistics, 'ggplot2' (3.4.4) for plots, and base package 'stats' for statistical tests. we removed all identifiable "nulls" placeholder results entered to satisfy the system's upload requirement. we computed a pearson correlation coefficient to evaluate change in total thc potency from april 2021 to december 2023. we calculated total thc using the formula thc + (0.877*thca), as recently mandated by ma's regulatory agency. we calculated the tym fail rate as the percentage of results greater than the ma allowable limit of 10,000 cfu/g. we generated histograms of total thc and tym results for each licensed independent testing lab (itl) to visually inspect the distributions for anomalies or discontinuities. results: total thc trended upward from april 2021 to december 2023 (r(108,568)=0.33; p<.001). total thc calculation varied: 44% of reported results matched the formula now mandated in ma, while 47% of results matched the formula thc + thca, and most itls appeared to use both formulas. the overall tym fail rate was 8.48%, ranging by itl from 0.00% to 14.85%. 68.11% of tym results were exactly 0 cfu/g, and histograms showed lone spikes at 0 cfu/g for some itls, indicating that many unidentified nulls remain. histograms also showed procedural variation in reporting tym results, with some itls reporting failing results accurate to 500 or 1000 cfu/g, or reporting all passing results as 0 cfu/g. conclusions: the upward trend in total thc could reflect increasing potency in the industry overall, but may have other explanations. the range of tym fail rates and unusual data distributions indicate variation in data reporting standards by itls, complicating the validity and reliability of these metrics, and their analytic comparisons. these issues reflect the complexity of the testing data gathered by state regulators for use in research. creating a safe cannabis industry is a constantly evolving landscape. without federal oversight, it is critical for stakeholders to comprehensively assess testing protocols and data management to rectify issues as they arise, and for states to provide guidance for using data so safety can be assessed and standardized. the impact of cannabis on psychosis among young people in black racialized communities: fostering awareness through knowledge translation video games nima karimi (mcmaster university) sarah maginga (st. joseph's healthcare hamilton & mcmaster university) sandi johnson (mcmaster university) angela jaspan (mcmaster university) anthony olagunju (mcmaster university) heather mcneely (mcmaster university) suzanne archie conference abstracts 224 (mcmaster university) background: three times a week or more use of cannabis is widely known as a significant risk factor for subsequent psychosis among people under age 20. however, very few strategies exist that translate these research findings in an accessible way for young people. evidence from pilot studies suggests that youth from black african and caribbean communities may experience mental health inequities related to psychosis and could benefit from tailored education about cannabis risk (archie et al., 2022). purpose: the purpose of this study is to raise awareness about the consequences of choices involving cannabis use with a knowledge translation (kt) product designed for young people, the back to reality videogame series. the study aims to conceptualize what young people with early-phase psychosis/cannabis use disorder understand about the relationship between cannabis and psychosis, focusing on people from racialized backgrounds. methods: participants aged 16-30 years with a first episode of psychosis and cannabis use disorder of black african, black caribbean, and any ethnicity were recruited from early intervention psychosis programs in ontario. using a mixed methods design, participants were randomized to play either the kt videogame or a control videogame condition. participants underwent three individual interviews: 1) to obtain demographic and clinical data, 2) to explore their perspectives on the relationship between cannabis and psychosis, and 3) after playing the video game to assess their knowledge, perspectives, and attitudes about cannabis and psychosis. next, participants completed a quiz measuring factual knowledge about the impact of cannabis on psychosis and then played whichever game remained. the transcriptions of the qualitative data collected during visits 2 and 3 were subjected to thematic analysis. the quiz scores were statistically analyzed for significant differences based on whether the kt or control video game was played first. results in progress: the expected outcome of this study is knowledge acquisition about cannabis and psychosis after playing the kt series. the interview data collected before and after using the kt product will be interpreted using thematic analysis. preliminary quantitative findings from two previous pilot studies (n=10 young adults with first episode psychosis, and n=55 homeless youth) yielded significant improvements in mean quiz scores pre versus post playing the kt product with at least 18% improvement (p<.01, p<.05). it is hypothesized that there will be significant differences in participants' understanding of the emotional, social, and mental health impacts of ongoing cannabis use on early episodes of psychosis after playing the kt game compared to the control game. conclusion: to the best of our knowledge, this is the first study in canada to investigate the intersection of racial identity, gender, psychosis, and cannabis use, and the impact on the lives of young people with fep and cannabis use disorder from black racialized communities. the series may enable future studies conference abstracts 225 addressing awareness, access, and engagement of young people from traditionally marginalized communities. youth cannabis use in canada postlegalization: recommendations from youth, parents, and service providers toula kourgiantakis (université laval) angie hamilton (families for addiction recovery) background: canada has one of the highest global prevalences of cannabis use, with the highest rates among young adults aged 20-24 (50%) and youth aged 16-19 (37%). one of the objectives of the cannabis act was to protect young people by restricting their access, but youth and young adult cannabis rates have not declined, and young people report that cannabis is easily accessible. cannabis use among youth is associated with several adverse effects, including an increase in emergency department visits for cannabis-related injuries since its legalization. research on youth cannabis use since its legalization in canada remains limited, with a notable scarcity of qualitative studies, an overrepresentation of secondary data analysis across numerous studies, and a lack of studies that incorporate the voices of youth, parents, and/or service providers. this study aims to fill some of these gaps by exploring the perceptions of youth, parents, and service providers regarding youth cannabis use in canada since its legalization, along with their recommendations for policies, services, training, and education. methods: this qualitative study used a community-based participatory research approach, in partnership with families for addiction recovery (far) a national charity founded by parents of youth with addiction issues. virtual semi-structured interviews were conducted, and the data were analyzed using thematic analysis. the sample included 88 participants (n = 31 youth, n = 26 parents, n = 31 service providers). results: participants from all three groups made the following recommendations: (1) increase education about cannabis and the risks of youth cannabis use, (2) enhance training for service providers on how to more effectively screen, assess, and intervene with youth using cannabis and their families, (3) reduce access to cannabis for youth and young adults, (4) provide accessible and available public services for youth who are using cannabis, and (5) involve families and caregivers of youth using cannabis in service provision and policy decisions. conclusions: our findings align with the recent recommendations of an expert panel appointed by the government for a legislative review of cannabis legalization. the panel emphasized the critical need for a public health approach, including strategies to reduce cannabis use among youth and young adults (health canada, 2024). moreover, our study shows that the perspectives and recommendations of our three stakeholder groups – parents, youth, and service providers – are notably similar. moving forward, it is crucial that their voices are integrated into policy development, practice, and further research to ensure that youth are adequately protected. conference abstracts 226 knowledge and beliefs about blunts among youth in the us sarah d. kowitt (university of north carolina at chapel hill, chapel hill, nc, usa) michael jetsupphasuk (university of north carolina at chapel hill, chapel hill, nc, usa) sonia a. clark (university of north carolina at chapel hill, chapel hill, nc, usa) kristen l. jarman (university of north carolina at chapel hill, chapel hill, nc, usa) adam o. goldstein (university of north carolina at chapel hill, chapel hill, nc, usa) james f. thrasher (university of south carolina, columbia, sc, usa) rime jebai (boston university, boston, ma, usa) leah m. ranney (university of north carolina at chapel hill, chapel hill, nc, usa) jennifer cornacchione ross (boston university, boston, ma, usa) introduction: blunts (i.e., cannabis rolled in cigar paper with or without tobacco) have become a popular way of consuming cannabis among youth in the us. blunts can expose people to nicotine through the cigar wrapper and could lead to nicotine addiction, cannabis dependence, and use of other tobacco products. little survey research has examined knowledge and beliefs about blunts, especially among youth, or examined their associations with demographic characteristics, cigar use, and blunt use. methods: participants were a convenience sample of n = 506 us youth (ages 15-20) recruited apriljune 2023 through qualtrics who reported ever using little cigars or cigarillos (lccs), past 30-day use of lccs, or susceptibility to using lccs. we used adjusted logistic and ordinal regression models to examine correlates of knowledge that blunts contain nicotine and, separately, relative addiction/harm perceptions for blunts vs. unmodified cigars. results: onethird of youth (32.1%) thought that blunts do not contain nicotine, and 25.7% were not sure. around half of youth thought that blunts were “much less” or “slightly less” addictive (45.0%) and “much less” or “slightly less” harmful (51.5%) than cigars containing only tobacco. youth who identified as black/african american had lower odds (relative to those identifying as white) of knowledge that blunts contain nicotine (aor = 0.51, 95% ci = 0.30, 0.87). youth who frequently used blunts were less likely to report that blunts were more addictive (aor = 0.39; 95% ci = 0.24, 0.63) and harmful (aor = 0.31; 95% ci = 0.19, 0.52 (vs. unmodified cigars) compared with youth who never used blunts. conclusions: our study with a sample of us youth – who have used or are susceptible to using lccs – found that about 1 in 3 participants did not know that blunts contain nicotine, and many believed blunts were less harmful and addictive than unmodified cigars that only contain tobacco. associations between affect and simultaneous use of alcohol and cannabis in young adults: the role of depression, anxiety, and stress petra legaspi (york university) nicolle fox conference abstracts 227 (york university) christian s. hendershot (university of southern california) jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto) background: young adults frequently use alcohol and cannabis at the same time (i.e., simultaneous alcohol and cannabis use), which is associated with greater harms than using alcohol or cannabis alone. affect plays a key role in motivating substance use; however, there has been relatively little research investigating how positive and negative affect relate to simultaneous alcohol and cannabis use. further, individuals who experience symptoms of depression, anxiety, or stress may be more likely to engage in simultaneous use to cope with negative affect, but whether the relationship between affect and simultaneous use is stronger for those with elevated depression, anxiety, or stress symptoms requires further study. accordingly, this study aimed to investigate (1) the role of typical positive and negative affect, as well as positive and negative affect variability, in simultaneous alcohol and cannabis use, and (2) whether these associations were moderated by symptoms of depression, anxiety, and stress. methods: 144 young adults (mage = 22.08, age range = 19-25, 65% female) completed daily surveys for 21 days assessing morning affect (positive and negative mood), as well as their alcohol use, cannabis use, and simultaneous use during the previous day. participants also completed the depression, anxiety, and stress scale (dass-21; lovibond & lovibond, 1995) at baseline. positive and negative affect ratings were averaged across days for each participant, and affect variability was calculated as the standard deviation of affect ratings across days for each participant. frequency of simultaneous use was derived by summing the number of simultaneous use days for each participant. multiple linear regression analyses assessed the associations of typical morning positive and negative affect (in one model), and positive and negative affect variability (in another model), with the frequency of simultaneous use, controlling for the number of daily morning surveys completed. depression, anxiety, and stress were entered separately into models as moderators. results: typical morning positive affect (b = 1.01, se = 0.40, p = .013) was significantly associated with greater frequency of simultaneous alcohol and cannabis use, while typical morning negative affect (b = 0.04, se = 0.43, p = .94), negative affect variability (b = -0.31, se = 0.98, p = .75), and positive affect variability (b = 1.40, se = 1.24, p = .26) were not. no interactions between symptom and affect variables were statistically significant (all p > .05), so these interactions were trimmed from models. regarding main effects, higher levels of depression (b = 0.23, se = 0.06, p < .001), anxiety (b = 0.30, se = 0.08, p < .001), and stress (b = 0.23, se = 0.07, p < .001) were all associated with greater frequency of simultaneous use (controlling for typical morning positive and negative affect). these main effects of symptom measures were also observed in models controlling for morning affect variability (all p < .01). conference abstracts 228 conclusions: findings indicate that while depression, anxiety, and stress symptoms do relate to frequency of simultaneous use, typical morning negative affect does not. instead, typical morning positive affect appears to play a unique role in simultaneous use. findings suggest that harm reduction interventions for simultaneous use may benefit from focusing on the role of positive affect and mood/anxiety-related symptoms in simultaneous use. as this study assessed only morning affect, future research should explore momentary associations between affect and simultaneous use. demography and health history of dogs with cannabidiol and hemp use in the dog aging project maxwell c.k. leung (arizona state university) kendra d. conrow (arizona state university) richard haney (arizona state university) yi su (banner alzheimer's institute) noah snyder-mackler (arizona state university) kathleen kerr (university of washington) daniel promislow (tufts university) julia albright (university of tennessee) emily bray (university of arizona) one of the biggest challenges of being a pet owner is when a companion animal experiences pain or discomfort, whether from disease, injury, or age. the quest of owners to provide relief for their pets has led to the use of myriad over-thecounter remedies, some with more research support than others. in particular, the increasing accessibility of cannabis-related products for dogs, such as cannabidiol (cbd) and hempderived products, has attracted the interest of pet owners for treating diseases like arthritis and dementia; addressing behavioral problems like anxiety and aggression; and relieving pain caused by injuries and age. currently, little is known about how often, or for what reasons, companion dogs receive cbd or hemp products. here, we present survey data from the dog aging project (dap), an open science initiative that has collected data from dog owners in the u.s. since 2018. we identified 1,533 dogs (out of 18,541 dogs, or 8.3%) that were given cbd and hemp products. most products were used as a daily supplement (76.5%), followed by non-frequent supplement (23.5%) and non-prescription medication (17.3%) with some overlap. west virginia had the highest percentage of dogs using cbd and hemp at 14.0% (8/57), with hawaii a close second at 13.9% (11/79). the dachshund and poodle breeds had the highest and lowest reported usage (9.7% and 4.4%; 22/226 and 15/338), respectively, from the ten most common purebred dogs in the dap. when both purebred and primary breed data were combined, the breed with the highest and lowest percent of dogs using cbd and hemp in the top 10 breeds were american pitbull terriers and poodle, respectively, at 11.9% and 5.7% (56/472 and 46/814). a higher percentage of mature and senior dogs (i.e., > 6 years old; 10.1%) was reported to use cbd and hemp than conference abstracts 229 young dogs (< 6 years old; 5.5%), and a slightly higher percentage of male than female dogs (8.6% vs 8.0%). 9,898 dogs 6 years and older completed the canine social and learned behavior survey between 3 months prior and 1 year after data on cbd and hemp use were collected. dogs with cbd or hemp use had slightly higher (worse) scores, on average (38 ± 6.5 vs. 36 ± 5.1 on a scale from 16 to 80). they were also more likely to have arthritis (22% vs. 13%), suggesting that cognitive decline and arthritis are reasons owners may give their dogs cbd or hemp products. further analyses of longitudinal data will evaluate associations between extended cbd and hemp use and dementia-related behaviors, such as aggression, non-cognitive aspects of dementia, and cognitive aspects of dementia. latent class analysis of cannabis use characteristics and associations with problematic use outcomes, quittingrelated factors, and mental health among us young adults cassidy r. loparco (george washington university) carla j. berg (george washington university) yuxian cui (george washington university) katelyn f. romm (university of oklahoma health sciences center) darcey m. mccready (george washington university) yan wang (george washington university) hannah szlyk (washington university at st. louis) y. tony yang (george washington university) erin kasson (washington university at st. louis) rishika chakraborty (george washington university) patricia a. cavazos-rehg (washington university at st. louis) objective: given the changes in cannabis use trends (use frequency, product types, modes of use), this study examined latent classes of young adults based on cannabis use characteristics, and use-related outcomes. methods: we analyzed 2023 survey data among 4,031 young adults (ages 18-34) across the us. latent class analysis (lca) identified cannabis use classes among those reporting past-month use, using: days of use (1-5 days [36.0%], 6-20 [31.8%], 2130 [32.3%]), use/day (1 time/day [27.8%], 2-4 [40.8%], ≥5 [31.4%]), and use modes (herb [56.0%], edibles [16.4%], oils [20.3%], concentrates/other [7.3%]). multivariable regressions examined: 1) sociodemographics and state non-medical law in relation to: a) any vs. no past-month use; and b) use class among those reporting use; and 2) use class in relation to problematic use, quitting-related factors, and mental health. results: in this sample (m age = 26.29, sd = 4.81, 59.4% female, 27.4% sexual minority, 19.0% hispanic, 13.5% black, 13.6% asian), 48.8% reported past-month cannabis use. in multivariable analyses, those reporting past-month use (vs. no) were older and more likely in legalized states, male, sexual minority, black (vs. white), white (vs. asian), employed full-time (vs. students), urban (vs. rural), cohabitating (vs. single/other), and parents. among those reporting pastconference abstracts 230 month use, lca identified 4 use classes: 1) 'infrequent' (41.4%), primarily using herb and edibles; 2) 'frequent' (16.8%), primarily using herb; 3) 'moderate-herb' (28.0%), primarily using herb; and 4) 'moderate-oil/other' (13.8%), primarily using oils or other forms. multinomial logistic regression analyses characterized differences in sociodemographic factors among all classes. first, all other classes were compared to the 'infrequent' use class (referent): other classes were more likely black (vs. white), less likely college-educated, and more likely parents; 'frequent' and 'moderate-herb' classes were older and more likely male, non-asian, and cohabitating (vs. single/other); 'frequent' was less likely employed part-time or students (vs. employed full-time) and single/other (vs. married); and 'moderate-oil/other' was less likely to live in suburban or urban settings (vs. rural). compared to the 'moderate herb' class: the 'frequent' class was less educated and more likely employed part-time (vs. full-time) and suburban; the 'moderate oil/other' class was more educated and less likely unemployed (vs. full-time), suburban or urban (vs. rural), and single/other (vs. cohabitating). compared to the 'frequent' class, the 'moderate-oil/other' class was younger and more likely straight, asian (vs. white), collegeeducated, employed part-time or students (vs. employed full-time), and single/other (vs. cohabitating). in multivariable analyses, compared to the 'moderate-herb' class (referent): 'frequent' reported less problematic use, and 'moderate-oil/other' reported greater; 'infrequent' was less likely to drive after cannabis use and after cannabis and alcohol use while 'frequent' and 'moderate-oil/other' were more likely to drive after cannabis and alcohol use; 'moderate-oil/other' reported higher importance of quitting; 'frequent' and 'moderate-oil/other' reported lower confidence to quit while 'infrequent' reported higher; and 'infrequent' reported lower mental health symptoms while 'moderateoil/other' reported more. other comparisons showed no differences. conclusions: frequent and moderate cannabis use, particularly of oils and concentrates, may increase risk for mental health symptoms and problematic use, and reduce confidence to quit. thus, addressing and preventing such use patterns is crucial. derived psychoactive cannabis use among a national sample of us young adults cassidy r. loparco (george washington university) matthew e. rossheim (university of north texas health science center) yuxian cui (george washington university) darcey m. mccready (george washington university) katelyn f. romm (university of oklahoma health sciences center) yan wang (george washington university) y. tony yang (george washington university) patricia a. cavazos-rehg (washington university at st. louis) carla j. berg (george washington university) conference abstracts 231 objective: considering the swift growth of the derived psychoactive cannabis product (dpcp) market, this study examined perceptions, usage, and associated factors of dpcp among young adults across the us. methods. we analyzed 2023 survey data among 4,031 young adults (ages 18-34) across the us recruited via social media and intended to comprise ~50% reporting past-month cannabis use (achieved 48.9%). descriptive statistics characterized the sample and three multivariable regression analyses examined sociodemographic factors, cannabis use, and dpcp risk perceptions in relation to: 1) past-month dpcp use status among all participants, 2) number of days used among those reporting past-month use, and 3) likelihood to use dpcps in the next year among those reporting no past-month use. results. in this sample (mage= 26.3, 59.8% female, 64.9% white, 19.4% hispanic, 49.6% living in states with legal non-medical cannabis), 41.7% reported lifetime use of any dpcp and 24.4% reported past-month dpcp use. those with past-month dpcp use reported m=8.2 days used, and 91.3% reported past-month cannabis use (vs. 35.2% among those without dpcp use). most participants had heard of dpcps prior to the survey (67.5%), mainly learning about them from friends or family (44.5%) or online (23.9%). delta-8 was the most known dpcp (52.1%) and most used among those reporting lifetime use (69.7%). participants reporting lifetime use most often used dpcps via edibles (50.5%), dried herbs (50.0%), and vapes (47.1%); used due to curiosity (55.5%), belief that it was federally legal (34.1%), and friend suggestion (34.0%); and accessed them via smoke shops (46.3%) or friends/family (24.7%). most participants inaccurately believed that dpcps were required to be tested and approved to be safe (70.3%), were approved by the fda (59.0%), and were required to have evidence substantiating any health claims (59.7%). further, in rating dpcps vs. cannabis, 20.4% perceived dpcps as less harmful (57.8% same level of harm), 37.7% less addictive (52.2% same), and 10.8% more socially acceptable (59.1% same). among all participants, correlates of past-month dpcp use were: being black (vs. white), living in states without legal nonmedical cannabis, past-month 'regular' cannabis use, lower perceived dpcp harm, and greater perceived addictiveness and social acceptability. correlates of more days used among those with past-month use included: not being hispanic/latino, having a high school degree or less (vs. undergraduate degree), greater perceived addictiveness, and lower perceived harm. correlates of reporting a greater likelihood to use dpcps in the next year among those without past-month use included: living in states without legal non-medical cannabis, being older, black (vs. white), having a high school degree or less (vs. undergraduate), pastmonth 'regular' cannabis use, lower perceived harm, and greater perceived addictiveness and social acceptability. conclusions: in this sample, with ~50% of young adults reporting past-month cannabis use, rates of lifetime dpcp use and awareness were high, yet knowledge about dpcp requirements (e.g., testing, fda approval) was conference abstracts 232 lacking. risk perceptions and state nonmedical cannabis laws were associated with past-month usage and the likelihood of future use. regulations are necessary to limit dpcps and their marketing to safeguard consumers from misinformation. derived psychoactive cannabis product online retail: age and shipping restrictions cassidy r. loparco (george washington university) kayla k. tillett (university of north texas health science center) carla j. berg (george washington university) matthew e. rossheim (university of north texas health science center) background: the 2018 u.s. farm bill's definition of hemp (cannabis products with <0.3% delta-9 thc [the most naturally prevalent intoxicating form of thc in the plant] by dry weight) resulted in the proliferation of derived psychoactive cannabis products (dpcps), often chemically created rather than grown. dpcps lack federal regulations and thus products may be contaminated, marketed towards youth, and are readily available online for purchase. despite the importance of restricting youth access, few studies have systematically examined the online dpcp retail environment. methods: in may 2023, google incognito mode was used to search “buy delta thc.” among the first 100 results, data were collected from the 20 most trafficked websites that sold and delivered dpcps. for each site, we documented the following policy-relevant information: 1) age verification measures for site entry and purchase attempts, 2) adult signature reportedly required upon delivery (and if it had to match the purchaser's identity), and 3) shipping restrictions (i.e., for certain dpcps and/or certain states). websites were independently coded; discrepancies were discussed, and consensus was reached. results: overall, 14 websites (70%) required individuals to indicate their age to access the website (n = 7 checkbox for 'age 21+'; n = 2 checkbox for 'of legal smoking age'; n = 2 checkbox 'age 21+ and legal smoking age'; n = 2 required input of date-of-birth; n = 1 checkbox for 'age 18+'). most websites (n = 13, 65%) did not verify age at attempted purchase, nor indicated that an adult signature was required upon delivery (n = 15, 75%). only 3 websites (15%) had rigorous age verification procedures during checkout that included contact information as well as an image of their photo id, which would then be validated through third-party software. none required age verification upon both purchase and delivery. of the 5 (25%) websites that reportedly required an adult signature upon delivery, 2 only required a signature for vaping devices (1 of these specified the signer must be the purchaser), 1 specified deliveries could not be sent to po boxes due to signatures but then did not mention anywhere that signatures were required, 1 required signature for all products, and n = 1 allowed individuals to choose between age verification at checkout or adult signature upon delivery. thirteen websites (65%) mentioned state shipping restrictions; 3 conference abstracts 233 provided lists of states where they would not ship any dpcps due to bans, 4 provided lists of states to which they would not ship certain dpcp types/forms, 4 provided conflicting information across different sections of the website regarding which states they would not ship to, 1 specified they would only ship 'where legal' but did not provide a list of states, and 1 provided a list of states that may have banned dpcps but did not specify they would not ship their products there. discussion: as the e-commerce landscape continues to evolve, clearer regulations regarding dpcp online retail sales and related enforcement are needed. in particular, measures are needed to enforce shipping restrictions and prevent youth access, including increasing the rigor of age verification. a marketing analysis of four prominent us cannabis companies darcey mccready (george washington university) cassidy r. loparco (george washington university) yuxian cui (george washington university) matthew e. rossheim (university of north texas) julia chen-sankey (rutgers university) katelyn f romm (university of oklahoma) yan wang (george washington university) y. tony yang (george washington university) patricia a. cavazos-rehg (washington university) carla j berg (george washington university) introduction: cannabis marketing drives consumer perceptions and use. despite state regulatory oversight often explicitly prohibiting youth-oriented marketing, false or misleading claims, and requiring health warnings on products, these policies vary across states and in their enforcement. given the recent, substantial expansion of the us cannabis market, cannabis marketing surveillance is needed to inform regulations and protect consumers. methods: we analyzed 2020-2021 vivvix advertising data from 4 us non-medical cannabis companies including two top national companies (cresco and medmen), a small national boutique company (mindy's, which was affiliated with and later acquired by cresco), and a local company (uncle ike's, which only operates in washington state). specifically, we examined (1) general advertising characteristics (e.g., number of unique ads and ad occurrences, ad expenditures, market [national or local/regional], media channel [mobile, online, print]); and (2) ad content (i.e., headlines, imagery) and placement (i.e., source themes, e.g., specific websites, magazines), overall and by company. content was dual-coded independently; discordances were discussed, and consensus was reached. results: there were 399 unique ads and 1,171 occurrences, totaling $488,617 in expenditures. cresco and uncle ike's accounted for the most unique ads (~45% each); cresco represented the majority of ad occurrences (52.4%) and expenditures (63.4%). the average expenditure per ad occurrence was $417.26 ($139.29 [uncle ike's] to conference abstracts 234 $642.17 [medmen]). most ad occurrences and expenditures targeted national markets for cresco (occurrences: 96.4%; expenditures: 61.9%) and mindy's (occurrences: 98.7%; expenditures: 73.4%), while most targeted local/regional markets for medmen (occurrences: 53.8%; expenditures: 52.8%) and uncle ike's (occurrences: 99.3%; expenditures: 98.9%). most ads were disseminated via online displays (occurrences = 69.2% [62.0% uncle ike's to 98.7% mindy's]; expenditures = 45.8%) or mobile (occurrences = 28.9% [0% mindy's to 38.0% uncle ike's]; expenditures = 23.3%). however, print ad occurrences accounted for 31.0% of expenditures (0% uncle ike's to 37.6% cresco). the primary types of sources for ad dissemination were news/weather (occurrences = 36.3%; expenditures = 40.2%) and pop culture/entertainment (occurrences = 28.9%; expenditures = 26.0%). the most prominent source themes differed by company: pop culture/entertainment (cresco occurrences: 32.2%; mindy's: 66.2%); news/weather (medmen occurrences: 47.2%; uncle ike's: 99.3%). ad headlines most frequently emphasized product type (occurrences = 40.1%; expenditures = 37.0%), holidays/seasons (occurrences = 37.2%; expenditures = 22.9%), and price promotions/discounts/membership programs (occurrences = 24.4%; expenditures = 15.1%). the most common headline themes by company were: holiday/seasonal (cresco occurrences: 50.0%); product type (mindy's occurrences: 100%; medmen: 50.9%); price promotion, discounts, and/or membership programs (medmen occurrences: 50.9%; uncle ike's: 78.1%). uncle ike's was also the only company that had headline themes focusing on social responsibility (occurrences: 10.8%). visual strategies to attract consumer attention included moving ads (e.g., gifs; occurrences = 63.6%; expenditures = 71.1%) and cartoon-like images (occurrences = 10.6%; expenditures = 7.4%). mindy's also prominently featured food (occurrences: 88.3%; expenditures: 97.4%). conclusions: companies differed in their marketing strategies (i.e., volume, markets, media channels, and ad content). findings underscore the need to restrict cannabis marketing strategies promoting product accessibility and youth-oriented content, to restrict marketing via channels appealing and accessible to young people (e.g., digital, pop culture sources), and to enhance enforcement efforts. examining moment-to-moment associations between cannabis use, context, and problems in college students brandon p. miller (university of kansas) noah n. emery (colorado state university) michael amlung (university of kansas) cannabis use and problems are influenced by a variety of contextual factors. the social context surrounding use has been shown to impact the amount of cannabis consumed and the reinforcing value of cannabis in behavioral economic frameworks. research examining specific links between social context, cannabis use, conference abstracts 235 and problems has revealed mixed results, with some studies reporting that solitary use is associated with more adverse consequences and solitary use in adolescence predicts cannabis use disorders symptoms in young adulthood. other studiesincluding ecological momentary assessment (ema) protocols-have found that consuming cannabis alone and at home is associated with lower quantity and duration of cannabis use, lower subjective effects, and fewer cannabis use disorder symptoms. therefore, the specific relationship between cannabis use, problems, and social context is unclear. the current study examined the moment-tomoment association between contextual variables, cannabis use, and problems using ema data acquired in a college student sample exhibiting hazardous cannabis use. undergraduate students who reported a cudit score of 8+ (n = 62) completed a 14-day ema protocol consisting of 4 random prompts within 3.5-hour blocks from 10am-midnight (total observations = 1,846, mean observations/participant = 30). each assessment collected information about cannabis use, context (i.e., current location [home/school vs. another location], social context [alone vs. with other people], and problems experienced since their last survey (e.g., got into a fight, neglected responsibilities, blacked out, got injured), among other variables. we estimated multilevel negative binomial models (moments [level 1] nested within persons [level 2]), with total problems at each moment as the outcome and location, social context, and cannabis use as lagged focal variables. sex, day of the week, cumulative days in the study were covariates. the main effect model revealed a significant effect for lagged social context, such that being with people who are using substances or people they typically drink / use with was associated with greater problems at the next moment (irr = 2.10, p = .022, 95% ci: 1.11-3.95). neither location nor being alone were significantly associated with problems at the next moment (ps > .305). there were no significant interactions (ps > .205). these results suggest that being around people who consume substances is associated with experiencing more problems in the future. counter to prior research, we did not find that being alone or being at home significantly predicted problems. taken together, these findings provide additional evidence of moment-tomoment links between cannabis use context and problems. using phenomenography to understand native american perspectives on cannabis use for pain management sara r. mills (washington state university) marian l. wilson (washington state university) ashlin parsons (washington state university) naomi bender (washington state university) ross bindler (washington state university) crystal smith (washington state university) michael mcdonell conference abstracts 236 (washington state university) marjorie matheson (qwibil: a natural healing consultation & research center) melissa owens (qwibil: a natural healing consultation & research center) stephanie negley (qwibil: a natural healing consultation & research center) introduction: american indians and alaska native (ai/an) people are disproportionately affected by chronic pain and mental health conditions, life events, as well as social and economic factors associated with chronic pain and decreased access to pain treatment.1,2.3,4 the use of marijuana for medical purposes has been legalized in 34 states, and the recreational use of marijuana has been legalized in 12 states.5,6,7 a pacific northwest tribe in the u.s. developed a clinic for natural healing and research that provides cannabis-based care as one avenue for treatment. this clinic offers a unique avenue for understanding ai/an perspectives regarding cannabis use for pain management. methods: the current study uses qualitative methods to explore how patients seeking care for pain experience cannabis and its impact on pain. phenomenography was selected as a methodology to understand and appreciate the differences and similarities between participant experiences with cannabis use and pain management. this methodology will be piloted in a sample of 10 ai/an participants to evaluate how well it preserves ai/an voices, experiences, and perspectives. analysis will be completed through several rounds of coding by the research team that includes native american (na) and non-na researchers. frequent meetings between researchers will occur to ensure agreement and consensus on emerging codes, categories, and themes. preliminary results will be shared with 3-5 na participants for feedback on how well the resulting themes represent the completed interviews as a step in member-checking. results: pilot data has been collected from 10 selfidentified na participants through 3060 minute one-on-one qualitative interviews. the sample consisted of 6 female and 4 male patients, with 60% over the age of 50. the sample was recruited from two pain clinics in the pacific northwest, 90% from the tribally-owned clinic. all 10 of the participants reported using both thc and cbd products. participants shared their experiences and perspectives about the use of cannabis for pain management. interviews were transcribed verbatim. first round methods of coding, including open coding, began in the spring of 2024. emerging themes will be presented along with results of validation from participants. discussion/conclusion: an understanding of the use of cannabis for pain management among tribal members will allow for future research on the role of cannabis for medicinal use within na populations. working with a sample of selfidentified ai/an participants allows for further understanding of how cannabis does or does not align with personal and tribal values, experiences, and perspectives. feedback will be used to conference abstracts 237 refine analysis methods for the full data set anticipating recruitment of 30 participants. endocannabinoid science: cannabis, sex, and therapeutic insights hiral mistry (ontario tech university) the endocannabinoid system (ecs) is a complex network of neurotransmitters and receptors known to regulate various physiological processes, including mood, appetite, pain perception, and reproductive health. recent research suggests a significant interconnection between the ecs, sexual function, and the therapeutic potential of cannabis. this poster presentation aims to provide comprehensive insights into this relationship through a combined approach of survey methodology and meta-analysis of existing literature. methodology: the study adopts a dualpronged methodology. first, a surveybased approach was employed to gather perceptions and experiences related to cannabis use and sexual health. participants aged 18 and above were recruited through online platforms, and the survey comprised questions addressing demographics, patterns of cannabis use, perceived therapeutic benefits, and sexual health concerns. concurrently, a metaanalysis review of existing literature was conducted to synthesize findings from relevant studies exploring the association between the ecs, sex, and therapeutic effects of cannabis. the meta-analysis involved systematic identification, screening, and analysis of peer-reviewed articles, clinical trials, and observational studies. results: the survey results are currently pending analysis. preliminary examination suggests a diverse demographic profile among respondents, with varying cannabis use patterns and perceived therapeutic benefits related to sexual health. concurrently, the meta-analysis review identified a wealth of literature exploring the intricate relationship between the ecs, sexual function, and cannabis use. preliminary findings from the meta-analysis indicate a substantial body of evidence supporting the role of the ecs in modulating sexual behaviour, arousal, and reproductive function. discussion: the combined approach of survey methodology and meta-analysis offers a comprehensive understanding of the interplay between the ecs, sex, and therapeutic effects of cannabis. anticipated survey findings may complement existing literature by providing real-world insights into individuals' perceptions and experiences with cannabis use for sexual health purposes. concurrently, the meta-analysis review synthesizes and contextualizes existing evidence, highlighting the potential mechanisms underlying the observed associations. by integrating survey data and metaanalytic findings, this study aims to provide a nuanced perspective on the therapeutic potential of cannabis in enhancing sexual well-being. conclusion: anticipated findings hold implications for advancing research in sexual medicine and guiding evidencebased interventions aimed at optimizing sexual health outcomes. further analysis of survey results and conference abstracts 238 meta-analytic findings will contribute to refining our understanding of the therapeutic potentials of cannabis in the context of sexual health. cannabis cigarette smoke impairs syncytiotrophoblast and mitochondrial function and dysregulates endocannabinoid system homeostasis cristina monaco (graduate program in medical sciences, department of pediatrics, mcmaster university) tina podinic (graduate program in medical sciences, department of pediatrics, mcmaster university) sandeep raha (graduate program in medical sciences, department of pediatrics, mcmaster university) rationale: trophoblast differentiation is a process contingent on the fusion of cytotrophoblasts (ct) into syncytiotrophoblasts (st) that comprise the maternal-fetal interface. the bioactive components of cannabis, delta‐9‐tetrahydrocannabinol (thc) and cannabidiol (cbd), disrupt processes involved in syncytiotrophoblast function. mitochondrial are integral in facilitating stem cell differentiation and are impaired by cannabinoid components. however, less is understood about the effects of thc, delivered in cigarette smoke, on syncytiotrophoblast stress and mitochondrial regulation. we hypothesized that cannabis cigarette smoke conditioned media (scm) impairs syncytiotrophoblast and mitochondrial function in vitro. methods: bewo b30 cells were exposed to scm from cannabis cigarettes (14% thc:1% cbd) during the process of differentiation, initiated by the addition of forskolin. following 48 hrs, cells were subjected to cytotoxicity and gene expression analyses. we investigated pathways responsible for cellular differentiation, cellular stress, mitochondrial function, and endocannabinoid signaling. results: sts treated for 48h, with a range of cannabis smoke concentrations, showed decreased proliferation and cytotoxicity at 10% scm. we report 500-fold increases in transcript levels of metabolic enzyme cyp1a1 following treatment with 5% scm. the expression of trophoblast fusion ervw1 was reduced by 50% following 5% scm treatment. we also observed an increase in the expression of stress markers (hsp60 and sod1) in scm treated cells. similarly, mitochondrial dynamics regulator mfn-2 was downregulated 2.2-fold and a marker of mitochondrial stress, tfam was upregulated by 3.9-fold in scm. we report 3.1-fold increases in cb1 transcript levels with 2.5% scm and 2.6-fold increases in faah transcript levels with 5% scm. additionally, nuclear receptor pparγ was downregulated by 1.3-fold and ion channel receptor trpv1 was elevated by 2.1-fold with 5% scm. conclusion: overall, we demonstrate cannabis cigarette smoke impacts syncytiotrophoblast stress and dysregulates mitochondrial and endocannabinoid system homeostasis. since placentae are rich in mitochondria and its functions are bioenergetically demanding, disruption conference abstracts 239 of mitochondrial function may have significant consequences for fetal development and programming. positive childhood experiences and prospective cannabis use frequency and quantity in adolescent and emerging adult females by ace dimension susette a. moyers (department of rural health, oklahoma state university center for health sciences) emily a. doherty (department of rural health, oklahoma state university center for health sciences) erica k. crockett-barbera (department of rural health, oklahoma state university center for health sciences) hannah s. appleseth (department of psychology, oklahoma state university) quinn leffingwell (department of rural health, oklahoma state university center for health sciences) julie m. croff (department of rural health, oklahoma state university center for health sciences) background: exposure to multiple adverse childhood experiences (aces) is related to cannabis use in a dosedependent manner and this association disproportionately effects females. protective and compensatory experiences (paces) during childhood build resilience despite adversity and can offset the negative behavioral effects of aces. most research on aces and paces focuses on a cumulative approach, whereas regardless of the dimensional nature of childhood adversity (e.g., abuse vs. household dysfunction) or resilience factors, aces and paces are summed to create overall adversity and resilience scores. a more nuanced approach may be necessary to understand associations between positive childhood experiences and behavioral outcomes that are influenced by childhood adversity. objective: this study examines the association between individual paces and prospective cannabis use at high and low levels of two ace dimensions; household dysfunction and emotional abuse/neglect. participants and setting: one hundred forty-three adolescent and emerging adult females (ages 15-24) completed a sociodemographic questionnaire, the 6item aces scale, and the paces scale at baseline. participants returned to the office weekly thereafter for an average of 27 days and were asked to report the frequency and quantity of the prior week's cannabis use via the timeline follow back method. methods: the sample was stratified by level of household dysfunction (0-1 = low; 2-4 = high) and emotional abuse/neglect (0 = low; 1-2 = high). scales were created reflecting cannabis use frequency and heavy cannabis use frequency. poisson regression analyses were conducted to examine the association between paces items and prospective cannabis use frequency and heavy cannabis use frequency in each ace dimension. results: unconditional love from a caregiver was associated with less frequent heavy cannabis use in those with high household dysfunction (b = -2.24, 95% conference abstracts 240 ci -3.98, -.493, p = 0.012) and high emotional abuse/neglect (b = -2.78, 95% ci -4.95, -.602, p = .012). further, living in a clean, safe home with enough food to eat was predictive of less frequent heavy cannabis use in females with high household dysfunction (b = -1.23, 95% ci -2.36, .091, p = 0.034). in low adversity contexts, helping others was associated with less frequent cannabis use (low household dysfunction; b = -.908, 95% ci -1.47, -.346, p = 0.002) and less frequent heavy cannabis use (low household dysfunction; b = -1.54, 95% ci -2.43, -.647, p < 0.001; and low emotional abuse/neglect; b = -1.68, 95% ci -2.71, -.640, p = .002). finally, participation in organized sports was related to more frequent heavy cannabis use in those with high emotional abuse/neglect (b = 1.82, 95% ci .125, 3.51, p = 0.035). conclusions: positive childhood experiences have differing strengths of association with prospective cannabis use frequency and quantity in adolescent and emerging adult females, depending on the dimension of cumulative adversity experiences. while results should be replicated in a larger sample, this evidence suggests that in the context of high adversity, unconditional love and living in a clean, safe home with enough food are promotive for less frequent heavy cannabis consumption. using triple network theory of psychopathology to identify potential biomarkers of cannabis use disorder peter najdzionek (mcmaster university) james mackillop (mcmaster university) background: as rates of cannabis usage increase, it is imperative to understand the neurobiological underpinning of cannabis use disorder (cud). resting-state fmri is a popular method of investigating neural activity and has been implicated in psychiatric disorders such as major depressive disorder, anxiety disorders, and post traumatic stress disorder. the triple network theory of psychopathology suggests that abnormalities across three brain networks are responsible for mental disorders: 1) central executive network, 2) default mode network, 3) salience network (menon, 2011). while previous literature has investigated resting-state functional connectivity of cud individuals, no study has assessed whether the triple network theory applies to cud. method: the sample consisted of 80 participants from the human connectome project young adults sample. 40 participants with presumed cud (i.e. a history of cannabis dependence and urinary traces of thc at the time of scan) were matched with 40 adults with previous cannabis experience but without a history of cannabis dependence and thcat time of scan. 30 minutes of resting-state functional connectivity was analyzed using the conn toolbox, with a priori seeds corresponding to nodes within 3 brain networks implicated, and an additional node from the dorsal attention network. significant clusters survived cluster and voxel threshold p <.0001 with family-wise error correction. group differences were examined with one-way anovas. results: 60 clusters of resting-state conference abstracts 241 functional connectivity from 18 different seeds differed between cud+ and cud-. cud+ default mode network exhibited a weaker dissociation of the preand post-central gyrus (9 clusters), as well as frontal and parietal regions. cud+ central executive network exhibited altered connectivity with frontal and parietal regions. cud+ salience network recruited frontal regions such as the frontal medial and frontal middle gyrus, as well as the temporal gyrus. the dorsal attention network nodes showed altered connectivity with the cerebellum, occipital lobe, and pre/post-central gyrus. across all networks, there was aberrant recruitment of frontal regions, as well as the cerebellum. often cud+ individuals exhibited weaker functional connectivity (both negative and positive) than cudindividuals. some clusters were larger than 1000 voxels and will be further investigated to better detect signal of brain connectivity. conclusion: cannabis use disorder has distinct resting-state functional connectivity, compared to healthy individuals who've previously used cannabis. while the triple network theory does not aptly represent cud (i.e. a majority of significant differences were not between network nodes), improper recruitment between salience network and central-executive nodes in addition to recruitment of frontal regions and the cerebellum across networks implies neuroimaging and / or behavioral studies are still worth pursuing. future studies should try and correlate brain activity with behavioural differences. a prospective examination of cannabis and alcohol use associations during covid-19 pandemic faiyaz s. omerjee (brown university) rachel l. gunn (brown university) elizabeth r. aston (brown university) christopher w. kahler (brown university) jane metrik (brown university) (providence va medical center) introduction: the covid-19 pandemic was associated with serious health concerns, including significant increases in alcohol consumption and related harms. given cannabis and alcohol co-use is prevalent, we need to understand whether and how changes in cannabis use (cu) may be associated with increases in alcohol use and problems in the context of the pandemic. cu is strongly linked with heavy drinking and has been shown to be either complementary (i.e., associated with increased drinking) or substitutive (i.e., associated with reduced drinking). this study aimed to examine prospective changes in cannabis and alcohol use following the onset of covid-19 among individuals endorsing heavy drinking and cu. we hypothesized that 1) both cannabis and alcohol use and problems would increase during the covid-19 quarantine relative to pre-pandemic use and 2) increases in cu would be prospectively associated with increases in alcohol use and problems. methods: data came from 77 participants conference abstracts 242 (m[sd]age=25.8[5.6] years; 33.8% female; 35.1% ethnoracial minorities) who completed a pre-pandemic baseline assessment as part of a placebocontrolled laboratory study and a subsequent follow-up survey during the pandemic stay-at-home-orders. cu frequency and alcohol use frequency and quantity (timeline followback interview, 60 days), cannabis use quantity (grams per week), and hazardous alcohol use (alcohol use disorders identification test [audit]) were assessed at both timepoints. paired samples t-tests were used to examine preto post-covid changes in alcohol and cu variables. multiple regression analyses were used to examine associations between changes in cu with changes in alcohol use. covariates included time since baseline, baseline score of the respective dependent variable, and baseline cannabis quantity. results: participants reported drinking on 41.1% days and cu on 79.5% days on average at baseline. results of the ttests indicated significant preto postcovid increases in mean change scores for % drinking days (m=15.50(31.09), t(76) = 4.38, p < 0.001), % heavy drinking days (m=6.93(31.18), t(76) = 1.95, p = 0.027) and % cannabis-alcohol co-use days (m = 11.66(31.73), t(76) = 3.22,p< 0.001); a decrease in average drinks/drinking day (m = -0.98(2.76), t(76) = -3.14, p= 0.001) and weekly cu quantity (m = 1.52(7.03), t(76) = -1.90, p= 0.03); and no significant changes in audit. regression analyses indicated pre-topost increases in weekly cannabis quantity were positively associated with pre-to-post increases in audit scores (b=.20, sr2=0.47,p=0.016), average number of drinks/drinking day (b=.13, sr2=0.08,p=0.008), and percent co-use days (b=1.74, sr2=0.03,p=0.002) but not with changes in % drinking or % heavy drinking days. changes in cannabis frequency were not significantly associated with changes in alcohol use variables, except for co-use days (b=.43, sr2=0.16,p<.001). discussion: findings indicate robust increases in drinking and co-use of alcohol and cannabis, but a decrease in cu after the start of covid. however, increases in weekly cu quantity were associated with increased quantity of drinking and hazardous alcohol use during covid-19. consistent with prior research, cannabis use appeared to serve as a complement to alcohol use in this young adult cohort. our findings on complementary co-use are important to consider in the context of evaluating global impact of the pandemic on alcohol risks and interventions targeting combined cu and alcohol use. digital education for canadians with chronic pain using mlearning and edutech for teaching about therapeutic cannabis and chronic pain: a canadian study judy parnell (athabasca university) overview: with the risks associated with pain medications like opioids, there is growing interest in using cannabis for pain management. despite the legalization of both medical and recreational cannabis across canada, digital learning gaps in chronic pain and cannabis for conference abstracts 243 therapeutic purposes (ctp) persist, making it challenging for canadians with chronic pain to make informed decisions. however, unfortunately, there is a rather large segment of the canadian chronic pain population with no family doctors or pain specialists, so they fend for themselves. as a result, they do not qualify for many of the services afforded to those with medical access, which also affects many marginalized populations; these unserved (or unknown) populations also tend to self-administer cannabis for their pain management more frequently. therefore, this study's purpose is to explain and understand the phenomena of digital learning for canadians with chronic pain, gain insight into where they are currently receiving their digital education on chronic pain (the condition), pain management (the treatment), and the use of cannabis as an analgesic, and gain a better understanding of their digital learning preferences. it will also seek to explain what else they would like to learn about chronic pain and cannabis for therapeutic purposes (ctp), and last but not least, seek to understand better the equity, diversity, and inclusivity issues or barriers that affect digital education and delivery, especially for marginalized or underserved canadians with chronic pain. based on these findings, this study will determine if mobile learning (mlearning) and education technology (edutech) can assist in filling the digital education gaps for canadians with chronic pain. [note: education technology (edutech) consists of systems such as ai (artificial intelligence), vr (virtual reality), ar (augmented reality), and gamification]. methodology: a crosssectional explanatory sequential mixed methods approach has been selected for this study. the aim is to determine whether the qualitative and quantitative data converge (or relate); therefore, the convergent design will also be incorporated into the methodology, which is permitted according to creswell & plano clark (2018). the data collection process will begin with a mobile-optimized survey (quantitative) followed by a focus group to gain perspective on the previously collected quantitative data. to recruit participants for the survey, we will network with relevant professional sites, associations, industry, health organizations, forums, and support groups related to chronic pain or cannabis using online searches and social media through convenience sampling. we will ask them to help by reaching out to their members. for the focus group, the ontario pain foundation director has permitted its members to assist in this study for the qualitative data collection. the final thesis research document will summarize the findings from both methods. investigating daily harms associated with cannabis and alcohol co-use among transgender and gender diverse youth who drink stephanie m. penta (toronto metropolitan university) alexandra uhrig (toronto metropolitan university) theo quinn (toronto metropolitan university) jeffrey d. wardell conference abstracts 244 (york university) sarah s. dermody (toronto metropolitan university) background: cannabis and alcohol couse is common among youth and associated with increased substance use harms, including heightened psychological distress. emerging evidence indicates that transgender and gender diverse (tgd) youth experience a disproportionate impact from substance use and its corresponding harms. this discrepancy is likely influenced by the minority stress prevalent in their daily lives on account of their marginalized gender identities. most studies on substance use and co-use among tgd youth have been cross-sectional or descriptive in nature. consequently, our understanding of the relationships between gender minority stress (gms) and resilience, cannabis and alcohol couse, and corresponding harms remains limited. the current study employed ecological momentary assessment (ema) to explore daily associations between cannabis and alcohol co-use and (1) corresponding harms, (2) psychological distress, and (3) gms and resilience. method: forty canadian tgd youth who typically consume alcohol at least twice per week were included in this secondary analysis. of these, 12 participants (30.0%) identified as transmasculine, 11 (27.5%) as transfeminine, and 17 (42.5%) as gender diverse (e.g., nonbinary, genderfluid). participants completed daily ema measures which assessed their past-day substance use (i.e., frequency of use, number of standard drinks consumed, forms of cannabis consumed), corresponding harms (e.g., engaging in risky behaviours, interpersonal conflict, hangover symptoms), psychological distress, and gms and resilience for 21 days. to examine associations between these variables at the daily level, generalized linear mixed models (glmm) were constructed. results: across all participants, 104 cannabisonly days, 180 alcohol-only days, and 41 co-use days were reported. across alcohol use days, the mean number of standard drinks consumed was 2.94 (sd = 2.01). on cannabis use days, cannabis flower, edibles, concentrates, and beverages were consumed on 52.4%, 23.4%, 22.8%, and 1.4% of days, respectively. glmm results revealed that, on days when participants experienced greater gms, they were more likely to co-use than to use alcohol only (or = 1.48, se = 0.18, 95% ci [1.04-2.11]). conversely, on days when participants experienced greater resilience, they were more likely to couse than to use cannabis only (irr = 1.76, se = 0.21, 95% ci [1.18-2.64]). on days when participants co-used, they experienced more harms than on alcohol-only days (irr = 1.63, se = 0.24, 95% ci [1.03-2.60]), but not cannabis-only days (irr = 1.03, se = 0.18, 95% ci [0.73-1.47]). despite this, on days when participants co-used, they did not experience significantly greater psychological distress than on alcohol-only (b = 0.23, se = 0.84, 95% ci [-1.42-1.88]) or cannabis-only (b = 0.78, se = 0.61, 95% ci [-1.98-0.41]) days. conclusions: these findings raise further concerns about the impacts of gms and cannabis and alcohol co-use on tgd youth. first, the results conference abstracts 245 suggest that experiencing increased gms or resilience is associated with greater odds of engaging in cannabis and alcohol co-use, as compared to alcohol-only or cannabis-only use, respectively. in turn, co-use is associated with experiencing more harms than alcohol-only use at the daily level, which suggests that co-use worsen harms among tgd youth who drink. the results of this study may ultimately inform tailored harmreduction policy and intervention efforts for tgd youth. cannabis use among a statewide sample of young adults: is student status a risk factor? adriana raass (university at buffalo) kenneth e. leonard (university at buffalo) gregory g. homish (university at buffalo) m. vest (university at buffalo) jessica a. kulak (university at buffalo) aim: there is growing research on the use of legalized cannabis, however, little has examined differences in use by college student status. thus, the aim of this project is to understand the use of cannabis among non-students and parttime college students compared to college students enrolled full-time in new york state (nys). methods: data was collected from a self-administered, web-based survey that included items on alcohol, patterns of use, other substance awareness, and potential couse with cannabis. participants were recruited from a commercial database of young adults (18-25 years) in nys via postcard mailing and/or e-mail to participate in the online survey. separate logistic regression models examined the relationship between current (past 30-day) cannabis use and student status and negative binomial models examined cannabis use disorder (cud; measured with the cudit-r) and student status. both models were stratified by student status (non-student, part-time, full-time) and controlled for college type (i.e., 2 or 4year college), residency, age, gender, employment, and relationship status. results: the odds of current cannabis use are higher for part-time students (aor = 1.44, p = 0.015) and nonstudents (aor = 1.72, p < 0.001) compared to full-time students. the incidence of cud is greater for nonstudents (irr = 1.42, p < 0.001) and part-time students (irr = 1.15, p < 0.001) compared to full-time students. among full-time students, those attending 2-year colleges (aor = 1.69, p = 0.009) were more likely to report current cannabis use and have a higher incidence of cud (irr = 1.27, p = 0.047) compared to those attending 4-year colleges. primary residency for full-time students also increases the odds of current cannabis use for those living in a house/apartment with roommates when compared to living with parents (aor = 2.26, p < 0.05) and when compared to living with a partner/spouse (aor = 2.35, p = 0.001). additionally, non-students living with a partner/spouse compared to those who live with their parents have increased odds of current cannabis use (aor = 1.59, p = 0.045), but there is no significant association for living in a conference abstracts 246 house/apartment with roommates. nonstudents with a relationship status in which the person lives with a dating partner (irr = 1.33, p = 0.007) compared to being single also increases the incidence of cud. conclusion: student status has a significant impact on the odds of current cannabis use and risk of cud. further research is recommended to look at the differences in outcomes among those attending 2year and 4-year colleges, and for fulltime students compared to part-time students. residence, specifically living with roommates and dating partners, has a significant association with a higher risk of cannabis use. more research may want to be considered looking at social use of cannabis within primary residency comparing romantic partners and platonic roommates. comparison of legal and illegal cannabis vapes and extracts that contain novel intoxicating cannabinoids by lc-ms/ms and lchrms. renee r. v. robinson (health canada) joshua marleau-gillette (national research council canada) andrew waye (health canada) ashley cabecinha (health canada) michelle farhat (national research council canada) jeremy e. melanson (national research council canada) hanan abramovici (health canada) on october 17, 2018, cannabis was legalized and regulated under the cannabis act, with cannabis edibles, extracts (e.g., vaping products), and topicals becoming available to canadians in early 2020. as the cannabis industry continues to innovate and expand, new cannabis extract products containing cannabinoids other than δ9-thc or cbd are becoming available to consumers from both the legal and illegal markets, with limited understanding of their health risks. while many of these novel cannabinoids such as cbn or δ8-thc can be found in cannabis plants at trace levels, they are typically produced using synthetic or semisynthetic techniques in order to obtain sufficient amounts for use in products deliberately made to contain them. the conditions under which these novel cannabinoids are synthesized can result in unknown impurities in the form of unreacted starting materials, reaction by-products, and degradants, such as synthetic cannabinoid derivatives that are not naturally found in the cannabis plant. moreover, whereas there is a legal framework that requires that legal cannabis products adhere to strict quality control measures to help mitigate potential quality-associated risks, there are no such controls over the products manufactured and sold by the illegal market. additionally, significant data gaps exist regarding the composition of canadian cannabis products containing novel intoxicating cannabinoids regardless of source. this research therefore aims to identify and compare the composition of vaping liquids and other extracts containing novel cannabinoids sourced from the legal and illegal markets. thirteen legal vape products purchased from the ontario cannabis store, and 16 illegal products conference abstracts 247 (13 vape, 1 shatter, and 2 distillate products) obtained from canadian law enforcement were analyzed using uhplc-hrms in an untargeted approach to detect unknown compounds. eighty and 81 different compounds were detected and putatively identified in the legal and illegal samples respectively. illegal vapes were shown to have a 1.6x higher number of cannabinoid isomers and synthetic cannabinoid derivatives than legal vapes. illegal products also contained confirmed identifications of pesticides and numerous polyethylene glycol (peg) compounds. studies have shown that when peg is vaped, the carcinogenic compounds formaldehyde and acetaldehyde can be formed. additionally, a putative identification of a flame retardant was observed in one of the illegal products. conversely, legal vape products contained putative identifications of flavouring agents and plant fatty acids. three out of 13 products had putative identifications of plasticizers. these results emphasize the importance of a quality-controlled supply of legal and regulated cannabis products. furthermore, identifying the impurities of synthesis in such products is important to the understanding of their health and safety risks, including for those who choose to consume illegal products. to our knowledge, this is the first time that canadian cannabis vapes and other extracts containing novel cannabinoids from the legal and illegal markets have been compared and examined for their composition. the highs and lows: cannabis use and bipolar spectrum disorders in a large sample of emerging adults luiza rosa (university of colorado, boulder) gerald young (university of california, berkeley) stevi g. ibonie (university of colorado, boulder) joelle lemoult (university of british columbia, vancouver, canada) iris b. mauss (university of california, berkeley) lauren b. alloy (temple university, usa) jessica l. borelli (university of california, irvine) sarah r. holley (san francisco state university, usa) ellen jopling (university of british columbia, vancouver, canada) jay van bavel (new york university, usa) daniel moriarity (temple university, usa) robin nusslock (northwestern university, usa) gregory strauss (university of georgia, usa) cynthia m. villanueva (university of colorado, boulder) l. cinnamon bidwell (university of colorado, boulder) june gruber (university of colorado, boulder) introduction: bipolar spectrum disorders (bsd) are associated with difficulties in positive emotional processes. although bsds and cannabis often co-occur and can lead to worse health outcomes, there is a dearth of work examining the relationships between bsds, as well as clinically-relevant positive emotion conference abstracts 248 processes, with cannabis use. this is especially important to investigate among emerging adults who are at both peak risk of mood onset and progression, as well as initial onset of cannabis use and associated difficulties. accordingly, this study examines associations between bsd risk and mood severity with cannabis use (aim 1) and bsd-relevant positive emotion processes and cannabis use (aim 2). methods: participants were 963 emerging adults recruited as part of a multi-site investigation across nine north american universities who completed questionnaires assessing bsd risk (hps-20), current mania and depression symptoms (dsm-5 cross cutting measure-mania and depression domains and the altman self-rating mania scale, asrm), cannabis use (cupit adapted), and three clinicallyrelevant positive emotion processes (valuing happiness questionnaire [vhq], the behavioral activation system-reward responsiveness [basrr], and the modified differential emotions scale-positive affect subscale [mdes-pa]). the main study analyses were pre-registered on the open science framework (https://osf.io/ag39d). results: from 1,921 participants who completed the cannabis measure, 49.9% had never used cannabis before and were excluded from the analysis. the remaining 963 participants had an average age of 18.3±0.5 years, 73.5% were female, and 63.4% of the sample was white. for aim 1, bsd risk was associated with greater scores on the cannabis use composite measure, controlling for age, gender, and study site (b=0.07, p=0.034); however, this association did not remain significant when additionally controlling for current mania or depression symptoms (b=0.06, p=0.079). no significant association was found between cannabis use and current symptoms. for aim 2, positive emotion experience was associated with decreased cannabis use composite scores when controlling for age, gender, study site, and negative emotion (b= -0.10, p<0.005). however, there was no significant association between either reward responsiveness or positive emotion beliefs and cannabis use. discussion: in a large and diverse multi-site sample of emerging adults, greater self-reported bsd risk was associated with greater cannabis use, though this association did not hold when controlling for current bsdrelevant mood symptoms. this suggests a complex relationship between cannabis use, bsd risk, and current mood symptoms. further work that can disentangle broader bsd risk from shorter-term mood state is warranted. furthermore, results indicated that greater positive emotion experience, but not reward responsiveness or positive emotion beliefs, was associated with lower selfreported cannabis use. this suggests divergent associations between basic positive emotion processes and clinically-relevant disorders of positive emotion (i.e., bsds) with self-reported cannabis use. the study highlights the complexity of cannabis use in relation to emotion processes and mood risk, emphasizing the need for research that integrates clinical science and affective science approaches. conference abstracts 249 cannabis products in vape shops: united states, 2023 matthew e. rossheim (university of north texas health science center) cassidy r. loparco (george washington university) kayla k. tillett (university of north texas health science center) ryan d. treffers (pacific institute for research and evaluation) melvin d. livingston (emory university) carla j. berg (george washington university) objectives: since 2020, many new types of derived intoxicating cannabis products (icps) have entered the us market. icps pose concerns regarding their youth-oriented marketing, potency, and health effects. while research has documented >20 different intoxicating compounds in icps in the us market, some icps (e.g., delta-8 thc, thco) are registered as schedule 1 substances by the us drug enforcement administration (dea). some states have also attempted to ban, restrict, or regulate icp retail, although the comprehensiveness and enforceability of these laws are unclear. this study provides insights into the retail landscape of icps sold across the us. methods: in november-december 2023, we systematically identified and called vape shops near landmarks (the largest commercial airport and the capitol building) in each us state, washington dc, and puerto rico (52 locations * 2 landmarks each * 5 locations per landmark = 520 total n [661 shops were called to achieve target sample; 79% response rate]). licensed cannabis dispensaries were excluded. we assessed icp product availability of: delta-8 thc, delta-9 thc, delta-10 thc, hhc, thca, and thco. legal data regarding state non-medical cannabis retail sales and state delta-8 thc laws were collected. descriptive statistics and bivariate analyses were used to characterize the sample and summarize patterns. results: 74% of vape shops sold any icp (61% delta-8, 60% delta-9, 54% hhc, 50% thca, 47% delta-10, 26% thco). icps were sold in shops in each state except washington and alaska, which banned icps and had active retail of legalized non-medical cannabis. states with active retail of legal non-medical cannabis had significantly fewer shops selling icps (55% vs. 87%). more shops sold icps in states with limited delta-8 regulations than in states with delta-8 bans (92% vs. 43%, p < .05). there were comparable percentages of shops selling any icps between states with limited and severe delta-8 restrictions (92% vs. 90%). in states where delta-8 was banned, 43% of vape shops reported selling any icps. among most states with delta-8 regulations or bans, the icp most sold in each state varied in ways that may reflect industry response to state laws (e.g., hhc was most often sold if the law required all thcs to be <0.3% by weight). conclusions: icps are widely available in vape shops, even in states with relevant bans/restrictions. the differential availability of icps in states with diverse legal frameworks suggests that state-level regulations influence, but do not fully deter, the retail presence of these products. conference abstracts 250 enhanced laws, surveillance, and enforcement are needed. the 2024 farm bill and state laws should explicitly prohibit derived icps. help-seeking behaviours among cannabis consumers in canada and the united states: findings from the international cannabis policy study samantha m. rundle (university of waterloo) david hammond (university of waterloo) background: a goal of the federal cannabis act was to enhance public awareness of cannabis-related risks and investment in greater addiction support services, including online sources of support. little evidence exists on the minority of cannabis consumers who have sought or received help from both formal and informal sources, for their cannabis use. objectives: the current study examined the percentage of cannabis consumers who sought help to manage cannabis-related problems, the most common sources of help sought, and factors associated with seeking help. methods: a total of 13,209 past 12month cannabis consumers in canada and the us, aged 16-65, completed wave 5 of the cross-sectional online survey, the international cannabis policy study. respondents past 12-month help-seeking behaviours, along with their perceived addiction to cannabis, legal status of cannabis in their jurisdiction, and scores on the who assist scale for problematic cannabis use were assessed. logistic regression models examined correlates of help seeking and sources of help. results: a total of 9.2% individuals sought help from any source with the most likely being a doctor/physician (44.9%), followed by online sources (29.2%). younger, mixed race, more educated, financially stable males who perceived themselves to be more addicted to cannabis were most likely to seek help. no overall differences were observed in the percentage of consumers who sought any type of help based on cannabis laws/jurisdiction between canada (8.4%), us 'illegal' states (9.2%), us 'medical' states (9.1%), and us 'recreational' cannabis states (9.9%). that said, those who resided in illegal jurisdictions were less likely than those in legal jurisdictions to seek help from a doctor or physician and more likely to seek help from family and friends. implications: few consumers report seeking help to manage their cannabis use problems with similar levels of help seeking across jurisdictions with different cannabis laws. food restriction on cannabis use days: an assessment of consequences and motivations ireland m. shute (university of southern california keck school of medicine) megan e. brown (university of southern california keck school of medicine) keegan buch (university of southern california keck school of medicine) reagan e. fitzke (colorado state university colorado springs) mark a. prince (colorado state university fort collins) stuart b. murray conference abstracts 251 (university of southern california keck school of medicine) eric r. pedersen (university of southern california keck school of medicine) cannabis is one of the most used substances among college students, a population at risk for experiencing its negative use-related effects. college students also commonly exhibit disordered eating behaviors such as food restriction (e.g., intentional fasting, not eating on a day leading up to an event), which frequently co-occurs with substance use. this pattern of behavior is associated with greater use related consequences regarding other substances (i.e., alcohol), but little research exists on the effects of food restriction and cannabis use. the current cross-sectional study investigated college student cannabis use consequences, food restriction, and disordered eating motivations on cannabis use days in the past year and month. the sample contained 614 students who used cannabis in the past year (58.9%; n = 496 past month use). independent samples t-tests revealed that those who restricted food on cannabis use days in the past year (n = 128; 20.8% of past year cannabis users) exhibited significantly higher scores on the cannabis use disorders identification test (cudit) than those who did not restrict. those who restricted food on a cannabis use day in the past month (n = 96; 15.6% of past year cannabis users) reported significantly more cannabis consequences on the brief marijuana consequences questionnaire (bmacq) than those who did not restrict. a cannabis-adapted college eating and drinking behaviors scale (cedbs) was used to assess motivations for disordered eating on cannabis use days in the past year. the cedbs has 3 subscales: quickened intoxication (qi), offsetting calories (oc), and alternative methods (am). we retained these subscales for the cannabis version of the measure. most items were modified by replacing "alcohol" with "cannabis," but some items were modified in greater detail to capture more nuanced differences in eating behaviors among cannabis restriction days. the adapted measure and two of its subscales had excellent reliability (⍺total = .95, ⍺qi = .94, ⍺oc = .96), but the alternative methods subscale was less than adequate (⍺am = .69). restricting because you plan to eat after you've consumed cannabis, consuming cannabis by inhalation/ smoking rather than edibles, and being so busy you forget to eat were the most endorsed items on the adapted cedbs. regression analyses revealed that, after controlling for sex, greater scores on the adapted cedbs quickened intoxication subscale were associated with significantly higher scores on the cudit and bmacq, as well as significantly greater cannabis use frequency in the past 30 days. higher scores on the cedbs offsetting calories subscale were associated with significantly lower scores on the cudit, as well as lower past 30-day cannabis use frequency. cedbsqi scores were not significantly associated with bmacq sum scores. these results establish the presence of the risk associated with food restriction on cannabis use days, meriting additional conference abstracts 252 research on the contexts of this restriction, bottom-up developed disordered eating measures specific to cannabis, and targeted interventions to reduce harm. the role of cannabis motives in the association between medicinal cannabis use and cannabis related outcomes christina simms (york university) kyra n. farrelly (york university) jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto) background: a growing number of young adults are using cannabis to manage both mental health and physical symptoms (i.e., medicinal cannabis use), and they often report using cannabis for self-medication without consulting a healthcare provider or obtaining medical cannabis authorization. this is notable as medicinal cannabis use is linked with greater frequency of cannabis use and risk for cannabis-related problems compared to recreational-only cannabis use. however, there has been little research on mechanisms that may help to explain the relationship between medicinal cannabis use and cannabisrelated problems. one potential mechanism is motives for cannabis use, which have been shown to play a role in individual differences in cannabis use outcomes. for example, reporting greater coping motives for cannabis use is associated with greater cannabis use and problems. however, how medicinal cannabis use relates to common motives for cannabis use in young adults has received little research attention. the aim of this study was to examine the role of motives for cannabis use in the relationship between self-reported medicinal cannabis use and both frequency of cannabis use and risk for cannabis use disorder. methods: undergraduate students (n = 295; 70.1% female; m age = 19.51, sd = 1.8) who were part of a research participant pool at a large canadian university completed an online questionnaire, including items assessing medicinal and recreational reasons for cannabis use, past month frequency of cannabis use, the marijuana motives measure (mmm; simons et al., 1998), and the cannabis use disorders identification testrevised (cudit-r; adamson et al., 2010). two path models were specified, one for each of the outcome variables (cannabis use frequency and cudit-r score). in both models, medicinal cannabis use status (i.e., any medicinal use vs. recreational-only use) was specified as the independent variable, and all five cannabis motives from the mmm (i.e., coping, enhancement, social, conformity, and expansion) were entered as parallel mediators. results: 37.6% (n = 111) of participants reported any medicinal cannabis use, while 62.4% (n = 184) reported only recreational cannabis use. findings revealed significant indirect associations between medicinal cannabis use and both cannabis outcomes through two of the five cannabis motives. specifically, there were significant indirect associations between medicinal cannabis use and frequency of consumption via both conference abstracts 253 coping motives (95% ci = [0.12, 1.42]) and expansion motives (95% ci = [0.13, 1.73]), as well as significant indirect associations between medicinal cannabis use and cudit-r scores via coping (95% ci = [0.3, 1.6]) and expansion motives (95% ci = [0.12, 0.94]). conclusions: our results suggest that coping and expansion motives partially explain the association between medicinal cannabis use and both increased frequency of cannabis use and risk for cannabis use disorder, providing new insight into the specific types of motives that are implicated in these associations. these findings may help to inform harm reduction efforts for young adults who engage in medicinal cannabis use, suggesting that interventions should target elevated coping and expansion motives in this population and raise awareness about the links between these motives and cannabis use problems. grant funding in cannabis research: perspectives across training stages and us and canadian mechanisms kirstyn n. smith-lecavalier (university of washington) jamie e. parnes (brown university & bradley hospital) jane metrik (brown university & providence va medical center) jeffrey d. wardell (york university, centre for addiction and mental health, & university of toronto) grant funding plays a crucial role for psychologists in advancing research, clinical care, and professional careers. in research settings, grant funding provides support for understanding, addressing, and solving current issues by covering various research-related expenses including researcher and staff income, participant compensation, lab materials and equipment, and travel for collaborations and research activities. clinically, grant funding can assist in better serving communities by providing, maintaining, and expanding programs, interventions, and resources. professionally, experience and skill in writing and obtaining grants can increase an individual's competitiveness for future job and promotion opportunities, academic productivity and contributions, and breadth of training experiences for mentors and mentees. however, the grant funding process is becoming increasingly competitive and there is a lack of accessibility to training and collaborations in grant writing. therefore, it is imperative that efforts are made to increase accessibility, transparency, and education about the grant writing process for those interested in obtaining funding, such as discussing strategies, barriers, and solutions for securing funding. this panel discussion will focus on writing and obtaining grants in cannabis research across career stages with inclusion from us and canadian researchers. panelists are successful, grant-funded researchers with experience in various mechanisms at the national, local, and university level. panel members will provide unique perspectives on grant writing during the predoctoral (smith-lecavalier, us), postdoctoral (parnes, us), and independent investigator (metrik, us; conference abstracts 254 wardell, canada) stages as well as mentoring training grants (metrik, us; wardell, canada). panelists will provide an overview of grant mechanisms, discuss strategies for grant writing, and explore current barriers and solutions to obtaining grant funding. we don't all like being stoned the same way: cannabis use across sexual orientation paige d. strait (colorado state university) brenna a. carter (colorado state university) hollis c. karoly (colorado state university) bradley t. conner (colorado state university) introduction: this study explores relations between cannabis use patterns and sexual orientation. although there is a growing acceptance of cannabis use in the united states, limited research exists on its differences across sexual orientations (so). there is a consistent trend of condensing sexual orientation into broad categories (e.g. heterosexual, gay/lesbian, and bi +) due to insufficient representation of so across data. previous literature suggests there is a higher frequency of cannabis use among individuals who identify as pansexual when compared to individuals who identify as gay or lesbian (scroggs, 2022), suggesting that pattern variations across sexual orientation merit additional research. this study builds on existing research by comparing cannabis use patterns among both discrete identities and traditionally combined identity categories to evaluate methodology concerns that may stem from the different categorization approaches. further research is needed to understand the complexities of identitybased use patterns, to develop targeted interventions for the well-being of diverse sexual communities, and to continue refining methodological approaches to marginalized populations. method: the study is a secondary analysis using prolific data on cannabis and alcohol co-use (n = 410). we used the new statistics to conducted cohen's d analyses comparing effect sizes across expanded and condensed models of so within a typical week's consumption pattern. results: we hypothesized that cohen's d would highlight meaningful differences between the expanded and condensed models of so, particularly among participants holding infrequently acknowledged identities when predicting typical cannabis use patterns. this hypothesis was supported by our results. in contrast to the results indicated by condensed models, results highlighted a small, positive effect size (d = 0.36) in both lesbian and pan identity groups. results also indicated a small, negative effect size (d = -0.44) among individuals who identify as asexual. discussion: our hypothesis was supported, highlighting significant differences in effect size between some identities in the sample, notably centered on under-represented so identities often endorsed by women and gender-expansive individuals. these results suggest that researchers should utilize expanded models of so when possible and should acknowledge the limitation of gender bias in conference abstracts 255 condensed so models when looking at cannabis usage. popular brands of intoxicating cannabis products sold in vape shops across the united states, 2023 kayla k. tillett (university of north texas health science center) cassidy r. loparco (george washington university) carla j. berg (george washington university) matthew e. rossheim (university of north texas health science center) background: the 2018 u.s. farm bill's definition of hemp resulted in the emergence of numerous derived psychoactive cannabis products (dpcps, such as delta-8 thc) because many have interpreted their retail sale as federally legal. a concerning trend is the increase in the number of dpcp brands that have become available. however, no study has systematically documented dpcp brands sold in physical stores, which is critical to informing effective regulations and understanding the evolving cannabis market. methods: in november and december 2023, we contacted vape shops (excluding licensed cannabis dispensaries) that were systematically identified near landmarks (the largest commercial airport and capitol building) in each us state, washington dc, and puerto rico (5 calls for each of the 2 landmarks for each of the 52 locations, n = 520 [661 shops were called to achieve target sample; 79% response rate]). we inquired about popular brands of thc products sold at each location. descriptive statistics were used to characterize the sample and summarize patterns. results: across the 520 shops, 464 (89.2%) provided brand information over the phone. in sum, there were over 300 brands. the top 10 brands (in descending order) included: mellow fellow (sold in 4.1% of shops), torch (4.0%), hidden hills (3.7%), cake (3.1%), urb (3.0%), looper (2.3%), extrax (2.1%), ghost (1.8%), space gods (1.8%), and stiizy (1.8%). the top 10 brands only accounted for 27.7% of brand responses captured through the 520 calls. discussion: across the us, there are hundreds of reportedly popular thc product brands available in vape shops, including in states that have bans/restrictions on dpcps. this demonstrates the rapidly evolving market, which is important given the role of market competition in prices and promotions. given the lack of data on product safety and that their production can result in toxic chemical byproducts and residue, which has led to a rising number of poisonings, hospitalizations and, in rare cases, death the 2024 farm bill and state laws should unambiguously exclude dpcps from the federal definition of "hemp". information on currently popular cannabis brands will facilitate related monitoring, implementation, and enforcement efforts. disentangling in-the-moment effects of cannabis co-use on antecedents and responses to cigarette smoking and alternative tobacco product use among youth hayley treloar padovano (brown university) suzanne m. colby conference abstracts 256 (brown university) jennifer w. tidey (brown university) rachel n. cassidy (brown university) cannabis and tobacco co-use among youth is a prevalent and concerning use pattern for public health. simultaneous use of these two substances may be primed, such that using cannabis elicits craving and use of tobacco. little work, however, has evaluated in-the-moment antecedents of tobacco use among youth. we analyzed one week of ecological momentary assessment (ema) data from a pre-randomization period of a larger clinical trial of adolescent daily smokers. preand post-use cigarette craving, pre-use affect, and subjective smoking response were assessed via self-initiated reports of cigarette and alternative tobacco product use with a custom smartphone application. participants were a subset who reported past-month cannabis use (n= 39; m age= 18.8 years, sd= 0.9; 51% female sex at birth; 85% cisgender; 41% minoritized race or ethnicity; 66% gay/lesbian, bisexual, or unsure/questioning). youth selfinitiated 476 cigarette and 190 alternative-product reports; to reduce burden, two-thirds were selected to include additional queries. despite high rates of baseline daily cannabis use, only 85 of 526 tobacco-use reports indicated recent cannabis use (16%), and 16 indicated recent alcohol use (3%). mixed, random-intercept models accounted for nested ema reports and disaggregated momentary effects by covarying participant means. herein, "craving," refers to assessments of "desire or craving to smoke [a] cigarette," completed before and after tobacco use. craving had significant momentary and participant-level variability (iccs= .28, .50, respectively). on average, cravings were lower prior to using alternative products, relative to cigarettes, where cravings were higher after using alternative products, ps< .001. accounting for use type, sex, age, race and ethnicity, nicotine dependence, and average craving, momentary cigarette cravings were positively related before and after tobacco use (b= 0.20, se=0.04, p< .001). pre-use cigarette craving was elevated during times of heightened anger, anxiety, difficulty concentrating, impatience, and stress, but lower when reporting greater happiness and unaffected by depression, hunger, and boredom. anger and impatience were uniquely related to pre-use craving, over and above other affective precursors (b= 0.21, se= 0.06, p< .001; b= 0.18, se= 0.05, p= .001), whereas average happiness, rather than momentary fluctuations, was uniquely related (b= 0.45, se= 0.18, p= .019). recent cannabis use (just before tobacco use) and baseline (daily vs. non-daily) cannabis use did not have direct effects on pre-use craving and did not moderate affective relations. recent cannabis use was marginally related to elevated residual cigarette craving just after use, however (p= .078), as was recent alcohol use (p= .090; but note infrequent reports). in contrast, baseline daily cannabis use was related to lower cigarette craving after tobacco use (p= .084), and neither recent nor conference abstracts 257 baseline cannabis use were related to subjective smoking response (i.e., pleasure, satisfaction). these data do not support the theory that cannabis use increases cigarette craving or subjective responses in the moment, either directly or via affective mechanisms. rather, cannabis use may elicit sustained craving after tobacco use, an effect which could prompt additional smoking. overall, findings point to the importance of disentangling effects of co-use at multiple levels, and much work remains to understand co-use patterns. mental health and dispositional predictors of simultaneous versus concurrent cannabis and alcohol use in a canadian context jenna l. vieira (toronto metropolitan university) sophie g. coelho (york university) lindsey a. snaychuk (toronto metropolitan university) nassim tabri (carleton university) samantha j. dawson (university of british columbia) david c. hodgins (university of calgary) matthew t. keough (york university) n. will shead (mount saint vincent university) andrew (hyounsoo) kim (university of calgary) background: cannabis has become more available in canada since its legalization in 2018. many individuals who use cannabis also use alcohol (couse), which can be used either at the same time (simultaneous use) or at different times (concurrent use). though studies have identified predictors of co-use relative to singlesubstance use, less is known about the predictors of specific types of co-use. the present study examined the mental health and dispositional predictors of simultaneous relative to concurrent use of the two legal substances (cannabis and alcohol) among adults in canada. method: canadian adults reporting past-year use of both cannabis and alcohol (n = 1,528) were recruited from academic prolific and six canadian universities. participants completed online self-report measures of demographic characteristics, cannabis and alcohol co-use, mental health symptoms, impulsivity, and personality traits. results: binary logistic regression analyses revealed that when independent variables were each entered separately into their own model, greater severity of depressive, anxiety, ptsd, and adhd symptoms; impulsivity; and negative urgency and lack of premeditation each predicted increased likelihood of reporting pastyear simultaneous versus concurrent use. when independent variables were entered simultaneously, greater severity of anxiety and adhd symptoms remained significant predictors of simultaneous relative to concurrent use. discussion: individuals with elevated anxiety and adhd symptoms may be more inclined to engage in simultaneous use to selfmedicate and achieve greater symptom reduction. future studies may examine the directionality of these relations and motives (e.g., coping) that may conference abstracts 258 differentiate simultaneous and concurrent use. consumer perceptions of fda prohibited claims in cbd advertisements kimberly wagoner (wake forest university school of medicine) olivia horton (wake forest university school of medicine) cindy suerken (wake forest university school of medicine) allison j. lazard (university of north carolina at chapel hill) edgar alfonso romero-sandoval (wake forest university school of medicine) beth reboussin (wake forest university school of medicine) background: cbd products are advertised to consumers in ways that are prohibited by the us food and drug administration (fda), including the use of health claims that promote unsubstantiated medicinal benefits, and misleading marketing indicating the products are fda-approved. products are sold as dietary supplements or food products, and target youth. we evaluated consumer perceptions of real-world cbd advertisements in three states with disparate cannabis policies (north carolina, maryland, colorado). methods: two trained data collectors conducted observational assessments of cbd retailers (n=150) using wearable imaging technology. ads were content analyzed for the fda prohibited claim types (i.e. unapproved drug/therapeutic benefit, fda-approved/endorsed; marketing to youth; dietary supplement; and food additive). a total of 1,176 unique ads were documented that contained at least one fdaprohibited claim. of those, 55 were included in a 20-minute online survey of 3,076 adults, ages 18-65 who were from a probability-based panel (amerispeak) to assess consumer perceptions. current cbd and ever cbd users were oversampled. eligible participants were randomly assigned to view five claims and rate the extent the ad conveyed content for the fda prohibited claim types. of the 55 ads in the survey, 87% were coded by the study team as unapproved drug/therapeutic benefit; 33% as food additive; 13% as dietary supplement; 5% as marketing to youth; and 4% as fda-approved/endorsed. results: the sample was 53.5% female, 70.1% white and 14.3% hispanic; mean age of 42.9 years. the sample was 32.8% current cbd users, 34.2% ever cbd users, and 33% non-users. among all ads, 71% were perceived by consumers as making an unapproved drug/therapeutic claim; 21.8% as promotion as a dietary supplement and 18.2% as a food additive; 34.5% were perceived as marketing to youth and 3.6% were perceived as fda approved/endorsed. we compared agreement between consumer perceptions and the study team's content analysis and found similar agreement for fda approved/endorsed claims; however, consumers perceived more ads to be targeting youth and making dietary supplement claims. they were less likely to perceive cbd as a making unapproved conference abstracts 259 drug/therapeutic or food additive claims. we also examined differences between consumers by cbd use status and found among all ads, cbd current users reported higher ad appeal and ad believability compared to non cbd users (p < 0.05). in addition, compared to ever users, current cbd users reported higher ad appeal for 47.3% (n=26) of ads and higher believability for 60% (n=33) of ads (p < 0.05). current cbd users consistently perceived ads to make claims of therapeutic effect and dietary supplement more than ever cbd users or non-users. conclusions: consumers perceived the majority of ads as making at least one fdaprohibited health claim, with therapeutic benefit being the most common. consumers were more likely to perceive ads targeting youth and as a dietary supplement compared to researchers. understanding consumer perceptions of cbd advertising is important, as prohibited claims could mislead consumers about the risks and benefits of cbd use. this study provides critical data that can inform regulatory action at the state and federal level. inhaled cannabis for medical purposes for chronic pain: a systematic review and meta-analysis of randomized clinical trials li wang (mcmaster university) kevin shao (mcmaster university) vahid ashoorion (mcmaster university) fares hayek (mcmaster university) wenjun jiang (mcmaster university) vivian chen (cornell university) cody tran (mcmaster university) henry kwon (wayne state university school of medicine) rachel j. couban (mcmaster university) jason w. busse (mcmaster university) background: use of cannabis and cannabinoids for medical purposes is increasingly common for chronic pain, particularly in north america where there is considerable interest in alternatives to opioids. inhalation (i.e., smoked, vaporized) is a common form of consuming cannabis for medical purposes; however, the benefits and harms of inhaled cannabis for chronic pain are uncertain. objectives: we conducted a systematic review and meta-analysis of randomized clinical trials (rcts) to assess the effectiveness of inhaled forms of cannabis for medical purposes for chronic pain. methods: we searched medline, embase, amed, psycinfo, central, cinahl pubmed, web of science, cannabismed, epistemonikos, and trial registries up to january 2024 to identify rcts of inhaled cannabis for medical purposes for chronic pain. paired reviewers independently assessed risk of bias and extracted data from eligible studies. we used random-effect models for all metaanalyses and the grading of recommendations assessment, development, and evaluation (grade) approach to assess the certainty of conference abstracts 260 evidence. results: a total of 12 eligible trials with 395 adult patients living with chronic non-cancer pain compared inhaled cannabis for medical purposes vs. placebo. seven trials administered cannabis cigarettes and five trials randomized patients to receive vaporized cannabis. the median sample size was 33 patients (interquartile range [iqr] 26-39) and the median length of follow-up was 1.6 days (iqr 5 hours to 5 days). moderate to high certainty evidence shows that, compared with placebo, inhaled medical cannabis probably improves short-term pain relief with a larger proportion of patients achieving at least 30% pain reduction: risk difference [rd] 20% (95% ci 11% to 30%) based on a relative risk [rr] 1.60 (95% ci 1.30 to 1.95), and a weighted mean difference [wmd] of 0.70 cm on a 10 cm visual analogue scale [vas] (95% ci 1.04 to -0.36 cm); and increases the risk of dizziness (rd 10%, 95% ci 3% to 25%), cough (rd 16%, 95% ci 3% to 44%), and euphoria (rd 12%, 95% ci 4% to 23%); but probably results in little or no improvement in physical, emotional, role functioning, or sleep quality at a short-term use. low to very low certainty evidence shows that shortterm inhaled medical cannabis might not increase the risk of cognitive impairment, anxiety, paranoia, shortness of breath, tachycardia, hypotension, fatigue, weakness, vomiting, nausea, bad taste, and dry mouth. conclusions: short-term use of non-inhaled medical cannabis results in an important improvement in pain relief among patients who live with chronic noncancer pain, along with several transient adverse side effects, compared to placebo. however, the longterm benefits and harms of inhaled cannabis remain uncertain. non-inhaled medical cannabis or cannabinoids for chronic pain: a systematic review and meta-analysis of randomized clinical trials li wang (mcmaster university) vahid ashoorion (mcmaster university) kevin shao (mcmaster university) wenjun jiang (mcmaster university) vivian chen (cornell university) lucas lorimer (western university) wahaj khan (mcmaster university) rachel j. couban (mcmaster university) jason w. busse (mcmaster university) background: chronic pain affects one in five adults globally and is associated with reduced quality of life and increased healthcare costs. the shift away from long-term opioid therapy to medical cannabis or cannabinoids for chronic pain has increased dramatically. there is conflicting evidence and recommendations from guidelines. objectives: we conducted a systematic review and meta-analysis of randomized clinical trials (rcts) to assess the benefits and harms of noninhaled medical cannabis or cannabinoids for chronic pain. methods: we searched medline, embase, amed, psycinfo, central, cinahl, pubmed, web of science, cannabisconference abstracts 261 med, epistemonikos, and trial registries up to january 2024 to identify rcts of medical cannabis or cannabinoids for chronic pain at ≥1 month follow-up. paired reviewers independently screened literature, assessed risk of bias, and extracted data. we performed random-effects models meta-analyses and used grade to assess the certainty of evidence. results: a total of 34 rcts with 5195 adult patients were included, 30 of which compared medical cannabis with placebo. medical cannabis was administered orally (n = 32) or topically (n = 2) for chronic non-cancer pain (n = 30) and cancer-related pain (n = 4). length of follow-up ranged from 1 to 5 months. compared with placebo, noninhaled medical cannabis or cannabinoids probably result in a small increase in the proportion of patients experiencing at least the minimally important difference (mid) improvement in pain relief (modelled risk difference [rd] of 11%, 95% confidence interval [ci] 5% to 16% for achieving at least mid of 1.5 cm on a 10 cm visual analogue scale [vas], based on a weighted mean difference [wmd] of −0.53 cm, 95% ci −0.79 to −0.27 cm, moderate certainty), physical functioning improvement (4% modelled rd, 95% ci 0.1% to 8% for achieving at least mid of 10 points on the 100-point sf-36 physical functioning scale, wmd of 1.7 points, 95% ci 0.06 to 3.34, high certainty), and sleep quality improvement (7% modelled rd, 95% ci 4% to 11% for achieving at least mid of 1 cm on a 10 cm vas, wmd of −0.42 cm, 95% ci −0.63 to −0.22 cm, high certainty). medical cannabis or cannabinoids taken orally does not improve emotional, role, or social functioning (high certainty). moderate certainty evidence shows medical cannabis or cannabinoids taken orally probably results in a small increased risk of memory impairment (rd 3%; 95% ci 0.4% to 7%), vomiting (rd 3%; 95% ci 0.4% to 6%), drowsiness (rd 4%; 95% ci 2% to 8%), impaired attention (rd 3%; 95% ci 1% to 8%), nausea (rd 5%; 95% ci 2% to 8%), and diarrhoea (rd 4%; 95% ci 2% to 8%); while high certainty evidence shows greater increased risk of dizziness (rd 8%; 95% ci 4% to 12% for trials with <3 months follow-up versus rd 33; 95% ci 21% to 50% for trials with ≥3 months follow-up; interaction test p < 0.001; moderate credibility of subgroup effect). conclusions: non-inhaled medical cannabis or cannabinoids result in a small improvement in pain relief, physical functioning, and sleep quality among patients with chronic pain, along with several transient adverse side effects, compared with placebo. this review provides evidence for canadian cannabis for medical purposes and chronic pain guideline. who is asked about marijuana use during pregnancy? identifying racial differences in a sample of pregnant women with sti risk golfo tzilos wernette (university of michigan) ananda sen (university of michigan) dongru chen (university of michigan) kristina countryman (university of michigan) okeoma mmeje (university of michigan) melanie herschel conference abstracts 262 (university of michigan) kalli mulholland (university of michigan) caron zlotnick (brown university, women and infants hospital) background: marijuana use during pregnancy is on the rise, increasing by 62% over the past decade, in part due to an increased perception of its safety. marijuana use during pregnancy is associated with preterm birth, stillbirth, growth restriction, and developmental problems. the national guidelines recommend that all pregnant people should be asked about their marijuana use by their healthcare provider. the objective of the current study is to characterize the experiences of our sample of pregnant women at risk for marijuana use and sexually transmitted infections (stis). methods: we enrolled 176 pregnant cisgender women (mean age = 30.2, sd = 5.02; 26% black) who endorse alcohol/drug use and condomless sex or multiple sexual partners in our randomized controlled trial testing an innovative, technology-delivered brief intervention, the health check-up for expectant moms (hcem), which aims to reduce these health risks during pregnancy. participants completed baseline questions regarding marijuana use, risk perceptions, and attitudes around use during pregnancy. possible racial bias in discussions about marijuana use was investigated through a logistic regression adjusting for prior marijuana use. results: overall, 15% (n = 26) selfreported their frequency of marijuana use as four or more times a week, and 13% (n = 22) reported using monthly or less. the most cited reasons for marijuana use were relaxation or tension relief (53%), sleep aid (45%), and euphoria or to get high (43%). on a 1-10 likert scale asking how harmful to your health smoking marijuana is, the average score of all women was 5.10 (sd = 3.17). the majority of the sample (55%) responded "no" to "since being pregnant, has your doctor or nurse asked you about your marijuana use?" and 65% responded "no" to "has your doctor or nurse ever talked to you in general about marijuana use during pregnancy or breastfeeding?" we found that black women were significantly more likely than their white counterparts to have been talked to by their provider about marijuana use during pregnancy or breastfeeding (51% vs. 29%, p = 0.007). the significant difference prevailed even after adjusting for prior marijuana use (adjusted odds ratio = 2.27, 95% ci: 1.10 -4.71, p = 0.028). conclusions: these findings highlight reasons why our sample of pregnant women are using marijuana during pregnancy. our results suggest that, among our sample, there is a perception that marijuana is not harmful to maternal and fetal health during pregnancy. furthermore, the majority of women reported that their providers seemingly neglected the topic of marijuana use during their prenatal visits. importantly, our results suggest a racial bias that led to significantly more black women being asked about marijuana use during pregnancy or breastfeeding, as compared to their white counterparts, even when adjusting for prior marijuana use. based on these findings and prior studies that have conference abstracts 263 demonstrated racial bias in the context of the provision of perinatal care and breastfeeding, there is a clear need to improve bias training and its impact on health equity for providers, to minimize stigmatization during the antenatal period. pain as a predictor of cannabis initiation among emerging adults: results from the population assessment of tobacco and health (path) study callon m. williams (binghamton university) nadine r. mastroleo (binghamton university) mark f. lenzenweger (binghamton university) emily l. zale (binghamton university) purpose: pain is highly prevalent among emerging adults (18-25 years old), and rates of cannabis use are increasing among this population. indeed, 1.2 million emerging adults in the us initiated cannabis use in 2022 alone. a growing body of research suggests pain may be a unique antecedent and motivator for substance use. although several risk factors for cannabis initiation have been identified (e.g., alcohol use and depression), this is the first study to examine pain as a prospective predictor of cannabis initiation among emerging adults. methods: data were drawn from five annual waves of the population assessment of tobacco and health study (path) study. emerging adults who denied cannabis use at baseline (n = 4,185; 53.4% female; 69.5% white) were included in the analysis. adjusted cox regression analysis tested pain as a predictor of cannabis initiation across four subsequent waves of data. covariates included: sex, race, ethnicity, lifetime alcohol use, pastmonth polysubstance use, current cigarette use, and mental health. population weights and balanced repeated replication methods were applied to produce nationally representative estimates per path requirements. data: past-week pain was assessed using a 0-10 numerical rating scale at baseline and dichotomized to indicate no/low (<4/10) or moderate/severe pain (≥4/10), which is a commonly used cutoff in research and practice to suggest clinically relevant pain. initiation of cannabis use was defined as respondents who did not endorse lifetime cannabis use at wave 1 and who subsequently endorsed pastyear cannabis use at any of the following four waves. time to cannabis initiation was measured in years (waves). results: at baseline, 10.9% of emerging adults reported moderate/severe pain (≥4/10), which is consistent with pooled prevalence rates from a prior metaanalysis. adjusted cox regression analysis revealed that emerging adults with moderate/severe pain at baseline initiated cannabis use earlier than those with no/low baseline pain (ahr = 1.19, se = 0.10; 95% ci [1.01, 1.41], p = .039). conclusions: emerging adults with moderate/severe pain were more likely to initiate cannabis use earlier than those with no/low baseline pain. these findings provide initial evidence for pain as a risk factor for cannabis initiation during emerging adulthood. future research should investigate how pain may motivate cannabis initiation conference abstracts 264 in the context of a changing legal landscape, beliefs about the efficacy of cannabis for pain management, and how other motives (e.g., social) may vary among emerging adults with and without pain. the impact of cannabis legalization on drug-related offenses in washington state guangzhen wu (university of utah) roarke r. cullenbine (university of maryland francis king carey school of law) an important public concern surrounding the legalization of recreational cannabis is its impact on offenses related to hard drugs such as heroin, cocaine, and other dangerous drugs, about which competing perspectives exist. prior research using rigorous methodology to empirically examine this issue remains limited. based on uniform crime reporting (ucr) program data from 2007 to 2019 and a quasi-experimental research design involving interrupted time series analysis (itsa) and the synthetic control method (scm), this study examines the effects of recreational cannabis legalization on the rates of a variety of drug offenses including possession violations related to cannabis, heroin/cocaine and their derivatives, and other dangerous nonnarcotic drugs in washington state (wa), which passed its recreational cannabis law (rcl) in late 2012 and began legal sales in july 2014. this study found that wa has experienced decreases in the rate of possession offenses for the two categories of more harmful drugs-heroin/cocaine and their derivatives, and other dangerous nonnarcotic drugs-over the post-sale period, relative to the states that have not legalized cannabis for recreational use, offering some evidence suggesting a drug offense reduction effect of cannabis legalization. symposia symposium title: new directions in the use of the marijuana purchase task to assess behavioral economic demand for cannabis: meta-analytic, laboratory, and neuroimaging findings chair: michael amlung (university of kansas) discussant: r. lorraine collins (university at buffalo) the marijuana purchase task (mpt) is an efficient and ethical method of measuring behavioral economic demand for cannabis (i.e., hypothetical cannabis consumption across escalating prices, reflecting the relative reinforcing value of cannabis). nearly a decade of research using the mpt has characterized associations between cannabis demand and cannabis use as well as the severity of cannabis-related problems at the trait level. more recently, experimental studies using state-based mpts have begun to examine how cannabis demand fluctuates in response to internal and external factors (e.g., cue-elicited craving, next-day responsibilities, and other experimental manipulations). this symposium will feature three talks by behavioral economists and cognitive neuroscientists who are expanding the conference abstracts 265 use of the mpt in several new directions. first, dr. james mackillop will review the trait cannabis demand literature, including findings from a recent meta-analysis documenting the concurrent validity of mpt indicators of cannabis demand in relation to cannabis use and cannabis use disorder severity. second, dr. michael amlung will present findings from three laboratory and crowdsourcing studies investigating contextual influences on cannabis demand, including cannabisrelated cues, next-day responsibilities, and everyday cannabis use scenarios. third, dr. iris balodis will present findings from a neuroeconomics study using functional mri to investigate the neural correlates of cannabis demand in individuals with heavy cannabis use. finally, dr. r. lorraine collins (discussant), will integrate these findings and discuss the proliferation of cannabis demand research and priorities for the future. talk 1: cannabis reinforcing value in relation to cannabis use and misuse: a meta-analysis of trait-level cannabis demand and cannabis involvement as measured by a marijuana purchase task james mackillop (mcmaster university alba gonzález-roz (university of oviedo) víctor martínez-loredo (university of sevilla) elizabeth r aston (brown university) jane metrik (brown university) james murphy (university of memphis) iris balodis (mcmaster university) roberto secades-villa (university of oviedo) kyla belisario (mcmaster university) a reinforcer pathology approach to addictive disorders emphasizes drug reinforcing value, immediate reward orientation, and availability of alternative reinforcers as key determinants. reinforcing value is increasingly assessed using the marijuana purchase task (mpt), leading to a sizable literature of behavioral studies. this meta-analysis sought to synthesize the concurrent validity of mpt indicators of cannabis demand in relation to cannabis involvement across studies. electronic databases and pre-print repositories were searched for mpt studies that examined the cross-sectional relationship between frequency and quantity of cannabis use, problems, dependence, and five mpt indicators: intensity (i.e. unrestricted consumption), omax (i.e. maximum consumption), pmax (i.e. price at which demand becomes elastic), breakpoint (i.e. first price at which consumption ceases), and elasticity (i.e. sensitivity to rising costs). random effects metaanalyses of cross-sectional effect sizes were conducted, with q tests for examining differences by cannabis variables, meta-regression to test quantitative moderators, and publication bias assessment. moderators included sex, number of mpt prices, variable transformations, and year of publication. the searches conference abstracts 266 yielded 14 studies (n = 4077, median % females: 44.8%: weighted average age = 29.08. intensity, omax, and elasticity showed the most robust concurrent validity (|rs| = 0.147-325, ps < 0.014) with the largest significant effect sizes for quantity (|r| intensity = 0.325) and cannabis dependence (|r| omax = 0.320, |r| intensity = 0.305, |r| elasticity = 0.303). a higher proportion of males was associated with increased estimates for elasticity-quantity and pmax-problems. a larger number of mpt prices significantly altered the magnitude of effects sizes for pmaxproblems, suggesting biased estimates when few prices are used. methodological quality was good, with minimal evidence of publication bias observed. across studies, the reinforcing value of cannabis was consistently associated with cannabis involvement outcomes, most robustly for intensity, omax, and elasticity. moderator analyses suggest potentially meaningful sex differences in the reinforcing value of cannabis and the importance of enough prices for a highresolution demand curve. talk 2: laboratory and crowdsourcing studies investigating contextual influences on cannabis demand michael amlung (university of kansas) brandon p. miller (university of kansas) elizabeth r. aston (brown university) william davis (johns hopkins university) benjamin l. berey (brown university) ashley n. dowd (johns hopkins university) tory r. spindle (johns hopkins university) behavioral economic demand reflects the relative reinforcing value of a substance and is commonly assessed via hypothetical purchase tasks. in the context of cannabis, the marijuana purchase task (mpt) provides an efficient measure of self-reported cannabis consumption (e.g., in hits, grams, joints, etc.) at escalating prices (e.g., free to $20/hit). at the trait level, indices of cannabis demand obtained from the mpt are significantly correlated with level of cannabis use and cannabis use disorder severity. however, cannabis demand is also sensitive to contextual and environmental factors at the state level. assessments of cannabis demand at the state level commonly use a modified version of the mpt that measures cannabis consumption in the present moment instead of a typical cannabis use scenario. an expanding body of research has begun to characterize how cannabis demand fluctuates in different situations and in response to various experimental manipulations. this talk will share results from three studies that investigated the effects of cannabis-related cues, next-day responsibilities, and other hypothetical cannabis use scenarios on cannabis demand assessed via state mpts. the first laboratory study assessed the effects of cannabis cues and upcoming activities on cannabis demand in a community sample of regular cannabis consumers. participants underwent a cue exposure protocol involving conference abstracts 267 exposure to either cannabis or neutral pictorial cues. following the cues, participants completed multiple mpts measuring cannabis consumption in a typical situation and in the context of having to drive or of going to sleep. cannabis demand was sensitive to the driving requirements, such that participants reported lower consumption and expenditure when they had to drive soon compared to a typical use situation. when participants were told they would be going to sleep soon, cannabis demand was increased following exposure to cannabis cues but not neutral cues. the second study used online crowdsourcing to examine the effects of various next-day responsibilities (e.g., work, recreation, and caregiving) on cannabis demand in adult cannabis consumers. results indicated that cannabis demand was significantly reduced in the context of next-day responsibilities, but potentially important individual differences in the degree of reduction were present. the final crowdsourcing study is examining different hypothetical driving scenarios on cannabis demand, including manipulations of the timing of the driving, the distance to be traveled, and other driving conditions. data collection from this study is ongoing, and we will present preliminary findings in this symposium. taken together, these studies reveal that cannabis demand fluctuates in meaningful ways in response to different contextual factors. implications for reducing harms from cannabis use will be discussed. talk 3: exploring the neural substrates of valuation in cannabis use disorder iris balodis (mcmaster university) with increases in cannabis use and rates of cannabis use disorder (cud) across north america, understanding the biobehavioural determinants of cannabis risks and harms is critical for informing treatment and policy. this presentation will explore behavioural and neural motivational profiles for cannabisand non-cannabis-related stimuli in heavy cannabis users. an established characteristic of cud is overvaluation of cannabis, which is typically measured by cannabis demand, a behavioural economic measure of an individual's value of cannabis as a reinforcer. cannabis demand is linked to cannabis misuse by overvaluation of cannabis; the current presentation applies principles of neuroeconomics to understand cannabis demand choice behaviour in cud. the project characterizes the neural activity associated with existing behavioural findings on a marijuana purchase task (mpt) adapted for functional magnetic resonance imaging (fmri). here, we demonstrate how the brain represents cannabis value as measured by cannabis demand in individuals with heavy cannabis use (n = 20), in areas including the anterior cingulate cortex, insula, and caudate. the findings also show differential recruitment of these areas during the inelastic, elastic, and suppressed motivational phases of the task, with the greatest activity during the elastic phase. additionally, the current study was able to detect relationships between thc metabolites conference abstracts 268 and multiple behavioural economic demand measures and find associations between thc metabolites and specific brain activity (bilateral caudate) during distinct mpt phases. in contrast to overvaluation of cannabis, low motivation for non-cannabis related stimuli is also a characteristic of cud. we present data assessing effort-based decision-making for non-cannabis rewards using the effort expenditure for rewards task (eefrt) during fmri. applying this task in a cud population (n = 21), we demonstrate alterations in valuation signaling relative to a healthy control group (n = 20). in particular, the cud group showed decreased ventromedial prefrontal cortex activation relative to the hc group during initial coding of a prospective effort. exploratory correlational analyses demonstrate multiple positive relationships between bilateral vs activity during prospective effort processing and choice behaviour, driven mostly by the cud group. collectively, these findings show behavioural and neural alterations underlying effortbased decision-making process in cud, further highlighting important differences in fronto-striatal processing that may occur with heavy cannabis use. characterizing how valuation processes are represented in the brain can help us understand influences on choice behaviour. symposium title: advancing science on cannabis' potential harms and therapeutic benefits: insights from experimental cannabis administration studies chair: benjamin l. berey (providence va medical center; brown university) discussant: jane metrik (brown university; providence va medical center) recreational and medical cannabis use is now legal in 76% and 48% of us states, respectively, and historical trends indicate that past-month and near-daily cannabis use among adults ages 19-55 has increased substantially since 2013. contemporaneously, burgeoning access to novel and increasingly potent products necessitates a deeper understanding of cannabis' potential harms and factors linked to the progression from initial to hazardous use. experimental cannabis administration studies using fixed-dose or self-administration paradigms are ideal for examining how individuals use cannabis within a session, identifying formulation-specific psychopharmacological and potential therapeutic effects, and testing behavioral and pharmacotherapy intervention efficacy. these talks will highlight the utility of different experimental methodologies to identify how different populations use cannabis, risk-factors for hazardous cannabis use, and inform future prevention and intervention efforts. dr. elder will present on methodological considerations for human laboratory cannabis, cannabinoid, and phytochemical studies including blinding, route of administration, and drug preparation. dr. berey will present data on individual-difference and state affective predictors of cannabis smoking behaviors in the laboratory. dr. lisano will present conference abstracts 269 research exploring the moderating effects of physical activity on affective changes among adults with mild-tomoderate anxiety randomized to three different cannabis chemovars for ad libitum use over four weeks. dr. aston will present data characterizing the effects of behavioral economic demand and delay discounting on cannabis smoking topography in the laboratory. dr. metrik will synthesize findings from these studies by discussing the utility of various experimental paradigms to advance knowledge concerning cannabis use etiology, prevention, and intervention. talk 1: best practices for human lab studies of cannabis and cannabis constituents: considerations for blinding and drug preparation for different routes of administration harrison j. elder (johns hopkins university) tory r. spindle (johns hopkins university) controlled human laboratory studies are critical to increasing understanding of the behavioral, toxicological, and therapeutic effects of cannabis and its constituents. however, given the diversity of cannabis products and cannabis constituents, conducting such studies presents numerous challenges and there are important methodological factors to consider. this talk will discuss various methodological strategies for conducting rigorous human laboratory research using four recent exemplar studies. issues related to dosing, blinding of participants and research staff, and drug formulation/preparation across various routes of administration (e.g., oral, vaporized) will be discussed. a study (n=20) assessing the pharmacokinetic and pharmacodynamic effects of acute oral (0, 10, 25mg) and vaporized (0, 5, 20mg) thc in healthy volunteers was conducted to characterize impairment using novel (driving under the influence of drugs, druid®) and standard (e.g. divided attention test, dat) performance measures. drug preparation and formulation methods utilized in this study illustrate some best practices for ensuring consistent drug delivery and absorption. oral ingestion occurred via cannabis-infused brownies, which is a high fat vehicle known to result in robust absorption of cannabinoids such as thc, and 0mg thc brownies were infused with placebo cannabis to account for potential differences in taste between active and inactive doses. participants were also fed a standardized low-fat breakfast at a fixed time prior to dosing to minimize the influence of food on cannabinoid absorption. a different study of smoked and vaporized cannabis (thc: 0, 10, 25mg) in 17 infrequent cannabis users illustrates the use of certain best practices for inhaled dosing to preserve blinding and minimize variability in dose. for smoked cannabis, participants were instructed to inhale the entire dose of cannabis within a constrained period (10 minutes) from a pipe fitted with a metal top to preserve blinding and minimize drug loss due to side-stream smoke. for vaporized conditions, the self-administration period was constrained to the same length of time, conference abstracts 270 but participants inhaled the study drug using a medical-grade vaporizer (volcano medic) which captures cannabinoids in a plastic clear balloon (an opaque bag was placed around the balloon to minimize vapor visibility and preserve the study blind). lastly, in two recent studies, thc and two terpenes (pinene and limonene) were self-administered using a handheld vaporizer (the mighty medic). as with our other studies, the timing of dosing was constrained to reduce variability in drug absorption and the onset of effects. because of differences in visibility between terpenes and thc, participants exhaled into a smoke filter (sploofy) after each puff to preserve study blinding. additional observations from the studies that warrant consideration in future research include key differences in the magnitude and onset of effects across routes of administration. specifically, the timecourse of effects between smoked and vaporized cannabis were similar, but vaporization produced significantly stronger drug effects, while oral dosing resulted in a significant delay in the onset of effects (but similar magnitude) to inhaled dosing. thus, inhalation requires more frequent measurement of pharmacodynamic outcomes after dosing and a shorter overall observation period (6 hrs) compared with oral administration (8 hrs). talk 2: using experimental laboratory methods to identify affective and individual-difference predictors of cannabis smoking topography benjamin l. berey (providence va medical center, brown university) holly k. boyle (brown university) elizabeth r. aston (brown university) medical cannabis legislation in the u.s. implicitly conveys that cannabis can effectively treat myriad conditions despite minimal empirical support. contemporaneously, cannabis risk perceptions have declined despite welldocumented potential harms from cannabis misuse. research often focuses on use frequency/quantity but more nuanced behaviors, like how cannabis is used within a session (e.g., topography), can provide insights about when and for whom cannabis may result in negative outcomes. indeed, alcohol and tobacco research indicate that certain topography profiles (e.g., faster pace of consumption, shorter intervals between drinks/puffs) relate to negative consequences. yet, minimal cannabis smoking topography research exists and knowledge about situational and individual-difference factors impacting these behaviors is limited. this laboratory study examined affective predictors of cannabis smoking topography. we hypothesized greater pre-session negative affect and craving would predict more cannabis puffs, longer puff durations, greater overall puff volume (inhalation amount) and average puff flow (inhalation speed), and shorter interpuff-intervals (ipis). given limited prior research, an exploratory aim examined whether participants' baseline proportions of medical/recreational cannabis use conference abstracts 271 related to smoking topography. adults (n=67; 63% male, mean [sd] age=23 [5]) reporting frequent pastmonth cannabis use completed a laboratory session where they used the clinical research support system (cress) device and smoked up to two cannabis cigarettes ad libitum over 1hour. cannabis use (medical use frequency, medical/recreational cannabis use proportions, typical grams used per session) was assessed at baseline; state negative affect (positive and negative affect schedule) and cannabis craving (marijuana craving questionnaire) were measured immediately before the experimental session. the cress topography device recorded each self-administered puff, individual puff duration and volume, ipi, and average puff flow. study hypotheses and exploratory aims were tested via bivariate correlations, oneway anovas, and hierarchical linear regressions controlling for age, sex, and baseline cannabis. higher pre-session craving was correlated with shorter ipis (r=-.25, p<.05). a higher baseline proportion of medical cannabis use was positively associated with number of puffs, faster smoking pace (total puff volume/smoking duration), and average puff flow (rs=.30-.33, ps<.05). negative affect was not significantly correlated with smoking topography. one-way anovas indicated that participants with less than monthly medical cannabis use (versus monthly, weekly, or daily/almost daily) took significantly fewer puffs and had smaller total puff volumes (ps<.05). smoking topography did not significantly differ among participants with monthly, weekly, or daily/almost daily medical cannabis use. regressions demonstrated that a larger proportion of baseline medical cannabis use predicted more selfadministered puffs, higher total puff volume and average puff flow, and faster smoking paces (ps<.024). neither pre-session craving nor negative affect predicted smoking topography. hypotheses were partially supported. participants with more medical cannabis use had topography profiles characterized by more frequent and intense puffs. future prevention, intervention, and public health efforts targeting higher-risk cannabis smoking topographies (e.g., tailored protective behavioral strategies) may reduce potential harms. likewise, knowledge about smoking topography can help clinicians educate patients about safer ways to use cannabis medicinally. given the emergence of novel cannabis products, future research should examine how different formulations, modes, and potencies affect smoking topography. talk 3: synergistic effects of physical activity and cannabis use on negative affect: exploration in a sample with elevated anxiety symptoms jonathon k. lisano (university of colorado boulder) paige phillips (university of colorado boulder) greg giordano (university of colorado boulder) marco ortiz torres (university of colorado boulder) angela d. bryan (university of colorado boulder) l. cinnamon bidwell (university of colorado boulder) conference abstracts 272 emerging research indicates that seeking relief from depression and anxiety, two core components of negative affect, are some of the strongest medical motives for cannabis use. physical activity (pa) is associated with reductions in negative affect, with reviews showing it is as effective as medication for mild to moderate depression. given the linkages between cannabis use and pa, there may be synergistic effects between pa and cannabis use on affect. in a group of individuals with self-reported anxiety symptoms using either a cbddominant (cbd), thc-dominant (thc), or equal parts thc+cbd (thc+cbd) cannabis product ad libitum over 4 weeks, this study aimed to explore if levels of pa were different between product groups (cbd vs. thc vs. thc+cbd), and if pa moderated changes in negative affect over time by group (cbd vs. thc vs. thc+cbd). 178 participants with actigraphmeasured pa data were analyzed from a larger nih-funded study assessing outcomes of thc and cbd in individuals using cannabis to cope with their anxiety. participants had generalized anxiety disorder scores ≥ 5, mean age of 34±14 years, and were randomly assigned to use cbd (n=60), thc (n=62), or thc+cbd (n=56) cannabis flower or edible products at the beginning of the 4-week study. participants were asked to consume their products ad libitum over the study period and negative affect was measured at baseline and week 4 via the depression, anxiety, and stress scale-21 (dass-21). participants were asked to wear wrist-worn activity monitors (actigraph llc) to measure pa during the second 2 weeks of their cannabis use. activity data were analyzed using actilife 6.13.5. a comparison of average pa by group over the wear period was done using anova. due to the non-normal distribution of pa data, a generalized estimating equation (gee) multilevel model assessed whether pa moderates the relationship among cannabis group (cbd, thc, and thc+cbd) and changes in negative affect over time (baseline to week 4). a trend was observed (f(2,170)=2.65, p=.07) for the thc group to engage in more pa compared to the cbd group (p=.06), but not the thc+cbd group (p=.37). in the moderation model, there was a main effect of time showing decreases in dass-21 scores from baseline to week 4 (p=.01). qualifying this main effect was a significant three-way interaction between cannabis group, time, and pa (p=.03). at low (mean-1 sd), moderate (mean), and high (mean+1 sd) pa, the cbd and thc groups demonstrated improvements in negative affect over time (p's<.01). in the thc+cbd group negative affect improved over time at moderate and high pa (p's<.01), but not at low pa (p=.77). these results are the first to explore whether pa moderates cannabis-associated improvements in negative affect. these data suggest that various cannabis products may be associated with differences in pa engagement in individuals with selfreported anxiety and that there is a complex interplay between pa, cannabis use, and negative affect. talk 4: conference abstracts 273 leveraging experimental methods to assess cannabis reinforcer pathology via smoking topography elizabeth r. aston (brown university) benjamin l. berey (providence va medical center; brown university) james mackillop (mcmaster university) jane metrik (brown university; providence va medical center) reinforcer pathology (i.e., rp) is one way to conceptualize hazardous substance use that is characterized by preferences for substances immediately (i.e., delay discounting; dd) paired with willingness to pay for substances despite increasing cost (i.e., demand). rp relates to more frequent selfreported cannabis use in cross-sectional surveys/research; however, no previous study has extended rp to actual cannabis use in the laboratory. moreover, the way in which one smokes (i.e., topography) has been linked to numerous negative outcomes in tobacco research, but there is a paucity of work on cannabis smoking topography. the present investigation sought to replicate rp at baseline in a sample endorsing frequent cannabis flower smoking; this was subsequently extended to ad libitum smoking topography. this study recruited adults endorsing cannabis flower smoking (≥twice weekly) to participate in a laboratory cannabis administration study. at baseline, participants completed a trait-marijuana purchase task (mpt), monetary choice questionnaire (mcq), daily sessions, frequency, age of onset, and quantity of cannabis use inventory, and a structured clinical interview to assess cannabis use disorder symptoms (cud). participants returned for ad libitum cannabis smoking topography; they completed a state-mpt and smoked up to two cannabis cigarettes via a smoking topography device over 1-hour. the device measured puff number, volume, duration, and inter-puff-interval [ipi]. the final analytic sample (n = 61) included participants with complete mpt data (37.7% female, mean [sd] age = 22.9 [4.8], cannabis use days/week = 5.2 [1.6]). linear regressions controlling for age and sex examined whether trait demand, dd, and their interaction predicted baseline cannabis use (i.e., typical grams/session) and cud symptoms. rp was next tested during ad libitum laboratory cannabis administration by examining whether state demand, dd, and their interaction predicted topography. crosssectionally, demand (i.e., breakpoint: price suppressing demand to zero) was uniquely positively associated with grams/session (p < .01) and dd (i.e., log k) was uniquely positively associated with cud symptoms (p < .05). state demand prior to ad libitum administration (i.e., breakpoint, elasticity: decreased consumption as price escalates) was negatively associated with puff number ( ps < .05) and volume (ps < .05). omax (i.e., maximum expenditure) was negatively associated with smoking duration (p < .05). dd and dd by demand interactions were not significantly associated with smoking topography. this is the first study to extend rp to ad libitum cannabis administration with conference abstracts 274 an emphasis on smoking topography. rp was confirmed cross-sectionally via unique prediction of cannabis use and cud symptoms by trait demand and dd, respectively. subsequently, significant relations between state demand and topography, but not dd, were demonstrated. demand and dd tap distinct aspects of choice: demand is strongly linked with volumetric use, while dd is strongly associated with cannabis problems and addiction pathology. the lack of relation between dd and topography may be explained by dd reflecting decisions that typically impact distal substance-related problems rather than topography, which may be more reflective of immediate volumetric use. topography is likely an important process for continued study, particularly in light of the rapid evolution of cannabis legalization. future work should assess whether topography may be manipulated to facilitate cessation or reduction in cannabis use. symposium title: advances in understanding antecedents and consequences of cannabis and alcohol co-use: insights from momentary data in young adults chair: rachel gunn (brown university) discussant: jeffrey d. wardell (york university; university of toronto; centre for addiction and mental health, toronto) research on the widespread use of cannabis with alcohol (co-use) and specifically, simultaneous use (using cannabis and alcohol together so that their effects overlap), has generated compelling data suggesting that co-use is associated with increased alcohol and cannabis consumption and greater risk of substance-related consequences. the increased prevalence of cannabis use among young adults in the wake of expanding legalization has raised important questions about the impact of cannabis use on alcohol-related risk in this population, who have the highest prevalence of co-use. however, given the complexity and heterogeneity of cannabis use patterns, the impact of couse (and simultaneous use) is nuanced and evolving. in particular, there is significant variability from between (individual-level) and within-person (event-level) patterns of use, and parsing these effects is critical to furthering our understanding of co-use. in this symposium, we will present four studies on co-use that provide new insight into these complex substance use behaviors, with a focus on daily and momentary studies that disentangle betweenand within-person variance in co-use. this symposium takes a thorough look at predictors of simultaneous use, in-the-moment changes in subjective response during use episodes, and next-day consequences. we provide a nuanced analysis of cognitive, social, and physiological predictors of co-use patterns and consequences. we will also synthesize competing findings to understand how co-use may confer specific risks relative to cannabis-only and alcohol-only events. findings reflect cutting-edge research in the area and discussion will include clinical, policy, and public health implications of this work. conference abstracts 275 talk 1: a systematic review of proximal antecedents and acute outcomes of simultaneous alcohol and cannabis use: findings from within-person studies kyra n. farrelly (york university) tahmina amini (york university) sophie g. coelho (york university) nicolle fox (york university) nicole dimitrova (york university) christian s. hendershot (university of north carolina-chapel hill) jeffrey d. wardell (york university, university of toronto) background: research on simultaneous alcohol and cannabis use is rapidly growing against the backdrop of recent changes in cannabis regulations occurring globally. examining simultaneous use is important given its high prevalence and association with elevated substance-related consequences compared to single substance use. between-person comparisons have revealed increased substance-related consequences between those who engage in simultaneous use and those who use alcohol or cannabis alone, yet more recent within-person studies examining dailyand event-level associations with simultaneous use are less consistent. understanding within-person differences is imperative, as differences between those who use alcohol and cannabis simultaneously and those who do not could be explained by dispositional risk factors for engaging in simultaneous use rather than by the acute effects of simultaneous use. thus, within-person comparisons are needed to examine the acute consequences of simultaneous use versus single substance use. although previous reviews have broadly summarized the simultaneous use literature, many were published prior to the recent growth in daily and event-level studies and did not specifically look at within-person associations. method: this systematic review aimed to summarize the emerging literature on within-person differences in proximal antecedents and acute outcomes between simultaneous use and single substance use occasions. this review followed prisma guidelines and was pre-registered with prospero (registration id: crd42023425606). empirical studies that compared simultaneous use to alcohol-only and/or cannabis-only use, within-person, using dayor event-level data were eligible for inclusion. our search revealed 21 eligible studies. two categories of antecedents (i.e., internal motives for use and external location and social context of use) and three classes of outcomes (i.e., consumption behavior, general positive and negative consequences, and specific consequences) were identified. results: the current literature suggests that within-person variation in certain antecedents (i.e., increased social and enhancement motives, social context with more people) were proximal predictors of engaging in simultaneous use compared to alcoholor cannabisconference abstracts 276 only use at the dayor event-level. however, while most evidence pointed to heavier alcohol consumption on simultaneous use versus single substance occasions, findings of risk for acute consequences on simultaneous use occasions compared to single substance use occasions were mixed and appeared to depend on the level of alcohol consumed. there was preliminary evidence that engaging in simultaneous use increased the risk of specific consequences (e.g., sleep problems, impaired driving); however, evidence that simultaneous use led to more negative consequences at the event level was less consistent. further, some findings showed more consistent evidence of increased consequences when comparing simultaneous use to cannabis-only use rather than to alcohol-only use. conclusion: this review identifies specific antecedents for simultaneous use events but suggests that simultaneous use events are not always associated with more acute harms than single substance use events. this review helps to highlight areas for future research and could inform "just in time" interventions to target antecedents of engaging in a simultaneous use event. findings may also inform harm reduction efforts by suggesting a need to focus on levels of alcohol consumption as an important variable in understanding the acute consequences of simultaneous use. talk 2: descriptive norms for simultaneous cannabis and alcohol use predict simultaneous use patterns assessed via daily surveys sophie g. coelho (york university) christian s. hendershot (university of north carolina-chapel hill) roisin m. o'connor (concordia university) john a. cunningham (kings college london, institute for mental health policy research, university of toronto) jeffrey d. wardell (york university, university of toronto) background: simultaneous use of cannabis and alcohol is common among young adults. given the often-social nature of simultaneous use, perceived descriptive norms – or individuals' perceptions about others' simultaneous use patterns – may help to explain young adult simultaneous use. select studies have examined associations of descriptive norms for simultaneous use with simultaneous use patterns. however, these studies have not controlled for normative perceptions of the frequency and quantity of cannabis use and alcohol use in general (i.e., not limited to simultaneous use). thus, the specificity of descriptive norms for simultaneous use in predicting simultaneous use patterns is unclear. this study examined the unique associations of descriptive norms for simultaneous use with simultaneous use patterns assessed via daily surveys, including the tendency to engage in simultaneous use across days and quantities of cannabis and alcohol consumed on simultaneous use days. method: young adults reporting simultaneous use (n = 150; 63% female; mean age 22 years) completed a conference abstracts 277 baseline questionnaire that included measures of descriptive norms for the frequency of simultaneous use and the amounts of cannabis and alcohol consumed during a typical simultaneous use occasion. further, participants completed standard measures of descriptive norms for the frequency and quantity of cannabis and alcohol use in general (i.e., not limited to simultaneous use). all norms were assessed with reference to both peers of the same age and gender and friends of the same gender. participants subsequently completed daily smartphone surveys for 21 days, which assessed cannabis use and alcohol use each day. results: multilevel models showed that perceiving more frequent simultaneous use among friends was associated with a greater propensity for simultaneous use relative to cannabisonly use across the daily assessments (or = 0.81, b = -0.21, se = 0.07, p = .003), even while controlling for descriptive norms for cannabis use frequency and alcohol use frequency in general. however, descriptive norms for simultaneous use were not significantly associated with propensity for simultaneous use relative to alcoholonly use across days (p > .05). in addition, in multilevel models predicting quantities of cannabis consumed on simultaneous use days, normative perceptions of heavier cannabis consumption during simultaneous use occasions among friends (b = 0.31, se = 0.10, p = .002) were associated with greater quantities of cannabis consumed across simultaneous use days, controlling for descriptive norms for quantities of cannabis consumed in general. further, in multilevel models predicting quantities of alcohol consumed on simultaneous use days, normative perceptions of heavier alcohol consumption during simultaneous use occasions among friends (b = 0.08, se = 0.03, p = .014) were associated with greater quantities of alcohol consumed across simultaneous use days, controlling for descriptive norms for quantities of alcohol consumed in general. conclusions: this study provides novel evidence that descriptive norms for simultaneous use contribute uniquely to simultaneous use patterns, over and above standard measures of descriptive norms for cannabis use and alcohol use in general. findings suggest that normative perceptions that are specific to simultaneous use should be examined in future research as potential targets of harm reduction interventions for simultaneous use among young adults. talk 3: exploring planned vs. unplanned cannabis use on cannabis only and alcohol co-use days: cannabis outcomes and order effects lindy k. howe (brown university) holly k. boyle (brown university) jane metrik (brown university) timothy j. trull (university of missouri) sharon lipperman-kreda (pacific institute for research and evaluation) rachel l. gunn (brown university) conference abstracts 278 background. alcohol and cannabis couse, including simultaneous use (sam; using alcohol and cannabis at the same time so that the effects overlap), is increasingly prevalent among young adults, prompting research into factors influencing risky patterns and outcomes of co-use. such factors may include intentions (i.e., plans) for using each substance. growing research has examined planned and unplanned alcohol use, and ecological momentary assessment (ema) studies have found that planned (versus unplanned) alcohol use is associated with increased consumption and likelihood of alcoholrelated consequences. however, studies examining planned and unplanned cannabis use are scarce. given unique patterns and contexts of cannabis and alcohol use, specific examination of cannabis intentions (planned/unplanned use) is warranted. additionally, emerging evidence indicates that the order of alcohol and cannabis consumption during co-use events influences consumption levels, yet no studies have examined the impact of order effects in the context of planned versus unplanned cannabis use. the current study explores the significance of cannabis intentions by investigating associations with consumption patterns, consequences, and the influence of co-use order effects. methods. 103 non-treatment seeking individuals aged 18-30 participated in a 28-day ema study. participants completed morning surveys (n=2,585 days) of previous day's cannabis and alcohol use, positive (e.g., “was more sociable”, “felt more energetic”) and negative (e.g., “neglected responsibilities”, “had difficulty concentrating”) consequences, and intentions to use cannabis on current day. separate multilevel models (controlling for between-person effects) assessed the associations between cannabis intentions and quantity of flower consumed and experience of positive/negative cannabis-attributed consequences on all cannabis use days (n=1,711 days). the interaction between daily order and intentions on consequences was examined on co-use days (n=1,014 days). results. person-level planned cannabis use predicted increased flower consumption (β=0.77, p<.001). also, planned cannabis use predicted the likelihood of experiencing a negative (but not positive) cannabis consequence at the day level (or=1.77, p<.01). analyses examining co-use days revealed no main effect of order, and no interaction between planned cannabis use and order. however, findings did reveal a main effect of sam use (versus co-use). specifically, sam use was associated with a higher likelihood of experiencing a negative consequence at the day level (or=2.66, p<.001). conclusions. findings underscore the importance of considering cannabis intentions when examining the relationships between cannabis use and consequences. findings indicate that planned cannabis use may increase the risk of negative outcomes, paralleling observations on alcohol intentions. although no significant order effects were found, main effects of sam use suggest that overlapping effects may contribute to negative cannabis outcomes. integrating these findings into preventive interventions, such as conference abstracts 279 addressing cannabis intentions before or after alcohol use, could enhance targeted approaches to mitigate the harms associated with alcohol and cannabis co-use among young adults. talk 4: within-episode relations among simultaneous alcohol and cannabis use and continued drinking: the role of momentary subjective responses, craving, and drinking context jack t. waddell (arizona state university) william r. corbin (arizona state university) kevin j. grimm (arizona state university) jane metrik (brown university) christine m. lee (university of washington) timothy j. trull (university of missouri) objective: simultaneous alcohol and cannabis use is associated with riskier daily drinking. however, little research has focused on momentary mechanisms through which simultaneous use confers risk for continued drinking behavior during acute drinking episodes. the current study tested whether simultaneous use moments conferred risk for within-episode increases in subjective responses, craving, and continued drinking, and whether these relations were potentiated in social vs. solitary settings. methods: emerging adults who co-use alcohol and cannabis (n = 85) completed 21 days of ecological momentary assessment with eventcontingent reports during drinking episodes. three-level multilevel models tested whether moments characterized by simultaneous use were indirectly associated with subsequent, continued drinking through subjective response patterns (i.e., high arousal positive/reward, high arousal negative/aggression, low arousal positive/relaxation, low arousal negative/impairment) and alcohol craving, and whether relations differed by social vs. solitary contexts. results: within drinking episodes, simultaneous use moments were associated with increased reward, which was indirectly associated with continued drinking through increased alcohol craving. in addition, the relation between simultaneous use and rewarding effects was potentiated during solitary drinking moments, whereas the relation between rewarding effects and craving was potentiated during social drinking moments. finally, simultaneous use moments were associated with increased relaxation, which was indirectly associated with a lower likelihood of continued drinking through lesser craving. conclusions: simultaneous use conferred acute risk for within-episode drinking, and acute subjective effects and craving served as mechanisms of risk, dependent upon drinking context. just-in-time interventions should consider the role of affect, craving, and context in eventspecific interventions. making decisions about cannabis use before, during, and after pregnancy chair: lauren micalizzi (brown university) discussant: robin j. mermelstein (university of illinois chicago) conference abstracts 280 the prevalence of cannabis use during pregnancy mirrors the upward trend seen in the general population, despite potential risks to both the pregnant person and child. it is therefore imperative and timely to delve into decision-making surrounding cannabis use before conception, in pregnancy, and postpartum. this symposium serves as a platform to present a comprehensive array of empirical findings, encompassing qualitative, quantitative, and mixed-method studies conducted on both local and national levels. dr. gunn will present a qualitative analysis of symptom management posts from an online procannabis forum for expecting parents. ms. denson will share insights from a mixed-method study examining motives for cannabis use and information sources among women planning to conceive or in the early postpartum phase. dr. mian will present findings from a mixed-methods study exploring clinical decisionmaking around intervention and impact on intervention engagement from the perspectives of mental health clinicians working with pregnant patients who use cannabis. dr. micalizzi will report on a national study of disclosure to providers and sources of information regarding cannabis use during pregnancy. discussant, dr. mermelstein will synthesize findings and explore pathways for evaluating perinatal cannabis use and for providing stigmafree information about cannabis use before, during, and after pregnancy. this symposium brings together researchers studying perinatal cannabis use through diverse lenses and methods, shedding light on provider and patient perspectives to provide a balanced understanding of the needs and concerns of individuals who engage in cannabis use while also identifying avenues to mitigate potential adverse effects. talk 1: use of cannabis to manage symptoms of mental health and physical conditions during pregnancy: analysis of a pro-cannabis pregnancy forum rachel l. gunn (brown university) elizabeth r. aston (brown university) lia artis (brown university) jacqueline nesi (brown university) lauren micalizzi (brown university) background: rates of prenatal cannabis use (pcu) have increased in recent years in tandem with the legalization and medicalization of cannabis. despite clear evidence of developmental health consequences to offspring, there has been a reduction in the perception of pcu-related harms. due to the stigma and risk of legal consequences associated with reporting cannabis use (cu) during pregnancy, individuals are often cautious to seek information about cu during pregnancy from their healthcare providers. thus, pregnant people are more likely to seek information from anonymous sources, such as online support forums. information from these anonymous online forums can shed conference abstracts 281 light on the patterns and motives for cu among this population. these insights can help to better inform prevention efforts aimed at reducing potential harms of pcu and improve intervention efforts for symptoms that are being managed with cu. methods: posts (n= 120) from an online pro-cannabis pregnancy forum called "ganja mamas" on whattoexpect.com were randomly selected (ten threads per month from june 2020 to may 2021) and analyzed if they covered topics related to pcu. a qualitative coding structure based on the existing pcu literature was used to apply thematic analysis to posts. each post was analyzed by two coders and associated codes were grouped into themes. codes on symptom management for physical and mental health were analyzed for the current study. results: four themes related to symptom management were identified. first, forum members discussed the use and impacts of cannabis use for a variety of mental health symptoms and related conditions including depression and anxiety. posters also discussed how they used cannabis for physical health symptoms and conditions, such as nausea and pain. third, they discussed the use of cannabis to achieve a general state of homeostasis and manage stress. finally, forum members discussed decision-making about using cannabis for symptom management, such as using cannabis instead of prescription medications. conclusions: individuals use cannabis during pregnancy for a wide variety of mental and physical health symptoms, including as a general strategy for managing pregnancy-related stress. in this pro-cannabis forum, most discussions reflected perceptions that cannabis was effective in treating the conditions for which it was used, but limitations of cannabis' efficacy were also discussed. there is a need for reduced stigma and increased open communication between pregnant persons who use cannabis and their providers in discussing how to manage their mental and physical health symptoms. understanding the various symptoms for which individuals use cannabis during pregnancy to self-treat can inform these conversations and the expansion of harm reduction strategies. talk 2: beliefs, message sources and message impact about preand postnatal cannabis exposure rebecca k. denson (university of illinois chicago) natania a. crane (university of illinois chicago) mayra guerrero (university of illinois chicago) robin j. mermelstein (university of illinois chicago) background and aims: the american college of obstetricians and gynecologists and public health agencies recommend that people who are pregnant, planning to get pregnant, or breastfeeding not use cannabis, as not all of the potential harms of cannabis use surrounding pregnancy are known. despite these cautionary messages, reported use of cannabis during pregnancy is increasing. many women are unaware of the risks of prenatal cannabis use or do not discuss conference abstracts 282 their use with their health care providers. the goals of this study were to understand more about reasons and beliefs about prenatal cannabis use, messages, and trusted sources of information about cannabis use during and after pregnancy among individuals contemplating pregnancy or recently pregnant to help guide future message development. methods: females aged 21-40 were recruited for focus groups. eligible participants used cannabis at least once/week and had been pregnant in the last year or planned to become pregnant in the next year. a baseline questionnaire assessed substance use and pregnancy history. focus group discussions covered reasons for cannabis use during pregnancy, messaging received, and trusted sources of information on prenatal cannabis exposure. focus groups were audio-recorded, transcribed, and analyzed using dedoose to identify key themes. results: participants (mean age =31 years, 17% hispanic/latina, 83% black/african-american, 17% white; mean cannabis use 4.08 days/week (sd=0.41); mean cudit-r score 14.0 (sd=6.07)) reported an average of 1.17 pregnancies (sd=0.41), and half planned to become pregnant in the next year; half reported current breastfeeding, and all planned to breastfeed in the future. most got their cannabis products through social sources and not formal dispensaries. most reported current alcohol drinking (2-4x/month), and 17% reported current use of cigarettes or e-cigarettes. thematic analyses revealed the importance of cannabis use to cope with physical and mental symptoms (e.g., nausea, stress) both during and post-pregnancy and its use to help increase enjoyment of the postpartum period. relative risks/benefits of not using cannabis versus using were also apparent in their decision making. participants perceived cannabis to be safer than tobacco or alcohol during pregnancy, but myths about potential negative effects on infants through breast feeding were also voiced. participants were eager to have information about cannabis from trustworthy sources and most relied on friends/family or internet sources. mixed experiences with medical providers about potential cannabis discussions were reported, with trust issues paramount. for example, concerns were expressed about potential negative outcomes with reporting use, particularly if states required reporting of use to public health authorities. conclusions: addressing mental health concerns throughout pre and post pregnancy may help reduce preand postnatal cannabis exposure. efforts to educate women about the health effects of cannabis use surrounding pregnancy should consider reasons for use and trust of medical providers. women may prefer to learn about the risks of prenatal cannabis use from friends and family members. talk 3: mental health clinicians' perceptions on patient motivations and intervention engagement for prenatal cannabis use: a mixed methods study maha n. mian conference abstracts 283 (university of california, san francisco; kaiser permanente northern california) monique b. does (kaiser permanente northern california) andrea altschuler (kaiser permanente northern california) andrea green (sacramento medical center, kaiser permanente northern california) deborah r. ansley (regional offices, kaiser permanente northern california) carley castellanos (regional offices, kaiser permanente northern california) derek d. satre (university of california, san francisco; kaiser permanente northern california) kelly c. young-wolff (university of california, san francisco; kaiser permanente northern california) aims: mental health clinicians are uniquely suited to provide interventions to individuals who use cannabis during pregnancy. examining the perspectives of these clinicians can provide important insights about pregnant patients' motivations for cannabis use and the factors that keep patients engaged in care. this mixedmethods study explored how mental health clinicians engage pregnant patients using cannabis. methods: participants were licensed mental health clinicians (early start specialists; ess) from kaiser permanente northern california's early start perinatal substance use screening, assessment and counseling program embedded within obstetrics clinics. ess completed an online survey (n=27; 100 % female; 73.1% white; mage=48.1) and a semi-structured qualitative interview (n=14) on their perceptions about patients' motivations for prenatal cannabis use and factors contributing to patient engagement in the early start program. interviews were transcribed and thematically analyzed. results: quantitative results indicated that ess perceived that nausea/morning sickness was the most common motive for using cannabis during pregnancy, and that pregnant individuals were most likely to get information about prenatal cannabis use from their peers. quantitative and qualitative results indicated that ess most often used motivational interviewing (mi) and psychoeducation to directly address cannabis use (100%). when working with patients who used cannabis to alleviate pregnancy-related symptoms, ess most often used psychoeducation (88.5%) to discuss alternatives to using cannabis. ess most often considered patients' motivation to change (100%) and prioritized harm reduction (hr) content (76.9%) when choosing an intervention, and further reported how patient readiness, therapeutic rapport, and interest in mental health support, particularly at the first clinical encounter, broadly facilitated intervention engagement and willingness to quit and/or reduce cannabis use during pregnancy. qualitative results also demonstrated that ess often integrated their expertise in other areas (e.g., sleep, family/child therapy, child conference abstracts 284 development) to support their work with pregnant patients who used cannabis. conclusions: this mixedmethods study found that developing strong rapport and using interventions that are tailored to patients' readiness to quit and include harm-reduction components can increase pregnant patients' willingness to engage in a perinatal substance use intervention. future clinical interventions might benefit from opportunities to address motivations for use and readiness to engage in care, emphasize peer support, bolster other sources of information for patients, and supporting the implementation of complementary interventions to address cannabis use. talk 4: prenatal cannabis use: disclosure and sources of information lauren micalizzi (brown university) lia artis (brown university) eric pedersen (university of southern california) rachel gunn (brown university) background: concern over reports to child protective services and stigma can serve as powerful incentives for pregnant people to conceal cannabis consumption from their providers. this reluctance presents a significant obstacle that hampers the delivery of comprehensive and effective prenatal care. consequently, other anonymous, but potentially less accurate, sources of information are often pursued. this study characterizes disclosure of prenatal cannabis use (pcu) to healthcare providers and assesses the sources of pcu-related information. methods: n=25 pregnant persons (mage = 30.24 [sd = 5.81], 68% white, 22% hispanic/latine) who currently use cannabis products with thc and live in the united states completed a video conferencing call to confirm their identity, screen for eligibility, and provide consent. this call was followed by a self-administered survey that queried demographics, substance use, disclosure, and cannabis-related beliefs and behavior via both closedand openended questions. participants in the first (28%), second (56%), and third (16%) trimesters retrospectively reported on pcu since finding out they were pregnant. results: first trimester pcu was daily or almost daily for 44% of the sample. while nicotine use was uncommon, 52% of the sample reported any alcohol use in the first trimester. of those, 38% reported drinking at least weekly. second trimester pcu was daily or almost daily for 33% of the sample and 33% reported any alcohol use; of those, one-third used alcohol at least weekly. frequency of pcu was at least weekly for all participants in their third trimester. use of other substances was uncommon, with no third trimester nicotine use identified, and only one participant reported any third trimester alcohol use. approximately half (52%) of the sample had not disclosed pcu to their provider; of those who did, 83% reported being completely honest about their use. of the 96% who sought pcurelated information, the internet (75%) and family/friends (63%) were the sources most used. less than half of the sample sought information about conference abstracts 285 cannabis use from their physician (42%) and/or a midwife (33%). qualitative analysis of responses to open-ended questions about the information received from these sources indicated that some pregnant people feel that they received mixed messages about the harms of pcu (e.g., “mixed messages…it’s old research that needs to be considered”) while others concluded that pcu was safe based on the information garnered (e.g., “there are no case studies of weed being harmful during pregnancy”). conclusions: it is imperative to create a safe space for non-judgmental, accurate patient-provider conversations about pcu. exploring individual difference characteristics of patients and providers, as well as aspects of the patient-provider relationship that promote honesty and disclosure, are worthy of further investigation. symposium title: reaching the modern cannabis consumer: using research to guide messages and strategies to close knowledge gaps and catch up to rapidly changing cannabis policy landscapes chair: sarah okey (washington state liquor and cannabis board) discussant: kristen haley (washington state liquor and cannabis board) cannabis policy has outpaced scientific knowledge on cannabis. as a result, misinformation about cannabis use is a concern and exists at both the industry and consumer-level. this symposium discusses current dissemination practices of evidence-based health and safety cannabis information to consumers. the first presentation by dr. loparco explores the quickly evolving online cannabis market space and shared findings on the prevalence and change in health warnings, benefits, and promotions across 175 u.s. cannabis retailers with online storefronts. the second presentation by dr. williams explores the extent to which consumers recognize health warning labels and recalls on cannabis packaging across three years using the international cannabis policy study. the third presentation by dr. okey discusses knowledge levels, current purchasing decisions, potential avenues for education, and areas of interest for washington state consumers and retail employees. all presentations explore differences between important subgroups, such as gender, age, and cannabis use characteristics. finally, discussant kristen haley, public health education liaison at the washington state liquor and cannabis board, integrates these three presentations. with her background in public health for over a decade overseeing instrumental marketing campaigns to promote health education, she highlights the importance of promoting evidence-based information for legal cannabis users to reduce harm and promote safety. she additionally discussed the importance of continued collaboration across regulators, researchers, and public health professionals within this quickly evolving cannabis landscape. talk 1: non-medical cannabis online retail practices in 5 us cities: 2022 to 2023 conference abstracts 286 cassidy loparco (george washington university) yuxian cui (george washington university) zongshuan duan (georgia state university) katie vinson (george washington university) katelyn romm (university of oklahoma health sciences center) yan wang (george washington university) patricia a. cavazos-rehg (washington university) erin kasson (washington university) y. tony yang (george washington university) carla j. berg (george washington university) objectives – cannabis industry marketing is a well-documented determinant of individual perceptions and use. retailers frequently promote their business/products online, reaching a broad range of consumers. however, online cannabis retail regulations are often non-existent, vague, or difficult to enforce. given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time. methods – in 2022 and 2023, researchers independently assessed 175 randomly-selected non-medical cannabis retailers’ websites across 5 us cities (denver, colorado; seattle, washington; portland, oregon; las vegas, nevada; los angeles [la], california, n = ~35/city) and dual-coded website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies); consensus was reached. analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities. results – similar to 2022, in 2023, 76.6% required age verification for site entry, 85.1% used social media promotion, and 90.9% offered online sales (82.4% of which required age verification for online purchase, 34.6% offered delivery, and 39.0% [vs. 57.6% in 2022, p < .001] indicated age verification for pickup/delivery). there were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4% to 15.4%), purchase limits (59.4% to 47.4%), health warnings (38.9% to 29.7%), health benefits (60% to 47.4%), discounts/price promotions (92.6% to 86.3%), and providing information/links to medical/mental health resources (25.7% to 3.4%). less than half (41-45%) sold cbd-only products across time points; there was a decrease in those selling delta-8 thc (8.0% to 0.6%, p < .001). across time points, similar proportions had imagery targeting teens/young adults (25.7%-30.3%), veterans (22.3%28.6%), and lgbtq+ (5.7%), but there were increases in imagery targeting racial/ethnic minorities (4.6% to 21.1%) and sexualized imagery (1.7% to 12.6%). in 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90% in denver, las vegas, la), allowed discounts/price promotions (100% in denver and las vegas), or required health warnings (48-60% in seattle and la vs. <20% elsewhere). despite all sites prohibiting youthoriented content and all but denver and las vegas prohibiting health claims, conference abstracts 287 30.3% posted content targeting youth/young adults (la = 8.1% to denver = 74.2%) and 47.4% health claims (seattle = 27.0% to denver = 71.0%). conclusions – increased use of social media, online cannabis retail, and delivery (especially without clear age verification procedures) presents risks for access and appeal to minors. moreover, online retail tended to emphasize health benefits and use price promotions, regardless of restrictions, indicating a need for greater regulatory efforts. notably, the proportion of websites showing health warnings decreased over time, which is concerning given that each of these states mandates specific warnings at the point of sale, indicating additional risk with online retail. additionally, the study revealed evidence of targeting specific subpopulations (e.g., youth, veterans, racial/ethnic minorities), indicating the need for increased surveillance among these populations and policies (and related enforcement) to restrict targeted marketing. talk 2: health warning labels awareness and recall and health beliefs in washington state jason williams (university of washington) sharon garrett (university of washington) beatriz carlini (university of washington) david hammond (university of waterloo) health warning labels (hwl) are a low-cost, sustainable way of communicating the health effects of products to consumers. in washington state cannabis product packages are required to display some hwls. we include under the umbrella of hwls warnings about legality that are implicitly about health, regarding driving after consumption and consumption by those under 21 years of age. hwl requirements vary slightly by product type. the current presentation provided wa state findings on hwl awareness and recall from three years of data post-legalization (2020-2022) from the international cannabis policy study, a repeat cross-sectional study. the presentation focused on respondents who had reported seeing a cannabis product package in the past 12 months (n = 1018 in 2020, n = 1061 in 2021, n = 1848 in 2022). initial analysis indicated 40% of these respondents reported seeing at least one hwl, with higher levels among more frequent cannabis users. among those who reported seeing a hwl, 50% recalled a warning against driving or operating machinery, the highest rate of recall. the presentation included information on the correspondence of specific hwl recall and specific health beliefs, and the relationship between hwl awareness and recall and gender, age, and cannabis use patterns. talk 3: current knowledge levels and interest in education among cannabis consumers and retail employees in washington state sarah okey (washington state liquor and cannabis board) kristen haley conference abstracts 288 (washington state liquor and cannabis board) brian mcquay (washington state liquor and cannabis board) jordan arias (washington state department of health) nikki meline (washington state department of health) sally riggs (washington state department of health) mary segawa (washington state liquor and cannabis board) objectives: more adults have access to legal cannabis than ever before. however, content knowledge about cannabis products and safer ways to use remains limited. research is needed to better understand what extent consumers are interested in learning more and potential avenues to promote informed decision making. as such, the washington state liquor and cannabis board (lcb) and the washington state department of health collaborated to develop a survey that would inform future educational campaigns and promote public health and public safety of adults who use cannabis. methods: adults aged 21+ (n = 439) completed an anonymous, voluntary survey from december 2023 through january 2024. respondents were both legal cannabis consumers and retail employees who accessed the online survey through qr codes displayed in washington retail cannabis stores. survey respondents answered questions on demographics, cannabis use, where they typically get information about cannabis, information currently used to make purchasing decisions, and interest in further education. respondents additionally took a knowledge quiz that tested current understanding of basic cannabis information (e.g., “true or false: cannabis products are approved by the fda to treat, cure, and prevent disease”). linear and binary logistic regressions were used to examine purchasing decisions, interest in learning more, and avenues for education. covariates included age, gender, frequency of cannabis use, length of time using cannabis, knowledge levels, and employment at a retail store. results: current knowledge levels for consumers were relatively low with the average score on the knowledge check being 43% for consumers and 57% for retail staff. cannabis retail staff (β = 1.03, p < .001) and those who had been using cannabis for a longer period of time (β = 0.02, p = 0.05) answered more questions correctly. when examining information used to make purchasing decisions, subgroup differences emerged. for example, employees were less interested in knowing the thc concentration when making a purchase relative to cannabis consumers (β = 1.72, p < .001). most people (50%) reported being interested or extremely interested in receiving more education at retail stores. again, subgroup differences emerged on what information would be most interesting. for example, more frequent users were more likely to be interested in tips for safer use relative to less frequent users (or = 1.26, p = 0.03). by far, the two most popular avenues for education identified by all respondents were conference abstracts 289 cannabis product labels and budtenders. conclusions: consistent with prior research, findings underscore the need to increase effective, evidencebased information for both cannabis consumers and retail employees. survey results provide a positive outlook that consumers and staff are interested in becoming more informed about cannabis. group differences emerged related to specific types of information consumers currently weigh when making purchases as well as what types of information would captivate their attention. further research is needed on how to provide reliable and evidencebased information using the avenues (budtenders and packaging) identified by respondents. symposium title: the effects of cannabinoids in different contexts, age groups, and conditions: new neuroscientific and behavioral directions chair & discussant: godfrey d. pearlson (yale university/institute of living) the symposium focuses on a series of new directions in emerging neuroscience research, investigating two of the best-studied cannabinoids – thc and cbd. although the field is poised to use cannabinoids to modify behavior in a wide variety of circumstances, there is a clear need to quantify the real-world impact of potential risks (e.g. cognitive impairment, motor vehicle crashes) versus benefits (e.g. clinical treatment of a wide variety of medical and psychiatric conditions). in turn, these risks and benefits are likely to differ across different populations, doses, and at different life stages. similarly, cannabinoid effects may vary significantly across different cognitive domains, and differentially affect underlying neurobiological mechanisms. different effects across the adult age spectrum are particularly important to study. increasing numbers of older individuals are beginning to use cannabis both recreationally and medicinally, yet reported evidence is contradictory (e.g., thc is reported to improve certain aspects of memory in aging rodents but impairs immediate memory function in younger human laboratory participants). this symposium focuses on using neuroscience tools to quantify cannabinoid effects on brain and behavior at different doses and in different age and diagnostic groups. we report on five diverse questions: 1) cannabis-related driving behavioral and subjective impairment, 2) thc effects on resting-state fmri, 3) thc effects on memory and subjective effects across the adult age span, 4) potential therapeutic effects of cbd on memory function in psychosis, and 5) thc impairment of mental timekeeping mechanisms. talk 1: cannabis-impaired driving: insights from a randomized, placebocontrolled, double-blind driving simulator study shashwath a. meda (yale university/institute of living) godfrey d. pearlson (yale university /institute of living) erwin boer (entropy control inc.) conference abstracts 290 nicholas ward (university of montana) marilyn huestis (institute for emerging health professions/thomas jefferson university) nina fernandez (institute of living) cole arnold (institute of living) michael c. stevens (institute of living/yale university) background: driving safety under the influence of prescribed and recreational drugs is a major concern. with the legalization of medical and recreational cannabis, the number of drivers intoxicated from recent cannabis use will continue to increase. different studies provide wide ranges of risk estimates for being involved in a cannabis-associated motor vehicle crash or driving-related injury. thus, we need more direct, informative approaches to understand cannabis effects on driving safety. methods: we utilized a randomized, placebo-controlled, counterbalanced, double-blind design to study 38 psychiatrically healthy adults, aged 18-40 years, with >2 years of recent highway driving experience and a current driver's license. 34/38 participants were regular cannabis users, (at least once weekly for the last 3 months). each participated in three separate full-day sessions. participants inhaled an acute dose of vaporized cannabis, either 29.5 mg, 65 mg thc, or an identical placebo using a computerpaced inhalation protocol, ensuring standardized route and timing. throughout each 8-hour assessment day, at four time points, participants underwent simulated driving tests, including lane-keeping, car following, and overtaking tasks, capturing nineteen different behavioral metrics. a linear mixed model in spss assessed main effects of dose, time, and dose × time adjusted for sex, time since dose, usage group, and age for the above driving metrics. results: blood metabolite analysis revealed that primary delta-9-thc levels increased significantly until ~22 minutes after cannabis inhalation. subsequently, differences in thc levels compared to placebo became non-significant. secondary delta-9-carboxy-thc levels were significantly higher until ~ 83 minutes post-dose. blood thc and metabolite measures were essentially unrelated to driving impairment. we identified six specific impaired driving outcomes that were significantly affected by cannabis use across the three simulated driving tasks. lane keeping task: participants exhibited reduced steering reversal rates (srr) post-drug. this impairment in vehicle control persisted for up to 5.5 hours following the 65 mg and 3.5 hours following the 29.5 mg dose of cannabis. car following task: participants showed significant reductions in pedal engagement and reversal rates postdrug, indicating impaired responsiveness to changes in driving conditions. similar to the lane-keeping task, these impairments persisted for 13 hours after cannabis use (65 mg dose only). overtaking task: post-drug, drivers demonstrated a shorter median gap to passed cars, resulting in less time estimated to a potential collision. they spent more time in the oncoming traffic lane while passing, an effect that conference abstracts 291 persisted longer in the 65 mg condition. these measurements improved slowly and to varying degrees over time. selfreported assessments indicated that two-thirds of the participants were willing to drive despite being subjectively aware that they were impaired. objective measurements, however, revealed significant impairments in driving performance during these periods, highlighting the potential risks associated with individuals underestimating their impairment. conclusion: this study provides valuable insights into cannabis effects on driving behavior. findings highlight the complex nature of cannabis-related impairments, affecting both automatic and goaldirected driving behaviors. future research should explore the interaction between drug effects and drivers' risk awareness to inform public health policies and legal standards for cannabis-related driving safety. talk 2: thc affects resting state brain network connectivity differently in older and younger adults michael c. stevens (institute of living/yale university) shashwath a. meda (yale university /institute of living) cole arnold (institute of living) nina fernandez (institute of living) godfrey d. pearlson (yale university /institute of living) background: as cannabis legalization expands, it becomes more important to understand its acute effects on brain function across different age groups. the effects of δ9-tetrahydrocannabinol (thc) – the primary psychoactive compound in cannabis – on cognition and brain function have been extensively studied in younger populations, but almost entirely neglected in older adults. there are well-described age-related changes in brain structure and function that raise the possibility that the endocannabinoid system changes with age in ways that could influence the older individuals' response to thc. this study compared the acute effects of thc on resting-state brain function in young and older subjects using functional magnetic resonance imaging to quantify whole brain connectivity during an unstructured resting state paradigm (rs-fcmri). methods: we conducted a double-blind, randomized, placebocontrolled, within-subject crossover acute cannabis challenge study with 29 adults, comprising 15 younger (mean/sd age = 25.5/4.2 years) and 14 older individuals (66.2/3.5 years). on two separate days, participants received a single dose of 65 mg of thc or a 0 mg thc placebo using a paced inhalation vaporizer administration protocol. approximately 30 minutes after dosing, participants underwent 7 minutes of eyes-open rs-fmri data collection. fmri data was prepared for modeling using a standard fmriprep 20.2.6 protocol. an automated and adaptive independent component analysis (ica) based on the neuromark template in the gift toolbox was used to derive 53 statistically independent intrinsic networks across eight functional domains sensorimotor (sm), visual (vis), auditory (aud), default mode (dmn), cognitive control (cc), conference abstracts 292 cerebellar (cb) and subcortical (sc). individual level static functional network connectivity matrices were computed by calculating pearson correlations between the time courses of the 53 intrinsic ica networks, fisher ztransformed, then subjected to a mixedmodel analysis in r to explore the effects of drug, group, and drug × group interactions (pilot results thresholded p < 0.01 uncorrected). results: after placebo, older adults had increased connectivity between nodes of smsc/aud/vis networks and sm-cb, as well as lower connectivity between smaud/vis and sc-cb networks. this age-related difference was comparable after active thc, but older adults showed additional reductions in audvis and increased sm-cb connectivity compared to younger adults. drug × group interactions were noted primarily in network connections between scsm/vis/cc, sm-cc/dmn, vis-cc, and cc-dmn, many of whose regions are rich in cb1 receptors. conclusion: these alterations in functional connectivity suggest older adults' brains have distinctly different responses to thc, potentially indicating the drugs' agonist effect on cannabinoid receptors alters the exchange of information among distal brain regions. these findings contribute to our understanding of the impact of cannabis on brain function across the lifespan and emphasize the importance of considering age-related variables in cannabis research and clinical interventions. further investigation into the underlying mechanisms driving age-related differences in thc effects on brain connectivity is warranted, with implications for informing personalized approaches to cannabis use and mitigating potential risks associated with its consumption, particularly in older populations. talk 3: acute effects of thc on memory performance and related brain activation across the adult age spectrum shashwath a. meda (yale u./institute of living) godfrey d. pearlson (yale u./institute of living) nique pichette (institute of living) nina fernandez (institute of living) cole arnold (institute of living) michael c. stevens (institute of living/yale u.) background: cannabis legalization has significantly increased cannabis use among older adults. compared to extensive research on acute thc effects in young adults, little is known about whether thc affects older adults differently or confers greater risk. thc impacts memory significantly, a domain crucial for function and quality-of-life at older ages, whose impairments may presage dementia. we examined whether thc disrupts short-term relational and item-specific memory performance and associated hippocampal activity more in older vs younger adults. methods: fifteen younger (mean/sd age = 25.5/4.2 years) and 14 older cannabis-using adults (66.2/3.5 years) participated in a doubleblind, randomized, counterbalanced, placebo-controlled, within-subject, conference abstracts 293 crossover, acute cannabis challenge study. on two separate study days, participants inhaled a single dose of either 65 mg thc or 0 mg (placebo) thc from vaporized cannabis plant material. twenty minutes later, they underwent fmri using the relational and item-specific encoding (rise) paradigm. after quantifying expected memory performance and brain activity alterations in both groups on relational encoding, item-specific encoding, and recall/recognition, differences between age groups were evaluated in r mixed models (i.e., the drug × group interaction). preliminary results at p <. 05 are reported (fmri results used a contiguous clusterwise extent k = 10). results: behavioral analyses revealed slowed (p < 0.05) overall reaction time for older versus younger adults, with similar accuracy across all conditions. during the associative recognition phase, there was a trend-level significance for a drug × group interaction (p < 0.08) for rt. older adults also reported feeling more subjective intoxication (vas 'high') on the active drug, (trend-level p < 0.1). across all conditions, placebo administration resulted in significantly greater hippocampus/ parahippocampus brain response in older adults. thc altered this profile of older adult activity in different ways for every stage of memory encoding and recognition we examined older adults 1) activated more voxels during encoding, 2) had a more widespread extent of decreased activity compared to younger subjects during item recognition, 3) failed to show the expected normal older adult difference during relational memory recognition, and 4) activated a greater extent of voxels during associative item recognition. in the rest of the brain, we observed many group × drug interactions that indicate thc affected widespread brain activity differently for older and younger adults. these included the insula, cerebellum, anterior cingulate, thalamus, and caudate across all conditions, as well as prefrontal (ba 10/11) and inferior frontal (ba 47) cortices during encoding and item recognition. conclusions: our findings show that in older adults the same 65 mg thc dose slows memory task performance more and that this is accompanied by diverse, widespread differences in cortical and subcortical brain activation during some forms of recognition. the greater impact on memory-related circuitry in older adults suggests that thc intoxication can induce complex differential effects in key brain regions related to memory function between younger and older adult populations. further research is warranted to replicate these findings and to address existing knowledge gaps, to help develop informed public health strategies and to guide clinical practices tailored to the unique needs and vulnerabilities of older cannabis users. talk 4: exploring cannabidiol effects on memory dysfunction in psychosis: a pilot fmri study godfrey d. pearlson (yale university /institute of living) michael c. stevens (institute of living/yale university) cole arnold (institute of living) nina fernandez conference abstracts 294 (institute of living) tremearne hotz (institute of living) shashwath a. meda (yale university /institute of living) background: deficits in relational memory are extensively documented in individuals with psychosis. contradictory evidence suggests that cannabidiol (cbd), a non-intoxicating constituent of cannabis, may possess antipsychotic properties in individuals with established psychosis. this study sought to elucidate the potential impact of cbd on mitigating memory impairments and clinical symptoms observed in psychosis. methods: fourteen patients with established psychosis, not currently in an acute episode, but with significant residual symptoms (mean/sd age = 37.5/9.5; 7 females) and five healthy controls (27.2/7.6; 3 females) participated in a double-blind, randomized, placebocontrolled, within-subject, crossover design study. participants received a single dose of orally administered cbd (600 mg) or a matched placebo on separate days. three hours postadministration, participants underwent fmri scanning using a relational and item-specific encoding (rise) paradigm. during the rise fmri task, participants engaged in encoding tasks where they formed associations between stimuli (relational encoding) or remembered individual items (itemspecific encoding). subsequently, memory for these stimuli was assessed, including recognition of individual items and associations. corresponding behaviors (accuracy and reaction time) for the above task conditions were evaluated for group, dose, and group × drug interactions using r. brain activation interactions between controls/psychosis groups and dose conditions were analyzed across the three task phases (encoding, item recognition, and associative recognition) using a second-level analysis in spm. given the exploratory nature of the study, fmri results were thresholded at p < 0.05 uncorrected voxelwise, k = 10 cluster. results: during the relational item recognition phase, a significant main effect of drug (p = 0.004; cbd > placebo) and drug × group interaction (p = 0.003) emerged for the standard deviation of reaction time, while all other behavioral effects were nonsignificant. in terms of brain function, under the placebo condition, the psychosis group exhibited lesser brain activity in the hippocampus and/or parahippocampus across all task phases. furthermore, there were many drug × group interactions across all task phases in various brain regions, including the hippocampus/ parahippocampus, putamen, caudate, cerebellum, anterior cingulate, fusiform gyrus, and insula. notably, interactions were also observed in inferior/midprefrontal regions during encoding and item-specific recognition tasks. for the psychosis subjects, a modest (but nonsignificant) improvement in positive symptoms as assessed using the positive and negative syndrome scale (panss) was noted after cbd administration. conclusions: current findings from this small-scale study suggest cbd has the potential to change memory-related brain activation in psychosis, performance variability, and symptom severity. these results conference abstracts 295 highlight potential therapeutic targets for future interventions aimed at improving psychosis-associated cognitive deficits. talk 5: new insights into how thc disrupts our estimation of time michael c. stevens (institute of living/yale university) shashwath a. meda (yale university /institute of living) erwin boer (entropy control inc.) nicholas ward (university of montana) godfrey d. pearlson (yale university /institute of living) background: thc can alter how we experience the passage of time, most notably over-estimation of elapsed time interval duration. some believe thc may speed up the brain's internal clock, possibly through cb1 receptor agonist effects. but it is unknown exactly how thc alters timekeeping-related processing, or what macro-scale brain systems are involved. design: we used "drift-diffusion" computational modeling to test whether thc accelerates information aggregation when comparing time interval estimates. we also examined fmrimeasured brain activity to identify regions underlying thc's effects. n = 44 healthy adult cannabis users underwent an acute drug challenge using inhaled vaporized cannabis of 0 mg, 29.5 mg, or 65 mg thc on separate study days in a within-subject, randomized, counterbalanced design. at fixed times between 0.5and 5.5-hours post-dosing, participants completed an fmri time estimation task. they attended to two successively presented short(500-900 msec) or long-interval (1500-1900 msec) visual stimuli, then discriminated which had the longest duration. average reaction-time differences were evaluated using r mixed-models. informative parameters were derived from individual trial choice and reaction-time data using a python-based hierarchical drift diffusion modeling toolbox (hddmv0.8.0). parameters included speed of information accumulation ('v'), amount of evidence needed to reach a threshold that triggered responses ('a'), and speed of non-decision sensory and motor processes ('t'). single-trial brain activity estimates were extracted from fmri timeseries so hddm regression models could identify which regions' activity predicted parameter values and evaluated thc's effects on these relationships. dose and persistence effects for hddm parameters and fmri brain activity were evaluated using bayesian statistics (p > .90 were meaningful). results: following 65 mg thc doses, neither information accumulation rate 'v' nor non-decision time 't' changed. participants showed significantly higher 'a' decision-making for 65 mg thc versus placebo for longinterval trials, both 0.5 (p = .93) and 2.5 (p = .92) hours post-dose. parameter effects after 29.5 mg thc were comparable but less definitive. fmri analysis found trials with lower activity, relative to placebo, in left dorsolateral, ventrolateral, anterior cingulate and other prefrontal regions predicted higher 'a' decision thresholds. higher 'a' thresholds were also linked to greater activity in the left cerebellum, left thalamus, and left-hemisphere conference abstracts 296 frontoparietal network regions. conclusion: while 65 mg thc doses generally slowed time estimation task performance for up to 3.5 hours, this appeared unrelated to information aggregation speed, sensory, or motor processing on long-interval trials. instead, 65 mg thc caused participants' decisions to require greater neural evidence compared to placebo, reflecting diminished activity in brain regions specialized for executive function and working memory. this drug-induced threshold change could reflect many mechanisms. prior research reports that higher 'a' thresholds typically lead to slower but more accurate responses to overcome 'noise' in decision-making processes. however, the relevance of specific disruption to mental timekeeping is underscored by this 'a' threshold effect being only observed clearly for longinterval trials that presumably confer greater demands to represent and use time duration information to guide choices. future studies can use driftdiffusion modeling with a different tasks and various endocannabinoid system altering drugs to better understand thc's modulatory effects of brain function and cognition. symposium title: retail cannabis dispensaries: examining purchasing behavior and exposure to product marketing chair: eric r. pedersen (keck school of medicine, university of southern california) cannabis retail dispensaries have proliferated in the united states in recent years, making it an important time for conducting research on purchasing behaviors and exposure to product marketing within these environments. purchasing behaviors may be driven by how consumers in dispensaries view and interpret cannabis product packaging, including how they view the health benefit claims and warning labels displayed on the products. storefront employees are also promoters of the products and the claims employees make could influence purchase decisions. thus, it is important to better understand how cannabis products are marketed to consumers within dispensaries. in this series of four talks, presenters will describe research studies conducted within cannabis dispensaries to examine regulatory compliance (e.g., age verification), health warnings displayed, promotion of health benefits, and purported effects on mood and behavior (e.g., sleep, energy). researchers will discuss a variety of methods to obtain their findings, including self-report surveys, observations, qualitative interviews, and experimental manipulation of products within controlled settings. in addition to informing methods for the future of cannabis dispensary research, findings have implications for policy around dispensary locations and regulation within these environments. talk 1: young adults' experiences with cannabis retailer marketing and regulatory compliance: differences by sociodemographic characteristics and associations with cannabis userelated outcomes carla j. berg conference abstracts 297 (milken institute school of public health, george washington cancer center, george washington university) katelyn romm (tset health promotion research center, stephenson cancer center, university of oklahoma health sciences center) cassidy r. loparco (milken institute school of public health, george washington university) matthew e. rossheim (school of public health, university of north texas health science center) yuxian cui (milken institute school of public health, george washington university) darcey mccready (milken institute school of public health, george washington university) y. tony yang (george washington cancer center, school of nursing, george washington university) elizabeth platt (center for public health law research, temple university beasley school of law) patricia a. cavazos-rehg (washington university school of medicine) objectives – limited cannabis retail surveillance has been conducted, particularly assessing retailer practices in relation to consumer sociodemographic factors or use-related outcomes. this study examined young adults’: exposure to promotions, health claims, warnings, and age restrictions at cannabis retailers; demographic correlates of retail exposures; and retail exposures in relation to use-related outcomes. study design – crosssectional quantitative analysis. methods – we analyzed 2023 survey data among 876 young adults in states with legal non-medical cannabis, reporting past-month cannabis use and past-year retailer visits. results – in this sample (mage = 27.1, 44.1% male, 31.7% sexual minority, 17.7%, black, 11.2% asian, 25.1% hispanic), 46.7% ‘at least sometimes’ noticed free samples, 76.5% price-promotions, 37.4% subpopulation-targeted promotions; 72.5% health claims on products/ads, 63.1% signage, and 70.5% from budtenders; 72.5% warnings on labels, 65.5% signage, and 38.9% from budtenders; and >80% age verifications. multivariable analyses identified sociodemographic correlates of exposure outcomes: greater promotion exposure was associated with black race; greater health claim exposure with being heterosexual, black, and less educated; less warning exposure with less education; and less age restriction exposure with being younger, male, and black. retail exposures were associated with use-related outcomes: more frequent cannabis use was associated with less health claim exposure; greater perceived social acceptability with greater promotion and age restriction exposure; greater perceived risk with greater warning and less age restriction exposure; more problematic use and driving after use with greater promotion and less age restriction exposure. conclusions – cannabis retail exposure disparities and their associations with use-related outcomes highlight the conference abstracts 298 importance of regulatory and prevention efforts. talk 2: point-of-sale cannabis marketing: findings from a direct observation study of recreational cannabis outlets in massachusetts kristina m. jackson (rutgers addiction research center, rutgers robert wood johnson medical) michelle l. rogers (survey research center, brown university school of public health) elizabeth r. aston (center for alcohol and addiction studies, brown university school of public health) katie m. yetter (center for alcohol and addiction studies, brown university school of public health) jennifer merrill (center for alcohol and addiction studies, brown university school of public health) holly k. boyle (center for alcohol and addiction studies, brown university school of public health) jane metrik (center for alcohol and addiction studies, brown university school of public health, providence va medical center) messages about the health benefits and risks of cannabis products directly shape individuals' reasons for use. identifying the sources of messaging about the effects of cannabis is critical for understanding the processes by which messages impact cannabis use. the goal of this direct observation study was to explore point-of-sale marketing as an important cannabis messaging source. we conducted systematic coding of cannabis retail outlets in massachusetts, a state with legalized recreational cannabis use since 2016. sixty licensed retail outlets were randomly selected within six regions from the massachusetts cannabis control commission website. trained coders aged 21+ conducted site visits in two-person teams and coded aspects of the outlet exterior (e.g., signage) and interior (e.g., product labels) during the visit or immediately upon exit. codebooks were developed based on existing surveillance tools and our pilot work to develop codes for therapeutic benefits and/or health harms/warnings. coders noted minimal signage on the exterior, with 27% displaying sidewalk signs about cannabis products sold, and only one billboard in view. other visible buildings/retail stores (83% of outlets) included 9 alcohol retailers, 3 vape shops, and 3 tobacco retailers. in the interior, warning signs related to id and age 21+ were common (85%, 87%), followed by bans on consumption on premises (~50%). thirteen percent of outlets had signage that vape products may cause harm; information about consumption during pregnancy was noted in only 2 outlets. displays with cannabis risks were minimal and were present largely at the ordering counter (13% of outlets), with none on product display cases and only one on the wall. in the vast majority of outlets (82%), no warnings about cannabis' effects were displayed openly, and those shown were few (e.g., caution about driving after using, protect from kids). effects ("buzzwords") of cannabis were presented primarily on product display conference abstracts 299 cases (63%), with 23% on wall displays and only 8% at the counter. improved sleep was the most commonly reported effect (50% of outlets); others pertained to energizing effects: energetic (37%), uplifting (28%), aroused (10%); sedating effects: relaxed (28%), calm (22%); mood effects: happy (20%), stress (15%), mood (7%), anxiety/anti-anxiety (5%); other: focus (15%), creative, inspired (10% each). pain relief was reported as a benefit in 20% of outlets. terpenespecific displays were few and predominately contained therapeutic effects, including anti-anxiety, antiinflammatory, anti-depressant, and pain relief. few risks of cannabis use were depicted across outlets and were only displayed at point of purchase. effect descriptions were limited to product display cases and included energizing and sedating effects; other than sleep there were modest claims about therapeutic effects. retail outlets may be motivated to promote positive effects and minimize negative effects as a means of increasing sales revenue. findings also provide early evidence that the cannabis industry is marketing terpenes as a means to promote the health benefits of cannabis products. as the legal cannabis market continues to rapidly increase nationwide, a better understanding of marketing strategies is imperative as these venues become an even greater influential source of messaging. talk 3: budtender recommendations of cannabis products for therapeutic and recreational use: a cannabis retailer surveillance study jane metrik (center for alcohol and addiction studies, brown university school of public health, providence va medical center) elizabeth r. aston (center for alcohol and addiction studies, brown university school of public health) holly k. boyle center for alcohol and addiction studies, brown university school of public health) jennifer merrill (center for alcohol and addiction studies, brown university school of public health) katie m. yetter (center for alcohol and addiction studies, brown university school of public health) michelle l. rogers (survey research center, brown university school of public health) kristina m. jackson (rutgers addiction research center, rutgers robert wood johnson medical school) cannabis is widely perceived as normative and therapeutic despite limited scientific evidence to support such claims for many conditions. there is insufficient data to provide guidance on the use of cannabinoids for the treatment of various medical and mental health conditions within the current regulatory framework. nevertheless, cannabis retail outlet employees (i.e., budtenders) guide patrons in their selection of specific product strains, cannabinoid profiles, and formulations for desired physical and mental effects. in states with legal cannabis markets, budtenders are an important transmitter of knowledge conference abstracts 300 regarding benefits and potential risks of cannabis; however, little is known about the types of messages communicated to customers looking to use cannabis recreationally or for common indications such as pain, anxiety, and sleep. the current study aims to characterize cannabis messaging from budtenders using validated surveillance and qualitative methods. in summer 2023, trained coders (n=4) aged 21+ visited 60 licensed adult-use recreational cannabis retail outlets that were randomly selected from 6 regions in massachusetts (ma). working in 2person teams, one coder engaged a budtender in a conversation seeking product recommendations for pain (n=22), anxiety (n=23), or sleep problems (n=17) as well as recommendations for recreational use (n=41). the other coder listened and recorded the recommendations electronically using a checklist and open-ended field notes. both coders debriefed and audio-recorded their narrative immediately upon exiting the outlet. field notes were reviewed against transcribed audio-recordings and quantitative checklists for accuracy and then dual-coded using applied thematic analysis by two individuals not involved in data collection. several prominent themes were identified in budtender recommendations across condition: (1) product formulation, (2) plant species, and (3) cannabinoid profiles. for pain, the majority of recommendations were for edible products containing cannabidiol (cbd) in higher or equal ratios to delta-9-tetrahydrocanabinol (thc), as well as those labeled as "hybrid" (indica and sativa) species. for sleep, the vast majority of recommendations were for edible indica products containing cannabinol (cbn) or a thc/cbd combination. for anxiety, the majority of recommendations were for edibles or flower, indica-based products, cbd in higher or equal ratios to thc, low thc concentrations, and warnings against use of primary sativa products. for recreational use, the majority of recommendations were for edibles/drinkables followed by flower pre-rolls containing lower thc and/or cbd doses; recommendations for sativa-dominant or hybrid products were predominant, often including explicit mention of expected effects (e.g., social, uplifting). consistent with the documented expansion of the cannabis edibles industry, findings suggest oral formulations are now marketed for both medicinal and recreational purposes, often to a greater extent than inhaled cannabis products. products with specific cannabinoid profiles and plant species were recommended for their alleged therapeutic effects despite the dearth of controlled research on the pharmacological effects of the specific cannabis chemotypes and constituents as well as lack of standardized dosing guidelines. this research finds evidence of cannabis retailers sending influential messages to consumers, even though ma state regulatory requirements prohibit advertisement of cannabis' therapeutic effects when not supported by substantial scientific evidence. talk 4: conference abstracts 301 developing a retail cannabis shop for research: exploring employee messaging and consumer decisions on cannabis products eric r. pedersen (keck school of medicine, university of southern california) mark a. prince (colorado state university) bethany gray (colorado state university) ireland m. shute (keck school of medicine, university of southern california) megan b. brown (keck school of medicine, university of southern california) keegan buch (keck school of medicine, university of southern california) john monterosso (university of southern california) almost half of the states in the u.s. have legalized recreational cannabis for sale and possession. most of the legalized states have licensed retail stores that offer purchase and delivery of cannabis products. the city of los angeles alone has over 230 of these licensed retail cannabis dispensaries, where consumers are exposed to a wide variety of products in packages that contain unique labels describing the required risk statements, recommended serving sizes, purported health benefits, and ingredients. researchers have begun to examine how cannabis consumers view and interpret cannabis product packaging, including how they view the health benefits and stated risks of the product based on labeling. given the increasing access to cannabis dispensaries, it is important to examine the purchasing behavior of young adults, to learn more about what attracts them to certain products and what health and risk messages they glean from product packings. beyond the messaging that the products alone convey to consumers, it is important to examine how storefront employees (managers, budtenders, cannabis consultants) interpret product messaging and how they would convey such messaging to consumers. employees have been shown to be an influential source of messaging about products for young adults, including promotion of health benefits and minimization of potential risks. in this presentation, we describe the development of a mock cannabis dispensary, where we observe cannabis consumers' product purchasing decisions and employees' selling behaviors in an experimentally manipulated environment. we built connections with local dispensaries to help us stock the shelves with packaging-only products (i.e., products that contain no cannabis but look and feel like they do). we gathered and labeled products of different types (edibles, vapes, flower prerolls, concentrates, beverages, topicals) with different amounts of cannabinoid concentrations (e.g., thc, cannabidiol [cbd], cannabinol [cbn]) and varying levels of potency (e.g., high levels thc in a single edible). we named the facility the cannex (or the "cannabis annex") and it serves as a mock cannabis dispensary where we invite cannabis retail store workers to view the products we are offering and describe, via recorded qualitative interviews and brief surveys, what conference abstracts 302 messages they would share about the products with consumers if they were selling those products in their stores. we also invite young adults with varying levels of cannabis use experience (infrequent use of < 6 times per year, occasional use with between 2 times per month to once per week, and regular use with near daily/daily use) to come to the cannex, view the products on display, and use a generous "budget" to "purchase" products. research staff interview the participants to learn why they chose each product for purchase, what subjective effects they believe the product would have based on packaging, and why they did not purchase other products within the dispensary. the cannex represents one of the first mock cannabis dispensary labs in the country that allows for observation of participants in a dispensary environment that can be manipulated to fit the needs of researchers. symposium title: a within-subjects and placebocontrolled observational assessment of self-administered cannabis edibles chair: emma e. smith (colorado state university) discussant: bradley t. conner (colorado state university) the present study is a double-blind, placebo-controlled investigation of the subjective and objective intoxication onset from different thc forms in edibles among 20 regular cannabis users across three sessions in a mobile laboratory. participants consumed regular-acting thc gummies (10mg thc), fast-acting thc gummies (10mg thc), and placebo gummies (0mg thc) they purchased from dispensaries. the study measured subjective and objective intoxication and biological outcomes at 13 time points before and after ingestion, aiming to determine if fast-acting gummies induced quicker intoxication compared to regular-acting and placebo gummies by assessing blood concentrations of thc and its metabolites, thc-oh, and thccooh. participants were screened for cannabis use and other drug use at each session, and those meeting inclusion criteria underwent a series of intoxication measures and blood draws via an intravenous port placed by researchers at the beginning of each session. the research sought to provide empirical evidence on the effects of thc in edible forms, contributing to the understanding of typical intoxication profiles of thc compounds in legally marketed edibles and their public health implications. this observational study aimed to close gaps in cannabis science, particularly around the onset of intoxication from thc, offering insights into safer consumption practices and informing future cannabis research and policy. talk 1: methods and recruitment in a mobile cannabis van study: an overview kira sturgess (colorado state university) emma e. smith (colorado state university) samuel m. dicecco (colorado state university) katelyn weldon conference abstracts 303 (colorado state university) bradley t. conner (colorado state university) at first glance, it may seem like finding potential participants who are willing to engage in multiple six-hour long experimental sessions while using cannabis provided by a stranger in a white van would be an impossible task. however, researchers at a large western state university successfully recruited and screened 687 participants for a mobile van study examining if fast acting cannabis compounds act faster than typical cannabis compounds. prior research reveals that targeted advertisements through social media posts show significantly higher recruitment numbers in cannabis-specific studies (satchell et al., 2023). with this knowledge, recruitment methods consisted of circulating flyers around town and posting reddit and craigslist ads weekly. specifically, flyers were placed in local businesses, ranging from dispensaries and bars to ice cream shops. additionally, flyers were posted around the campus of the university and dispersed within some classrooms. within the participant pool, 106 individuals met inclusion and exclusion criteria and 465 were deemed ineligible. specifically, eligible participants had no prior history of self-harm or psychiatric disorders and were not taking medications that could interfere with cannabis use. additionally, participants were between the ages of 21-65, had not used recreational drugs besides cannabis within the last 60 days, and had used cannabis products within the last ten days. participant cannabis usage must have been at least twice a week for three months or more. participants also had to have used a cannabis edible product within the past year, had no prior history of a serious medical condition, and must had been willing to have their blood drawn. we had 49 participants requiring followups for clarification in determining their eligibility, and 7 participants within the eligible pool who chose to withdraw. in total, we had 20 participants complete all three experimental sessions. out of the eligible participants, 53% identified their sex as male and 47% identified as female. the average participant age was 29.63 (sd = 8.19, range = 21-57). when asked to indicate their racial identity, 75.51% reported white, 6.12% black, 5.10% american indian or alaska native, 4.08% another, 3.06% asian, 3.06% do not wish to respond, 2.04% native hawaiian or pacific islander, and 1.02% arab or muslim. further, 27.17% reported their ethnicity as hispanic or latin/a/o/x/e, 66.3% as not hispanic or latin/a/o/x/e, 5.43% as another, and 1% do not wish to respond. the future of conducting successful cannabis research may lie in the way in which we choose to advertise and recruit participants. the ease and convenience of mobile recruitment, in conjunction with local advertisement methods resulted in successful data collection over the course of only one year. this dynamic model of recruitment methods and the mobility of the lab offers the potential to improve the efficacy of future behavioral and therapeutic studies on cannabis efficacy. observing real-time conference abstracts 304 effects of cannabis use can further the science and understanding of cannabis on cognition, behavior, physiology, and psychology. talk 2: subjective and objective intoxication of self-administered cannabis edibles over time emma e. smith (colorado state university) samuel m. dicecco (colorado state university) katelyn weldon (colorado state university) kira sturgess (colorado state university) bradley t. conner (colorado state university) cannabis is a commonly used drug and is used in many ways, yet evidence elucidating the effects of using cannabis in different routes of administration, as well as the compounds present, are limited. considering recent advances in legalmarket products that have led to the development of presumably fastingacting forms of edibles, literature into the acute physical and psychological effects of these legal-market products is crucial to deepen our understanding of cannabis use's public health implications (ewell, 2021). the present study sought to close gaps in the current cannabis literature though providing empirical support for the onset of subjective and objective intoxication effects of thc in multiple forms. researchers at colorado state university recruited a community sample of individuals who regularly use cannabis (n=20) to participate in 3 study sessions, which involved individuals self-administering different cannabis gummy products (regular acting thc-dominant gummies [10mgthc], fast acting thc-dominant gummies [10mgthc], and placebo gummies [0mg thc]) that participants purchase themselves from cannabis dispensaries. subjective intoxication, objective intoxication, and biological outcomes assessed via the collection of blood samples were measured repeatedly over the course of the experiment, specifically at 13 intervals before and after cannabis consumption: at baseline, then at 5, 10, 15, 30, 60, 90, 120, 150, 180-, 210-, 240-, and 270minutes post-ingestion. specifically, participants reported on their subjective intoxication and related affect by responding to the subject high assessment (shas) and the drug effects questionnaire (deq). due to the ongoing nature of blood sample analysis, researchers and participants of this double-blind, placebo-controlled study remain blinded to the three edible conditions prior to presenting full results at the conference itself. despite being blinded to the products at this time, preliminary time series analysis and one-and two-way anovas were conducted to detect differences in subjective high/intoxication across products and time. results revealed a significant effect of time (f = 4.43, p < .001), with peak intoxication for edible a occurring at 30-minutes, while edible c showed a peak intoxication around 60-minutes post-ingestion. in addition, there was a significant main effect of product on intoxication across time (f = 4.59, p = .02), and a significant interaction effect conference abstracts 305 between product and time (product × time interaction f = 2.108, p = .003). the data collected from this observational study aimed to close significant gaps in cannabis science, particularly regarding the typical intoxication onset profiles of thc compounds in legally marketed edibles. this research may further underscore the complexity of cannabis use and the need for detailed measures beyond use frequency to comprehend its full impact. talk 3: exploring objective physical health measures during cannabis edible consumption katelyn weldon (colorado state university) emma e. smith (colorado state university) samuel m. dicecco (colorado state university) kira sturgess (colorado state university) bradley t. conner (colorado state university) despite the increasing prevalence of legal-market cannabis use, there remains a startling lack of empirical data on its objective effects. as methods for cannabis administration evolve, this disparity becomes increasingly more evident. this is particularly relevant for cannabis edible products, including fast-acting thc compounds, which remain largely unexplored in scientific research. recent national data reveals that nearly 30% of adults have consumed a cannabis edible product in their lifetime, highlighting the pressing need for further investigation into its effects (schauer et al., 2016). therefore, the present study aims to bridge this gap in the existing literature by evaluating the objective intoxication effects of thc-dominant edibles in multiple forms. participants engaged in three five-hour mobile laboratory sessions in which they consumed one of the following cannabis edible products at each session: regular-acting thcdominant gummy (10mg thc), fastacting thc-dominant gummy (10mg thc), and placebo gummy (<0.1% thc). for at least four days prior to each study session, participants were instructed to refrain from cannabis use to mitigate the effects of tolerance on results. further, participants were required to fast for eight hours before their sessions and were provided with a 400-calorie snack with approximately (6%) of fat to regulate the absorption and metabolism of cannabinoids. throughout each mobile laboratory session, objective physical health measures, including heart rate, blood oxygen saturation, blood pressure, and temperature were assessed at multiple time points before and after cannabis consumption. finally, following each study session, participants were instructed to complete a post-session survey in which they answered questions to determine if there were any lasting effects of their cannabis edible product ingestion. although currently blinded, preliminary findings offer substantial insights into the effects of thc consumption on objective physical health measures. these findings hold particular promise in elucidating distinctions between regular and fastacting gummies, thus enhancing our understanding of cannabis edibles. conference abstracts 306 this study serves as a novel solution to the methodological barriers present in current cannabis research. foremost, the utilization of a mobile laboratory provides a unique experimental environment that allows for robust, observational research that is highly representative of real-world cannabis use. it facilitates participants' consumption of legal market cannabis and enables researchers to observe objective intoxication effects in realtime. this fills a large gap in previous research which predominantly utilized low-potency thc and animal models. further, the use of a within-subjects design eliminates individual differences in participant data, allowing for a more holistic comparison of fast-acting and regular-acting cannabis edibles. talk 4: acute cognitive and behavioral effects of self-administered cannabis edibles samuel m. dicecco (colorado state university) emma e. smith (colorado state university) katelyn weldon (colorado state university) kira sturgess (colorado state university) bradley t. conner (colorado state university) cannabis use can cause significant cognitive changes following acute administration, resulting in various forms of impairment such as difficulty concentrating, confusion, and time dilation. however, the time effects of these impairments as well as if certain cannabis products may result in greater impairment along certain dimensions requires further investigation. in our observational assessment of edible cannabis products, we measured both behavioral and subjective reports of impairment at various timepoints post administration of two cannabis products (one fast acting and one standard 10mg edible product) and a placebo. these measurements were taken using the druid app for behavioral impairment and the subjective high assessment scale for subjective reports. due to ongoing double-blind conditions prior to blood processing, the identity of these products is still unknown at the time, however several differences between the edible products have been identified. for the purposes of this abstract, the products will be referred to as "a", "b", and "c", to be fully disclosed at the conference itself. through time series analysis, oneand two-way anova analyses, and post hoc analyses, product a was found to have significantly different and earlier behavioral measures of impairment compared to product b and c, peaking at 90 minutes. this behavioral impairment was followed by product c reaching its behavioral impairment peak at 150 minutes post ingestion. further, product c appeared to have stronger and significantly delayed subjective reports of confusion, intoxication, and difficulty concentrating effects found through an interaction effect between time and product at 180 minutes post ingestion. meanwhile time dilation and alcoholuse-like effects were found to only differ between product b and the other two products and with no difference in time course. the differences in conference abstracts 307 behavioral measurements as well as subjective reports of effect of impairment found in this study indicate some level of variance in both the time course of the edible cannabis products and the cognitive impairments specific to each product. while blood level analysis will be needed for a fuller picture on the thc levels coinciding with these impairment time courses, these findings suggest a need for greater understanding of different pharmacokinetic, behavioral, and subjective effects of similar commercially available cannabis products. symposium title: cannabis and physical activity joanna s. zeiger (canna research foundation) studies have shown that cannabis and physical activity are used concomitantly among people of all ages and athletic ability. cannabis is being used for reduction in anxiety, pain relief, sleep improvement, and enjoyment of exercise, among other reasons. this symposium will focus on cannabis use and physical activity. abstracts will focus on studies that are cross-sectional, observational, longitudinal, or clinical trials. topic areas include, but are not limited to: differences in cannabis use in athletes with varying demographic and athletic backgrounds, impact of route of administration on athletic performance, cannabis use and mental health, impact of physical activity on cannabis use, metrics of athletic performance while using cannabis. original research is encouraged, but a literature review or history of cannabis use in athletics will also be considered. talk 1: moderating effect of physical activity on cannabis use and psychological distress in a national cohort joanna s. zeiger (canna research foundation) robert s. zeiger (kaiser permanente bernard j. tyson school of medicine, canna research foundation) bradley conner (colorado state university, ft. collins) background: psychological distress (pd) impacts daily living and well-being of millions of individuals worldwide. physical activity (pa) has been shown to decrease the physiological and psychological impacts whereas cannabis use has been related to increases in pd. objective: to determine how cannabis use impacts pd and whether pa moderates this relationship in a national cohort. methods: data from the 2023 american college health association-national college health assessment iii (acha-ncha iii) survey were used to evaluate past 3month cannabis use, average weekly leisure time physical activity, and pd [measured by the kessler psychological distress scale (k6); higher scores indicate more severe pd]. only participants who ever used cannabis in their lifetime were included in the analyses. past 3-month cannabis use (cu) was categorized as 'never', 'oncemonthly', and 'weekly-daily'. average weekly pa was categorized in hours, as '0', '1-5', and "6+'. anova and chisquare were used to examine conference abstracts 308 continuous and categorical variables. the process macro in spss was utilized to test for main effects of pa and cu on pd and for moderation of pa on cu and pd. univariate logistic regression was used to obtain k6 estimated marginal means (emm) for the main effects and the interaction of pa and cu (i.e. moderation). all analyses were adjusted for age, biological gender, and ethnicity. results: 170,006 of the 394,184 (43.1%) total participants met eligibility for these analyses, 70% were biologically female and 72% were white. the unadjusted mean k6 score was 9.0 (sd = 5.3), 23.3% had 0 hours of pa, 46.1% had 1-5 hours of pa, and 30.7% had 6+ hours of pa. 34.3% did not use cannabis in the past 90 days, while 39.9% used it one time up to monthly, and 25.8% used cannabis weekly to daily. the main effects of both pa (p < 0.001) and cannabis use (p < 0.001) were significantly associated with k6 scores (model: f = 1346.7, df = 11, r2 = 0.29). hours of pa lowered k6 scores from an emm of 10.7 (se = 0.03) for none, 8.96 (se = 0.2) for 1-5 hours, and 8.12 (se = 0.02) for 6+ hours (p < 0.001). cannabis use increased emm for k6 scores from 8.5 (se = 0.02) in never users, to 9.1 (se = 0.02) in once-monthly users, and 10.3 (se = 0.02) in weekly-daily users (p < 0.001). the moderating effect of pa on cu for pd was significant (f = 7.94, df = 1.0, p < 0.001). k6 scores were always higher as cannabis use increased, but these scores were ameliorated as pa increased. pa reduced k6 scores by a clinically meaningful difference within each cannabis use category for the three levels of exercise with reductions in scores ranging from 1.6 to 2.7 points. conclusions: increased cannabis use increased psychological distress as measured by the kessler psychological distress scale while physical activity decreased k6 scores. moderation between cannabis use and physical activity was significant with pa enhancing the decrease in k6. physical activity can be a valuable means of reducing pd in cannabis users. talk 2: can physical activity manage cannabis use? findings from conducting experimental and intervention research r. lorraine collins (university at buffalo, suny) research suggests that physical activity (pa) has numerous benefits including enhancing fitness and promoting positive affect. pa has shown some success for managing tobacco and alcohol use. these findings led us to conduct research on pa as an approach for managing young adults' cannabis use. we began by examining pa to manage craving, as a precursor to using cannabis. to explore this issue, we conducted a 3-week within subject crossover experiment with young adult (ages 18 to 25 years) men and women who self-reported regularly (> 3 per week) using cannabis. we used a cue exposure paradigm to stimulate craving, followed by 10-minutes of exercise (rest, moderate, vigorous). craving was assessed multiple times; before and immediately after the induction and at three 10-minute intervals (total = 30 minutes). although post exercise craving rebounded for both exercise conditions, among those who consumed larger quantities of cannabis, conference abstracts 309 craving rebounded more quickly after vigorous exercise compared to moderate exercise; an unexpected finding that led us to conclude that moderate exercise might be the best option for managing cannabis use. results for our craving experiment were incorporated into a pilot test of an intervention that included four in-person sessions to learn cognitive behavioral (cb) + motivational enhancement (me) strategies for managing cannabis. all participants used a study-specific smartphone app for reporting ecological momentary assessment data. along with the cb and me strategies, one of the intervention conditions included a pa component in which participants were encouraged to regularly use one of three pa apps that had been vetted by the program staff. cannabis use was examined at the end of the intervention and at 1-month, 3-month, and 6-month follow-ups. at 6months, results showed that both cb + me conditions led to reductions in cannabis use. however, participants in the pa intervention reduced their use of cannabis to a significantly greater degree than participants in the cb + me condition. thus, even when left to make their own decisions about the nature and frequency of pa, having access to pa via a smartphone app proved to be a useful strategy for young adults to manage/reduce cannabis use over time. a second intervention study involved random assignment of young adults who regularly use cannabis to one of three conditions (attention control, paonly, pa + cannabis management strategies). participants in the two intervention conditions were randomly assigned to facebook groups where they received 8-weeks of e-health coaching. the intervention conditions were more effective in reducing cannabis use (smoking and vaping), compared to the control condition. at 3-month and 6month follow-ups, pa-only participants showed reductions in cannabis use. the pa + cannabis groups also showed reductions but had higher rates of attrition. although findings were mixed, this study showed that interventions that included pa content were feasible and acceptable to young adults seeking to manage their cannabis use. in conclusion, regardless of methodology, pa has been shown to be a useful component of cannabis interventions. future research is needed to explore the parameters of the use of pa-based interventions. talk 3: towards precise mental health screening in college athletics and associations with cannabis use and other health-risk behaviors samuel r. davis (ohio state university) sydney mack (ohio state university) mark a. prince (colorado state university, ft. collins) background: college mental health symptomatology is highly prevalent on college campuses across the nation. student-athletes experience mental health issues at similar rates to their non-athlete peers. while colleges and universities have introduced mental health screening efforts to the general student body, most do not have formal plans to screen and treat studentathlete mental health concerns despite conference abstracts 310 widespread interest. purpose: considering the heterogeneity in experiences with mental health issues like anxiety and depression, applying person-centered analyses may help discern unidentified subgroups of student-athletes at greater risk of cannabis use and other potential health-risk behaviors. these efforts can help inform precise, cost-effective procedures for athletics departments to use for screening, prevention, and intervention. methods: participants were 27,642 student-athletes that completed the american college health association's (acha) national college health assessment between 2015 and 2019. the present study used latent class analysis to discern unidentified subgroups of student-athletes characterized by patterns of mental health symptoms. we compared rates of help-seeking behaviors, health risk behaviors, and performance-related outcomes across latent classes. results: results indicated that a five-class model best fit the data. patterns of symptom endorsement within these classes ranged from high symptom endorsement within the past month, to recent experiences of feeling overwhelmed and exhausted, to no current or past-year mental health symptoms. we identified significant differences in engagement of health-risk behaviors among latent classes of mental health symptoms. classes characterized by high general symptom and high anxiety symptom reported using significantly more cannabis than classes characterized by feeling overwhelmed and exhausted or no recent mental health symptoms. discussion: this study is the first effort to discern latent subgroups of studentathletes characterized by self-reported mental health symptoms. findings from the present study can help identify student-athletes in need of mental health and/or behavioral support. additionally, these findings provide guidance for quick and cost-effective ways to conduct precise mental health screening that can inform effective prevention, intervention, and referral efforts. talk 4: association between physical activity and cannabis use: a cluster analysis joanna s. zeiger (canna research foundation) robert s. zeiger (kaiser permanente bernard j. tyson school of medicine, canna research foundation) bradley conner (colorado state university, ft. collins) background: the relationship between exercise and cannabis is unclear with some studies indicating that exercise reduces cannabis use while others show the opposite. it has been observed that cannabis is used in conjunction with exercise to increase enjoyment, reduce pain, and aid in recovery. objective: this secondary analysis of the 2023 american college health associationnational college health assessment iii (acha-ncha iii) survey sought to determine the relationship between exercise habits and cannabis use. methods: a two-step cluster analysis in spss which included days per week of strength exercise and minutes of moderate and vigorous physical activity revealed a two-cluster solution named: conference abstracts 311 high exercise (n = 83,198, 49.5%) and low exercise (n = 84,853, 50.5%). the dependent variable, past 90 days of cannabis use, was dichotomized as 'use' or 'no use'. binomial logistic regression was used to assess the relationship between cluster membership and cannabis use adjusted for age, biological sex, and ethnicity. results: moderate physical activity mean minutes were 295 (sd = 394) for the high exercise cluster and 164 (sd = 262) for the low exercise cluster while vigorous physical activity for the high compared to low exercise cluster was 217 minutes (sd = 229) vs. 8 minutes (sd = 13). the high exercise group had a mean of 2.87 (sd = 1.9) days of strength training whereas the low exercise had less than one day of strength training (m = 0.9, sd = 1.5). there was a significant association between cluster membership (i.e. levels of exercise) and cannabis use, with those in the high exercise cluster showing higher cannabis use (p < 0.001). however, it should be noted the differences between groups were nominal (high exercise cluster cannabis use = 50.8%; low exercise cluster cannabis use = 49.2%). conclusions: these findings challenge conventional assumptions about cannabis use and alleged idleness and underscore the complex interplay between exercise behaviors and cannabis use. these analyses further contribute to our understanding of the relationship between cannabis use and exercise. future research should explore underlying mechanisms and potential confounding factors to better inform interventions aimed at promoting healthier lifestyle behaviors and reducing substance misuse. research article 98 ved abstract objective: cannabis legalization may impact both cannabis and tobacco use, given the high prevalence of co-use (including blunt use) among young adults (yas) in the united states. the objective of this descriptive ecological study was to examine trends in ya cannabis and tobacco use from 2002-2018 in states that passed adult and medical use (amu) or medical use only (muo) cannabis laws during that time (n = 16). method: using data from the national survey on drug use and health, we conducted a segmented regression analysis to calculate absolute percent change in past 30-day cannabis, blunt, cigarette, and cigar use between time points. we descriptively compared points of slope inflection with key legalization dates. results: all states showed a decline in ya cigarette smoking over time, a slight decline in cigar smoking, and increases in cannabis and blunt use. cannabis use increased following opening of muo retail outlets and, in several states, increased following adult use law implementation and/or opening of retail outlets. for example, in maine, cannabis use plateaued after a muo law was adopted (2009) until about 1-2 years after retail outlets opened (2011), when ya cannabis use increased by 22.4% (95% ci: 19.0, 29.4) and continued increasing steadily after adult use was adopted (2017). conclusions: cannabis and blunt use increased more in states where amu laws were in place compared to those with muo laws, though causality was not assessed. varying trends may correlate with cannabis policies, tobacco policies and other political, economic, or social factors at the state level. key words: = cannabis; tobacco; young adult cannabis is legal to sell to adults 21 years of age or older for medical use in 38 states, and ‘recreational’ use in 24 us states and the district of columbia (dc; national conference of state legislatures, 2024). however, the group with the highest prevalence of past-month cannabis use are young adults (yas; ages 18-25 years), who span the legal age of cannabis sales (national academy of sciences engineering and medicine [nasem], 2017) and who may be more susceptible to the neurocognitive effects of cannabis due to continued brain development (jacobus & tapert, 2014). most studies on the impact of cannabis laws suggest that they lead to allison m. glasser1, caitlin uriarte1, jessica king jensen1,2, kymberle sterling1,3, ce shang4, david hammond5, & andrea c. villanti1,3 1rutgers institute for nicotine & tobacco studies, rutgers university 2department of family medicine and community health, rutgers robert wood johnson medical school 3department of health behavior, society and policy, rutgers school of public health 4department of internal medicine, ohio state university wexner medical center 5school of public health sciences, university of waterloo cannabis 2025 © author(s) 2025 researchmj.org 10.26828/cannabis/2025/000288 volume 8, issue 2 temporal trends in young adult cannabis and tobacco use in states with different cannabis policies corresponding author: allison glasser, phd, mph, rutgers university, 303 george street. new bruswick, new jersey, 08901. email: allison.glasser@rutgers.edu cannabis, a publication of the research society on marijuana 99 non-significant changes or small increases in cannabis use among yas following implementation (lachance et al., 2022). data from the international cannabis policy study and other cross-sectional studies suggest that noncombustible modes of cannabis delivery, primarily vaping and consuming edibles, are more prevalent where cannabis is legal to sell (borodovsky et al., 2016; borodovsky et al., 2017; goodman et al., 2020; hammond et al., 2022; shi, 2021). the prevalence of cannabis use has increased over time, with 28.8% of yas reporting past-month use in 2022 (patrick et al., 2023) and a high prevalence of tobacco and cannabis co-use in this age group (cohn & chen, 2022). blunt use (modified cigar with tobacco filling replaced or mixed with cannabis) is a particularly important form of cannabis and tobacco co-use, given its unique health impacts. people who use blunts initiate cannabis use earlier (seaman et al., 2019), smoke more frequently (reboussin et al., 2021), develop greater dependence or problem use (timberlake, 2009), and are more likely to use other substances (montgomery & mantey, 2018) than people who use cannabis in other ways. evidence is mixed on whether tobacco and cannabis are substitutes or complements (agrawal et al., 2012; lemyre et al., 2019), yet cannabis legalization may lead to change in both cannabis and tobacco use, and particularly, co-use of these products among yas. research on the impact of cannabis legalization on tobacco use has primarily focused on cigarette smoking among adolescents (schlienz & lee, 2018). these studies have had mixed findings, with one showing no effect (vuolo et al., 2022), one showing increases in adolescent cigarette use (cerda et al., 2018), and one showing a reduction (mason et al., 2016). other us-based studies found no evidence of an association between medical or recreational cannabis legalization and changes in cigarette sales per capita (veligati et al., 2020) or tobacco retail availability (timberlake et al., 2021). studies of non-cigarette tobacco products found an increase in adolescent e-cigarette use in states with cannabis legalization (bhatia et al., 2022; coley et al., 2020; nicksic et al., 2020), while another study found reduced cigar sales in legalized states (giovenco et al., 2018). only one study has assessed the impact of cannabis policy on blunt use, which found increased blunt use in states with recreational cannabis, but only in those states with a smokefree indoor air tobacco policy (orsini et al., 2024). cannabis policy evaluation using trend data has primarily involved statistically comparing trends preand post-policy enactment or implementation. however, an alternative approach can allow the data to show where there are changes in trends over time, informing whether change observed corresponds to policy events and if there are lag times. joinpoint trend analysis uses this approach and can characterize significant changes in trends of prevalence of tobacco and cannabis use over time at the state level and allow researchers to observe how these changes correspond descriptively with cannabis policy enactment and implementation (national cancer institute, 2023). the objective of this descriptive ecological study was to examine trends among yas for cannabis, blunt, cigarette, and cigar use over a 16-year period (2002-2018), using the national survey on drug use and health (nsduh), in states that passed adult and medical use (amu) or medical use only (muo) cannabis laws during that time (n = 15 and dc). we use a regression technique to identify inflection points rather than make a priori assumptions about time periods when change should occur. given greater access to legal cannabis for sale in amu states, we hypothesized that there would be greater increases in cannabis and blunt use in states with amu than muo laws; additionally, more inflection points would be observed in amu states due to more policy changes over time. given the mixed evidence on cannabis policy’s impact on tobacco use, we did not have specific a priori hypotheses regarding cigarette or cigar use trends. methods data sources national survey on drug use and health (nsduh) restricted-use data analysis system 2year state estimates of tobacco and cannabis use are publicly available and were obtained from the substance abuse and mental health services administration (samhsa) data archive (https://rdas.samhsa.gov/#/). nsduh is an annual nationally representative survey of the us population aged 12 and older and measures use of tobacco, alcohol, and illicit drugs; substance use https://rdas.samhsa.gov/#/ policy and young adult cannabis/tobacco use 100 disorders; receipt of substance use treatment; mental health issues; and the use of mental health services. this analysis is limited to yas ages 18-25 years residing in states with amu (n = 7 and dc) or muo (n = 8) laws that were passed between 2002-2016, to allow for at least two data points following the policy event (policy adopted, policy effective, and retailer permitted). while data were collected annually, small area estimates are available in two-year pooled datasets, which are available for the following years: 2002/2003, 2004/2005, 2006/2007, 2008/2009, 2010/2011, 2012/2013, 2014/2015, 2016/2017, and 2018/2019. the average sample size ranged from 461 to 602 across years in states except california, florida, ohio, and pennsylvania (states in which nsduh recruits a larger sample), in which the sample size ranged from 1499 to 2404. detailed sample size by state and year is presented in supplemental table a. cannabis legalization data amu states (n = 8; alaska, california, colorado, maine, nevada, oregon, washington, and dc) included states that have passed both medical use and adult use cannabis laws, while muo states (n = 8; arkansas, delaware, florida, minnesota, new hampshire, north dakota, ohio, and pennsylvania) have only passed medical use laws. as we were interested in observing the timing of when change in trends occurs, we included states that allowed for the possibility of changes in use after passage of a law, even if it had not yet gone into effect. we recorded key policy events (table 1), including the date a law was adopted and went into effect, as well as when retail outlets were permitted. these data were obtained from the marijuana policy project (marijuana policy project, 2021) and the national conference of state legislatures (national conference of state legislatures, 2023). table 1. key cannabis legalization dates state mu law adopted mu law effective mu retail permitted au law adopted au law effective au retail permitted amu alaska nov. 1998 jun. 1999 nov. 2014 feb. 2015 oct. 2016 california nov. 1996 jan. 2004 -a nov. 2016 nov. 2016 jan. 2018 colorado nov. 2000 jun. 2001 jun. 2010 nov. 2012 nov. 2012 jan. 2014 maine nov. 2009 may. 2010 mar. 2011 nov. 2016 jan. 2017 oct. 2020 nevada jun. 2001 oct. 2001 aug. 2015 nov. 2016 jan. 2017 jul. 2017 oregon nov. 1998 may. 1999 mar. 2014 nov. 2014 jul. 2015 oct. 2016 washington nov. 1998 nov. 1998 -b nov. 2012 dec. 2013 jul. 2014 wash, dc may. 2010 jan. 2011 jul. 2013 nov. 2014 feb. 2015 muo arkansasc nov. 2016 may. 2017 may. 2019 delaware may. 2011 jul. 2011 jun. 2015 floridac nov. 2016 jul. 2017 sept. 2016 minnesota may. 2014 jun. 2015 jul. 2015 new hampshire jul. 2013 dec. 2015 apr. 2016 north dakotac nov. 2016 oct. 2018 mar. 2019 ohioc jun. 2016 dec. 2018 jan. 2019 pennsylvaniac apr. 2016 nov. 2017 feb. 2018 aretail operated in a legal grey area until 2018; bendorsement in jul. 2016; cexcluded from sensitivity analysis focused only on states with post-implementation data (after the policy went into effect); amu/au=adult and medical use; muo/mu = medical use only cannabis, a publication of the research society on marijuana 101 measures past 30-day use of the following products was assessed. cannabis. “sometimes called pot, weed, hashish, or concentrates. some of the ways these products can be used are smoking (such as in joints, pipes, bongs, blunts, or hookahs), vaping (using vape pens, dab pens, tabletop vaporizers, or portable vaporizers), dabbing, eating or drinking, or applying as a lotion.” blunts. “smoked part or all of a cigar with marijuana in it.” blunts were not assessed in 2002/2003. blunt use, by definition, may overlap with cannabis use. tobacco. cigarettes and cigars (“made only of tobacco, such as cigarillos, big cigars, and little cigars that look like cigarettes”). analysis first, we conducted a segmented regression analysis to calculate absolute percent change (apc) in past 30-day use of each product between time points using the national cancer institute’s joinpoint software (national cancer institute, 2023). points of inflection (joinpoints) are specific points in time in which the slope of a trend in product use significantly changes. separate models were estimated for each product by state, measuring within-state changes, as well as for each product in states combined by policy type (amu or muo); in all models, time was the independent variable measured in years. homoscedastic variance was assumed and controlled for first-order autocorrelation. two datapoints were allowed from a joinpoint to the first or the final datapoint and between two joinpoints. up to two joinpoints per model were allowed (except for blunts, for which only one joinpoint was allowed due to having one less datapoint; irimata et al., 2022). the model with optimal joinpoints was determined using a model selection criterion via a permutation test. slopes and slope changes were considered statistically different from zero if the p value was < .05. average changes over the full study period were also calculated using a weighted average of the slope coefficients of the underlying joinpoint regression line with the weights equal to the length of each segment over the interval. pairwise comparisons were made to determine whether trends in product use differed significantly between combined amu and muo states through tests for parallelism. joinpoints and apcs were descriptively compared with key cannabis legalization dates to describe patterns within and across states with varying cannabis policies. finally, as change may not be expected until after implementation of a policy, we conducted a sensitivity analysis including only those states with post-effective data (see footnote in table 1 for exclusions). individual state trends are presented in supplemental figures b-q. results most states showed increases in cannabis and blunt use over the 16-year period (2002/20032018/2019). amu states had greater increases than muo states (table 2) in cannabis (amu: 6.5%; muo: 2.5%) and blunt use (amu: 6.2%; muo: 3.4%), though trends were statistically parallel (cannabis use trends: p = .099; for blunt use trends: p = .162; supplemental table b). states showed similar declines by amu vs. muo status in ya cigarette smoking (amu: -9.5%; muo: -9.3%) and cigar smoking (amu: -7.0%; muo: -3.8%) over time (test for parallelism for cigarette use trends: p = .097; for cigar use trends: p = .104). trends across products were parallel between amu and muo states in sensitivity analyses conducted in states with post-effective data (supplemental table b and supplemental figure a). table 2. average absolute percent change in past 30-day product use over the 16-year (2002-2018*) study period and joinpoints, by state state cannabis blunts cigarettes cigars % (95% ci) % (95% ci) % (95% ci) % (95% ci) amu 6.5 (4.3, 8.7) 6.2 (5.3, 7.3) 2004-2010: 17.7 (14.7, 21.1) 2010-2018: -1.6 (-3.4, 0.0) -9.5 (-10.9, -8.2) 2002-2012: -4.0 (-5.5, -2.6) 2012-2018: -18.0 (-22.0, -13.8) -7.0 (-11.8, -1.9) 2002-2006: 5.7 (-51.9, 132.6) 2006-2014: -8.2 (-29,8, 20.0) 2014-2018: -15.9 (-69.0, 128.1) policy and young adult cannabis/tobacco use 102 alaska 2.2 (-4.5, 9.1) 7.8 (2.4, 11.4) 2002-2008: 24.0 (9.0, 44.0) 2008-2018: 1.9 (-14.0, 4.7) -8.7 (-16.0, -0.7) 2002-2014: -2.9 (-5.2, -0.5) 2014-2018: -24.1 (-52.5, 21.5) -5.4 (-9.7, -0.9) 2002-2006: 14.7 (-38.1, 112.6) 2006-2014: -5.2 (-21.6, 14.6) 2014-2018: -22.2 (-70.5, 105.3) california 6.2 (3.9, 9.0) 6.5 (4.9, 8.3) 2004-2010: 20.0 (14.0, 27.9) 2010-2018: -2.7 (-6.2, 0.6) -10.6 (-11.7, -9.5) 2002-2012: -3.3 (-4.3, -2.3) 2012-2018: -21.5 (-24.8, -18.1) -7.6 (-13.9, -0.8) 2002-2006: 5.8 (-27.2, 53.7) 2006-2018: -11.7 (-15.8, -7.3) colorado 6.4 (5.6, 7.2) 2002-2006: 1.2 (-1.8, 5.1) 2006-2012: 10.6 (8.8, 12.6) 2012-2018: 5.7 (1.6, 7.1) 6.1 (3.3, 8.5) 2004-2012: 12.8 (9.2, 21.2) 2012-2018: -2.3 (13.7, 3.0) -9.6 (-14.9, -4.0) 2002-2014: -5.4 (-7.0, -3.9) 2014-2018: -21.0 (-43.7, 10.8) -6.1 (-9.2, -2.9) 2002-2012: 1.8 (-1.9, 5.6) 2012-2018: -17.9 (-26.6, -8.2) maine 7.3 (6.2, 8.4) 2002-2006: 6.3 (1.1, 11.3) 2006-2010: -5.3 (-7.8, -1.9) 2010-2018: 22.4 (19.0, 29.4) 8.1 (1.0, 16.2) 2004-2012: -0.4 (-26.4, 31.9) 2012-2018: 20.5 (-6.1, 53.7) -8.2 (-11.1, -5.1) 2002-2008: -2.8 (-11.6, 6.9) 2008-2018: -11.2 (-15.3, -6.9) -7.3 (-11.0, -3.5) 2002-2010: -0.5 (-8.2, 7.9) 2010-2018: -13.8 (-20.4, -6.5) nevada 9.9 (4.1, 15.7) 2002-2014: 2.6 (-20.8, 15.8) 2014-2018: 35.0 (8.4, 65.7) 9.8 (1.5, 19.8) -9.5 (-13.7, -5.0) 2002-2012: -2.6 (-6.5, 1.5) 2012-2018: -19.9 (-32.3, -5.1) -1.9 (-15.1, 13.4) 2002-2006: 3.1 (-91.8, 1203.2) 2006-2012: -9.4 (-52.9, 74.1) 2012-2018: 9.7 (-90.4, 1158.8) oregon 7.0 (1.8, 12.8) 5.2 (-2.5, 10.9) 2004-2008: 22.2 (3.0, 53.4) 2008-2018: -0.9 (-24.5, 5.9) -8.0 (-12.5, -3.2) 2002-2010: -4.1 (-11.6, 4.1) 2010-2018: -11.7 (-21.5, -0.6) -6.6 (-17.8, 6.2) 2002-2014: -2.8 (-6.5, 1.1) 2014-2018: -17.0 (-59.5, 69.8) washington 5.4 (-4.6, 17.3) 5.4 (-0.2, 12.2) 2004-2010: 16.6 (7.2, 53.3) 2010-2018: -2.3 (-22.5, 3.1) -10.5 (-14.4, -6.4) 2002-2010: -1.7 (-8.8, 5.9) 2010-2018: -18.5 (-26.3, -9.8) 0.0 (-10.7, 12.0) 2002-2006: 29.8 (-30.3, 141.8) 2006-2018: -8.3 (-13.0, -3.3) wash, dc 6.2 (4.5, 7.7) 2002-2008: -3.6 (-12.4, 0.9) 2008-2018: 12.6 (9.5, 17.1) -3.8 (-6.5, 15.8) -7.9 (-20.1, 6.0) 2002-2014: -3.6 (-9.1, 2.2) 2014-2018: -19.7 (-63.3, 75.3) -6.1 (-10.8, -1.1) 2002-2014: 4.5 (1.4, 7.7) 2014-2018: -31.8 (-48.4, -9.9) muo 2.5 (1.3, 4.3) 2002-2008: -1.1 (-7.4, 5.7) 2008-2014: 6.2 (-8.7, 23.6) 2014-2018: 2.4 (-14.4, 22.5) 3.4 (2.4, 4.2) -9.3 (-10.3, -8.2) 2002-2006: -3.2 (-15.8, 11.3) 2006-2012: -6.3 (-19.3, 8.9) 2012-2018: -15.9 (-23.1, -7.9) -3.8 (-5.2, -2.3) 2002-2008: -0.3 (-4.9, 4.5) 2008-2018: -5.8 (-7.5, -4.0) arkansas -0.8 (-3.1, 1.4) 0.5 (-4.5, 5.0) 2004-2010: 8.1 (1.3, 30.7) 2010-2018: -4.9 (-22.9, -0.7) -9.4 (-10.8, -7.9) 2002-2008: -5.7 (-9.8, -1.4) 2008-2018: -11.5 (-13.6, -9.4) -7.9 (-11.4, -4.2) 2002-2008: -14.1 (-23.7, -3.2) 2008-2018: -4.0 (-8.9, 1.2) delaware 3.3 (-0.0, 4.7) 2002-2014: 0.2 (-6.9, 6.6) 2014-2018: 13.2 (-0.9, 28.1) 3.0 (0.8, 5.0) -12.1 (-23.8, 1.4) 2002-2010: -3.7 (-6.9, -0.5) 2010-2018: -33.0 (-69.9, 49.2) -0.8 (-9.7, 9.0) 2002-2014: -6.3 (-9.5, -3.0) 2014-2018: 18.0 (-30.1, 99.1) florida 3.5 (0.8, 6.4) 2002-2008: -3.6 (-16.0, 4.8) 2008-2018: 8.1 (2.3, 21.2) 3.3 (-1.5, 7.7) -12.1 (-13.6, -10.6) 2002-2006: -0.4 (-19.4, 23.2) 2006-2014: -9.0 (-16.7, -0.7) 2014-2018: -27.7 (-49.2, 2.9) -4.7 (-8.7, -0.5) 2002-2006: -0.4 (-21.5, 26.3) 2006-2018: -6.1 (-8.1, -4.0) minnesota 3.6 (2.7, 4.2) 2002-2006: 13.7 (11.0, 16.4) 2006-2012: -4.3 (-5.7, -2.6) 2012-2018: 5.3 (2.9, 10.9) 5.0 (-1.6, 13.4) -9.9 (-11.7, -8.1) 2002-2010: -4.5 (-7.6, -1.4) 2010-2018: -15.0 (-18.8, -11.1) -2.9 (-5.3, -0.4) 2002-2010: 6.4 (1.7, 11.3) 2010-2018: -11.3 (-16.1, -6.3) new hampshire 1.7 (0.9, 2.6) 6.8 (1.4, 10.8) 2004-2008: 28.9 (10.3, 51.8) 2008-2018: -1.0 (-11.4, 1.8) -6.8 (-8.5, -5.1) 2002-2008: -1.4 (-6.6, 4.0) 2008-2018: -9.9 (-12.4, -7.4) 1.0 (-2.8, 4.9) 2002-2008: 3.9 (-0.2, 8.2) 2008-2018: -3.7 (-15.1, 9.4) north dakota 0.4 (-3.1, 4.6) 2002-2006: -12.8 (-24.5, 4.9) 2006-2018: 4.7 (-9.8, 22.6) 12.8 (5.1, 21.3) -7.8 (-9.8, -5.8) 2002-2012: -4.3 (-6.5, -2.2) 2012-2018: -13.3 (-19.4, -6.7) -5.2 (-16.4, 7.4) 2002-2006: 12.5 (-42.2, 118.9) 2006-2018: -10.5 (-17.6, -2.8) ohio 3.9 (2.7, 4.8) 2002-2012: 1.8 (-1.9, 3.3) 2012-2018: 7.5 (3.9, 13.3) 5.5 (1.9, 8.3) 2004-2008: 12.8 (1.6, 26.6) 2008-2018: 2.7 (-9.9, 9.2) -7.1 (-8.8, -5.4) 2002-2006: -0.1 (-18.1, 21.8) 2006-2014: -6.8 (-14.3, 1.4) 2014-2018: -14.2 (-41.7, 26.1) -2.6 (-9.7, 5.2) 2002-2008: 1.2 (-24.0, 34.7) 2008-2014: -8.8 (-59.3, 104.3) 2014-2018: 1.7 (-77.4, 356.9) pennsylvania 1.8 (0.7, 3.4) 2002-2006: -5.7 (-10.2, 1.3) 2006-2018: 4.5 (2.5, 9.8) 1.8 (-0.0, 3.4) -8.5 (-10.4, -6.5) 2002-2012: -4.7 (-6.2, -3.3) 2012-2018: -14.4 (-20.8, -7.5) -2.3 (-3.4, -1.1) 2002-2010: 1.8 (-0.3, 3.9) 2010-2018: -6.1 (-8.5, -3.6) note. blunt use was not measured until 2004; amu = adult and medical use; muo = medical use only; bolded estimates are statistically significant at p < .05; for spaces without data, there were no joinpoints. cannabis, a publication of the research society on marijuana 103 in 2018/2019, amu states had lower average prevalence of cigarette smoking than muo states (16% vs. 19%) and higher cannabis use (29% vs. 21%; supplemental table c). all states with amu laws had higher prevalence of cannabis use than cigarette smoking by 2018/2019, as well as the three muo states with post-effective data. in all amu states, blunt use surpassed cigar smoking over time, while in most muo states, the prevalence of blunt and cigar use were similar. trends in relation to policy changes cannabis use there were two joinpoints in trends of cannabis use over time across muo states (figure 1), but none of these correspond with an apparent policy change. in state-specific analyses, six muo states showed at least one joinpoint in cannabis use trends over time (table 2), and one of these appeared to correspond with a cannabis policy event. in delaware (supplemental figure c), cannabis use was flat from 2002/2003 to 2012/2013, then increased by 13.3% (95% ci: -1.0, 28.1) from 2014/2015 to 2018/2019, about two years after a medical use law went into effect in july 2011 and at about the same time as muo retail outlets opened in june 2015. despite a steady increase in cannabis use, there were no joinpoints in trends in amu states (figure 1). state-specific analyses showed four amu states with at least one joinpoint in cannabis use trends, three of which may correspond with a policy event. these changes show increased cannabis prevalence after medical use laws go into effect and/or permitting of retail outlets and continued increases after passage of adult use laws. in maine (supplemental figure m), cannabis use plateaued after a medical use law was adopted in november 2009 until about 12 years after retail outlets opened in march 2011, when ya cannabis use increased from 23% (2010/2011-2012/2013) to 39% (2018/2019), which was an increase of 22.4% (95% ci: 19.0, 29.4) and a trend that continued after the adult use law was adopted. similarly, nevada (supplemental figure n) showed an increase (35.0%; 95% ci: 8.4, 65.7) in cannabis use prevalence after 2014/2015, corresponding with when muo retail outlets opened in august 2015 and subsequently, an adult use law was adopted. in colorado, increases in cannabis use prevalence slowed after muo retail outlets opened in june 2010 (5.7% from 2012/2013 to 2018/2019 vs. 10.6% from 2006/2007 to 2010/2011; supplemental figure l), also corresponding with passage of an adult use law in november 2012. figure 1. prevalence of past 30-day cannabis, cigarette, cigar, and blunt use among young adults in us states with adult and medical use (amu) cannabis laws (n = 8) and laws permitting medical use only (muo; n = 8) from 2002-2018 policy and young adult cannabis/tobacco use 104 note. data collection occurred annually, but data were pooled into 2-year estimates (2002/2003, 2004/2005, 2006/2007, 2008/2009, 2010/2011, 2012/2013, 2014/2015, 2016/2017, 2018/2019). datapoints are shown on the first year of the 2year period. time periods described on the right correspond to periods of constant slope and with joinpoints (inflection points in trend slope) in the final selected model for each product. blunt use there were no joinpoints in combined muo states; only three muo states showed a joinpoint in blunt use trends over time (table 2), and none appeared to correspond with a cannabis policy event. there was one joinpoint in the blunt use observed among combined amu states (figure 1), although this does not appear to relate to policy changes. six amu states showed joinpoints, two of which may related to cannabis policy. in maine, blunt use prevalence increased by 20.5% (95% ci: -6.1, 53.7) from 2012/2013 to 2018/2019, following the opening of muo retail outlets in march 2011. in colorado, blunt use changed from an increasing trend to a plateau in 2012/2013 (-2.3%; 95% ci: 13.7, 3.0) following passage of an adult use law in november 2012. tobacco use all states showed at least one joinpoint in cigarette and cigar use trends over time (table 2). the observed joinpoints mostly correspond with two points in time: 2009-2012 and 2014/2015. eight states (arkansas, minnesota, north dakota, pennsylvania, california, nevada, oregon, washington) showed a significant decline in cigarette use prevalence, and four states (minnesota, new hampshire, pennsylvania, colorado, maine) showed a decline in cigar use prevalence that began between 2009-2012. this joinpoint pattern was also observed for cigarette use over time among amu and muo states combined (figure 1). second, five states (delaware, florida, ohio, alaska, colorado) and dc showed a decline in cigarette use prevalence, and two states (alaska, oregon) and dc showed a decline in cigar use prevalence around 2014/2015. conversely, two states (delaware and ohio) showed an increase in cigar use around this time. for some states, declines in cigarette smoking in 2014/2015 corresponded with muo (delaware, dc) or adult use law implementation (alaska, colorado). in maine, after a long period of a flat cigar use prevalence (-0.5%; 95% ci: -8.2, 7.9), prevalence declined by 13.8% (95% ci: -20.4, -6.5) from 2010/2011-2012/2013 to 2018/2019, following muo implementation and opening of retail outlets. similarly, cigar use prevalence in oregon (supplemental figure o) began a decline (2014/2015) of 17.1% (95% ci: -59.5, 69.7) when muo retail outlets opened (march 2014), followed by adult use law passage (november 2014). cigar use also declined by 17.9% (95% ci: -26.6, -8.2) in 2012/2013 in colorado following muo retail outlet opening and at the beginning of an adult use passage law, and by 31.8% (95% ci: -48.4, 9.9) in dc (supplemental figure q) in 2014/2015, beginning when an adult use law went into effect. conversely, the increase in cigar use in delaware starting in 2014/2015 (18.0% ; 95% ci: -30.1, 99.1) cannabis, a publication of the research society on marijuana 105 occurred after a formerly steady decline (-6.3%; 95% ci: -9.5, 3.0; since 2002/2003) and 2-3 years after muo was implemented. discussion this is one of the first studies to assess change in blunt use following cannabis policy implementation, by allowing the data to show where change occurred over time, and focused on yas. from 2002-2018, muo and amu states experienced increases in past 30-day cannabis and blunt use among yas and declines in cigarette and cigar smoking. these patterns are consistent with the direction of national trends, and muo trends mirror those in the us overall (substance abuse and mental health services administration, 2023). changes over time in cigar and cigarette smoking did not differ between muo and amu states, and while amu states experienced steeper increases in cannabis and blunt use than muo states, trends were considered to be parallel. this is consistent with a review which concluded that muo laws have had minimal impact on cannabis use among young people, but that adult use laws may result in a small increase in cannabis use (melchior et al., 2019). these patterns are expected, as adult use cannabis laws increase the availability and accessibility of cannabis for yas without need for a medical card. as of 2018, the prevalence of cannabis use had surpassed that of cigarette smoking in all states with amu laws. similarly, the prevalence of blunt use surpassed cigar smoking in all amu states. as tobacco laws have become more restrictive over time, cannabis laws have become more permissive in states that allow the legal use of cannabis. although some evidence suggests that tobacco and cannabis may not be economic substitutes (cooper et al., 2023), a common liability, or shared propensity, to use these substances supports greater use of cannabis as it becomes more available and reduced tobacco use prevalence as accessibility/appeal decline (van leeuwen et al., 2011; vanyukov et al., 2012). in addition, social acceptability of cannabis use has increased, while acceptability of tobacco has declined; furthermore, perceptions of harm of cannabis are lower than tobacco, corresponding with use patterns observed in this analysis (chambers et al., 2023; romm et al., 2022). some research also shows more positive perceptions of cannabis in states with amu laws compared with muo states (steigerwald et al., 2020), although these perceptions may be present prior to policy change and due to other social and political factors that differentiate states (mccarthy, 2022; spetz et al., 2019). amu and muo states, in aggregate, showed a greater decline in cigarette smoking prevalence following the passage of the 2009 federal tobacco control act, which imposed stricter restrictions on cigarette smoking, including marketing and sales to youth, requiring disclosure of product ingredients, and banning the sale of flavored cigarettes (except menthol; tobacco control act, 2009). there did not appear to be as consistent of an impact of this major legislation on ya cigar smoking, which is likely due to the fact that cigars were not included as tobacco products under the rule until 2016 (u.s. food & drug administration, 2016). although some states showed declines in cigarette smoking in 2014/2015 after medical (delaware, dc) or adult use (alaska, colorado) law implementation, there were no apparent changes in cigarette use trends based on cannabis policy. the timing of these joinpoints may have more to do with tobaccorelated factors; the steep decline coincides with the introduction and increased prevalence of ecigarettes. another study using three national datasets found that youth cigarette smoking sharply declined from 2013-2022. and that the emergence of e-cigarettes coincides with this period (delnevo & villanti, 2023). however, it is not possible to evaluate whether these trends would have been observed had e-cigarettes not existed. only one joinpoint in cannabis or blunt use in a muo state appeared to follow a policy change (delaware). in amu states, trends in relation to policy changes varied across states, but a few patterns were observed. one of the more consistent patterns across states was an increase in ya cannabis use following the opening of muo retail outlets (delaware, maine, nevada). although no joinpoints were detected, similar patterns were reflected in minnesota, new hampshire, oregon, and dc, with an increased cannabis use prevalence in the 1-2 years following this policy event. relatedly, in states where ya cannabis use prevalence surpassed cigarette smoking over time, this typically occurred within 1-2 years of the opening of muo retail outlets. policy and young adult cannabis/tobacco use 106 this finding is inconsistent with previous studies that found no change in cannabis use before/after medical use laws (lachance et al., 2022). however, these evaluations may not have accounted for the delay in opening of retail outlets after the laws were adopted. greater availability of cannabis retail outlets are associated with greater cannabis use (manthey et al., 2023), which may contribute to the pattern observed in this study. few joinpoints corresponded with adult use laws, yet several states showed increases following adult use laws going into effect and/or the opening of retail outlets (alaska, california, washington) or a continuation of increasing prevalence previous to and following adult use laws (joinpoints: colorado and maine; no joinpoints: nevada and oregon). for states that had muo laws and then adopted adult use laws, there were no notable fluctuations in product use, but cannabis and blunt use continued to increase. the delay in seeing change in cannabis use after a cannabis policy may explain the high number of policy evaluations with null results, as most have measured change within a year of policy implementation (lachance et al., 2022). change may be occurring in the long-term, and cumulative over time with progression of medical to adult use cannabis law enactment. blunt use trends mirrored overall cannabis use trends, often increasing after medical use retail outlets opened (nevada, oregon), and in some states, initially declining after adult use law passage, then increasing (dc), or increasing steadily through passage of adult use laws (maine, nevada). a key relationship of interest in this study was the comparison of cigar use and blunt use trends, where we did not see consistent relationships between policy events and changes in use of these products. in two states (maine and oregon), as blunt use increased following medical use dispensaries opening, cigar use declined. in other states (nevada, colorado, delaware, and dc), blunt and cigar use trends followed a similar pattern to each other, but varied in whether they decreased or increased after a policy event. about half of yas who smoke cigars report using cannabis, and two-thirds of yas who co-use these products smoke blunts (glasser et al., 2023; schauer et al., 2016; strong et al., 2018). therefore, one might expect changes in the prevalence of cigars and blunts to follow similar patterns. on the other hand, the availability of a range of products in a legal cannabis market may shift use from cigars to blunt wraps, pre-rolled blunts, or other modes of cannabis administration. limited evidence suggests that non-combustible modes may be more prevalent in states with adult use cannabis (smart & pacula, 2019), though there is a greater availability of blunt wraps and cigarillos co-marketed with cannabis in those states (giovenco et al., 2018; henriksen et al., 2018). given the diverging patterns shown in the current study in relationship to cannabis policy, further research is needed on the impact of policy on blunt and cigar use. limitations this study has several limitations to note. first, although there is substantial overlap in vaping of cannabis and nicotine among yas (mattingly et al., 2022), vaping was not assessed in nsduh until 2019-2020, and due to the covid-19 pandemic, state-level estimates from this time period are not available due to methodological concerns. therefore, patterns of ya vaping in relation to cannabis policy were not explored in this study; the impact of cannabis policy on ya use of both cannabis and nicotine vaping is needed in future research. second, the analysis does not include the full scope of states with cannabis legalization, nor do we compare to non-policy states, resulting in a small sample size of states. several states passed medical cannabis laws prior to 2002, and other states passed adult use laws after 2018 but were not able to be included in this analysis because nsduh 2-year estimates of product use prevalence after that time were not yet available. third, due to the common conflating of cigar products and blunts, misclassification of cigar and/or blunt use is possible, so it cannot be assumed that reporting use of cigars always means use of cigars containing tobacco (jackson et al., 2022). fourth, legal age of sale of cannabis is 21 years (and tobacco after 2019), so there may be heterogeneity in patterns of use by yas under the legal age compared to those 21 years and up; however, given the small cell sizes, especially for use of blunts and cigars, samhsa suppressed these estimates. for the same reasons, we were not able to examine any differences by sex or gender. cannabis, a publication of the research society on marijuana 107 future research should examine moderation of policy effects for different groups of yas. fifth, given the number of datapoints, we were only able to permit modeling of two joinpoints (one for blunts), so some variability in trends could have been masked. last, this study is a descriptive ecological study, so we are unable to determine causal relationships between policy and changes in ya product use. however, not making a priori assumptions about the timing and magnitude of trends based on policy is a strength of the current study. conclusions states with cannabis laws vary in prevalence of ya cannabis and tobacco use over time in relation to policy changes. cannabis and blunt use 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(2022). further consideration of the impact of tobacco control policies on young adult smoking in light of the liberalization of cannabis policies. nicotine & tobacco research, 24(1), 60-68. https://doi.org/10.1093/ntr/ntab149 funding and acknowledgements: this work was supported by the national center for advancing cannabis, a publication of the research society on marijuana 111 translational sciences of the national institutes of health under award number tl1tr003019 (amg) and p30ca072720-5931 (amg, acv). the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors have no conflicts of interest to declare. copyright: © 2025 authors et al. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction, provided the original author and source are credited, the original sources is not modified, and the source is not used for commercial purposes. citation: glasser, a. m., uriarte, c. king jensen, j., sterling, k., shang, c., hammond, d., & villanti, a. c. (2025). temporal trends in young adult cannabis and tobacco use in different states with different cannabis policies. cannabis, 8(2), 98 111. https://doi.org10.26828/cannabis/2025/000288 issue date: july 15, 2025 https://creativecommons.org/licenses/by/4.0/